ohanaamend3.htm


    Back to Form 8-K

    Exhibit 10.1


     

    
      STATE
OF HAWAII


    

    
       

      SUPPLEMENTAL CONTRACT NO. 3

      TO CONTRACT DHS-08-MQD-5129                                                                     

           
(Insert contract
number or other identifying information)

    

    
      


       

                              
This Supplemental Contract No. 3                                                                                                                                                                      , executed on the respective dates
indicated
below, is effective as of January 30                                                                                                                                                           ,
2009                                                          
, between the 

      Department of Human
Services/Med-QUEST
Division                                                                                                                                                                                                         
, State of
Hawaii

    

    
         (Insert name of state
department, agency, board or commission)

      ("STATE"), by its Director,
Lillian B.
Koller,                                                                                                                                                                                                                                                         

    

    
                                         (Insert
title of state officer executing contract)

      (hereafter
also referred to as the HEAD OF THE PURCHASING AGENCY or designee ("HOPA")),
whose
address is 1390
Miller Street, Honolulu, Hawaii  
96813                                    ,
and

      WellCare Health Insurance of
Arizona, Inc. dba 'Ohana Health Plan, Inc.                                                                                                                                                                   ("CONTRACTOR"),

      a Corporation                                                                                                                                                                                                                                                                                                                                                                                   

    

    
      (Insert
corporation, partnership, joint venture, sole proprietorship, or other legal
form of the CONTRACTOR)

    

    
      under the
laws of the State of Arizona                                                                                                                                                                                                ,
whose business address and federal

    

    
      
        	
                and
      state taxpayer identification numbers are as
      follows:    8735 Henderson Rd.,
      Tampa, FL
      33634                                                                                                                                                  

              

GET#W11018973-01   Fed ID#
86-0269558                                                                                                                                                                                         
                                                          



    

    
       

      RECITALS

       

                    A.     WHEREAS,
the STATE and the CONTRACTOR entered into Contract

    

    
      
        
          	
                  DHS-08-MQD-5129

                


        

           (Insert
contract number or other identifying information)

      

    

    
      	
              
                dated
      February
      4     , 2008 , which
      was amended by Supplemental Contract No(s).  1

              

            
	
              
                dated May
      15         
      ,  2008 , which was amended by
      Supplemental Contract No(s).  2

              

            
	
              
                dated December 15
       , 2008 , which was
      amended by Supplemental Contract No(s).   n/a

              

            
	
              
                dated __________ 
      ____, (hereafter collectively referred to as "Contract") whereby the
      CONTRACTOR agreed to provide the goods or services, or both, described in
      the Contract; and

              

            


    

    
       

                                       
       
B.      WHEREAS, the parties now desire to amend
the Contract.  

                    NOW,
THEREFORE, the STATE and the CONTRACTOR mutually agree to amend the Contract as
follows: (Check Applicable box(es))

    

    
       

      
        	
                x   
      

              	
                Amend
      the SCOPE OF SERVICES according to the terms set forth in Attachment-S 1,
      which is made a part of the
Contract.

              


      

    

    
      
        	
                □   
      

              	
                Amend
      the COMPENSATION AND PAYMENT SCHEDULE according to the terms set forth in
      Attachment-S2, which is made a part of the
  Contract.

              


      

    

    
      
        	
                □   
      

              	
                Amend
      the TIME OF PERFORMANCE according to the terms set forth in Attachment-S3,
      which is made a part of the
Contract.

              


      

    

    
      
        	
                □   
      

              	
                Amend
      the SPECIAL CONDITIONS according to the terms set forth in Attachment-S6
      SUPPLEMENTAL SPECIAL CONDITIONS, which is made a part of the
      Contract.

              
	
                                                  
       □

              	Recognize
      the CONTRACTOR'S change of name.


