Contractual Document (CD) Responsible Office: HHSC Office of General Counsel (OGC) HHSC Contract No. 529-06-0280-00002R
Exhibit 10.20.6
| Contractual Document (CD) |  |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
Part 1: Parties to the Contract:
This Contract Amendment (the “Amendment”) is between the Texas Health and Human Services
Commission (HHSC), an administrative agency within the executive department of the State of
Texas, having its principal office at 0000 Xxxxx Xxxxx Xxxxxxxxx, Xxxxxx, Xxxxx 00000, and
Amerigroup Texas, Inc. (HMO) a corporation organized under the laws of the State of
Texas, having its principal place of business at: 0000 X. Xxxxxxx 000, Xxxxx 000, Xxxxx
Xxxxxxx, Xxxxx 00000. HHSC and HMO may be referred to in this Amendment individually as a
“Party” and collectively as the “Parties.”
The Parties hereby agree to amend their original contract, HHSC contract number
529-06-0280-00002 (the “Contract”) as set forth herein. The Parties agree that the terms of the
Contract will remain in effect and continue to govern except to the extent modified in this
Amendment.
This Amendment is executed by the Parties in accordance with the authority granted in
Attachment A to the HHSC Managed Care Contract document, “HHSC Uniform Managed Care Contract
Terms & Conditions,” Article 8, “Amendments and Modifications.”
| Part 2: Effective Date of | Part 3: Contract Expiration | |||
| Amendment: | Date | Part 4: Operational Start Date: | ||
December 1, 2010
|
August 31, 2013 | STAR and CHIP HMOs: September 1, 2006 | ||
| STAR+PLUS HMOs: February 1, 2007 | ||||
| CHIP Perinatal HMOs: January 1, 2007 |
Part 5: Project Managers:
HHSC:
|
HMO: | |
Xxxxx Xxxxxxxxxx
|
Xxxxxx XxXxxxxxx | |
Director, Health Plan Operations
|
Amerigroup Texas, Inc. | |
00000 Xxxxxx Xxxxxxxxx, Xxxxxxxx H
|
0000 Xxxxxxx Xxxxxxxx, Xxxxx 000 | |
Xxxxxx, Xxxxx 00000
|
Xxxxxxx, Xxxxx 00000 | |
Phone: 000-000-0000
|
Phone: 000-000-0000 | |
Fax: 000-000-0000
|
Fax: 000-000-0000 | |
| E-mail: xxxxxxx@xxxxxxxxxxxxxx.xxx |
Part 6: Deliver Legal Notices to:
HHSC:
|
HMO: | |
General Counsel
|
Amerigroup Texas, Inc. | |
0000 Xxxxx Xxxxx Xxxxxxxxx, 4th
Floor
|
0000 Xxxxxxx Xxxxxxxx, Xxxxx 000 | |
Xxxxxx, Xxxxx 00000
|
Xxxxxxx, Xxxxx 00000 | |
Fax: 000-000-0000
|
Fax: 000-000-0000 |
Part 7: HMO Programs and Service Areas:
This Contract applies to the following HHSC HMO Programs and Service Areas (check all that apply). All references in the Contract Attachments to
HMO Programs or Service Areas that are not checked are superfluous and do not apply to the HMO.
Page 1 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
þ Medicaid STAR HMO Program
Service Areas:
|
o Bexar | o Lubbock | |||
| þ Dallas | þ Nueces | ||||
| o El Paso | þ Tarrant | ||||
| þ Xxxxxx | þ Xxxxxx |
See Attachment B-6, “Map of Counties with HMO Program Service Areas,” for listing of counties
included within the STAR Service Areas.
þ Medicaid STAR+PLUS HMO Program
Service Areas:
|
þ Bexar | o Nueces | |||
| þ Xxxxxx | þ Xxxxxx |
See Attachment B-6.1, “Map of Counties with STAR+PLUS HMO Program Service Areas,” for listing
of counties included within the STAR+PLUS Service Areas.
þ CHIP HMO Program
Core Service Areas:
|
o Bexar | þ Nueces | |||
| þ Dallas | þ Tarrant | ||||
| o El Paso | o Travis | ||||
| þ Xxxxxx | |||||
| o Lubbock | |||||
Optional Service Areas:
|
o Bexar | o Lubbock | |||
| o El Paso | o Nueces | ||||
| o Xxxxxx | x Xxxxxx |
See Attachment B-6, “Map of Counties with HMO Program Service Areas,” for listing of counties
included within the CHIP Core Service Areas and CHIP Optional Service Areas.
