ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION DIVISION OF BUSINESS AND FINANCE SECTION A: CONTRACT

 1. AMENDMENT

    NUMBER:

2. CONTRACT NO.:

3.    EFFECTIVE DATE OF

       AMENDMENT:

4. PROGRAM

         

5. CONTRACTOR'S NAME AND ADDRESS:

6. PURPOSE OF AMENDMENT:  To allow for payment of rural hospital inpatient reimbursement pursuant to A.R.S. §36-2905.02.

7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS

The Contractor will be paid the attached supplemental payment amounts to increase rural hospital inpatient reimbursement. The supplemental payment amounts are allocated to the appropriate risk groups based on historical utilization. AHCCCS requires that the Contractor make one-time payments to each rural hospital as prescribed on the attached schedule, pursuant to A.R.S. §36-2905.02, to increase inpatient reimbursement to these small rural hospitals.

The Contractor shall make the prescribed payments to the rural hospitals 15 days from receipt of the funds and submit proof of payment to the rural hospitals to the Assistant Director of the Division of Health Care Management 30 days from receipt of the funds.

The regular per member per month capitation rates for the period of October 1, 2011 through September 30, 2012 remains unchanged.

NOTE: Please sign, date, and return executed file by E-Mail to: Mark Held at ***@*** Sr. Procurement Specialist, AHCCCS Contracts and Purchasing and P.J. Schoenstene at ***@*** Contracts and Policy Administrator, Division of Health Care Management

9. SIGNATURE OF AUTHORIZED REPRESENTATIVE: /s/ Nancy Novick

10. SIGNATURE OF AHCCCS CONTRACTING OFFICER: /s/ Michael Veit

TYPED NAME: NANCY NOVICK

TYPED NAME: MICHAEL VEIT

TITLE: CHIEF EXECUTIVE OFFICER

TITLE: CONTRACTS & PURCHASING ADMINISTRATOR

DATE: 05/8/2012