STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES CONTRACT AMENDMENT
Exhibit
10.1
STATE
OF CONNECTICUT
DEPARTMENT
OF SOCIAL SERVICES
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Amendment
Number:
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23
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Contract
#:
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093-MED-WCC-1
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Contract
Period:
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08/11/2001
– 03/31/08
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Contractor
Name:
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WELLCARE
OF CONNECTICUT, INC.
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Contractor
Address:
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000
Xxxxxxxxxx Xxxxxx, 0xx
Xxxxx Xxxxx Xxxxx,
XX 00000
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Contract
number 093-MED-WCC-1 by and between the Department of Social Services (the
“Department”) and WELLCARE of CONNECTICUT, Inc. (the “Contractor”)
for the provision of services under the HUSKY A program as amended by Amendments
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22
is hereby further amended as follows:
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1.
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Paragraph
1 of Part I as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
12, 13, 14, 15, 16, 17, 18,19, 20, 21 and 22 is further amended to extend
the contract end date from February 29, 2008 to March 31,
2008.
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2.
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Part
II “GENERAL CONTRACT TERMS FOR MCOs” dated 05/07 remain unchanged and in
full force and effect subject to the provisions of this and all prior
amendments.
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3.
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Effective
February 1, 2008 the Contractor will no longer be required to administer
the HUSKY A pharmacy benefit, however the Contractor shall retain all its
contractual obligations with regard to pharmacy claims with dates of
service before February 1, 2008.
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4.
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Paragraph
5 of Amendment 22 is deleted in its entirety and replaced with the
following: The Department and the Contractor agree that the
Contractor shall continue participating in the HUSKY A program through
March 31, 2008. During the period 01/01/08 through 03/31/08 , however the
Contractor will be operating as a Pre-paid Inpatient Health Plan (PIHP)
and, as such, shall not be responsible for the costs of covered services
incurred by the Contractor’s HUSKY A enrollees. The costs of such covered
services shall be the responsibility of the Department and the Department
shall reimburse the Contractor for any amounts paid by the Contractor for
such covered services on a monthly basis upon the presentation of
documentation from the Contractor to the Department for such paid
amounts. The Department shall reimburse the Contractor
for any amounts paid by the Contractor to providers for covered services
rendered to its HUSKY A enrollees in accordance with the Contractor’s then
current provider contracts, (which may include capitated and other payment
arrangements in addition to fee for service payments), or where services
are provided by non-contracted providers, the then current Medicaid fee
schedule or other rate paid by the Contractor to the non-contracted
provider.
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5.
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Any
other changes to Part II “GENERAL CONTRACT TERMS FOR MCOS” dated 05/07
that are necessitated by the transition from managed care to a PIHP
arrangement shall be directed by Department’s authorized personnel in
writing to the Contractor in a manner consistent with the Contract, and
may be relied upon by Contractor. For purposes of this
amendment the Department’s authorized personnel shall be limited to the
Commissioner, or his designee; the Director of Medical Care
Administration, or his designee; the Director of Medical Administration
Managed Care, or her designee and/or the Department’s Medical Director, or
his designee.
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6.
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Effective
January 1, 2008 through March 31, 2008 the Department shall suspend the
Contractor’s HUSKY A new Member enrollment unless otherwise notified in
writing by the Department.
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7.
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Paragraph 9 of Amendment 22 is deleted in its
entirety and replaced with the following: During the period
January 1, 2008 through March 31, 2008 the Department and the Contractor
shall agree to and implement the terms of a plan to transition each of the
Contractor’s HUSKY A enrollees to another MCO in the HUSKY
A program by March 31, 2008 with the understanding that the goal of the
transition plan is to conduct an orderly transition that will protect the
health, safety and welfare of the Contractor’s HUSKY A
members.
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8.