þ CHIP Perinatal Program
Core Service Areas:
|
o Bexar | o Nueces | |||
| o Dallas | þ Tarrant | ||||
| o El Paso | o Xxxxxx | ||||
| x Xxxxxx | |||||
| o Lubbock |
Page 2 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
Optional Service Areas:
|
o Bexar | o Lubbock | ||
| o El Paso | o Nueces | |||
| o Xxxxxx | x Xxxxxx |
See Attachment B-6.2, “Map of Counties with CHIP Perinatal HMO Program Service Areas,” for a
list of counties included within the CHIP Perinatal Service Areas.
Part 8: Payment
Part 8 of the HHSC Managed Care Contract document, “Payment,” is modified to add the capitation
rates for Rate Period 5.
þ Medicaid STAR HMO PROGRAM
Capitation: See Attachment A, “HHSC Uniform Managed Care Contract Terms and
Conditions,” Article 10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the STAR Program. The following Rate Cells and Capitation
Rates will apply to Rate Period 5:
Service Area: DALLAS
| Rate Period 5 | Rate Period 5 | ||||||||
| Rate Cell | 9/1/10-11/30/10 | 12/1/10-8/31/10 | |||||||
| 1 | TANF Child > 12 months |
$ | 127.00 | $ | 127.20 | ||||
| 2 | TANF child < 12 months |
$ | 412.12 | $ | 417.34 | ||||
| 3 | TANF Adult |
$ | 312.44 | $ | 307.23 | ||||
| 4 | Pregnant Woman |
$ | 551.81 | $ | 540.79 | ||||
| 5 | Newborn < 12 months |
$ | 581.95 | $ | 580.65 | ||||
| 6 | Expansion
Child > 12 months |
$ | 148.81 | $ | 149.31 | ||||
| 7 | Expansion child < 12 months |
$ | 265.57 | $ | 267.77 | ||||
| 8 | Federal Mandate child |
$ | 105.44 | $ | 105.54 | ||||
| 9 | Delivery Supplemental Payment |
$ | 3,537.13 | $ | 3,537.13 | ||||
| 10. | Bariatric Supplemental Payment |
$ | 23,000.00 | $ | 23,000.00 | ||||
Page 3 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
Service Area: XXXXXX
| Rate Period 5 | Rate Period 5 | |||||||||
| Rate Cell | 9/1/10-11/30/10 | 12/1/10-8/31/10 | ||||||||
| 1 | TANF Child > 12 months |
$ | 130.00 | $ | 128.57 | |||||
| 2 | TANF child < 12 months |
$ | 371.17 | $ | 369.78 | |||||
| 3 | TANF Adult |
$ | 508.17 | $ | 481.84 | |||||
| 4 | Pregnant Woman |
$ | 605.75 | $ | 565.49 | |||||
| 5 | Newborn < 1 2 months |
$ | 670.32 | $ | 681.16 | |||||
| 6 | Expansion Child > 12 months |
$ | 125.14 | $ | 124.59 | |||||
| 7 | Expansion child < 12 months |
$ | 290.90 | $ | 289.07 | |||||
| 8 | Federal Mandate child |
$ | 98.76 | $ | 98.03 | |||||
| 9 | Delivery Supplemental Payment |
$ | 3,519.20 | $ | 3,519.20 | |||||
| 10. | Bariatric Supplemental Payment |
$ | 23,000.00 | $ | 23,000.00 | |||||
| Service Area: NUECES | ||||||||||
| Rate Period 5 | Rate Period 5 | |||||||||
| Rate Cell | 9/1/10-11/30/10 | 12/1/10-8/31/10 | ||||||||
| 1 | TANF Child > 12 months |
$ | 159.39 | $ | 160.82 | |||||
| 2 | TANF child < 12 months |
$ | 460.06 | $ | 471.71 | |||||
| 3 | TANF Adult |
