exv10w23w1



 



Exhibit 10.23.1



	 	 	 
	STATE OF TEXAS	 	
HHSC CONTRACT No.: 529-00-139-J



COUNTY OF TRAVIS



AMENDMENT 10

TO THE AGREEMENT BETWEEN THE

HEALTH & HUMAN SERVICES COMMISSION

AND

AMERIGROUP TEXAS, INC.

FOR HEALTH SERVICES

TO THE

CHILDREN’S HEALTH INSURANCE PROGRAM



     THIS CONTRACT AMENDMENT (the “Amendment”) is entered
into between the HEALTH & HUMAN SERVICES COMMISSION (“HHSC”), an
administrative agency within the executive department of the State of Texas,
and AMERIGROUP Texas, Inc. (“CONTRACTOR”), a health
maintenance organization organized under the laws of the State of Texas,
possessing a certificate of authority issued by the Texas Department of
Insurance to operate as a health maintenance organization, and having its
principal office at 1200 Copeland Road, Suite 200, Arlington, Texas 76011.
HHSC and CONTRACTOR 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 529-00-139 (the “Agreement”), as set forth in
Article 2 of this Amendment.


ARTICLE 1. PURPOSE.



Section 1.01  Authorization.



     This Amendment is executed by the Parties in accordance with
Article 8 of the Agreement.


Section 1.02  Effective Date of changes



     (a)  General effective date of changes.


     Except as provided in paragraph (b) of this Section
1.02 below, this Amendment is effective September 1, 2003, and
terminates on the Expiration Date of the Agreement, unless extended or
terminated sooner by HHSC in accordance with the Agreement.


     (b)  Notwithstanding the effective date established under paragraph (a) of
this Section 1.02, Section 2.04 of this
Amendment, which modifies Section 11.06 of the Agreement,
is effective November 1, 2003.


ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES.



Section 2.01 General




		
	 	     “The Texas Legislature enacted Senate Bill 418
during its 78th Regular Session. Section 20 of the
bill adds Article 21.03 to Chapter 21, Subchapter E
of the Insurance Code. Article 21.30 provides:




		
	 	     If the commissioner of insurance, in
consultation with the commissioner of health
and human services, determines that a
provision of Section 3A, 3C-J, or 10-12,
Article 3.70-3C, or




			
	HHSC Contract 529-00-139-J	Page 1 of 10	 





 







 




		
	 	10-12, Article 3.70-3C of this code, as added
by Chapter 1024, Acts of the 75th Legislature,
Regular Session, 1997, Section 843.209 or
843.319 of this code, Subchapter J, Chapter
843 of this Code, or Article 21.52Z of this
code will cause a negative fiscal impact on
the state with respect to providing benefits
or services under Subchapter XIX, Social
Security Act (42 U.S.C. Section 1396 et seq.),
as amended, or Subchapter XXI, Social Security
Act (42 U.S.C. Section 1397aa et seq.), as
amended, the commissioner of insurance by rule
shall waive the application of that provision
to the providing of those benefits and
services.




		
	 	     Pursuant to this authority, TDI waived
application of Senate Bill 418 as it pertains to the
above-referenced provisions of the Insurance Code
for CHIP benefits and services. The intent of the
Parties to this Agreement is that, for the
above-referenced provisions of the Insurance Code,
the law in effect immediately prior to the effective
date of Senate Bill 418 will continue to govern the
CONTRACTOR’s performance under this Agreement.
Consequently, all citations in this Agreement to the
above-referenced provisions of the Insurance Code,
their predecessor statutes, and related
administrative rules refer to the laws and rules in
effect immediately prior to the effective date of
Senate Bill 418.”



