EX-10.12



 Exhibit 10.12 
  

			
	



	 	 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE
  

CONTRACT AMENDMENT


  

							
	 1.     AMENDMENT NUMBER:
	 	 2.      CONTRACT NO.:
	 	 3.     EFFECTIVE DATE OF AMENDMENT:
	 	 4.      PROGRAM

				
	12	 	YH14-0001-07	 	October 1, 2014	 	DHCM - ACUTE

  

	5.	CONTRACTOR’S NAME AND ADDRESS: 

 Health Choice Arizona 

410 N. 44th Street, Suite 900 

Phoenix, AZ 85008 
  

	6.	PURPOSE: To retroactively amend select Capitation Rates for the month of October, 2014. 

  

	7.	THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS 

 Section 9010 of the Patient
Protection and Affordable Care Act (ACA) requires that the Contractor pay a Health Insurer Assessment Fee (HIF) annually based on its respective market share of premium revenues from the preceding year (calendar year 2014 revenue). AHCCCS provides
funding to the Contractor for the Health Insurer Assessment Fee and associated taxes subject to receipt and review of documentation from the Contractor as required by AHCCCS. 

This contract amendment serves to retroactively adjust the October, 2014 prospective capitation rates to include the federal and state income
taxes associated with the 2015 Health Insurer Assessment Fee, and amends the following sections of the contract: 
  

	 	•	 	Section B, Capitation Rates and Contractor Specific Information 

 Prospective Capitation
Rates (Per Member — Per Month) revised for the month of October, 2014 as shown below 
 October 1, 2014 – October 31,
2014 
  

																	
	 	  	GSA 4	 	  	GSA 08	 	  	GSA 10	 	  	GSA 12	 
	 County
	  	(Apache, Coconino,
Mohave, Navajo)	 	  	(Gila, Pinal)	 	  	(Pima Only)	 	  	Maricopa	 
	 TANF/KC < 1
	  	$	443.25 $604.01	  	  	$
 $
	476.54
 649.37
	  
   
	  	$
 $
	413.43
 563.37
	  
   
	  	$	484.48 $656.10	  
	 TANF/KC 1-13
	  	$	102.51 $139.69	  	  	$
 $
	99.43
 135.49
	  
   
	  	$
 $
	83.68
 114.03
	  
   
	  	$	103.53 $141.08	  
	 TANF/KC 14-44 F
	  	$	250.03 $340.71	  	  	$
 $
	259.30
 353.34
	  
   
	  	$
 $
	213.82
 291.37
	  
   
	  	$	230.96 $314.72	  
	 TANF/KC 14-44 M
	  	$	168.67 $229.84	  	  	$
 $
	160.67
 218.94
	  
   
	  	$
 $
	130.98
 178.48
	  
   
	  	$	140.10 $190.91	  
	 TANF 45+
	  	$	388.55 $529.47	  	  	$
 $
	443.32
 602.74
	  
   
	  	$
 $
	339.90
 463.17
	  
   
	  	$	399.04 $543.76	  
	 SSIW
	  	$	106.36 $144.93	  	  	$
 $
	134.29
 182.99
	  
   
	  	$
 $
	105.33
 143.53
	  
   
	  	$	132.52 $180.58	  
	 SSIWO
	  	$	876.16 $1193.92	  	  	$
 $
	714.07
 973.05
	  
   
	  	$
 $
	656.66
 894.81
	  
   
	  	$	759.13 $1034.45	  
	 *AHCCCS Care
	  	$	403.17 $549.39	  	  	$
 $
	411.32
 560.50
	  
   
	  	$
 $
	326.32
 444.67
	  
   
	  	$	419.06 $571.04	  
	 **Newly Eligible Adults
	  	$	313.93 $427.78	  	  	$
 $
	317.41
 432.53
	  
   
	  	$
 $
	268.00
 365.20
	  
   
	  	$	315.97 $430.56	  

  

	*	This group was known as AHCCCS Care for the October 2014 capitation rate-setting; this is now referred to as Adult Group at or below 106% Federal Poverty Level (Adults </= 106%). 


	**	This group was known as Newly Eligible Adults for the October 2014 capitation rate-setting; this is now referred to as Adult Group above 106% Federal Poverty Level (Adults > 106%). 


  
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	 	 ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

DIVISION OF BUSINESS AND FINANCE
  

CONTRACT AMENDMENT


  

	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 AHCCCS CONTRACTING OFFICER:

		
	



	 	




		
	TYPED NAME:	 	TYPED NAME:
	MIKE UCHRIN	 	MEGGAN HARLEY
		
	TITLE:	 	TITLE:
	ADMINISTRATOR/CEO	 	PROCUREMENT MANAGER
		
	DATE:	 	DATE:
	12/2/15	 	11/16/2015


  
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