$ | 392.84 | $ | 396.17 | |||||
| 4 | Pregnant Woman |
$ | 570.50 | $ | 601.66 | |||||
| 5 | Newborn < 12 months |
$ | 834.51 | $ | 857.24 | |||||
| 6 | Expansion Child > 12 months |
$ | 172.14 | $ | 173.83 | |||||
| 7 | Expansion child < 12 months |
$ | 415.97 | $ | 422.71 | |||||
| 8 | Federal Mandate child |
$ | 124.49 | $ | 125.16 | |||||
| 9 | Delivery Supplemental Payment |
$ | 3,203.82 | $ | 3,203.82 | |||||
| 10. | Bariatric Supplemental Payment |
$ | 23,000.00 | $ | 23,000.00 | |||||
Page 4 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
Service Area: TARRANT
| Rate Period 5 | Rate Period 5 | ||||||||
| Rate Cell | 9/1/10-11/30/10 | 12/1/10-8/31/10 | |||||||
| 1 | TANF Child > 12 months |
$ | 131.00 | $ | 129.96 | ||||
| 2 | TANF child < 12 months |
$ | 266.98 | $ | 268.87 | ||||
| 3 | TANF Adult |
$ | 313.54 | $ | 303.42 | ||||
| 4 | Pregnant Woman |
$ | 530.17 | $ | 482.71 | ||||
| 5 | Newborn < 12 months |
$ | 633.85 | $ | 612.33 | ||||
| 6 | Expansion
Child > 12 months |
$ | 134.77 | $ | 134.74 | ||||
| 7 | Expansion child < 12 months |
$ | 247.30 | $ | 247.33 | ||||
| 8 | Federal Mandate child |
$ | 100.70 | $ | 100.38 | ||||
| 9 | Delivery Supplemental Payment |
$ | 3,635.64 | $ | 3,635.64 | ||||
| 10. | Bariatric Supplemental Payment |
$ | 23,000.00 | $ | 23,000.00 | ||||
Service Area: XXXXXX
| Rate Period 5 | Rate Period 5 | ||||||||
| Rate Cell | 9/1/10-11/30/10 | 12/1/10-8/31/10 | |||||||
| 1 | TANF Child > 12 months |
$ | 115.31 | $ | 114.51 | ||||
| 2 | TANF child < 12 months |
$ | 224.84 | $ | 219.17 | ||||
| 3 | TANF Adult |
$ | 301.35 | $ | 281.05 | ||||
| 4 | Pregnant Woman |
$ | 577.45 | $ | 510.63 | ||||
| 5 | Newborn < 12 months |
$ | 707.57 | $ | 691.19 | ||||
| 6 | Expansion Child > 12 months |
$ | 118.36 | $ | 118.36 | ||||
| 7 | Expansion child < 12 months |
$ | 337.34 | $ | 337.64 | ||||
| 8 | Federal Mandate child |
$ | 92.99 | $ | 92.80 | ||||
| 9 | Delivery Supplemental Payment |
$ | 3,247.49 | $ | 3,247.49 | ||||
| 10. | Bariatric Supplemental Payment |
$ | 23,000.00 | $ | 23,000.00 | ||||
STAR SSI Administrative Fee: HHSC will pay a STAR HMO a monthly Administrative Fee of
$14.00 per SSI Beneficiary who voluntarily enrolls in the HMO in accordance with Attachment A,
“HHSC Uniform Managed Care Contract Terms and Conditions,” Article 10.
Delivery Supplemental Payment: See Attachment A, “HHSC Uniform Managed Care Contract Terms
and Conditions,” Article 10, for a description of the methodology for establishing the Delivery
Supplemental Payment for the STAR Program.
Bariatric Supplemental Payment: See Attachment A, “HHSC Uniform Managed Care Contract Terms
and Conditions,” Article 10, for a description of the methodology for establishing the Bariatric
Supplemental Payment for the STAR Program.