Section 2.02 Modification to Section 10.02, Time and manner
of premium payment


     Section 10.02, Time and manner of premium payment, is
modified with the addition of a new subsection (d), as follows:



		
	 	     “Section 10.03 Time and manner of Premium Payment
	 
	 	     (d) For the period beginning September 1, 2003
and ending August 31, 2004, CONTRACTOR will be
entitled to a payment in accordance with this
subsection (d). CONTRACTOR will be paid based on per
member/per month premiums and new and current
enrollment figures (including disenrollment
adjustments to previous monthly enrollment totals).
The Administrative Services Contractor will convey
premiums payable information to CONTRACTOR for data
reconciliation and to the Management Services
Contractor. CONTRACTOR must reconcile the data and
report any errors to the Management Services
Contractor by the cut-off date of the next month.
The Management Services Contractor will pay
CONTRACTOR by the first business day following the
14th day of each month. CONTRACTOR must accept
payment for premiums by direct deposit into
CONTRACTOR’s account. For the period beginning
September 1, 2003 and ending August 31, 2004, the
premium rates are:




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	CSA #	 	Under Age 1	 	Ages 1-5	 	Ages 6-14	 	Ages 15-18
	
	 	
	 	
	 	
	 	

	CSA #2
	 	$	326.77	 	 	$	66.51	 	 	$	43.56	 	 	$	86.65	 
	CSA #6
	 	$	332.14	 	 	$	67.60	 	 	$	44.30	 	 	$	88.82	 




		
	 	     CONTRACTOR does not bill HHSC, the
Administrative Services Contractor, other state
agencies, or institutions for the monthly premium
payment.”





			
	HHSC Contract 529-00-139-J	Page 2 of 10	 




 









 



Section 2.03 Modifications to Article 11, CHIP Eligibility,
Enrollment, Disenrollment, And Cost-Sharing, of the Agreement


     Sections 11.01, 11.02, 11.03, and 11.04
are replaced with the following language:



		
	 	     “Section 11.01 
CHIP Eligibility.” (a) Generally.




		
	 	     CHIP eligibility will be determined by the
Administrative Services Contractor. The
Administrative Services Contractor will enroll and
disenroll eligible individuals into and out of CHIP.
Parents or guardians will enroll eligible
individuals into a health plan.
	 
	 	     (b) Continuous coverage for first six months.
	 
	 	     A child who is CHIP-eligible will have six
months of continuous coverage. An exception to this
occurs for children enrolled between July 1, 2003
and October 1, 2003, who initially receive 12 months
of continuous coverage, at the time of enrollment.
However, these children will actually begin the
renewal process in the fourth month of coverage and
complete a six-month term of coverage.
	 
	 	     Through September 30, 2003, MEMBER is covered
as of the first day of the month following the
MEMBER’S enrollment. If a MEMBER’S enrollment occurs
after the monthly enrollment cut-off, the MEMBER
will be covered on the first day of the second month
following the month of enrollment. Upon enrollment,
a MEMBER will be issued a Member identification card
by HEALTH PLAN. Coverage will be in effect for an
initial term of six months or the extended time
period for a pregnant MEMBER.
	 
	 	     As of October 1, 2003, children enrolling in
CHIP for the first time, or returning to CHIP after
disenrollment, will be subject to a waiting period
before coverage actually begins. The waiting period
for a child is determined by the date on which
he/she is found eligible for CHIP, and extends for a
duration of 3 months. If the child is found eligible
for CHIP on or before the 15th day of a month, then
the waiting period begins on the first day of that
same month. If the child is found eligible on or
after the 16th day of a month, then the waiting
period begins on the first day of the next month.
Please refer to the table below for examples of how
the waiting period affects the beginning of
coverage. A child will remain covered for a term of
6 continuous months.
	 
	 	     (c) Pregnant Members and infants.
	 
