Salt Lake City, Utah
EX-10.12 3 c92860exv10w12.htm EXHIBIT 10.12 Exhibit 10.12
Exhibit 10.12
 | ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION DIVISION OF BUSINESS AND FINANCE SECTION A: CONTRACT |
1. AMENDMENT | 2. CONTRACT | 3. EFFECTIVE DATE OF | 4. PROGRAM | |||
NUMBER: | NO.: | AMENDMENT: | ||||
3 | YH09-0001-04 | May 1, 2009 | DHCM — ACUTE |
5. CONTRACTOR’S NAME AND ADDRESS:
Health Choice Arizona
1600 W. Broadway, Suite 260
Tempe, AZ 85282
6. PURPOSE OF AMENDMENT: To amend Section B, Capitation Rates, effective May 1, 2009.
7. THE CONTRACT REFERENCED ABOVE FOLLOWS
To amend Section B, Capitation Rates, effective May 1, 2009.
NOTE: Please sign and date all copies and then return one executed original to: | Mark Held | |
| Sr. Procurement Specialist | ||
| AHCCCS Contracts | ||
| 701 E. Jefferson St., MD 5700 | ||
| Phoenix, AZ 85034 |
8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.
IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT
9. SIGNATURE OF AUTHORIZED REPRESENTATIVE: | 10. SIGNATURE OF AHCCCSA CONTRACTING OFFICER: | |
| [ILLEGIBLE] | ||
| /s/ Carolyn Rose | /s/ Pat Watkinson for Michael Veit | |
TYPED NAME: CAROLYN ROSE | MICHAEL VEIT | |
TITLE: CHIEF EXECUTIVE OFFICER | CONTRACTS & PURCHASING ADMINISTRATOR | |
DATE: | DATE: 3-30-09 |
| SECTION B: CAPITATION RATES | Contract/RFP No. YH09-0001 | |
SECTION B: CAPITATION RATES
The Contractor shall provide services as described in this contract. In consideration for these services, the Contractor will be paid Contractor-specific rates per member per month for the term May 1, 2009 through September 30, 2009. See attached revised rates.
CYE ‘09 Acute Care Contract
May 1, 2009
May 1, 2009
61
ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM
CAPITATION RATE SUMMARY — ACUTE RATES
Health Choice Arizona
05/01/2009-9/30/2009
CAPITATION RATE SUMMARY — ACUTE RATES
Health Choice Arizona
05/01/2009-9/30/2009
| Maternity | ||||||||||||||||||||||||||||||||||||||||||||
| TANF | TANF | TANF | TANF | TANF | SSI | SSI | Delivery | |||||||||||||||||||||||||||||||||||||
| Title XIX and KidsCare Rates 1: | <1, M/F | 1-13, M/F | 14-44, F | 14-44, M | 45+, M/F | w/ Med | w/o Med | SFP | Supplement | Non-MED | MED | |||||||||||||||||||||||||||||||||
2 Yuma/La Paz | $ | 451.13 | $ | 105.33 | $ | 204.19 | $ | 118.67 | $ | 365.40 | $ | 178.29 | $ | 693.11 | $ | 20.43 | $ | 6,190.52 | $ | 443.94 | $ | 1,636.99 | ||||||||||||||||||||||
4 Apache/Coconino/Mohave/Navajo | $ | 474.50 | $ | 111.49 | $ | 270.70 | $ | 157.82 | $ | 409.11 | $ | 160.98 | $ | 775.55 | $ | 19.00 | $ | 6,241.93 | $ | 578.20 | $ | 1,433.37 | ||||||||||||||||||||||
10 Pima/Santa Cruz | $ | 448.76 | $ | 100.79 | $ | 230.46 | $ | 127.70 | $ | 396.08 | $ | 145.39 | $ | 734.80 | $ | 20.91 | $ | 6,519.63 | $ | 485.35 | $ | 1,329.96 | ||||||||||||||||||||||
12 Maricopa | $ | 558.77 | $ | 114.80 | $ | 239.88 | $ | 150.74 | $ | 410.20 | $ | 157.50 | $ | 744.97 | $ | 18.65 | $ | 6,646.66 | $ | 626.59 | $ | 1,415.16 | ||||||||||||||||||||||
| TANF | TANF | TANF | TANF | TANF | SSI | SSI | ||||||||||||||||||||||||||||||
| PPC Rates: | <1, MF | 1-13, M/F | 14-44, F | 14-44, M | 45+, M/F | w/ Med | w/o Med | Non-MED | MED | |||||||||||||||||||||||||||
2 Yuma/La Paz | $ | 1,204.81 | $ | 61.66 | $ | 238.16 | $ | 212.19 | $ | 436.74 | $ | 134.22 | $ | 410.31 | $ | 1,075.65 | $ | 7,443.55 | ||||||||||||||||||
4 Apache/Coconino/Mohave/Navajo | $ | 1,190.43 | $ | 62.09 | $ | 264.19 | $ | 215.00 | $ | 439.32 | $ | 135.74 | $ | 405.56 | $ | 1,127.34 | $ | 7,404.72 | ||||||||||||||||||
10 Pima/Santa Cruz | $ | 1,192.26 | $ | 56.23 | $ | 247.42 | $ | 196.93 | $ | 439.38 | $ | 132.24 | $ | 408.04 | $ | 887.69 | $ | 7,387.84 | ||||||||||||||||||
12 Maricopa | $ | 1,217.54 | $ | 66.04 | $ | 255.60 | $ | 224.64 | $ | 446.27 | $ | 132.38 | $ | 425.30 | $ | 1,319.34 | $ | 7,668.50 | ||||||||||||||||||
| Option 1 | Option 2 | |||||||
| Other Rates: | Transplant | Transplant | ||||||
2 Yuma/La Paz | $ | 40.00 | $ | 40.00 | ||||
4 Apache/Coconino/Mohave/Navajo | $ | 40.00 | $ | 40.00 | ||||
10 Pima/Santa Cruz | $ | 40.00 | $ | 40.00 | ||||
12 Maricopa | $ | 40.00 | $ | 40.00 | ||||
| 1. | Rates have been adjusted for $50,000 Reinsurance Deductible |