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Paragraph
10 and each subsection in Paragraph 10 of Amendment 22 is deleted in their
entirety and replaced with the
following:
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During
the period January 1, 2008 through March 31, 2008, in consideration of the
Contractor’s performance of HUSKY A services in accordance with the terms of the
original contract as amended, the Department shall pay the Contractor the
following:
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A.An
administrative fee of $18.18 (which includes the administration of dental
services) per HUSKY A member per month enrolled with Contractor, payable
by February 15 for January enrollees March 15 for February
enrollees and April 15 for March
enrollees.
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B.The
Department may withhold up to 8% of each of the payments described in
subsections C through H of this section to be kept by the Department in a
reserve account for medical expenses. The reserve account shall
not exceed $750,000.00 and shall be used for the final reconciliation of
medical expense as set forth in Section 8 J of this
amendment.
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C.On
or before February 15, 2008, the Department shall advance a payment to the
Contractor for medical services furnished in January 2008 to Contractor’s
enrollees. The payment shall be equal to 60% of
Contractor’s monthly claims PMPM experience for covered
services calculated in accordance with the provision of Section
8 L of this amendment applied to the number of Contractor’s enrollees in
January 2008.
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D.On
or before March 15, 2008 the Department shall advance a payment to the
Contractor for medical services furnished in January 2008 to Contractor’s
enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims PMPM experience for
covered services calculated in accordance with the provision of Section 8
L of this amendment applied to the number of Contractor’s enrollees in
January 2008.
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E.
On or before April 15, 2008 the Department shall advance a payment
to the Contractor for medical services furnished in January 2008 to
Contractor’s enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims experience for covered calculated
in accordance with the provision of Section 8 L of this amendment applied
to the number of Contractor’s enrollees in January
2008.
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F.
On or before March 15, 2008, the Department shall advance a payment
to the Contractor for medical services furnished in February 2008 to
Contractor’s enrollees. The payment shall be equal
to 60% of Contractor’s monthly claims PMPM experience for
covered services calculated in accordance with the provision of Section 8L
of this amendment applied to the number of Contractor’s enrollees in
February 2008.
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G.On
or before April 15, 2008 the Department shall advance a payment to the
Contractor for medical services furnished in February 2008 to Contractor’s
enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims PMPM experience for
covered services calculated in accordance with the provision of Section 8
L of this amendment applied to the number of Contractor’s enrollees in
February 2008.
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H.On
or before May 15, 2008 the Department shall advance a payment to the
Contractor for medical services furnished in February 2008 to Contractor’s
enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims experience for covered calculated
in accordance with the provision of Section 8 L of this amendment applied
to the number of Contractor’s enrollees in February
2008.
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I.
On or before April 15, 2008, the Department shall advance a payment
to the Contractor for medical services furnished in March 2008 to
Contractor’s enrollees. The payment shall be equal
to 60% of Contractor’s monthly claims PMPM experience for
covered services calculated in accordance with the provision of Section 8
L of this amendment applied to the number of Contractor’s enrollees in
March 2008.
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J.
On or before May 15, 2008 the Department shall advance a payment to
the Contractor for medical services furnished in March 2008 to
Contractor’s enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims PMPM experience for
covered services calculated in accordance with the provision of Section 8
L of this amendment applied to the number of Contractor’s enrollees in
March 2008.
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K.On
or before June 15, 2008 the Department shall advance a payment to the
Contractor for medical services furnished in March 2008 to Contractor’s
enrollees. The payment shall be equal to 20% of
Contractor’s monthly claims experience for covered calculated
in accordance with the provision of Section 8 L of this amendment applied
to the number of Contractor’s enrollees in March
2008.
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L.
For the purposes of calculating the Contractor’s monthly
claims PMPM experience for covered services, the Department shall
calculate a PMPM that shall be applied to the number of Contractor
enrollees each month. The PMPM shall equal 85% of the
risk-based average PMPM premium payment paid to the Contractor in January
2008 for December 2007
enrollees.
