exv10w6w2



 



Exhibit 10.6.2


STATE OF NEW JERSEY



DEPARTMENT OF HUMAN SERVICES



DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES



AND



AMERIGROUP NEW JERSEY, INC.



AGREEMENT TO PROVIDE HMO SERVICES



In accordance with Article 7, section 7.11.2A and 7.11.2B of the contract
between AMERIGROUP New Jersey, Inc. and the State of New Jersey, Department of
Human Services, Division of Medical Assistance and Health Services (DMAHS),
effective date
October 1, 2000, all parties agree that certain sections of the contract shall
be amended to be effective October 1, 2003, as follows:


 






 



NJ FamilyCare Extension - October 1, 2003




	1.	 	Article 1,
“Definitions” section - for the following definition:



            •
NJ FamilyCare Plan H


shall be amended as reflected in the relevant pages of Article 1 attached hereto and incorporated herein.




	2.	 	Article 8, “Financial Provisions,” Sections 8.5.1 and 8.7(F)4 shall be
amended as reflected in Article 8, Sections 8.5.1 and 8.7(F)4 attached
hereto and incorporated herein.
	 
	3.	 	Appendix, Section C, “Capitation Rates,” shall be revised as reflected in
SFY 2004 Capitation Rates attached hereto and incorporated herein.




 






 






NJ FamilyCare Extension -October 1, 2003



All other terms and conditions of the October 1, 2000 contract and
subsequent amendments remain unchanged except as noted above.


The contracting parties indicate their agreement by their signatures.



	 	 	 	 	 	 	 
	 	 	
AMERIGROUP
	 	State of New Jersey
	 	 	
New Jersey, Inc.
	 	Department of Human Services
	 	 	 	 	 	 	 
	 	 	
BY: /s/ Norine Yukon
	 	BY:	 	 
	 	 	


	 	 	 	

	 	 	 	 	 	 	    Matthew D. D’Oria
	 	 	 	 	 	 	 
	 	 	
TITLE: President & CEO
	 	TITLE:
	 	Acting Director, DMAHS
	 	 	 	 	 	 	 
	 	 	
DATE: August 27, 2003
	 	DATE	 	 
	 	 	 
	 	 	 	




APPROVED AS TO FORM ONLY



Attorney General State


of New Jersey



	 	 	 
	BY:	 	 
	 	 	


	 	 	
Deputy Attorney General



DATE:



 






 



NJ FamilyCare Plan D—means the State-operated program which provides
managed care coverage to uninsured:



		
	 	Parents/caretakers with children below the age of 19 who do not
qualify for AFDC Medicaid with family incomes up to and including 200
percent of the federal poverty level; and

Parents/caretakers with children below the age of 23 years and
children from the age of 19 through 22 years who are full time
students who do not qualify for AFDC Medicaid with family incomes up
to and including 250 percent of the federal poverty level; and
Children below the age of 19 with family incomes between 201 percent
and up to and including 350 percent of the federal poverty level.



Eligibles with =incomes above 150 percent of the federal poverty level
are required to participate in cost sharing in the form of monthly
premiums and copayments for most services with the exception of both
Eskimos and Native American Indians under the age of 19 years. These
groups are identified by-Program Status Codes (PSCs) or Race Code on the
eligibility system as indicated below. For clarity, the Program Status
Codes or Race Code, in the case of Eskimos and Native American Indians
under the aj; ‘of 19 years, related to Plan D non-cost sharing groups are
also listed.



	 	 	 	 	 	 	 	 	 
	PSC	 	PSC	 	Race Code
	Cost Sharing	 	No Cost Sharing	 	No Cost Sharing
	
	 	
	 	

	301
	 	 	300
	 	 	 	3	 
	
493	 	 	
380
	 	 	 	 	 
	
494	 	 	
497	 	 	 	 	 
	
495	 	 	 
	 	 	 	 	 
	498	 	 	 	 	 	 	 	 



In addition to covered managed care services, eligibles under these
programs may access certain services which are paid fee-for-service and
not covered under this contract.


NJ FamilyCare Plan H-means the State-operated program which provides
managed care administrative services coverage to uninsured:



		
	 	Adults and couples without dependent children under the age of 19 with
family incomes up to and including 100 percent of the federal poverty
level;

Adults and couples without dependent children under the age of 23
years, who do not qualify for AFDC Medicaid, with family incomes up to
and including 250 percent of the federal poverty level.



Eligibles with incomes above 150 percent of the federal poverty level are
required to participate in cost sharing in the form of monthly premiums
and copayments for most services. These groups are identified by the
program status code (PSC) indicated below. For clarity, the program
status codes related to Plan H non-cost sharing groups are also listed.



	 	 	 
	Amended as of October 1, 2003	 	
I-19



 






 



Rates for DYFS, NJ FamilyCare Plans B, C, D, and Plan H and the non
risk-adjusted rates for AIDS and clients of DUD are statewide. Rates for
all other premium groups are regional in each of the following regions:



		
	 	     • Region 1: Bergen, Hudson, Hunterdon, Morris,
Passaic, Somerset, Sussex, and Warren counties




		
	 	     • Region 2: Essex, Union, Middlesex, and Mercer counties




		
	 	     • Region 3: Atlantic, Burlington, Camden, Cape May,
Cumberland, Gloucester, Monmouth, Ocean, and Salem counties




	 	 	Contractors may contract for one or more regions but, except as
provided in Article 2, may not contract for part of a region.
	 
