Document:

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                                                                    EXHIBIT 10.1

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                         IT CONSOLIDATION AND OPERATIONS
                               SERVICES AGREEMENT

                                 BY AND BETWEEN

                       DUKE ENERGY BUSINESS SERVICES, LLC

                                       AND

                         DUKE ENERGY FIELD SERVICES, LP

                            DATED AS OF JULY 30, 2003

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                                TABLE OF CONTENTS

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<S>                                                                                                          <C>
                                                    ARTICLE I
                                                   THE SERVICES

SECTION 1.1    THE SERVICES....................................................................................1
SECTION 1.2    MODIFICATION OF SERVICES........................................................................2

                                                    ARTICLE II
                                                COSTS AND EXPENSES

SECTION 2.1    CHARGES FOR SERVICES............................................................................2
SECTION 2.2    PER UNIT RATE INCREASES.........................................................................2
SECTION 2.3    INVOICES........................................................................................3
SECTION 2.4    AUDIT OF EXPENSES...............................................................................3
SECTION 2.5    ADDITIONAL EQUIPMENT, TECHNOLOGY OR THIRD PARTY SERVICES........................................3
SECTION 2.6    TAXES...........................................................................................3

                                                   ARTICLE III
                                                TERM OF AGREEMENT

SECTION 3.1    TERM............................................................................................4
SECTION 3.2    EARLY TERMINATION...............................................................................4

                                                    ARTICLE IV
                                                 REPRESENTATIVES

SECTION 4.1     REPRESENTATIVES................................................................................4

                                                    ARTICLE V
                                              PERFORMANCE STANDARDS

SECTION 5.1    PERFORMANCE STANDARDS...........................................................................4

                                                    ARTICLE VI
                                                 INDEMNIFICATION

SECTION 6.1    INDEMNIFICATION.................................................................................5
SECTION 6.2    LIMITATION OF DAMAGES...........................................................................5

                                                   ARTICLE VII
                                                SCOPE OF AGREEMENT

SECTION 7.1    RELATIONSHIP OF PARTIES.........................................................................5
SECTION 7.2    ACCESS TO OFFICES...............................................................................5
SECTION 7.3    REASONABLE AVAILABILITY OF PERSONNEL............................................................5
SECTION 7.4    SCOPE OF DUKE'S AUTHORITY.......................................................................5
SECTION 7.5    INSURANCE.......................................................................................6
SECTION 7.6    COMPLIANCE WITH AFFILIATE RULES.................................................................6

                                                   ARTICLE VIII
                                                 CONFIDENTIALITY

SECTION 8.1    CONFIDENTIALITY.................................................................................6

                                                    ARTICLE IX
                                             MISCELLANEOUS PROVISIONS

SECTION 9.1    COUNTERPARTS....................................................................................7
SECTION 9.2    GOVERNING LAW; JURISDICTION AND FORUM; WAIVER OF JURY TRIAL.....................................7
SECTION 9.3    ENTIRE AGREEMENT................................................................................7
SECTION 9.4    NOTICES.........................................................................................7
SECTION 9.5    SUCCESSORS AND ASSIGNS..........................................................................8
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<S>                                                                                                          <C>
SECTION 9.6    HEADINGS; DEFINITIONS...........................................................................8
SECTION 9.7    AMENDMENTS AND WAIVERS..........................................................................8
SECTION 9.8    SEVERABILITY....................................................................................8
SECTION 9.9    INTERPRETATION..................................................................................9
SECTION 9.10   SPECIFIC PERFORMANCE............................................................................9
SECTION 9.11   NO THIRD PARTY BENEFICIARIES....................................................................9
SECTION 9.12   FURTHER ASSURANCES..............................................................................9
SECTION 9.13   FORCE MAJEURE...................................................................................9
SECTION 9.14   ALTERNATIVE DISPUTE RESOLUTION.................................................................10
SECTION 9.15   CONFLICTS OF INTEREST..........................................................................11
SECTION 9.16   CONSTRUCTION...................................................................................11

APPENDIX 1 - IT TRANSFER SERVICES............................................................................___

APPENDIX 2 - IT SERVICES.....................................................................................___

APPENDIX 3 - DISASTER RECOVERY SERVICES......................................................................___

APPENDIX 4 - FINANCIAL AGREEMENT.............................................................................___

APPENDIX 5 - REPRESENTATIVES AND ROLES.......................................................................___

APPENDIX 6 - ENTERPRISE SERVICE MEASURES AND REPORTING.......................................................___
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                         IT CONSOLIDATION AND OPERATIONS
                               SERVICES AGREEMENT

                  This IT CONSOLIDATION AND OPERATIONS SERVICES AGREEMENT (this
"Agreement") is made as of the 30th day of July, 2003, by and between Duke
Energy Business Services LLC ("Duke") and Duke Energy Field Services, LP (the
"Company") (each, a "Party", and together the "Parties").

                                    RECITALS:

                  WHEREAS, Duke has agreed to assist the Company in transferring
and consolidating its information technology operations into Duke's information
technology operations and provide future ongoing information technology services
to the Company, on such terms as set forth in this Agreement; and

                  WHEREAS, the Parties believe that the provisions of this
Agreement as a whole are fair.

                  NOW, THEREFORE, in consideration of the premises and the
representations, warranties, covenants and agreements contained herein, and for
other good and valuable consideration, the receipt and sufficiency of which are
hereby acknowledged, and intending to be legally bound hereby, the Parties
hereby agree as follows:

                                    ARTICLE I

                                  THE SERVICES

                  Section 1.1 The Services.

                  (a) Duke agrees to provide the support and services associated
with the transfer and consolidation of the Company's information technology
operations from Denver, Colorado to Duke's information technology operations in
Charlotte, North Carolina, all as described in Appendix 1 (the "IT Transfer
Services").

                  (b) Duke agrees to provide to the Company the information
technology services described in Appendices 2 and 3 (together with the IT
Transfer Services referred to herein as the "Services"), for the term described
in Section 3.1.

                  (c) Duke shall perform the Services for the Company with the
same degree of care, skill and prudence customarily exercised by it for its own
operations, consistent with industry practices, in compliance with statutory and
regulatory requirements.

                  (d) If Duke is unable to perform the Services in accordance
with Section 1.1(a) and (b), then Duke shall hire the personnel required to
provide such Services. Duke is authorized to provide any part of the Services
either from its own resources and employees, or, by a subcontractor(s).
Subcontractor(s) shall be made subject to no less stringent performance
requirements than Duke is required to comply with under this Agreement,
including confidentiality and compliance with statutory and regulatory
requirements.

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                  (e) In accordance with the terms and conditions of this
Agreement and the Services described in Appendices 1, 2 and 3, Duke shall
provide records, financial information, or other information that is reasonably
requested by the Company to support the Services which may not have been kept or
reported in the ordinary course of business by Duke, even if not provided to the
Company prior to the date hereof. Notwithstanding the foregoing, in the event
that the records, financial information or other information requested by the
Company is not contemplated by the Services or the rate sheet, then Duke and the
Company will negotiate in good faith the terms whereby such information will be
provided.

                  Section 1.2 Modification of Services. During the term of this
Agreement, the Company shall have the right to enter into other contracts with
third parties in connection with the Services described in this Agreement,
provided the Company receives Duke's prior written consent, which consent shall
not be unreasonably withheld. If the Company and Duke mutually agree, after a
reasonable transition period, the Parties may terminate any Services provided
for in this Agreement. Any changes in the scope of the Services and associated
changes in the applicable rates shall be in writing signed by an authorized
representative of each Party prior to implementation or effectiveness of such
changes.

                                   ARTICLE II

                               COSTS AND EXPENSES

                  Section 2.1 Charges for Services. Duke shall charge the
Company for the Services provided under this Agreement in accordance with the
rates described in Appendices 2, 3 and 4; provided, however, if any personnel or
assets of Duke Power ("Duke Power"), a division of Duke Energy Corporation and a
public utility regulated by the North Carolina Utilities Commission ("NCUC"),
the South Carolina Public Service Commission ("SCPSC") and the Federal Energy
Regulatory Commission ("FERC"), are used in the provision of the Services, Duke
shall charge the Company and the Company shall pay Duke in accordance with
Duke's North Carolina and FERC Codes of Conduct and any other applicable
regulatory rules governing affiliate transactions. Notwithstanding the
foregoing, in no event shall the Company be responsible for directly paying any
salaries, wages, benefits, withholding, severance payments or any other
compensation or payments with respect to the employees of Duke.

                  Section 2.2 Per Unit Rate Increases. The per unit rates
charged for the Services shall remain in effect for each calendar year during
the term of this Agreement. During the term of this Agreement, the rates may be
adjusted once annually, provided that no increase in the per unit rate listed in
Appendices 2, 3 and 4 shall exceed the most recent yearly increase in the
Consumer Price Index ("CPI") over the prior calendar year (calendar year 2002
shall be used to establish 2004 rates and calendar year 2003 shall be used to
establish 2005 rates). For purposes of this Section 2.2, the CPI shall be a
change in the CPI, U.S. City Average, All Items. Duke shall provide the Company
with written notice of any proposed increase in the per unit rates by October 15
of the calendar year prior to the year when such increase is to become effective
(the "Fee Notice"). The Parties shall come to a final agreement on any such
increase in the per unit rates within 30 days following the Company's receipt of
the Fee Notice. In addition, Duke agrees that during the term of this Agreement
neither changes in Duke's per unit rate calculation algorithms for the Services
nor changes in the way Duke establishes per unit rates, will increase the cost
of previously offered services.

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                  Section 2.3 Invoices. Duke shall prepare and deliver to the
Company a monthly invoice by the twenty-fifth day of the month following the
service month that describes the Services provided by Duke and the amount
charged to the Company hereunder. Each invoice shall be due and payable within
20 days after receipt by the Company. Duke shall use its reasonable efforts to
invoice all Services no later than 60 days after the performance of such
Services. The Company shall promptly and diligently pay all amounts due to Duke
under this Agreement and any amounts due and owed to Duke which are over 30 days
past due during the first two billing periods or 20 days past due after the
first two billing periods shall accrue late fees calculated at the average of
the Prime Rates as reported in the Wall Street Journal during such past due
payment period. In the event of the early termination of any Services hereunder,
the Company shall pay Duke for only those Services and costs (or portions
hereof) that have been (i) properly performed prior to such termination and (ii)
properly committed to in writing by Duke prior to the receipt of such
termination notice.

                  Section 2.4 Audit of Expenses. Duke shall maintain complete
and accurate records of and supporting documentation for all amounts billable to
the Company hereunder and shall retain such records for a period of at least two
years following the date of the inclusion in any invoice sent to the Company.
Duke agrees to provide the Company with documentation and other information with
respect to each invoice as may be reasonably requested by the Company to verify
that Duke's charges to the Company are accurate, correct and valid in accordance
with the provisions of this Agreement. The Company and its representatives shall
have access to such records for purposes of verifying all amounts billable to
and payments made by the Company hereunder upon reasonable notice during normal
business hours during the term of this Agreement and such subsequent period for
which Duke is required to maintain such records. If such examination reveals any
inaccuracy in any billing made hereunder, the necessary adjustment in such
billing and payments shall be made promptly, provided that no adjustment for any
billing or payment shall be made after the lapse of two years from the date of
invoice hereof unless challenged in writing prior thereto. If any of the
Services hereunder are performed using Duke Power employees or assets, then the
Company agrees to provide Duke with records and other information necessary for
an internal or external audit of affiliate transactions. Duke and its
representatives shall have access to such records and information during normal
business hours during the term of this Agreement and for the same period after
termination of this Agreement that Duke is required to retain similar records
hereunder.

                  Section 2.5 Additional Equipment, Technology or Third Party
Services. If additional equipment, software, technology or third party services
are employed by Duke to perform the Services and the costs associated with such
are not identified in Appendices 1, 2, 3 or 4, then the Company shall pay the
cost of such additional equipment, software, technology or third party services
only if previously approved in writing by the Company. To the greatest extent
feasible, charges for equipment, software, technology and third party services
will be billed directly to the Company. In the case of any emergency, prior
written approval of such expenses shall not be required; provided however, that
Duke shall obtain the Company's consent to such emergency services as soon as
reasonably practicable.

                  Section 2.6 Taxes. The Company shall pay all taxes, fees or
similar levies imposed on the Services provided hereunder (other than taxes
imposed on Duke's net income, including alternative minimum taxable income,
gain, excess profits or franchise taxes imposed on the capital or net income of
Duke and other than employment taxes imposed with respect to Duke's employees,
except to the extent such taxes are included in the rates designated in
Appendices 2, 3 and 4); and, in the event that Duke is required by law to pay
any of said taxes, fees or other similar levies, the Company shall reimburse
Duke for such payments.

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                                   ARTICLE III

                                TERM OF AGREEMENT

                  Section 3.1 Term. The term of this Agreement shall begin as of
the date first set forth above and remain in effect until December 31, 2005, and
shall automatically renew each December 31 thereafter and continue year to year,
unless terminated earlier as provided in Section 3.2 below.

