Document:

VANGUARD HEALTH SYSTEMS, INC.

EXHIBIT 4.1

SUPPLEMENTAL INDENTURE

                        EIGHTH SUPPLEMENTAL INDENTURE (this “Supplemental Senior Subordinated Indenture”), dated as of March 24,
2009, among BHS Physicians Alliance for ACE, LLC, a Delaware limited liability company ( the “New Guarantor”) and a subsidiary of Vanguard Health Holding Company II, LLC, a Delaware limited liability company (“VHS Holdco II”),
Vanguard Holding Company II, Inc., a Delaware corporation and a wholly owned subsidiary of VHS Holdco II (together with VHS Holdco II, the “Issuers”), