Amendment to Contract POHC-2002-D-0003 for DC Healthy Families Program between District of Columbia and AmeriGroup Maryland
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Summary
This amendment modifies the existing contract between the District of Columbia Department of Health and AmeriGroup Maryland (doing business as AmeriGroup District of Columbia) for the DC Healthy Families Program. The amendment updates the per member per month (PMPM) rates for various age and gender groups for Medicaid dental services, effective from August 2005 through July 2006, as mandated by the Fiscal Year 2006 Budget Support Amendment Act. All other terms of the original contract remain unchanged. Both parties have signed and agreed to these modifications.
EX-10.23.1 3 w20799exv10w23w1.htm EX-10.23.1 exv10w23w1
Exhibit 10.23.1
| AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT | 1. Contract Number | Page of Pages | ||||||||||||||||||||
| POHC-2002-D-0003 | 1 | 2 | ||||||||||||||||||||
| 2. Amendment/Modification Number | 3. Effective Date | 4. Requisition/Purchase Request No. | 5. Solicitation Caption | |||||||||||||||||||
| POHC-2002-D-0003 M0026 | 1/1/06 | D.C. Health Families Program | ||||||||||||||||||||
| 6. Issued By; | Code | 7. Administered By (If other than line 6) | ||||||||||||||||||||
| Office of Contracting and Procurement | Department of Health | |||||||||||||||||||||
| Human Care Supplies and Services Commodity Group | Medical Assistance Administration | |||||||||||||||||||||
| 441 4th Street, NW, Room 700 South | 825 North Capitol Street, NE, 5th Floor | |||||||||||||||||||||
| Washington, D.C., 20001 | Washington, D.C., 20002 | |||||||||||||||||||||
| Maude Holt ###-###-#### | ||||||||||||||||||||||
| 8. Name and Address of Contractor (No, Street, city, country, state and ZIP Code) | (X) | 9A. Amendment of Solicitation No. | ||||||||||||||||||||
| AmeriGroup Maryland | 9B. Dated (See Item 11) | |||||||||||||||||||||
| dba AmeriGroup District of Columbia | ||||||||||||||||||||||
| 750 First Street, NE Suite 1120 | 10A. Modification of Contract/Order No. | |||||||||||||||||||||
| Washington, D.C. 20001 | X | POHC-2002-D-0003 | ||||||||||||||||||||
| Phone 202 ###-###-#### Fax ###-###-#### | 10B. Dated (See Item 13) | |||||||||||||||||||||
| Code | Facility | 8/1/2002 | ||||||||||||||||||||
| 11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS | ||||||||||||||||||||||
| o | The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers o is extended. o is not extended. | |||||||||||||||||||||
| Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods: (a) By completing Items 8 and 15, and returning ___ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or fax which includes a reference to the solicitation and amendment number. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or fax, provided each letter or telegram makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified. | ||||||||||||||||||||||
| 12. Accounting and Appropriation Data (If Required) | ||||||||||||||||||||||
| 13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS, IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14 | ||||||||||||||||||||||
| A. This change order is issued pursuant to: (Specify Authority) | 27 DCMR, Chapter 36, Contract Modifications | |||||||||||||||||||||
| The changes set forth in Item 14 are made in the contract/order no. in Item 10A. | ||||||||||||||||||||||
| B. The above numbered contract/order is modified to reflect the administrative changes (such as changes in paying office, appropriation data, etc.) set forth in Item 14, pursuant to the authority of 27 DCMR, Chapter 36, Section 3601.2. | ||||||||||||||||||||||
