Exhibit 10.12





Exhibit 10.12




	 	 	 
	

	 	ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

SECTION A: CONTRACT






	 	 	 	 	 	 	 
	1. AMENDMENT

	 	2. CONTRACT
	 	3. EFFECTIVE DATE OF
	 	4. PROGRAM
	    NUMBER:

	 	NO.:
	 	    AMENDMENT:	 	 
	                3

	 	YH09-0001-04
	 	
          May 1,
2009
	 	 DHCM — ACUTE






5. CONTRACTOR’S NAME AND ADDRESS:


Health Choice Arizona



1600 W. Broadway, Suite 260



Tempe, AZ 85282




6. PURPOSE OF AMENDMENT: To amend Section B, Capitation Rates, effective May 1, 2009.



7. THE CONTRACT REFERENCED ABOVE FOLLOWS



To
amend Section B, Capitation Rates, effective May 1, 2009.



	 	 	 
	NOTE: Please sign and date all
copies and then return one
executed original to:

	 	Mark Held
	 

	 	Sr. Procurement Specialist
	 

	 	AHCCCS Contracts
	 

	 	701 E. Jefferson St., MD 5700
	 

	 	Phoenix, AZ 85034






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 AHCCCSA
CONTRACTING
OFFICER:

	

	 	[ILLEGIBLE]
	 
	/s/ Carolyn Rose
	 	/s/ Pat Watkinson for Michael Veit 
	TYPED
NAME: CAROLYN ROSE

	 	MICHAEL VEIT
	TITLE:
CHIEF EXECUTIVE OFFICER

	 	CONTRACTS & PURCHASING ADMINISTRATOR
	DATE:

	 	DATE: 3-30-09






 


 









 





			
	SECTION B: CAPITATION RATES
	 	Contract/RFP
No. YH09-0001
	 	 	 






SECTION B: CAPITATION RATES




The Contractor shall provide services as described in this contract. In consideration for these
services, the Contractor will be paid Contractor-specific rates per member per month for the
term May 1, 2009 through September 30, 2009. See attached revised rates.



CYE ‘09 Acute Care Contract

May 1, 2009



 


61









 





ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

CAPITATION RATE SUMMARY — ACUTE RATES

Health Choice Arizona

05/01/2009-9/30/2009




	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	Maternity	 	 	 	 	 	 	 
	 	 	TANF	 	 	TANF	 	 	TANF	 	 	TANF	 	 	TANF	 	 	SSI	 	 	SSI	 	 	 	 	 	 	Delivery	 	 	 	 	 	 	 
	Title XIX and KidsCare Rates 1:	 	<1, M/F	 	 	1-13, M/F	 	 	14-44, F	 	 	14-44, M	 	 	45+, M/F	 	 	w/ Med	 	 	w/o Med	 	 	SFP	 	 	Supplement	 	 	Non-MED	 	 	MED	 
	2 Yuma/La Paz
	 	$	451.13	 	 	$	105.33	 	 	$	204.19	 	 	$	118.67	 	 	$	365.40	 	 	$	178.29	 	 	$	693.11	 	 	$	20.43	 	 	$	6,190.52	 	 	$	443.94	 	 	$	1,636.99	 
	4 Apache/Coconino/Mohave/Navajo
	 	$	474.50	 	 	$	111.49	 	 	$	270.70	 	 	$	157.82	 	 	$	409.11	 	 	$	160.98	 	 	$	775.55	 	 	$	19.00	 	 	$	6,241.93	 	 	$	578.20	 	 	$	1,433.37	 
	10 Pima/Santa Cruz
	 	$	448.76	 	 	$	100.79	 	 	$	230.46	 	 	$	127.70	 	 	$	396.08	 	 	$	145.39	 	 	$	734.80	 	 	$	20.91	 	 	$	6,519.63	 	 	$	485.35	 	 	$	1,329.96	 
	12 Maricopa
	 	$	558.77	 	 	$	114.80	 	 	$	239.88	 	 	$	150.74	 	 	$	410.20	 	 	$	157.50	 	 	$	744.97	 	 	$	18.65	 	 	$	6,646.66	 	 	$	626.59	 	 	$	1,415.16	 






	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	TANF	 	 	TANF	 	 	TANF	 	 	TANF	 	 	TANF	 	 	SSI	 	 	SSI	 	 	 	 	 	 	 
	PPC Rates:	 	<1, MF	 	 	1-13, M/F	 	 	14-44, F	 	 	14-44, M	 	 	45+, M/F	 	 	w/ Med	 	 	w/o Med	 	 	Non-MED	 	 	MED	 
	2 Yuma/La Paz
	 	$	1,204.81	 	 	$	61.66	 	 	$	238.16	 	 	$	212.19	 	 	$	436.74	 	 	$	134.22	 	 	$	410.31	 	 	$	1,075.65	 	 	$	7,443.55	 
	4 Apache/Coconino/Mohave/Navajo
	 	$	1,190.43	 	 	$	62.09	 	 	$	264.19	 	 	$	215.00	 	 	$	439.32	 	 	$	135.74	 	 	$	405.56	 	 	$	1,127.34	 	 	$	7,404.72	 
	10 Pima/Santa Cruz
	 	$	1,192.26	 	 	$	56.23	 	 	$	247.42	 	 	$	196.93	 	 	$	439.38	 	 	$	132.24	 	 	$	408.04	 	 	$	887.69	 	 	$	7,387.84	 
	12 Maricopa
	 	$	1,217.54	 	 	$	66.04	 	 	$	255.60	 	 	$	224.64	 	 	$	446.27	 	 	$	132.38	 	 	$	425.30	 	 	$	1,319.34	 	 	$	7,668.50	 






	 	 	 	 	 	 	 	 	 
	 	 	Option 1	 	 	Option 2	 
	Other Rates:	 	Transplant	 	 	Transplant	 
	2 Yuma/La Paz
	 	$	40.00	 	 	$	40.00	 
	4 Apache/Coconino/Mohave/Navajo
	 	$	40.00	 	 	$	40.00	 
	10 Pima/Santa Cruz
	 	$	40.00	 	 	$	40.00	 
	12 Maricopa
	 	$	40.00	 	 	$	40.00	 








	 	 	 
	1.	 	Rates have been adjusted for $50,000 Reinsurance Deductible