Page 5 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
þ Medicaid STAR+PLUS HMO Program
Capitation: See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and the Capitation Payment
requirements for the STAR+PLUS Program. The following Rate Cells and Capitation Rates will apply to
Rate Period 5:
| STAR+PLUS Service Area: BEXAR | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1. | Medicaid Only Standard Rate |
$ | 530.20 | |||
| 2. | Medicaid Only 1915(C) Nursing Facility Waiver Rate |
$ | 2,967.95 | |||
| 3. | Dual Eligible Standard Rate |
$ | 270.12 | |||
| 4. | Dual Eligible 1915(C) Nursing Facility Waiver Rate |
$ | 1,672.83 | |||
| 5. | Nursing Facility – Medicaid Only |
$ | 530.20 | |||
| 6. | Nursing Facility – Dual Eligible |
$ | 270.12 | |||
| 7. | Bariatric Supplemental Payment |
$ | 23,000.00 | |||
| STAR+PLUS Service Area: XXXXXX (Xxxxxx Co. & Xxxxxx Contiguous) | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1. | Medicaid Only Standard Rate |
$ | 633.41 | |||
| 2. | Medicaid Only 1915(C) Nursing Facility Waiver Rate |
$ | 3,382.71 | |||
| 3. | Dual Eligible Standard Rate |
$ | 227.94 | |||
| 4. | Dual Eligible 1915(C) Nursing Facility Waiver Rate |
$ | 1,488.08 | |||
| 5. | Nursing Facility – Medicaid Only |
$ | 633.41 | |||
| 6. | Nursing Facility – Dual Eligible |
$ | 227.94 | |||
| 7. | Bariatric Supplemental Payment |
$ | 23,000.00 | |||
Page 6 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
| START+PLUS Service Area: XXXXXX | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1. | Medicaid Only Standard Rate |
$ | 631.23 | |||
| 2. | Medicaid Only 1915(C) Nursing Facility Waiver Rate |
$ | 3,825.77 | |||
| 3. | Dual Eligible Standard Rate |
$ | 175.39 | |||
| 4. | Dual Eligible 1915(C) Nursing Facility Waiver Rate |
$ | 1,803.90 | |||
| 5. | Nursing Facility – Medicaid Only |
$ | 631.23 | |||
| 6. | Nursing Facility – Dual Eligible |
$ | 175.39 | |||
| 7. | Bariatric Supplemental Payment |
$ | 23,000.00 | |||
Bariatric Supplemental Payment: See Attachment A, “HHSC Uniform Managed Care Contract Terms
and Conditions,” Article 10, for a description of the methodology for establishing the Bariatric
Supplemental Payment for the STAR+PLUS Program.
þ CHIP HMO PROGRAM
Capitation: See Attachment A, “HHSC Uniform Managed Care Contract Terms and
Conditions,” Article 10, for a description of the Capitation Rate-setting methodology and the
Capitation Payment requirements for the CHIP Program. The following Rate Cells and Capitation Rates
will apply to Rate Period 5:
| Service Area: DALLAS | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1 | < Age 1 |
$ | 130.73 | |||
| 2 | Ages 1 through 5 |
$ | 97.67 | |||
| 3 | Ages 6 through 14 |
$ | 77.66 | |||
| 4 | Ages 15 through 18 |
$ | 114.22 | |||
Page 7 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
| Service Area: XXXXXX | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1 | < Age 1 |
$ | 160.66 | |||
| 2 | Ages 1 through 5 |
$ | 96.69 | |||
| 3 | Ages 6 through 14 |
$ | 71.82 | |||
| 4 | Ages 15 through 18 |
$ | 106.50 | |||
| Service Area: NUECES | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1 | < Age 1 |
$ | 56.67 | |||
| 2 | Ages 1 through 5 |
$ | 99.33 | |||
| 3 | Ages 6 through 14 |
$ | 66.94 | |||
| 4 | Ages 15 through 18 |
$ | 109.97 | |||
| Service Area: TARRANT | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1 | < Age 1 |
$ | 203.57 | |||
| 2 | Ages 1 through 5 |
$ | 85.80 | |||
| 3 | Ages 6 through 14 |
$ | 65.44 | |||
| 4 | Ages 15 through 18 |
$ | 98.55 | |||
Delivery Supplemental Payment: See Attachment A, “HHSC Uniform Managed Care Contract
Terms and Conditions,” Article 10, for a description of the methodology for establishing the
Delivery Supplemental Payment for the CHIP Program. The CHIP Delivery Supplemental Payment is
$3,100.00 for all Service Areas.