	 	     CONTRACTOR, through electronic means, or the
providers, through calls to the provider hotline,
will notify the Administrative Services Contractor
when a pregnancy is diagnosed. Pregnant members,
with the exception of Legal Permanent Residents and
other legally qualified aliens who are not barred
from Medicaid due to federal eligibility
restrictions, will be referred to Medicaid for
eligibility determination. Those members who are
determined to be




			
	HHSC Contract 529-00-139-J	Page 3 of 10	 





 








 




		
	 	Medicaid eligible will be disenrolled from the
CONTRACTOR. Medicaid coverage will be coordinated to
begin immediately after CHIP eligibility ends so
that there is no gap in health care coverage. In the
event the CONTRACTOR remains unaware of a member’s
pregnancy until delivery, the delivery will be
covered by CHIP. The Administrative Services
Contractor will suspend the Member’s eligibility
expiration date after notification of the delivery
is received. The Administrative Services Contractor
will unsuspend the mother’s eligibility expiration
date and set the mother’s eligibility expiration
date at the later of (1) the end of the second month
following the month of the baby’s birth or (2) the
date when the mother’s eligibility would have
expired if it had not been suspended during her
pregnancy.
	 
	 	     To further ensure the reliability of the data,
families also will be encouraged to notify the
Administrative Services Contractor by phone or in
writing when delivery of a baby to a CHIP-enrolled
Member occurs.
	 
	 	     Most newborns born to CHIP members or CHIP
heads of household will be Medicaid eligible.
Eligibility of newborns must be determined for CHIP
before enrollment can occur. The CHIP Administrative
Services Contractor should be notified as soon after
delivery as possible. For newborns determined to be
CHIP-eligible, the baby will be covered from the
beginning of the month of birth.
	 
	 	     (d) Span of coverage.
	 
	 	     If a Member’s effective date of coverage occurs
while the Member is confined in a hospital, the
CONTRACTOR is responsible for the Member’s costs of
Covered Services beginning on the Effective Date of
Coverage. For each day that the Member is
hospitalized beginning on the Effective Date of
Coverage, HHSC will pay to CONTRACTOR $700 for
non-ICU care and $1400 for ICU care. If a Member is
disenrolled while the Member is confined in a
hospital, CONTRACTOR’s responsibility for the
Member’s costs of Covered Services terminates on the
Date of Disenrollment. Six months after the
Implementation Date, the Parties will review
CONTRACTOR’s data, and if either party believes that
these payments are insufficient, either Party can
instigate the Change Order process set out in
Article 8. The Parties agree to negotiate any
requested Change Order in good faith.”




		
	 	     Section 11.02 Enrollment




		
	 	     “To enroll in CONTRACTOR’s health plan, the
Member’s permanent residence must be located within
CONTRACTOR’s CSA.




		
	 	     HHSC makes no guarantees or representations to
CONTRACTOR regarding the number of eligible Members
who will ultimately be enrolled into CONTRACTOR’s
health plan.




		
	 	     The Administrative Services Contractor will
electronically transmit to CONTRACTOR new Member
information, PCP selections, and change information
applicable to active Members five (5) business days
prior to the first day of each month. This monthly
transmittal date is defined as the “cut-off date.” A
six-month term of coverage begins on the first day
of the month following transmittal of new member
data to




			
	HHSC Contract 529-00-139-J	Page 4 of 10	 





 







 




		
	 	CONTRACTOR. CONTRACTOR must accept all persons who
reside within CONTRACTOR’s CSA and who choose to
enroll in CONTRACTOR’s health plan without regard to
the Member’s health status or any other factor.
	 
	 	     A Member is enrolled in the health plan
initially selected for six (6) months, beginning
with the date that the individual is first covered
by that health plan or the applicable time period if
the Member is pregnant as is set out in section
11.01(c). However, CONTRACTOR must accommodate
Member requests to change health plans for
exceptional reason or good cause including, but not
limited to:




	 	(a)	 	permanent relocation from a CHIP Service Area; or
	 
	 	(b)	 	permanent relocation within
CONTRACTOR’s CSA that necessitates a change
in the Member’s Primary Care Provider that
CONTRACTOR cannot accommodate within the
prescribed TDI access standards.