                  Section 3.2 Early Termination. Either Party may terminate this
Agreement at any time for any reason upon one hundred eighty (180) days prior
written notice to the other Party, provided that Duke may not terminate this
Agreement under this provision until after December 31, 2005 unless the
ownership percentage of the Company by an affiliate of Duke Energy Corporation
goes below fifty percent (50%) or an affiliate of Duke Energy Corporation is no
longer responsible for the operation of the Company. Following notice of
termination, Duke and the Company will work together cooperatively to plan and
execute the migration of all Services covered in this Agreement from Duke within
a reasonable and expeditious time. Notwithstanding any such termination, Company
shall continue to be obligated to pay for any Services performed and expenses
incurred before such termination date.

                                   ARTICLE IV

                                 REPRESENTATIVES

                  Section 4.1 Representatives. The Parties shall each appoint
one or more representatives (each, a "Representative") to facilitate
communications and performance under this Agreement. Each Party may treat an act
of the Representative of the other Party as being authorized by such other Party
without inquiring behind such act or ascertaining whether such Representative
had authority to so act. The initial Representatives are named in Appendix 5
hereto as well as their initial roles and responsibilities. Each Party shall
have the right at any time and from time to time to replace its Representative
by giving notice in writing to the other Party setting forth the name of (i) the
Representative to be replaced and (ii) the replacement, and certifying that the
replacement Representative is authorized to act for the Party giving notice in
all matters relating to this Agreement.

                                    ARTICLE V

                              PERFORMANCE STANDARDS

                  Section 5.1 Performance Standards. Duke shall provide the
Services in accordance with the service standards and terms set forth in this
Agreement and APPENDIX 6.

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                                   ARTICLE VI

                                 INDEMNIFICATION

        Section 6.1 Indemnification. DUKE HEREBY AGREES TO INDEMNIFY AND HOLD
HARMLESS THE COMPANY AND ITS RESPECTIVE SUCCESSORS, ASSIGNS, AFFILIATES, AND ALL
OF THE COMPANY'S DIRECTORS, OFFICERS, EMPLOYEES, REPRESENTATIVES AND AGENTS
(EACH, AN "INDEMNIFIED PARTY") FROM AND AGAINST ANY AND ALL DAMAGES, EXPENSES
(INCLUDING, WITHOUT LIMITATION, REASONABLE ATTORNEYS' FEES), LOSSES, ACTIONS,
CLAIMS, SUITS, LIABILITIES AND COSTS INCURRED BY ANY INDEMNIFIED PARTY RESULTING
FROM THE GROSS NEGLIGENCE, OR WILLFUL MISCONDUCT OF DUKE TO THE EXTENT RELATING
TO DUKE'S PERFORMANCE OF (OR FAILURE TO PERFORM) THE SERVICES UNDER THIS
AGREEMENT.

        Section 6.2 Limitation of Damages. No Party shall be liable for any
special, indirect, incidental, consequential or punitive damages of any
character resulting from, arising out of, or in any way incident to any act or
omission hereunder, irrespective of whether claims or actions for such damages
are based upon contract, warranty, negligence, gross negligence, strict
liability or any other remedy at law or equity.

                                   ARTICLE VII

                               SCOPE OF AGREEMENT

                  Section 7.1 Relationship of Parties. Duke shall act as
independent contractor hereunder, and nothing herein shall at any time be
construed to create the relationship of employer and employee, partnership,
principal and agent, broker or finder or joint venturers as between Duke and the
Company.
                  Section 7.2 Access to Offices. Employees of the Company shall
be freely allowed to enter and leave the buildings and offices of Duke, subject
to any guidelines imposed by Duke. Employees of Duke shall be freely allowed to
enter and leave the buildings and offices of the Company, subject to any
guidelines imposed by the Company.

                  Section 7.3 Reasonable Availability of Personnel. The Company
acknowledges that Duke's employees are involved in the conduct of business for
Duke and may not be required to dedicate the entirety of their business days to
the performance of the Services; provided, however, that Duke agrees to use all
reasonable efforts to have its employees made available at the reasonable
request of the Company throughout the term of this Agreement, and the Parties
agree to make all reasonable efforts to cooperate mutually with each other so as
to achieve the intents and purposes of this Agreement.

                  Section 7.4 Scope of Duke's Authority. Without the prior
written consent of the Company, Duke, in performing the Services, shall not
borrow or lend money, except for short-term borrowings (such as commercial
paper) initiated through Duke's Corporate Cash Management in the ordinary course
of business; create any lien or encumbrance; execute, terminate, or amend any
contract in the name of or on behalf of the Company or its subsidiaries;
purchase or sell any asset of the Company or its subsidiaries; execute any
indemnification for the benefit of any party; or take any other action not in
the ordinary course of business of Duke or the Company. When performing this
Agreement, Duke shall receive the Company's written approval before incurring
any third party

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expense not identified in Appendices 1, 2 , 3 or 4; provided, however, Duke
shall not be obligated to obtain the Company's prior written consent for any
third party expense which is less than two-thousand dollars ($2,000.00).

                  Section 7.5 Insurance. During the term of this Agreement, Duke
shall be required to maintain the following types of insurance, as appropriate
to the Services provided: (a) Workers' Compensation Insurance as required by
state or federal law where the work is being performed; (b) General Liability
Insurance against claims for bodily injury and/or death of and property damage
to third parties; and (c) Business Automobile Liability Insurance against claims
of bodily injury, death and property damage to third parties covering all owned,
leased, and non-leased, and non-owned and hired vehicles.

                  Section 7.6 Compliance with Affiliate Rules. The performance
of this Agreement shall be in compliance with all applicable provisions of the
various Codes and Standards of Conduct to which Duke Energy Corporation and its
affiliates are subject by various energy and utility regulatory commissions,
including Duke Energy Corporation's North Carolina Code of Conduct, FERC Code of
Conduct with respect to the relationship between power marketing affiliates and
the electric utility and FERC Standards of Conduct for relations between
interstate pipelines and their marketing affiliates. Any term or condition of
this Agreement that is not in compliance with the various Codes and Standards of
Conduct noted above shall be renegotiated by the Parties.

                                  ARTICLE VIII

                                 CONFIDENTIALITY

                  Section 8.1 Confidentiality.

                  (a) Each Party shall (and each Party shall ensure that its
employees, contractors, subcontractors, agents and affiliates who perform or
receive Services under this Agreement shall) treat as strictly confidential (and
shall not disclose) all information received or obtained as a result of this
Agreement that relates to the other Party or any aspect of its business or
operations.

                  (b) A Party may disclose information that would otherwise be
confidential if and only to the extent: (i) required by applicable law or legal
process, provided that the disclosing Party has notified the other Party in
writing prior to disclosure; (ii) required by any securities exchange or agency
to which the Party is subject, wherever situated, whether or not the requirement
has the force of law, provided that the disclosing Party has taken all
practicable legal steps to prevent such disclosure and notified the other Party
in writing prior to disclosure; (iii) disclosed on a confidential basis to the
professional advisers or auditors of the Party or to any actual or potential
bankers or financiers of that Party; (iv) that the information has come into the
public domain through no fault of that Party or its employees, affiliates,
officers, directors, representatives, agents, or assigns; (v) that the other
Party has given prior approval to such disclosure; (vi) necessary to enforce,
comply with or perform any of the terms of this Agreement or the other
agreements contemplated hereby or thereby; or (vii) received from a third party,
unless, to the knowledge of the Party that would otherwise be subject to this
Section 8.1 or its employees, affiliates, officers, directors, representatives,
agents, or assigns, such third party is subject to an independent obligation to
keep such information confidential.

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                                   ARTICLE IX

                            MISCELLANEOUS PROVISIONS

                  Section 9.1 Counterparts. This Agreement may be executed in
one or more counterparts, all of which shall be considered one and the same
agreement, and shall become effective when one or more counterparts have been
signed by each of the Parties hereto and delivered (including by facsimile) to
the other Parties.

                  Section 9.2 Governing Law; Jurisdiction and Forum; Waiver of
Jury Trial.

                  (a) This Agreement shall be governed by and construed in
accordance with the laws of the State of Delaware, without reference to the
choice of law principles thereof.

                  (b) Each Party hereto irrevocably submits to the jurisdiction
of any Delaware state court or any federal court sitting in the State of
Delaware in any action arising out of or relating to this Agreement, and hereby
irrevocably agrees that all claims in respect of such action may be heard and
determined in such Delaware state or federal court. Each Party hereto hereby
irrevocably waives, to the fullest extent it may effectively do so, the defense
of an inconvenient forum to the maintenance of such action or proceeding. The
Parties hereto further agree, to the extent permitted by law, that final and
unappealable judgment against any of them in any action or proceeding
contemplated above shall be conclusive and may be enforced in any other
jurisdiction within or outside the United States by suit on the judgment, a
certified copy of which shall be conclusive evidence of the fact and amount of
such judgment.

                  (c) To the extent that any Party hereto has or hereafter may
acquire any immunity from jurisdiction of any court or from any legal process
(whether through service or notice, attachment prior to judgment, attachment in
aid of execution, execution or otherwise) with respect to itself or its
property, each Party hereto hereby irrevocably waives such immunity in respect
of its obligations with respect to this Agreement.

                  (d) Each Party hereto waives, to the fullest extent permitted
by applicable law, any right it may have to a trial by jury in respect of any
action, suit or proceeding arising out of or relating to this Agreement. Each
Party hereto certifies that it has been induced to enter into this Agreement by,
among other things, the mutual waivers and certifications set forth above in
this Section 9.2.

                  Section 9.3 Entire Agreement. This Agreement, together with
the exhibits hereto, constitutes the entire agreement of the Parties with
respect to the services and arrangements described herein, and supercedes all
prior contracts or agreements between the Parties solely with respect to the
subject matter hereof, whether written or oral. This Agreement is not intended
to confer upon any person not a party hereto (or their successors and assigns)
any rights or remedies hereunder.

                  Section 9.4 Notices. All notices and other communications to
be given to any Party hereunder shall be sufficiently given for all purposes
hereunder if in writing and delivered by hand, courier or overnight delivery
service or three days after being mailed by certified or registered

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mail, return receipt requested, with appropriate postage prepaid, or when
received in the form of a telegram or facsimile and shall be directed, if to a
Party hereunder, to the address or facsimile number set forth below (or at such
other address or facsimile number as such Party shall designate by like notice):

                  (a) If to Duke:

                              Duke Energy Corporation
                              422 South Church Street (CS02A)
                              Charlotte, North Carolina 28202-1904
                              Attention: C. K. Beam
                              Fax No.: 704-382-1037

                  (b) If to the Company:

                              Duke Energy Field Services, LP
                              370 17th Street, Suite 900
                              Denver, Colorado 80202
                              Attention: Allan Skov
                              Fax No.: 303-595-0480

                  Section 9.5 Successors and Assigns. This Agreement shall be
binding upon and inure to the benefit of the Parties hereto and their respective
successors and permitted assigns; provided, however, that (a) no Party hereto
will assign its rights or delegate any or all of its obligations under this
Agreement without the express prior written consent of the other Party hereto,
and (b) any assignment of the obligations of either Party hereto shall not
relieve that Party of its obligations under any and all of the provisions of
this Agreement. Notwithstanding the foregoing, any Party may assign its rights
or delegate any or all of its obligations under this Agreement to an affiliate
of such Party without the prior written consent of the other Party.

                  Section 9.6 Headings; Definitions. The section and article
headings contained in this Agreement are inserted for convenience of reference
only and will not affect the meaning or interpretation of this Agreement. All
capitalized terms defined herein are equally applicable to both the singular and
plural forms of such terms.

                  Section 9.7 Amendments and Waivers. This Agreement may not be
modified or amended except by an instrument or instruments in writing signed by
both Parties, except that the Appendices hereto may be amended in writing by the
Parties to add, delete or modify the Services, change the rates on the rate
sheet or replace the Representatives. The Company may, only by an instrument in
writing, waive compliance by Duke with any term or provision of this Agreement
on the part of Duke. The waiver by either Party hereto of a breach of any term
or provision of this Agreement shall not be construed as a waiver of any
subsequent breach. Except as otherwise expressly provided herein, no failure to
exercise, delay in exercising or single or partial exercise of any right, power
or remedy by any Party, and no course of dealing between the Parties, shall
constitute a waiver of any such right, power or remedy.

                  Section 9.8 Severability. If any provision of this Agreement
shall be held invalid, illegal or unenforceable, the validity, legality or
enforceability of the other provisions of this Agreement shall not be affected
thereby, and there shall be deemed substituted for the provision at issue a
valid, legal and enforceable provision as similar as possible to the provision
at issue.

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                  Section 9.9 Interpretation. In the event an ambiguity or
question of intent or interpretation arises with respect to this Agreement, this
Agreement shall be construed as if it was drafted jointly by the Parties, and no
presumption or burden of proof shall arise favoring or disfavoring any Party by
virtue of the authorship of any provisions of this Agreement.

                  Section 9.10 Specific Performance. The Parties hereto agree
that irreparable damage would occur in the event that any Party fails to
consummate the transactions contemplated by this Agreement in accordance with
the terms of this Agreement and that the Parties shall be entitled to specific
performance in such event, in addition to any other remedy at law or in equity,
including temporary restraining orders or temporary or permanent injunctions.

                  Section 9.11 No Third Party Beneficiaries. Except as expressly
provided herein, nothing in this Agreement shall entitle any person other than
Duke or the Company or their respective successors and assigns permitted hereby
to any claim, cause of action, remedy or right of any kind.

