exv10w43w1



 





Exhibit 10.43.1




HHSC Contract No. 65M1015HPC




STATE OF TEXAS

COUNTY OF TRAVIS



AMENDMENT 9

TO THE AGREEMENT BETWEEN THE

HEALTH & HUMAN SERVICES COMMISSION

AND

AMERIGROUP TEXAS, INC.

FOR HEALTH SERVICES

TO THE

MEDICAID STAR+PLUS PROGRAM

IN THE

HARRIS SERVICE DELIVERY AREA




     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. (“HMO”), 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 E. Copeland Rd. Suite 200, Arlington, TX
76011. HHSC and CONTRACTOR may be referred to within this Amendment
individually as a “Party” and collectively as the “Parties.”



     The Parties hereby agree to amend their Agreement as set forth herein.



ARTICLE 1. PURPOSE.




Section 1.01 Authorization.




     This Amendment is executed by the Parties in accordance with Article 15.2 of
the Agreement.



Section 1.02 Effective Date.




     The Effective Date of this Agreement is September 1, 2004, upon execution
by the parties and terminates on the Expiration Date of the Agreement, unless
extended or terminated sooner by HHSC, in accordance with the Agreement.



ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES




Section 2.01 Modification to Article 4, Fiscal, Financial, Claims and
Insurance Requirements





	 	 	 	Article 4, Fiscal, Financial, Claims and Insurance Requirements, is
amended by modifying Section 4.6 as follows:






4.6.3 HMO understands that acceptance of funds under
this Contract acts as acceptance of the authority of
the State Auditor’s Office (“SAO”), or any successor
agency, to conduct an investigation in connection with
those funds. HMO further agrees to cooperate fully
with the SAO or its successor in the conduct of the
audit or investigation, including providing all
records requested. HMO will ensure that this clause
concerning the authority to audit funds received



					
	 	 	 	 	 
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	 	 	 	indirectly by subcontractors through CONTRACTOR and
the requirement to cooperate is included in any
subcontract it awards





Section 2.02
Modification to Article 5, Compliance with State and Federal
Laws





	 	 	 	Article 5, Compliance with State and Federal Laws, is
amended by modifying Section 5.3, as follows:





     5.3 FRAUD AND ABUSE COMPLIANCE PLAN





     5.3.1 This contract is subject to all state and
federal laws and regulations relating to fraud and
abuse in health care and the Medicaid program. HMO
must cooperate and assist HHSC and any other state
or federal agency charged with the duty of
identifying, investigating, sanctioning or
prosecuting suspected fraud and abuse. HMO must
provide originals and/or copies of all records and
information requested and allow access to premises
and provide records to HHSC or its authorized
agent(s), HHSC, CMS, the U.S. Department of Health
and Human Services, FBI, TDI, and the Texas Attorney
General’s Medicaid Fraud Control Unit. All copies of
records must be provided free of charge.




     5.3.2 Compliance Plan. HMO must submit to HHSC
Office of Inspector General (HHSC-OIG) for approval
a written fraud and abuse compliance plan which is
based on the Model Compliance Plan issued by the
U.S. Department of Health and Human Services, the
Office of Inspector General (OIG), no later than 30
days after the effective date of the contract. HMO
must designate an officer or director in its
organization who has the responsibility and
authority for carrying out the provisions of its
compliance plan. HMO must submit any updates or
modifications in its compliance plan to I-IHSC-OIG
for approval at least 30 days prior to the
modifications going into effect. HMO’s fraud and
abuse compliance plan must:




     5.3.2.1 ensure that all officers, directors,
managers and employees know and understand the
provisions of HMO’s fraud and abuse compliance plan.




     5.3.2.2 contain procedures designed to prevent
and detect potential or suspected abuse and fraud in
the administration and delivery of services under
this contract.




     5.3.2.3 contain provisions for the confidential
reporting of plan violations to the designated
person in HMO.




     5.3.2.4 contain provisions for the
investigation and follow-up of any compliance plan
reports.




     5.3.2.5 ensure that the identity of individuals
reporting violations of the plan is protected.




     5.3.2.6 contain specific and detailed internal
procedures for officers, directors, managers and
employees for detecting, reporting, and
investigating fraud and abuse compliance plan
violations.



					
	 	 	 	 	 
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Exhibit 10.43.1





     5.3.2.7 require any confirmed or suspected fraud
and abuse under state or federal law be reported to
HHSC, the Medicaid Provider Integrity section of the
Office of Inspector General of the Texas Health and
Human Services Commission, and/or the Medicaid Fraud
Control Unit of the Texas Attorney General.