      

    

    
              

    

    
      
        	 	  From:
    	                                                                            
        
	 	 	 _________________________________              
      
	 	 	 _________________________________
	 	 	 _________________________________


      

                                                                                  

      AG-005 Rev
04/30/2007

    

    
      1


        
          
             


          

          
             


            
              

            

          

          
             


          

        

      

    

     

    
      	
            	To: 	 ________________________________
	 	 	 ________________________________
	 	 	 ________________________________
	 	
               

               As
      set forth in the documents attached hereto as Exhibit __ , and
      incorporated herein.

            


    

     

    
                                           
  A tax clearance certificate from the State of
Hawaii   o is  x is not required to be
submitted to the STATE prior to commencing any performance under this
Supplemental Contract.

    

    
      


                                           
  A tax clearance certificate from the Internal Revenue
Service o
is  x is
not required to be submitted to the STATE prior to commencing any performance
under this Supplemental Contract.

    

    
      


                          The
entire Contract, as amended herein, shall remain in full force and
effect.

    

    
       

                   IN
VIEW OF THE ABOVE, the parties execute this Contract by their signatures, on the
dates below, to be effective as of the date first above
written.

    

    
       

    

    
      	 
      	
              STATE

               

              
                /s/ Name
      Illegible                                             
      

              

              (Signature)

            
	 
      	
              
                for

                Lillian
      B.
      Koller                                                           
      

              

              (Print
      Name)

            
	 
      	
               

              
                Director                                                                       
      

              

              (Print
      Title)

            
	 
      	
               

              
                1/29/09                                                                          
      

                (Date)

              

            


    

    


    
      	
               

               

               

              CORPORATE
      SEAL

              (If
      available)

            	
              CONTRACTOR

               

              
                WellCare
      Health Insurance of Arizona,
      Inc.         

                dba
      ‘Ohana Health Plan,
      Inc.                                  
      

              

              (Name of
      Contractor)

            
	 
      	
               

              
                /s/
      Heath
      Schiesser                                                   
      

              

              (Signature)

            
	 
      	
               

              
                Heath
      Schiesser                                                        
      

              

              (Print
      Name)

            
	 
      	
               

              
                President
      and
      CEO                                                   
      *

              

              (Print
      Title)

            
	 
      	
               

              
                1-27-09                                                                      
      

              

              (Date)

            


    

    
       

      APPROVED
AS TO FORM:

    

    
       

      /s/ Name
Illegible                         


      Deputy
Attorney General

    

    
      


       

      *
Evidence
of authority of the CONTRACTOR'S representative to sign this Contract for the
CONTRACTOR must be attached.

    

     

    
      AG-005 Rev
04/30/2007

      2

       

      
        
          
          

        

        
          
          

          
            

          

        

        
          
          

        

      

    

    
       

      CONTRACT
NO. DHS – 08 – MQD -
5129

    

    
      


    

    
      PROVIDER’S
ACKNOWLEDGMENT

    

    
      


    

    
      	
              STATE
      OF

            	
              FLORIDA

            	
              )

            
	 	 	 	)	 
	 
      	
              COUNTY
      OF

            	
              HILLSBOROUGH

            	
              )
      ss.

            	 
      


    

    
       

    

    
      On this 27th
day of January, 2009, before me
appeared Heath Schiesser and ___________, to me known, to be the person(s)
described in and, who, being by me duly sworn, did say that he/she/they is/are the President  and
CEO of Wellcare Health Insurance of
Arizona, Inc.  the PROVIDER named in the foregoing instrument, and
that he/she/they is/are
authorized to sign said instrument on behalf of the PROVIDER, and acknowledges
that he/she/they executed said
instrument as the free act and deed of the PROVIDER.

    

    
       

    

    
      	
               

               

               

              (Notary
      Seal)

            	
              By /s/ Tolliver
      L.Rowson                                      
      

                         (Signature)

               

            
	
              Print
      Name Tollover L.
      Rowson                     
      

               

            
	
              Date
      January 27,
      2009                                            
      

               

            
	
              Notary
      Public, State of Florida                              

               

            
	
              My
      Commission expires: 11.30.2012                   
       

               

            


    

    
      	
              Doc.
      Date:

            	_______________        
      	
                
      # Pages:

            	________________ 
      
	
              Notary
      Name:

            	Tolliver L.
      Rowson  	 
      	 
      	
              Circuit

            


    

    


    
      	
              Doc
      Description:

            	 
      	 
      
	 
      	
               

               

               

               

              (Notary
      Stamp or Seal)

            
	 
      
	 
      
	
               

               

              /s/
      Tolliver L.
      Rowson                                      
      1.27.2009                                 
      

              Notary
      Signature                                                    Date

            
	
               

              NOTARY
      CERTIFICATION 

               

            


    

    
      


      AG Form
l03F( 10/08)

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

    


    
      CONTRACT
NO. DHS –
08-MQD-5129

    

    
       

      PROVIDERS


      STANDARDS
OF CONDUCT DECLARATION

    

    
      For the
purposes of this declaration:

    

    
       

      
        	
                 
      

              	
                 

              	
                "Agency"
      means and includes the State, the legislature and its committees, all
      executive departments, boards, commissions, committees, bureaus, offices;
      and all independent commissions and other establishments of the state
      government but excluding the
courts.

              


      

    

    
       

      
        	
                 
      

              	
                "Controlling
      interest" means an interest in a business or other undertaking which is
      sufficient in fact to control, whether the interest is greater or less
      than fifty per cent (50%).

              


      

    

    
       

      
        	
                 
      

              	
                "Employee"
      means any nominated, appointed, or elected officer or employee of the
      State, including members of boards, commissions, and committees, and
      employees under contract to the State or of the constitutional convention,
      but excluding legislators, delegates to the constitutional convention,
      justices, and judges. (Section 84-3,
HRS).

              


      

    

    
      


      On behalf
of:

    

    
       

      WellCare Health Insurance of
Arizona, Inc., dba 'Ohana Health Plan,
Inc.                                                                                                                                                                                             


      (Name
of Provider)

    

    
       

      PROVIDER,
the undersigned does declare as follows:


    

    
       

      
        	
                 
      

              	
                1.

              	
                PROVIDER     ̈    is*   x   is
      not a legislator or an employee or a business in which a legislator or an
      employee has a controlling interest. (Section 84-15(a),
    HRS).

              


      

    

    
       

      
        	
                 
      

              	
                2.

              	
                PROVIDER
      has not been represented or assisted personally in the matter by an
      individual who has been an employee of the agency awarding this Contract
      within the preceding two years and who participated while so employed in
      the matter with which the Contract is directly concerned. (Section
      84-15(b), HRS).

              


      

    

    
       

      
        	
                 
      

              	
                3.

              	
                PROVIDER
      has not been assisted or represented by a legislator or employee for a fee
      or other compensation to obtain this Contract and will not be assisted or
      represented by a legislator or employee for a fee or other compensation in
      the performance of this Contract, if the legislator or employee had been
      involved in the development or award of the Contract. (Section 84-14 (d),
      HRS).

              


      

    

    
       

      
        	
                 
      

              	
                4.

              	
                PROVIDER
      has not been represented on matters related to this Contract, for a fee or
      other consideration by an individual who, within the past twelve (12)
      months, has been an agency employee, or in the case of the Legislature, a
      legislator, and participated while an employee or legislator on matters
      related to this Contract. (Sections 84-18(b) and (c),
  HRS).

              


      

    

    
       

      PROVIDER
understands that the Contract to which this document is attached is voidable on
behalf of the STATE if this Contract was entered into in violation of any
provision of chapter 84, Hawai'i Revised Statutes, commonly referred to as the
Code of Ethics, including the provisions which are the source of the
declarations above. Additionally, any fee, compensation, gift, or profit
received by any person as a result of a violation of the Code of Ethics may be
recovered by the STATE.

      ____________________________

    

    
      * Reminder to agency:
If the "is" block is checked and if the Contract involves goods or services of a
value in excess of $10,000, the Contract may not be awarded unless the agency
posts a notice of its intent to award it and files a copy of the notice with the
State Ethics Commission. (Section 84-15(a), HRS).