                  Section 9.12 Further Assurances. Upon the terms and subject to
the conditions hereof, each of the Parties hereto shall use its reasonable best
efforts to take, or cause to take, all appropriate action, and to do or cause to
be done, all things necessary, proper or advisable under applicable laws and
regulations to make effective the transactions contemplated in this Agreement.
Notwithstanding the foregoing, the Company shall be responsible for providing
the information to Duke that is necessary for Duke to perform the Services.

                  Section 9.13 Force Majeure.

                  (a) No failure or omission to carry out or to observe any of
the terms, provisions or conditions of this Agreement, except the failure to
make payment for sums due hereunder, shall give rise to any claim by a Party
against another, or be deemed a breach of this Agreement, if the same shall have
been or shall be caused by or arise out of any event of force majeure, which
term as used herein shall include (but only to the extent that the affected
Party is unable to perform due to causes and events that are beyond the
reasonable control of the affected Party), but not be limited to, war,
hostilities, acts of the public enemy or of belligerents, sabotage, blockage,
revolution, insurrection, riot or disorder, requisitions or rationing, whether
imposed by law, decree or regulations or by voluntary cooperation of industry at
the insistence or request of any governmental authority or person purporting to
act therefor; compliance with allocation programs, voluntary or mandatory,
including reduction or cessation of production by reason of imposition by any
governmental authority or person purporting to act with government authority,
acts of God, fire, frost, earthquake, storm, or lightning, epidemic, quarantine,
strikes or combination of workmen lockouts or other labor disturbances,
explosion, accidents by fire or otherwise to pipe, storage facilities,
installations, machinery, unanticipated plant outages, delays in acquiring or
inability to acquire permits or licenses necessary to enable the Parties hereto
to perform, lack of adequate fuel, power, raw materials, labor, containers or
transportation facilities, delays or shortages caused by breakdowns, failures or
unavailability of materials or equipment, breakage, mechanical breakdowns or
accident to machinery; delay, breakdown, or destruction of a plant, terminal, or
equipment; provided, however, that the Party so affected thereby will exercise
reasonable efforts pursuant to prudent industry practice to prevent the
occurrence of the force majeure event and to cure the event of force majeure as
quickly as possible so that the Party so affected will be able to carry out and
observe all of the terms, provisions, and conditions of this Agreement, but such
Party shall not be required to settle any labor disputes giving rise to an event
of force majeure hereunder.

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<PAGE>

                  (b) If a Party hereunder is prevented from or delayed in
performing any of its obligations under this Agreement by a force majeure event,
the Party affected shall promptly notify the other in writing of the
circumstances constituting the force majeure event, indicating the performance
obligations which are thereby delayed or prevented and the length of the
resulting delay expected.

                  (c) In the event that Duke is excused from supplying a Service
in accordance with the terms of this Section, then the Company shall be free to
acquire the Services from any substitute source, for such period as the Company
deems necessary or expedient, and if so acquired, the Company shall not be
obligated to pay Duke for such Services during such period.

                  Section 9.14 Alternative Dispute Resolution. Any dispute
arising out of or relating to this Agreement shall be resolved in accordance
with the procedures specified below.

                  (a) Negotiations Between Executives. The Parties shall attempt
in good faith to resolve any dispute arising out of or relating to this
Agreement promptly by negotiation between executives who have authority to
settle the controversy and who are at a higher level of management than the
persons with direct responsibility for administration of this Agreement. Either
Party may give the other party written notice of any dispute not resolved in the
normal course of business. Within 15 days after delivery of the notice, the
receiving Party shall submit to the other a written response. The notice and the
response shall include a statement of each Party's position and a summary of
arguments supporting that position, and the name and title of the executive who
will represent that Party and of any other person who will accompany the
executive. Within 30 days after delivery of the initial notice, the executives
of both Parties shall meet at a mutually acceptable time and place, and
thereafter as often as they reasonably deem necessary, to attempt to resolve the
dispute. All reasonable requests for non-privileged and/or non-proprietary
information made by one Party to the other will be honored. All negotiations
pursuant to this clause shall be considered confidential and shall be treated as
compromise and settlement negotiations for purposes of applicable rules of
evidence.

                  (b) Rights of Parties. Notwithstanding the foregoing, nothing
contained in this Agreement shall limit or restrict in any way the right or
power of a Party at any time (1) to commence and prosecute a proceeding for a
preliminary or temporary injunction or other temporary order pending mediation
or arbitration under this Agreement (i) to restrain a Party from breaching this
Agreement or (ii) for specific enforcement of this Section 9.14, or (2) to
consult with the other Party in an attempt to negotiate a resolution of the
dispute. The Parties agree that any legal remedy available to them with respect
to a breach of this Section will not be adequate and that, in addition to all
legal remedies, each party is entitled to an order specifically enforcing this
Section 9.14.

                  (c) Mediation. If the dispute has not been resolved by
negotiation described in Section 9.14(a) within 45 days after the receipt of the
initial notice by the other Party, the Parties shall endeavor to settle the
dispute by mediation conducted in the English language under the then current
Center For Public Resources' CPR Model Mediation Procedure for Business
Disputes. The mediation will be conducted at a site agreed upon by the Parties.
All mediation costs are to be borne equally by the Parties. Each Party shall be
responsible for its own attorney's fees and costs.

                  (d) Arbitration. If a dispute or controversy shall arise
between the Parties with respect to any matter covered by this Agreement that
has not been resolved pursuant to either Section 9.14(a) or (c) above, any Party
involved in such controversy shall have the option of

                                       10
<PAGE>

submitting the matter to arbitration in the English language pursuant to the
guidelines set forth below. Demand and submission to arbitration as provided in
this Agreement must, unless otherwise agreed, be made in writing by the
requesting Party within the later of 1.) ten (10) days after negotiations and
mediation held pursuant to Sections 9.14(a) and (c) above have failed, and such
notifying Party intends to submit the matter for arbitration, and 2.) 60 days
following the effective date of notice of the dispute or controversy. The
failure to timely submit the matter to arbitration shall constitute a waiver of
the Parties to submit their dispute to arbitration. If submitted to arbitration,
the arbitration shall be binding on the Parties and the dispute shall be settled
in accordance with the Commercial Arbitration Rules of the American Arbitration
Association (the "AAA Rules"), and judgment upon the award rendered by the
arbitrators may be entered in any court having jurisdiction thereof. If a
dispute involves an amount in controversy of $100,000 or less, there shall be
one arbitrator. If a dispute involves an amount in controversy in excess of
$100,000 or a request for preliminary injunction, there shall be three
arbitrators. All arbitration proceedings shall be conducted in Houston, Texas.

                  Section 9.15 Conflicts of Interest. The Company and Duke
understand that conflicts of interest may arise during the course of Duke
providing the Services hereunder. The Company and Duke shall in good faith
cooperate in establishing reasonable guidelines for the Parties to follow in
order to minimize any unavoidable conflicts.

                  Section 9.16 Construction. Unless the context requires
otherwise: (a) the gender (or lack of gender) of all words used in this
Agreement includes the masculine, feminine and neuter; (b) references to
Articles and Sections refer to Articles and Sections of this Agreement; (c)
references to Appendix refer to the Appendices attached to this Agreement; (d)
references to laws refer to such laws as they may be amended from time to time,
and references to particular provisions of a law include any corresponding
provisions of any succeeding law; (e) references to money refer to legal
currency of the United States of America; and (f) the word "including" means
"including, without limitation."

                  IN WITNESS WHEREOF, each of the undersigned has caused this
Agreement to be duly executed and delivered on the date first set forth above.

                                DUKE ENERGY BUSINESS SERVICES LLC

                                By: /s/ A. R. Mullinax
                                   -------------------------------
                                      Name:  A. R. Mullinax
                                      Title: Executive Vice President

                                DUKE ENERGY FIELD SERVICES, LP

                                By:        /s/ Rose M. Robeson
                                   -------------------------------
                                      Name:  Rose M. Robeson
                                      Title: Vice President and
                                             Chief Financial Officer

                                       11VANGUARD HEALTH SYSTEMS, INC.

EXHIBIT 10.1

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

CONTRACT AMENDMENT

	
Page 1 of 1 with Attachment

	

 1. AMENDMENT NUMBER:

     02

		
2.  CONTRACT NO.:

      YH04-0001-06

		
3.  EFFECTIVE DATE OF MODIFICATION:

      October 1, 2003

		
4.  PROGRAM:

      DHCM-Acute

	

 5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Phoenix Health Plan/Community Connection

 1209 South 7th Avenue

 Phoenix, Arizona  85007

	

 6. PURPOSE:  To revise capitation rates contained in Section B.

	

 7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:

     A.   The rates contained in the existing Section B are deleted and replaced with the attached revised capitation rates.

     NOTE:  Please sign, date and return one original to:          Michael Veit, Contracts & Purchasing Administrator

                                                                                               
AHCCCS Contracts and Purchasing

                                                                                               
701 E Jefferson Street, MD5700

                                                                                               
Phoenix, AZ  85034

	

 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

 IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

	

 9. NAME OF CONTRACTOR:

     Phoenix Health Plan/Community Connection

	
 

	
10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

 

	

 SIGNATURE OF AUTHORIZED INDIVIDUAL:

 /s/ Nancy Novick                                   

 NANCY NOVICK

 CHIEF EXECUTIVE OFFICER

	
       

	

 SIGNATURE:

 /s/ Michael Veit                                       

 MICHAEL VEIT

 CONTRACTS & PURCHASING ADMINISTRATOR

	

 DATE:  9/8/03

	
    

	
DATE:  SEPTEMBER 5, 2003

	
As of:

	
 

	
10/1/2003

	
 

	
 

	
Plan:

	
 

	
PHOENIX HEALTH PLAN

	
 

	
 

	
Acute GSA:

	
 

	
8

	
 

	
 

	
County:

	
 

	
GILA/PINAL

	
 

	
 

	
 

	
 

	
 

	
ACUTE

 PPC

	
ACUTE

 ONGOING

	
TACI

	
 

	
TANF AND CHILDREN M & F < 1 YEAR

	
737.97

	
390.08

	
TACS

	
 

	
TANF, CHILDREN AND SOBRA PREG FEMALE

	
39.66

	
94.45

	
FMAL

	
 

	
TANF, CHILDREN, SOBRA FEMALES 14-44

	
151.00

	
165.93

	
MALE

	
 

	
TANF, CHILDREN MALES 14-44

	
122.40

	
117.37

	
ADLT

	
 

	
TANF M & F AND SOBRA FEMALES 45+

	
281.97

	
325.18

	
SSIW

	
 

	
SSI AGED, DISABLED, BLIND MEDICARE

	
38.50

	
240.16

	
SSIN

	
 

	
SSI AGED, DISABLED, BLIND NON-MEDICARE

	
86.12

	
519.86

	
SFPS

	
 

	
SOBRA FAMILY PLANNING SERVICES

	
 

	
14.67

	
SB10

	
 

	
TANF SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,687.46

	
SB11

	
 

	
SB PAYMENT FOR TANF EXPANDED

	
 

	
5,687.46

	
SB20

	
 

	
SSI W/O SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,687.46

	
SB21

	
 

	
SSI W/ SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,687.46

	
SB22

	
 

	
SB PAYMENT FOR SSI EXPANDED WITH MEDICARE

	
 

	
5,687.46

	
SB23

	
 

	
SB PAYMENT FOR SSI EXPANDED NO MEDICARE

	
 

	
5,687.46

	
SB33

	
 

	
SB PAYMENT FOR AHCCCS CARE

	
 

	
5,687.46

	
SB34

	
 

	
SB PAYMENT FOR MED ELIGIBLES

	
 

	
5,687.46

	
SB36

	
 

	
SB PAYMENT FOR AHC CARE/MI

	
 

	
5,687.46

	
SB50

	
 

	
SOBRA SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,687.46

	
SB60

	
 

	
KIDSCARE SUPPLEMENTAL BIRTH PAYMENT

	
 

	
 

	
ACMA

	
 

	
AHC CARE

	
554.83

	
386.59

	
MEDE

	
 

	
MED ELIGIBILITY

	
1,584.83

	
730.00

	
HS00

	
 

	
HOSPITALIZED KICK FOR AHCCCS CARE

	
 

	
0.00

	
HS01

	
 

	
HOSPITALIZED KICK FOR AHC CARE/MI

	
 

	
0.00

	
HS02

	
 

	
HOSPITALIZED KICK FOR MED ELIGIBLES

	
 

	
9,355.58

	
HFML

	
 

	
HIFA FEMALE 14-44

	
 

	
182.31

	
HMAL

	
 

	
HIFA MALE 14-44

	
 

	
128.95

	
HADT

	
 

	
HIFA ADULT 45+, M & F

	
 

	
357.42

	
KIDI

	
 

	
KIDS < 1 M & F     

	
 

	
 

	
KIDC

	
 

	
KIDS 1-13 M & F    

	
 

	
 

	
KIDF

	
 

	
KIDS 14-19 FEMALE  

	
 

	
 

	
KIDM

	
 

	
KIDS 14-19 MALE    

	
 

	
 

	
As of:

	
 

	
10/1/2003

	
 

	
 

	
Plan:

	
 

	
PHOENIX HEALTH PLAN

	
 

	
 

	
Acute GSA:

	
 

	
12

	
 

	
 

	
County:

	
 

	
MARICOPA

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
ACUTE

 PPC

	
ACUTE

 ONGOING

	
TACI

	
 

	
TANF AND CHILDREN M & F < 1 YEAR

	
1,196.40

	
379.89

	
TACS

	
 

	
TANF, CHILDREN AND SOBRA PREG FEMALE

	
39.66

	
93.71

	
FMAL

	
 

	
TANF, CHILDREN, SOBRA FEMALES 14-44

	
157.05

	
161.19

	
MALE

	
 

	
TANF, CHILDREN MALES 14-44

	
127.30

	
117.48

	
ADLT

	
 

	
TANF M & F AND SOBRA FEMALES 45+

	
293.24

	
336.37

	
SSIW

	
 

	
SSI AGED, DISABLED, BLIND MEDICARE

	
30.21

	
232.52

	
SSIN

	
 

	
SSI AGED, DISABLED, BLIND NON-MEDICARE

	
81.25

	
509.47

	
SFPS

	
 

	
SOBRA FAMILY PLANNING SERVICES

	
 

	
15.77

	
SB10

	
 

	
TANF SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,669.20

	
SB11

	
 

	
SB PAYMENT FOR TANF EXPANDED

	
 

	
5,669.20

	
SB20

	
 

	
SSI W/O SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,669.20

	
SB21

	
 

	
SSI W/ SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,669.20

	
SB22

	
 

	
SB PAYMENT FOR SSI EXPANDED WITH MEDICARE

	
 

	
5,669.20

	
SB23

	
 

	
SB PAYMENT FOR SSI EXPANDED NO MEDICARE

	
 

	
5,669.20

	
SB33

	
 

	
SB PAYMENT FOR AHCCCS CARE

	
 

	
5,669.20

	
SB34

	
 

	
SB PAYMENT FOR MED ELIGIBLES

	
 

	
5,669.20

	
SB36

	
 

	
SB PAYMENT FOR AHC CARE/MI

	
 

	
5,669.20

	
SB50

	
 

	
SOBRA SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,669.20

	
SB60

	
 

	
KIDSCARE SUPPLEMENTAL BIRTH PAYMENT

	
 

	
 

	
ACMA

	
 

	
AHC CARE

	
538.76

	
404.81

	
MEDE

	
 

	
MED ELIGIBILITY

	
1,572.86

	
734.18

	
HS00

	
 

	
HOSPITALIZED KICK FOR AHCCCS CARE

	
 

	
0.00

	
HS01

	
 

	
HOSPITALIZED KICK FOR AHC CARE/MI

	
 

	
0.00

	
HS02

	
 

	
HOSPITALIZED KICK FOR MED ELIGIBLES

	
 

	
9,244.71

	
HFML

	
 

	
HIFA FEMALE 14-44

	
 

	
177.10

	
HMAL

	
 

	
HIFA MALE 14-44

	
 

	
129.08

	
HADT

	
 

	
HIFA ADULT 45+, M & F

	
 

	
369.74

	
KIDI

	
 

	
KIDS < 1 M & F     

	
 

	
 

	
KIDC

	
 

	
KIDS 1-13 M & F    

	
 

	
 

	
KIDF

	
 

	
KIDS 14-19 FEMALE  

	
 

	
 

	
KIDM

	
 

	
KIDS 14-19 MALE    

	
 

	
 

	
Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 8

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF &

 KC 1-13

 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
-1.74%

	
0.09%

	
-0.13%

	
1.70%

	
-0.02%

	
0.18%

	
3.76%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment

 (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
1.45%

	
4.89%

	
4.97%

	
7.27%

	
4.75%

	
4.16%

	
8.53%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$367.36

	
$93.93

	
$163.79

	
$115.78

	
$322.39

	
$239.67

	
$503.05

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.18%

	
0.55%

	
1.31%

	
1.37%

	
0.87%

	
0.20%

	
3.34%

	
0.00%

	
-0.31%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$390.08

	
$94.45

	
$165.93

	
$117.37

	
$325.18

	
$240.16

	
$519.86

	
$14.67

	
$5,669.94

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI

 w/Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC

 <1 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI

 w/Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM 2

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

 

	

PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF &

 KC <1

 M&F

	
TANF &

 KC 1-13

 M&F

	
TANF &

 KC

 14 - 44 F 1

	
TANF &

 KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
$5.29

	
$2.49

	
$5.03

	
$4.00

	
$9.68

	
$4.61

	
$13.60

	
$0.00

	
($40.74)

	
$0.00

	
$14.71

	
$10.72

	
$40.31

	
$19.56

	
$126.36

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($17.56)

	
$0.00

	
($38.56)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
($6.40)

	
$0.08

	
($0.21)

	
$1.91

	
($0.06)

	
$0.42

	
$17.96

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.37)

	
($0.02)

	
($0.07)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.19)

	
($0.00)

	
($5.29)

	
$0.00

	
($0.31)

	
($0.21)

	
($0.91)

	
($0.42)

	
($21.01)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.61)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.31)

	
($0.21)

	
($1.81)

	
$0.00

	
$1.99

	
$0.00

	
($2.07)

	
($1.45)

	
($7.65)

	
($3.52)

	
($45.15)

	
Premium Tax Implementation Adjustment

	
$7.35

	
$1.88

	
$3.28

	
$2.28

	
$6.45

	
$4.78

	
$9.70

	
$0.29

	
$113.75

	
$15.11

	
$11.10

	
$7.73

	
$31.70

	
$14.60

	
$187.11

	
Total Adjustment Impacting Base PMPM

	
$5.25

	
$4.38

	
$7.75

	
$7.85

	
$14.61

	
$9.57

	
$39.55

	
$0.29

	
$69.71

	
$15.11

	
$23.42

	
($0.77)

	
$63.45

	
($8.34)

	
$247.32

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$367.36

	
$93.93

	
$163.79

	
$115.78

	
$322.39

	
$239.67

	
$503.05

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible

	
$22.72

	
$0.52

	
$2.14

	
$1.59

	
$2.79

	
$0.49

	
$16.81

	
$0.00

	
($17.52)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$390.08

	
$94.45

	
$165.93

	
$117.37

	
$325.18

	
$240.16

	
$519.86

	
$14.67

	
$5,669.94

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC

 <1 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
$10.44

	
$1.05

	
$4.63

	
$4.30

	
$8.46

	
$0.74

	
$2.42

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.75)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($1.23)

	
($0.02)

	
($0.24)

	
($0.36)

	
($1.15)

	
($0.03)

	
($0.32)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
$14.76

	
$0.79

	
$3.02

	
$2.45

	
$5.64

	
$0.77

	
$1.72

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM

	
$23.23

	
$1.82

	
$7.33

	
$6.35

	
$12.83

	
$1.47

	
$3.78

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.  The KidsCare age cohort includes individuals 14 - 18 years of age, while the TANF rate cell includes 14 - 44.

	

Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 12

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
-1.74%

	
0.09%

	
-0.13%

	
1.70%

	
-0.02%

	
0.18%

	
3.76%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
1.45%

	
4.89%

	
4.97%

	
7.27%

	
4.75%

	
4.16%

	
8.53%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$357.54

	
$93.21

	
$159.09

	
$115.93

	
$333.64

	
$232.05

	
$492.97

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.25%

	
0.54%

	
1.32%

	
1.34%

	
0.82%

	
0.20%

	
3.35%

	
0.00%

	
-0.30%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$379.89

	
$93.71

	
$161.19

	
$117.48

	
$336.37

	
$232.52

	
$509.47

	
$15.77

	
$5,652.00

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
$5.15

	
$2.48

	
$4.88

	
$4.01

	
$10.01

	
$4.47

	
$13.33

	
$0.00

	
($40.61)

	
$0.00

	
$14.28

	
$11.23

	
$40.00

	
$19.67

	
$124.86

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($18.39)

	
$0.00

	
($38.78)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
($6.23)

	
$0.08

	
($0.21)

	
$1.91

	
($0.06)

	
$0.41

	
$17.60

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.36)

	
($0.02)

	
($0.07)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.18)

	
($0.00)

	
($5.27)

	
$0.00

	
($0.30)

	
($0.22)

	
($0.90)

	
($0.42)

	
($20.76)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.59)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.36)

	
($0.21)

	
($1.77)

	
$0.00

	
$1.98

	
$0.00

	
($2.01)

	
($1.51)

	
($7.59)

	
($3.54)

	
($44.61)

	
Premium Tax Implementation Adjustment

	
$7.15

	
$1.86

	
$3.19

	
$2.28

	
$6.67

	
$4.63

	
$9.50

	
$0.32

	
$113.38

	
$15.11

	
$10.78

	
$8.10

	
$31.46

	
$14.68

	
$184.89

	
Total Adjustment Impacting Base PMPM

	
$5.11

	
$4.35

	
$7.53

	
$7.86

	
$15.12

	
$9.27

	
$38.76

	
$0.31

	
$69.48

	
$15.11

	
$22.74

	
($0.81)

	
$62.97

	
($8.38)

	
$244.39

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$357.54

	
$93.21

	
$159.09

	
$115.93

	
$333.64

	
$232.05

	
$492.97

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 2

	
$22.34

	
$0.51

	
$2.10

	
$1.55

	
$2.74

	
$0.48

	
$16.50

	
$0.00

	
($17.21)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$379.89

	
$93.71

	
$161.19

	
$117.48

	
$336.37

	
$232.52

	
$509.47

	
$15.77

	
$5,652.00

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC 1

 13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC 1

 13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$16.93

	
$1.05

	
$4.81

	
$4.48

	
$8.80

	
$0.58

	
$2.28

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.21)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.99)

	
($0.02)

	
($0.25)

	
($0.37)

	
($1.19)

	
($0.03)

	
($0.30)

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$23.93

	
$0.79

	
$3.14

	
$2.55

	
$5.86

	
$0.60

	
$1.63

	
Total Adjustment Impacting Base PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$37.66

	
$1.82

	
$7.63

	
$6.61

	
$13.34

	
$1.15

	
$3.57

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
Phoenix Health Plan

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
HIFA Parent Rates

	
 

					
	
 

	
 

	
 

					
	
GSA

	
 

	
 

	
14-44F

		
14-44M

		
45+

	
2

	
Yuma, La Paz

						
	
4

	
Mohave, Coconino, Apache, Navajo

						
	
6

	
Yavapai

						
	
8

	
Pinal, Gila

		
$  182.31

		
$  128.95

		
$  357.42

	
10

	
Pima, Santa Cruz

						
	
12

	
Maricopa

		
$  177.10

		
$  129.08

		
$  369.74

	
14

	
Graham, Greenlee, Cochise

	
 

					

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

CONTRACT AMENDMENT

	
Page 1 of 1

	

 1. AMENDMENT NUMBER:

     03

		
2.  CONTRACT NO.:

      YH04-0001-06

		
3.  EFFECTIVE DATE OF MODIFICATION:

      October 1, 2003

		
4.  PROGRAM:

      DHCM-Acute

	

 5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Phoenix Plan/Community Connection

 1209 S. 7th Avenue

 Phoenix, Arizona  85007

	

 6. PURPOSE:  To revise capitation rates contained in Section B.

	

 7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:

 The purpose of this amendment is to adjust the Maternity Delivery Payment.  In Amendment 02, the summary rate sheet by GSA had the incorrect rate stated; and, the Final Awarded Rate sheets had a rounding error in the reinsurance offset line.  These errors
have been corrected and are reflected in the attached revised capitation rates.

 All other terms and conditions of the contract remains the same.

     NOTE:  Please sign, date and return one original to:          Michael Veit

                                                                                               
Contracts & Purchasing Administrator

                                                                                               
AHCCCS Contracts and Purchasing

                                                                                               
701 E Jefferson Street, M 5700

                                                                                               
Phoenix, AZ  85034

	

 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

 IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

	

 9. NAME OF CONTRACTOR:

     Phoenix Health Plan/Community Connection

	
 

	
10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

	

 SIGNATURE OF AUTHORIZED INDIVIDUAL:

 /s/ Nancy Novick                                   

 NANCY NOVICK

 CHIEF EXECUTIVE OFFICER

	
       

	

 SIGNATURE:

 /s/ Michael Veit                                       

 MICHAEL VEIT

 CONTRACTS & PURCHASING ADMINISTRATOR

	

 DATE:  9/15/03

	
    

	
DATE:  SEPTEMBER 10, 2003

	
As of:

	
 

	
10/1/2003

	
 

	
 

	
Plan:

	
 

	
PHOENIX HEALTH PLAN

	
 

	
 

	
Acute

	
 

	
 

	
 

	
 

	
GSA:

	
 

	
8

	
 

	
 

	
County:

	
 

	
GILA/PINAL

	
 

	
 

	
 

	
 

	
 

	
ACUTE

 PPC

	
ACUTE

 ONGOING

	
TACI

	
 

	
TANF AND CHILDREN M & F < 1 YEAR

	
737.97

	
390.08

	
TACS

	
 

	
TANF, CHILDREN AND SOBRA PREG FEMALE

	
39.66

	
94.45

	
FMAL

	
 

	
TANF, CHILDREN, SOBRA FEMALES 14-44

	
151.00

	
165.93

	
MALE

	
 

	
TANF, CHILDREN MALES 14-44

	
122.40

	
117.37

	
ADLT

	
 

	
TANF M & F AND SOBRA FEMALES 45+

	
281.97

	
325.18

	
SSIW

	
 

	
SSI AGED, DISABLED, BLIND MEDICARE

	
38.50

	
240.16

	
SSIN

	
 

	
SSI AGED, DISABLED, BLIND NON-MEDICARE

	
86.12

	
519.86

	
SFPS

	
 

	
SOBRA FAMILY PLANNING SERVICES

	
 

	
14.67

	
SB10

	
 

	
TANF SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,670.30

	
SB11

	
 

	
SB PAYMENT FOR TANF EXPANDED

	
 

	
5,670.30

	
SB20

	
 

	
SSI W/O SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,670.30

	
SB21

	
 

	
SSI W/ SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,670.30

	
SB22

	
 

	
SB PAYMENT FOR SSI EXPANDED WITH MEDICARE

	
 

	
5,670.30

	
SB23

	
 

	
SB PAYMENT FOR SSI EXPANDED NO MEDICARE

	
 

	
5,670.30

	
SB33

	
 

	
SB PAYMENT FOR AHCCCS CARE

	
 

	
5,670.30

	
SB34

	
 

	
SB PAYMENT FOR MED ELIGIBLES

	
 

	
5,670.30

	
SB36

	
 

	
SB PAYMENT FOR AHC CARE/MI

	
 

	
5,670.30

	
SB50

	
 

	
SOBRA SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,670.30

	
SB60

	
 

	
KIDSCARE SUPPLEMENTAL BIRTH PAYMENT

	
 

	
 

	
ACMA

	
 

	
AHC CARE

	
554.83

	
386.59

	
MEDE

	
 

	
MED ELIGIBILITY

	
1,584.83

	
730.00

	
HS00

	
 

	
HOSPITALIZED KICK FOR AHCCCS CARE

	
 

	
0.00

	
HS01

	
 

	
HOSPITALIZED KICK FOR AHC CARE/MI

	
 

	
0.00

	
HS02

	
 

	
HOSPITALIZED KICK FOR MED ELIGIBLES

	
 

	
9,355.58

	
HFML

	
 

	
HIFA FEMALE 14-44

	
 

	
182.31

	
HMAL

	
 

	
HIFA MALE 14-44

	
 

	
128.95

	
HADT

	
 

	
HIFA ADULT 45+, M & F

	
 

	
357.42

	
KIDI

	
 

	
KIDS < 1 M & F     

	
 

	
 

	
KIDC

	
 

	
KIDS 1-13 M & F    

	
 

	
 

	
KIDF

	
 

	
KIDS 14-19 FEMALE  

	
 

	
 

	
KIDM

	
 

	
KIDS 14-19 MALE    

	
 

	
 

	
As of:

	
 

	
10/1/2003

	
 

	
 

	
Plan:

	
 

	
PHOENIX HEALTH PLAN

	
 

	
 

	
Acute

	
 

	
 

	
 

	
 

	
GSA:

	
 

	
12

	
 

	
 

	
County:

	
 

	
MARICOPA

	
 

	
 

	
 

	
 

	
 

	
ACUTE

 PPC

	
ACUTE

 ONGOING

	
TACI

	
 

	
TANF AND CHILDREN M & F < 1 YEAR

	
1,196.40

	
379.89

	
TACS

	
 

	
TANF, CHILDREN AND SOBRA PREG FEMALE

	
39.66

	
93.71

	
FMAL

	
 

	
TANF, CHILDREN, SOBRA FEMALES 14-44

	
157.05

	
161.19

	
MALE

	
 

	
TANF, CHILDREN MALES 14-44

	
127.30

	
117.48

	
ADLT

	
 

	
TANF M & F AND SOBRA FEMALES 45+

	
293.24

	
336.37

	
SSIW

	
 

	
SSI AGED, DISABLED, BLIND MEDICARE

	
30.21

	
232.52

	
SSIN

	
 

	
SSI AGED, DISABLED, BLIND NON-MEDICARE

	
81.25

	
509.47

	
SFPS

	
 

	
SOBRA FAMILY PLANNING SERVICES

	
 

	
15.77

	
SB10

	
 

	
TANF SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,652.38

	
SB11

	
 

	
SB PAYMENT FOR TANF EXPANDED

	
 

	
5,652.38

	
SB20

	
 

	
SSI W/O SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,652.38

	
SB21

	
 

	
SSI W/ SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,652.38

	
SB22

	
 

	
SB PAYMENT FOR SSI EXPANDED WITH MEDICARE

	
 

	
5,652.38

	
SB23

	
 

	
SB PAYMENT FOR SSI EXPANDED NO MEDICARE

	
 

	
5,652.38

	
SB33

	
 

	
SB PAYMENT FOR AHCCCS CARE

	
 

	
5,652.38

	
SB34

	
 

	
SB PAYMENT FOR MED ELIGIBLES

	
 

	
5,652.38

	
SB36

	
 

	
SB PAYMENT FOR AHC CARE/MI

	
 

	
5,652.38

	
SB50

	
 

	
SOBRA SUPPLEMENTAL BIRTH PAYMENT

	
 

	
5,652.38

	
SB60

	
 

	
KIDSCARE SUPPLEMENTAL BIRTH PAYMENT

	
 

	
 

	
ACMA

	
 

	
AHC CARE

	
538.76

	
404.81

	
MEDE

	
 

	
MED ELIGIBILITY

	
1,572.86

	
734.18

	
HS00

	
 

	
HOSPITALIZED KICK FOR AHCCCS CARE

	
 

	
0.00

	
HS01

	
 

	
HOSPITALIZED KICK FOR AHC CARE/MI

	
 

	
0.00

	
HS02

	
 

	
HOSPITALIZED KICK FOR MED ELIGIBLES

	
 

	
9,244.71

	
HFML

	
 

	
HIFA FEMALE 14-44

	
 

	
177.10

	
HMAL

	
 

	
HIFA MALE 14-44

	
 

	
129.08

	
HADT

	
 

	
HIFA ADULT 45+, M & F

	
 

	
369.74

	
KIDI

	
 

	
KIDS < 1 M & F     

	
 

	
 

	
KIDC

	
 

	
KIDS 1-13 M & F    

	
 

	
 

	
KIDF

	
 

	
KIDS 14-19 FEMALE  

	
 

	
 

	
KIDM

	
 

	
KIDS 14-19 MALE    

	
 

	
 

	
Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 8

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
-1.74%

	
0.09%

	
-0.13%

	
1.70%

	
-0.02%

	
0.18%

	
3.76%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
1.45%

	
4.89%

	
4.97%

	
7.27%

	
4.75%

	
4.16%

	
8.53%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$367.36

	
$93.93

	
$163.79

	
$115.78

	
$322.39

	
$239.67

	
$503.05

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.18%

	
0.55%

	
1.31%

	
1.37%

	
0.87%

	
0.20%

	
3.34%

	
0.00%

	
-0.30%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$390.08

	
$94.45

	
$165.93

	
$117.37

	
$325.18

	
$240.16

	
$519.86

	
$14.67

	
$5,670.30

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC

 <1 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM 2

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

	
3.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
$5.29

	
$2.49

	
$5.03

	
$4.00

	
$9.68

	
$4.61

	
$13.60

	
$0.00

	
($40.74)

	
$0.00

	
$14.71

	
$10.72

	
$40.31

	
$19.56

	
$126.36

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($17.56)

	
$0.00

	
($38.56)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
($6.40)

	
$0.08

	
($0.21)

	
$1.91

	
($0.06)

	
$0.42

	
$17.96

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.37)

	
($0.02)

	
($0.07)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.19)

	
($0.00)

	
($5.29)

	
$0.00

	
($0.31)

	
($0.21)

	
($0.91)

	
($0.42)

	
($21.01)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.61)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.31)

	
($0.21)

	
($1.88)

	
$0.00

	
$1.99

	
$0.00

	
($2.07)

	
($1.45)

	
($7.65)

	
($3.52)

	
($45.15)

	
Premium Tax Implementation Adjustment

	
$7.35

	
$1.88

	
$3.28

	
$2.32

	
$6.45

	
$4.79

	
$10.06

	
$0.29

	
$113.75

	
$15.11

	
$11.10

	
$7.73

	
$31.70

	
$14.60

	
$187.11

	
Total Adjustment Impacting Base PMPM

	
$5.25

	
$4.38

	
$7.75

	
$7.85

	
$14.61

	
$9.57

	
$39.55

	
$0.29

	
$69.71

	
$15.11

	
$23.42

	
($0.77)

	
$63.45

	
($8.34)

	
$247.32

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$367.36

	
$93.93

	
$163.79

	
$115.78

	
$322.39

	
$239.67

	
$503.05

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible 2

	
$22.72

	
$0.52

	
$2.14

	
$1.59

	
$2.79

	
$0.49

	
$16.81

	
$0.00

	
($17.16)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$390.08

	
$94.45

	
$165.93

	
$117.37

	
$325.18

	
$240.16

	
$519.86

	
$14.67

	
$5,670.30

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC <1

 M&F

	
PPC Rural

 TANF & KC 1-13

 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+ M&F

	
PPC Rural

 SSI w/ Medicare

	
PPC Rural

 SSI w/o Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC 1-13

 M&F

	
PPC

 Urban                           TANF

 & KC

 14 -

 44 F 1

	
PPC

 Urban

 TANF

 & KC

 14 -

 44 M 1

	
PPC

 Urban

 TANF

 45+

 M&F

	
PPC

 Urban

 SSI w/

 Medicare

	
PPC

 Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
$10.44

	
$1.05

	
$4.63

	
$4.30

	
$8.46

	
$0.74

	
$2.42

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.75)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($1.23)

	
($0.02)

	
($0.24)

	
($0.36)

	
($1.15)

	
($0.03)

	
($0.32)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
$14.76

	
$0.79

	
$3.02

	
$2.45

	
$5.64

	
$0.77

	
$1.72

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM

	
$23.23

	
$1.82

	
$7.33

	
$6.35

	
$12.83

	
$1.47

	
$3.78

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1. The KidsCare age cohort covers individuals 14 - 18 years of age while the TANF rate cell includes 14 - 44.

									
	
2. The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the Maternity
Delivery Payment, and the female rate is directly affected by a new reinsurance election.

					

	
Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 12

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
-1.74%

	
0.09%

	
-0.13%

	
1.70%

	
-0.02%

	
0.18%

	
3.76%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
1.45%

	
4.89%

	
4.97%

	
7.27%

	
4.75%

	
4.16%

	
8.53%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$357.54

	
$93.21

	
$159.09

	
$115.93

	
$333.64

	
$232.05

	
$492.97

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.25%

	
0.54%

	
1.32%

	
1.34%

	
0.82%

	
0.20%

	
3.35%

	
0.00%

	
-0.30%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$379.89

	
$93.71

	
$161.19

	
$117.48

	
$336.37

	
$232.52

	
$509.47

	
$15.77

	
$5,652.38

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

	
3.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
$5.15

	
$2.48

	
$4.88

	
$4.01

	
$10.01

	
$4.47

	
$13.33

	
$0.00

	
($40.61)

	
$0.00

	
$14.28

	
$11.23

	
$40.00

	
$19.67

	
$124.86

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($18.39)

	
$0.00

	
($38.78)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
($6.23)

	
$0.08

	
($0.21)

	
$1.91

	
($0.06)

	
$0.41

	
$17.60

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.37)

	
($0.02)

	
($0.07)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.18)

	
($0.00)

	
($5.27)

	
$0.00

	
($0.30)

	
($0.22)

	
($0.90)

	
($0.42)

	
($20.76)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.61)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.36)

	
($0.21)

	
($1.77)

	
$0.00

	
$1.98

	
$0.00

	
($2.01)

	
($1.51)

	
($7.59)

	
($3.54)

	
($44.61)

	
Premium Tax Implementation Adjustment

	
$7.28

	
$1.86

	
$3.19

	
$2.28

	
$6.67

	
$4.63

	
$9.50

	
$0.32

	
$113.38

	
$15.11

	
$10.78

	
$8.10

	
$31.46

	
$14.68

	
$184.89

	
Total Adjustment Impacting Base PMPM

	
$5.11

	
$4.35

	
$7.53

	
$7.86

	
$15.12

	
$9.27

	
$38.76

	
$0.31

	
$69.48

	
$15.11

	
$22.74

	
($0.81)

	
$62.97

	
($8.38)

	
$244.39

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$357.54

	
$93.21

	
$159.09

	
$115.93

	
$333.64

	
$232.05

	
$492.97

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 2

	
$22.34

	
$0.51

	
$2.10

	
$1.55

	
$2.74

	
$0.48

	
$16.50

	
$0.00

	
($16.83)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$379.89

	
$93.71

	
$161.19

	
$117.48

	
$336.37

	
$232.52

	
$509.47

	
$15.77

	
$5,652.38

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC <1

 M&F

	
PPC Rural

 TANF & KC 1

 13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+ M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC 1-13

 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$16.93

	
$1.05

	
$4.81

	
$4.48

	
$8.80

	
$0.58

	
$2.28

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.21)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.99)

	
($0.02)

	
($0.25)

	
($0.37)

	
($1.19)

	
($0.03)

	
($0.30)

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$23.93

	
$0.79

	
$3.14

	
$2.55

	
$5.86

	
$0.60

	
$1.63

	
Total Adjustment Impacting Base PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$37.66

	
$1.82

	
$7.63

	
$6.61

	
$13.34

	
$1.15

	
$3.57

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort covers individuals 14 - 18 years of age while the TANF rate cell includes 14 - 44.

