exh10-1.htm


    
      

    

    Back to Form
8-K

     

    Exhibit
10.1

    
 

    STATE
OF CONNECTICUT

    DEPARTMENT
OF SOCIAL SERVICES

     

     

    CONTRACT
AMENDMENT

    


     

    
      	
              Amendment
      Number:

            	
              23

            
	
              Contract
      #:

            	
              093-MED-WCC-1

            
	
              Contract
      Period:

            	
              08/11/2001
      –  03/31/08

            
	
              Contractor
      Name:

            	
              WELLCARE
      OF CONNECTICUT, INC.

            
	
              Contractor
      Address:

            	
              116
      Washington Avenue, 2nd
      Floor  North Haven,
  CT  06473

            


    

    
      
        
          

        

      

      


    

    Contract
number 093-MED-WCC-1 by and between the Department of Social Services (the
“Department”) and WELLCARE of  CONNECTICUT, Inc. (the “Contractor”)
for the provision of services under the HUSKY A program as amended by Amendments
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 and 22
is hereby further amended as follows:

     

    
      	
              1.

            	
              Paragraph
      1 of Part I as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11,
      12, 13, 14, 15, 16, 17, 18,19, 20, 21 and 22 is further amended to extend
      the contract end date from  February 29, 2008 to March 31,
      2008.

            


    

     

    
      	
              2.

            	
              Part
      II “GENERAL CONTRACT TERMS FOR MCOs” dated 05/07 remain unchanged and in
      full force and effect subject to the provisions of this and all prior
      amendments.

            


    

     

    
      	
              3.

            	
              Effective
      February 1, 2008 the Contractor will no longer be required to administer
      the HUSKY A pharmacy benefit, however the Contractor shall retain all its
      contractual obligations with regard to pharmacy claims with dates of
      service before February 1, 2008.

            


    

     

    
      	
              4.

            	
              Paragraph
      5 of Amendment 22 is deleted in its entirety and replaced with the
      following:  The Department and the Contractor agree that the
      Contractor shall continue participating in the HUSKY A program through
      March 31, 2008. During the period 01/01/08 through 03/31/08 , however the
      Contractor will be operating as a Pre-paid Inpatient Health Plan (PIHP)
      and, as such, shall not be responsible for the costs of covered services
      incurred by the Contractor’s HUSKY A enrollees. The costs of such covered
      services shall be the responsibility of the Department and the Department
      shall reimburse the Contractor for any amounts paid by the Contractor for
      such covered services on a monthly basis upon the presentation of
      documentation from the Contractor to the Department for such paid
      amounts.   The Department shall reimburse the Contractor
      for any amounts paid by the Contractor to providers for covered services
      rendered to its HUSKY A enrollees in accordance with the Contractor’s then
      current provider contracts, (which may include capitated and other payment
      arrangements in addition to fee for service payments), or where services
      are provided by non-contracted providers, the then current Medicaid fee
      schedule or other rate paid by the Contractor to the non-contracted
      provider.

            


    

     

    
      	
              5.

            	
              Any
      other changes to Part II “GENERAL CONTRACT TERMS FOR MCOS” dated 05/07
      that are necessitated by the transition from managed care to a PIHP
      arrangement shall be directed by Department’s authorized personnel in
      writing to the Contractor in a manner consistent with the Contract, and
      may be relied upon by Contractor.  For purposes of this
      amendment the Department’s authorized personnel shall be limited to the
      Commissioner, or his designee; the Director of Medical Care
      Administration, or his designee; the Director of Medical Administration
      Managed Care, or her designee and/or the Department’s Medical Director, or
      his designee.

            


    

     

    
      	
              6.

            	
              Effective
      January 1, 2008 through March 31, 2008 the Department shall suspend the
      Contractor’s HUSKY A new Member enrollment unless otherwise notified in
      writing by the Department.

            


    

     

     

     

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      	
              7.

            	
              Paragraph 9 of Amendment 22 is deleted in its
      entirety and replaced with the following:  During the period
      January 1, 2008 through March 31, 2008 the Department and the Contractor
      shall agree to and implement the terms of a plan to transition each of the
      Contractor’s HUSKY A enrollees to another MCO in the HUSKY
      A program by March 31, 2008 with the understanding that the goal of the
      transition plan is to conduct an orderly transition that will protect the
      health, safety and welfare of the Contractor’s HUSKY A
      members.

            


    

     

    
      	
              8.

