Exhibit 10.12

 

LOGO [g275632ex1012pg01.jpg]  

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE

 

CONTRACT AMENDMENT

 

1.     AMENDMENT NUMBER:

 

2.      CONTRACT NO.:

 

3.     EFFECTIVE DATE OF AMENDMENT:

 

4.      PROGRAM

12   YH14-0001-07   October 1, 2014   DHCM - ACUTE

 

5. CONTRACTOR’S NAME AND ADDRESS:

Health Choice Arizona

410 N. 44th Street, Suite 900

Phoenix, AZ 85008

 

6. PURPOSE: To retroactively amend select Capitation Rates for the month of
October, 2014.

 

7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS

Section 9010 of the Patient Protection and Affordable Care Act (ACA) requires
that the Contractor pay a Health Insurer Assessment Fee (HIF) annually based on
its respective market share of premium revenues from the preceding year
(calendar year 2014 revenue). AHCCCS provides funding to the Contractor for the
Health Insurer Assessment Fee and associated taxes subject to receipt and review
of documentation from the Contractor as required by AHCCCS.

This contract amendment serves to retroactively adjust the October, 2014
prospective capitation rates to include the federal and state income taxes
associated with the 2015 Health Insurer Assessment Fee, and amends the following
sections of the contract:

 

  •   Section B, Capitation Rates and Contractor Specific Information

Prospective Capitation Rates (Per Member — Per Month) revised for the month of
October, 2014 as shown below

October 1, 2014 – October 31, 2014

 

     GSA 4      GSA 08      GSA 10      GSA 12  

County

   (Apache, Coconino,
Mohave, Navajo)      (Gila, Pinal)      (Pima Only)      Maricopa  

TANF/KC < 1

   $ 443.25 $604.01       $

$

476.54

649.37

  

  

   $

$

413.43

563.37

  

  

   $ 484.48 $656.10   

TANF/KC 1-13

   $ 102.51 $139.69       $

$

99.43

135.49

  

  

   $

$

83.68

114.03

  

  

   $ 103.53 $141.08   

TANF/KC 14-44 F

   $ 250.03 $340.71       $

$

259.30

353.34

  

  

   $

$

213.82

291.37

  

  

   $ 230.96 $314.72   

TANF/KC 14-44 M

   $ 168.67 $229.84       $

$

160.67

218.94

  

  

   $

$

130.98

178.48

  

  

   $ 140.10 $190.91   

TANF 45+

   $ 388.55 $529.47       $

$

443.32

602.74

  

  

   $

$

339.90

463.17

  

  

   $ 399.04 $543.76   

SSIW

   $ 106.36 $144.93       $

$

134.29

182.99

  

  

   $

$

105.33

143.53

  

  

   $ 132.52 $180.58   

SSIWO

   $ 876.16 $1193.92       $

$

714.07

973.05

  

  

   $

$

656.66

894.81

  

  

   $ 759.13 $1034.45   

*AHCCCS Care

   $ 403.17 $549.39       $

$

411.32

560.50

  

  

   $

$

326.32

444.67

  

  

   $ 419.06 $571.04   

**Newly Eligible Adults

   $ 313.93 $427.78       $

$

317.41

432.53

  

  

   $

$

268.00

365.20

  

  

   $ 315.97 $430.56   

 

* This group was known as AHCCCS Care for the October 2014 capitation
rate-setting; this is now referred to as Adult Group at or below 106% Federal
Poverty Level (Adults </= 106%).

** This group was known as Newly Eligible Adults for the October 2014 capitation
rate-setting; this is now referred to as Adult Group above 106% Federal Poverty
Level (Adults > 106%).

 

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LOGO [g275632ex1012pg02a.jpg]  

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE

 

CONTRACT AMENDMENT

 

8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL
CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL
EFFECT.

IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT.

 

9.      SIGNATURE OF AUTHORIZED REPRESENTATIVE:

 

10.    SIGNATURE OF AHCCCS CONTRACTING OFFICER:

LOGO [g275632ex1012pg02b.jpg]   LOGO [g275632ex1012pg02c.jpg] TYPED NAME:  
TYPED NAME: MIKE UCHRIN   MEGGAN HARLEY TITLE:   TITLE: ADMINISTRATOR/CEO  
PROCUREMENT MANAGER DATE:   DATE: 12/2/15   11/16/2015

 

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