				
	
2.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

CONTRACT AMENDMENT

	
Page 1 of 1

	

 1. AMENDMENT NUMBER:

     04

		
2.  CONTRACT NO.:

      YH04-0001-06

		
3.  EFFECTIVE DATE OF MODIFICATION:

      October 1, 2003

		
4.  PROGRAM:

      DHCM-Acute

	

 5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Phoenix Health Plan/Community Connection

 1209 South 7th Avenue

 Phoenix, Arizona  85007

	

 6. PURPOSE:  To change specific sections of the Contract

	

 7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:

 The primary purpose of this amendment is to incorporate the BBA changes as summarized in the attached Summary of Changes and pursuant to the attachments to this Amendment.

 All other terms and conditions of the contract remains the same.

     NOTE:  Please sign, date and return one original to:          Michael Veit

                                                                                               
Contracts & Purchasing Administrator

                                                               
                                AHCCCS Contracts and Purchasing

                                                                                               
701 E Jefferson Street, MD5700

                                                                                               
Phoenix, AZ  85034

	

 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

 IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

	

 9. NAME OF CONTRACTOR:

     Phoenix Health Plan/Community Connection

	
 

	
10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

	

 SIGNATURE OF AUTHORIZED INDIVIDUAL:

 /s/ Nancy Novick                                   

 NANCY NOVICK

 CHIEF EXECUTIVE OFFICER

	
       

	

 SIGNATURE:

 /s/ Michael Veit                                       

 MICHAEL VEIT

 CONTRACTS & PURCHASING ADMINISTRATOR

	

 DATE:  9/23/03

	
    

	
DATE:  SEPTEMBER 15, 2003

	
REVISED SUMMARY OF CHANGES –RFP 10/1/03-9/30/04

	
This summary is provided as a convenience to highlight the changes to the Acute Care Contract that have taken place primarily based on responses received from CMS during their review of the document.  Any conflict between the summary and the text will be
resolved in favor of the text.

All text revisions summarized below are considered either an actual change to contract requirements or a clarification of existing requirements.  Finally, punctuation, grammar and style changes have been made throughout the revised text which have no effect
on the contract requirements and which may not be otherwise identified.

	
Para #:

	
PARAGRAPH TITLE:

	
SUMMARY OF CHANGE OR CLARIFICATION:

	
Pg.#

	
Sect.

	
 

	
See detail below

	
 

	
 

	
 

	
 

	
 

	
Various

	
Various

	
All references to OMM or OMC were changed to refer to the Division of Health Care Management

	
Various

	
C

	
Definitions

	
Removed “The services must be provided at the site where the member was treated for the emergency medical condition.” from the definition of Post-stabilization services.

	
7-

	
D-3

	
Enrollment and Disenrollment

	
Add the following after the 3rd sentence of the first paragraph of  Paragraph 3., “The Contractor may not request disenrollment because of an adverse change in the enrollee’s health status, or because of the enrollee’s
utilization of medical services, diminished mental capacity, or uncooperative or disruptive behavior resulting from his or her special needs.  An AHCCCS member may request disenrollment from the contractor for cause at any time.  Please refer those requests
due to situations defined in Section A (1) of the AHCCCS Change of Plan policy to the AHCCCS Verification Unit via mail or at (602) 417-4000 or (800) 962-6690.  For medical continuity requests, the contractor shall follow the procedures outlined in the 
AHCCCS Change of Plan Policy page 5, 2.b., before notifying the AHCCCSA.”

	
17

	
D-3

	
Enrollment and Disenrollment

	
Add ...during the member’s open enrollment/annual enrollment choice period, “the Contractor does not, because of moral or religious objections, cover the service the member seeks” or when approved for ...”

Also added “Grievance Rights:  Members may submit plan change requests to the Contractor or the AHCCCS Administration.  A denial of any plan change request must include a description of the member’s right to appeal the
denial.”

	
17

	
D-10

	
Scope of Services

	
After the first paragraph, insert the following:

‘Authorization of Services:  For the processing of requests for initial and continuing authorizations of services, the Contractorshall have in place, and follow, written policies and procedures; The Contractor shall have mechanisms in place to ensure
consistent application of review criteria for authorization decisions.  Any decision to deny a service authorization request or to authorize a service in an amount, duration, or scope that is less than requested, shall be made by a health care professional who
has appropriate clinical expertise in treating the member’s condition or disease.

Notice of Adverse Action: The Contractor shall notify the requesting provider, and give the member written notice of any decision by the Contractor to deny a service authorization request, or to authorize a service in an amount, duration, or scope that is less
than requested.  The notice shall meet the requirements of Sec. 438.404, except that the notice to the provider need not be in writing.”

	
22

	
D-10

	
Scope of Services

	
Change “Except for behavioral health  and children’s preventive dental  services, covered services must be provided by, or coordinated with, a primary care provider.  Services must be rendered......” to read as follows:
“Except for behavioral health  and children’s preventive dental  services, covered services must be provided by, or coordinated with, a primary care provider.  The Contractor must ensure the coordination of services it provides with
services the member receives from other entities.  The Contractor must ensure that, in the process of coordinating care, each member’s privacy is protected in accordance with the privacy requirements in 45 CFR Parts 160 and 164 Subparts A and E, to the
extend that they are applicable.  Services must be rendered......”

	
21

	
 

	
 

	

Change “The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely because of the diagnosis, type of illness, or condition.” to read as follows:  “The Contractor must ensure that the
services are sufficient in amount, duration, or scope to reasonably be expected to achieve the purpose for which the services are furnished.  The Contractor may not arbitrarily deny or reduce the amount, duration, or scope of a required service solely
because of diagnosis, type of illness, or condition of the enrollee.”

	

22

	
D-10

	
Scope of Services

	
Pregnancy Termination, replace entire paragraph with the following:

AHCCCS covers pregnancy termination if the pregnant member suffers from a physical disorder, physical injury, or physical illness, including a life endangering physical condition caused by, or arising from, the pregnancy itself, that would, as certified by a
physician, place the member in danger of death unless the pregnancy is terminated; the pregnancy is a result of rape or incest.

The attending physician must acknowledge that a pregnancy termination has been determined medically necessary by submitting the Certificate of Necessity for Pregnancy Termination.  This form must be submitted to the appropriate assigned Health Plan Medical
Director.  The Certificate must certify that, in the physician's professional judgment, one or more of the previously mentioned criteria have been met.

	
28

	
D-11

	
Special Health Care Needs

	
Delete “The Contractor must implement mechanisms to identify persons with special health care needs in accordance with the guidelines provided in the AMPM.”

Also, in the sentence “The Contractor must implement mechanisms to assess each member identified as having special health care needs, in order to identify any ongoing special conditions of the member which require a course of treatment or regular care
monitoring in accordance with the guidelines provided in the AMPM.” delete “in accordance with the guidelines provided in the AMPM” so the sentence will read as follows:  “The Contractor must implement mechanisms to assess each
member identified as having special health care needs, in order to identify any ongoing special conditions of the member which require a course of treatment or regular care monitoring.”  Immediately following the revised sentence, insert “The
assessment mechanisms must use appropriate health care professionals.  The Contractor shall share with other entities providing services to that member the results of its identification and assessment of that member’s needs.”

	
29

	
D-12

	
Behavioral Health Services

	
Change Section D,   “AHCCCS members are eligible for comprehensive behavioral health services.” to read as follows: “AHCCCS members, except for SOBRA Family Planning members, are eligible for comprehensive behavioral health
services.”

	
29

	
D-16

	
Staff Requirements and Support Services

	
Added the italicized language:  “For the purposes of this contract, the Contractor shall not employ or contract with any individual that has been debarred, suspended or otherwise lawfully prohibited from participating in any public procurement activity
or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order 12549.  The Contractor is responsible for maintaining a significant local (within the State of
Arizona) presence.  This presence would include staff as described below.  After contract award, the Contractor must obtain approval from AHCCCS prior to moving functions outside the State of Arizona. Such a request for approval must include a description
of the processes in place that assure rapid responsiveness to effect changes for contract compliance.

The Contractor shall be responsible for any additional costs associated with on-site audits or other oversight activities which result from required system located outside of the State of Arizona.”

	
32

	
D-18

	
Member Information

	
Added “The Contractor will, on an annual basis, inform all members of their right to request the following information:

            a.         An updated member handbook

             b.         The network description as described in the

                         AHCCCS Division of Health Care

                         Management Member Information Policy

This information may be sent in a separate written communication or included with other written information such as in a member newsletter.”

	
35

	
D-22

	
Advance Directives

	
Section D, add the word “law” to item c. (4) so it will read:

 (4) Changes to State law as soon as possible, but no later than 90 days after the effective date of the change.

	
37

	
D-22

	
Advance Directives

	
In item c. 3), change the word state to AHCCCSA.

	
37

	
D-23

	
Quality Management and Utilization Mangement

	
Replace entire paragraph with the following:

See Attached

	
37

	
D-24

	
Performance Indicators

	
Replace the Minimum Performance Standards, Goals and Benchmarks table and language below with the following:

See Attached 

	
38

	
D-25

	
Grievance System

	
See revised language

	
41

	
D-27

	
Network Development

	
Add the italicized language:

The plan shall identify the current status of the Contractor’s network, and project future needs based upon, at a minimum, membership growth; the number and types (in terms of training, experience and specialization) of providers that exist in the
Contractor’s service area, as well as the number of physicians who have privileges with and practice in hospitals; the expected utilization of services..... 

	
42

	
D-37

	
Subcontracts

	
Add the following italicized language:

The Contractor shall not include covenant-not-to-compete requirements in its provider agreements.  Specifically, the Contractor shall not contract with a provider and require that the provider not provide services for any other AHCCCS Contractor. In
addition, except for cost sharing requirement, the Contractor shall not enter into subcontracts that contain compensation terms that differ depending upon a member's eligibility category.

If the Contractor delegates duties or responsibilities such as utilization management or claims processing to a subcontractor, then the Contractor shall establish a written agreement that specifies the activities and reporting responsibilities delegated to the
subcontractor.  The written agreement shall also provide for revoking delegation or imposing other sanctions if the subcontractor’s performance is inadequate.  In order to determine adequate performance, the Contractor shall monitor the
subcontractor’s performance on an ongoing basis and subject it to formal review according to a periodic schedule. The schedule for review shall be submitted to AHCCCSA Division of Health Care Management for prior approval.  As a result of the performance
review, any deficiencies must be communicated to the subcontractor in order to establish a corrective action plan.  The results of the performance review and the correction plan shall be communicated to AHCCCS.

	
49

	
D-38

	
Claims Payment System

	
Change the title of the Paragraph to “Claims Payment/Health Information System” and insert last paragraph as follows “The Contractor shall develop and maintain a health information system that collects, analyzes, integrates, and reports
data.  The system shall provide information on areas including, but not limited to, service utilization and grievance and appeals.”

	
50

	
D-40

	
Hospital Subcontracting and Reimbursement

	
Replace the first four sentences with the following:

“Effective October 1, 2003, legislation authorizes the Inpatient Hospital Reimbursement Program (Program).  The Program, as defined in the Arizona Revised Statutes 36-2905.01, replaces the previous Hospital Reimbursement Pilot Program, which expires
September 30, 2003.  The program requires hospital subcontracts to be negotiated between health plans in Maricopa and Pima counties and hospitals to establish reimbursement levels, terms and conditions.”

	
51

	
D-59

	
Copayments

	
Revised entire paragraph.

	
66

	
D-72

	
Sanctions

	
Delete “such as termination of the contract” from item f. of the listing of intermediate sanctions.

	
72

	
D-75

	
Pending Legislative/Other Issues

	
Remove Prescription Drug paragraph, Hospice paragraph.

	
73

	
D-76

	
Balanced Budget Act of 1997 (BBA)

	
Change paragraph to read as follows:

“In August of 2002, CMS issued final regulations for the implementation of the BBA.  AHCCCS is currently reviewing all areas of the regulations to ensure full compliance with the BBA; however, there are some issues that require further clarification
from CMS.  Any program changes due to the resolution of the issues will be reflected in amendments to the RFP.  Final awarded capitation rates may be also be adjusted to reflect the financial impact of the program changes.

AHCCCSA is currently revising policies, as needed, to reflect the BBA  regulations.  As the policies are updated, they will be issued to all Contractors, both via the AHCCCS website and in hard copy.”

	
74

	
E-10

	
Compliance with Applicable Laws, Rules and Regulations

	
Changed “the Rehabilitation Act of 1972” to “the Rehabilitation Act of 1973”

	
76

	
E-17

	
Suspension or Debarment

	
Added the italicized language:  “The Contractor shall not employ, consult, subcontract  or enter into any agreement for Title XIX  services with any person or entity who is debarred, suspended or otherwise excluded from Federal procurement
activity or from participating in non-procurement activities under regulations issued under Executive Order No. 12549 or under guidelines implementing Executive Order 12549.” 

	
77

	
Section I

	
Instructions to Offerors

	
Remove the words “and benchmarked” from item #22.

	
103

	
Section I

	
Instructions to Offerors

	
Item 40, claims aging reports, has been eliminated – note in final document (do not remove as the numbering system would change).