            	
              Paragraph
      10 and each subsection in Paragraph 10 of Amendment 22 is deleted in their
      entirety and replaced with the
following:

            


    

     

    During
the period January 1, 2008 through March 31, 2008, in consideration of the
Contractor’s performance of HUSKY A services in accordance with the terms of the
original contract as amended, the Department shall pay the Contractor the
following:

     

    
      	
               
      

            	
              A.An
      administrative fee of $18.18 (which includes the administration of dental
      services) per HUSKY A member per month enrolled with Contractor, payable
      by February 15 for January enrollees  March 15 for February
      enrollees and April 15 for March
enrollees.

            


    

     

    
      	
               
      

            	
              B.The
      Department may withhold up to 8% of each of the payments described in
      subsections C through H of this section to be kept by the Department in a
      reserve account for medical expenses.  The reserve account shall
      not exceed $750,000.00 and shall be used for the final reconciliation of
      medical expense as set forth in Section 8 J of this
    amendment.

            


    

     

    
      	
               
      

            	
              C.On
      or before February 15, 2008, the Department shall advance a payment to the
      Contractor for medical services furnished in January 2008 to Contractor’s
      enrollees.  The payment shall be equal to 60% of
      Contractor’s  monthly claims PMPM experience for covered
      services  calculated in accordance with the provision of Section
      8 L of this amendment applied to the number of Contractor’s enrollees in
      January 2008.

            


    

     

    
      	
               
      

            	
              D.On
      or before March 15, 2008 the Department shall advance a payment to the
      Contractor for medical services furnished in January 2008 to Contractor’s
      enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims PMPM  experience for
      covered services calculated in accordance with the provision of Section 8
      L of this amendment applied to the number of Contractor’s enrollees in
      January 2008.

            


    

     

    
      	
               
      

            	
               

            	
              
                E.
      On or before April 15, 2008 the Department shall advance a payment
      to the Contractor for medical services furnished in January 2008 to
      Contractor’s enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims experience for covered calculated
      in accordance with the provision of Section 8 L of this amendment applied
      to the number of Contractor’s enrollees in January
    2008.

              

            


    

     

    
      	
               
      

            	
               

            	
              
                F.
      On or before March 15, 2008, the Department shall advance a payment
      to the Contractor for medical services furnished in February 2008 to
      Contractor’s enrollees.  The payment  shall be equal
      to 60% of Contractor’s  monthly claims PMPM experience for
      covered services calculated in accordance with the provision of Section 8L
      of this amendment applied to the number of Contractor’s enrollees in
      February 2008.

              

            


    

     

    
      	
               
      

            	
              G.On
      or before April 15, 2008 the Department shall advance a payment to the
      Contractor for medical services furnished in February 2008 to Contractor’s
      enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims PMPM  experience for
      covered services calculated in accordance with the provision of Section 8
      L of this amendment applied to the number of Contractor’s enrollees in
      February 2008.

            


    

     

    
      	
               
      

            	
              H.On
      or before May 15, 2008 the Department shall advance a payment to the
      Contractor for medical services furnished in February 2008 to Contractor’s
      enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims experience for covered calculated
      in accordance with the provision of Section 8 L of this amendment applied
      to the number of Contractor’s enrollees in February
  2008.

            


    

     

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


     

     

    
      	
               
      

            	
               

            	
              
                I.
      On or before April 15, 2008, the Department shall advance a payment
      to the Contractor for medical services furnished in March 2008 to
      Contractor’s enrollees.  The payment  shall be equal
      to 60% of Contractor’s  monthly claims PMPM experience for
      covered services calculated in accordance with the provision of Section 8
      L of this amendment applied to the number of Contractor’s enrollees in
      March 2008.

              

            


    

     

    
      	
               
      

            	
               

            	
              
                J.
      On or before May 15, 2008 the Department shall advance a payment to
      the Contractor for medical services furnished in March 2008 to
      Contractor’s enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims PMPM  experience for
      covered services calculated in accordance with the provision of Section 8
      L of this amendment applied to the number of Contractor’s enrollees in
      March 2008.

              

            


    

     

    
      	
               
      

            	
              K.On
      or before June 15, 2008 the Department shall advance a payment to the
      Contractor for medical services furnished in March 2008 to Contractor’s
      enrollees.  The payment shall be equal to 20% of
      Contractor’s  monthly claims experience for covered calculated
      in accordance with the provision of Section 8 L of this amendment applied
      to the number of Contractor’s enrollees in March
  2008.