		
	 	     Additional reasons that qualify as an
exceptional reason or good cause will be determined
by HHSC on a case-by-case basis or by rule. Members
may change health plans the first day of the month
following the month in which exceptional reason or
good cause situation occurred, in accordance with
the same cut-off processing timeframes applied to
new Members. All changes must be handled through the
Administrative Services Contractor. If a Member
changes health plans while the Member is confined in
a hospital, the health plan from which the Member is
moving is responsible for all charges until the
Member is discharged.
	 
	 	     There is no retroactive
enrollment in CHIP.”




		
	 	Section 11.03
Re-enrollment




		
	 	     “At the beginning of the fourth month of
coverage, the Administrative Services Contractor
will send a notice to the family outlining the next
steps for renewal or continuation of coverage. The
Administrative Services Contractor will also send a
notice to CONTRACTOR regarding its Members and to a
community-based outreach organization providing
follow-up assistance in the Members’ areas. To
promote continuity of care for children eligible for
re-enrollment, CONTRACTOR may facilitate
re-enrollment through reminders to Members and other
appropriate means. Failure of the family to respond
to the Administrative Services Contractor’s renewal
notice will result in disenrollment from the plan
and from CHIP.”




		
	 	Section 11.04 Disenrollment due to loss of
eligibility.
	 
	 	     “For those Members who are disenrolled because
they are no longer eligible for CHIP, CONTRACTOR
will receive from the Administrative Services
Contractor notice informing CONTRACTOR that the
Members’ coverage will end on a particular date.
Disenrollment due to loss of eligibility includes,
but is not limited to:




	 	•	 	“Aging-out” when a child turns nineteen;





			
	HHSC Contract 529-00-139-J	Page 5 of 10	 





 







 




	 	•	 	Failure to re-enroll at the conclusion of the
6-month term of coverage;
	 
	 	•	 	Change in health insurance
status, such as a child enrolling in an
employer-sponsored health plan;
	 
	 	•	 	Failure to meet monthly cost-sharing obligation;
	 
	 	•	 	Death of a child;
	 
	 	•	 	The child permanently moves out of the state; and
	 
	 	•	 	Data match with the
Medicaid system indicates dual enrollment in
Medicaid and CHIP.




		
	 	     In most cases, if a child is disenrolled from
CHIP, the child loses his or her CHIP eligibility
and will have to re-apply for a determination of
CHIP eligibility. Children not subject to
re-application include, but are not necessarily
limited to:
	 
	 	     Children who meet reinstatement requirements
after disenrollment due to failure to meet
cost-share obligation; and,
	 
	 	     Children who successfully re-enroll in the
first month after disenrollment due to failure to
re-enroll by the conclusion of their 6-month term of
coverage.
	 
	 	     Regardless of the reason for retroactive
disenrollment, recoupment of premium payments by
HHSC shall be in accordance with section 10.05.
Under no circumstances may HHSC recoup premiums paid
for a period greater than two (2) months.”



Section 2.04 Modification to Section
11.06, Cost-Sharing, of the Agreement


          Section 11.06, Cost-Sharing is
replaced with the following language:



          Section 11.06 Cost-Sharing.




		
	 	     “Health care providers within CONTRACTOR’s
network are responsible for collecting all Member
co-payments and deductibles at the time of service.
Co-payments that families must pay vary according to
their income level. Applicable co-payments effective
as of November 1, 2003 are listed in Cost Sharing
table below. No co-payments apply, at any income
level, to well-child or well-baby visits or
immunizations.
	 
	 	     Upon notification from the Administrative
Services Contractor that a family is approaching its
cost-sharing limit for the term of coverage,
CONTRACTOR will generate and mail to the Member a
new Member ID card, showing that the Member’s
cost-sharing obligation for that term of coverage
has been met. No cost-sharing may be collected from
these Members for the balance of their term of
coverage.
	 