	
105

	
Attachment A

	
Item 13, Fraud and Abuse

	
Delete “Incidents involving potential member eligibility fraud should be reported to AHCCCSA, Office of Managed Care, Member Fraud Unit.” and change “All other incidents of potential fraud should be reported to AHCCCSA, Office of the
Director, Office of Program Integrity.  (ARS 36-2918.01; AAC R9-22-511.) ” to read as follows: “All incidents of potential fraud should be reported to AHCCCSA, Office of the Director, Office of Program Integrity.  (ARS 36-2918.01; AAC
R9-22-511.)”

	
114

	
Attachment B

	
Geographic Service Area

Minimum Network Requirements

	
Add “95% of” to the first sentence of the second paragraph after the zip code table so it will read as follows:

In Tucson (GSA  10) and Metropolitan Phoenix (GSA 12), the Contractor must demonstrate its ability to provide PCP, dental  and pharmacy  services so that 95% of members do not have to travel more than 5 miles from their residence. 

	
117

	
Attachment E

	
 

	
Change second paragraph, second sentence “In the event that the Web application bid submission differs from the bid submission included with Section B of the RFP, the bid submitted via the Web application will prevail.” to read as follows “In the
event that the Web application bid submission differs from the bid submission included with Section B of the RFP, the bid submitted with Section B of the RFP will prevail.”

	
152

	
H (1) H(2)

	
Enrollee and Provider Grievance System Standards and Policy

	
See revised language.

	
159-165

	
L

	
Cost Sharing Copayments

	
Added attachment

	
175

23.                QUALITY MANAGEMENT AND UTILIZATION MANAGEMENT (QM/UM)

Quality Management (QM):  The Contractor shall provide quality medical care to members, regardless of payer source or eligibility category.  The Contractor shall use and disclose medical records and any other health and enrollment
information that identifies a particular member in accordance with Federal and State privacy requirements.  The Contractor shall execute processes to assess, plan, implement and evaluate quality management and performance improvement activities, as specified in
the AMPM, that include at least the following:

1.                Conducting Performance Improvement Projects (PIPs);

2.             QM monitoring and evaluation activities;

3.                Investigation, analysis, tracking and trending of quality of care issues, abuse and/or complaints;

4.                AHCCCS mandated performance indicators; and

5.                Credentialing and recredentialing processes.

AHCCCS has established a uniform credentialing and recredentialing policy.  The Contractor shall demonstrate that its providers are credentialed and:

                a.  Shall follow a documented process for credentialing and recredentialing of providers who have signed

                      contracts or participation agreements with the Contractor;

                b.  Shall not discriminate against particular providers that serve high-risk populations or specialize in

                      conditions that require costly treatment; and

                c.  Shall not employ or contract with providers excluded from participation in Federal health care programs.

The Contractor shall submit, within timelines specified in Attachment F, a written QM plan that addresses its strategies for performance improvement and conducting the quality management activities described in this section. The Contractor shall conduct
performance improvement projects as required by the AMPM.

The Contractor may combine its quality management plan with the plan that addresses utilization management as described below.

Utilization Management (UM):  The Contractor shall execute processes to assess, plan, implement and evaluate utilization management activities, as specified in the AMPM, that include at least the following:

1.                Pharmacy Management;

2.             Prior authorization;

                a.  For the processing of requests for initial and continuing authorizations of services the Contractor shall:

                                1)  Have in effect mechanisms to ensure consistent application of review
criteria

                                      for authorization

                                      decisions; and

                                2)  Consult with the requesting provider when appropriate

                b.  Adoption of Practice Guidelines, that

                                1)  Are based on valid and reliable clinical evidence or a consensus of
health care professionals in

                                      the particular field;

                                2)  Consider the needs of the Contractor’s members;

                                3)  Are adopted in consultation with contracting health care
professionals;

                                4)  Are disseminated by Contractors to all affected providers and, upon
request, to enrollees and

                                      potential enrollees; and

                                5)  Provide a basis for consistent decisions for utilization management,
member education,

                                      coverage of services, and other areas to which the
guidelines apply

3.                Concurrent review;

4.                Continuity and coordination of care;

5.                Monitoring and evaluation of over and/or under utilization of services;

6.                Evaluation of new medical technologies, and new uses of existing technologies;

7.                Development and/or adoption of practice guidelines; and

8.                Consistent application of review criteria.

The Contractor shall maintain a written UM plan that addresses its plan for monitoring UM activities described in this section.  The plan must be submitted for review by AHCCCS Division of Health Care Management (DHCM) within timelines specified in Attachment
F.

24.                PERFORMANCE STANDARDS

All Performance Standards described below apply to all member populations.

Contractors must meet AHCCCS stated Minimum Performance Standards.  However, it is equally important that Contractors continually improve their performance indicator outcomes from year to year.  Contractors shall strive to meet the ultimate standard, or
benchmark, established by AHCCCS.

Any statistically significant drop in the Contractor’s performance level for any indicator must be explained by the Contractor in its annual quality management program evaluation.  If a Contractor has a significant drop in any indicator without a
justifiable explanation, it will be required to submit a corrective action plan and may be subject to sanctions.

AHCCCS has established three levels of performance:

                Minimum Performance Standard– A Minimum Performance Standard is the minimal expected level of

                 performance by the Contractor.   If a Contractor does not achieve this standard, or any indicator declines to

                 a level below the AHCCCS Minimum Performance, the Contractor will be required to submit a corrective

                 action plan and may be subject to sanctions.

                Goal– A Goal is a reachable standard for a given performance indicator for the Contract Year.  If the

                 Contractor has already met or exceeded the AHCCCS Minimum Performance Standard for any indicator,

                 the Contractor must strive to meet the established Goal for the indicator(s).

                Benchmark – A Benchmark is the ultimate standard to be achieved.  Contractors that have already

                 achieved or exceeded the Goal for any performance indicator must strive to meet the Benchmark for the

                 indicator(s).  Contractors that have achieved the Benchmark are expected to maintain this level of

                 performance for future years.

A Contractor that has not shown demonstrable and sustained improvement toward meeting AHCCCS Performance Standards shall develop a corrective action plan.  The corrective action plan must be received by AHCCCS, Division of Health Care Management within 30
days of receipt of notification from AHCCCS.  This plan must be approved by AHCCCS prior to implementation.  AHCCCS may conduct one or more follow-up onsite reviews to verify compliance with a corrective action plan.  Failure to achieve adequate
improvement may result in sanction imposed by AHCCCS.

Performance Indicators:  The Contractor shall comply with AHCCCS quality management requirements to improve performance for all AHCCCS established performance indicators.  Complete descriptions of these indicators can be found in the
Technical Specifications section of the most recently published Health Plan Performance Standards Results and Analysis documents for perinatal, pediatric and adult/adolescent services.  The indicators for postpartum  visits and low birth weight have
been eliminated as contractual performance standards.  The Contractor shall continue to monitor rates for postpartum visits and low birth weights and implement interventions as necessary to improve or sustain these rates.  These activities will be monitored
by AHCCCSA during the Operational and Financial Review.

CMS has been working in partnership with states in developing core performance measures for Medicaid and SCHIP programs.  The current AHCCCS established performance indicators may be subject to change when these core measures are finalized and
implemented.

In addition, AHCCCS has established standards for the following indicators:

EPSDT  Participation:  The Contractor shall take affirmative steps to increase member participation in the EPSDT program.  The participation rate is the number of children younger than 21 years receiving at least one
medical screen during the contract year, compared to the number of children expected to receive at least one medical screen.  The number of children expected to receive at least one medical screen is based on the AHCCCS EPSDT periodicity schedule  and the
average period of eligibility.

Pediatric immunizations:  The Contractor shall ensure members under age 21 receive age-appropriate immunizations as specified in the AMPM.

The Contractor shall participate in immunization  audits, at intervals specified by AHCCCSA, based on random sampling to assess and verify the immunization status of two-year-old members.  AHCCCS will provide the Contractor the selected sample,
specifications for conducting the audit, the AHCCCSA reporting requirements, and technical assistance.  The Contractor shall identify each child’s PCP, conduct the assessment, and report to AHCCCSA, in the required format, all immunization data for the
two-year-old children sampled.  If medical records are missing for more than 5 percent of the sample group, the Contractor is subject to sanctions  by AHCCCSA.  An External Quality Review Organization (EQRO) may conduct a study to validate the
Contractor’s reported rates.

The following table identifies the Minimum Performance Standards, Goals and Benchmarks for each indicator:

	
Performance Indicator

	
CYE 04 Minimum Performance Standard

	
CYE 04 Goal

	
Benchmark * (Healthy People Goals)

	
Reporting Frequency

	
Immunization  of two-year-olds 3 antigen series (4:3:1)

	
78%

	
  82%

	
90%

	
Odd years

	
Immunization  of two-year-olds 5 antigen series (4:3:1:2:3)

	
67%

	
  73%

	
90%

	
Odd years

	
Immunizations  of two-year-olds

	
 

	
 

	
 

	
Odd years

	
     DtaP         4 doses

	
82%

	
  85%

	
90%

	
Odd years

	
     Polio        3 doses

	
88%

	
  90%

	
90%

	
Odd years

	
     MMR -    1 dose

	
88%

	
  90%

	
90%

	
Odd years

	
     Hib           2 doses

	
85%

	
  90%

	
90%

	
Odd years

	
     HBV        3 doses

	
81%

	
  87%

	
90%

	
Odd years

	
Varicella  1 dose

	
73%

	
  80%

	
90%

	
Odd years

	
Dental  visits

	
45%

	
  55%

	
56%

	
Odd years

	
Well-child Visits 15 Months

	
58%

	
  64%

	
90%

	
Odd years

	
Well-child Visits 3-6 Years

	
48%

	
  64%

	
80%

	
Odd years

	
EPSDT  Participation

	
58%

	
  80%

	
80%

	
Annually

	
Children’s Access to PCP’s

	
77%

	
  80%

	
97%

	
Annually

	
Cervical Cancer Screening (3-yr period)

	
57%

	
  60%

	
90%

	
Even years

	
Breast Cancer Screening

	
55%

	
  60%

	
70%

	
Even years

	
Adolescent Well-care Visits

	
48%

	
  49%

	
50%

	
Odd years

	
Adult Ambulatory/Preventive Care

	
78%

	
  80%

	
96%

	
Annually

	
Timeliness of Prenatal  Care

	
59%

	
  65%

	
90%

	
Even years

*Benchmarks for each performance indicator are based on Healthy People 2000 or 2010 goals for health promotion and disease prevention, as determined by the U.S. Department of Health and Human Services.

Contractors shall implement an ongoing quality assessment and performance improvement programs for the services it furnishes to members.  Basic elements of the Contractor quality assessment and performance improvement programs, at a minimum, shall comply with
the following requirements:

Quality Assessment Program

The Contractor shall have an ongoing quality assessment program for the services it furnishes to members that includes the following:

1.             The program shall be designed to achieve, through ongoing measurements and intervention, significant

                 improvement, sustained over time, in clinical care and non-clinical care areas that are expected to have a

                favorable effect on health outcomes and member satisfaction.

2.                Annually, the Contractor shall:

                a.  If required, measure and report to the State its performance, using standard measures required by the

                      State, or

                 b.  Submit to the State, data specified by the State, that enables the State to measure the Contractor’s

                      performance; or

                c.  Perform a combination of the activities.

3.             The Contractor shall have in effect mechanisms to detect both underutilization and overutilization of

                 services.

4.             The Contractor shall have in effect mechanisms to assess the quality and appropriateness of care furnished

                 to members with special health care needs.

Performance Improvement Program

The Contractor shall have an ongoing program of performance improvement projects that focus on clinical and non-clinical areas, and that involve the following:

1.                Measurement of performance using objective quality indicators.

2.                Implementation of system interventions to achieve improvement in quality

3.                Evaluation of the effectiveness of the interventions.

4.             Planning and initiation of activities for increasing or sustaining improvement.

The Contractor shall report the status and results of each project to the AHCCCSA as requested.  Each performance improvement project must be completed in a reasonable time period so as to generally allow information on the success of performance improvement
projects in the aggregate to produce new information on quality of care every year.

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

CONTRACT AMENDMENT

	
Page 1 of 1 with Attachment

	

 1. AMENDMENT NUMBER:

     05

		
2.  CONTRACT NO.:

      YH04-0001-06

		
3.  EFFECTIVE DATE OF MODIFICATION:

      October 1, 2003

		
4.  PROGRAM:

      DHCM-Acute

	

 5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Phoenix Health Plan/Community Connection

 1209 South 7th Avenue

 Phoenix, Arizona  85007

	

 6. PURPOSE:  To revise capitation rates contained in Section B.

	

 7. THE CONTRACT REFERENCED ABOVE IS AMENDED AS FOLLOWS:

 A.  The rates contained in the existing Section B are deleted and replaced with the attached revised capitation rates.  The purpose of this amendment is to adjust the TANF/KC and SSI prospective rates.  It is the opinion of Mercer and AHCCCS that
the net capitation rates should not have included the reinsurance adjustment stated in the Final Awarded Rate sheet.  This adjustment was explained in a memo to the CFO’s on September 22, 2003.  These rates have been adjusted and are reflected in the
attached document.

