exv10w3






Exhibit 10.3



Confidential treatment pursuant to Rule 24b-2 of the Securities Exchange Act of 1934 has been
requested with respect to portions of pages 12-14 of this contract exhibit. The omitted
confidential portions of the contract exhibit have been filed separately with the Commission.




STATE OF CALIFORNIA

STANDARD AGREEMENT AMENDMENT

STD 213A (DHS Rev 7/04)




	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 
	 

	 	 	
AGREEMENT NUMBER
	 	 	
AMENDMENT NUMBER	 
	x CHECK HERE IF ADDITIONAL PAGES ARE ADDED 20 PAGES

	 	 	
05-46130 


	 	 	
A-01

	 
	 	 	 	 	 	 	 	 
	 	 	 	
REGISTRATION NUMBER:

	 
	 	 	 	 	 	 	 	 





									
	 1.	 	This Agreement is entered into between the State Agency and Contractor named below:
	 	 	 	 	 
	 

	 	STATE AGENCY’S NAME
	 	 	 	(Also referred to as CDHS, DHS, or the State)	 	 
	 	 	California Department of Health Services	 	 
	 	 	 	 	 
	 

	 	CONTRACTOR’S NAME
	 	 	 	(Also referred to as Contractor)	 	 
	 	 	Molina Healthcare of California Partner Plan, Inc.	 	 
	 	 	 
	 2.

	 	The term of this	 	 	 	 	 	 
	 	 	Agreement is	 	January 1, 2006      
      
through
           
December 31, 2008	 	 
	 	 	 
	 3.	 	The maximum amount	 	 $428,964,000	 	 
	 	 	of this Agreement is:	 	Four Hundred Twenty-eight Million Nine Hundred Sixty-four Thousand Dollars
	 	 	 
	 4.	 	The parties mutually agree to this amendment as follows. All actions noted below are
by this reference made a part of the Agreement and incorporated herein:







	 	1)	 	Amendment effective date: April 12, 2007
	 
	 	2)	 	Purpose of amendment: To amend quality improvement language; to add an additional
aid code; to remove some aid codes; to amend the Non-Contracting Emergency Service Providers language; to
remove Medicare
Part D as a Covered Service; to amend the Alcohol and Substance Abuse Treatment Services
language and to
add its related Attachment 10-C; to add the Erectile Dysfunction language and to add its
related Attachment 10-
D; to amend Attachment 10-B; to amend the Grievance language; to amend the enrollment
capacity; to amend
the Negotiation/ Determination of Rates language; to extend the contract term; to add the
Confidential Contract
Terms language; to add the Federal False Claim Act Compliance language; to amend payment
provision
language; to adjust rates and to adjust the encumbrances/amounts payable accordingly.
	 
	 	3)	 	Exhibit A, Attachment 4 Quality Improvement System, Section 9 External Quality
Review Requirements,
is amended to read:





(Continued on next page)





	 	All other terms and conditions shall remain the same.






IN
WITNESS WHEREOF, this Agreement has been executed by the parties
hereto.




							
	 	 	 	 	 
	
CONTRACTOR

	 	 	CALIFORNIA

Department of General Services
Use Only	 
	 	 	 	 
	CONTRACTOR’S NAME (If other than an individual, state whether a corporation, partnership, etc.)
	 	 	 
	 Molina Healthcare of California Partner Plan, Inc.	 	 	 
	 	 	 	 	 	 
	BY (Authorized Signature)


	 	DATE SIGNED (Do not type)	 	 	 	 
	 
	 	 	 	 	 	 
	 /s/ Stephen T. O’Dell
	 	4/25/07 	 	 	 	 
	 	 	 	 	 
	PRINTED NAME AND TITLE OF PERSON SIGNING
	 	 	 	 
	 
	 	 	 	 	 	 
	 Stephen T. O’Dell, President	 	 	 	 
	 	 	 	 	 
	ADDRESS
	 	 	 	 
	 One Golden Shore Drive	 	 	 	 
	 Long Beach, CA 90802	 	 	 	 
	 	 	 	 	 
	
STATE OF CALIFORNIA

	 	 	 	 
	 	 	 	 	 
	AGENCY NAME
	 	 	 	 
	 California Department of Health Services	 	 	 	 
	 	 	 	 	 	 
	BY (Authorized Signature)


	 	DATE SIGNED (Do not type)	 	 	 	 
	 
	 	 	 	 	 	 
	 /s/ Stan Rosenstein
	 	6/5/07 	 	 	 	 
	 	 	 	 	 
	PRINTED NAME AND TITLE OF PERSON SIGNING
	 	 	Exempt per:	 
	 
	 	 	 	 	o   Welfare and Institutions Code section 14087.55(c)
	 
	 Stan Rosenstein, Deputy Director, Medical Care Services	 	 	 
	 	 	 	 	 
	ADDRESS
	 	 	x   Welfare and Institutions Code section 14089.8(b)
	 
	 1501 Capitol Avenue, 6th Floor, MS 4000, PO Box 997413 
 Sacramento, CA 95899-7413	 	 	 
	 	 	 	 	 


















 





Molina Healthcare of California Partner Plan, Inc.

