Financial Statements

EX-10.49.1 4 w14217exv10w49w1.txt EX-10.49.1 Exhibit 10.49.1 (STATE OF NEW YORK DEPARTMENT OF HEALTH LOGO) CORNING TOWER THE GOVERNOR NELSON A. ROCKEFELLER EMPIRE STATE PLAZA ALBANY, NEW YORK 12237 ANTONIA C. NOVELLO, M.D., M.P.H., DR.P.H. DENNIS P. WHALEN COMMISSIONER EXECUTIVE DEPUTY COMMISSIONER DATE: Aug. 30, 2005 CONTRACT #: C015473 CONTRACTOR: CAREPLUS HEALTH PLAN CONTRACT PERIOD: Jan. 01, 2005 - Dec. 31, 2005 Attached is your copy of the approved contract. The Contract number must appear on all vouchers and correspondence. Reports of the Expenditures and Budget Statements should be submitted as outlined in the Contract. In accordance with the contract, properly completed vouchers and/or programmatic questions should be addressed to the State's designated payment office as stated in the Contract. Failure of the contracting Agency to comply with payment provisions as set forth in the approved Contract may result in non-payment. An additional supply of vouchers to be used in submitting claims may be obtained by written request from the Office of the State Comptroller, Supply Room, 110 State Street, 2nd Floor, Albany, New York 12236. New York State Department of Health Contract Unit Page 2 Please note the following new information regarding payments: OSC now offers Electronic Payments. Payments formerly made by check can be made by electronic funds transfer through the Automated Clearinghouse (ACH) network, and with OSC optional e-mail notification service, you will receive advance notice of your electronic payments. Additional information is available on-line at HTTP://WWW.OSC.STATE.NY.US/EPAY/HOW.HTM or by calling ###-###-####. APPENDIX X AGENCY CODE: 12000 CONTRACT NO.: C-015473 PERIOD: JULY 1, 1998 - FUNDING AMOUNT FOR PERIOD: $214,906,633 DECEMBER 31, 2005 This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through the Department of Health, having its principal office at Corning Tower, Empire State Plaza, Albany, NY, (hereinafter referred to as the STATE), and CARE PLUS HEALTH PLAN hereinafter referred to as the CONTRACTOR), for modification of Contract Number C-015473 as reflected in the attached provisions to Section I.B.1. of the Agreement and Appendices E and L,, and to extend the period of the contract through December 31, 2005. All other provisions of said AGREEMENT shall remain in full force and effect. IN WITNESS WHEREOF, the parties hereto have executed this AGREEMENT as of the dates appearing under their signatures. CONTRACTOR SIGNATURE STATE AGENCY SIGNATURE By: /s/ Nasry Michelen By: /s/ Judith Arnold --------------------------------- ------------------------------------ Nasry Michelen Judith Arnold Printed Name Printed Name Title: Chief Executive Officer Title: Deputy Commissioner Division of Planning, Policy, & Resource Development Date: 6/20/05 Date: 7/6/05 State Agency Certification: "In addition to the acceptance of this contract, I also certify that original copies of this signature page will be attached to all other exact copies of this contract." STATE OF NEW YORK )SS.: ) Country of New York ) On the 20th day of June 2005, before me personally appeared Yosry Michelen, to me known, who being by me duly sworn, did depose and say that he/she resides at 360 west 31st. NY, NY 10001 that he/she is the Chief Executive Office of the Core Plus Health Plus the corporation described herein which executed the foregoing instrument; and that he/she signed his/her name thereto by order of the board of directors of said corporation. (Notary) /s/ Gerard Harrington - ------------------------------------- GERARD HARRINGTON Notary Public, State of New York No. 01HA6102369 Qualified in New York County Commission Expires Dec. 8, 2007 STATE COMPTROLLER SIGNATURE /s/ Charlotte (?????) - ------------------------------------- Title: --------------------------------- Date: 8/22/05 --------------------- APPROVED AS TO FORM NYS ATTORNEY GENERAL AUG 02 2005 /s/ STEPHEN J. HENSEL --------------------- STEPHEN J. HENSEL ASSOCIATE ATTORNEY --------------------- STATE OF NEW YORK AGREEMENT Section I.B.1. is revised to read as follows: I. Conditions of Agreement B.1. This AGREEMENT is extended through December 31, 2005. APPENDIX E FINANCIAL INFORMATION Section A is revised to read as follows: A. Care Plus Health Plan shall receive, for the period July 1, 2005 through December 31, 2005, an amount up to, but not to exceed, $16,300,000 to provide and administer a Child Health Plus program for uninsured children in the counties identified in Appendix A-2, Section II.B.1 of this AGREEMENT or as modified by the STATE. Payment of this amount is based on the CONTRACTOR meeting the responsibilities provided in this AGREEMENT. Additional Premium Information: For Kings, New York, Queens and Richmond county(ies): The total monthly premium shall be: $110.70 The State share of the total monthly premium shall be $110.70 or the total monthly premium for children in families with gross household income less than 160% of the federal poverty level and children who are American Indians or Alaskan Natives (AI/AN). The State share of the total monthly premium shall be $101.70 or the total monthly premium minus $9 for children in families with gross household income between 160% and 222% of the federal poverty level with a maximum of $27 per month per family. The State share is the total monthly premium less $9 for each of the first three children. For additional children, the State share is the total monthly premium. The State share of the total monthly premium shall be $95.70 or the total monthly premium minus $15 for children in families with gross household income between 223% and 250% of the federal poverty level with a maximum of $45 per month per family. The State share is the total monthly premium less $15 for each of the first three children. For additional children, the State share is the total monthly premium. In the absence of an approved premium modification by the Department of Health and State Insurance Department, the premium above or subsequent premium approved (whichever is in effect) shall continue as the State's subsidy through December 31, 2005. APPENDIX L PRIVACY AND CONFIDENTIALITY Section II is revised as follows: II. Effective April 14, 2003, the CONTRACTOR shall comply with the following agreement: Federal Health Insurance Portability and Accountability Act (HIPAA) Business Associate Agreement ("Agreement") This Business Associate Agreement between the New York State Department of Health and Care Plus Health Plan, hereinafter referred to as the Business Associate, is effective on April 14, 2003 to December 31, 2005.