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Back to Form 8-K [form8k.htm]
 
Exhibit 10.1

 
STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
 
 
CONTRACT AMENDMENT

 
Amendment Number:
23
Contract #:
093-MED-WCC-1
Contract Period:
08/11/2001 –  03/31/08
Contractor Name:
WELLCARE OF CONNECTICUT, INC.
Contractor Address:
116 Washington Avenue, 2nd Floor  North Haven, CT  06473

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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:
 
1.
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.

 
2.
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.

 
3.
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.

 
4.
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.

 
5.
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.

 
6.
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.
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.

 
8.
Paragraph 10 and each subsection in Paragraph 10 of Amendment 22 is deleted in
their entirety and replaced with the following:

 
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:
 
 
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.

 
 
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.

 
 
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.

 
 
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.

 
 
 
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.

 
 
 
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.

 
 
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.

 
 
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.

 
 
 
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.

 
 
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.

 
 
 
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.

 
 
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.

 
9.
Paragraphs 11 through and including 17 of Amendment 22 remain in full force and
effect.

 
10.
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.

 
 
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.
 
CONTRACTOR
DEPARTMENT
WellCare of Connecticut, Inc.
Department of Social Services
  /s/  Heath Schiesser
2/28/2008
/s/  Michael P. Starkowski
2/29/08
Signature (Authorized Official)
Date
 
Signature (Authorized Official)
Date
Heath Schiesser
President & CEO
Michael P. Starkowski
Commissioner
Typed Name (Authorized Official)
Title
Typed Name (Authorized Official)
Title

 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: ______________

 
 

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