     NOTE:  Please sign, date and return one original to:          Michael Veit, Contracts & Purchasing Administrator

                                               
                                               
AHCCCS Contracts and Purchasing

                                                                                               
701 E Jefferson Street, MD5700

                                                                                               
Phoenix, AZ  85034

	

 8. EXCEPT AS PROVIDED FOR HEREIN, ALL TERMS AND CONDITIONS OF THE ORIGINAL CONTRACT NOT HERETOFORE CHANGED AND/OR AMENDED REMAIN UNCHANGED AND IN FULL EFFECT.

 IN WITNESS WHEREOF THE PARTIES HERETO SIGN THEIR NAMES IN AGREEMENT

	

 9. NAME OF CONTRACTOR:

     Phoenix Health Plan/Community Connection

	
 

	
10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

	

 SIGNATURE OF AUTHORIZED INDIVIDUAL:

 /s/ Nancy Novick                                   

 NANCY NOVICK

 CHIEF EXECUTIVE OFFICER

	
       

	

 SIGNATURE:

 /s/ Michael Veit                                       

 MICHAEL VEIT

 CONTRACTS & PURCHASING ADMINISTRATOR

	

 DATE:  9/25/03

	
    

	
DATE:  SEPTEMBER 22, 2003

	
Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 8

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$373.88

	
$93.85

	
$164.01

	
$113.84

	
$322.45

	
$239.24

	
$484.80

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.08%

	
0.55%

	
1.31%

	
1.40%

	
0.87%

	
0.20%

	
3.47%

	
0.00%

	
-0.30%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$396.60

	
$94.36

	
$166.15

	
$115.43

	
$325.24

	
$239.73

	
$501.61

	
$14.67

	
$5,670.30

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC

 <1 M&F

	
PPC Urban

 TANF & KC 1

 13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM 2

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

	
3.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$362.11

	
$89.55

	
$156.04

	
$107.93

	
$307.78

	
$230.10

	
$463.50

	
$14.38

	
$5,617.75

	
$740.35

	
$531.41

	
$387.36

	
$1,521.38

	
$738.34

	
$9,108.27

	
Outpatient & Emergency Room Adjustment

	
$5.29

	
$2.49

	
$5.03

	
$4.00

	
$9.68

	
$4.61

	
$13.60

	
$0.00

	
($40.74)

	
$0.00

	
$14.71

	
$10.72

	
$40.31

	
$19.56

	
$126.36

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($17.56)

	
$0.00

	
($38.56)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.38)

	
($0.02)

	
($0.08)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.19)

	
($0.00)

	
($5.29)

	
$0.00

	
($0.31)

	
($0.21)

	
($0.91)

	
($0.42)

	
($21.01)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.62)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.31)

	
($0.21)

	
($1.81)

	
$0.00

	
$1.99

	
$0.00

	
($2.07)

	
($1.45)

	
($7.65)

	
($3.52)

	
($45.15)

	
Premium Tax Implementation Adjustment

	
$7.48

	
$1.88

	
$3.28

	
$2.28

	
$6.45

	
$4.78

	
$9.70

	
$0.29

	
$113.75

	
$15.11

	
$11.10

	
$7.73

	
$31.70

	
$14.60

	
$187.11

	
Total Adjustment Impacting Base PMPM

	
$11.77

	
$4.30

	
$7.97

	
$5.91

	
$14.67

	
$9.14

	
$21.30

	
$0.29

	
$69.71

	
$15.11

	
$23.42

	
($0.77)

	
$63.45

	
($8.34)

	
$247.32

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$373.88

	
$93.85

	
$164.01

	
$113.84

	
$322.45

	
$239.24

	
$484.80

	
$14.67

	
$5,687.46

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
Impact of Electing the $50k Reinsurance Deductible 2

	
$22.72

	
$0.52

	
$2.14

	
$1.59

	
$2.79

	
$0.49

	
$16.81

	
$0.00

	
($17.16)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$396.60

	
$94.36

	
$166.15

	
$115.43

	
$325.24

	
$239.73

	
$501.61

	
$14.67

	
$5,670.30

	
$755.46

	
$554.83

	
$386.59

	
$1,584.83

	
$730.00

	
$9,355.58

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC 1

 13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC

 <1 M&F

	
PPC Urban

 TANF & KC 1

 13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
$714.74

	
$37.84

	
$143.67

	
$116.05

	
$269.14

	
$37.03

	
$82.34

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Outpatient & Emergency Room Adjustment

	
$10.44

	
$1.05

	
$4.63

	
$4.30

	
$8.46

	
$0.74

	
$2.42

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.75)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($1.23)

	
($0.02)

	
($0.24)

	
($0.36)

	
($1.15)

	
($0.03)

	
($0.32)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Premium Tax Implementation Adjustment

	
$14.76

	
$0.79

	
$3.02

	
$2.45

	
$5.64

	
$0.77

	
$1.72

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Total Adjustment Impacting Base PMPM

	
$23.23

	
$1.82

	
$7.33

	
$6.35

	
$12.83

	
$1.47

	
$3.78

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Impact of Electing the $50k Reinsurance Deductible

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$737.97

	
$39.66

	
$151.00

	
$122.40

	
$281.97

	
$38.50

	
$86.12

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
Final Awarded Rate – CYE04

 Phoenix Health Plan:  GSA 12

 (Effective 10/01/03)

 

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
0.00%

	
-0.73%

	
0.00%

	
2.77%

	
2.77%

	
2.65%

	
2.65%

	
1.39%

	
Cost Sharing Proposal Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
-4.41%

	
0.00%

	
-5.09%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
-0.02%

	
-0.09%

	
0.00%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.06%

	
-0.23%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
0.00%

	
0.04%

	
0.00%

	
-0.38%

	
-0.38%

	
-0.49%

	
-0.49%

	
-0.49%

	
Premium Tax Implementation Adjustment

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
2.02%

	
1.24%

	
2.04%

	
4.41%

	
-0.20%

	
4.17%

	
-1.13%

	
2.72%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$363.88

	
$93.13

	
$159.30

	
$113.99

	
$333.70

	
$231.63

	
$475.09

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 3

	
6.14%

	
0.54%

	
1.32%

	
1.36%

	
0.82%

	
0.21%

	
3.47%

	
0.00%

	
-0.30%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$386.23

	
$93.63

	
$161.40

	
$115.54

	
$336.43

	
$232.11

	
$491.59

	
$15.77

	
$5,652.38

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PERCENT CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC

 1-13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC

 1-13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
1.46%

	
2.79%

	
3.22%

	
3.71%

	
3.14%

	
2.00%

	
2.94%

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.10%

	
-0.02%

	
-0.05%

	
-0.03%

	
-0.05%

	
-0.02%

	
-0.04%

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
-0.17%

	
-0.06%

	
-0.16%

	
-0.30%

	
-0.41%

	
-0.09%

	
-0.38%

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
2.04%

	
Total Adjustment Impacting Base PMPM 2

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
3.25%

	
4.80%

	
5.11%

	
5.47%

	
4.77%

	
3.97%

	
4.60%

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
0.00%

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort includes individuals 14 to 18 years of age, while the TANF rate cell includes 14 - 44.

	
2.  The adjustment is multiplicative, not additive.

	
3.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
TANF & KC

 <1 M&F

	
TANF & KC

 1-13 M&F

	
TANF & KC

 14 - 44 F 1

	
TANF & KC

 14 - 44 M 1

	
TANF 45+

 M&F

	
SSI w/

 Medicare

	
SSI w/o

 Medicare

	
Extended

 Family

 Planning

 Services

	
Maternity

 Delivery

 Payment

	
AIDS / HIV

 Supplemental

 Payment

	
Non-MED

 Prior Period

 Coverage

	
Non-MED

 Prospective

	
MED

 Prior Period

 Coverage

	
MED

 Prospective

	
MED

 Hospitalized

 Supplemental

	
Originally Awarded PMPM

	
$352.43

	
$88.86

	
$151.56

	
$108.07

	
$318.52

	
$222.78

	
$454.21

	
$15.46

	
$5,599.72

	
$740.35

	
$516.02

	
$405.62

	
$1,509.89

	
$742.57

	
$9,000.32

	
Outpatient & Emergency Room Adjustment

	
$5.15

	
$2.48

	
$4.88

	
$4.01

	
$10.01

	
$4.47

	
$13.33

	
$0.00

	
($40.61)

	
$0.00

	
$14.28

	
$11.23

	
$40.00

	
$19.67

	
$124.86

	
Cost Sharing Proposal Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
($18.39)

	
$0.00

	
($38.78)

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
($0.37)

	
($0.02)

	
($0.07)

	
($0.04)

	
($0.15)

	
($0.04)

	
($0.18)

	
($0.00)

	
($5.27)

	
$0.00

	
($0.30)

	
($0.22)

	
($0.90)

	
($0.42)

	
($20.76)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
($0.61)

	
($0.06)

	
($0.26)

	
($0.34)

	
($1.36)

	
($0.21)

	
($1.77)

	
$0.00

	
$1.98

	
$0.00

	
($2.01)

	
($1.51)

	
($7.59)

	
($3.54)

	
($44.61)

	
Premium Tax Implementation Adjustment

	
$7.28

	
$1.86

	
$3.19

	
$2.28

	
$6.67

	
$4.63

	
$9.50

	
$0.32

	
$113.38

	
$15.11

	
$10.78

	
$8.10

	
$31.46

	
$14.68

	
$184.89

	
Total Adjustment Impacting Base PMPM

	
$11.45

	
$4.27

	
$7.74

	
$5.92

	
$15.18

	
$8.85

	
$20.88

	
$0.31

	
$69.48

	
$15.11

	
$22.74

	
($0.81)

	
$62.97

	
($8.38)

	
$244.39

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
$363.88

	
$93.13

	
$159.30

	
$113.99

	
$333.70

	
$231.63

	
$475.09

	
$15.77

	
$5,669.20

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
Impact of Electing the $50k Reinsurance Deductible 2

	
$22.34

	
$0.51

	
$2.10

	
$1.55

	
$2.74

	
$0.48

	
$16.50

	
$0.00

	
($16.83)

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
$386.23

	
$93.63

	
$161.40

	
$115.54

	
$336.43

	
$232.11

	
$491.59

	
$15.77

	
$5,652.38

	
$755.46

	
$538.76

	
$404.81

	
$1,572.86

	
$734.18

	
$9,244.71

	
PMPM CHANGE DUE TO PROGRAMMATIC ADJUSTMENTS

	
PMPMs & PROGRAMMATIC ADJUSTMENTS

	
PPC Rural

 TANF & KC

 <1 M&F

	
PPC Rural

 TANF & KC 1

 13 M&F

	
PPC Rural

 TANF & KC

 14 - 44 F 1

	
PPC Rural

 TANF & KC

 14 - 44 M 1

	
PPC Rural

 TANF 45+

 M&F

	
PPC Rural

 SSI w/

 Medicare

	
PPC Rural

 SSI w/o

 Medicare

	
PPC Urban

 TANF & KC <1

 M&F

	
PPC Urban

 TANF & KC 1

 13 M&F

	
PPC Urban

 TANF & KC

 14 - 44 F 1

	
PPC Urban

 TANF & KC

 14 - 44 M 1

	
PPC Urban

 TANF 45+

 M&F

	
PPC Urban

 SSI w/

 Medicare

	
PPC Urban

 SSI w/o

 Medicare

	
Originally Awarded PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,158.74

	
$37.84

	
$149.42

	
$120.69

	
$279.90

	
$29.06

	
$77.68

	
Outpatient & Emergency Room Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$16.93

	
$1.05

	
$4.81

	
$4.48

	
$8.80

	
$0.58

	
$2.28

	
Cost Sharing Proposal Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Reinsurance Incorporating Catastrophic and Transplant Data Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Hospital Inpatient DRI Trend Update Adjustment - (4.0% estimate changed to 3.8% actual)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.21)

	
($0.01)

	
($0.07)

	
($0.04)

	
($0.13)

	
($0.01)

	
($0.03)

	
Fee-for-Service Schedule Change

 (Referral Physician and Lab & X-Ray COS)

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
($1.99)

	
($0.02)

	
($0.25)

	
($0.37)

	
($1.19)

	
($0.03)

	
($0.30)

	
Premium Tax Implementation Adjustment

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$23.93

	
$0.79

	
$3.14

	
$2.55

	
$5.86

	
$0.60

	
$1.63

	
Total Adjustment Impacting Base PMPM

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$37.66

	
$1.82

	
$7.63

	
$6.61

	
$13.34

	
$1.15

	
$3.57

	
Adjusted Awarded PMPM for Plans Electing the $20k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
Impact of Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
$0.00

	
Adjusted Awarded PMPM for Plans Electing the $50k Reinsurance Deductible

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
N/A

	
$1,196.40

	
$39.66

	
$157.05

	
$127.30

	
$293.24

	
$30.21

	
$81.25

	
1.  The KidsCare age cohort covers individuals 14 - 18 years of age while the TANF rate cell includes 14 - 44.

	
2.  The Maternity Delivery Payment does not have a reinsurance component built directly into the rate. However, it is indirectly affected by choosing a different deductible level because the TANF 14-44 female rate is applied as an 8-month offset to the
Maternity Delivery Payment, and the female rate is directly affected by a new reinsurance election.

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00058-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00058-of-00352.parquet"}]]