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	 	9.	 	External Quality Review Requirements






	 	D.	 	Quality Improvement Projects (QIPs)






	 	1)	 	For this Contract, Contractor is required to
conduct or participate in two Quality Improvement Projects (QIPs)
approved by DHS. If Contractor holds multiple managed care contracts
with DHS, Contractor is required to conduct or participate in two QIPs
for each contract.






	 	(a)	 	One QIP must be either an
internal quality improvement project (IQIP) or a small group
collaborative (SGC) facilitated by a health plan or DHS. The
SGC must include a minimum of two DHS health plan contractors
and must use standardized measures and clinical practice
guidelines. Additionally, all contracting health plans
participating in a SGC must agree to the same goal, timelines
for development, implementation, and measurement. Contracting
health plans participating in a SGC must also agree on the
nature of contracting health plan commitment of staff and other
resources to the collaborative project.
	 
	 	(b)	 	One QIP must be a DHS facilitated
Statewide Collaborative. If this Contract’s operation start
date is after the Statewide Collaborative has begun
implementation, upon DHS’ approval, Contractor may substitute a
SGC or an IQIP in place of the Statewide Collaborative.






	 	2)	 	If this Contract covers multiple counties,
Contractor must include all counties in a QIP unless otherwise approved
by DHS.
	 
	 	3)	 	Contractor shall comply with the MMCD All Plan
Letter 06010 and shall use the QIP reporting format designated therein
to request approval of proposed QIPs from DHS and to report at least
annually to DHS on the status of each QIP. The required documentation
for QIP proposals and for QIP status reports shall include but is not
limited to:






	 	a)	 	In-depth qualitative and
quantitative analysis of barriers and results.




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	 	b)	 	Evidence-based interventions and
best practices, when available, and system wide intervention,
when appropriate.
	 
	 	c)	 	Interventions that address health
disparities.
	 
	 	d)	 	Measurement of performance using
objective quality indicators.
	 
	 	e)	 	Strategies for sustaining and
spreading improvement beyond the duration of the QIP.






	4)	 	Exhibit A, Attachment 8 Provider Compensation Arrangements, Section 13 Non-Contracting
Emergency Service Providers, is amended to read:






	 	13.	 	Non-Contracting Emergency Service Providers






	 	A.	 	Contractor shall pay for Emergency Services received by a
Member from non-contracting providers. Payments to non-contracting providers
shall be for the treatment of the Emergency Medical Condition, including
Medically Necessary inpatient services rendered to a Member until the Member’s
condition has stabilized sufficiently to permit referral and transfer in
accordance with instructions from Contractor, or the Member is stabilized
sufficiently to permit discharge. The attending emergency physician, or the
provider treating the Member is responsible for determining when the Member is
sufficiently stabilized for transfer or discharge and that determination is binding on the Contractor. Emergency Services shall
not be subject to Prior Authorization by Contractor.
	 
	 	B.	 	At a minimum, Contractor must reimburse the non-contracting
emergency department and, if applicable, its affiliated providers for Physician
services at the lowest level of emergency department evaluation and management
CPT (Physician’s Current Procedural Terminology) codes, unless a higher level
is clearly supported by documentation, and for the facility fee and diagnostic
services such as laboratory and radiology.
	 
	 	C.	 	For all non-contracting providers, reimbursement by Contractor,
or by a subcontractor who is at risk for out-of-plan Emergency Services, for
properly documented claims for services rendered on or after January 1, 2007 by
a non-contracting provider pursuant to 




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	 	 	 	this provision shall be made in accordance with provision 5. Claims Processing, above, and 42 USC Section
1396u-2(b)(2)(D).






	 	D.	 	Contractor shall not refuse to cover reimbursement for
Emergency Services rendered by a non-contracting provider based on the
emergency room provider, hospital, or fiscal agent not notifying the Member’s
Primary Care Physician or Contractor of the Member’s screening and treatment
within 10 calendar days of presentation for emergency. Contractor shall not
limit what constitutes an Emergency Medical Condition solely on the basis of
lists of diagnoses or symptoms.
	 
	 	E.	 	In accordance with California Code of Regulations, Title 28,
Section 1300.71.4, Contractor shall approve or disapprove a request for
post-stabilization inpatient services made by a non-contracting provider on
behalf of a Member within 30 minutes of the request. If Contractor fails to
approve or disapprove authorization within the required timeframe, the
authorization will be deemed approved. Contractor is financially responsible
for post-stabilization service payment as provided in subprovision C above.
	 