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M.Through
July 31, 2008 the Contractor shall be responsible for
adjudicating claims for services rendered from January 1, 2008 through
March 31, 2008 to Contractor’s enrollees. From the effective
date of this amendment through September 15, 2008 the
Contractor shall, on a monthly basis submit to the
Department capitated payment data and HIPAA-compliant paid
claims file that must report the following data elements: date
of service, date of payment, Member name, Member Medicaid Eligibility ID
number, Provider name, Provider FEIN, claim number, location of service,
service diagnosis/procedure and paid amount for claims adjudicated by the
Contractor for services rendered from January 1, 2008 through March 31,
2008 to Contractor’s enrollees. On or
before September 15, 2008 the Contractor shall submit to the
Department final HIPAA-compliant paid claims data and capitated payment
data for claims adjudicated by the Contractor for services rendered from
January 1, 2008 through March 31, 2008 to Contractor’s
enrollees. By October 31, 2008 the Department shall conduct a
reconciliation of actual medical expenses incurred by Contractor’s
enrollees from January 1, 2008 through March 31, 2008 utilizing
the paid claims data file supplied by the Contractor to the Department
with the Contractor’s invoice for payment and the Contractor’s encounter
data required pursuant to Part II Section 3.38h including the following
data elements: date of service, date of payment, member name, Member
Medicaid Eligibility ID number, provider name, provider FEIN, claim
number, location of service, service diagnosis/procedure and paid
amount. If following the completion of the reconciliation the
payments made by the Department to the Contractor under subsections C
through K exceed the actual medical expenses incurred by the Contractor
for services rendered from January 1, 2008 through March 31,
2008 to Contractor’s enrollees, the Contractor shall reimburse the
Department the excess payment. If, however, following the
completion of the reconciliation the payments made by the Department to
the Contractor under subsections C through K were less than the
actual medical expenses incurred by the Contractor for services rendered
in January 1, 2008 through March 31, 2008 to Contractor’s
enrollees, the Department shall reimburse the Contractor the difference
between the total of the payments made by the Department to the Contractor
for medical expenses and the total actual medical expenses incurred
from January 1, 2008 through March 31, 2008 by the Contractor’s
enrollees. Payment to the Department or the Contractor in accordance with
this subsection shall be made by November 30,
2008.
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9.
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Paragraphs
11 through and including 17 of Amendment 22 remain in full force and
effect.
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10.
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Pursuant
to Public Act 07-1, An Act Concerning the State Contractor Contribution
Ban and Gifts to State and Quasi-Public Agencies the Department must
provide and each Contractor must acknowledge receipt of the State
Elections Enforcement Commission’s notice advising state contractors of
state campaign
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contribution
and solicitation prohibitions. Through the execution of this
amendment the Department certifies that SEEC FORM 11 -
NOTICE TO
EXECUTIVE BRANCH STATE CONTRACTORS AND PROSPECTIVE STATE CONTRACTORS OF
CAMPAIGN CONTRIBUTION AND SOLICITATION BAN has been provided to the
Contractor and the Contractor acknowledges receipt of the
same.
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ACCEPTANCES
AND APPROVALS
This
document constitutes an amendment to the above numbered contract. All provisions
of that contract, except those explicitly changed or described above
in this or in all prior amendments, remain in full force
and effect.
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CONTRACTOR
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DEPARTMENT
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WellCare
of Connecticut, Inc.
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Department
of Social Services
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/s/ Xxxxx
Xxxxxxxxx
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2/28/2008
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/s/ Xxxxxxx
X. Xxxxxxxxxx
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2/29/08
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Signature
(Authorized Official)
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Date
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Signature
(Authorized Official)
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Date
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Xxxxx
Xxxxxxxxx
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President
& CEO
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Xxxxxxx
X. Xxxxxxxxxx
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Commissioner
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Typed
Name (Authorized Official)
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Title
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Typed
Name (Authorized Official)
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Title
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OFFICE
OF THE ATTORNEY GENERAL
Attorney
General (as to
form) Date
( ) This contract does not
require the signature of the Attorney General pursuant to an agreement between
the Department and the Office of the Attorney General dated:
______________
