EX-10.3 INSURANCE CONTRACT FOR SOUTH WEST REGION



 








Exhibit 10.3




2003-000021H

HEALTH INSURANCE CONTRACT

NO. 03-021H FOR THE

SOUTH WEST HEALTH REGION

BETWEEN

PUERTO RICO HEALTH INSURANCE ADMINISTRATION

AND

TRIPLE S, INC.



This Amendment entered into this 18th  day of July, 2006, at San Juan, Puerto
Rico, by and between PUERTO RICO HEALTH INSURANCE ADMINISTRATION, a public instrumentality of the
Commonwealth of Puerto Rico, organized under Law 72 approved on September 7, 1993, hereinafter
referred to as the “ADMINISTRATION”, represented by its Executive Director, Nancy Vega Ramos and
TRIPLE S, INC. a domestic corporation duly organized and doing business under the laws of the
Commonwealth of Puerto Rico, with employer social security number ###-##-####, hereinafter referred
to as the “INSURER” represented by its Chief Executive Director, Socorro Rivas.



WITNESSETH



In consideration of the mutual covenants and agreements hereinafter set forth, the parties, their
personal representatives and successors, agree as follows:



WHEREAS: On June 13th, 2002, the ADMINISTRATION and INSURER entered into Contract No. 03-021 for
the South West Health Region, a three-year contract with an effective date of July 1st,
2002 (the “Contract”) subject to annual renegotiations of the premiums. Said contract provides
health insurance coverage to all enrollees in and within the South West Health Area/Region,
composed of the municipalities of Adjuntas, Guánica, Guayanilla, Jayuya, Peñuelas, Ponce and Yauco.



WHEREAS: On July 2005 and due to the assessment that was being conducted by the Evaluating
Commission for the Health Reform Program the ADMINISTRATION agreed with the Insurer to amend the
contract for another twelve consecutive months until June 30, 2006.




 









 







WHEREAS: Considering that the ADMINISTRATION is in the process of amending the State Plan to
introduce several changes and initiatives in accordance with the Commonwealth fiscal situation; it
has agreed with the Insurer to amend the contract with respect to the following Articles as
provided herein.



HENCEFORTH: The Contract is hereby amended to read as follows:




ARTICLE I

DEFINITIONS



In Article I, the following definition is amended and substituted to read as follows:



CONTRACT TERM: The contract term is for sixty-three (63) months after its effective date
July 1st, 2002 until September 30, 2007.




ARTICLE XVIII




PAYMENT OF PREMIUMS



In Article XVIII letters (c, d and e) are added to paragraph three (3) to read as follows:




	 	 	 	 	 	 	 
	3.

	 	The monthly premiums	 	 	 	 
	 

	 	 	 	 

	 	 






	 	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	a.	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 

	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	1.	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	b.	 	 	 	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 
	 

	 	 	 	 	1.	 	 	 	 	 
	 

	 	 	 	 	 	 	 	 	 	 
	 
	 	 	 	 	 	 	 	 	 	 






	 	c.	 	The aforementioned premium rates (FY 2005-2006, amendment number 03-021G signed
October 10, 2005) constitute the interim rates for the period beginning July
1st, 2006 to September 30, 2006, until a final rate be negotiated and agreed
upon by the parties. Payments will be made from account number 5030-113.
	 
	 	d.	 	The interim rate for July 1st, 2006 to September 30, 2006, shall be
subject to an adjustment in the event there is a difference between the interim and
final agreed premium rate.
	 
	 	e.	 	For the period beginning October 1st, 2006 to September 30, 2007 a




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	 	 	 	different rate will be negotiated between the parties in accordance with the new
coverage that will become effective on October 1st , 2006.





ARTICLE XXVIII



Effective Date and Term In Article XXVIII, paragraph (5) is deleted; paragraph (6) is renumbered as
(5) and paragraph (1) is amended to read as follows:





	 	1.	 	This contract shall be in effect starting at 12:01 AM Puerto Rico Time on July
1st, 2002, and is due on September 30, 2007





ARTICLE XL



MODIFICATION OF COVERAGE AND CONTRACT



A new Article XL is added to read as follows:





	 	A.	 	The Administration will define the health services coverage
for the population in accordance with their health needs, determined eligibility type and
income level.
	 
	 	B.	 	Several dispositions of the contract could be amended to include:






	 	1.	 	Utilizations review and Quality Assurance
	 
	 	2.	 	Information Systems and Reporting Requirements
	 
	 	3.	 	Plan Compliance Evaluation Program
	 
	 	4.	 	Preventive Medicine Program
	 
	 	5.	 	Mental Health Program
	 
	 	6.	 	Demonstration Project
	 
	 	7.	 	Pharmacy Benefits Management
	 
	 	8.	 	Penalties and Sanctions Clauses






	 	C.	 	The aforementioned clauses do not preclude that during the process of
evaluation of the contract and implementation of new models, other dispositions could
be amended.
	 
	 	D.	 	The ADMINISTRATION reserves the right to modify the contract to replicate, on
any Region, the “Integrated Regional Services Model” being




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	 	 	 	implemented in the
Metro-North Region. Such modification will be the result of either an RFP process or
an extension of the contract with current region insurers.




The present amendments take precedence and shall prevail over any remaining sections and articles
of the contract which are maintained but could conflict with these amendments.



This being the amendment that the parties have agreed to, each party places its initials at the
margin of each of the pages contained herein, and affixes below its signature. In San Juan,
Puerto Rico, on this 18th day of July, 2006.




	 	 	 
	/s/ Nancy Vega Ramos
	 	 
	 
	 	 
	 

NANCY VEGA RAMOS, MHs, HIA, MHP

	 	 
	Executive Director
	 	 
	Puerto Rico Health Insurance Administration
	 	 
	 
	 	 
	/s/ Socorro Rivas
	 	 
	 
	 	 
	 

SOCORRO RIVAS

	 	 
	Chief Executive Officer
	 	 
	Triple S, Inc.
	 	 
	 
	 	 
	/s/ Luis A. Marini
	 	 
	 
	 	 
	 

LUIS A. MARINI, DMD


Chief Executive Officer


Triple-C, Inc.

	 	 







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