	 	F.	 	Disputed Emergency Services claims may be submitted to DHS,
Office of Administrative Hearings and Appeals, 1029 J Street, Suite 200,
Sacramento, California, 95814 for resolution under the provisions of Welfare
and Institutions Code Section 14454 and California Code of Regulations, Title 22, Section 53620 et. seq., except
Section 53698. Contractor agrees to abide by the findings of DHS in such
cases, to promptly reimburse the non-contracting provider within 30 calendar
days of the effective date of a decision that Contractor is liable for
payment of a claim and to provide proof of reimbursement in such form as the
DHS Director may require. Failure to reimburse the non-contracting provider
and provide proof of reimbursement to DHS within 30 calendar days shall
result in liability offsets in accordance with Welfare and Institutions Code
Sections 14454(c) and 14115.5, and California Code of Regulations, Title 22,
Section 53702.




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	5)	 	Exhibit A, Attachment 9 Access and Availability, Section 12 Cultural and Linguistic Program,
is amended to read:






	 	12.	 	Cultural and Linguistic Program
	 
	 	 	 	Contractor shall have a Cultural and Linguistic Services Program that monitors,
evaluates, and takes effective action to address any needed improvement in the
delivery of culturally and linguistically appropriate services. Contractor shall
review and update their cultural and linguistic services consistent with the group
needs assessment requirements stipulated below.






	 	A.	 	Written Description
	 
	 	 	 	Contractor shall implement and maintain a written description of its
Cultural and Linguistic Services Program, which shall include at minimum the
following:






	 	1)	 	An organizational commitment to deliver
culturally and linguistically appropriate health care services.
	 
	 	2)	 	Goals and objectives.
	 
	 	3)	 	A timetable for implementation and
accomplishment of the goals and objectives.
	 
	 	4)	 	An organizational chart showing the key staff
persons with overall responsibility for cultural and linguistic
services and activities. A narrative shall explain the chart and
describe the oversight and direction to the Community Advisory
Committee, provisions for support staff, and reporting relationships.
Qualifications of staff, including appropriate education, experience
and training shall also be described.
	 
	 	5)	 	Standards and Performance requirements for the
delivery of culturally and linguistically appropriate health care
services.






	 	B.	 	Linguistic Capability of Employees
	 
	 	 	 	Contractor shall assess, identify and track the linguistic capability of
interpreters or bilingual employees and contracted staff (clinical and
non-clinical).




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	 	C.	 	Group Needs Assessment (GNA)
	 
	 	 	 	Contractor shall conduct group needs assessments as specified below, to
identify the health education and cultural and linguistic needs of its
Members; and utilize the findings for continuous development and improvement
of contractually required health education and cultural linguistic programs
and services.






	 	1)	 	Contractor shall conduct a GNA and submit a GNA
Summary to DHS every five years. Contractor shall conduct an initial
GNA within 12 months from the commencement of the Operations Period
unless within the last five years, Contractor has conducted a GNA and
submitted a GNA Summary to DHS for this Service Area, in which case,
Contractor will have until the end of the five-year term to conduct its
next GNA.
	 
	 	2)	 	Contractor shall submit a GNA Summary Report to
DHS at the completion of each GNA. The summary report must include:






	 	a)	 	The objectives; methodology; data
sources; survey instruments; findings and conclusions; program
and policy implications; and references contained in the GNA.
	 
	 	b)	 	The findings and conclusions must
include the following information for Medi-Cal plan Members: 1)
demographic profile; 2) related health risks, problems and
conditions; 3) related knowledge, attitudes and practices
including cultural beliefs and practices; 4) perceived health
education needs including learning needs, preferred methods of
learning and literacy level; 5) culturally competent community
resources.






	 	3)	 	Contractor shall demonstrate that GNA and
summary report findings and conclusions in item 2(b) above are utilized
for continuous development of its health education and cultural and
linguistic services program. Contractor must maintain documentation of
program priorities, target populations and program goals/objectives as
they are revised to meet the identified and changing needs of the
Member population.




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	 	4)	 	Contractor shall annually update the GNA
summary report including a current update on the information required
in 2(b) above. The GNA summary report updates shall be maintain and
available for DHS review.






	 	D.	 	The results of the GNA shall be considered in the development
of any Marketing materials prepared by the Contractor.
	 
	 	E.	 	Cultural Competency Training
	 
	 	 	 	Contractor shall provide cultural competency, sensitivity, or diversity
training for staff, providers and subcontractors at key points of contact.
The training shall cover information about the identified cultural groups in
the Contractor’s Service Areas, such as the groups’ beliefs about illness and health; methods of interacting with
providers and the health care structure; traditional home remedies that may
impact what the provider is trying to do to treat the patient; and language
and literacy needs.
	 
	 	F.	 	Program Implementation and Evaluation
	 
	 	 	 	Contractor shall develop and implement policies and procedures for assessing
the performance of individuals who provide linguistic services as well as
for overall monitoring and evaluation of the Cultural and Linguistic
Services Program.






	6)	 	Exhibit A, Attachment 10 Scope of Services, Section 1 Covered Services, is amended to read:






	 	1.	 	Covered Services
	 
	 	 	 	Contractor shall provide or arrange for all Medically Necessary Covered Services for
Members. Covered Services are those services set forth in Title 22, CCR, Chapter 3,
Article 4, beginning with Section 51301, and Title 17, CCR, Division 1, Chapter 4,
Subchapter 13, beginning with Section 6840, unless otherwise specifically excluded
under the terms of this Contract.
	 
