APPENDIX X Agency Code 12000 Contract No. C020429Period 10/1/05 9/30/08 Funding Amount for Period Based on approved capitation rates

Contract Categories: Business Operations - Agency Agreements
EX-10.29.1 6 w20799exv10w29w1.htm EX-10.29.1 exv10w29w1
 

Exhibit 10.29.1
APPENDIX X
     
Agency Code 12000
  Contract No. C020429
Period 10/1/05 – 9/30/08
  Funding Amount for Period Based on approved capitation rates
This is an AGREEMENT between THE STATE OF NEW YORK, acting by and through The New York State Department of Health, having its principal office at Corning Tower, Room 2001, Empire State Plaza, Albany NY 12237, (hereinafter referred to as the STATE), and CarePlus, LLC, (hereinafter referred to as the CONTRACTOR), to modify Contract Number C020429 by substituting the attached Appendix L “Approved Capitation Payment Rates.” The effective date of these modifications is October 1, 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:            
 
                       
 
  Nasry Michelen                    
 
                        
 
                       
 
  Printed Name           Printed Name        
 
                        
Title:
  Chief Executive Officer       Title:            
 
                       
 
                        
Date:
  3/12/06       Date:            
 
                       
 
                        
            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.:
County of New York
    )      
On the 13TH day of March 2006, before me personally appeared Nasry Michelen, to me known, who being by me duly sworn, did depose and say that he/she resides at 11 Wells Ave., Goton on Hudson, NY 10520 that he/she is the CEO of Careplus Health Plan LLc, 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)     [ILLEGIBLE]
          /s/ [ILLEGIBLE]    
 
                
STATE COMPTROLLER’S SIGNATURE
      Title:        
 
               
 
                
 
      Date:        
 
               

 

 

APPENDIX L
Approved Capitation Payment Rates
APPENDIX L
October 1, 2005
L-l

 

 

CAREPLUS, LLC
Medicaid Managed Care Rates
     
MMIS ID #: 01617894
  Effective Date: 10/01/05
Approved by DOB: Yes
  Region: Northern Metro
DOH HMO #: 05-035
  County: PUTNAM
Reinsurance: No
  Status: Voluntary
         
Premium Group   Rate Amount  
TANF/SN <6mo M/F
   $ 204.87  
TANF/SN 6mo-14 F
   $ 67.30  
TANF/SN 15-20 F
   $ 158.53  
TANF/SN 6mo-20 M
   $ 72.23  
TANF 21+ M/F
   $ 177.28  
SN 21-29 M/F
   $ 214.04  
SN 30+ M/F
   $ 304.57  
SSI 6mo-20 M/F
   $ 249.18  
SSI 21-64 M/F
   $ 429.38  
SSI 65+ M/F
   $ 454.10  
Maternity Kick Payment
   $ 3,819.45  
Newborn Kick Payment
   $ 2,216.32  
Optional Benefits Offered:
     
o  Emergency Transportation
  o  Dental
 
    
o  Non-Emergent Transportation
  þ  Family Planning
Box will be checked if the optional benefit is covered by the plan

 

 

CAREPLUS, LLC
Family Health Plus Rates
Effective September 1, 2005
                                                 
                                    Optional
                                    benefits covered
    Adults with   Adults without   Adults without           Family    
County   Children 19 - 64   Children 19 - 29   Children 30 - 64   Maternity Kick   Planning   Dental
NEW YORK CITY
   $ 183.45     $ 198.39     $ 258.07     $ 4,700.67     Yes   Yes
Date: 7/28/05