	8.5.2	 	MAJOR PREMIUM GROUPS
	 
	 	 	The following is a list of the major premium groups. The individual
rate groups (e.g. children under 2 years, etc.) with their
respective rates are presented in the rate tables in % the appendix.
	 
	8.5.2.1	 	AFDC/TANF, NJC PREGNANT WOMEN, AND NJ FAMILYCARE PLAN A CHILDREN
	 
	 	 	This grouping includes capitation rates for Aid to Families with
Dependent Children (AFDC)/Temporary Assistance for Needy Families
(TANF), New Jersey Care Pregnant Women and Children, and NJ
FamilyCare Plan A children (includes individuals under 21 in PSC
380), but excludes individuals who have AIDS or are clients of DDD.
	 
	8.5.2.2	 	NJ FAMILYCARE PLANS B & C
	 
	 	 	This grouping includes ~ capitation rates for NJ FamilyCare Plans. B
and C enrollees, excluding individuals with AIDS- and/or DDD.
clients.
	 
	8.5.2.3	 	NJ FAMILYCARE PLAN D CHILDREN
	 
	 	 	This grouping includes capitation rates for NJ FamilyCare Plan D
children, excluding individuals with AIDS.
	 
	8.5.2.4	 	NJ FAMILYCARE PLAN D PARENTS/CARETAKERS
	 
	 	 	This grouping includes capitation rates for NJ FamilyCare Plan D
parents/caretakers, excluding individuals with AIDS, and include
only enrollees 19 years of age or older.




	 	 	 
	Amended as of October 1, 2003	 	
V111-6



 






 




	 	b.	The claim is for prenatal care for a pregnant
woman or for preventive pediatric services. (including EPSDT
services) that are covered by the Medicaid program.
	 
	 	c.	 	The claim is for labor, delivery, and
post-partum care and does not involve hospital costs
associated with the inpatient. hospital stay.
	 
	 	d.	 	The claim is for a child who is in a DYFS
supported out of home placement.
	 
	 	e.	 	The claim involves coverage or services
mentioned in La, Lb, Lc, or Ld, above in combination with
another service.




	 	2.	 	If the contractor knows that the third party will neither
pay for nor provide the covered service, and the service is
medically necessary, the contractor shall neither deny payment for
the service nor require a written denial from the third party.
	 
	 	3.	 	If the contractor does not know whether a particular service
is covered by the third party, and the service is medically
necessary, the contradtor shall contact the third party and
determine whether or not such service is covered rather than
requiring the enrollee to do so. Further, the contractor shall
require the provider or subcontractor to bill the third party if
coverage is available.
	 
	 	4.	 	In certain circumstances, and with the prior approval of the
DMAHS, the contractor shall retain the ability to initiate TPL
recovery actions against health insurance, as defined in section
8.7.D.1. These circumstances include; but are not limited . to,
information system failures, claims settlements, and appeal
resolutions. In these cases, all recovered funds shall be retained
by the contractor; a summary level of the recovery experience, net
of -any vendor fees directly related to the specific recovery
activity, will, be reported to the State on a quarterly basis; and
the recoveries will be reflected in claims adjustments that are
submitted to the State with the monthly claims files, referenced in
section 8.7.D.l.a. The State will take into account these net
recoveries in setting capitation rates and determining the payment
amounts.




	G.	 	Sharing of TPL Information by the State.




	 	1.	By the fifteenth (15th) day after the close of the month
during which the State learns of such information, the State may
provide the contractor with a list of all known health insurance
coverage information for the purpose of updating the contractor’s
files. This information will be in the format of the State’s TPL
Resource File.




	 	 	 
	Amended as of October 1, 2003	 	
V111-13



 






 




	 	 	 
	State of New Jersey	 	
Confidential



FamilyCare Rates for Adults 0-100% (includes applicable HANJ)

Terms of Eligibility - October 2003




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	One Month Extension	 	 	 	 	 	 	 	 	SFY04 Rates	 	 	 	 	 	 	SFY03 Rates	 	 	 	 
	 	 	 	 	 	 	Contract Period: October 1, 2003 - October 31, 2003	 	Contract Period: March 1, 2003 - June 30, 2003
	Category.	 	Age/Sex	 	Northern	 	Central	 	Southern Statewide	 	Northern	 	Central	 	Southern Statewide
	
	 	
	 	
	 	
	 	
	 	
	 	
	 	

	FamilyCare Adults 0 - 100%
	 	19 - 44 Female	 	 	 	 	 	 	 	 	 	$	258.35	 	 	 	 	 	 	 	 	 	 	$	215.97	 
	FamilyCare Adults 0 - 100%
	 	19 - 44 Male	 	 	—	 	 	 	 	 	 	$	218.16	 	 	 	 	 	 	 	 	 	 	$	181.07	 
	FamilyCare Adults 0 - 100%
	 	45+ M&F	 	 	 	 	 	 	 	 	 	$	414.02	 	 	 	 	 	 	 	 	 	 	$	354.16	 




	 	 	 
	Mercer Government Human Services Consulting	 	
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