	 	 	 	Except as set forth in Attachment 3.1.B.1 (effective 1/1/2006) of the California
Medicaid State Plan or as otherwise authorized by Welfare & Institutions Code
Section 14133.23, effective January 1, 2006, drug benefits for full-benefit dual
eligible beneficiaries who are eligible for drug benefits under Part D of Title
XVIII of the Social Security Act (42 USC 




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	 	 	 	Section 1395w-101 et seq) are not a Covered Service under this Contract. Consequently, effective January 1, 2006, the
capitation rates shall not include reimbursement for such drug benefits and existing
capitation rates shall be adjusted accordingly, even if the adjustment results in a
change of less than one percent of cost to Contractor. Additionally, Contractor
shall comply with all applicable provisions of the Medicare Prescription Drug
Improvement and Modernization Act of 2003, 42 USC 1395(x) et seq.






	7)	 	Exhibit A, Attachment 10-B, is amended to read:
	 
	 	 	EXCLUDED DRUGS FOR THE TREATMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND ACQUIRED
IMMUNODEFICIENCY SYNDROME (AIDS)
	 
	 	 	Generic Name




Abacavir Sulfate (Ziagen)

Abacavir /Lamivudine (Epzicom)

Amprenavir (Agenerase) Oral

Amprenavir (Agenerase) Tabs/Caps

Atazanavir Sulfate (Reyataz)

Delavirdine Mesylate (Rescriptor)

Efavirenz (Sustiva)

Emtricitabine (Emtriva)

Enfuvirtide (Fuzeon)

Fosamprenavir (Lexiva)

Indinavir Sulfate (Crixivan)

Lamivudine (Epivir)

Lopinavir/Ritonavir (Kaletra)

Nelfinavir Mesylate (Viracept)

Nevirapine (Viramune)

Ritonavir (Norvir)

Saquinavir (Fortovase)

Saquinavir Mesylate (Invirase)

Stavudine (Zirit)

Tenofovir Disoproxil Fumarate (Viread)

Tenofovir Disoproxil-Emtricitabine (Trudada)

Tipranavir

Zidovudine/Lamivudine (Combivir)

Zidovudine/Lamivudine/Abac Sulf (Trizivir)









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	8)	 	Exhibit A, Attachment 11 Case Management and Coordination of Care, Section 6 Alcohol and
Substance Abuse Treatment Services, is amended to read:






	 	6.	 	Alcohol and Substance Abuse Treatment Services
	 
	 	 	 	Alcohol and substance abuse treatment services available through Drug Medi-Cal
Substance Abuse Services defined in Title 22, CCR, Section 51341.1, and outpatient
heroin detoxification services defined in Title 22, CCR, Section 51328 are excluded
from this Contract.
	 
	 	 	 	These excluded services include all drugs used for the treatment of alcohol and
substance abuse covered by State of California Department of Alcohol and Drug
Programs (ADP) Drug Medi-Cal Substance Abuse Services as well as the drugs listed in
Exhibit A, Attachment 10-C not currently covered by ADP, but reimbursed through the
Medi-Cal FFS program.
	 
	 	 	 	Contractor shall identify individuals requiring alcohol and or substance abuse
treatment services and arrange for their referral to the ADP, including outpatient
heroin detoxification providers, for appropriate services. Contractor shall assist
Members in locating available treatment service sites. To the extent that treatment
slots are not available in the ADP within the Contractor’s Service Area, the
Contractor shall pursue placement outside the area. Contractor shall continue to
cover and ensure the provision of primary care and other services unrelated to the
alcohol and substance abuse treatment and coordinate services between the primary
care providers and the treatment programs.






	9)	 	Exhibit A, Attachment 11 Case Management and Coordination of Care, Section 19 Erectile
Dysfunction (ED) Drugs and Other ED Therapies, is added:






	 	19.	 	Erectile Dysfunction (ED) Drugs and Other ED Therapies
	 
	 	 	 	Erectile dysfunction drugs and other ED therapies are excluded from this Contract.
These excluded drugs include all drugs used for the treatment of ED that are listed
in Exhibit A, Attachment 10-D (consisting of one page). The drugs listed in Exhibit
A, Attachment 10-D are covered by the Medi-Cal Fee-For-Service program.
	 
	 	 	 	Contractor shall identify individuals requiring ED drugs or ED therapies and arrange
for their referral for appropriate services. Contractor shall




9









 






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	 	 	 	assist Members in locating available treatment service sites. Contractor shall continue to cover and
ensure the provision of primary care and other services unrelated to the ED drugs or ED therapies and coordinate services between
the primary care providers and the treatment programs.






	10)	 	Exhibit A, Attachment 14 Member Grievance System, Section 3 Grievance Log and Quarterly
Grievance Report, is amended to read:






	 	3.	 	Grievance Log and Quarterly Grievance Report






	 	B.	 	Contractor shall submit the quarterly grievance report for
Medi-Cal Members only in the form that is required by and submitted to the
Department of Managed Health Care (DMHC) as set forth in Title 28, CCR, Section
1300.68(f).






