exv10w4






Exhibit 10.4




2007-000057-D




MEDICARE PLATINO CONTRACT AMENDMENT

(Medicaid Wraparound)




Agreement Between



Puerto Rico Health Insurance Administration (PRHIA) a public instrumentality of the Commonwealth of
Puerto Rico organized pursuant to Act 72, of September 7, 1993, as amended, hereinafter referred to
as the “PRHIA”, and represented by its Executive Director, Domingo Nevárez Ramírez, MHSA;
 





And



TRIPLE-S SALUD, INC., a private corporation duly organized and authorized to do business under the
laws of the Commonwealth of Puerto Rico, with Employer Social Security Number ###-##-####,
hereinafter referred to as “CONTRACTOR”, and represented by its Chief Executive Director, Socorro
Rivas;
 





Contractor Name




For the Provision of the wraparound coverage for the Government Health Insurance Dual-Eligible

Population




 









 








WITNESSETH



In consideration of the mutual covenants and agreements hereinafter set forth; the parties, their
personal representatives and successors, agree as follows:



WHEREAS: The parties entered into a contract to provide all the health care services and supplies
that are covered by the contractor’s Medicare Advantage Product and the Medicaid wraparound
benefits known as Medicare Platino; to serve the “dual eligible” population and the government
employees qualified to participate in the Puerto Rico Health Insurance Administration program
(PRHIA); during the calendar year 2009; contracts numbers 07-057, 07-057A, 07-057B, and 07-057C.



WHEREAS: The PRHIA has decided to renegotiate rates with the plans currently contracted and revise
the Plan Benefit Package to assure compliance with CMS regulations for the calendar year 2009 and
PRHIA population needs and services requested.



Now therefore; according to the above premise the PRHIA and Triple-S Salud, Inc. have decided to
amend the contract as follows:



Article I: To amend provision 2.1 to read as follows:




     2.1 Term


This agreement is effective January 1st, 2010 and shall remain in effect until December
31, 2010 or until the execution of an extension renewal or successor Agreement approved by PRHIA
Board of Directors.



Article II: To amend provision 3.1 (b) to read as follows:




 









 








     3.1 Premium Payments




	 	a.	 	...
	 
	 	b.	 	The monthly premiums are attached hereto as Appendix B (1)(10) and shall be
deemed incorporated into this Agreement without further action by the parties...




Article III. To amend provision 4 to reads as follows:





The service area described in Appendix A (1)(10) of this Agreement; which is hereby made
part of this agreement as if set forth fully herein, is the specific geographic area within
which Eligible persons shall enroll in the contractor’s Medicare Platino Product.


Article IV. To amend provision 6.5 to read as follows:





	 	6.5	 	Contractor Liability




As part of the Effective Date of Enrollment, and until the Effective Date of Disenrollment from the
Contractor’s product, the Contractor shall be responsible for the provision and cost of the
Medicare Platino Benefit Package as described in:





	 	Appendix	 	C (1) (10) Medicare Advantage Product
	 
	 	Appendix	 	C (2) (10) Medicaid Product (Wraparound) of this Agreement;
With co-payments for Enrollees whose names appear on the prepaid Premium Plan
Roster.




Article V. To amend provision 10.2 to read as follows:



The Medicare Platino Benefit Package and Non-Covered Services agreed to by the contractor and the
PRHIA are contained in:





	Appendix	 	C-1(10) Medicare Advantage Product
	 
	 	 	C-2(10) Medicaid Wraparound
	 
	 	 	C-3(10) Services not covered by Medicare Platino but provided by the Department of
Health which are hereby made a part of this agreement as if set forth fully herein.




 









 









	 	 	 	C-4(10) Summary of Benefits Report — The Summary Benefits (SB) included as Appendix
C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to
be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the
SB does not mean that the same have already been approved and that, if necessary,
changes could be requested. Therefore, since the SB needs the approval of the
PRHIA, this section could be amended subject to PRHIA’s review.





Article VI: To amend provision 13 to read as follows:





	 	13.	 	Access Requirements



The Contractor agrees to provide enrollees access to Medicare Platino Benefit
Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner
consistent with professionally recognized standards of health care and access
standards required by 42CFR Section 422.11/438.206 and Law 72 of
September 7, 1993
respectively.





Article VII: All other terms provisions and conditions of the contract remains unchanged.




In witness whereof, the parties have duly executed this Amendment of the dates appearing below
their respective signatures.




	 	 	 
	PUERTO RICO HEALTH

	 	TRIPLE-S SALUD, INC.
	INSURANCE ADMINISTRATION
	 	 
	

	 	
	 

	 	 
	Domingo
Nevárez Ramírez, MHSA 

Executive Director

	 	Socorro Rivas

Chief Executive Officer

Triple-S Salud, Inc.
	