Page 8 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
þ CHIP Perinatal Program
Capitation: See Attachment A, “HHSC Uniform Managed Care Contract Terms and Conditions,”
Article 10, for a description of the Capitation Rate-setting methodology and the Capitation Payment
requirements for the CHIP Perinatal Program.
| Service Area: TARRANT | ||||||
| Rate Period 5 | ||||||
| Rate Cell | Capitation Rates | |||||
| 1 | Perinate Newborn 0% to 185% |
$ | 276.50 | |||
| 2 | Perinate Newborn Above 185% to 200% |
$ | 508.97 | |||
| 3 | Perinate 0% to 185% |
$ | 433.32 | |||
| 4 | Perinate Above 185% to 200% |
$ | 345.91 | |||
Delivery Supplemental Payment: See Attachment A, “HHSC Uniform Managed Care Contract Terms
and Conditions,” Article 10, for a description of the methodology for establishing the Delivery
Supplemental Payment for the CHIP Perinatal Program. The CHIP Perinatal Delivery Supplemental
Payment is $3,100.00 for Perinates between 186% and 200% of the Federal Poverty Level for all
Service Areas.
Part 9: Contract Attachments:
Modifications to Part 9 of the HHSC Managed Care Contract document, “Contract Attachments,”
are italicized below:
A: HHSC Uniform Managed Care Contract Terms & Conditions – Version 1.16 is replaced with Version
1.17
B: Scope of Work/Performance Measures – Version 1.16 is replaced with Version 1.17 for all
attachments, except if noted.
B-1: HHSC RFP 000-00-000, Sections 6-9
B-2: Covered Services
B-2.1 STAR+PLUS Covered Services
B-2.2 CHIP Perinatal Program Covered Services
B-3: Value-added Services
B-3.1 STAR+PLUS Value-added Services
B-3.2 CHIP Perinatal Program Value-added
Services
B-4: Performance Improvement Goals
B-4.1 SFY 2008 Performance Improvement Goals
B-5: Deliverables/Liquidated Damages
Matrix
B-6: Map of Counties with STAR and CHIP HMO Program Service Areas
B-6.1 STAR+PLUS Service Areas
Page 9 of 10
| Contractual Document (CD) | |
Responsible Office: HHSC Office of General Counsel (OGC)
|
HHSC Contract No. 529-06-0280-00002R |
Subject: HHSC Managed Care Contract
B-6.2 CHIP Perinatal Program Service Areas
B-7: STAR+PLUS Attendant Care Enhanced Payment Methodology
| C: HMO’s Proposal and Related Documents |
C-1: HMO’s Proposal
C-2: HMO Supplemental Responses
C-3: Agreed Modifications to HMO’s Proposal
C-2: HMO Supplemental Responses
C-3: Agreed Modifications to HMO’s Proposal
Part 10: Special Provision for Nueces Service Area
Attachment A, Section 10.04 is amended to include sub-part (b) as follows:
| (b) In addition to the reasons set forth in Section 10.04(a), the Parties expressly understand and agree that HHSC may, at any time, unilaterally adjust the Rate Period 2 STAR Program Capitation Rates for the Nueces Service Area. HHSC is entitled to unilaterally adjust such rates, prospectively and/or retrospectively, if it determines that: (1) the cumulative Rate Period 2 Encounter Data for all HMOs in the Nueces Service Area does not support the Capitation Rates; or (2) economic factors in the Nueces Service Area significantly and measurably impact providers or the delivery of Covered Services to Members. For adjustments made pursuant to this Section 10.04(b), HHSC will provide written notice at least ten (10) Business Days before: (1) the effective date of a prospective adjustment; (2) offsetting Capitation Payments to recover retrospective adjustments. Any adjustments to the Rate Period 2 Capitation Rates must meet the actuarial soundness requirements of Attachment A, Section 10.03, “Certification of Capitation Rates.” |
Part 11: Signatures:
The Parties have executed this Contract Amendment in their capacities as stated below with
authority to bind their organizations on the dates set forth by their signatures. By signing this
Amendment, the Parties expressly understand and agree that this Amendment is hereby made part of
the Contract as though it were set out word for word in the Contract.
Texas Health and Human Services Commission
|
Amerigroup Texas, Inc. | |
/s/ Xxxxxxx X. Xxxx, M.D.
|
/s/ Xxxxxx XxXxxxxxx
|
|
Deputy Executive Commissioner for Health Services
|
Title: President and CEO | |
Date: 11/5/10
|
Date: October 13, 2010 |
Page 10 of 10