	 	1)	 	In addition to the types or nature of
grievances listed in Title 28, CCR, Section 1300.68(f)(2)((D), the
report shall also include, but not be limited to, timely assignments to
a provider, issues related to cultural and linguistic sensitivity, and
difficulty with accessing specialists.
	 
	 	2)	 	For the Medi-Cal category of the report,
provide the following additional information: the average time it took
for the plan to respond to all Member grievances; a listing of the zip
codes, ethnicity, gender and primary language of the Members that filed
grievances; and the total number of grievances in which the
outcome/resolution was not in the Member’s favor.






	11)	 	Exhibit A, Attachment 16 Enrollments and Disenrollments, Section 2 Enrollment, is amended to
read:






	 	2.	 	Enrollment






	 	E.	 	Enrollment Capacity (only to specific contractors that choose
limitations)
	 
	 	 	 	All Eligible Beneficiaries shall be accepted by Contractor up to the limits
of Contractor’s Enrollment capacity approved by DHS. Contractor’s maximum enrollment capacity under this Contract shall not
exceed 207,000.




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	12)	 	Exhibit B, Budget Detail and Payment Provisions, Section 1 Budget Contingency Clause, is
amended to read:






	 	1.	 	Budget Contingency Clause






	 	A.	 	It is mutually agreed that if the Budget Act of the current
year and/or any subsequent years covered under this Contract does not
appropriate sufficient funds for the Medi-Cal program, this Contract shall be
of no further force and effect. In this event, the State shall have no
liability to pay any funds whatsoever to Contractor or to furnish any other
considerations under this Contract and Contractor shall not be obligated to
perform any provisions of this Contract.
	 
	 	 	 	All payments and rate adjustments are subject to appropriations of Medi-Cal
funds by the Legislature and may include Department of Finance approval.
Further, all payments are subject to the availability of Federal
congressional appropriation of funds.
	 
	 	B.	 	If funding for any fiscal year is reduced or deleted by the
Budget Act specifically for purposes of the Medi-Cal Geographic Managed Care
Program, the State shall have the option to either cancel this Contract with no
liability occurring to the State, or offer an amendment to Contractor to
reflect the reduced amount.






	13)	 	Exhibit B, Budget Detail and Payment Provisions, Section 2 Amounts Payable, is amended to
read:






	 	2.	 	Amounts Payable
	 
	 	 	 	The amounts payable under this Contract shall not exceed:






	 	A.	 	$42,040,000 for the 2005-06 Fiscal Year ending June 30, 2006.
	 
	 	B.	 	$87,840,900 for the 2006-07 Fiscal Year ending June 30, 2007.
	 
	 	C.	 	$92,023,800 for the 2007-08 Fiscal Year ending June 30, 2008.
	 
	 	D.	 	$46,011,900 for the 2008-09 Fiscal Year ending June 30, 2009.






	 	 	 	The maximum amount payable for this Contract shall not exceed $267,916,600.






11












 





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	14)	 	Exhibit B, Budget Detail and Payment Provisions, Section 4 Capitation Rates, is amended to
read:






	 	4.	 	Capitation Rates






	 	A.	 	DHS shall remit to Contractor a capitation payment each month
for each Medi-Cal Member that appears on the approved list of Members supplied
to Contractor by DHS. The capitation rate shall be the amount specified below.
The payment period for health care services shall commence on the first day of
the Operations Period. Capitation payments shall be made in accordance with
the following schedule of capitation payment rates at the end of the month for
the month of service:





	 	 	 	 	 
	From January 1, 2006 through June 30, 2006:	 	San Diego
	Groups	 	Aid Codes	 	Rate
	Family	 	01, 02, 03, 04, 08, 0A, 30,
    32, 33, 34, 35, 38, 39, 3A,
    3C, 3E, 3G, 3H, 3L, 3M, 3N,
    3P, 3R, 3U, 3W*, 40, 42, 45,
    47, 4A, 4C, 4F, 4G, 4K, 4M,
    54, 59, 5K, 5X, 72, 7A, 7J,
    7X, 82, 8P, 8R
	 	$**
	 
	 	 	 	 
	Disabled/
Medi-Cal Only	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V
	 	$**
	 
	 	 	 	 
	Aged/
Medi-Cal Only	 	10, 14, 16, 1E, 1H
	 	$**
	 
	 	 	 	 
	Adult	 	86	 	$**
	 
	 	 	 	 
	Breast and
Cervical Cancer

Treatment

Program 

(BCCTP)	 	0N, 0P	 	$**
	 
	 	 	 	 
	Disabled/
Dual Eligible	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V	 	$**
	 
	 	 	 	 
	Aged/
Dual Eligible	 	10, 14, 16, 1E, 1H	 	$**
	 
	 	 	 	 







 




			
	*	 	The effective date of the addition of Aid Code 3W is January 1, 2006.