	 	     Except for costs associated with unauthorized
non-emergency services provided to a Member by
out-of-network providers and for non-covered
services, the co-payments and deductibles outlined
in the table below are the only amounts that a
provider may collect from a CHIP-eligible family.




			
	HHSC Contract 529-00-139-J	Page 6 of 10	 





 







 




		
	 	     Federal law prohibits charging co-payments or
deductibles to Members of Native American Tribes. The
Administrative Services Contractor will notify
CONTRACTOR of Members who are Native Americans and
who are not subject to cost-sharing requirements.
CONTRACTOR is responsible for educating providers
about the cost-sharing waiver for this population.
	 
	 	     A CONTRACTOR’s monthly premium payment will not
be reduced for a family’s failure to make its premium
payment. There is no relationship between the per
member/per month amount owed to an CONTRACTOR for
coverage provided during a month and the family’s
payment of its premium obligation for that month.



CHIP COST SHARING

(as of November 1, 2003)




	 	 	 	 	 
	 	 	 	Charge
	At or below 100% of FPL	 	 	(Changes in Bold)
	
	 	 	

	Enrollment Fee	 	 	
$0
	Monthly Premium	 	 	
$0
	Office Visit	 	 	
$ 3
	ER	 	 	
$3
	Generic Drug	 	 	
$0
	Brand Drug	 	 	
$3
	Co-pay Cap	 	 	
1.25% (of family’s income)
	Deductible, non-institutional	 	 	
$0
	Deductible, institutional	 	 	
$0
	Facility Co-pay, Inpatient	 	 	
$10
	Facility Co-pay, Outpatient	 	 	
$0
	101% to 150% of FPL	 	 	
Charge
	Enrollment Fee	 	 	
$ 0
	Monthly Premium	 	 	
$15
	Office Visit	 	 	
$ 5
	ER	 	 	
$5
	Generic Drug	 	 	
$0
	Brand Drug	 	 	
$5
	Co-pay Cap	 	 	
1.25% (of family’s income)
	Deductible, non-institutional	 	 	
$0
	Deductible, institutional	 	 	
$0
	Facility Co-pay, Inpatient (per admission)	 	 	
$25
	Facility Co-pay, Outpatient	 	 	
$0
	151% to 185% of FPL	 	 	
Charge
	Enrollment Fee	 	 	
$ 0
	Monthly Premium	 	 	
$20 per mo./per family
	Office Visit	 	 	
$7
	ER	 	 	
$50
	Generic Drug	 	 	
$5
	Brand Drug	 	 	
$20
	Co-pay Cap	 	 	
2.5% (of family’s income)
	Deductible, non-institutional	 	 	
$0
	Deductible, institutional	 	 	
$0
	Facility Co-pay, Inpatient (per admission)	 	 	
$50
	Facility Co-pay, Outpatient	 	 	
$0
	186% to 200% of FPL	 	 	
Charge
	Enrollment Fee	 	 	
$0
	Monthly Premium	 	 	
$25 per mo./per family





			
	HHSC Contract 529-00-139-J	Page 7 of 10	 





 







 



CHIP COST SHARING

(as of November 1, 2003)




	 	 	 	 	 
	Office Visit	 	 	
$10
	ER	 	 	
$50
	Generic Drug	 	 	
$5
	Brand Drug	 	 	
$20
	Co-pay Cap	 	 	
2.5% (of family’s income)
	Deductible, non-institutional	 	 	
$0
	Deductible, institutional	 	 	
$0
	Facility Co-pay, Inpatient (per admission)	 	 	
$100
	Facility Co-pay, Outpatient	 	 	
$0




	Section2.05 Modification to Article 12, Scope of
CHIP Covered Services, of the Agreement




	 	Section
12.07 is deleted in its entirety and new Section 12.07
is added as follows.
	 