     5.3.2.8 ensure that no individual who reports
plan violations or suspected fraud and abuse is
retaliated against.




     5.3.3 Training. HMO must designate executive and
essential personnel to attend mandatory training in
fraud and abuse detection, prevention and reporting.
The training will be conducted by the Office of
Inspector General, HHSC, and will be provided free of
charge. HMO must schedule and complete training no
later than 90 days after the effective date of any
updates or modification of the written Model
Compliance Plan.




     5.3.3.1 If HMO’s personnel have attended OIG
training prior to the effective date of this
contract, they are not required to attend additional
OIG training unless new training is required due to
changes in federal and/or state law or regulations.
If additional OIG training is required, HHSC will
notify HMO to schedule this additional training.




     5.3.3.2 If HMO updates or modifies its written
fraud and abuse compliance plan, HMO must train its
executive and essential personnel on these updates or
modifications no later than 90 days after the
effective date of the updates or modifications.




     5.3.3.3 If HMO’s executive and essential
personnel change or if HMO employs additional
executive and essential personnel, the new or
additional personnel must attend OIG training within
90 days of employment by HMO.




     5.3.4 HMO’s failure to report potential or
suspected fraud or abuse may result in sanctions,
contract cancellation, or exclusion from
participation in the Medicaid program.




     5.3.5 HMO must allow the Texas Medicaid Fraud
Control Unit and HHSC’s Office of Inspector General,
to conduct private interviews of HMO’s employees,
subcontractors and their employees, witnesses, and
patients. Requests for information must be complied
with in the form and the language requested. HMO’s
employees and its subcontractors and their employees
must cooperate fully and be available in person for
interviews, consultation, grand jury proceedings,
pre-trial conference, hearings, trial and in any
other process.




     5.3.6 Subcontractors. HMO must submit the
documentation described in Articles 5.3.6.1 through
5.3.6.3, in compliance with Texas Government Code
‘533.012, regarding any subcontractor providing
health care services under this contract except for
those providers who have re-enrolled as a provider in
the Medicaid program as required by Section 2.07,
Chapter 1153, Acts of the 75th Legislature, Regular
Session, 1997, or who modified a contract in
compliance with that section. HMO must submit
information in a format as specified by HHSC.
Documentation must be submitted no later than I20
days after the effective date of this contract.
Subcontracts



					
	 	 	 	 	 
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Exhibit 10.43.1





	 	 	 	entered into after the effective date of this
contract must be submitted no later than 90 days
after the effective date of the subcontract. The
required documentation required under this provision
is not subject to disclosure under Chapter 552,
Government Code.






     5.3.6.I a description of any financial or other
business relationship between HMO and its
subcontractor;




     5.3.6.2 a copy of each type of contract between
HMO and its subcontractor;




     5.3.6.3 a description of the fraud control
program used by any subcontractor. Per HHSC request,
and on an ad-hoc basis, HMOs will be required to
submit a list of Health-related Materials currently
being used, or used previously; HHSC may request the
review of selected materials from that list. HHSC
will provide HMO a reasonable amount of time to
respond to such requests, generally no less than I0
business days.




     5.3.7 Special Investigations Unit. An HMO that
provides or arranges for the provision of health care
services to an individual under the Medical
Assistance Program (Medicaid), must arrange for a
special investigative unit to investigate fraudulent
claims and other types of program abuse by recipients
and providers. An HMO may choose to:




     (1) Establish and maintain the special
investigative unit within the managed care
organization; or




     (2) Contract with another entity for the investigation.




     5.3.7.1 An HMO must develop a plan to prevent
and reduce waste, abuse, and fraud. The plan must
meet the requirements of the rules established by
HHSC and be submitted annually to the HHSCOIG for
approval each year the HMO is enrolled with the State
of Texas. The plan must be submitted 60 days prior to
the start of the State fiscal year.




     5.3.7.1.1 If the initial plan to prevent and
reduce waste, abuse, and fraud is not approved, the
HMO must resubmit the plan to HHSCOIG within 15
working days of receiving the denial letter, which
will explain the deficiencies. If the plan is not
resubmitted within the time allotted, the HMO will be
in default and sanctions may be imposed.




     5.3.7.2 If the HMO elects to contract with
another entity for the investigation of fraudulent
claims and other types of program abuse as referenced
in paragraph (b)(2) of this section, the HMO must
adhere to all requirements of Chapter 42, § 438.230
of the Code of Federal Regulations.



