229.22 230.75 9/1/2016 · 2016-07-21 · medicaid reimbursement per diem rates provider number: 0...

658
Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider Type: Current New Effective Rate Rate Date Nursing Home Single Level 229.22 230.75 9/1/2016 State of Florida Office of Medicaid Cost Reimbursement Planning and Finance 2727 Mahan Drive - Mail Stop 23 Tallahassee, Florida 32308 Rate Type: Interim X Prospective Total Interim X Total Prospective Interim Component Total Prospective with Interim Component Settlement based on cost Prior Provider Prospective data Basis: Budget X Unaudited costs Field audited costs Desk audited costs Changes: X Rate Semester Change Distribution: Contract Management / Fiscal Agent Permanent File For Information Only No Change in Rate Lisa Smith Medicaid Cost Reimbursement Planning and Finance Signature Healthcare LLC 12201 Bluegrass Parkway Louisville, KY 40299 2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 001135073120150801201403142016112219 SURREY PLACE CARE CENTER 110 SE LEE AVE LIVE OAK, FL 32060 Home Office:

Upload: others

Post on 02-Aug-2020

0 views

Category:

Documents


0 download

TRANSCRIPT

Page 1: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 001135-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.22 230.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 001135073120150801201403142016112219

SURREY PLACE CARE CENTER

110 SE LEE AVE

LIVE OAK, FL 32060

Home Office:

Page 2: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 001136-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.82 232.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 001136073120150801201403142016113124

SIGNATURE HEALTHCARE OF PALM BEACH

4405 LAKEWOOD ROAD

LAKE WORTH, FL 33461

Home Office:

Page 3: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 001416-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.20 208.92 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 001416123120140101201406262015110645

FLORIDA BAPTIST RETIREMENT CENTER

1006 33RD ST

VERO BEACH, FL 32960

Home Office:

Page 4: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 002400-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 260.53 261.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 002400083120140101201411192014133156

VILLAGE PLACE HEALTH AND REHAB CENTER

2370 HARBOR BLVD

PORT CHARLOTTE, FL 33952

Home Office:

Page 5: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005219-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.54 235.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005219123120140701201404212015154724

OSCEOLA HEALTH CARE CENTER

4201 W NEW NOLTE ROAD

SAINT CLOUD, FL 34772

Home Office:

Page 6: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005372-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.76 235.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005372063020140101201410122014133247

DEBARY HEALTH AND REHABILITATION CENTER

60 N HWY 17/92

DEBARY, FL 32713

Home Office:

Page 7: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005374-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.09 235.86 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005374063020140101201410122014132004

FLAGLER HEALTH AND REHABILITATION CENTER

300 DR CARTER BOULEVARD

BUNNELL, FL 32110

Home Office:

Page 8: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005379-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.72 238.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005379063020140101201410132014132230

LONGWOOD HEALTH AND REHABILITATION CENTER

1520 S GRANT ST

LONGWOOD, FL 32750

Home Office:

Page 9: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005380-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.40 246.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005380063020140101201410132014150000

THE REHABILITATION CENTER OF WINTER PARK

1700 MONROE AVE

MAITLAND, FL 32751

Home Office:

Page 10: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005381-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.54 247.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005381063020140101201410132014160002

BRYNWOOD HEALTH AND REHABILITATION CENTER

1656 SOUTH JEFFERSON STREET

MONTICELLO, FL 32344

Home Office:

Page 11: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005383-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.39 237.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005383063020140101201410122014130233

CHIPOLA HEALTH AND REHABILITATION CENTER

4294 3RD AVENUE

MARIANNA, FL 32446

Home Office:

Page 12: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005384-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.35 241.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005384063020140101201410122014131408

GLENCOVE HEALTH AND REHABILITATION CENTER

1027 E HWY 98

PANAMA CITY, FL 32401

Home Office:

Page 13: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005385-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.55 233.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005385063020140101201410112014161020

PANAMA CITY HEALTH AND REHABILITATION CENTER

924 W 13TH ST

PANAMA CITY, FL 32401

Home Office:

Page 14: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005386-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.18 235.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005386063020140101201410132014161243

RIVERCHASE HEALTH AND REHABILITATION CENTER

1017 STRONG RD

QUINCY, FL 32351

Home Office:

Page 15: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005387-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.30 246.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005387063020140101201410132014155217

SUWANNEE HEALTH AND REHABILITATION CENTER

1620 HELVENSTON ST SE

LIVE OAK, FL 32064-3474

Home Office:

Page 16: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005519-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.80 251.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005519063020140101201410112014160654

WAVE CREST HEALTH AND REHABILITATION CENTER

1415 S HICKORY ST

MELBOURNE, FL 32901

Home Office:

Page 17: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005543-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.03 241.55 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005543063020140101201410122014135403

SEASIDE HEALTH AND REHABILITATION CENTER

324 WILDER BLVD

DAYTONA BEACH, FL 32114

Home Office:

Page 18: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005547-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.69 232.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005547063020140101201410122014135946

PARKSIDE HEALTH AND REHABILITATION CENTER

451 S AMELIA AVE

DELAND, FL 32724

Home Office:

Page 19: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005549-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.17 249.25 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005549063020140101201410122014124836

OAKS OF KISSIMMEE

320 N MITCHELL ST

KISSIMMEE, FL 34741

Home Office:

Page 20: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005701-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.15 229.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005701123120140601201407062015132018

AVANTE AT OCALA

2021 SW 1ST AVE

OCALA, FL 34471

Home Office:

Page 21: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005811-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.04 250.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005811123120140701201404132015134820

PALATKA HEALTH CARE CENTER

110 KAY LARKIN DR

PALATKA, FL 32177

Home Office:

Page 22: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005814-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 263.75 264.77 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005814063020140101201410122014121820

BOYNTON HEALTH CARE CENTER

7900 VENTURE CENTER WAY

BOYNTON BEACH, FL 33437-7402

Home Office:

Page 23: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005826-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.45 236.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005826063020140101201410122014123932

ACCENTIA HEALTH & REHAB. CENTER OF TAMPA

1818 E FLETCHER AVE

TAMPA, FL 33612-3770

Home Office:

Page 24: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005849-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 272.49 274.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005849063020140101201410132014160617

GLEN OAKS HEALTH CARE CENTER

1100 N PINE ST

CLEARWATER, FL 33756-4104

Home Office:

Page 25: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005850-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.15 232.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005850063020140101201410132014132816

HERITAGE PARK

37135 COLEMAN AVE

DADE CITY, FL 33525-4526

Home Office:

Page 26: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 005851-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.24 236.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 005851063020140101201410132014110207

LAKE EUSTIS CARE CENTER

411 W WOODWARD AVE

EUSTIS, FL 32726

Home Office:

Page 27: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 006339-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.31 244.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 006339063020140101201410132014112001

LAKE PLACID HEALTH AND REHABILITATION CENTER

125 TOMOKA BLVD S

LAKE PLACID, FL 33852-8123

Home Office:

Page 28: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 006340-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.46 235.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 006340063020140101201410132014110751

WINDSOR HEALTH AND REHABILITATION CENTER

602 E LAURA ST

STARKE, FL 32091

Home Office:

Page 29: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 006483-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.69 243.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 006483063020140101201410132014133428

SALERNO BAY HEALTH AND REHABILITATION CENTER

4801 SE COVE RD

STUART, FL 34997-1602

Home Office:

Page 30: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 006489-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.43 245.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 006489063020140101201410132014111430

ROYAL PALM BEACH HEALTH AND REHABILITATION CENTER

600 BUSINESS PARK WAY

ROYAL PALM BEACH, FL 33411-1747

Home Office:

Page 31: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 006767-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.25 253.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 006767063020140101201410122014132634

OAKBROOK HEALTH AND REHABILITATION CENTER

250 BROWARD AVE

LABELLE, FL 33935

Home Office:

Page 32: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 008793-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.42 229.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cardinal Resources, LLC

16 Norcross Street

Roswell, GA 30075

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 008793123120140101201407172015084321

WOODS OF MANATEE SPRINGS

5627 9TH ST E

BRADENTON, FL 34203

Home Office:

Page 33: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 010082-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.93 225.34 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 010082063020140701201304272015113542

COURTYARD GARDENS REHABILITATION CENTER

17781 THELMA AVE

JUPITER, FL 33458

Home Office:

Page 34: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 010453-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.76 249.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 010453123120140101201405282015093151

HEARTLAND HEALTH CARE & REHABILITATION CENTER

5401 SAWYER RD

SARASOTA, FL 34233

Home Office:

Page 35: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 011997-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.42 243.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 011997123120140101201405282015094749

HEARTLAND HEALTH CARE AND REHABILITATION CENTER OF BOCA RATON

7225 BOCA DEL MAR DRIVE

BOCA RATON, FL 33433

Home Office:

Page 36: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 011998-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.77 242.38 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Grace Healthcare, Inc

7201 Shallowford Rd, STE 200

Chattanooga, TN 37421

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 011998123120150101201504262016151432

GRACE REHABILITATION CENTER OF VERO BEACH

2180 10TH AVENUE

VERO BEACH, FL 32960

Home Office:

Page 37: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 014169-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.02 250.34 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 014169123120140201201404252015154626

GULF SHORE REHAB & NURSING

6767 86TH AVE N

PINELLAS PARK, FL 33782

Home Office:

Page 38: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 015613-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.85 207.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Saber Healthcare Group, LLC

26691 Richmond Road

Bedford Heights, OH 44146

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 015613123120140101201405142015092143

ST. JAMES HEALTH AND REHABILITATION CENTER

239 CROOKED RIVER ROAD

CARRABELLE, FL 32322

Home Office:

Page 39: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017221-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.06 232.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017221063020140101201410122014140646

BAYSIDE HEALTH AND REHABILITATION CENTER

4343 LANGLEY AVENUE

PENSACOLA, FL 32504

Home Office:

Page 40: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017222-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.47 247.40 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017222063020140101201410132014134039

MARGATE HEALTH AND REHABILITATION CENTER

5951 COLONIAL DRIVE

MARGATE, FL 33063

Home Office:

Page 41: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017223-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.40 239.34 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017223063020140101201410112014160148

ROSEWOOD HEALTHCARE AND REHABILITATION CENTER

3107 NORTH H STREET

PENSACOLA, FL 32501-1043

Home Office:

Page 42: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017225-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.18 245.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017225063020140101201410122014142122

BAY BREEZE SENIOR LIVING AND REHABILITATION CENTER

3387 GULF BREEZE PARKWAY

GULF BREEZE, FL 32563

Home Office:

Page 43: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017230-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.91 244.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017230063020140101201410132014105545

SILVERCREST HEALTH AND REHABILITATION CENTER

910 BROOKMEADE DRIVE

CRESTVIEW, FL 32539

Home Office:

Page 44: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017236-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.55 246.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017236063020140101201410122014142356

SPECIALTY HEALTH AND REHABILITATION CENTER

6984 PINE FOREST ROAD

PENSACOLA, FL 32526

Home Office:

Page 45: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 017242-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.26 251.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 017242063020140101201410122014123221

GRAND BOULEVARD HEALTH & REHAB. CENTER

138 SANDESTIN LANE

MIRAMAR BEACH, FL 32550

Home Office:

Page 46: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 018066-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.77 236.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

FiveStar Quality Care Inc

400 Centre Street

Newton, MA 02458

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 018066123120150101201503262016142110

THE PARK SUMMIT AT CORAL SPRINGS

8500 ROYAL PALM BLVD

CORAL SPRINGS, FL 33065

Home Office:

Page 47: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 018777-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 262.69 272.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 018777123120140101201405212015102809

BAY VILLAGE OF SARASOTA

8400 VAMO ROAD

SARASOTA, FL 34231

Home Office:

Page 48: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 019085-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.16 209.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 019085073120150801201403142016133924

GOLFVIEW HEALTHCARE CENTER

3636 10TH AVE N

SAINT PETERSBURG, FL 33713

Home Office:

Page 49: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 019282-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 191.26 195.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 019282073120150801201403282016102245

SOUTHERN PINES HEALTHCARE CENTER

6140 CONGRESS ST

NEW PORT RICHEY, FL 34653

Home Office:

Page 50: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 019284-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.47 202.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 019284073120150801201403142016131649

SIGNATURE HEALTHCARE OF JACKSONVILLE

2061 HYDE PARK RD

JACKSONVILLE, FL 32210

Home Office:

Page 51: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 019287-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.86 202.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 019287073120150801201403142016132142

GOLFCREST HEALTHCARE CENTER

600 NORTH 17TH AVE

HOLLYWOOD, FL 33020

Home Office:

Page 52: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 021261-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.39 216.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 021261063020140101201410122014134040

COASTAL HEALTH AND REHABILITATION CENTER

820 N CLYDE MORRIS BLVD

DAYTONA BEACH, FL 32117

Home Office:

Page 53: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 022138-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.93 242.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 022138123120150901201404292016141227

CARLTON SHORES HEALTH AND REHAB CENTER

1350 S NOVA RD

DAYTONA BEACH, FL 32114

Home Office:

Page 54: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 022987-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.57 212.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

WW Healthcare Consultants, LLC

1978 8th Avenue NW

Hickory, NC 28603

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 022987123120140101201406302015115717

BLOUNTSTOWN HEALTH AND REHABILITATION CENTER

16690 SW CHIPOLA RD

BLOUNTSTOWN, FL 32424

Home Office:

Page 55: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 022994-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.72 211.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 022994063020150701201411092015093211

THE HOME ASSOCIATION, INC.

1203 E 22ND AVE

TAMPA, FL 33605

Home Office:

Page 56: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 023067-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 265.22 268.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 023067033120151001201404292015144210

OKEECHOBEE HEALTHCARE FACILITY

1646 HIGHWAY 441 N

OKEECHOBEE, FL 34972

Home Office:

Page 57: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 024167-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.07 218.20 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 024167063020150701201411032015073045

KEY WEST HEALTH & REHABILITATION

5860 W JUNIOR COLLEGE RD

KEY WEST, FL 33040

Home Office:

Page 58: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 026536-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.80 262.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 026536123120150101201504272016145017

WEST BROWARD REHABILITATION AND HEALTHCARE

7751 W BROWARD BLVD

PLANTATION, FL 33324

Home Office:

Page 59: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 032049-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.59 249.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 032049063020150701201411232015125519

CLYDE E. LASSEN STATE VETERANS' NURSING HOME

4650 STATE RD 16

SAINT AUGUSTINE, FL 32092

Home Office:

Page 60: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 032482-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.31 246.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 032482083120140101201411192014165437

UNITY HEALTH AND REHAB CENTER

1404 NW 22ND STREET

MIAMI, FL 33142

Home Office:

Page 61: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 032486-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.30 250.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 032486083120140101201410092014140735

LADY LAKE SPECIALTY CARE CENTER

630 GRIFFIN AVENUE

LADY LAKE, FL 32159

Home Office:

Page 62: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 032551-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.96 257.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 032551083120140101201411202014165527

SUNSET LAKE HEALTH AND REHAB CENTER

832 SUNSET LAKE BOULEVARD

VENICE, FL 34292

Home Office:

Page 63: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 032553-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.91 227.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 032553123120150901201404292016004102

LEXINGTON HEALTH & REHABILITATION CENTER

6300 46TH AVE N

SAINT PETERSBURG, FL 33709

Home Office:

Page 64: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 033175-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.70 230.37 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 033175013120160201201504292016105106

SEVEN HILLS HEALTH & REHAB CENTER

3333 CAPITAL MEDICAL BLVD

TALLAHASSEE, FL 32308

Home Office:

Page 65: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 033717-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.47 242.46 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 033717063020150701201406012016153735

BENDERSON FAMILY SKILLED NURSING & REHAB CENTER

1959 N HONORE AVE

SARASOTA, FL 34235

Home Office:

Page 66: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 034504-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.73 215.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Grace Healthcare, Inc

7201 Shallowford Rd, STE 200

Chattanooga, TN 37421

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 034504123120150101201504282016111947

GRACE HEALTHCARE OF LAKE WALES

730 N SCENIC HWY

LAKE WALES, FL 33853-3208

Home Office:

Page 67: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 038640-00

Date: 6/30/2016

Fiscal Year End: 6/30/2012

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.00 234.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

NUVISTA LIVING AT WELLINGTON GREEN

10330 NUVISTA AVENUE

WELLINGTON, FL 33414

Home Office:

Page 68: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 041324-00

Date: 6/30/2016

Fiscal Year End: 6/30/2012

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.23 231.47 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

NUVISTA LIVING AT HILLSBOROUGH LAKES

19091 N DALE MABRY HWY

LUTZ, FL 33548

Home Office:

Page 69: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 041685-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.14 218.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 041685022820150901201407072015141215

UNIVERSITY CENTER WEST

545 WEST EUCLID AVENUE

DELAND, FL 32720

Home Office:

Page 70: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 041686-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.82 225.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 041686013120160201201504202016112008

UNIVERSITY CENTER EAST

991 E NEW YORK AVE

DELAND, FL 32724

Home Office:

Page 71: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043832-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 189.03 189.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043832123120150101201504252016110649

HERON POINTE HEALTH AND REHABILITATION

1445 HOWELL AVE

BROOKSVILLE, FL 34601-1502

Home Office:

Page 72: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043833-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.83 196.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043833123120150101201504252016120205

HERITAGE HEALTHCARE CENTER AT TALLAHASSEE

3101 GINGER DR

TALLAHASSEE, FL 32308-4437

Home Office:

Page 73: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043835-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.05 215.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043835123120150101201504252016112754

BAY BREEZE HEALTH AND REHABILITATION CENTER

1026 ALBEE FARM RD

VENICE, FL 34285-6213

Home Office:

Page 74: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043838-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.10 209.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043838123120150101201504252016113106

HERITAGE HEALTHCARE AND REHABILITATION CENTER

777 9TH ST N

NAPLES, FL 34102

Home Office:

Page 75: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043839-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 189.98 185.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043839123120150101201504252016125023

KEYSTONE REHABILITATION AND HEALTH CENTER

1120 W DONEGAN AVE

KISSIMMEE, FL 34741-2247

Home Office:

Page 76: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043841-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.56 202.55 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043841123120140101201411102015115120

OAKBRIDGE HEALTHCARE CENTER

3110 OAKBRIDGE BLVD E

LAKELAND, FL 33803-5987

Home Office:

Page 77: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043843-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.79 207.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043843123120150101201504252016140336

OAKTREE HEALTHCARE

650 REED CANAL RD

SOUTH DAYTONA, FL 32119-3230

Home Office:

Page 78: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043846-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.49 196.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043846123120150101201504252016135749

RIO PINAR HEALTH CARE

7950 LAKE UNDERHILL ROAD

ORLANDO, FL 32822

Home Office:

Page 79: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043847-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.83 204.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043847123120140101201411102015105030

THE PALMS REHABILITATION AND HEALTHCARE CENTER

5405 BABCOCK ST NE

PALM BAY, FL 32905

Home Office:

Page 80: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043848-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.15 200.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043848123120150101201504252016105837

CORAL TRACE HEALTH CARE

216 SANTA BARBARA BLVD

CAPE CORAL, FL 33991-2031

Home Office:

Page 81: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043850-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.57 211.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043850123120140101201411102015123747

THE PARKS HEALTHCARE AND REHABILITATION CENTER

9311 S ORANGE BLOSSOM TRL

ORLANDO, FL 32837-8301

Home Office:

Page 82: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043851-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.73 216.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043851123120140101201411102015124123

CORAL BAY HEALTHCARE AND REHABILITATION

2939 S HAVERHILL RD

WEST PALM BCH, FL 33415-8118

Home Office:

Page 83: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043853-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.85 203.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043853123120140101201411182015112227

PLANTATION BAY REHABILITATION CENTER

4641 OLD CANOE CREEK ROAD

SAINT CLOUD, FL 34769

Home Office:

Page 84: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043854-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 188.62 187.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043854123120150101201504252016144350

COLONIAL LAKES HEALTH CARE

15204 W COLONIAL DR

WINTER GARDEN, FL 34787-6042

Home Office:

Page 85: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043856-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.16 225.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043856123120140101201411102015114858

CENTRAL PARK HEALTHCARE AND REHABILITATION CENTER

702 S KINGS AVE

BRANDON, FL 33511-5925

Home Office:

Page 86: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043857-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.72 224.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043857123120150101201504252016144626

BENEVA LAKES HEALTHCARE AND REHABILITATION CENTER

741 SOUTH BENEVA ROAD

SARASOTA, FL 34232

Home Office:

Page 87: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043859-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.22 212.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043859123120150101201504252016105110

BRADENTON HEALTH CARE

6305 CORTEZ RD W

BRADENTON, FL 34210-2604

Home Office:

Page 88: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043860-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.11 199.30 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043860123120150101201504252016105442

BRANDON HEALTH AND REHABILITATION CENTER

1465 OAKFIELD DR

BRANDON, FL 33511-4854

Home Office:

Page 89: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043861-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.31 206.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043861123120150101201504252016112038

FORT PIERCE HEALTH CARE

611 S 13TH ST

FORT PIERCE, FL 34950-4054

Home Office:

Page 90: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043862-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.13 209.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043862123120150101201504252016143220

HABANA HEALTH CARE CENTER

2916 HABANA WAY

TAMPA, FL 33614

Home Office:

Page 91: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043863-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.37 224.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043863123120150101201504252016144846

THE HEALTH AND REHABILITATION CENTRE AT DOLPHINS VIEW

1820 SHORE DR S

SOUTH PASADENA, FL 33707

Home Office:

Page 92: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043864-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.65 207.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043864123120150101201504252016132333

GRAND OAKS HEALTH AND REHABILITATION CENTER

3001 PALM COAST PARKWAY SE

PALM COAST, FL 32137

Home Office:

Page 93: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043865-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 186.47 188.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043865123120150101201504252016135142

HARTS HARBOR HEALTH CARE CENTER

11565 HARTS RD

JACKSONVILLE, FL 32218-3777

Home Office:

Page 94: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043866-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.21 202.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043866123120150101201504252016111755

FLETCHER HEALTH AND REHABILITATION CENTER

518 W FLETCHER AVE

TAMPA, FL 33612-3419

Home Office:

Page 95: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043867-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.73 201.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043867123120150101201504252016125649

WEDGEWOOD HEALTHCARE CENTER

1010 CARPENTERS WAY

LAKELAND, FL 33809-3926

Home Office:

Page 96: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043868-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.33 209.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043868123120150101201504252016110425

DELTONA HEALTH CARE

1851 ELKCAM BLVD

DELTONA, FL 32725-3922

Home Office:

Page 97: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043871-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.80 212.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043871123120150101201504252016125419

LAKE MARY HEALTH AND REHABILITATION CENTER

710 NORTH SUN DRIVE

LAKE MARY, FL 32746

Home Office:

Page 98: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043872-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.23 197.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043872123120140101201411102015083940

COUNTRYSIDE REHAB AND HEALTHCARE CENTER

3825 COUNTRYSIDE BLVD N

PALM HARBOR, FL 34684-4928

Home Office:

Page 99: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043873-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.30 217.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043873123120140101201411102015094623

HARBOR BEACH NURSING AND REHABILITATION CENTER

1615 MIAMI RD

FT LAUDERDALE, FL 33316-2933

Home Office:

Page 100: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043874-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.05 188.22 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043874123120150101201504252016112525

HEALTH CENTER AT BRENTWOOD

2333 N BRENTWOOD CIR

LECANTO, FL 34461-8536

Home Office:

Page 101: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043875-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.08 194.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043875123120150101201504252016131949

GOVERNOR'S CREEK HEALTH AND REHABILITATION

803 OAK ST

GREEN COVE SPRINGS, FL 32043

Home Office:

Page 102: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043876-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.73 195.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043876123120140101201411172015134947

LARGO HEALTH AND REHABILITATION CENTER

9035 BRYAN DAIRY RD

LARGO, FL 33777-1104

Home Office:

Page 103: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043877-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.24 208.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043877123120150101201504252016111041

MAGNOLIA HEALTH AND REHABILITATION CENTER

1507 S TUTTLE AVE

SARASOTA, FL 34239-2608

Home Office:

Page 104: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043878-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 192.84 193.09 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043878123120140101201411102015105846

MARSHALL HEALTH AND REHABILITATION CENTER

207 MARSHALL DR

PERRY, FL 32347-1835

Home Office:

Page 105: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 043880-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.55 202.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 043880123120150101201504252016131242

NORTH FLORIDA REHABILITATION AND SPECIALTY CARE

6700 NW 10TH PLACE

GAINESVILLE, FL 32605

Home Office:

Page 106: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 044886-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 192.74 190.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 044886123120140101201403272015150542

CRESTVIEW REHABILITATION CENTER

1849 FIRST AVENUE EAST

CRESTVIEW, FL 32539

Home Office:

Page 107: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 044888-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.95 209.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 044888123120140101201403272015152945

FORT WALTON REHABILITATION CENTER

1 LBJ SR DRIVE

FORT WALTON BEACH, FL 32548

Home Office:

Page 108: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 044889-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.49 195.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 044889123120140101201403272015153338

RIVER VALLEY REHABILITATION CENTER

17884 NE CROZIER ST

BLOUNTSTOWN, FL 32424

Home Office:

Page 109: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 044975-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 257.59 247.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 044975073120140801201310222015115206

PLANTATION KEY NURSING CENTER

48 HIGH POINT ROAD

TAVERNIER, FL 33070

Home Office:

Page 110: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 046017-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 259.79 262.33 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Professional Care I, Inc.

10850 SW 113th Place

Miami, FL 33176

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 046017123120140701201404202015080945

HOMESTEAD MANOR A PALACE COMMUNITY

1330 NW 1ST AVE

HOMESTEAD, FL 33030

Home Office:

Page 111: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 046128-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.19 251.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 046128022920160301201504272016134457

VICTORIA NURSING AND REHABILITATION CENTER, INC.

955 NW 3RD ST

MIAMI, FL 33128

Home Office:

Page 112: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 046233-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 263.49 205.01 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 046233013120150201201408192015111150

CROSSBREEZE CARE CENTER

1755 18TH ST

SARASOTA, FL 34234

Home Office:

Page 113: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 046758-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 264.64 267.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Stacey Enterprises, Inc

421 Garrard Street

Covington, KY 41011

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 046758022820150301201404232015155227

RIVERSIDE CARE CENTER

899 NW 4TH STREET

MIAMI, FL 33128

Home Office:

Page 114: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 047787-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.14 216.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 047787123120150101201504252016144134

RENAISSANCE HEALTH AND REHABILITATION

5065 WALLIS ROAD

WEST PALM BEACH, FL 33415

Home Office:

Page 115: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 047788-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.11 217.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 047788123120140101201411102015124421

WOOD LAKE NURSING AND REHABILITATION CENTER

6414 13TH RD S

GREENACRES, FL 33415-1401

Home Office:

Page 116: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 047795-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.27 193.86 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 047795123120150101201504252016143712

HILLCREST HEALTH CARE AND REHABILITATION CENTER

4200 WASHINGTON ST

HOLLYWOOD, FL 33021-7353

Home Office:

Page 117: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 048441-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.24 230.09 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 048441093020151001201402252016100607

HEALTH CENTRAL PARK

411 NORTH DILLARD STREET

WINTER GARDEN, FL 34787

Home Office:

Page 118: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 048611-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.54 210.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 048611123120140101201403272015153558

OCALA OAKS REHABILITATION CENTER

3930 E SILVER SPRINGS BLVD

OCALA, FL 34470-5006

Home Office:

Page 119: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 048807-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 267.53 264.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 048807022820151201201309282015165447

RIVIERA HEALTH RESORT

6901 YUMURI STREET

CORAL GABLES, FL 33146

Home Office:

Page 120: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 054789-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.50 204.85 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Adirhu Associates, LLC

12221 W Dixie Hwy

Miami, FL 33161

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 054789123120150101201504282016164511

SOUTH DADE NURSING AND REHABILITATION CENTER

17475 S DIXIE HWY

MIAMI, FL 33157

Home Office:

Page 121: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 054790-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.32 215.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Adirhu Associates, LLC

12221 W Dixie Hwy

Miami, FL 33161

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 054790123120140101201407282015090524

GOLDEN GLADES NURSING AND REHABILITATION CENTER

220 SIERRA DRIVE

MIAMI, FL 33179

Home Office:

Page 122: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059369-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 259.32 264.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059369123120140701201404042015133215

CALUSA HARBOUR

2525 FIRST ST

FORT MYERS, FL 33901

Home Office:

Page 123: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059400-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.12 255.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059400123120140701201404042015140021

STRATFORD COURT OF PALM HARBOR

45 KATHERINE BLVD

PALM HARBOR, FL 34684

Home Office:

Page 124: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059404-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 257.75 266.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059404123120150101201503282016171440

GARDENS OF PORT ST. LUCIE

1699 SE LYNGATE DRIVE

PORT SAINT LUCIE, FL 34952

Home Office:

Page 125: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059783-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 191.23 189.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059783123120140701201406082015110054

SUMMER BROOK HEALTH CARE CENTER

5377 MONCRIEF ROAD

JACKSONVILLE, FL 32209

Home Office:

Page 126: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059852-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 183.10 187.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059852123120150101201504252016131532

SHOAL CREEK REHABILITATION CENTER

500 HOSPITAL DRIVE

CRESTVIEW, FL 32539

Home Office:

Page 127: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059855-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.97 200.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059855123120150101201504252016111530

ENGLEWOOD HEALTHCARE & REHABILITATION CENTER

1111 DRURY LN

ENGLEWOOD, FL 34224-4545

Home Office:

Page 128: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059866-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.55 203.38 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059866123120150101201504252016130957

ISLAND HEALTH AND REHABILITATION CENTER

125 ALMA BLVD

MERRITT IS, FL 32953-4345

Home Office:

Page 129: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059869-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.26 206.33 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059869123120150101201504252016140100

ROSEWOOD HEALTH AND REHABILITATION CENTER

3920 ROSEWOOD WAY

ORLANDO, FL 32808

Home Office:

Page 130: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059873-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.20 204.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059873123120140101201411102015093437

EVANS HEALTH CARE

3735 EVANS AVE

FORT MYERS, FL 33901-9302

Home Office:

Page 131: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059874-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 182.87 187.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059874123120150101201504252016112259

SEA BREEZE HEALTH CARE

1937 JENKS AVE

PANAMA CITY, FL 32405-4510

Home Office:

Page 132: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 059877-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.43 197.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 059877123120150101201504252016143007

SPRING HILL HEALTH AND REHABILITATION CENTER

12170 CORTEZ BLVD

BROOKSVILLE, FL 34613-5578

Home Office:

Page 133: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 060972-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 195.63 198.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 060972123120150101201504252016111307

EMERALD SHORES HEALTH AND REHABILITATION

626 N TYNDALL PKWY

CALLAWAY, FL 32404-6132

Home Office:

Page 134: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 060993-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 192.91 195.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 060993123120150101201504252016110134

UNIVERSITY HILLS HEALTH AND REHABILITATION

10040 HILLVIEW ROAD

PENSACOLA, FL 32514

Home Office:

Page 135: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061095-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.72 196.55 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061095123120140101201411102015103810

HERITAGE PARK REHABILITATION AND HEALTHCARE

2826 CLEVELAND AVE

FORT MYERS, FL 33901-6001

Home Office:

Page 136: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061101-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.40 200.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061101123120140101201411102015091042

DESTIN HEALTHCARE AND REHABILITATION CENTER

195 MATTIE M KELLY BLVD

DESTIN, FL 32541-2811

Home Office:

Page 137: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061102-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.61 191.47 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061102123120150101201504252016103613

SAN JOSE HEALTH AND REHABILITATION CENTER

9355 SAN JOSE BLVD

JACKSONVILLE, FL 32257

Home Office:

Page 138: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061107-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.41 205.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061107123120150101201504252016135422

SEAVIEW NURSING AND REHABILITATION CENTER

2401 NE 2ND STREET

POMPANO BEACH, FL 33062

Home Office:

Page 139: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061109-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.25 195.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061109123120150101201504252016143442

VISTA MANOR

1550 JESS PARRISH CT

TITUSVILLE, FL 32796-2147

Home Office:

Page 140: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 061140-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.38 201.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 061140123120150101201504252016140740

LAKESIDE OAKS CARE CENTER

1061 VIRGINIA ST

DUNEDIN, FL 34698

Home Office:

Page 141: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 072048-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.55 245.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 072048123120140701201307202015085027

SOUTH CAMPUS REHABILITATION & NURSING CENTER

715 E DIXIE AVE

LEESBURG, FL 34748

Home Office:

Page 142: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 072054-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 266.83 267.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 072054123120140701201404132015163854

REHABILITATION CENTER OF ST. PETE

435 42ND AVE S

SAINT PETERSBURG, FL 33705

Home Office:

Page 143: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 072320-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.41 243.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 072320123120150901201404292016013718

THE CLUB HEALTH AND REHAB CENTER AT THE VILLAGES

16529 SE 86TH BELLE MEADE CIRCLE

THE VILLAGES, FL 32162-5885

Home Office:

Page 144: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 073324-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.12 210.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 073324123120140701201306042015162154

BRADEN RIVER REHABILITATION CENTER, LLC

2010 MANATEE AVE E

BRADENTON, FL 34208-1560

Home Office:

Page 145: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080062-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.65 200.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080062022920160301201504202016115421

THE GROVES CENTER

512 S 11TH ST

LAKE WALES, FL 33853-4901

Home Office:

Page 146: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080068-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.47 210.25 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080068022820150901201404192015121501

LAKELAND HILLS CENTER

610 E BELLA VISTA DR

LAKELAND, FL 33805

Home Office:

Page 147: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080079-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.69 213.95 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080079022820150901201404192015115418

TARPON BAYOU CENTER

515 CHESAPEAKE DR

TARPON SPRINGS, FL 34689

Home Office:

Page 148: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080374-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.42 193.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080374123120150101201504252016151239

CONSULATE HEALTH CARE OF BAYONET POINT

8132 HUDSON AVENUE

HUDSON, FL 34667-8571

Home Office:

Page 149: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080377-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.03 198.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080377123120140101201411112015102108

CONSULATE HEALTH CARE OF BRANDON

701 VICTORIA ST

BRANDON, FL 33510-4100

Home Office:

Page 150: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080384-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.28 214.82 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080384123120150101201504252016151636

CONSULATE HEALTH CARE OF JACKSONVILLE

4101 SOUTHPOINT DRIVE EAST

JACKSONVILLE , FL 32216

Home Office:

Page 151: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080387-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.67 199.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080387123120140101201411172015145719

CONSULATE HEALTH CARE OF KISSIMMEE

2511 JOHN YOUNG PARKWAY NORTH

KISSIMMEE, FL 34741

Home Office:

Page 152: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080391-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.09 193.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080391123120140101201411112015084851

CONSULATE HEALTH CARE OF LAKELAND

5245 N SOCRUM LOOP RD

LAKELAND, FL 33809

Home Office:

Page 153: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080393-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.31 200.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080393123120140101201411112015102456

CONSULATE HEALTH CARE OF LAKE PARKER

2020 W LAKE PARKER DR

LAKELAND, FL 33805-5005

Home Office:

Page 154: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080394-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.26 208.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080394123120140101201411112015102840

CONSULATE HEALTH CARE OF MELBOURNE

3033 SARNO RD

MELBOURNE, FL 32934

Home Office:

Page 155: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080397-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 191.85 191.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080397123120140101201411112015101340

CONSULATE HEALTH CARE OF NEW PORT RICHEY

8417 OLD COUNTY RD 54

NEW PORT RICHEY, FL 34653

Home Office:

Page 156: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080400-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.45 195.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080400123120140101201411172015135946

CONSULATE HEALTH CARE OF NORTH FT. MYERS

991 PONDELLA RD

NORTH FORT MYERS, FL 33903

Home Office:

Page 157: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080402-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 199.13 196.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080402123120150101201504252016151901

CONSULATE HEALTH CARE OF ORANGE PARK

1215 KINGSLEY AVE

ORANGE PARK, FL 32073

Home Office:

Page 158: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080405-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.16 206.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080405123120140101201411172015151107

CONSULATE HEALTH CARE OF PENSACOLA

235 WEST AIRPORT BLVD

PENSACOLA , FL 32505

Home Office:

Page 159: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080406-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.02 197.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080406123120140101201411112015111105

CONSULATE HEALTH CARE OF SAFETY HARBOR

1410 DR MARTIN LUTHER KING JR ST N

SAFETY HARBOR, FL 34695-3303

Home Office:

Page 160: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080409-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.13 202.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080409123120140101201411112015111750

CONSULATE HEALTH CARE OF ST. PETERSBURG

9393 PARK BLVD

SEMINOLE, FL 33777-4140

Home Office:

Page 161: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080413-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.32 226.02 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080413123120140101201411112015111430

CONSULATE HEALTH CARE OF SARASOTA

4783 FRUITVILLE ROAD

SARASOTA, FL 34232

Home Office:

Page 162: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080416-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.09 206.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080416123120140101201411112015110720

CONSULATE HEALTH CARE OF PORT CHARLOTTE

18480 COCHRAN BLVD

PORT CHARLOTTE, FL 33948

Home Office:

Page 163: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080428-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.09 209.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080428123120150101201504252016145419

CONSULATE HEALTH CARE OF TALLAHASSEE

1650 PHILLIPS RD

TALLAHASSEE , FL 32308

Home Office:

Page 164: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080430-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.93 200.17 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080430123120140101201411182015110915

CONSULATE HEALTH CARE OF VERO BEACH

1310 37TH ST

VERO BEACH, FL 32960-4860

Home Office:

Page 165: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080431-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.42 203.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080431123120140101201411172015142921

CONSULATE HEALTH CARE AT WEST ALTAMONTE

1099 WEST TOWN PARKWAY

ALTAMONTE SPRINGS, FL 32714

Home Office:

Page 166: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080432-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.52 216.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080432123120140101201411172015140607

CONSULATE HEALTH CARE OF WEST PALM BEACH

1626 DAVIS RD

WEST PALM BCH, FL 33406-5640

Home Office:

Page 167: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080434-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.02 196.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080434123120140101201407302015130228

CONSULATE HEALTH CARE OF WINTER HAVEN

2701 LAKE ALFRED RD

WINTER HAVEN, FL 33881

Home Office:

Page 168: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 080436-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.90 219.43 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Consulate Management Company

800 Concourse Parkway South

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 080436123120140101201411112015101729

FRANCO NURSING AND REHABILITATION CENTER

800 NW 95TH STREET

MIAMI , FL 33150

Home Office:

Page 169: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 082204-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 273.26 240.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 082204022820150301201409212015135240

UNIVERSITY PLAZA REHABILITATION & NURSING CENTER

724 NW 19TH ST

MIAMI, FL 33136

Home Office:

Page 170: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 085643-00

Date: 6/30/2016

Fiscal Year End: 10/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.87 274.13 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 085643103120141024201308282015170540

SARASOTA POINT REHABILITATION CENTER

2600 COURTLAND STREET

SARASOTA, FL 34237

Home Office:

Page 171: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 086990-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.71 252.32 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brooks Health System

3599 University Blvd, South

Jacksonville, FL 32216

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 086990123120140709201307282015142207

BARTRAM CROSSING

6209 BROOKS BARTRAM DRIVE

BUIDLING 100

JACKSONVILLE, FL 32258

Home Office:

Page 172: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 088049-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 275.48 221.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 088049013120150501201408132015095740

