EX-10.4








Exhibit 10.4




STATE OF CONNECTICUT

DEPARTMENT OF SOCIAL SERVICES




CONTRACT AMENDMENT




	 	 	 	 	 
	Amendment Number:
	 		10	
	Contract #:
	 	093-MED-FCHP-1
	Contract Period:
	 		08/11/2001 – 01/31/2005	
	Contract Name:
	 	FIRSTCHOICE HEALTHPLANS OF CONNECTICUT, INC.
	Contractor Address:
	 	116 Washington Avenue, North Haven, CT 06473







Contract number 093-MED-FCHP-1 by and between the Department of Social Services (the “Department”)
and Firstchoice Health Plan of CT (the “Contractor”) for the provision of services under the HUSKY
A program as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8 and 9 is hereby further amended as
follows:




	 	1.	 	Paragraph 1 of Part I as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8 and 9 is further
amended to extend the contract end date from September 30, 2004 to January 31, 2005.






	 	2.	 	Part II ‘GENERAL CONTRACT TERMS FOR MCOs” dated December 12, 2003 remain unchanged and in
full force and effect.






	 	3.	 	Appendix B Provider Credentialing and Enrollment, Appendix C EPSDT Periodicity Schedule,
Appendix D DSS Marketing Guidelines, Appendix E Quality Assurance Program; Appendix F
Unaudited Quarterly Financial Reports; Appendix H Managed Care Policy Transmittals; Appendix J
Physician Incentive Payments; and Appendix K Recategorization Chart which became effective on
August 11, 2001 remain unchanged and in full force and effect.






	 	4.	 	Appendix A HUSKY Covered Benefits; Appendix G Medicaid Managed Care Eligibility Categories
and Appendix L Quarterly Pharmacy Report which became effective August 13, 2003 remain
unchanged and in full force and effect.






	 	5.	 	Appendix I is deleted in its entirety and replaced with Appendix I attached hereto and
incorporated herein by reference. The capitation rates set forth in Appendix I attached
hereto and incorporated herein by reference are effective for the period 10/01/04 through
01/31/05.





ACCEPTANCES AND APPROVALS




This document constitutes an amendment to the above numbered contract. All provisions of that
contract and prior amendments, except those explicitly changed or described above by this
amendment, shall remain in full force and effect.



	 	 	 
	CONTRACTOR

	 	DEPARTMENT
	 
	 	 
	FirstChoice HealthPlans of Connecticut, Inc.

	 	Department of Social Services
	 
	 	 
	   Thaddeus Bereday   9/29/04   

	 	_Michael P. Starkowski   9/30/04_
	 

	 	 
	Signature (Authorized Official) Date

	 	Signature (Authorized Official) Date
	 
	 	 
	   Thaddeus Bereday   Secretary   

	 	_Michael P. Starkowski   Deputy Commissioner
	 

	 	 
	Signature (Authorized Official) Title

	 	Signature (Authorized Official) Title







OFFICE OF THE ATTORNEY GENERAL



Attorney General (as to form)
Date



( ) This contract does not require the signature of the Attorney General pursuant to an agreement
between the Department and the Office of the Attorney General dated:   



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APPENDIX A – Amended




Plan Name


FirstChoice



	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 	 
	Capitation Rates

10/01/04 – 01/31/05

	 	Fairfield            	 	Hartford            	 	Litchfield            	 	Middlesex            	 	New Haven            	 	New London            	 	Tolland            	 	Windham
	Under One
	 	$	580.21	 	 	$	656.41	 	 	$	654.49	 	 	$	775.69	 	 	$	652.17	 	 	$	648.96	 	 	$	783.92	 	 	$	628.96	 
	Ages 1 to 14
	 	$	110.68	 	 	$	119.48	 	 	$	119.14	 	 	$	140.71	 	 	$	118.75	 	 	$	118.14	 	 	$	142.19	 	 	$	116.49	 
	Male – Ages
	 	$	137.60	 	 	$	149.72	 	 	$	149.29	 	 	$	175.78	 	 	$	148.82	 	 	$	148.11	 	 	$	177.57	 	 	$	146.21	 
	15 to 39

Female – Ages
	 	$	224.72	 	 	$	250.37	 	 	$	249.64	 	 	$	296.11	 	 	$	248.76	 	 	$	247.51	 	 	$	299.28	 	 	$	241.27	 
	15-39

Male – Ages 40
	 	$	245.89	 	 	$	274.99	 	 	$	274.16	 	 	$	325.75	 	 	$	273.20	 	 	$	271.82	 	 	$	329.24	 	 	$	264.65	 
	and over

Female – Ages
	 	$	236.35	 	 	$	264.07	 	 	$	263.28	 	 	$	312.80	 	 	$	262.35	 	 	$	261.01	 	 	$	316.18	 	 	$	254.22	 







40 and over




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