			
	**	 	In accordance with the requirements of California Government Code Section 6254(q),
confidential treatment has been requested for the redacted rate information pursuant to Rule 24b-2 of the Securities Exchange
Act of 1934. The redacted rate information has been filed separately with the Commission.




12









 










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	From July 1, 2006 through June 30, 2007:	 	San Diego
	Groups	 	Aid Codes	 	Rate
	Family	 	01, 02, 03, 04, 08, 0A, 30,
    32, 33, 34, 35, 38, 39, 3A,
    3C, 3E, 3G, 3H, 3L, 3M, 3N,
    3P, 3R, 3U, 3W, 40, 42, 45,
    47, 4A, 4C, 4F, 4G, 4K, 4M,
    54, 59, 5K, 5X, 72, 7A, 7J,
    7X, 82, 8P, 8R	 	$**
	 
	 	 	 	 
	Disabled/
Medi-Cal Only	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V	 	$**
	 
	 	 	 	 
	Aged/
Medi-Cal Only	 	10, 14, 16, 1E, 1H	 	$**
	 
	 	 	 	 
	Adult	 	86	 	$**
	 
	 	 	 	 
	Breast and
Cervical Cancer

Treatment

Program

(BCCTP)	 	0N, 0P	 	$**
	 
	 	 	 	 
	Disabled/
Dual Eligible	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V	 	$**
	 
	 	 	 	 
	Aged/
Dual Eligible	 	10, 14, 16, 1E, 1H	 	$**
	 
	 	 	 	 






 




			
	**	 	In accordance with the requirements of California Government Code Section 6254(q),
confidential treatment has been requested for the redacted rate information pursuant to Rule 24b-2 of the Securities Exchange
Act of 1934. The redacted rate information has been filed separately with the Commission.



13









 






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	Commencing July 1, 2007:	 	San Diego
	Groups	 	Aid Codes	 	Rate
	Family	 	01, 02, 03, 04, 08, 0A, 30,
    32, 33, 34, 35, 38, 39, 3A,
    3C, 3E, 3G, 3H, 3L, 3M, 3N,
    3P, 3R, 3U, 3W, 40, 42, 45,
    47, 4A, 4C, 4F, 4G, 4K, 4M,
    54, 59, 5K, 5X, 72, 7A, 7J,
    7X, 82, 8P, 8R	 	$**
	 
	 	 	 	 
	Disabled/
Medi-Cal Only	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V	 	$**
	 
	 	 	 	 
	Aged/
Medi-Cal Only	 	10, 14, 16, 1E, 1H	 	$**
	 
	 	 	 	 
	Adult	 	86	 	$**
	 
	 	 	 	 
	Breast and
Cervical Cancer

Treatment

Program

(BCCTP)	 	0N, 0P	 	$**
	 
	 	 	 	 
	Disabled/
Dual Eligible	 	20, 24, 26, 2E, 36, 60, 64,
    66, 6A, 6C, 6E, 6H, 6J, 6N,
    6P, 6V	 	$**
	 
	 	 	 	 
	Aged/
Dual Eligible	 	10, 14, 16, 1E, 1H	 	$**







	15)	 	Exhibit B, Budget Detail and Payment Provisions, Section 6 Negotiation/ Determination of
Rates, is amended to read:






	 	6.	 	Negotiation/Determination of Rates






	 	A.	 	The capitation rates included in this Contract result from
voluntary negotiations between the Contractor and California Medical Assistance
Commission (CMAC). CMAC negotiates rates from an actuarial based range as
determined by DHS actuaries.
	 
	 	B.	 	Subject to subprovision A above, CMAC and Contractor for each
rate year shall review and renegotiate the capitation rates to determine
whether such rates should be increased, decreased, or remain the same. If it
is determined by CMAC and Contractor that the capitation rates should be
increased or decreased, such increase or decrease shall be effectuated through
an amendment to this Contract in accordance with the provisions of Exhibit E,
Attachment 2, provision 4, and subject to provision 8 of this Exhibit.






 




			
	**	 	In accordance with the requirements of California Government Code Section 6254(q),
confidential treatment has been requested for the redacted rate information pursuant to Rule 24b-2 of the Securities Exchange
Act of 1934. The redacted rate information has been filed separately with the Commission.



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05-46130, A-01





	16)	 	Exhibit B, Budget Detail and Payment Provisions, Section 7 Rate Year and Rate Determination
Date, is amended to read:






	 	7.	 	Rate Year and Rate Determination Date
	 
	 	 	 	The rate year for this Contract is July 1 through June 30, and this Contract’s rate
determination date is July 1 of each subsequent year.






	17)	 	Exhibit B, Budget Detail and Payment Provisions, Section 8 Implementation of Rate Amendments,
is amended to read:






	 	8.	 	Implementation of Rate Amendments






	 	A.	 	Upon final approval of a fully executed, negotiated rate
amendment, DHS will implement the rate adjustment(s) to commence on the
effective date(s) as specified in the approved rate amendment.
	 