CROSS GARDENS CARE CENTER

190 NE 191ST STREET

MIAMI , FL 33179

Home Office:

Page 173: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 088601-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 254.94 258.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Vanguard Healthcare, LLC

6 Cadillac Drive

Suite 310

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 088601123120140802201307302015155955

WHITEHALL BOCA RATON

7300 DEL PRADO CIRCLE SOUTH

BOCA RATON, FL 33433

Home Office:

Page 174: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 089220-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 260.18 254.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 089220013120150201201406262015092749

KRYSTAL BAY NURSING AND REHABILITATION

16650 W DIXIE HWY

NORTH MIAMI BEACH, FL 33160

Home Office:

Page 175: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 092678-00

Date: 6/30/2016

Fiscal Year End: 1/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.94 227.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 092678013120140801201302032015130820

OSPREY POINT NURSING CENTER

1104 NORTH MAIN STREET

BUSHNELL, FL 33513-5045

Home Office:

Page 176: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 092681-00

Date: 6/30/2016

Fiscal Year End: 1/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.37 234.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CMC II, LLC

800 Concourse Parkway South

Suite 200

Maitland, FL 32751

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 092681013120140801201302032015125337

BAYA POINTE NURSING AND REHABILITATION CENTER

587 SE ERMINE AVE

LAKE CITY, FL 32025

Home Office:

Page 177: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 094353-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 264.50 267.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 094353063020140115201312292014121958

HAWTHORNE HEALTH AND REHAB OF SARASOTA

5381 DESOTO ROAD

SARASOTA, FL 34235

Home Office:

Page 178: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 096150-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.91 226.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Acts, Inc

375 Morris Road

West Point, PA 19486

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 096150123120140101201405262015144932

WILLOWBROOKE COURT AT AZALEA TRACE

10100 HILLVIEW DR

PENSACOLA, FL 32514

Home Office:

Page 179: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098577-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.91 244.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098577093020150701201402262016133807

PALM GARDEN OF AVENTURA

21251 E DIXIE HIGHWAY

NORTH MIAMI BEACH, FL 33180

Home Office:

Page 180: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098580-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.62 241.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098580093020150701201402262016134910

PALM GARDEN OF CLEARWATER

3480 MCMULLEN BOOTH RD

CLEARWATER, FL 33761

Home Office:

Page 181: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098581-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.17 231.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098581093020150501201402262016140307

PALM GARDEN OF GAINESVILLE

227 SW 62ND BLVD

GAINESVILLE, FL 32607

Home Office:

Page 182: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098582-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.10 243.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098582093020150501201402262016133359

PALM GARDEN OF JACKSONVILLE

5725 SPRING PARK ROAD

JACKSONVILLE, FL 32216

Home Office:

Page 183: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098583-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.64 242.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098583093020150601201402262016153700

PALM GARDEN OF LARGO

10500 STARKEY RD

LARGO, FL 33777

Home Office:

Page 184: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098584-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.10 225.82 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098584093020150501201402262016141329

PALM GARDEN OF OCALA

2700 SW 34TH ST

OCALA, FL 34474

Home Office:

Page 185: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098586-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.91 220.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098586093020150701201402262016142543

PALM GARDEN OF ORLANDO

654 N ECONLOCKHATCHEE TRAIL

ORLANDO, FL 32825-6402

Home Office:

Page 186: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098587-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.92 241.55 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098587093020150501201402262016143859

PALM GARDEN OF PINELLAS

200 16TH AVE SE

LARGO, FL 33771

Home Office:

Page 187: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098588-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.50 233.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098588093020150501201402262016145000

PALM GARDEN OF PORT SAINT LUCIE

1751 SE HILLMOOR DRIVE

PORT SAINT LUCIE, FL 34952

Home Office:

Page 188: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098589-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.16 238.38 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098589093020150701201402262016154312

PALM GARDEN OF SUN CITY

3850 UPPER CREEK DR

SUN CITY CENTER, FL 33573

Home Office:

Page 189: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098590-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.72 243.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098590093020150701201402262016154436

PALM GARDEN OF TAMPA

3612 E 138TH AVE

TAMPA, FL 33613

Home Office:

Page 190: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098591-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.12 225.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098591093020150501201402262016151615

PALM GARDEN OF VERO BEACH

1755 37TH STREET

VERO BEACH, FL 32960

Home Office:

Page 191: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098592-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.33 223.17 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098592093020150601201402262016145248

PALM GARDEN OF WEST PALM BEACH

300 EXECUTIVE CENTER DRIVE

WEST PALM BEACH, FL 33401

Home Office:

Page 192: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098593-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.37 245.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Palm Garden Healthcare Holdings, LLC

2033 Main Street

Suite 300

Sarasota, FL 34237

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098593093020150901201402262016131819

PALM GARDEN OF WINTER HAVEN

1120 CYPRESS GARDENS BLVD

WINTER HAVEN, FL 33884

Home Office:

Page 193: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 098972-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.16 245.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 098972123120150701201503302016180318

COMMUNITY HEALTH AND REHABILITATION CENTER

3611 TRANSMITTER ROAD

PANAMA CITY, FL 32404-9799

Home Office:

Page 194: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 099366-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.62 205.29 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 099366073120150801201403142016135436

GULFPORT REHABILITATION CENTER

1430 PASADENA AVE S

SOUTH PASADENA, FL 33707

Home Office:

Page 195: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 100487-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.65 205.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 100487022820151201201301082016104721

THE TERRACE OF KISSIMMEE

221 PARK PLACE BLVD

KISSIMMEE, FL 34741

Home Office:

Page 196: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 100509-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.82 233.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Gulf Coast Healthcare, LLC

40 South Palafox Place

Suite 400

Pensacola, FL 32502

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 100509063020141201201310202014130627

ARCADIA HEALTH & REHABILITATION CENTER

10095 HILLVIEW ROAD

PENSACOLA, FL 32514

Home Office:

Page 197: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 101391-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.30 204.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

TJM Properties

5801 Ulmerton Road

Suite 200

Clearwater, FL 33760

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 101391123120140117201408312015140423

THE OAKS OF CLEARWATER

420 BAY AVE

CLEARWATER, FL 33756

Home Office:

Page 198: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 101959-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.57 211.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Traditions Management of Florida, LLC

24641 US Highway 19 North

Clearwater, FL 33763

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 101959123120140101201405192015070854

CARRINGTON PLACE OF ST. PETE

10501 ROOSEVELT BLVD N

SAINT PETERSBURG, FL 33716

Home Office:

Page 199: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 101961-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.65 214.42 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Traditions Management of Florida, LLC

24641 US Highway 19 North

Clearwater, FL 33763

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 101961123120140101201405182015151718

TRINITY REGIONAL REHAB CENTER

2144 WELBILT BLVD

TRINITY, FL 34655

Home Office:

Page 200: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 101963-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.54 216.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Traditions Management of Florida, LLC

24641 US Highway 19 North

Clearwater, FL 33763

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 101963123120140101201405182015144038

EAGLE LAKE REHAB & CARE CENTER

1100 66TH ST N

ST PETERSBURG, FL 33710-6224

Home Office:

Page 201: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102419-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.45 203.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102419022820151201201301072016113346

THE TERRACE OF ST. CLOUD

3855 OLD CANOE CREEK ROAD

SAINT CLOUD, FL 34769

Home Office:

Page 202: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102586-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 271.60 279.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102586073120141230201312142015150952

THE CROSSROADS

206 W ORANGE ST

DAVENPORT, FL 33837

Home Office:

Page 203: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102592-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 298.89 308.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102592073120141230201301052016102508

THE CROSSINGS

4445 PINE FOREST DR

LAKE WORTH, FL 33463-4676

Home Office:

Page 204: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102787-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 293.57 299.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102787073120141230201301122016134425

CROSS POINTE CARE CENTER

440 PHIPPEN WAITERS ROAD

DANIA BEACH, FL 33004

Home Office:

Page 205: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102791-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 254.72 257.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102791073120141230201312032015124037

CROSS TERRACE REHABILITATION CENTER

1351 SAN CHRISTOPHER DR

DUNEDIN, FL 34698

Home Office:

Page 206: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102832-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 264.34 269.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102832073120141230201301052016104334

CROSS LANDINGS HEALTH AND REHABILITATION CENTER

1780 N JEFFERSON ST

MONTICELLO, FL 32344

Home Office:

Page 207: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 102833-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.13 267.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 102833073120141230201301052016113234

CROSSWINDS HEALTH AND REHABILITATION CENTER

13455 W US HWY 90

GREENVILLE, FL 32331

Home Office:

Page 208: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103165-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.58 214.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

TLC Management

1800 North Wabash Ave

Suite 300

Marion, IN 46952

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103165063020150701201410282015073332

ASTORIA HEALTH & REHABILITATION CENTER

701 OVERLOOK DR SE

WINTER HAVEN, FL 33884-1671

Home Office:

Page 209: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103177-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 278.15 280.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103177063020141231201307022015101609

DESOTO HEALTH AND REHAB

475 NURSING HOME DR

ARCADIA, FL 34266

Home Office:

Page 210: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103425-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.06 204.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103425123120150101201503282016130617

COMMUNITY CONVALESCENT CENTER

2202 W OAK AVE

PLANT CITY, FL 33563

Home Office:

Page 211: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103475-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.78 252.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103475083120141205201302042015163007

WESTWOOD NURSING & REHABILITATION CENTER

1001 MAR-WALT DRIVE

FORT WALTON BEACH, FL 32547

Home Office:

Page 212: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103852-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.28 232.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Preferred Care Inc.

5500 W. Plano Parkway

Plano, TX 75093

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103852123120140301201403292016174338

OCOEE HEALTH CARE CENTER

1556 MAGUIRE RD

OCOEE, FL 34761

Home Office:

Page 213: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 103858-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.30 255.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 103858022820150301201409282015152438

NORTH CAMPUS REHABILITATION AND NURSING CENTER

700 N PALMETTO ST

LEESBURG, FL 34748

Home Office:

Page 214: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 104875-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.32 247.95 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Trillium Healthcare Consulting, LLC

5265 Office Park Boulevard

Suite 101

Bradenton , FL 34203

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 104875093020140401201403182015154529

REHABILITATION CENTER AT PARK PLACE

1717 W AVERY ST

PENSACOLA, FL 32501

Home Office:

Page 215: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 108507-00

Date: 6/30/2016

Fiscal Year End: 4/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.52 227.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

THE TERRACE OF JACKSONVILLE

10680 OLD ST AUGUSTINE RD

JACKSONVILLE, FL 32257

Home Office:

Page 216: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 110482-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.61 241.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 110482123120150101201504292016020133

VIERA HEALTH & REHABILITATION CENTER

8050 SPYGLASS HILL RD

VIERA, FL 32940

Home Office:

Page 217: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 111543-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.29 237.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

St. Vincent Health System

1 Shircliff Way

Jacksonville, FL 32204

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 111543063020150701201404152016114514

ST. CATHERINE LABOURE MANOR, INC.

1750 STOCKTON ST

JACKSONVILLE, FL 32204

Home Office:

Page 218: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122229-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.86 220.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

HARBOUR HEALTH CENTER

23013 WESTCHESTER BLVD

PORT CHARLOTTE, FL 33980

Home Office:

Page 219: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122232-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.96 220.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211885123120140101201407272015202310

PLAZA WEST

912 AMERICAN EAGLE BLVD

SUN CITY CENTER, FL 33573

Home Office:

Page 220: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122236-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.96 220.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122236123120150101201505242016142149

SEMINOLE PAVILION REHABILITATION & NURSING SERVICES

10800 TEMPLE TERRACE

SEMINOLE, FL 33772

Home Office:

Page 221: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122239-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.03 222.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122239123120150101201506082016142942

FREEDOM SQUARE REHABILITATION & NURSING SERVICES

10801 JOHNSON BLVD

SEMINOLE, FL 33772

Home Office:

Page 222: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122242-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.86 231.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122242123120150101201505242016143421

CYPRESS VILLAGE

4600 MIDDLETON PARK CIR E

JACKSONVILLE, FL 32224

Home Office:

Page 223: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122243-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.89 206.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

LAKE HARRIS HEALTH CENTER

701 LAKE PORT BLVD

LEESBURG, FL 34748

Home Office:

Page 224: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122248-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.57 247.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SYLVAN HEALTH CENTER

2770 REGENCY OAKS BLVD

CLEARWATER, FL 33759

Home Office:

Page 225: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122250-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.58 234.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122250123120150101201506132016140136

THE NURSING CENTER AT FREEDOM VILLAGE

6410 21ST AVE W

BRADENTON, FL 34209

Home Office:

Page 226: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122340-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.19 236.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122340123120140701201404152015131742

CITRUS HILLS HEALTH & REHABILITATION CENTER

124 W NORVELL BRYANT HWY

HERNANDO, FL 34442

Home Office:

Page 227: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122341-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.52 237.50 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122341123120140701201408192015132021

WOODLAND GROVE HEALTH & REHABILITATION CENTER

4325 SOUTHPOINT BOULEVARD

JACKSONVILLE, FL 32216

Home Office:

Page 228: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122342-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.71 236.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122342123120140701201404302015111729

THE GARDENS HEALTH & REHABILITATION CENTER

1704 HUNTINGTON VILLAGE CIRCLE

DAYTONA BEACH, FL 32114

Home Office:

Page 229: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122343-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.59 233.67 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122343123120140701201404152015150926

ISLE HEALTH & REHABILITATION CENTER

1125 FLEMING PLANTATION BLVD

ORANGE PARK, FL 32003

Home Office:

Page 230: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122344-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.10 235.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122344123120140701201404142015142115

RIVERWOOD HEALTH & REHABILITATION CENTER

808 S COLLEY RD

STARKE, FL 32091

Home Office:

Page 231: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122346-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.35 227.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122346123120140701201404152015143657

TERRACE HEALTH & REHABILITATION CENTER

7207 SW 24TH AVE

GAINESVILLE, FL 32607

Home Office:

Page 232: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 122347-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.94 231.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 122347123120140701201404152015090317

VILLA HEALTH & REHABILITATION CENTER

120 CHIPOLA AVE

DELAND, FL 32720

Home Office:

Page 233: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 128848-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.64 210.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 128848022920160301201504202016114016

BAY CENTER

1336 ST ANDREWS BLVD

PANAMA CITY, FL 32405

Home Office:

Page 234: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 129312-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 209.71 207.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

THE PAVILION FOR HEALTH CARE

ONE PAVILION PLACE

PENNEY FARMS, FL 32079

Home Office:

Page 235: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 130817-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.99 246.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 130817022820150901201404282016180908

OAK VIEW REHABILITATION CENTER

833 KINGSLEY AVE

ORANGE PARK, FL 32073

Home Office:

Page 236: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 132045-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.11 214.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

NORTH DADE NURSING AND REHABILITATION CENTER

1255 NE 135TH STREET

NORTH MIAMI, FL 33161

Home Office:

Page 237: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 132449-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.67 220.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

FOUNTAIN MANOR HEALTH & REHABILITATION CENTER

390 NE 135TH ST

NORTH MIAMI, FL 33161-3967

Home Office:

Page 238: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 133196-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.02 198.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 133196013120150801201404192015120305

EMERALD COAST CENTER

114 THIRD STREET SE

FORT WALTON BEACH, FL 32548

Home Office:

Page 239: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 133348-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.63 220.27 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 133348013120160201201504202016105350

EGRET COVE CENTER

550 62ND ST S

SAINT PETERSBURG, FL 33707

Home Office:

Page 240: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 134463-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.63 255.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

FT LAUDERDALE HEALTH AND REHABILITATION CENTER

2000 EAST COMMERCIAL BLVD

FORT LAUDERDALE, FL 33308

Home Office:

Page 241: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 135581-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.69 239.46 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 135581063020150101201501222016183648

THE MANOR AT BLUE WATER BAY

1500 NORTH WHITE POINT ROAD

NICEVILLE , FL 32578

Home Office:

Page 242: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 135647-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.74 243.17 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

X Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 135647063020150101201501222016171715

LAKE BENNETT HEALTH AND REHABILITATION

1091 KELTON AVE

OCOEE, FL 34761

Home Office:

Page 243: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 140643-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.76 216.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212911022820150901201407072015134635

CLEARWATER CENTER

1270 TURNER ST

CLEARWATER, FL 33756

Home Office:

Page 244: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 140648-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.52 200.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 140648022920160301201504202016113213

BARTOW CENTER

2055 E GEORGIA ST

BARTOW, FL 33830

Home Office:

Page 245: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 141466-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.59 204.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

LANIER TERRACE

12740 LANIER ROAD

JACKSONVILLE, FL 32226-1704

Home Office:

Page 246: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 143762-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.96 226.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 143762022920160301201504202016114624

BOCA CIEGA CENTER

1414 59TH ST S

GULFPORT, FL 33707

Home Office:

Page 247: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 146222-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 261.53 257.37 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

THE FLORIDEAN NURSING AND REHABILITATION CENTER

47 NW 32ND PLACE

MIAMI, FL 33125

Home Office:

Page 248: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 147672-00

Date: 6/30/2016

Fiscal Year End: 4/30/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.91 239.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

BAY VUE NURSING AND REHABILITATION CENTER

105 15TH ST E

BRADENTON, FL 34208

Home Office:

Page 249: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 147958-00

Date: 6/30/2016

Fiscal Year End: 5/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 261.11 258.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

EXCEL CARE CENTER

2811 CAMPUS HILL DR

TAMPA, FL 33612

Home Office:

Page 250: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 148040-00

Date: 6/30/2016

Fiscal Year End: 6/30/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.06 225.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

THE TERRACE AT HOBE SOUND

9555 SE FEDERAL HWY

HOBE SOUND, FL 33455

Home Office:

Page 251: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 153181-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 254.01 251.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

GLADES WEST REHABILITATION AND NURSING CENTER

15955 BASS CREEK ROAD

PEMBROKE PINES, FL 33027

Home Office:

Page 252: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 155062-00

Date: 6/30/2016

Fiscal Year End: 9/30/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 277.56 274.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

PINES NURSING HOME

301 NE 141 STREET

MIAMI, FL 33161

Home Office:

Page 253: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 156586-00

Date: 6/30/2016

Fiscal Year End: 10/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.71 220.55 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

NORTHBROOK HEALTH AND REHABILITATION CENTER

575 LAMAR AVE

BROOKSVILLE, FL 34601

Home Office:

Page 254: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 158851-00

Date: 6/30/2016

Fiscal Year End: 7/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.73 232.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

THE VILLAGES REHABILITATION AND NURSING CENTER

900 HIGHWAY 466

LADY LAKE, FL 32159

Home Office:

Page 255: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162218-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.08 251.82 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE BAYONET POINT

7210 BEACON WOODS DR

HUDSON, FL 34667-1974

Home Office:

Page 256: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162219-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.55 257.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE CHARLOTTE HARBOR

4000 KINGS HWY

PORT CHARLOTTE, FL 33980

Home Office:

Page 257: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162220-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.92 260.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE COCONUT CREEK

4125 WEST SAMPLE RD

COCONUT CREEK, FL 33073

Home Office:

Page 258: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162221-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.28 249.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE DAYTONA

550 NATIONAL HEALTHCARE DRIVE

DAYTONA BEACH, FL 32114

Home Office:

Page 259: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162222-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 253.97 253.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE IMPERIAL

900 IMPERIAL GOLF COURSE BLVD

NAPLES, FL 34110

Home Office:

Page 260: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162224-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.98 245.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE LAKE CITY

560 SW MCFARLANE AVE

LAKE CITY, FL 32025

Home Office:

Page 261: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162225-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.56 251.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE MERRITT ISLAND

500 CROCKETT BLVD

MERRITT ISLAND, FL 32953

Home Office:

Page 262: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162226-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 285.82 288.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS SENIOR LIVING NORTH NAPLES

10949 PARNU STREET

NAPLES, FL 34109

Home Office:

Page 263: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162228-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 256.71 256.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE PARKWAY

800 SE CENTRAL PKWY

STUART, FL 34994

Home Office:

Page 264: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162230-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.84 247.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE PENSACOLA

8475 UNIVERSITY PARKWAY

PENSACOLA, FL 32514

Home Office:

Page 265: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162231-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.43 250.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE PLANT CITY

701 N WILDER RD

PLANT CITY, FL 33566-7547

Home Office:

Page 266: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 162232-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.46 248.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

SOLARIS HEALTHCARE WINDERMERE

4875 CASON COVE DRIVE

ORLANDO, FL 32811

Home Office:

Page 267: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 163903-00

Date: 6/30/2016

Fiscal Year End: 12/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 256.88 258.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

X Interim Prospective

X Total Interim Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

X Budget

Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID:

FORT MYERS REHABILITATION AND NURSING CENTER

7173 CYPRESS DRIVE SW

FORT MYERS, FL 33907-2994

Home Office:

Page 268: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200107-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.03 242.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Bon Secours Health System, Inc

1505 Marriottsville Road

Marriottsville, MD 21104-1399

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200107083120150901201401152016160058

BON SECOURS MARIA MANOR NURSING CARE CENTER

10300 4TH ST N

SAINT PETERSBURG, FL 33716

Home Office:

Page 269: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200409-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.18 213.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200409033120150401201409152015090727

WESTMINSTER OAKS

4449 MEANDERING WAY

TALLAHASSEE, FL 32308

Home Office:

Page 270: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200506-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.63 252.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200506063020150701201411202015171049

MIAMI JEWISH HEALTH SYSTEMS

5200 NE 2ND AVENUE

MIAMI, FL 33137

Home Office:

Page 271: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200735-00

Date: 6/30/2016

Fiscal Year End: 12/31/2013

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.11 231.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200735123120130101201304302014092150

CROSS CARE CENTER

5888 BLANDING BLVD

JACKSONVILLE, FL 32244

Home Office:

Page 272: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200859-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 257.20 260.32 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

River Garden Holding Company

11401 Old St. Augustine Road

Jacksonville, FL 32258

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200859123120140101201404082015133239

RIVER GARDEN HEBREW HOME FOR THE AGED

11401 OLD SAINT AUGUSTINE RD

JACKSONVILLE, FL 32258-1402

Home Office:

Page 273: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200913-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.85 237.20 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200913123120150101201504152016095352

AVANTE VILLA AT JACKSONVILLE BEACH INC

1504 SEABREEZE AVE

JACKSONVILLE BEACH, FL 32250

Home Office:

Page 274: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 200956-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.97 252.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 200956083120140901201304252015110653

COMPREHENSIVE HEALTHCARE OF CLEARWATER

2055 PALMETTO ST

CLEARWATER, FL 33765

Home Office:

Page 275: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 201006-00

Date: 6/30/2016

Fiscal Year End: 4/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.24 245.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Memorial Healthcare System

3501 Johnson Street

Hollywood, FL 33021

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 201006043020150501201411232015143932

MEMORIAL MANOR

777 SOUTH DOUGLAS ROAD

PEMBROKE PINES, FL 33025

Home Office:

Page 276: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 201120-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.42 268.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 201120123120150101201504302016092301

GULF COAST VILLAGE

1333 SANTA BARBARA BLVD

CAPE CORAL, FL 33991

Home Office:

Page 277: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 201588-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.68 230.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 201588123120140101201405222015131722

MARY LEE DEPUGH NURSING HOME ASSOCIATION INC

550 W MORSE BLVD

WINTER PARK, FL 32789

Home Office:

Page 278: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 201651-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.13 251.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 201651123120140701201404292015083230

GUARDIAN CARE NURSING & REHABILITATION CENTER

2500 W CHURCH STREET

ORLANDO, FL 32805

Home Office:

Page 279: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202011-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.52 235.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

The Goodman Group, LLC

1107 Hazeltine Blvd

Chaska, MN 55318

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202011123120140701201404152015163407

WESTCHESTER GARDENS REHABILITATION & CARE CENTER

3301 N MCMULLEN BOOTH RD

CLEARWATER, FL 33761

Home Office:

Page 280: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202533-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 261.15 259.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202533093020151001201404202016101321

THE ROHR HOME

2120 MARSHALL EDWARDS DR

BARTOW, FL 33830

Home Office:

Page 281: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202606-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.14 242.40 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202606093020151001201403052016195907

SAMANTHA WILSON CARE CENTER

161A MARINE STREET

SAINT AUGUSTINE, FL 32084

Home Office:

Page 282: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202703-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 270.55 273.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202703073120140801201312092014104903

PINES OF SARASOTA

1501 N ORANGE AVE

SARASOTA, FL 34236

Home Office:

Page 283: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202711-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 283.32 290.01 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunnyside Properties Of Sarasota

5201 Bahia Vista Street

Sarasota, FL 34232

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202711123120140701201404222015133250

SUNNYSIDE NURSING HOME

5201 BAHIA VISTA STREET

SARASOTA, FL 34232

Home Office:

Page 284: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202789-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.77 199.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202789123120150101201503162016100906

CENTER FOR HEALTH CARE OF THE ALLIANCE COMMUNITY

130 W ARMSTRONG AVENUE

Home Office:

Page 285: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 202941-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.45 229.37 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 202941063020140701201308202015174707

MIRACLE HILL NURSING AND REHABILITATION CENTERS, INC.

1329 ABRAHAM STREET

TALLAHASSEE, FL 32304

Home Office:

Page 286: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203122-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.48 241.27 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203122123120150101201504252016141703

AVANTE AT LEESBURG, INC.

2000 EDGEWOOD AVE

LEESBURG, FL 34748

Home Office:

Page 287: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203165-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 266.24 269.10 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Catholic Health Services

4790 N. State Road 7

Lauderdale Lakes, FL 33319

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203165093020151001201404202016114411

VILLA MARIA NURSING CENTER

1050 NE 125TH STREET

NORTH MIAMI, FL 33161

Home Office:

Page 288: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203203-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.91 259.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Council on Aging of Florida, Inc.

1311 SW 16th Street

Gainesville, FL 32608

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203203022820150301201404272015101317

GLADES HEALTH CARE CENTER

230 SOUTH BARFIELD HIGHWAY

PAHOKEE, FL 33476

Home Office:

Page 289: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203220-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.13 225.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203220123120140601201403172015091954

AVANTE AT INVERNESS

304 S CITRUS AVE

INVERNESS, FL 34452

Home Office:

Page 290: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203238-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.10 243.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203238123120150101201504132016105134

AVANTE AT LAKE WORTH

2501 N A ST

LAKE WORTH, FL 33460-6013

Home Office:

Page 291: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203327-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 263.53 264.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Professional Care I, Inc.

10850 SW 113th Place

Miami, FL 33176

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203327013120150801201404272015091640

THE PALACE AT KENDALL NURSING AND REHAB CENTER

11215 SW 84TH STREET

MIAMI, FL 33173

Home Office:

Page 292: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203335-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.95 239.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203335123120140101201405142015103904

TIMBERRIDGE NURSING & REHAB CENTER

9848 SW 110TH ST

OCALA, FL 34481

Home Office:

Page 293: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203475-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 228.76 229.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203475123120141001201305142015093835

MARIANNA HEALTH & REHABILITATION

4295 FIFTH AVENUE

MARIANNA, FL 32446

Home Office:

Page 294: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203599-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.49 253.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203599123120140101201403252015144951

THE MANOR AT CARPENTER'S

1001 CARPENTERS WAY

LAKELAND, FL 33809

Home Office:

Page 295: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203670-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 265.55 271.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203670093020151001201402242016110508

JACKSON MEMORIAL PERDUE MEDICAL CENTER

19590 OLD CUTLER ROAD

CUTLER RIDGE, FL 33157

Home Office:

Page 296: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203769-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.83 231.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203769123120140101201405292015162643

JOHN KNOX VILLAGE OF POMPANO BEACH

700 S.W. 4TH STREET

POMPANO BEACH, FL 33060

Home Office:

Page 297: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203815-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.23 211.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203815033120150401201409152015090107

WESTMINSTER TOWERS AND SHORES OF BRADENTON

1533 4TH AVE W

BRADENTON, FL 34205

Home Office:

Page 298: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 203980-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 175.12 174.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 203980123120140101201405282015081007

LISENBY ON LAKE CAROLINE

1400 W 11TH ST

PANAMA CITY, FL 32401

Home Office:

Page 299: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204072-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.46 229.43 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204072073120140801201302172015101322

MEASE CONTINUING CARE

910 NEW YORK AVE

DUNEDIN, FL 34698-6600

Home Office:

Page 300: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204161-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.41 246.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204161093020151001201402242016114807

JACKSON MEMORIAL LONG TERM CARE CENTER

2500 NW 22ND AVE

MIAMI, FL 33142

Home Office:

Page 301: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204170-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 260.95 265.20 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Stirling LTC, Corp

2699 Stirling Road

Suite B100

Ft. Lauderdale, FL 33180

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204170022820150301201404222015143945

REGENTS PARK NURSING & REHABILITATION CENTER

6363 VERDE TRAIL

BOCA RATON, FL 33433

Home Office:

Page 302: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204391-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.88 249.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Evangelical Lutheran Good Samaritan

4800 West 57th Street

Sioux Falls, SD 57117

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204391123120140101201406042015101034

GOOD SAMARITAN SOCIETY-DAYTONA

325 S SEGRAVE STREET

DAYTONA BEACH, FL 32114

Home Office:

Page 303: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204536-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.31 192.64 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Taylor Foundation Services, Inc.

6601 Chester Avenue

Jacksonville, FL 32217

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204536083120150901201404292016084321

FANNIE E TAYLOR HOME FOR THE AGED INC

3937 SPRING PARK ROAD

JACKSONVILLE, FL 32207

Home Office:

Page 304: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 204625-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.86 218.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 204625123120150101201504292016142054

TRI-COUNTY NURSING HOME

7280 SW STATE RD 26

TRENTON, FL 32693

Home Office:

Page 305: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205303-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.39 224.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Evangelical Lutheran Good Samaritan

4800 West 57th Street

Sioux Falls, SD 57117

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205303013120160201201504202016132432

GOOD SAMARITAN SOCIETY-KISSIMMEE VILLAGE

1500 SOUTHGATE DRIVE

KISSIMMEE, FL 34746

Home Office:

Page 306: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205460-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.64 222.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205460063020150701201412162015144017

THE VILLAGE ON HIGH RIDGE

1800 SOUTH DRIVE

LAKE WORTH, FL 33461

Home Office:

Page 307: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205745-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 261.85 282.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

LifeSpace Communities, Inc.

100 East Grand Ave.

Suite 200

Des Moines, IA 50309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205745123120140101201404062016132855

ABBEY DELRAY

2105 SW 11TH COURT

DELRAY BEACH, FL 33445

Home Office:

Page 308: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205796-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.11 220.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205796083120140901201310172014090747

COMMONS AT ORLANDO LUTHERAN TOWERS

210 LAKE AVENUE

ORLANDO, FL 32801

Home Office:

Page 309: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205800-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 257.90 256.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Catholic Health Services

4790 N. State Road 7

Lauderdale Lakes, FL 33319

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205800093020151001201406032016150615

ST. JOHN'S NURSING CENTER

3075 NW 35TH AVE

LAUDERDALE LAKES, FL 33311

Home Office:

Page 310: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 205923-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 273.89 274.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 205923123120140101201404212015104559

LOURDES-NOREEN MCKEEN RESIDENCE FOR GERIATRIC CARE, INC.

315 S FLAGLER DR

WEST PALM BEACH, FL 33401

Home Office:

Page 311: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 206300-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 256.47 251.85 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 206300083120150901201401282016170057

SUWANNEE VALLEY NURSING CENTER

427 15TH AVENUE NORTHWEST

JASPER, FL 32052-5874

Home Office:

Page 312: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 206431-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.31 246.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Baycare Health System

2985 Drew Street

Clearwater, FL 33759

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 206431123120140101201404282016153742

MORTON PLANT REHABILITATION CENTER

400 CORBETT ST

BELLEAIR, FL 33756

Home Office:

Page 313: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 206521-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.43 296.42 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Acts, Inc

375 Morris Road

West Point, PA 19486

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 206521123120140101201405262015144249

WILLOWBROOKE COURT AT ST ANDREWS ESTATES

6152 N VERDE TRAIL

BOCA RATON, FL 33433

Home Office:

Page 314: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 206610-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 271.70 285.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Retirement Comm.,Inc.

200 East Grand Avenue

Suite 390

Des Moines, IA 50309-1800

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 206610123120140101201404062016142742

THE WATERFORD

601 UNIVERSE BLVD

JUNO BEACH, FL 33408

Home Office:

Page 315: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 206865-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 253.08 274.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

LifeSpace Communities, Inc.

100 East Grand Ave.

Suite 200

Des Moines, IA 50309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 206865123120140101201404062016145809

ABBEY DELRAY SOUTH

1717 HOMEWOOD BLVD

DELRAY BEACH, FL 33445

Home Office:

Page 316: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207381-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.07 248.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207381053120150601201410232015160809

JOSEPH L MORSE GERIATRIC CENTER INC

4847 FRED GLADSTONE DRIVE

WEST PALM BEACH, FL 33417

Home Office:

Page 317: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207446-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.84 230.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Taylor Foundation Services, Inc.

6601 Chester Avenue

Jacksonville, FL 32217

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207446083120150901201404282016123345

TAYLOR CARE CENTER

6535 CHESTER AVENUE

JACKSONVILLE, FL 32217

Home Office:

Page 318: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207497-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.47 248.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Subacute Services, Inc.

4800 Nob Hill Road

Sunrise, FL 33351

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207497123120150101201504282016084929

SUNRISE HEALTH AND REHABILITATION CENTER

4800 N NOB HILL RD

SUNRISE, FL 33351-4722

Home Office:

Page 319: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207527-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.01 225.93 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207527083120140901201304272015073855

ORCHARD PARK HEALTH AND REHABILITATION

919 OLD WINTER HAVEN RD

AUBURNDALE, FL 33823-4329

Home Office:

Page 320: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207683-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 237.89 238.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207683073120140801201310192014102554

LAKESIDE HEALTH CENTER

2501 N AUSTRALIAN AVENUE

WEST PALM BEACH, FL 33407

Home Office:

Page 321: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 207799-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.69 248.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HPSA, Inc.

5409 Maryland Way, Suite 304

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 207799013120150801201404212015115942

THE PONCE THERAPY CARE CENTER

1999 OLD MOULTRIE ROAD

SAINT AUGUSTINE, FL 32086

Home Office:

Page 322: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 208442-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.03 259.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 208442123120150701201504222016145727

BERNARD L SAMSON NURSING CENTER

255 59TH ST N

SAINT PETERSBURG, FL 33710

Home Office:

Page 323: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 208485-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.82 250.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 208485093020151001201403072016093135

JUPITER MEDICAL CENTER PAVILION INC.

1230 SOUTH OLD DIXIE HWY

JUPITER, FL 33458-7297

Home Office:

Page 324: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 208507-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.05 233.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Stirling LTC, Corp

2699 Stirling Road

Suite B100

Ft. Lauderdale, FL 33180

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 208507022920160301201504192016093602

CLARIDGE HOUSE NURSING & REHABILITATION CENTER

13900 NE 3RD COURT

NORTH MIAMI, FL 33161

Home Office:

Page 325: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 208540-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.97 216.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 208540033120150401201409152015100016

WESTMINSTER TOWERS

70 WEST LUCERNE CIRCLE

ORLANDO, FL 32801

Home Office:

Page 326: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209325-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 262.87 284.50 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Retirement Housing Foundation

911 N. Studebaker Rd

Long Beach, CA 90815-4900

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209325093020151001201402252016083929

COURTENAY SPRINGS VILLAGE

1100 SOUTH COURTENAY PARKWAY

MERRITT IS, FL 32952-3804

Home Office:

Page 327: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209422-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.00 230.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209422033120150401201409152015082920

WESTMINSTER COMMUNITIES OF BRADENTON WESTMINSTER MANOR

1700 21ST AVE W

BRADENTON, FL 34205

Home Office:

Page 328: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209473-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.85 255.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Catholic Health Services

4790 N. State Road 7

Lauderdale Lakes, FL 33319

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209473093020151001201404202016151537

ST. ANNE'S NURSING CENTER

11855 QUAIL ROOST DRIVE

MIAMI, FL 33177

Home Office:

Page 329: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209511-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.79 256.30 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Retirement Housing Foundation

911 N. Studebaker Rd

Long Beach, CA 90815-4900

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209511093020151001201402242016152004

BISHOPS GLEN RETIREMENT CENTER

900 LPGA BLVD

HOLLY HILL, FL 32117-3100

Home Office:

Page 330: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209848-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.83 210.47 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209848033120150401201409152015094412

WINTER PARK TOWERS

1111 S LAKEMONT AVE

STE 101

WINTER PARK, FL 32792-5469

Home Office:

Page 331: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 209856-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.39 239.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 209856083120150901201411052015094043

SUN TERRACE HEALTH CARE CENTER

105 TRINITY LAKES DR

SUN CITY CENTER, FL 33573

Home Office:

Page 332: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210137-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.75 228.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210137073120140801201310192014113004

LIFE CARE CENTER OF ALTAMONTE SPRINGS

989 ORIENTA AVE

ALTAMONTE SPRINGS, FL 32701

Home Office:

Page 333: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210188-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 237.34 243.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Covenant Retirement Communities

5700 Old Orchard Road

Skokie, IL 60077

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210188013120160201201504272016173045

COVENANT VILLAGE CARE CENTER

9211 W BROWARD BLVD

PLANTATION, FL 33324

Home Office:

Page 334: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210285-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 228.88 244.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Baycare Health System

2985 Drew Street

Clearwater, FL 33759

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210285123120140101201406032016152045

JOHN KNOX VILLAGE MED CENTER

4100 E FLETCHER AVE

TAMPA, FL 33613

Home Office:

Page 335: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210463-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 273.92 275.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210463123120140101201403132015122523

VILLAGE ON THE ISLE

910 TAMIAMI TRAIL SOUTH

VENICE, FL 34285

Home Office:

Page 336: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210587-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 253.93 254.92 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lee Memorial Health System

636 Del Prado Boulevard

Cape Coral, FL 33990

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210587093020151001201402292016103153

HEALTHPARK CARE CENTER INC.

16131 ROSERUSH COURT

FORT MYERS, FL 33908-3634

Home Office:

Page 337: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210676-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.98 261.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210676123120150101201504252016163114

AVANTE AT BOCA RATON INC.

1130 NW 15TH STREET

BOCA RATON, FL 33486

Home Office:

Page 338: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210684-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.26 237.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210684093020151001201402222016090050

EDGEWATER AT WATERMAN VILLAGE

300 BROOKFIELD AVE

MOUNT DORA, FL 32757-9562

Home Office:

Page 339: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210889-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.92 248.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210889063020150701201411232015112335

EMORY L BENNETT MEMORIAL VETERANS NURSING HOME

1920 MASON AVENUE

DAYTONA BEACH, FL 32117

Home Office:

Page 340: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 210951-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.94 207.82 9/1/2016

Level U: Fragile Under 21 504.57 507.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

The Goodman Group, LLC

1107 Hazeltine Blvd

Chaska, MN 55318

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 210951123120140701201404282015105005

SABAL PALMS HEALTH CARE CENTER

499 ALTERNATE KEENE RD NE

LARGO, FL 33771

Home Office:

Page 341: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211010-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.34 260.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunrise Senior Living

7900 W. Park Drive, STE T900

McLean, VA 22102

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211010123120150101201504282016142405

STRATFORD COURT OF BOCA RATON

6343 VIA DE SONRISA DEL SUR

BOCA RATON, FL 33433

Home Office:

Page 342: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211052-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 266.03 269.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211052093020151001201402292016152859

W FRANK WELLS NURSING HOME

210 N 2ND ST

MACCLENNY, FL 32063

Home Office:

Page 343: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211281-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.42 192.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Genesis HealthCare Corp

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211281013120160201201504262016115029

HUNTINGTON PLACE

1775 HUNTINGTON LANE

ROCKLEDGE, FL 32955

Home Office:

Page 344: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211435-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 194.90 198.38 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Diversicare Healthcare Services Inc.