            


    

     

    
      	
               
      

            	
               

            	
              
                L.
      For the purposes of calculating the Contractor’s  monthly
      claims PMPM experience for covered services, the Department shall
      calculate a PMPM that shall be applied to the number of Contractor
      enrollees each month.  The PMPM shall equal 85% of the
      risk-based average PMPM premium payment paid to the Contractor in January
      2008 for December 2007
enrollees.

              

            


    

     

    
      	
               
      

            	
              M.Through
      July  31, 2008 the Contractor shall be responsible for
      adjudicating claims for services rendered from January 1, 2008 through
      March 31, 2008 to Contractor’s enrollees.  From the effective
      date of this amendment through September  15, 2008 the
      Contractor shall, on a monthly basis  submit  to the
      Department capitated payment data  and HIPAA-compliant paid
      claims file that must report the following data elements:  date
      of service, date of payment, Member name, Member Medicaid Eligibility ID
      number, Provider name, Provider FEIN, claim number, location of service,
      service diagnosis/procedure and paid amount for claims adjudicated by the
      Contractor for services rendered from January 1, 2008 through March 31,
      2008  to Contractor’s enrollees.  On or
      before  September 15, 2008 the Contractor shall submit to the
      Department final HIPAA-compliant paid claims data and capitated payment
      data for claims adjudicated by the Contractor for services rendered from
      January 1, 2008 through March 31, 2008  to Contractor’s
      enrollees.  By October 31, 2008 the Department shall conduct a
      reconciliation of actual medical expenses incurred by Contractor’s
      enrollees  from January 1, 2008 through March 31, 2008 utilizing
      the paid claims data file supplied by the Contractor to the Department
      with the Contractor’s invoice for payment and the Contractor’s encounter
      data required pursuant to Part II Section 3.38h including the following
      data elements: date of service, date of payment, member name, Member
      Medicaid Eligibility ID number, provider name, provider FEIN, claim
      number, location of service, service diagnosis/procedure and paid
      amount.  If following the completion of the reconciliation the
      payments made by the Department to the Contractor under subsections C
      through K exceed the actual medical expenses incurred by the Contractor
      for services rendered from  January 1, 2008 through March 31,
      2008 to Contractor’s enrollees, the Contractor shall reimburse the
      Department the excess payment.  If, however, following the
      completion of the reconciliation the payments made by the Department to
      the Contractor under subsections C through K  were less than the
      actual medical expenses incurred by the Contractor for services rendered
      in January 1, 2008 through March 31, 2008  to Contractor’s
      enrollees, the Department shall reimburse the Contractor the difference
      between the total of the payments made by the Department to the Contractor
      for medical expenses and the total actual medical expenses incurred
      from  January 1, 2008 through March 31, 2008 by the Contractor’s
      enrollees. Payment to the Department or the Contractor in accordance with
      this subsection shall be made by November 30,
  2008.

            


    

     

    
      	
              9.

            	
              Paragraphs
      11 through and including 17 of Amendment 22 remain in full force and
      effect.

            


    

     

    
      	
              10.

            	
              Pursuant
      to Public Act 07-1, An Act Concerning the State Contractor Contribution
      Ban and Gifts to State and Quasi-Public Agencies the Department must
      provide and each Contractor must acknowledge receipt of the State
      Elections Enforcement Commission’s notice advising state contractors of
      state campaign

            


    

     

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      	
               
      

            	
              contribution
      and solicitation prohibitions.  Through the execution of this
      amendment the Department certifies that SEEC FORM 11 -
      NOTICE TO
      EXECUTIVE BRANCH STATE CONTRACTORS AND PROSPECTIVE STATE CONTRACTORS OF
      CAMPAIGN CONTRIBUTION AND SOLICITATION BAN has been provided to the
      Contractor and the Contractor acknowledges receipt of the
      same.

            


    

     

     

    ACCEPTANCES
AND APPROVALS

     

     

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

     

    
      	
              CONTRACTOR

            	
              DEPARTMENT

            
	
              WellCare
      of Connecticut, Inc.

            	
              Department
      of Social Services

            
	
                /s/  Heath
      Schiesser

            	
              2/28/2008

            	
              /s/  Michael
      P. Starkowski

            	
              2/29/08

            
	
              Signature
      (Authorized Official)

            	
              Date

               

            	
              Signature
      (Authorized Official)

            	
              Date

            
	
              Heath
      Schiesser

            	
              President
      & CEO

            	
              Michael
      P. Starkowski

            	
              Commissioner

            
	
              Typed
      Name (Authorized Official)

            	
              Title

            	
              Typed
      Name (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:
______________