    

    
       

      AG Form
103F (10/08) 

      Standards
of Conduct Declaration

    

    
      Page 1 of
2

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    CONTRACT NO. DHS –
08-MQD-5129


    
       

    

    
      	 
      	
              PROVIDER

               

              By /s/ Heath
      Schiesser                      
      

                            (Signature)

            
	 
      	
               

              Print
      Name Heath
      Schiesser             
      

            
	 
      	
               

              Print
      Title President
      and CEO           
      

            
	 
      	
               

              Date
      1-27-09 
                                             
      

            


    

    
       

    

    
      AG Form
103F (10/08) 

      Standards
of Conduct Declaration

    

    Page 2 of 2

     

    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    
      CONTRACTNO.   DHS –
08-MQD-5129

    

    
       

      CERTIFICATE
OF EXEMPTION FROM CIVIL SERVICE

    

    
       

      
        	
                1.

              	
                By
      Heads of Departments or Agencies as Delegated by the Director of Human
      Resources Development1.

              


      

    

    
       

      Pursuant to the delegation of the
authority by the Director of Human Resources Development, I certify that the
services provided under this Contract, and the person(s) providing the services
under this Contract are exempt from the civil service, pursuant to §76-16,
Hawai'i Revised Statutes ("HRS").

    

    
       

    

    
      	
              
                /s/ Name
      Illegible                             

              

              (Signature)

              for

            	
              
                01/29/09                                     
      

              

              (Date)

            
	
              
                Lillian
      B.
      Koller                                  
      

              

              (Print
      Name)

               

            	 
      
	
              
                Director
      of Human
      Services             
      

              

              (Print
      Title)

               

            	 
      


    

    
      ______________________________

    

    
      1 This
part of the form may be used by all department heads and others to whom the
Director of Human Resources Development (DHRD) has delegated authority to
certify §76-16, HRS, civil service exemptions. The specific paragraph(s) of
§76-16, HRS, upon which an exemption is based should be noted in the contract
file. NOTE: Authority to certify
exemptions under §§ 76-16(2), 76-16(12), and 76-16(15), HRS, has not been
delegated; only the Director of DHRD may certify §§76-16(2), 76-16(12), and
76-16(15) exemptions.

    

    
       

      
 

    

    
      2.           By
the Director of Human Resources Development, State of
Hawai'i.

    

    
      


    

    
      I certify
that the services to be provided under this Contract, and the person(s)
providing the services under this Contract are exempt from the civil service,
pursuant to §76-16, HRS.


    

    
      	
              
                 

                _______________________

              

              (Signature)

            	
              
                 

                ________________

              

                            (Date)

            
	
              
                 

                _______________________

              

              (Print
      Name)

            
	
              
                 

                _______________________

              

              (Print Title, if
      designee of the Director of
DHRD)

            


    

    
      


    

    
      
        	
                 
      

              	
                AG
      Form 103F (9/08)

                Competitive

              


      

    

    
      Page
1

    

    


    
      
        
           


        

        
           


          
            

          

        

        
           


        

      

    

     

    STATE
OF HAWAII

     

    SCOPEOF
SERVICES

    
      
      

       

      
        	 41.510 	
                 

                Transition to the
      Health Plan

                 

              
	 	
                 Replace the
      first paragraph of this section, as amended, with the
      following:

                 

              
	 	In the event a
      member entering the health plan is receiving medically necessary covered
      services in addition to or other than prenatal services (see below for
      members in the second and third trimester receiving prenatal services) the
      day before enrollment into the health plan, the health plan shall be
      responsible for the costs of continuation of such medically necessary
      services, without any form of prior approval and without regard to whether
      such services are being provided by contract or non-contract providers.
      The health plan shall provide continuation of such services for
      one-hundred and eighty (180) days for all members OR until the member has
      had a HFA from his or her service coordinator, had a care plan developed
      and has been seen by the assigned PCP who has authorized a course of
      treatment. The health plan is responsible for the cost of continuation of
      services for a member living in a nursing facility that are provided by
      non-contract providers. All non-contract providers being paid under this
      amendment shall be paid at the Medicaid FFS rates in effect at the time of
      service delivery.