2007-000057-D MEDICARE PLATINO CONTRACT AMENDMENT (Medicaid Wraparound) Agreement Between

Exhibit 10.4

2007-000057-D

MEDICARE PLATINO CONTRACT AMENDMENT
(Medicaid Wraparound)

Agreement Between

Puerto Rico Health Insurance Administration (PRHIA) a public instrumentality of the Commonwealth of Puerto Rico organized pursuant to Act 72, of September 7, 1993, as amended, hereinafter referred to as the “PRHIA”, and represented by its Executive Director, Xxxxxxx Xxxxxxx Xxxxxxx, MHSA;

And

TRIPLE-S SALUD, INC., a private corporation duly organized and authorized to do business under the laws of the Commonwealth of Puerto Rico, with Employer Social Security Number ###-##-####, hereinafter referred to as “CONTRACTOR”, and represented by its Chief Executive Director, Xxxxxxx Xxxxx;

Contractor Name

For the Provision of the wraparound coverage for the Government Health Insurance Dual-Eligible
Population

WITNESSETH

In consideration of the mutual covenants and agreements hereinafter set forth; the parties, their personal representatives and successors, agree as follows:

WHEREAS: The parties entered into a contract to provide all the health care services and supplies that are covered by the contractor’s Medicare Advantage Product and the Medicaid wraparound benefits known as Medicare Platino; to serve the “dual eligible” population and the government employees qualified to participate in the Puerto Rico Health Insurance Administration program (PRHIA); during the calendar year 2009; contracts numbers 07-057, 07-057A, 07-057B, and 07-057C.

WHEREAS: The PRHIA has decided to renegotiate rates with the plans currently contracted and revise the Plan Benefit Package to assure compliance with CMS regulations for the calendar year 2009 and PRHIA population needs and services requested.

Now therefore; according to the above premise the PRHIA and Triple-S Salud, Inc. have decided to amend the contract as follows:

Article I: To amend provision 2.1 to read as follows:

     2.1 Term

This agreement is effective January 1^st, 2010 and shall remain in effect until December 31, 2010 or until the execution of an extension renewal or successor Agreement approved by PRHIA Board of Directors.

Article II: To amend provision 3.1 (b) to read as follows:

     3.1 Premium Payments

	a.		...
	b.		The monthly premiums are attached hereto as Appendix B (1)(10) and shall be deemed incorporated into this Agreement without further action by the parties...

Article III. To amend provision 4 to reads as follows:

The service area described in Appendix A (1)(10) of this Agreement; which is hereby made part of this agreement as if set forth fully herein, is the specific geographic area within which Eligible persons shall enroll in the contractor’s Medicare Platino Product.

Article IV. To amend provision 6.5 to read as follows:

6.5 Contractor Liability

As part of the Effective Date of Enrollment, and until the Effective Date of Disenrollment from the Contractor’s product, the Contractor shall be responsible for the provision and cost of the Medicare Platino Benefit Package as described in:

	Appendix		C (1) (10) Medicare Advantage Product
	Appendix		C (2) (10) Medicaid Product (Wraparound) of this Agreement; With co-payments for Enrollees whose names appear on the prepaid Premium Plan Roster.

Article V. To amend provision 10.2 to read as follows:

The Medicare Platino Benefit Package and Non-Covered Services agreed to by the contractor and the PRHIA are contained in:

Appendix		C-1(10) Medicare Advantage Product
		C-2(10) Medicaid Wraparound
		C-3(10) Services not covered by Medicare Platino but provided by the Department of Health which are hereby made a part of this agreement as if set forth fully herein.

C-4(10) Summary of Benefits Report — The Summary Benefits (SB) included as Appendix C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the SB does not mean that the same have already been approved and that, if necessary, changes could be requested. Therefore, since the SB needs the approval of the PRHIA, this section could be amended subject to PRHIA’s review.

Article VI: To amend provision 13 to read as follows:

13. Access Requirements

The Contractor agrees to provide enrollees access to Medicare Platino Benefit Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner consistent with professionally recognized standards of health care and access standards required by 42CFR Section 422.11/438.206 and Law 72 of September 7, 1993 respectively.