	 	
	 	 
	 	Dr. Luis A. Marini

Chief Executive Officer

Triple C, Inc.
	 
	10/2/09	 	10/2/09
	 	 
	Date

	 	Date
	Cifra de Cuenta 5000-100
	 	 



















 






APPENDIX A(1)(10)




SERVICE AREA




 









 








APPENDIX A(1)(10)




TRIPLE-S SALUD, INC.




	 	 	 
	Geographic Areas:
	 	 
	 
	 	 
	North East Health Area

	 	composed of the municipalities of Canóvanas, Carolina, Ceiba, Culebra, Fajardo, Loíza, Luquillo, Rio
Grande, Trujillo Alto and Vieques.
	 
	 	 
	West Health Area

	 	composed of the municipalities of Aguada, Aguadilla, Añasco, Cabo Rojo, Hormigueros, Isabela, Lajas, Las
Marías, Maricao, Mayaguez, Moca, Rincón, Sabana Grande, San
Germán, and San Sebastián.
	 
	 	 
	South East Health Area

	 	composed of the municipalities of
Aibonito, Orocovis, Arroyo, Barranquitas,
Coamo, Guayama, Juana Díaz, Maunabo, Patillas, Salinas, Santa Isabel and Villalba.
	 
	 	 
	East Health Area/Region

	 	composed of Aguas Buenas, Caguas, Cayey, Cidra, Gurabo, Humacao, Juncos, Las Piedras, Naguabo, San Lorenzo, and Yabucoa.
	 
	 	 
	North Health Area

	 	composed of the municipalities of Arecibo, Barceloneta, Camuy, Ciales, Florida, Hatillo, Lares, Manatí, Morovis, Quebradillas, Utuado and Vega Baja.
	 
	 	 
	Metro-North Health Area

	 	composed of the municipalities of Bayamón, Cataño, Comerío, Corozal,
Dorado, Guaynabo, Naranjito, Toa Alta, Toa Baja and Vega Alta.
	 
	 	 
	South West Health Area

	 	composed of the municipalities of Adjuntas, Guánica, Guayanilla, Jayuya,
Peñuelas, Ponce and Yauco.
	 
	 	 
	San Juan Region

	 	composed only of the municipality of San Juan.






 









 






APPENDIX B(1)(10)




PREMIUM PAYMENT




 









 








Appendix B(1)(10)




Monthly Payment of Premiums per Member

by Geographic Areas




TRIPLE-S Salud, Inc. Plans

Product: SSS Selecto




	 	 	 	 	 
	 	 	DSH SNP
	 	 	Blended
	Area:	 	H4012-003
	East

	 	$	35.00	 
	Metro-North

	 	$	35.00	 
	North

	 	$	35.00	 
	North East

	 	$	35.00	 
	San Juan

	 	$	35.00	 
	South East

	 	$	35.00	 
	South-West

	 	$	35.00	 
	West

	 	$	35.00	 







 











 









	 	 	 	C-4(10) Summary of Benefits Report — The Summary Benefits (SB) included as Appendix
C-4 (10) was submitted by the Medicare Advantage Association (MAO) and has yet to
be approved by PRHIA Compliance Office. The Parties agree that the inclusion of the
SB does not mean that the same have already been approved and that, if necessary,
changes could be requested. Therefore, since the SB needs the approval of the
PRHIA, this section could be amended subject to PRHIA’s review.





Article VI: To amend provision 13 to read as follows:





	 	13.	 	Access Requirements



The Contractor agrees to provide enrollees access to Medicare Platino Benefit
Package and Covered Services as describe in Appendix C-1(10) and C-2(10) in a manner
consistent with professionally recognized standards of health care and access
standards required by 42CFR Section 422.11/438.206 and Law 72 of
September 7, 1993
respectively.





Article VII: All other terms provisions and conditions of the contract remains unchanged.




In witness whereof, the parties have duly executed this Amendment of the dates appearing below
their respective signatures.




	 	 	 
	PUERTO RICO HEALTH

	 	TRIPLE-S SALUD, INC.
	INSURANCE ADMINISTRATION
	 	 
	

	 	
	 

	 	 
	Domingo
Nevárez Ramírez, MHSA 

Executive Director

	 	Socorro Rivas

Chief Executive Officer

Triple-S Salud, Inc.
	

	 	
	 	 
	 	Dr. Luis A. Marini

Chief Executive Officer

Triple C, Inc.
	 
	10/2/09	 	10/2/09
	 	 
	Date

	 	Date
	Cifra de Cuenta 5000-100