	 	“Section 12.07
Court-ordered Commitments.




		
	 	     [Deleted]
	 
	 	     Section 12.07 In-patient Psychiatric.
	 
	 	     HHSC will reimburse CONTRACTOR for members
receiving services on an inpatient basis in a
psychiatric facility on August 31, 2003, for the
lengths of their stays, based on their contracted
rates with providers. Inpatient psychiatric services
may not extend more than 45 days, including the
length of stay before August 31, 2003.
	 
	 	     The process for reimbursement will be
consistent with new enrollee hospital and
supplemental reimbursement claims submitted on the
Supplemental Claims Form for CHIP Health Plans.”



Section 2.06 Modification to Article
13, Member Services, of the Agreement



	 	Section 13.01 is replaced with the
following language: “Section 13.01 Member Education.
	 




		
	 	     “CONTRACTOR must, at a minimum, develop and
implement health education initiatives that educate
Members about:




	 	(a)	 	How the HMO system operates;
	 
	 	(b)	 	How to obtain services, including:




	 	(1)	 	Accessing OB/GYN and
plan requirements concerning specialty
care;
	 
	 	(2)	 	Emergency services;
	 
	 	(3)	 	Behavioral health care services;





			
	HHSC Contract 529-00-139-J	Page 8 of 10	 





 







 




	 	(4)	 	Care and treatment, under CONTRACTOR’s
plan, for Members with disabilities and
Children with Special Health Care Needs;
and
	 
	 	(5)	 	Early Childhood Intervention (ECI) Services;




	 	(c)	 	Covered Services, limitations
and any Value-added Services offered by
CONTRACTOR;
	 
	 	(d)	 	Member co-payments, if applicable; and
	 
	 	(e)	 	The value of screening and preventive care.




		
	 	     CONTRACTOR also must provide child-oriented,
disease specific-information, and educational
materials to Members.




		
	 	     CONTRACTOR must educate members about the following:




	 	•	 	Requirement that pregnant
members notify CONTRACTOR upon learning of
pregnancy,
	 
	 	•	 	Requirement that
Medicaid-eligible members receive services
through Medicaid,
	 
	 	•	 	The more comprehensive scope
of services provided through Medicaid,
	 
	 	•	 	Automatic newborn coverage
until age one year provided in Medicaid for
babies of mothers enrolled in Medicaid at the
time of delivery,
	 
	 	•	 	Requirement that if a CHIP
member does not notify CONTRACTOR of
pregnancy until or after delivery, the
newborn will have to go through eligibility
determination with the CHIP Administrative
Services Contractor for Medicaid and CHIP
before enrollment can begin.




		
	 	     In addition to the above requirements,
CONTRACTOR must make any additional educational
initiatives outlined in its Proposal appropriately
available to Members.”





			
	HHSC Contract 529-00-139-J	Page 9 of 10	 





 







 



ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES



     The Parties contract and agree that the terms of the Agreement will remain
in effect and continue to govern except to the extent modified in this
Amendment.


     By signing this Amendment, the Parties expressly understand and agree that
this Amendment is hereby made a part of the Agreement as though it were set out
word for word in the Agreement.


     IN WITNESS HEREOF, HHSC and the CONTRACTOR have each caused this Amendment
to be signed and delivered by its duly authorized representative.



	 	 	 	 	 	 	 	 	 	 	 
	 	 	AMERIGROUP TEXAS, INC.	 	HEALTH AND HUMAN SERVICES COMMISSION
	 
	By:	 	 	 	By:	 	 	 	 	 	 
	 	 	

	 	 	 	 	 	 	 	 
	 	 	James D. Donovan, Jr.	 	Albert Hawkins
	 	 	President and CEO	 	Commissioner
	 
	Date:	 	 	 	Date:	 	 	 	 	 	 
	 	 	


	 	 	 	






			
	HHSC Contract 529-00-139-J	Page 10 of 10