Article VII: All other terms provisions and conditions of the contract remains unchanged.

In witness whereof, the parties have duly executed this Amendment of the dates appearing below their respective signatures.

PUERTO RICO HEALTH		TRIPLE-S SALUD, INC.
INSURANCE ADMINISTRATION
Xxxxxxx Xxxxxxx Xxxxxxx, MHSA Executive Director		Xxxxxxx Xxxxx Chief Executive Officer Triple-S Salud, Inc.
		Xx. Xxxx X. Xxxxxx Chief Executive Officer Triple C, Inc.
	10/2/09		10/2/09
Date		Date
Cifra de Cuenta 5000-100

APPENDIX A(1)(10)

SERVICE AREA

APPENDIX A(1)(10)

TRIPLE-S SALUD, INC.

Geographic Areas:
North East Health Area		composed of the municipalities of Canóvanas, Carolina, Ceiba, Culebra, Fajardo, Loíza, Luquillo, Rio Grande, Xxxxxxxx Alto and Vieques.
West Health Area		composed of the municipalities of Aguada, Aguadilla, Añasco, Cabo Rojo, Hormigueros, Isabela, Lajas, Las Marías, Maricao, Mayaguez, Moca, Rincón, Sabana Grande, San Germán, and San Sebastián.
South East Health Area		composed of the municipalities of Aibonito, Orocovis, Xxxxxx, Barranquitas, Coamo, Guayama, Xxxxx Xxxx, Maunabo, Patillas, Xxxxxxx, Santa Xxxxxx and Villalba.
East Health Area/Region		composed of Aguas Buenas, Caguas, Cayey, Cidra, Gurabo, Humacao, Juncos, Las Piedras, Naguabo, San Xxxxxxx, and Yabucoa.
North Health Area		composed of the municipalities of Arecibo, Barceloneta, Camuy, Ciales, Florida, Hatillo, Lares, Manatí, Morovis, Quebradillas, Utuado and Xxxx Baja.
Metro-North Health Area		composed of the municipalities of Bayamón, Cataño, Comerío, Corozal, Dorado, Guaynabo, Naranjito, Toa Alta, Toa Baja and Xxxx Xxxx.
South West Health Area		composed of the municipalities of Adjuntas, Guánica, Guayanilla, Jayuya, Peñuelas, Ponce and Yauco.
San Xxxx Region		composed only of the municipality of San Xxxx.

APPENDIX B(1)(10)

PREMIUM PAYMENT

Appendix B(1)(10)

Monthly Payment of Premiums per Member
by Geographic Areas

TRIPLE-S Salud, Inc. Plans
Product: SSS Selecto

		DSH SNP
		Blended
Area:		H4012-003
East		$	35.00
Metro-North		$	35.00
North		$	35.00
North East		$	35.00
San Xxxx		$	35.00
South East		$	35.00
South-West		$	35.00
West		$	35.00

C-4(10) Summary of Benefits Report — The Summary Benefits (SB) included as Appendix C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the SB does not mean that the same have already been approved and that, if necessary, changes could be requested. Therefore, since the SB needs the approval of the PRHIA, this section could be amended subject to PRHIA’s review.

Article VI: To amend provision 13 to read as follows:

13. Access Requirements

The Contractor agrees to provide enrollees access to Medicare Platino Benefit Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner consistent with professionally recognized standards of health care and access standards required by 42CFR Section 422.11/438.206 and Law 72 of September 7, 1993 respectively.

Article VII: All other terms provisions and conditions of the contract remains unchanged.

In witness whereof, the parties have duly executed this Amendment of the dates appearing below their respective signatures.

PUERTO RICO HEALTH		TRIPLE-S SALUD, INC.
INSURANCE ADMINISTRATION
Xxxxxxx Xxxxxxx Xxxxxxx, MHSA Executive Director		Xxxxxxx Xxxxx Chief Executive Officer Triple-S Salud, Inc.
		Xx. Xxxx X. Xxxxxx Chief Executive Officer Triple C, Inc.
	10/2/09		10/2/09
Date		Date
Cifra de Cuenta 5000-100