1621 Galleria Blvd.

Brentwood, TN 30727

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211435123120140101201404272016100630

HARDEE MANOR HEALTHCARE CENTER

401 ORANGE PLACE

WAUCHULA, FL 33873

Home Office:

Page 345: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211516-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.89 198.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211516083120140901201304272015080325

LAUREL POINTE HEALTH AND REHABILITATION

703 S 29TH ST

FORT PIERCE, FL 34947

Home Office:

Page 346: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211532-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.81 230.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211532073120140801201310192014114408

LIFE CARE CENTER OF CITRUS COUNTY

3325 W JERWAYNE LN

LECANTO, FL 34461

Home Office:

Page 347: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 211923-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.17 198.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CNH, LLC

46 Third Street NW

Hickory, NC 28601

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 211923022820150901201404232015125849

LAKE PARK OF MADISON

259 SW CAPTAIN BROWN RD

MADISON, FL 32340

Home Office:

Page 348: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212032-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.51 252.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212032093020151001201402252016132948

EDWARD J HEALEY REHABILITATION AND NURSING CENTER

5101 WEST BLUE HERON BLVD

RIVIERA BEACH, FL 33418

Home Office:

Page 349: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212083-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.00 230.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212083033120150401201409152015091802

WESTMINSTER WOODS ON JULINGTON CREEK

25 STATE ROAD 13

JACKSONVILLE, FL 32259

Home Office:

Page 350: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212164-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.15 224.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212164073120140801201310292014165909

YBOR CITY HEALTHCARE AND REHABILITATION CENTER

1709 TALIAFERRO AVE

TAMPA, FL 33602

Home Office:

Page 351: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212393-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.07 247.64 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Rohm Service Corp

740 East Avenue

Rochester, NY 14607

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212393123120140101201404282015175551

THE FOUNTAINS NURSING HOME INC

3800 N FEDERAL HWY

BOCA RATON, FL 33431

Home Office:

Page 352: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212709-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.45 207.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Westminster Services

80 West Lucerne Circle

Orlando, FL 32801

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212709033120150401201409152015084918

WESTMINSTER SUNCOAST

1095 PINELLAS POINT DR S

SAINT PETERSBURG, FL 33705-6272

Home Office:

Page 353: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212733-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 179.21 177.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212733123120140101201405222015150856

OCEANSIDE EXTENDED CARE CENTER

550 9TH STREET

MIAMI BEACH, FL 33139

Home Office:

Page 354: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212792-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.78 215.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Evangelical Lutheran Good Samaritan

4800 West 57th Street

Sioux Falls, SD 57117

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212792123120150101201504202016130156

GOOD SAMARITAN SOCIETY-FLORIDA LUTHERAN

450 NORTH MCDONALD AVENUE

DELAND, FL 32724

Home Office:

Page 355: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212806-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 272.20 263.28 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212806013120160201201504192016141734

PALMETTO SUB ACUTE CARE CENTER INC

7600 SW 8TH STREET

MIAMI, FL 33144

Home Office:

Page 356: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 212971-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.51 264.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 212971123120150101201504182016135057

FLORIDA PRESBYTERIAN HOMES INC

909 LAKESIDE AVE

LAKELAND, FL 33803

Home Office:

Page 357: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213098-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.04 240.43 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213098123120140201201406112015101909

TAMARAC REHABILITATION AND HEALTH CENTER

7901 NW 88TH AVENUE

TAMARAC, FL 33321

Home Office:

Page 358: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213152-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 275.82 286.02 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213152123120150101201504112016143630

WATERS EDGE EXTENDED CARE

1500 SW CAPRI ST

PALM CITY, FL 34990

Home Office:

Page 359: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213161-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.73 217.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213161073120140801201310152014112024

LIFE CARE CENTER AT WELLS CROSSING

355 CROSSING BLVD

ORANGE PARK, FL 32073

Home Office:

Page 360: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213322-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.03 225.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213322123120150101201504082016105049

HARBORCHASE OF VENICE

950 PINEBROOK ROAD

VENICE, FL 34285-7147

Home Office:

Page 361: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213403-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.78 224.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213403123120150801201404182016144349

LIFE CARE CENTER OF ORLANDO

3211 ROUSE ROAD

ORLANDO, FL 32817

Home Office:

Page 362: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213462-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.51 246.77 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213462123120150801201404292016081638

MADISON HEALTH AND REHABILITATION CENTER

2481 WEST US 90

MADISON, FL 32340-9540

Home Office:

Page 363: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213837-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 270.02 280.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213837123120140101201405252015185940

VI AT LAKESIDE VILLAGE

2792 DONNELLY DRIVE

LANTANA, FL 33462

Home Office:

Page 364: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213900-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.41 244.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213900093020151001201403212016153016

PAGE REHABILITATION AND HEALTHCARE CENTER

2310 N AIRPORT ROAD

FORT MYERS, FL 33907

Home Office:

Page 365: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 213934-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.34 231.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 213934093020141001201303022015134650

TMH SKILLED NURSING FACILITY

1609 MEDICAL DRIVE

TALLAHASSEE , FL 32308

Home Office:

Page 366: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 214035-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.52 278.01 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

DOS Health Care, Inc

300 71st Street, Suite 400

Miami, FL 33141

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 214035013120160201201504252016090609

MIAMI SHORES NURSING AND REHAB CENTER

9380 NW 7TH AVENUE

MIAMI, FL 33150

Home Office:

Page 367: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 214060-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.25 206.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 214060123120150801201404172016155907

LIFE CARE CENTER OF HILLIARD

3756 W THIRD ST

HILLIARD, FL 32046

Home Office:

Page 368: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 214914-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.89 250.30 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 214914063020150701201411232015112441

BALDOMERO LOPEZ MEMORIAL VETERANS NURSING HOME

6919 PARKWAY BLVD

LAND O LAKES, FL 34639

Home Office:

Page 369: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 216399-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.74 278.64 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

LifeSpace Communities, Inc.

100 East Grand Ave.

Suite 200

Des Moines, IA 50309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 216399123120140101201404062016144949

HARBOUR'S EDGE

401 E LINTON BLVD

DELRAY BEACH, FL 33483

Home Office:

Page 370: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217263-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.12 217.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

NHS Management

931 Fairfax Park

Tuscaloosa, AL 35406

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217263063020150701201412082015141054

CRYSTAL RIVER HEALTH AND REHABILITATION CENTER

136 NORTHEAST 12TH AVENUE

CRYSTAL RIVER, FL 34429

Home Office:

Page 371: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217395-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.24 203.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

NHS Management

931 Fairfax Park

Tuscaloosa, AL 35406

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217395063020150701201412082015163250

OCALA HEALTH AND REHABILITATION CENTER

1201 SE 24TH RD

OCALA, FL 34471

Home Office:

Page 372: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217727-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.23 226.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

NHS Management

931 Fairfax Park

Tuscaloosa, AL 35406

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217727063020150701201412082015161551

WEST MELBOURNE HEALTH & REHABILITATION CENTER

2125 WEST NEW HAVEN AVE

WEST MELBOURNE, FL 32904

Home Office:

Page 373: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217735-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.29 228.29 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

NHS Management

931 Fairfax Park

Tuscaloosa, AL 35406

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217735063020150701201412082015164215

ST AUGUSTINE HEALTH AND REHABILITATION CENTER

51 SUNRISE BLVD

SAINT AUGUSTINE, FL 32084

Home Office:

Page 374: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217743-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.33 248.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

NHS Management

931 Fairfax Park

Tuscaloosa, AL 35406

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217743063020150701201412082015153304

DAYTONA BEACH HEALTH AND REHABILITATION CENTER

1055 3RD STREET

DAYTONA BEACH, FL 32117-4196

Home Office:

Page 375: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 217824-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.39 241.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 217824123120150801201404202016203458

LIFE CARE CENTER OF PORT SAINT LUCIE

3720 SE JENNINGS RD

PORT ST LUCIE, FL 34952-7701

Home Office:

Page 376: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 218171-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.37 203.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 218171083120140901201304252015112459

WEST JACKSONVILLE HEALTH AND REHABILITATION CENTER

1650 FOURAKER RD

JACKSONVILLE, FL 32221

Home Office:

Page 377: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 219380-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.46 244.13 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 219380123120150801201404222016104307

LIFE CARE CENTER OF WINTER HAVEN

1510 CYPRESS GARDENS BLVD

WINTER HAVEN, FL 33884

Home Office:

Page 378: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 220604-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 228.89 229.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 220604073120140801201310292014165059

CENTURY HEALTH AND REHABILITATION CENTER

6020 INDUSTRIAL BLVD

CENTURY, FL 32535

Home Office:

Page 379: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 220612-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.00 222.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 220612073120140801201310292014163606

SANTA ROSA HEALTH & REHABILITATION CENTER

5386 BROAD ST

MILTON, FL 32570-2235

Home Office:

Page 380: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 220621-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.61 235.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 220621123120150801201405242016105428

SANDY RIDGE HEALTH AND REHABILITATION

5360 GLOVER LANE

MILTON, FL 32570

Home Office:

Page 381: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 221465-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.26 201.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 221465123120140101201407022015132834

CLERMONT HEALTH AND REHABILITATION CENTER

151 E MINNEHAHA AVE

CLERMONT, FL 34711

Home Office:

Page 382: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 221589-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.11 216.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 221589123120150101201504272016144536

DELANEY PARK HEALTH AND REHABILITATION CENTER

215 ANNIE STREET

ORLANDO, FL 32806

Home Office:

Page 383: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 223239-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.67 243.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Stirling LTC, Corp

2699 Stirling Road

Suite B100

Ft. Lauderdale, FL 33180

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 223239022820150901201404222015134748

REGENTS PARK AT AVENTURA

18905 NE 25TH AVE

AVENTURA, FL 33180

Home Office:

Page 384: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 223654-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 194.07 193.30 9/1/2016

Level U: Fragile Under 21 493.70 492.93 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 223654123120140701201407072015102451

ORLANDO HEALTH AND REHABILITATION CENTER

830 WEST 29TH STREET

ORLANDO, FL 32805

Home Office:

Page 385: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 223786-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.84 248.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 223786013120160201201504202016213119

LIFE CARE CENTER OF SARASOTA

8104 TUTTLE AVE

SARASOTA, FL 34243-2885

Home Office:

Page 386: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 223808-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.33 248.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 223808123120150101201504252016144210

AVANTE AT ORLANDO INC.

2000 NORTH SEMORAN BOULEVARD

ORLANDO, FL 32807

Home Office:

Page 387: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 224341-00

Date: 6/30/2016

Fiscal Year End: 11/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.74 244.38 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

M-K Management, LLC

1181 Vickery Lane, Suite 200

Cordova, TN 38016-0633

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 224341113020151201201404212016145124

HAINES CITY HEALTH CARE

409 S 10TH ST

HAINES CITY, FL 33845-1476

Home Office:

Page 388: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 224910-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.90 214.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 224910063020150701201406102016101251

SOUTH TAMPA HEALTH AND REHABILITATION CENTER

4610 S MANHATTAN AVE

TAMPA, FL 33611

Home Office:

Page 389: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225053-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.53 250.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

M-K Management, LLC

1181 Vickery Lane, Suite 200

Cordova, TN 38016-0633

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225053022820150301201404082015110140

QUALITY HEALTH OF NORTH PORT

6940 OUTREACH WAY

NORTH PORT, FL 34287-0947

Home Office:

Page 390: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225274-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.59 220.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

M-K Management, LLC

1181 Vickery Lane, Suite 200

Cordova, TN 38016-0633

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225274123120140101201404012015103831

QUALITY HEALTH OF FERNANDINA BEACH

1625 LIME STREET

FERNANDINA BEACH, FL 32034

Home Office:

Page 391: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225410-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.86 247.80 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

M-K Management, LLC

1181 Vickery Lane, Suite 200

Cordova, TN 38016-0633

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225410123120140101201404062015142559

QUALITY HEALTH OF ORANGE COUNTY

12751 W COLONIAL DRIVE

WINTER GARDEN, FL 34787

Home Office:

Page 392: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225631-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.51 229.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225631022920160301201504252016144731

SPRINGTREE REHABILITATION & HEALTH CARE CENTER

4251 SPRINGTREE DRIVE

SUNRISE, FL 33351-6119

Home Office:

Page 393: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225754-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 264.96 261.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225754022820150901201406232015101841

PINECREST REHABILITATION CENTER

13650 NE 3RD COURT

NORTH MIAMI, FL 33161

Home Office:

Page 394: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 225991-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.30 247.09 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Eden Park Health Services, Inc.

45 Learned Street

Albany, NY 12207

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 225991123120150101201504012016111023

STUART NURSING & RESTORATIVE CARE CENTER

1500 SE PALM BEACH RD

STUART, FL 34994

Home Office:

Page 395: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226009-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.76 237.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Eden Park Health Services, Inc.

45 Learned Street

Albany, NY 12207

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226009123120140101201403312015093035

PORT ST. LUCIE NURSING AND RESTORATIVE CARE CENTER

7300 OLEANDER AVE

PORT ST LUCIE, FL 34952-8299

Home Office:

Page 396: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226017-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.09 261.09 9/1/2016

Level U: Fragile Under 21 557.72 560.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226017022920160301201504262016080906

PLANTATION NURSING & REHABILITATION CENTER

4250 NW 5TH ST

PLANTATION, FL 33317

Home Office:

Page 397: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226033-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.06 245.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Eden Park Health Services, Inc.

45 Learned Street

Albany, NY 12207

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226033123120150101201504012016114755

MARTIN NURSING AND RESTORATIVE CARE CENTER

6011 SE TOWER DR

STUART, FL 34997

Home Office:

Page 398: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226068-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.22 245.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cathedral Foundation, Inc.

4250 Lakeside Drive

Suite 204

Jacksonville, FL 32210

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226068093020151001201403292016155821

CATHEDRAL GERONTOLOGY CENTER INC

333 E ASHLEY ST

JACKSONVILLE, FL 32202

Home Office:

Page 399: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226335-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 237.63 239.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226335022920160301201504252016091027

BROWARD NURSING & REHABILITATION CENTER

1330 S ANDREWS AVE

FORT LAUDERDALE, FL 33316

Home Office:

Page 400: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226351-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.19 217.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Millenium Health Systems

5310 NW 33rd Avenue

Suite 211

Ft. Lauderdale, FL 33309

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226351123120140201201404282015093842

OCEAN VIEW NURSING & REHABILITATION CENTER LLC

2810 SOUTH ATLANTIC AVENUE

NEW SMYRNA BEACH, FL 32169

Home Office:

Page 401: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226360-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.32 233.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226360123120140701201407072015115900

SOUTH HERITAGE HEALTH & REHABILITATION CENTER

718 LAKEVIEW AVE S

SAINT PETERSBURG, FL 33705

Home Office:

Page 402: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 226602-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.50 218.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 226602123120140701201404192015111423

TREASURE ISLE CARE CENTER

1735 N TREASURE DRIVE

NORTH BAY VILLAGE, FL 33141

Home Office:

Page 403: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227226-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 164.06 166.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227226123120140101201405142015103232

FAIR HAVENS CENTER

201 CURTISS PKWY

MIAMI SPRINGS, FL 33166-5291

Home Office:

Page 404: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227251-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.26 230.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227251123120150101201503282016124814

ALPINE HEALTH AND REHABILITATION CENTER

3456 21ST AVE S

SAINT PETERSBURG, FL 33711

Home Office:

Page 405: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227579-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.20 258.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227579083120140101201411172014114309

WILTON MANORS HEALTH & REHABILITATION CENTER

2675 N ANDREWS AVE

WILTON MANORS, FL 33311

Home Office:

Page 406: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227587-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.20 238.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227587083120140101201411172014101947

ROCKLEDGE HEALTH AND REHABILITATION CENTER

587 BARTON BLVD

ROCKLEDGE, FL 32955

Home Office:

Page 407: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227625-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.16 253.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227625083120140101201410092014144935

GREENBRIAR REHABILITATION AND NURSING CENTER

210 21ST AVE W

BRADENTON, FL 34205

Home Office:

Page 408: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227633-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.42 234.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227633123120150901201404282016233002

APOLLO HEALTH AND REHABILITATION CENTER

1000 24TH ST N

SAINT PETERSBURG, FL 33713

Home Office:

Page 409: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227641-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.79 238.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227641083120140101201410102014111739

NORTH REHABILITATION CENTER

1301 16TH ST N

SAINT PETERSBURG, FL 33705

Home Office:

Page 410: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227765-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.89 238.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227765123120150901201404292016133321

PARK MEADOWS HEALTH AND REHABILITATION CENTER

3250 SW 41ST PLACE

GAINESVILLE, FL 32608

Home Office:

Page 411: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227773-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.72 254.33 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227773083120140101201409292014121647

THE LODGE HEALTH AND REHABILITATION CENTER

635 SE 17TH STREET

OCALA, FL 34471

Home Office:

Page 412: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227838-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.83 221.33 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227838123120140701201404192015113818

FIRST COAST HEALTH & REHABILITATION CENTER

7723 JASPER AVENUE

JACKSONVILLE, FL 32211

Home Office:

Page 413: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 227871-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.94 199.96 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 227871073120140801201310292014123423

AYERS HEALTH AND REHABILITATION CENTER

606 NE 7TH ST

TRENTON, FL 32693

Home Office:

Page 414: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228001-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 273.36 277.00 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228001083120140101201410032014092241

NORTH BEACH REHABILITATION CENTER

2201 NE 170TH STREET

NORTH MIAMI BEACH, FL 33160

Home Office:

Page 415: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228320-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 254.49 265.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228320123120150901201404202016214810

THE GARDENS COURT

3803 PGA BOULEVARD

PALM BEACH GARDENS, FL 33410

Home Office:

Page 416: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228338-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.87 219.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228338022920160301201504222016091531

LIFE CARE CENTER OF MELBOURNE

606 E SHERIDAN RD

MELBOURNE, FL 32901

Home Office:

Page 417: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228401-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.61 203.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Care Managers, Inc

2380 Sadler Road Suite 201

Fernandina Beach, FL 32034

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228401123120140101201407282015163637

PARK RIDGE NURSING CENTER

730 COLLEGE STREET

JACKSONVILLE, FL 32204

Home Office:

Page 418: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228567-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.85 195.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228567073120140801201311132014111937

BEAR CREEK NURSING CENTER

8041 STATE RD 52 E

HUDSON, FL 34667

Home Office:

Page 419: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228575-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.64 206.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228575073120140801201310292014152142

ROYAL OAK NURSING CENTER

37300 ROYAL OAK LANE

DADE CITY, FL 33525

Home Office:

Page 420: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228591-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.77 205.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228591073120140801201310292014133050

HEATHER HILL HEALTHCARE CENTER

6630 KENTUCKY AVE

NEW PORT RICHEY, FL 34653

Home Office:

Page 421: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228621-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 290.60 298.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228621123120140101201408102015112002

INN AT SARASOTA BAY CLUB

1303 NORTH TAMIAMI TRAIL

SARASOTA, FL 34236

Home Office:

Page 422: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228702-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.72 200.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228702123120140701201407072015113957

WINTER HAVEN HEALTH AND REHABILITATION CENTER

202 AVE O NE

WINTER HAVEN, FL 33881

Home Office:

Page 423: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228788-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.50 252.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228788123120140101201405262015084517

EAST RIDGE RETIREMENT VILLAGE INC

19225 SW 87TH AVE

CUTLER BAY, FL 33157-8984

Home Office:

Page 424: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228940-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.69 209.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228940073120140801201310292014122822

CYPRESS COVE CARE CENTER

700 SE 8TH AVE

CRYSTAL RIVER, FL 34429

Home Office:

Page 425: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 228958-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 192.34 193.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Services Mgt., Inc.

