Agency Code 12000 Contract No. C020429 Period 10/1/05 – 9/30/08 Funding Amount for Period Based on approved capitation rates
Exhibit
10.29.1
APPENDIX X
Agency Code 12000
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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 0000,
Xxxxxx Xxxxx Xxxxx, Xxxxxx XX 00000, (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/ Xxxxx Xxxxxxxx | By: | ||||||||||
| Xxxxx Xxxxxxxx | ||||||||||||
| Printed Name | Printed Name | |||||||||||
Title:
|
Chief Executive Officer | Title: | ||||||||||
Date:
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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
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) |
On the 13TH day of March 2006, before me personally appeared
Xxxxx Xxxxxxxx, to me known, who being by me duly sworn, did depose
and say that he/she resides at 00 Xxxxx Xxx., Xxxxx xx Xxxxxx, XX 00000 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
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Title: | |||||||
| Date: | ||||||||
APPENDIX L
Approved Capitation Payment Rates
APPENDIX L
October 1, 2005
L-l
October 1, 2005
L-l
CAREPLUS, LLC
Medicaid Managed Care Rates
MMIS ID #: 01617894
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Effective Date: 10/01/05 | |
Approved by DOB: Yes
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Region: Northern Metro | |
DOH HMO #: 05-035
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County: XXXXXX | |
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
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
