Exhibit 10.4
 2007-000057-E
 MEDICARE PLATINO CONTRACT
AMENDMENT
(Medicaid Wraparound)
  Puerto Rico Health Insurance Administration (PRHIA) PRHIA
 
  TRIPLE-S SALUD, INC., ###-##-#### CONTRACTOR
 
  For the Provision of the wraparound
 coverage for the Government Health
 Insurance Dual-Eligible Population




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WITNESSETH
  WHEREAS: 07-057, 07-057A, 07-057B, 07-057C and
07-057D
 WHEREAS:
 PRHIA Triple-S Salud, Inc.
 Article I




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Article II:
  a)
    
    This agreement is effective January 1st, 2011 and shall
remain in effect until December 31, 2011 or until the execution of an extension
renewal or successor Agreement approved by the PRHIA Board of Directors.
 Article III
  a)
    
    ....b)
    
    The monthly premiums are attached hereto as Appendix B(1)(11) and shall
be deemed incorporated into this Agreement without further action by the
parties .....
 Article IV
   Article V
   Appendix C 1 (11)
    
    Medicare Advantage Product (PBP) submitted to CMS
on June 7, 2010Appendix C 2 (11)
    
    Medicaid Product (Wraparound) of this Agreement; without co-payments for
Enrollees whose names appear on the prepaid Premium Plan Roster.Appendix C-5 (11)
    
    Coordinated Care Model Norms 2011 Certification




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Article VI
    Appendix
    
    C-1 (11)
    
    Medicare Advantage Product (PBP) submitted to CMS for
approval on June 7, 2010Appendix
    
    C-2 (11)
    
    Medicaid WraparoundAppendix
    
    C-3 (11)
    
    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.Appendix
    
    C-4 (11)
    
    Summary of Benefits Report  The Summary Benefits (SB)
included as Appendix C-4 (11) 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 PRIHA, this
Section could be amended subject to PRHIA, review.Appendix
    
    C-5 (11)
    
    Coordinated Care Model Norms 2011 CertificationAppendix
    
    C-6 (11)
    
    Co-payments CertificationsAppendix
    
    C-7 (11)
    
    Value Added Benefits CertificationAppendix
    
    C-8 (11)
    
    Amendment Appendix F




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Article VI
   Article VII:
   Unclean Claims




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Refusals
    Hospitalization services or extending for more than thirty (30) days
  Other Contract Provisions
  Recoupment to Providers




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Article IX
 Utilization Guidelines
  Reports
  Penalties for Non-Compliance




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Normative Letter
  Article X:
  PUERTO RICO HEALTH
    
    
    
    TRIPLE-S SALUD, INC.INSURANCE ADMINISTRATION/s/ Domingo Nevárez Ramírez
    
    
    
    /s/ Socorro RivasDomingo Nevárez Ramírez, MHSA
    
    
    
    Socorro RivasExecutive Director
    
    
    
    Chief Executive Officer
Triple-S Salud, Inc.




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APPENDIX A(1)(11)
 SERVICE AREA
 APPENDIX A(1)(11)
 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 Altoand Vieques.




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West Health Area
    
    composed of the municipalities of Aguada, Aguadilla, Añasco, Cabo Rojo, Hormigueros, Isabela, Lajas, Las Marías,
Maricao, Mayagüez, 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.




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APPENDIX B(1)(11)
 PREMIUM PAYMENT
 Appendix B(1)(11)
 Monthly Payment of Premiums per Member
by Geographic Areas
 TRIPLE-S Salud, Inc. Plans
Product: SSS Selecto




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DSH SNPBlendedArea:
    
    H4012-003East
    
    $
    10.00Metro-North
    
    $
    10.00North
    
    $
    10.00North East
    
    $
    10.00San Juan
    
    $
    10.00South East
    
    $
    10.00South-West
    
    $
    10.00West
    
    $
    10.00




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APPENDIX C-3 (11)
 SERVICES PROVIDED BY DEPARTMENT OF HEALTH
 Appendix C-3 (11)




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
    
    Vaccines for children from 0 to 21 years of age.
 -
    
    Diphteria-
    
    Polio (ipv)-
    
    Polio (opv)-
    
    Hepatitis B-
    
    MMR-
    
    Tetanus (TD)-
    
    Pneumonia-
    
    HPV-
    
    Tetramune (DTP-Hip)-
    
    Immunoglobulin-
    
    Synagis (for babies)-
    
    Hepatitis A vaccine for children from 12 to 17 months of age-
    
    Tetanus/Diphtheria booster every 10 year-
    
    Chickenpox vaccine for 12 year old child-
    
    PCV-7 ( for girls and adolescents)-
    
    Influenza (for 65 years and older)