AMENDMENT NO.: 004 REQ NO.: NR 886 ###-###-#### CONTRACT NO.: C306118005 BUYER: Laura Ortmeyer TITLE: Medicaid Managed Care - Eastern Region PHONE NO.: (573) 751-4579 ISSUE DATE: 04/10/07 E-MAIL: ***@***
EX-10.1 2 exhibit10-1.htm EXHIBIT 10.1 Exhibit 10.1
Exhibit 10.1
STATE OF MISSOURI
OFFICE OF ADMINISTRATION
DIVISION OF PURCHASING AND MATERIALS MANAGEMENT (DPMM)
CONTRACT RENEWAL
| AMENDMENT NO.: 004 | REQ NO.: NR 886 ###-###-#### |
| CONTRACT NO.: C306118005 | BUYER: Laura Ortmeyer |
| TITLE: Medicaid Managed Care - Eastern Region | PHONE NO.: (573) 751-4579 |
| ISSUE DATE: 04/10/07 | E-MAIL: ***@*** |
TO: HARMONY HEALTH PLAN INC
23 PUBLIC SQUARE STE 400
BELLEVILLE IL 62220
RETURN AMENDMENT NO LATER THAN: 04/24/07 AT 5:00 PM CENTRAL TIME
RETURN AMENDMENT TO:
| (U.S. Mail) Div of Purchasing & Matls Mgt (DPMM) OR PO BOX 809 JEFFERSON CITY MO 65102-0809 | (Courier Service) Div of Purchasing & Matls Mgt (DPMM) 301 WEST HIGH STREET, ROOM 630 JEFFERSON CITY MO 65101 |
OR FAX TO: (573) 526-9817 (either mail or fax, not both)
DELIVER SUPPLIES/SERVICES FOB (Free On Board) DESTINATION TO THE FOLLOWING ADDRESS:
Department of Social Services
Division of Medical Services
PO Box 6500
Jefferson City MO 65102-6500
SIGNATURE REQUIRED
| DOING BUSINESS AS (DBA) NAME Harmony Health Plan of Illinois Inc., d/b/a/ Harmony Health Plan of Missouri | LEGAL NAME OF ENTITY/INDIVIDUAL FILED WITH IRS FOR THIS TAX ID NO. Harmony Health Plan of Illinois, Inc. | |
| MAILING ADDRESS 23 Public Square, Suite 400 | IRS FORM 1099 MAILING ADDRESS 200 West Adams Street, Suite 800 | |
| CITY, STATE, ZIP CODE Belleville, IL 62220 | CITY, STATE, ZIP CODE Chicago, IL 60606 |
| CONTACT PERSON Ms. Tina Gallagher | EMAIL ADDRESS ***@*** | ||
| PHONE NUMBER (800) 608-8158 Ext. 2405 | FAX NUMBER (800) 608-8157 | ||
| TAXPAYER ID NUMBER (TIN) 36 ###-###-#### | TAXPAYER ID (TIN) TYPE (CHECK ONE) _X__ FEIN ___ SSN | VENDOR NUMBER (IF KNOWN) 3640504950 1 | |
| VENDOR TAX FILING TYPE WITH IRS (CHECK ONE) (NOTE: LLC IS NOT A VALID TAX FILING TYPE.) _X__ Corporation ___ Individual ___ State/Local Government ___ Partnership ___ Sole Proprietor ___Other ________________ | |||
| AUTHORIZED SIGNATURE /s/ Thaddeus Bereday | DATE April 24, 2007 | ||
| PRINTED NAME Thaddeus Bereday | TITLE Secretary | ||
AMENDMENT #004 TO CONTRACT C306118005
CONTRACT TITLE: Medicaid Managed Care - Eastern Region
CONTRACT PERIOD: July 1, 2007 through June 30, 2008
The State of Missouri hereby exercises its option to renew the above-referenced contract.
The contractor shall indicate in Column 2 on the attached Pricing page, any changes to the firm, fixed prices of the contract for performing the required services in accordance with the terms, conditions, and provisions of the contract. The contractor's firm, fixed PMPM Net Capitation Rate for Each Category of Aid (COA) Rate subgroup must not exceed the State's Maximum Net Capitation Rate listed in Column 1.
The contractor must furnish a performance security deposit in accordance with the terms and conditions stated in the original contract in the amount of $1,000,000.00. The performance security deposit must specify the contract number and contract period.
All other terms, conditions and provisions of the previous contract period shall remain and apply hereto. The contractor shall sign and return this document, along with completed pricing and the applicable bond, on or before the date indicated.
| NOTE: | The contractor’s failure to complete and return this document shall not stop the action specified herein. If the contractor fails to complete and return this document prior to the return date specified or the effective date of the contract period stated above, whichever is later, the state may renew the contract at the same price(s) as the previous contract period or at the price(s) allowed by the contract, whichever is lower. |
| 5.3 East Region - Firm Fixed Net Capitation Pricing Page | |||||||
| | | | Column 1 | | | Column 2 | |
| State's Maximum Net | | Firm Fixed Net | |||||
| Capitation Rate | Capitation Rate | ||||||
| Category of Aid | Age | Sex | | (Per Member Per Month) | | (Per Member Per Month) | |
| 1 | Newborn < 01 | Male and Female | $ | 863.53 | | $ | 863.53 |
| 1 | 01 - 06 | Male and Female | $ | 125.55 | | $ | 125.55 |
| 1 | 07 - 13 | Male and Female | $ | 98.44 | | $ | 98.44 |
| 1 | 14 - 20 | Female | $ | 306.93 | | $ | 306.93 |
| 1 | 14 - 20 | Male | $ | 126.73 | | $ | 126.73 |
| 1 | 21 - 44 | Female | $ | 418.80 | | $ | 418.80 |
| 1 | 21 - 44 | Male | $ | 191.64 | | $ | 191.64 |
| 1 | 45 - 99 | Male and Female | $ | 436.77 | | $ | 436.77 |
| 4 | 00 - 20 | Male and Female | $ | 233.97 | | $ | 233.97 |
| | | | | | | | |
| 5 | 00 - 06 | Male and Female | $ | 152.68 | | $ | 152.68 |
| 5 | 07 - 13 | Male and Female | $ | 117.88 | | $ | 117.88 |
| 5 | 14 - 18 | Male and Female | $ | 175.38 | | $ | 175.38 |