| X | C. This supplemental agreement is entered into pursuant to authority of: | 27 DCMR, Chapter 36, Contract Modifications | ||||||||||||||||||||
| The changes set forth In Item 14 are made In the contract/order no. in item 10A. | ||||||||||||||||||||||
| D. Other (Specify type of modification and authority) | ||||||||||||||||||||||
| E. IMPORTANT: Contractor o is not, x is required to sign this document and return 2 originals to the issuing office. | ||||||||||||||||||||||
| 14. Description of amendment/modification (Organized by UCF Section headings, including solicitation/contract subject matter where feasible.) | ||||||||||||||||||||||
| In accordance with Title V Subtitle N Designated Appropriation Allocations Section 5258 Funds for Medicaid Dental Services of the Fiscal Year 2006 Budget Support Amendment Act of 2005 | ||||||||||||||||||||||
| Contract POHC-2002-D-0003 is hereby modified as described on page 2: | ||||||||||||||||||||||
| ALL OTHER TERMS AND CONDITIONS OF THE CONTRACT REMAIN UNCHANGED | ||||||||||||||||||||||
| Except as provided herein, all terms and conditions of the document referenced In Item (9A or 10A) remain unchanged and in full force and effect | ||||||||||||||||||||||
| 15A. Name and Title of Signer (Type or print) | 16A. Name of Contracting Officer | |||||||||||||||||||||
| Dr. Sandra Nichols | James H. Marshall | |||||||||||||||||||||
| 15B. Name of Contractor | 15C. Date Signed | 16B. District of Columbia | 16C. Date Signed | |||||||||||||||||||
| -s- Dr. Sandra Nichols | -s- James H. Marshall | |||||||||||||||||||||
| (Signature of person authorized to sign) | 12/19/05 | (Signature of Contracting Officer) | 12-30-05 | |||||||||||||||||||
Amerigroup Health Plan.
DCHFP Rates August 2005 to July 2006
DCHFP Rates August 2005 to July 2006
POHC-2002-D-0003 M0026
Page 2
Insert:
B.6.2 Supplies/Services
Page 2
Insert:
B.6.2 Supplies/Services
CONTRACT NO: POHC-2002-D-0003
| LINE | Annualized | PMPM* Rates from | PMPM* Rates from | |||||||||||
| ITEM | October* | August 2005 through | January 2006 through | |||||||||||
| NUMBER | SUPPLIES/SERVICES | December 2004 | December 2005 | July 2006 | ||||||||||
| 0001 | DC HEALTHY FAMILIES PROGRAM (DCIIFP) | |||||||||||||
| 0001AA | Infants Under 1 year of age (months 2 through 12) | 20,272 | $ | 283.83 | $ | 283.83 | ||||||||
Delivery month (projected delivery) | 1,244 | $ | 6,761.98 | $ | 6,761.98 | |||||||||
Birth Month (actual month of birth) | 1,352 | $ | 4,826.96 | $ | 4,826.96 | |||||||||
| 0001AB | Children of 1 year of age through 12 years of age | 223,524 | $ | 104.16 | $ | 107.65 | ||||||||
| 0001AC | Females ages 13 through 18 years | 43,596 | $ | 146.03 | $ | 150.41 | ||||||||
| 0001AD | Males ages 13 through 18 years of age | 37,488 | $ | 137.44 | $ | 142.04 | ||||||||
| 0001AE | Females ages 19 through 36 years of age | 90,428 | $ | 215.75 | $ | 215.75 | ||||||||
| 0001AF | Males ages 19 through 36 years of age | 10,740 | $ | 124.10 | $ | 124.10 | ||||||||
| 0001AG | Females 37 years of age and older | 43,224 | $ | 369.69 | $ | 369.69 | ||||||||
| 0001AH | Males 37 years of age and older | 9,536 | $ | 261.26 | $ | 261.26 | ||||||||
Estimated Total Dollars based on Annualized MMs | 478,808 | $ | 39,502,592 | $ | 55,970,667 | |||||||||
*PMPM = per member per month | $ | 198.00 | $ | 200.39 | ||||||||||
FOR DISTRICT USE ONLY | ||||||||||||||
| LINE | AGY YR Index PCA OBJ AOB Grant Proj AG1 AG2 | AG3 | ||||||||||||
J PH PH | ||||||||||||||
FY06 Estimated Total Dollars based on Annualized MMs at August 2005 Rates | $ | 94,806,220 | ||
FY06 Estimated Total Dollars based on Annualized MMs and Rate Update January 2006 | $ | 95,473,258 | ||
Estimated Increase in FY06 Total Dollars based on Dental Rate Adjustment | $ | 667,036 |