Section 2.03 Modification to Article 6, Scope of Services





	 	 	 	Article 6, Scope of Services, is amended by modifying Section 6.1.6.2, as follows:





					
	 	 	 	 	 
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Exhibit 10.43.1





     6.1.6.2 Value-added services can only be added
or removed by written amendment of this contract one
time per fiscal year. HMO cannot include a
value-added service in any material distributed to
Members or prospective Members until this contract
has been amended to include that value-added service
or HMO has received written approval from HHSC
pending finalization of the contract amendment.



Section 2.04  Modification to Article 7, Provider Network Requirements





	 	 	 	Article 7, Provider Network Requirements, is amended by
modifying Section 7.6, as follows:






     7.6 PROVIDER COMPLAINT AND APPEAL PROCEDURES




     7.6.1 HMO must develop, implement and maintain
a provider complaint system. The complaint and
appeal procedures must be in compliance with all
applicable state and federal law or regulations. All
Member complaints and/or appeals of an adverse
determination requested by the enrollee, or any
person acting on behalf of the enrollee, or a
physician or provider acting on behalf of the
enrollee must comply with the provisions of this
Article. Modifications and amendments to the
complaint system must be submitted to HHSC no later
than 30 days prior to the implementation of the
modification or amendment.




     7.6.2 HMO must include the provider complaint
and appeal procedure in all network provider
contracts or in the provider manual.




     7.6.3 HMO’s complaint and appeal process cannot
contain provisions requiring a provider to submit a
complaint or appeal to HHSC for resolution in lieu
of the HMO’s process.




     7.6.4 HMO must establish mechanisms to ensure
that network providers have access to a person who
can assist providers in resolving issues relating to
claims payment, plan administration, education and
training, and complaint procedures.




     7.6.5 Beginning August 1, 2004, providers must
file appeals or adjustment requests within 120 days
from the date of disposition, which is the date of
the Remittance and Status (R&S) report on which the
last action on the claims appears; the deadline is
applicable to both paper and electronic submissions.




     7.6.6 Fiscal Agent Payment Deadlines. The
state’s Claims Administrator must finalize all
claims, including appeals, within 24 months; the
24-month deadline is a payment deadline, and is not
the claims filing deadline that is in place for
claims submissions and appeals. Please refer to
Texas Medicaid Bulletin, No. 178, March/ April 2004
edition, “Fiscal Agent Payment Deadlines” for more
specific information regarding payment deadlines.



					
	 	 	 	 	 
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Exhibit 10.43.1




Section 2.05 Modification of Article 13, Payment Provisions





	 	 	 	Article 13, Payment Provisions, is amended by modifying
Section 13.1.1, as follows:






     13.1.1 HHSC will reimburse HMO based on a fixed
monthly Capitation rate for each enrolled Member.
Capitation Rates for each HMO may vary by Service
Area and HMO. HHSC and/or contracted actuaries will
perform data analysis and calculate the Capitation
Rates for each Rate Period.




     The monthly Capitation Rate will consist of the
following components:




	 	1.	 	cost to cover the health care services;
	 
	 	2.	 	cost of administering the program; and
	 
	 	3.	 	allowance for risk.





Section 2.06 Modification of Article 13, Payment Provisions





	 	 	 	Article 13, Payment Provisions, is amended by modifying
Section 13.1.2, as follows:






     13.1.2 The monthly capitation amounts for the
Harris County Service Delivery Area are as follows:



	 	 	 	 	 
	 	 	FY 2005
	 	 	Monthly Capitation Amounts
	Member Risk Groups
	 	9/1/2004 - 8/31/2005

	CBA Waiver Clients-Dual Eligible
	 	$	1,453.65	 
	CBA Waiver Clients-Medicaid Only
	 	$	3,442.06	 
	Other Community Clients-Dual Eligible
	 	$	155.23	 
	Other Community Clients-Medicaid Only
	 	$	754.94	 







Section 2.07 Modification of Article 19, Term





	 	 	 	Article 19, Term, is amended by modifying Section 19, as follows:






     19.1 The effective date of this contract is
August 31, 1999. The contract will terminate on
August 31, 2005, unless extended or terminated
earlier as provided for elsewhere in this contract.



					
	 	 	 	 	 
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Exhibit 10.43.1




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.



	 	 	 
	AMER1GROUP TEXAS, INC.


	 	HEALTH & HUMAN SERVICES COMMISSION 







	 	 	 	 	 	 	 
	By:

	 	/s/ Eric Yoder
	 	By:	 	 
	

	 	

Eric Yoder
President and CEO
	 	 	 	

Albert Hawkins

Executive Commissioner
	 
	 	 	 	 	 	 
	Date:

	 	7/23/04
	 	Date:	 	 
	

	 	

	 	 	 	








					
	 	 	 	 	 
	HHSC Contract 65M1015HPC
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	 	Effective Date: September 1, 2004