206 Fortress Blvd.

Murfreesboro, TN 37128

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 228958073120140801201310292014101359

BROOKSVILLE HEALTHCARE CENTER

1114 CHATMAN BLVD

BROOKSVILLE, FL 34601

Home Office:

Page 426: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 229202-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.11 240.50 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 229202063020150701201412042015113455

SHELL POINT NURSING PAVILION

15071 SHELL POINT BLVD

FORT MYERS, FL 33908

Home Office:

Page 427: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 229288-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.38 217.22 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Council on Aging of Florida, Inc.

1311 SW 16th Street

Gainesville, FL 32608

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 229288123120140901201307272015130740

GAINESVILLE HEALTH CARE CENTER

4842 SW ARCHER ROAD

GAINESVILLE, FL 32607

Home Office:

Page 428: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 229610-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.64 237.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 229610123120150101201505102016152855

LAKE VIEW CARE CENTER AT DELRAY

5430 LINTON BLVD

DELRAY BEACH, FL 33484

Home Office:

Page 429: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 229628-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.49 239.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 229628123120150101201505102016150619

MENORAH HOUSE

9945 CENTRAL PARK BLVD N

BOCA RATON, FL 33428-1745

Home Office:

Page 430: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 229849-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 246.20 255.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 229849063020150701201411232015113806

ALEXANDER "SANDY" NININGER STATE VETERANS NURSING HOME

8401 W CYPRESS DR

PEMBROKE PINES, FL 33025

Home Office:

Page 431: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 250988-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.78 252.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

DOS Health Care, Inc

300 71st Street, Suite 400

Miami, FL 33141

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 250988022820150901201404272015084306

HIALEAH SHORES NURSING AND REHAB CENTER

8785 NW 32ND AVENUE

MIAMI, FL 33147

Home Office:

Page 432: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 251399-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.31 199.52 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 251399073120150801201404272016142506

BRANDYWYNE HEALTH CARE CENTER

1801 N LAKE MARIAM DR

WINTER HAVEN, FL 33884

Home Office:

Page 433: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 251666-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.38 197.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 251666123120140701201407072015112640

CONCORDIA MANOR

321 13TH AVE N

SAINT PETERSBURG, FL 33701

Home Office:

Page 434: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 251721-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.28 198.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Genesis HealthCare Corp

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 251721013120150801201407142015150939

OAKHURST CENTER

1501 SE 24TH RD

OCALA, FL 34471-6005

Home Office:

Page 435: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252018-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.08 249.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252018123120150101201504252016151722

AVANTE AT MELBOURNE INC

1420 SOUTH OAK STREET

MELBOURNE, FL 32901

Home Office:

Page 436: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252034-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.87 240.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252034123120150101201504252016153951

AVANTE AT ORMOND BEACH INC

170 N KINGS ROAD

ORMOND BEACH, FL 32174

Home Office:

Page 437: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252042-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.10 215.43 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252042123120140601201402202015173515

AVANTE AT MT DORA INC

3050 BROWN AVE

MOUNT DORA, FL 32757

Home Office:

Page 438: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252662-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.04 227.92 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sun Healthcare Group, Inc.

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252662013120150801201404242015130139

PINEBROOK CENTER

1240 PINEBROOK ROAD

VENICE, FL 34285

Home Office:

Page 439: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252671-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.68 207.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Covington Senior Living, LLC

1175 Peachtree Street

Suite 1230

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252671123120140101201407282015094030

THE PALMS OF SEBRING

725 S PINE ST

SEBRING, FL 33870

Home Office:

Page 440: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 252689-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.15 195.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Genesis HealthCare Corp

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 252689013120150801201407142015150355

ORCHARD RIDGE

4927 VOORHEES RD

NEW PORT RICHEY, FL 34653

Home Office:

Page 441: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253014-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.04 217.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Genesis HealthCare Corp

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253014013120160201201504262016113822

SPRINGWOOD CENTER

4602 NORTHGATE COURT

SARASOTA, FL 34234

Home Office:

Page 442: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253430-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.14 198.46 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sun Healthcare Group, Inc.

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253430013120160201201504262016112622

SUNSET POINT

1980 SUNSET POINT RD

CLEARWATER, FL 33765-1132

Home Office:

Page 443: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253448-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 197.99 200.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sun Healthcare Group, Inc.

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253448013120150801201404242015120822

BAY TREE CENTER

2600 HIGHLANDS BLVD N

PALM HARBOR, FL 34684-2114

Home Office:

Page 444: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253456-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.71 217.85 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253456063020150701201411242015101531

HAWTHORNE HEALTH AND REHAB OF OCALA

4100 SW 33RD AVE

OCALA, FL 34474

Home Office:

Page 445: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253464-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.68 202.01 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sun Healthcare Group, Inc.

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253464013120150801201407142015145525

WEST BAY OF TAMPA

3865 TAMPA RD

OLDSMAR, FL 34677

Home Office:

Page 446: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253481-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 269.74 273.17 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

FiveStar Quality Care Inc

400 Centre Street

Newton, MA 02458

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253481123120140701201404042015135110

FORUM AT DEER CREEK

3001 DEER CREEK COUNTRY CLUB

DEERFIELD BEACH, FL 33442

Home Office:

Page 447: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253707-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.69 229.40 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

DOS Health Care

300 71 Street

Suite #400

Miami Beach, Fl 33141

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253707013120150801201404272015083910

EDEN SPRINGS NURSING AND REHAB CENTER

4679 CRAWFORDVILLE HWY

CRAWFORDVILLE , FL 32326

Home Office:

Page 448: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 253723-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 271.69 272.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 253723022820150301201406052015092911

JACKSON PLAZA NURSING & REHABILITATION CENTER

1861 NW 8TH AVENUE

MIAMI , FL 33136

Home Office:

Page 449: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 254177-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.31 225.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

1601 Management, LLC.

1701 N.E. 26th Street

Wilton Manors, FL 33305

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 254177013120160201201504252016113553

MANOR PINES CONVALESCENT CENTER

1701 NE 26TH ST

WILTON MANORS, FL 33305

Home Office:

Page 450: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 254291-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 269.47 262.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 254291013120150801201406012015134404

ARCH PLAZA NURSING & REHABILITATION CENTER

12505 NE 16TH AVE

NORTH MIAMI, FL 33161-6019

Home Office:

Page 451: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 254762-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.98 215.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

KR Management, LLC

20001 Gulf Boulevard

Suite 10

Indian Shores, FL 33785

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 254762123120140101201407272015092816

WRIGHTS HEALTHCARE AND REHABILITATION CENTER

11300 110TH AVE N

SEMINOLE, FL 33778-3711

Home Office:

Page 452: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 254878-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 213.61 214.72 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Putnam Council, Inc.

16 Norcross Street

Roswell, GA 30075

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 254878123120140101201404242015142744

EDGEWOOD NURSING CENTER

1771 EDGEWOOD AVE W

JACKSONVILLE, FL 32208

Home Office:

Page 453: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 256269-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.31 229.80 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 256269123120150101201504252016094304

DIAMOND RIDGE HEALTH AND REHABILITATION CENTER

2730 W MARC KNIGHTON CT

LECANTO, FL 34461

Home Office:

Page 454: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 256277-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 259.54 264.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 256277123120150101201504282016145312

SURREY PLACE HEALTHCARE AND REHABILITATION

5525 21ST AVE W

BRADENTON, FL 34209

Home Office:

Page 455: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 256757-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.65 212.49 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Health Care Managers, Inc

2380 Sadler Road Suite 201

Fernandina Beach, FL 32034

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 256757123120150101201504292016155312

LAKESIDE NURSING AND REHABILITATION CENTER

11411 ARMSDALE ROAD

JACKSONVILLE, FL 32218

Home Office:

Page 456: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 256846-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.54 200.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sun Healthcare Group, Inc.

101 East State Street

Kennett Square, PA 19348

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 256846013120150801201407142015152111

LAKESIDE PAVILION

2900 12TH STREET N

NAPLES, FL 34103

Home Office:

Page 457: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 256935-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.83 226.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

1601 Management, LLC.

1701 N.E. 26th Street

Wilton Manors, FL 33305

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 256935022920160301201504252016123206

MANOR OAKS NURSING & REHABILITATION CENTER

2121 E COMMERCIAL BLVD

FORT LAUDERDALE, FL 33308

Home Office:

Page 458: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 257419-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.61 240.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Provident Resources Group, Inc.

5565 Bankers Ave.

Baton Rouge, LA 70808

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 257419123120140601201405292015105801

CITRUS HEALTH AND REHABILITATION CENTER

701 MEDICAL COURT EAST

INVERNESS, FL 34452

Home Office:

Page 459: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 258342-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.69 208.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

KR Management, LLC

20001 Gulf Boulevard

Suite 10

Indian Shores, FL 33785

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 258342123120140101201407272015162453

OAK MANOR HEALTHCARE & REHABILITATION CENTER

3500 OAK MANOR LANE

LARGO, FL 33774

Home Office:

Page 460: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 258750-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.28 232.02 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Fairfax Senior Living

10387 Main Street, Suite 200

Fairfax, VA 22030

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 258750013120150701201408272015152420

INDIGO MANOR

595 N WILLIAMSON BLVD

DAYTONA BEACH, FL 32114

Home Office:

Page 461: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 258831-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.34 239.93 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sacred Heart Hospital

5151 North 9th Avenue

PO Box 2700

Pensacola, FL 32513-2700

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 258831063020150701201411232015152404

HAVEN OF OUR LADY OF PEACE

1900 SUMMIT BOULEVARD

PENSACOLA, FL 32503

Home Office:

Page 462: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259080-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.44 241.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259080083120140901201310192014101716

LIFE CARE CENTER AT INVERRARY

4300 ROCK ISLAND ROAD

LAUDERHILL, FL 33319

Home Office:

Page 463: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259225-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.87 215.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259225123120140101201405262015145406

LAKEVIEW TERRACE SKILLED NURSING FACILITY

110 LODGE TERRACE DR

ALTOONA, FL 32702

Home Office:

Page 464: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259331-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 194.62 194.32 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259331063020150701201411242015102103

PRUITTHEALTH - SANTA ROSA

5530 NORTHROP ROAD

MILTON, FL 32570

Home Office:

Page 465: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259357-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.61 228.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259357123120150901201404212016131808

LIFE CARE CENTER OF NEW PORT RICHEY

7400 TROUBLE CREEK ROAD

NEW PORT RICHEY, FL 34653

Home Office:

Page 466: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259462-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.56 203.94 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

John A. Mccoy, Inc.

3391 Cypress Gardens Road

Winter Haven, FL 33884

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259462123120140101201401212016162118

THE NURSING CENTER AT UNIVERSITY VILLAGE

12250 N 22ND ST

TAMPA, FL 33612-4955

Home Office:

Page 467: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259586-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 260.79 268.37 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259586083120150901201402182016162102

HAMLIN PLACE

2180 HYPOLUXO ROAD

LANTANA, FL 33462

Home Office:

Page 468: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 259870-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.35 236.22 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Avante Group, Inc.

4601 Sheridan Street

Suite 500

Hollywood, FL 33021-6744

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 259870123120150101201504252016155836

AVANTE AT ST CLOUD INC

1301 KANSAS AVE

SAINT CLOUD, FL 34769-5999

Home Office:

Page 469: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260355-00

Date: 6/30/2016

Fiscal Year End: 9/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.91 227.30 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260355093020151001201404212016111347

SARASOTA MEMORIAL NURSING AND REHABILITATION CENTER

5640 RAND BLVD

SARASOTA, FL 34238

Home Office:

Page 470: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260371-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.21 237.23 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260371123120140101201406302015184335

BRIDGEVIEW CENTER

350 S RIDGEWOOD AVENUE

ORMOND BEACH, FL 32174

Home Office:

Page 471: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260444-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.09 230.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260444123120150101201504222016152411

BAYVIEW CENTER

301 S BAY ST

EUSTIS, FL 32726

Home Office:

Page 472: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260452-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.16 231.53 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260452123120150101201504222016140453

RULEME CENTER

2810 RULEME ST

EUSTIS, FL 32726

Home Office:

Page 473: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260568-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.08 219.36 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260568123120140101201406302015212121

TIERRA PINES CENTER

7380 ULMERTON RD

LARGO, FL 33771

Home Office:

Page 474: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260576-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.94 221.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260576123120150101201504222016145901

HIGHLANDS LAKE CENTER

4240 LAKELAND HIGHLANDS RD

LAKELAND, FL 33813

Home Office:

Page 475: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260649-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.48 240.46 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260649123120140101201404242015115855

COQUINA CENTER

170 N CENTER STREET

ORMOND BEACH, FL 32174

Home Office:

Page 476: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260657-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 237.27 227.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260657123120150101201504222016135329

ISLAND LAKE CENTER

155 LANDOVER PLACE

LONGWOOD, FL 32750

Home Office:

Page 477: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260665-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.71 226.83 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260665123120150101201504222016144421

INDIAN RIVER CENTER

7201 GREENBORO DR

WEST MELBOURNE, FL 32904

Home Office:

Page 478: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260673-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.77 206.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260673123120150101201504222016121741

RIVERWOOD CENTER

2802 PARENTAL HOME ROAD

JACKSONVILLE, FL 32216

Home Office:

Page 479: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260690-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.11 233.10 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

OPIS Management Resources, LLC

10150 Highland Manor Drive

Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260690123120150101201504222016150953

FAIRWAY OAKS CENTER

13806 N 46TH ST

TAMPA, FL 33613

Home Office:

Page 480: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 260771-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 269.95 267.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 260771013120150801201406052015095756

SINAI PLAZA NURSING & REHAB CENTER

201 NE 112TH STREET

MIAMI, FL 33161

Home Office:

Page 481: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 261254-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.47 232.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 261254123120150901201404292016133830

ALHAMBRA HEALTH AND REHABILITATION CENTER

7501 38TH AVE N

SAINT PETERSBURG, FL 33710

Home Office:

Page 482: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 261611-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.90 209.06 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 261611123120140101201404282015092103

TERRA VISTA REHAB AND HEALTH CENTER

1730 LUCERNE TERRACE

ORLANDO, FL 32806

Home Office:

Page 483: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 261629-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.39 208.27 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Walton Road Mgmt LLC

3599 W Lake Mary Blvd

Ste 1-E

Lake Mary, FL 32746

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 261629123120140101201404282016144535

AVALON HEALTHCARE CENTER

1270 SW MAIN BLVD

LAKE CITY, FL 32025

Home Office:

Page 484: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 261637-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.52 230.46 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Walton Road Mgmt LLC

3599 W Lake Mary Blvd

Ste 1-E

Lake Mary, FL 32746

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 261637123120150101201506022016135937

EMERALD HEALTH CARE CENTER

1655 SE WALTON ROAD

PORT SAINT LUCIE, FL 34952

Home Office:

Page 485: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 261670-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.41 219.60 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 261670063020150701201411242015104224

HAWTHORNE HEALTH AND REHAB OF BRANDON

851 WEST LUMSDEN RD

BRANDON, FL 33511

Home Office:

Page 486: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263389-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.89 208.93 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263389123120150101201504022016171027

ATLANTIC SHORES NURSING AND REHAB CENTER

4251 STACK BLVD

MELBOURNE, FL 32901

Home Office:

Page 487: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263443-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 190.03 191.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263443123120150101201504022016172319

BONIFAY NURSING AND REHAB CENTER

306 WEST BROCK AVENUE

BONIFAY , FL 32425

Home Office:

Page 488: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263451-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.13 219.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263451123120150101201504022016171716

RIVIERA PALMS REHABILITATION CENTER

926 HABEN BLVD

PALMETTO, FL 34221

Home Office:

Page 489: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263460-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.06 210.70 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263460123120150101201504022016164701

BOYNTON BEACH REHABILITATION CENTER

9600 LAWRENCE RD

BOYNTON BEACH, FL 33436-3300

Home Office:

Page 490: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263478-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.92 195.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263478123120150101201504022016170237

ARBOR TRAIL REHAB AND SKILLED NURSING CENTER

611 TURNER CAMP RD

INVERNESS, FL 34453

Home Office:

Page 491: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263486-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.03 220.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263486123120150101201504022016165009

PINELLAS POINT NURSING AND REHAB CENTER

5601 31ST ST S

SAINT PETERSBURG, FL 33712

Home Office:

Page 492: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263494-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.56 205.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263494123120150101201504022016172922

JACKSONVILLE NURSING AND REHAB CENTER

4134 DUNN AVENUE

JACKSONVILLE , FL 32218

Home Office:

Page 493: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263508-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.25 223.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263508123120140101201403132015125720

PORT ORANGE NURSING AND REHAB CENTER

5600 VICTORIA GARDENS BLVD

PORT ORANGE, FL 32127

Home Office:

Page 494: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263516-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.77 197.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263516123120150101201504212016112915

MACCLENNY NURSING AND REHAB CENTER

755 S 5TH ST

MACCLENNY, FL 32063

Home Office:

Page 495: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263524-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.40 205.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263524123120150101201504022016163718

MEDICANA NURSING AND REHAB CENTER

1710 LAKE WORTH ROAD

LAKE WORTH, FL 33460

Home Office:

Page 496: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263532-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.89 206.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263532123120150101201504022016165318

TIFFANY HALL NURSING AND REHAB CENTER

1800 SE HILLMOOR DRIVE

PORT SAINT LUCIE, FL 34952

Home Office:

Page 497: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263541-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 212.83 217.34 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263541123120150101201504022016165932

METRO WEST NURSING AND REHAB CENTER

5900 WESTGATE DRIVE

ORLANDO, FL 32835

Home Office:

Page 498: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263559-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.07 223.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263559123120140101201403272015145601

MOULTRIE CREEK NURSING AND REHAB CENTER

200 MARINER HEALTH WAY

SAINT AUGUSTINE, FL 32086

Home Office:

Page 499: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263567-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 210.95 199.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263567123120140101201403132015084213

ORANGE CITY NURSING AND REHAB CENTER

2810 ENTERPRISE RD

DEBARY, FL 32713

Home Office:

Page 500: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263575-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 222.62 225.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263575123120150101201504022016173548

BAYSHORE POINTE NURSING AND REHAB CENTER

3117 W GANDY BLVD

TAMPA, FL 33611-2927

Home Office:

Page 501: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263583-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.86 204.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263583123120140101201403272015145033

ROYAL OAKS NURSING AND REHAB CENTER

2225 KNOX MCRAE DR

TITUSVILLE, FL 32780

Home Office:

Page 502: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263591-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.38 218.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263591123120150101201504022016165620

TUSKAWILLA NURSING AND REHAB CENTER

1024 WILLA SPRINGS DR

WINTER SPRINGS, FL 32708

Home Office:

Page 503: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263605-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 251.32 246.09 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263605123120140101201403272015150044

HUNTERS CREEK NURSING AND REHAB CENTER

14155 TOWN LOOP BLVD

ORLANDO, FL 32837

Home Office:

Page 504: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263613-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.05 204.09 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263613123120150101201504022016163259

BOULEVARD REHABILITATION CENTER

2839 S SEACREST BLVD

BOYNTON BEACH, FL 33435-7994

Home Office:

Page 505: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263621-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.56 226.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Southern HealthCare Management, LLC

5887 Glenridge Drive, Suite 150

Atlanta, GA 30328

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263621123120150101201504022016164403

PALM CITY NURSING & REHAB CENTER

2505 SW MARTIN HWY

PALM CITY, FL 34990

Home Office:

Page 506: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263834-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.98 218.82 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263834123120150101201504082016131514

BAY POINTE NURSING PAVILION

4201 31ST ST S

SAINT PETERSBURG, FL 33712

Home Office:

Page 507: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263842-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.24 205.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263842123120140101201407012015154417

BOCA RATON REHABILITATION CENTER

755 MEADOWS ROAD

BOCA RATON, FL 33486

Home Office:

Page 508: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263851-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.87 201.90 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263851123120150101201504082016135921

DEERFIELD BEACH HEALTH AND REHABILITATION CENTER

401 EAST SAMPLE ROAD

POMPANO BEACH, FL 33064

Home Office:

Page 509: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263869-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.82 216.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263869123120140101201407012015160053

REHAB & HEALTHCARE CENTER OF CAPE CORAL

2629 DEL PRADO BLVD

CAPE CORAL, FL 33904

Home Office:

Page 510: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263877-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.97 214.77 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263877123120150101201504082016142050

CARROLLWOOD CARE CENTER

15002 HUTCHINSON RD

TAMPA, FL 33625

Home Office:

Page 511: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263885-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.02 196.33 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263885123120140101201407012015163555

CASA MORA REHABILITATION AND EXTENDED CARE

1902 59TH ST W

BRADENTON, FL 34209

Home Office:

Page 512: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263893-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.93 213.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263893123120140101201407012015171934

EVERGREEN WOODS

7045 EVERGREEN WOODS TRL

SPRING HILL, FL 34608

Home Office:

Page 513: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263907-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.72 217.25 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263907123120150101201504242016141918

HIGHLAND PINES REHABILITATION CENTER

1111 S HIGHLAND AVE

CLEARWATER, FL 33756

Home Office:

Page 514: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263915-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.98 227.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263915123120140101201403222015114809

THE REHABILITATION CENTER OF THE PALM BEACHES

301 NORTHPOINTE PARKWAY

WEST PALM BEACH, FL 33407

Home Office:

Page 515: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263923-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.81 213.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263923123120150101201504082016132401

POMPANO HEALTH AND REHABILITATION CENTER

51 W SAMPLE ROAD

POMPANO BEACH, FL 33064

Home Office:

Page 516: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263931-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.35 199.91 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263931123120140101201407022015090429

HEALTHCARE AND REHAB OF SANFORD

950 MELLONVILLE AVE

SANFORD, FL 32771

Home Office:

Page 517: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263940-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.16 218.86 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263940123120150101201504082016144108

REHABILITATION AND HEALTHCARE CENTER OF TAMPA

4411 N HABANA AVE

TAMPA, FL 33614

Home Office:

Page 518: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263958-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.57 223.40 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263958123120140101201403252015125347

ABBEY REHABILITATION AND NURSING CENTER

7101 DR MARTIN LUTHER KING JR ST N

SAINT PETERSBURG, FL 33702

Home Office:

Page 519: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263966-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.85 210.84 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263966123120150101201504082016135232

OAKS AT AVON

1010 US 27 N

AVON PARK, FL 33825

Home Office:

Page 520: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263974-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.08 214.02 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263974123120150101201504082016150039

TITUSVILLE REHABILITATION AND NURSING CENTER

1705 JESS PARRISH CT

TITUSVILLE, FL 32796

Home Office:

Page 521: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263982-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.68 212.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263982123120140101201403222015112958

SARASOTA HEALTH AND REHABILITATION CENTER

1524 EAST AVENUE SOUTH

SARASOTA, FL 34239

Home Office:

Page 522: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 263991-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 202.15 205.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 263991123120150101201504082016150755

WINDSOR WOODS REHAB AND HEALTHCARE CENTER

13719 DALLAS DR

HUDSON, FL 34667

Home Office:

Page 523: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264008-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.90 219.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264008123120140101201403222015113943

WINKLER COURT

3250 WINKLER AVENUE EXTENSION

FORT MYERS, FL 33916

Home Office:

Page 524: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264482-00

Date: 6/30/2016

Fiscal Year End: 10/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 187.22 188.17 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CNH, LLC

46 Third Street NW

Hickory, NC 28601

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264482103120141101201303172015162537

LAFAYETTE HEALTH CARE CENTER

512 W MAIN ST

MAYO, FL 32066

Home Office:

Page 525: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264491-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.45 248.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264491063020150701201411232015121832

CLIFFORD CHESTER SIMS STATE VETERANS NURSING HOME

4419 TRAM ROAD

PANAMA CITY, FL 32404

Home Office:

Page 526: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264512-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.06 237.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264512123120140101201406162015123613

CONWAY LAKES HEALTH & REHABILITATION CENTER

5201 CURRY FORD ROAD

ORLANDO, FL 32812

Home Office:

Page 527: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264521-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.47 228.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264521123120140101201406162015143404

BELLEAIR HEALTH CARE CENTER

1150 PONCE DE LEON BLVD

CLEARWATER, FL 33756

Home Office:

Page 528: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264539-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 234.79 238.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264539123120150101201504202016143830

EAST BAY REHABILITATION CENTER

4470 E BAY DR

CLEARWATER, FL 33764

Home Office:

Page 529: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264547-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.66 232.62 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264547123120140101201403312015155817

MELBOURNE TERRACE REHABILITATION CENTER

251 FLORIDA AVE

MELBOURNE, FL 32901

Home Office:

Page 530: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264563-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.75 217.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264563123120150101201504202016153256

CENTRE POINTE HEALTH AND REHAB CENTER

2255 CENTERVILLE ROAD

TALLAHASSEE, FL 32308

Home Office:

Page 531: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 264571-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.41 244.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Clear Choice Health Care, LLC

709 S. Harbor City Blvd. Suite 240

Melbourne, FL 32901

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 264571123120140101201403312015160744

SPRING LAKE REHABILITATION CENTER

1540 6TH ST NW

WINTER HAVEN, FL 33881

Home Office:

Page 532: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 265381-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.21 243.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 265381063020140701201310192014115218

LIFE CARE CENTER OF ESTERO

3850 WILLIAMS ROAD

ESTERO, FL 33928

Home Office:

Page 533: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 265560-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 194.97 198.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 265560123120150101201504282016103557

VALENCIA HILLS HEALTH AND REHABILITATION CENTER

1350 SLEEPY HILL RD

LAKELAND, FL 33810

Home Office:

Page 534: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 265730-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.84 209.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 265730123120140101201404212015090128

HIALEAH NURSING AND REHABILITATION CENTER

190 W 28TH STREET

HIALEAH, FL 33010

Home Office:

Page 535: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 266108-00

Date: 6/30/2016

Fiscal Year End: 1/31/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.29 237.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 266108013120160201201504202016171920

LIFE CARE CENTER OF OCALA

2800 SW 41ST ST

OCALA, FL 34474

Home Office:

Page 536: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 266124-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.67 246.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 266124123120140101201405222015171641

OASIS HEALTH AND REHABILITATION CENTER

1201 12TH AVENUE SOUTH

LAKE WORTH, FL 33460

Home Office:

Page 537: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 266612-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 162.04 161.25 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 266612123120140101201407072015162640

WHISPERING OAKS

1514 E CHELSEA ST

TAMPA, FL 33610

Home Office:

Page 538: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 267724-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.27 242.42 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 267724123120150101201504272016091206

SPRINGS AT BOCA CIEGA BAY

1255 PASADENA AVE S, SUITE C

SOUTH PASADENA, FL 33707

Home Office:

Page 539: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 267902-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.47 198.02 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 267902123120140101201405222015121356

THE NURSING CENTER AT MERCY

3671 S MIAMI AVENUE

MIAMI, FL 33133

Home Office:

Page 540: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268062-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 265.75 265.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268062123120140101201407132015095616

SUSANNA WESLEY HEALTH CENTER

5300 W 16TH AVENUE

HIALEAH, FL 33012

Home Office:

Page 541: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268186-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.89 227.47 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268186123120150101201504202016183718

LIFE CARE CENTER OF PALM BAY

175 VILLA NUEVA AVE

PALM BAY, FL 32907

Home Office:

Page 542: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268585-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 264.75 272.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268585123120140101201404232015062442

HARBORCHASE OF NAPLES

7801 AIRPORT PULLING ROAD N

NAPLES, FL 34109

Home Office:

Page 543: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268755-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.95 251.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Synergy Health Care

1835 Miami Gardens Dr. Suite 167

North Miami Beach, FL 33179

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268755123120150101201504282016131956

ABBIEJEAN RUSSELL CARE CENTER LLC

700 S 29TH STREET

FORT PIERCE, FL 34947

Home Office:

Page 544: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268763-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.14 215.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268763063020150701201411242015135307

GOOD SAMARITAN CENTER

10676 MARVIN JONES BLVD

LIVE OAK, FL 32060

Home Office:

Page 545: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 268780-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.97 245.29 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Summit Care II, Inc

2123 Centre Pointe Blvd.

Tallahassee, FL 32308

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 268780123120150101201504292016102444

SPRINGS AT LAKE POINTE WOODS

3280 LAKE POINTE BLVD

SARASOTA, FL 34231

Home Office:

Page 546: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269000-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.00 222.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269000123120150101201504272016162640

MAJESTIC OAKS

901 VETERAN'S MEMORIAL PARKWAY

ORANGE CITY, FL 32763

Home Office:

Page 547: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269107-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.82 194.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SMJ Enterprises, LLC

480 Fentress Blvd. Suite H

Daytona Beach, FL 32114

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269107123120140101201405222015141259

HARMONY HEALTH CENTER

9820 N KENDALL DRIVE

MIAMI, FL 33176

Home Office:

Page 548: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269492-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 244.48 252.97 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Florida Dept. of Veterans Affairs

11351 Ulmerton Road, Room 332-I

Largo, Fl 33778-1630

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269492063020150701201411232015124314

DOUGLAS JACOBSON STATE VETERANS NURSING HOME

21281 GRAYTON TERRACE

PORT CHARLOTTE, FL 33954

Home Office:

Page 549: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269697-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.32 206.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269697123120150101201504242016145917

REGENTS PARK OF SUNRISE

9711 W OAKLAND PARK BLVD

SUNRISE, FL 33351

Home Office:

Page 550: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269719-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.35 208.31 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269719123120140101201407082015163747

REGENTS PARK OF WINTER PARK

558 N SEMORAN BLVD

WINTER PARK, FL 32792

Home Office:

Page 551: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 269727-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.99 206.12 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 269727123120140101201407082015161204

REGENTS PARK OF JACKSONVILLE

8700 A C SKINNER PARKWAY

JACKSONVILLE, FL 32256

Home Office:

Page 552: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 281743-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 180.52 176.22 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Grace Healthcare, Inc

7201 Shallowford Rd, STE 200

Chattanooga, TN 37421

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 281743123120140101201406242015111034

JACARANDA MANOR

4250 66TH ST N

SAINT PETERSBURG, FL 33709

Home Office:

Page 553: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282359-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.21 240.44 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Preferred Care, Inc.

5420 West Plano Parkway

Plano, TX 75093

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282359123120140101201407162015142800

WEST GABLES HEALTH CARE CENTER

2525 SW 75TH AVENUE

MIAMI, FL 33155

Home Office:

Page 554: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282464-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.86 228.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282464083120140101201410102014112252

RIDGECREST NURSING AND REHABILITATION CENTER

1200 NORTH STONE STREET

DELAND, FL 32720

Home Office:

Page 555: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282529-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 247.28 247.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282529123120140101201404272015114303

CORAL REEF NURSING & REHABILITATION CENTER

9869 SW 152ND STREET

MIAMI, FL 33157

Home Office:

Page 556: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282537-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.07 252.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cypress Administrative Services, LLC

4 West Red Oak Lane, Suite 201

White Plains, NY 10604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282537063020140701201310212014130441

PALM TERRACE OF ST PETERSBURG

521 69TH AVE N

SAINT PETERSBURG, FL 33702

Home Office:

Page 557: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282618-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 235.01 235.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cypress Administrative Services, LLC

4 West Red Oak Lane, Suite 201

White Plains, NY 10604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282618063020140701201310112014161438

PALM TERRACE OF CLEWISTON

301 SOUTH GLORIA ST

CLEWISTON, FL 33440

Home Office:

Page 558: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 282626-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.23 232.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim Total Prospective

Interim Component X Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cypress Administrative Services, LLC

4 West Red Oak Lane, Suite 201

White Plains, NY 10604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 282626063020140701201310202014121547

PALM TERRACE OF LAKELAND

1919 LAKELAND HILLS BLVD

LAKELAND, FL 33805

Home Office:

Page 559: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 283193-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.93 236.49 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 283193063020140701201310142014083334

LIFE CARE CENTER OF JACKSONVILLE

4813 LENOIR AVENUE

JACKSONVILLE, FL 32216

Home Office:

Page 560: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 284289-00

Date: 6/30/2016

Fiscal Year End: 7/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 203.59 204.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 284289073120140801201310192014105105

LIFE CARE CENTER OF ORANGE PARK

2145 KINGSLEY AVE

ORANGE PARK, FL 32073

Home Office:

Page 561: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 284793-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.21 247.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 284793123120140101201404272015103829

BRIGHTON GARDENS OF TAMPA

16702 NORTH DALE MABRY HWY

TAMPA, FL 33618-1055

Home Office:

Page 562: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 284823-00

Date: 6/30/2016

Fiscal Year End: 2/28/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 293.64 282.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 284823022820150901201406082015114210

AVENTURA PLAZA REHABILITATION & NURSING CENTER

1800 N E 168TH STREET

NORTH MIAMI BEACH, FL 33162

Home Office:

Page 563: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 308251-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.69 246.22 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 308251013120150201201406162015105249

PONCE PLAZA NURSING & REHABILITATION CENTER

335 SW 12 AVENUE

MIAMI, FL 33130

Home Office:

Page 564: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 309800-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.03 272.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Allegro Senior Living, LLC

212 S. Central Avenue

Suite 301

St. Louis, MO 63105

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 309800123120140101201404282015144349

THE ALLEGRO AT COLLEGE HARBOR

4600 54TH AVE S

SAINT PETERSBURG, FL 33711

Home Office:

Page 565: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 310581-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.40 209.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Lyric Healthcare Holdings III, Inc

1423 Clarkview Road

Suite 500

Baltimore, MD 21090

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 310581083120140901201304272015071513

ATLANTIC HEALTHCARE CENTER

3663 15TH AVE

VERO BEACH, FL 32960

Home Office:

Page 566: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 310841-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 240.35 245.57 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 310841123120140101201404292015150350

ST MARK VILLAGE

2655 NEBRASKA AVE

PALM HARBOR, FL 34684

Home Office:

Page 567: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 311308-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 195.66 198.66 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hebrew Homes Management Services

1800 NE 168th Street, Suite 200

North Miami Beach, FL 33162

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 311308013120150801201403262015155533

SOUTH POINTE PLAZA REHABILITATION AND NURSING CENTER

42 COLLINS AVENUE

MIAMI BEACH, FL 33139

Home Office:

Page 568: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 311685-00

Date: 6/30/2016

Fiscal Year End: 2/29/2016

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.66 249.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 311685022920160301201504202016215647

LIFE CARE CENTER OF PUNTA GORDA

450 SHREVE STREET

PUNTA GORDA, FL 33950

Home Office:

Page 569: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312045-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.90 198.61 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Cardinal Resources, LLC

16 Norcross Street

Roswell, GA 30075

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312045123120140101201407172015090508

SANDALWOOD NURSING CENTER

1001 S BEACH STREET

DAYTONA BEACH, FL 32114

Home Office:

Page 570: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312142-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.29 204.54 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Putnam Council, Inc.

16 Norcross Street

Roswell, GA 30075

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312142123120140101201407172015081853

LAKEWOOD NURSING CENTER

100 N LAKE ST

CRESCENT CITY, FL 32112

Home Office:

Page 571: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312151-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.96 196.85 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

CNH, LLC

46 Third Street NW

Hickory, NC 28601

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312151093020141001201310282014103043

CROSS CITY REHABILITATION & HEALTH CARE CENTER

583 NE 351 HWY

CROSS CITY, FL 32628

Home Office:

Page 572: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312274-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.57 198.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Putnam Council, Inc.

16 Norcross Street

Roswell, GA 30075

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312274123120150101201504262016122826

CRESTWOOD NURSING CENTER

501 S PALM AVE

PALATKA, FL 32177

Home Office:

Page 573: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312312-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.42 231.25 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Living Management Corporation

4661 Johnson Road, Suite 7

Coconut, FL 33073

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312312123120140101201404272015074021

SAVANNAH COVE

2090 N CONGRESS AVE

WEST PALM BEACH, FL 33401

Home Office:

Page 574: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312550-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 255.02 235.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Living Management Corporation

4661 Johnson Road, Suite 7

Coconut, FL 33073

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312550123120150701201504262016134423

SAVANNAH COVE

1301 W MAITLAND BLVD

MAITLAND, FL 32751

Home Office:

Page 575: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 312789-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 279.33 290.76 9/1/2016

Level U: Fragile Under 21 578.96 590.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Broward Children's Center, Inc.

200 SE 19th Avenue

Pompano Beach, FL 33072

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 312789073120150801201410012015140943

CHILDREN'S COMPREHENSIVE CARE CENTER INC.

200 SE 19TH AVENUE

POMPANO BEACH, FL 33060

Home Office:

Page 576: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 313424-00

Date: 6/30/2016

Fiscal Year End: 7/16/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 233.81 231.21 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Herlee, Inc

1201 North 37th Street

Hollywood, FL 33021

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 313424071620150701201411092015113152

HOLLYWOOD HILLS REHABILITATION CENTER LLC

1200 N 35TH AVE

HOLLYWOOD, FL 33021

Home Office:

Page 577: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 313718-00

Date: 6/30/2016

Fiscal Year End: 8/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.96 241.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 313718083120150901201402142016081522

LUTHERAN HAVEN NURSING HOME

1525 HAVEN DRIVE

OVIEDO, FL 32765

Home Office:

Page 578: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 315664-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.46 229.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 315664123120150101201504202016185323

LIFE CARE CENTER OF PENSACOLA

3291 EAST OLIVE RD

PENSACOLA, FL 32514

Home Office:

Page 579: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 316628-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 185.23 208.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 316628053120150601201410052015073708

LAURELLWOOD NURSING CENTER

3127 57TH AVE N

SAINT PETERSBURG, FL 33714

Home Office:

Page 580: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 316636-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.40 209.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 316636053120150601201410052015081209

HARBOURWOOD HEALTH AND REHAB CENTER

549 SKY HARBOR DR

BLDG 31

CLEARWATER, FL 33759

Home Office:

Page 581: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 316644-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 187.23 196.59 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 316644053120150601201410052015072603

GRACEWOOD REHABILITATION AND NURSING CARE

8600 US HWY 19 N

PINELLAS PARK, FL 33782

Home Office:

Page 582: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 316652-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.52 211.79 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Senior Care Group, Inc.