	 	B.	 	In the event there is a delay in the determination between CMAC
and Contractor under Provision 6 to modify the rates for a particular rate year
or there is a delay in DHS’ implementation of a negotiated rate amendment
approved by CMAC, the payment to Contractor shall continue at the rates then in
effect. Those continued payments shall constitute interim payments until such
time as the rate amendment, if any, is approved by CMAC and DHS’ implementation
of the new rate(s) occurs. DHS shall make adjustments for those months for
which interim payments were made as follows:






	 	1)	 	Any underpayment by the State shall be paid to
Contractor within 60 calendar days after final approval of the fully
executed rate amendment.
	 
	 	2)	 	Any overpayment to Contractor shall be
recaptured by the State’s withholding the amount due from Contractor’s
next capitation check. If the amount to be withheld from that
capitation check exceeds 25 percent of the capitation payment for that
month, amounts up to 25 percent shall be
withheld from successive capitation payments until the overpayment is
fully recovered by the State.





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	18)	 	Exhibit E, Additional Provisions, Section 1 Additional Incorporated Exhibits, is amended to
read:






	 	1.	 	Additional Incorporated Exhibits
	 
	 	 	 	The following additional exhibits are attached, incorporated herein, and made a part
hereof by this reference:





	 	 	 	 	 
	1) Exhibit A

	 	Scope of Work
	 	2 pages
	 

	 	Attachment 1 — Organization and Administration of the Plan
	 	4 pages
	 

	 	Attachment 2 — Financial Information
	 	4 pages
	 

	 	Attachment 3 — Management Information System
	 	2 pages
	 

	 	Attachment 4 — Quality Improvement System
	 	12 pages
	 

	 	Attachment 5 — Utilization Management
	 	4 pages
	 

	 	Attachment 6 — Provider Network
	 	8 pages
	 

	 	Attachment 7 — Provider Relations
	 	2 pages
	 

	 	Attachment 8 — Provider Compensation Arrangements
	 	6 pages
	 

	 	Attachment 9 — Access and Availability
	 	11 pages
	 

	 	Attachment 10 — Scope of Services
	 	19 pages
	 

	 	Attachment 11 — Case Management and Coordination of Care
	 	13 pages
	 

	 	Attachment 12 — Local Health Department Coordination
	 	3 pages
	 

	 	Attachment 13 — Member Services
	 	11 pages
	 

	 	Attachment 14 — Member Grievance System
	 	3 pages
	 

	 	Attachment 15 — Marketing
	 	5 pages
	 

	 	Attachment 16 — Enrollments and Disenrollments
	 	5 pages
	 

	 	Attachment 17 — Reporting Requirements
	 	2 pages
	 

	 	Attachment 18 — Implementation Plan and Deliverables
	 	15 pages
	2) Exhibit B

	 	Budget Detail and Payment Provisions
	 	8 pages
	3) Exhibit
C*

	 	General Terms and Conditions:
Notwithstanding provisions 15 and 18, which do not apply to this Contract.
	 	GTC 306*
	 

	 	Attachment 1 — Certifications:
Notwithstanding provisions 4, 5, and 7, which do not apply to this Contract.
	 	CCC-1005*






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Molina Healthcare of California Partner Plan, Inc.

05-46130, A-01




	 	 	 	 	 
	 

	 	Attachment 2 — Doing Business with the State of California:
Notwithstanding provisions 4 and 6, which do not apply to this Contract.
	 	CCC-1005*
	4) Exhibit
D(F)

	 	Special Terms and Conditions:
Notwithstanding provisions 2, 3, 4, 5, 6, 7, 10, 11, 12, 14, 15, 16,
18, 22, 25, 27, 29, 30, and 31, which do not apply to this Contract.
	 	10 pages
	5) Exhibit E

	 	Additional Provisions
	 	3 pages
	 

	 	Attachment 1 — Definitions
	 	17 pages
	 

	 	Attachment 2 — Program Terms and Conditions
	 	24 pages
	 

	 	Attachment 3 — Duties of the State
	 	5 pages
	6) Exhibit F

	 	Contractor’s Release
	 	1 page
	7) Exhibit G

	 	Health Insurance Portability and Accountability Act
	 	5 pages





Items shown above with an Asterisk (*), are hereby incorporated by reference
and made part of this agreement as if attached hereto. These documents can be
viewed at http://www.dgs.ca.gov/contracts.





	19)	 	Exhibit E, Attachment 1 Definitions, Section 34 Eligible Beneficiary, is amended to read:






	 	34.	 	Eligible Beneficiary means any Medi-Cal beneficiary who is residing in the
Contractor’s Service Area with one of the following aid codes:
	 
	 	 	 	Mandatory Aid Codes:
	 
	 	 	 	Family - 01, 02, 08, 0A, 30, 32, 33, 34, 35, 38, 39, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N,
3P, 3R, 3U, 3W, 47, 54, 59, 5X, 72, 7A, 7X, 82, 8P, 8R
	 
	 	 	 	Non-Mandatory Aid Codes:
	 
	 	 	 	Family - 03, 04, 40, 42, 45, 4A, 4C, 4F, 4G, 4K, 4M, 5K, 7J
	 
	 	 	 	Aged — 10, 14, 16, 1E, 1H
	 
	 	 	 	Disabled - 20, 24, 26, 2E, 36, 60, 64, 66, 6A, 6C, 6E, 6H, 6J, 6N, 6P, 6V
	 
	 	 	 	Adult — 86
	 
	 	 	 	Breast and Cervical Cancer Treatment Program (BCCTP) - 0N, 0P





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Molina Healthcare of California Partner Plan, Inc.

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	 	 	 	An Eligible Beneficiary may continue to be a Member following any redetermination of
Medi-Cal eligibility that determines that the individual is eligible for, and the
individual thereafter enrolls in, the BCCTP.
	 
	 	 	 	The following exclusions apply to all the above:






	 	A.	 	Individuals who have been approved by the Medi-Cal Field Office
or the California Children Services Program for any major organ transplant that
is a Medi-Cal FFS benefit except kidney transplants.
	 
	 	B.	 	Individuals who elect and are accepted to participate in the
following Medi-Cal waiver programs: In-Home Medical Care Waiver, the Nursing
Facility Subacute Waiver, and the Nursing Facility A/B Waiver.
	 
	 	C.	 	Individuals determined by the Medi-Cal Field Office to be in
need of long term care and residing in a Skilled Nursing Facility for 30
calendar days past the month of admission.
	 
	 	D.	 	Individuals who have commercial or Medicare HMO coverage,
unless the Medicare HMO is a provider under this Contract and DHS has agreed,
as a term of the HMO’s contract, that these individuals may be enrolled.
Individuals with Medicare fee-for-service coverage are not excluded from
enrolling under this Contract.






	20)	 	Exhibit E, Attachment 2 Program Terms and Conditions, Section 13 Term, is amended to read:






	 	13.	 	Term
	 
	 	 	 	The Contract will become effective January 1, 2006, and will continue in full force
and effect through December 31, 2008, subject to the provisions of Exhibit B,
provision 1. Budget Contingency Clause and Exhibit D(F), provision 9. Federal
Contract Funds.
	 
	 	 	 	The term of the Contract consists of the following three periods: 1) The
Implementation Period, which ended as of the effective date of this Contract; 2) The
Operations Period shall commence at the conclusion of the Implementation Period,
subject to DHS acceptance of the Contractor’s readiness to begin the Operations
Period. The term of the Operations
Period is subject to the termination provisions of provision 16. Termination, and
provision 18. Sanctions, and subject to the limitation





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Molina Healthcare of California Partner Plan, Inc.

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	 	 	 	provisions of Exhibit B, provision 1. Budget Contingency Clause; and 3) The Phaseout
Period shall extend for six (6) months from the end of the Operations Period,
subject to provision 15. Contract Extension, in which case the Phaseout Period shall
apply to the six (6) month period beginning with the first day after the end of the
Operations Period, as extended.






	21)	 	Exhibit E, Attachment 2 Program Terms and Conditions, Section 34 Confidential Contract Terms,
is added:






	 	34.	 	Confidential Contract Terms
	 
	 	 	 	The terms of this Contract are confidential and may be disclosed by the Contractor
or its providers and subcontractors only in accordance with the disclosure time
limits set forth in Government Code section 6254(q).






	22)	 	Exhibit E, Attachment 2 Program Terms and Conditions, Section 35 Federal False Claim Act
Compliance, is added:






	 	35.	 	Federal False Claim Act Compliance
	 
	 	 	 	Effective January 1, 2007, Contractor shall comply with 42 USC Section 1396a(a)(68),
Employee Education About False Claims Recovery, as a condition of receiving payments
under this Contract. Upon request by DHS, Contractor shall demonstrate compliance
with this provision, which may include providing DHS with copies of Contractor’s
applicable written policies and procedures and any relevant employee handbook
excerpts.






	23)	 	All rights, duties, obligations and liabilities of the parties hereto otherwise remain
unchanged.






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Molina Healthcare of California Partner Plan, Inc.

05-46130, A-01




ATTACHMENT 10-C




EXCLUDED DRUGS FOR ALCOHOL AND HEROIN (OPIOID) DEPENDENCE TREATMENT




Generic Name




Buprenorphine HCL

Buprenorphine HCL and Naloxone HCL dihydrate





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Molina Healthcare of California Partner Plan, Inc.

05-46130, A-01




ATTACHMENT 10-D




EXCLUDED DRUGS FOR THE TREATMENT OF

ERECTILE DYSFUNCTION (ED)




Generic Name




Alprostadil

Papaverine Injection

Phentolamine Mesylate

Sildenafil Citrate 25mg

Sildenafil Citrate 50mg

Sildenafil Citrate 100mg

Tadalafil

Vardenafil HCL

Yohimbine HCL

Yohimbine HCL/Strychnine

Yohimbine HCL/Zinc Sulfate





21