1240 Marbella Plaza Drive

Tampa, FL 33619

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 316652053120150601201410052015071049

BAYWOOD NURSING CENTER

2000 17TH AVE S

SAINT PETERSBURG, FL 33712

Home Office:

Page 583: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 317349-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 238.38 241.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Life Care Centers Of America

3570 NW Keith Street

Cleveland, TN 37312

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 317349123120150101201504172016143822

DARCY HALL OF LIFE CARE

2170 PALM BEACH LAKES BLVD

WEST PALM BEACH, FL 33409

Home Office:

Page 584: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 317578-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 242.00 239.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 317578123120140401201407172015133427

PARKLANDS REHABILITATION AND NURSING CENTER

1000 SW 16TH AVE

GAINESVILLE, FL 32601

Home Office:

Page 585: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 317586-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.34 244.50 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 317586123120140401201404272015102730

WILLISTON REHABILITATION AND NURSING CENTER

300 NW 1ST AVE

WILLISTON, FL 32696

Home Office:

Page 586: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 318795-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 248.46 250.19 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

FiveStar Quality Care Inc

400 Centre Street

Newton, MA 02458

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 318795123120140701201404042015140713

THE COURT AT PALM AIRE

2701 N COURSE DR

POMPANO BEACH, FL 33069-3058

Home Office:

Page 587: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 319244-00

Date: 6/30/2016

Fiscal Year End: 6/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.43 267.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Emeritus Senior Living

3131 Elliott Avenue,

Suite 500

Seattle, WA 98121

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 319244063020150701201401202016150544

BROOKDALE PALMER RANCH SNF

5111 PALMER RANCH PARKWAY

SARASOTA, FL 34238

Home Office:

Page 588: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 319325-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.63 241.89 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

SBK Capital, LLC

1935 Garraux Road, Northwest

Atlanta, GA 30327

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 319325123120150101201504202016152217

PORT CHARLOTTE REHABILITATION CENTER

25325 RAMPART BLVD

PORT CHARLOTTE, FL 33983

Home Office:

Page 589: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 319376-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.33 222.74 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Brookdale Senior Living, Inc.

111 Westwood Place

Suite 400

Brentwood, TN 37027

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 319376123120150101201504272016135247

BROOKDALE ATRIUM WAY 2

9960 ATRIUM WAY

JACKSONVILLE, FL 32225

Home Office:

Page 590: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320391-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.86 208.49 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Adventist Care Centers

602 Courtland Street, Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320391123120150101201504282016092121

ZEPHYR HAVEN HEALTH & REHAB CENTER, INC.

38250 A AVE

ZEPHYRHILLS, FL 33542

Home Office:

Page 591: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320404-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.35 228.56 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunbelt Health Care Centers,Inc.

602 Courtland Street

Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320404013120150801201404272015144259

ZEPHYRHILLS HEALTH & REHAB CENTER, INC.

7350 DAIRY RD

ZEPHYRHILLS, FL 33540

Home Office:

Page 592: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320412-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.42 218.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunbelt Health Care Centers,Inc.

602 Courtland Street

Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320412013120150801201404232015140917

SUNBELT HEALTH & REHAB CENTER - APOPKA, INC.

305 EAST OAK STREET

APOPKA, FL 32703

Home Office:

Page 593: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320421-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 245.88 246.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunbelt Health Care Centers,Inc.

602 Courtland Street

Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320421013120150801201404282015133140

EAST ORLANDO HEALTH & REHAB CENTER, INC.

250 SOUTH CHICKASAW TRAIL

ORLANDO, FL 32825-3308

Home Office:

Page 594: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320439-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.65 216.03 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Adventist Care Centers

602 Courtland Street, Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320439123120140101201407152015160537

ADVENTIST CARE CENTERS - COURTLAND, INC.

730 COURTLAND STREET

ORLANDO, FL 32804

Home Office:

Page 595: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320463-00

Date: 6/30/2016

Fiscal Year End: 1/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.87 231.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Sunbelt Health Care Centers,Inc.

602 Courtland Street

Suite 200

Orlando, FL 32804

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320463013120150801201404272015140833

FLORIDA LIVING NURSING CENTER

3355 E SEMORAN BLVD

APOPKA, FL 32703

Home Office:

Page 596: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 320978-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 260.99 261.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Greystone Healthcare Management, LLC

4042 Park Oaks Blvd, Suite 300

Tampa, FL 33610

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 320978083120140101201410092014164424

LEHIGH ACRES HEALTH & REHABILITATION CENTER

1550 LEE BOULEVARD

LEHIGH ACRES, FL 33936

Home Office:

Page 597: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 321532-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.09 252.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 321532123120140101201404262015153531

THE PALMS REHABILITATION AND NURSING CENTER

3370 NW 47TH TERRACE

LAUDERDALE LAKES, FL 33319

Home Office:

Page 598: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 323772-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 231.39 233.18 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 323772123120140101201404152015112158

CORAL GABLES NURSING AND REHABILITATION

7060 SW 8TH STREET

MIAMI, FL 33144

Home Office:

Page 599: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 323781-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 256.94 245.29 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Preferred Care, Inc.

5420 West Plano Parkway

Plano, TX 75093

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 323781123120140101201407162015113635

TARPON POINT NURSING AND REHABILITATION CENTER

5157 PARK CLUB DRIVE

SARASOTA, FL 34235

Home Office:

Page 600: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 323799-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 229.16 210.80 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Preferred Care, Inc.

5420 West Plano Parkway

Plano, TX 75093

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 323799123120140101201407162015145602

ST. ANDREW'S BAY SKILLED NURSING AND REHABILITATION

2100 JENKS AVE

PANAMA CITY, FL 32405

Home Office:

Page 601: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324027-00

Date: 6/30/2016

Fiscal Year End: 3/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 258.00 259.81 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324027033120151001201404292015121312

HAMPTON COURT NURSING CENTER

16100 NW 2ND AVENUE

NORTH MIAMI BEACH, FL 33169

Home Office:

Page 602: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324094-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 250.42 251.99 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324094123120140301201404272015105606

ADVANCED REHABILITATION & HEALTH CENTER

401 FAIRWOOD AVE

CLEARWATER, FL 33759

Home Office:

Page 603: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324108-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 268.99 269.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324108123120140301201404132015162606

BAYSIDE REHABILITATION & HEALTH CENTER

811 JACKSON ST N

SAINT PETERSBURG, FL 33705

Home Office:

Page 604: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324124-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 243.87 242.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324124123120140301201407202015082424

MADISON POINTE REHABILITATION & HEALTH CENTER

6020 INDIANA AVE

NEW PORT RICHEY, FL 34653-3214

Home Office:

Page 605: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324132-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 249.57 251.08 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324132123120140301201404272015100951

SHORE ACRES REHABILITATION & HEALTH CENTER

4500 INDIANAPOLIS ST NE

SAINT PETERSBURG, FL 33703

Home Office:

Page 606: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324141-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 252.90 254.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324141123120140301201404262015101542

WOODBRIDGE REHABILITATION & HEALTH CENTER

8720 JACKSON SPRINGS RD

TAMPA, FL 33615-3210

Home Office:

Page 607: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324167-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 270.80 274.26 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324167123120140301201404282015091458

PALMETTO REHABILITATION AND HEALTH CENTER

6750 WEST 22ND COURT

HIALEAH, FL 33016

Home Office:

Page 608: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324175-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 241.71 242.73 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324175123120140301201404272015092926

COURTYARDS OF ORLANDO REHABILITATION AND HEALTH CENTER

1900 MERCY DRIVE

ORLANDO, FL 32808

Home Office:

Page 609: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324213-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 206.82 198.58 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324213123120140101201404082016091922

ROYAL CARE OF AVON PARK

1213 W STRATFORD RD

AVON PARK, FL 33825

Home Office:

Page 610: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324345-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.97 207.27 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324345073120150801201403142016094627

HERITAGE PARK CARE AND REHABILITATION CENTER

2302 59TH ST W

BRADENTON, FL 34209

Home Office:

Page 611: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324353-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.56 197.93 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324353073120150801201403142016115242

WASHINGTON REHABILITATION & NURSING CENTER

879 USERY ROAD

CHIPLEY, FL 32428

Home Office:

Page 612: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324361-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.57 201.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324361073120150801201403142016084817

CHAUTAUQUA REHABILITATION & NURSING CENTER

785 S 2ND STREET

DEFUNIAK SPRINGS, FL 32433

Home Office:

Page 613: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324370-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 211.13 215.11 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324370073120150801201403282016134803

SIGNATURE HEALTHCARE OF COLLEGE PARK

13755 GOLF CLUB PKWY

FORT MYERS, FL 33919

Home Office:

Page 614: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324388-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 200.33 197.98 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324388073120150801201403282016104144

SIGNATURE HEALTHCARE OF GAINESVILLE

4000 SW 20TH AVE

GAINESVILLE, FL 32607

Home Office:

Page 615: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324396-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 191.02 198.78 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324396073120150801201403142016102924

SIGNATURE HEALTHCARE OF NORTH FLORIDA

1083 SANDERS AVENUE

GRACEVILLE, FL 32440

Home Office:

Page 616: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324400-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.87 198.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324400073120150801201403142016124238

SIGNATURE HEALTHCARE CENTER OF WATERFORD

8333 W OKEECHOBEE ROAD

HIALEAH GARDENS, FL 33016

Home Office:

Page 617: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324418-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.41 218.32 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324418073120150801201403112016164932

SIGNATURE HEALTHCARE OF BROOKWOOD GARDENS

1990 S CANAL DRIVE

HOMESTEAD, FL 33035

Home Office:

Page 618: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324426-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.39 210.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324426073120150801201403142016090206

SIGNATURE HEALTHCARE AT THE COURTYARD

2600 FOREST GLEN TRAIL

MARIANNA, FL 32446

Home Office:

Page 619: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324434-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.25 211.04 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324434073120150801201403142016095836

SIGNATURE HEALTHCARE OF ORANGE PARK

2029 PROFESSIONAL CENTER DR

ORANGE PARK, FL 32073

Home Office:

Page 620: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324442-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.24 204.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324442073120150801201403142016110109

SIGNATURE HEALTHCARE OF ORMOND

103 NORTH CLYDE MORRIS BLVD

ORMOND BEACH, FL 32174

Home Office:

Page 621: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324451-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 193.91 195.75 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324451073120150801201403142016100616

ANCHOR CARE & REHABILITATION CENTER

1515 PORT MALABAR BLVD NE

PALM BAY, FL 32905-5455

Home Office:

Page 622: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324469-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.80 216.39 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324469073120150801201403142016111510

SIGNATURE HEALTHCARE OF PINELLAS PARK

8701 49TH ST N

PINELLAS PARK, FL 33782

Home Office:

Page 623: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324477-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 217.84 222.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324477073120150801201403142016101435

SIGNATURE HEALTHCARE OF PORT CHARLOTTE

4033 BEAVER LANE

PORT CHARLOTTE, FL 33952

Home Office:

Page 624: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324485-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 196.39 205.35 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324485073120150801201403112016163655

THE BRIDGE AT BAY ST. JOE

220 NINTH STREET

PORT SAINT JOE, FL 32456

Home Office:

Page 625: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324493-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.29 198.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324493073120150801201403142016102207

KENILWORTH CARE AND REHABILITATION CENTER

3011 KENILWORTH BLVD

SEBRING, FL 33870

Home Office:

Page 626: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324507-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.94 197.77 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324507073120150801201403142016110824

PENINSULA CARE AND REHABILITATION CENTER

900 BECKETT WAY

TARPON SPRINGS, FL 34689

Home Office:

Page 627: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324515-00

Date: 6/30/2016

Fiscal Year End: 7/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 205.84 203.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Signature Healthcare LLC

12201 Bluegrass Parkway

Louisville, KY 40299

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324515073120150801201403142016130450

WINTER PARK CARE AND REHABILITATION CENTER

2970 SCARLETT RD

WINTER PARK, FL 32792

Home Office:

Page 628: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 324566-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 218.03 211.01 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 324566123120140101201407202015083842

SOUTHERN OAKS REHABILITATION AND NURSING CENTER

600 WEST GREGORY STREET

PENSACOLA, FL 32502-4744

Home Office:

Page 629: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325031-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 266.85 268.05 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325031123120140301201404282015083455

TERRACES OF LAKE WORTH REHAB AND HEALTH CENTER

1711 6TH AVENUE SOUTH

LAKE WORTH, FL 33460

Home Office:

Page 630: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325040-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 239.90 240.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325040123120140301201404272015131915

ARBOR VILLAGE NURSING CENTER

490 S OLD WIRE RD

WILDWOOD, FL 34785

Home Office:

Page 631: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325163-00

Date: 6/30/2016

Fiscal Year End: 12/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 274.75 276.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

Hallmark Accounting

368 New Hempstead Road #309

New City, NY 10956

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325163123120140301201404272015094559

NORTH LAKE REHABILITATION AND HEALTH CENTER

750 BAYBERRY DRIVE

LAKE PARK, FL 33403

Home Office:

Page 632: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325236-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.95 228.64 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325236063020140701201310022014152614

HEARTLAND HEALTH CARE CENTER-JACKSONVILLE

8495 NORMANDY BLVD

JACKSONVILLE, FL 32221

Home Office:

Page 633: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325244-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 201.18 213.80 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325244123120150701201404192016101055

HEARTLAND HEALTH CARE CENTER-KENDALL

9400 SW 137TH AVENUE

KENDALL, FL 33186

Home Office:

Page 634: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325252-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 227.11 221.87 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325252123120151001201404192016102711

HEARTLAND HEALTH CARE CENTER- MIAMI LAKES

5725 NW 186 STREET

HIALEAH, FL 33015

Home Office:

Page 635: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325261-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 207.65 205.63 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325261123120151001201404192016141821

HEARTLAND HEALTH CARE CENTER-ORANGE PARK

570 WELLS RD

ORANGE PARK, FL 32073-2999

Home Office:

Page 636: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325279-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.59 206.80 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325279093020141001201310282014095227

MANORCARE NURSING AND REHABILITATION CENTER

2075 LOCH LOMOND DRIVE

WINTER PARK, FL 32792

Home Office:

Page 637: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325287-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.50 210.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325287053120150601201409222015165254

HEARTLAND HEALTH CARE CENTER OF SOUTH JACKSONVILLE

3648 UNIVERSITY BLVD S

JACKSONVILLE, FL 32216

Home Office:

Page 638: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325309-00

Date: 6/30/2016

Fiscal Year End: 6/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 204.61 204.71 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325309063020140701201310072014155531

HEARTLAND HEALTH CARE CENTER- BOYNTON BEACH

3600 OLD BOYNTON ROAD

BOYNTON BEACH, FL 33436

Home Office:

Page 639: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325325-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.37 215.69 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325325093020141001201310282014085204

HEARTLAND HEALTH CARE CENTER-FT. MYERS

1600 MATTHEW DRIVE

FORT MYERS, FL 33907

Home Office:

Page 640: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325333-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 192.59 193.48 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325333123120150801201404192016143201

HEARTLAND HEALTH CARE CENTER- LAUDERHILL

2599 NW 55TH AVE

LAUDERHILL, FL 33313

Home Office:

Page 641: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325341-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 219.10 219.85 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325341093020141001201310292014091126

HEARTLAND HEALTH CARE CENTER-PROSPERITY OAKS

11375 PROSPERITY FARMS ROAD

PALM BEACH GARDENS, FL 33410

Home Office:

Page 642: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325350-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 214.71 232.16 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325350123120151001201404192016081221

HEARTLAND OF TAMARAC

5901 NW 79TH AVENUE

TAMARAC, FL 33321

Home Office:

Page 643: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325368-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 199.01 204.14 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325368053120150601201409222015161246

MANORCARE HEALTH SERVICES (BOCA RATON)

375 NW 51ST STREET

BOCA RATON, FL 33431

Home Office:

Page 644: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325376-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 223.77 218.29 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325376123120150601201504222016081623

MANORCARE HEALTH SERVICES-BOYNTON BEACH

3001 SOUTH CONGRESS AVENUE

BOYNTON BEACH, FL 33426

Home Office:

Page 645: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325384-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 216.94 202.20 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325384123120150601201504142016105806

MANORCARE HEALTH SERVICES

13881 EAGLE RIDGE DRIVE

FORT MYERS, FL 33912

Home Office:

Page 646: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325422-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 232.04 231.68 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325422123120151001201404142016105313

MANOR CARE @ LELY PALMS

6135 RATTLESNAKE HAMMOCK ROAD

NAPLES, FL 34113

Home Office:

Page 647: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325449-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 225.08 241.34 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325449123120150601201504142016105004

MANOR CARE NURSING AND REHABILITATION CENTER

3601 LAKEWOOD BLVD

NAPLES, FL 34112

Home Office:

Page 648: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325457-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 221.89 217.65 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325457123120150601201504192016151825

MANORCARE HEALTH SERVICES (PLANTATION)

6931 W SUNRISE BLVD

PLANTATION, FL 33313

Home Office:

Page 649: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325465-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 230.99 217.24 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325465053120150601201409232015140238

MANORCARE HEALTH SERVICES-SARASOTA

5511 SWIFT ROAD

SARASOTA, FL 34231

Home Office:

Page 650: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325473-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 220.34 221.76 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325473123120150601201504192016133238

MANOR CARE HEALTH SERVICES

1450 EAST VENICE AVENUE

VENICE, FL 34292

Home Office:

Page 651: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325481-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 215.39 215.07 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325481093020141001201310232014091341

MANORCARE HEALTH SERVICES-WEST PALM BEACH

2300 VILLAGE BLVD

WEST PALM BEACH, FL 33409

Home Office:

Page 652: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325490-00

Date: 6/30/2016

Fiscal Year End: 8/31/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 226.16 227.37 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325490083120140901201310202014154154

HEARTLAND HEALTH CARE CENTER-NORTH SARASOTA

3250 12TH ST

SARASOTA, FL 34237

Home Office:

Page 653: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325520-00

Date: 6/30/2016

Fiscal Year End: 4/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 190.79 195.77 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325520043020150501201409212015154055

MANORCARE HEALTH SERVICES (DELRAY BEACH)

16200 JOG ROAD

DELRAY BEACH, FL 33446

Home Office:

Page 654: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325678-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 224.27 228.51 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325678123120150601201504152016085930

MANORCARE HEALTH SERVICES-CARROLLWOOD

3030 BEARSS AVE

TAMPA, FL 33618

Home Office:

Page 655: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325686-00

Date: 6/30/2016

Fiscal Year End: 9/30/2014

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 208.02 209.15 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325686093020141001201310272014110005

MANOR-CARE HEALTH SERVICES-DUNEDIN

870 PATRICIA AVE

DUNEDIN, FL 34698

Home Office:

Page 656: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325694-00

Date: 6/30/2016

Fiscal Year End: 5/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 188.21 193.88 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325694053120150601201409232015080946

MANORCARE HEALTH SERVICES-PALM HARBOR

2851 TAMPA RD

PALM HARBOR, FL 34684

Home Office:

Page 657: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 325708-00

Date: 6/30/2016

Fiscal Year End: 12/31/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 198.15 196.45 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

HCR Manor Care

333 North Summit Street

Toledo, OH 43604

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 325708123120151001201404192016113439

HEARTLAND OF ZEPHYRHILLS

38220 HENRY DR

ZEPHYRHILLS, FL 33540

Home Office:

Page 658: 229.22 230.75 9/1/2016 · 2016-07-21 · Medicaid Reimbursement Per Diem Rates Provider Number: 0 001135-00 Date: 6/30/2016 Fiscal Year End: 7/31/2015 Audit Status: Unaudited Provider

Medicaid Reimbursement Per Diem Rates

Provider Number: 0 326011-00

Date: 6/30/2016

Fiscal Year End: 4/30/2015

Audit Status: Unaudited

Provider Type:Current New Effective

Rate Rate Date

Nursing Home Single Level 236.10 237.41 9/1/2016

State of Florida Office of Medicaid Cost Reimbursement Planning and Finance

2727 Mahan Drive - Mail Stop 23

Tallahassee, Florida 32308

Rate Type:

Interim X Prospective

Total Interim X Total Prospective

Interim Component Total Prospective with Interim Component

Settlement based on cost

Prior Provider Prospective data

Basis:

Budget

X Unaudited costs

Field audited costs

Desk audited costs

Changes:X Rate Semester Change

Distribution:Contract Management / Fiscal Agent

Permanent File

For Information Only

No Change in Rate

Lisa Smith

Medicaid Cost Reimbursement Planning and Finance

No Home Office

2Z0S4 Report Calculated: 6/30/2016 8:16:40 AM Report Printed :7/1/2016 ID: 326011043020150501201410012015094534

MOOSEHAVEN, INC.

1701 PARK AVENUE

ORANGE PARK, FL 32073

Home Office: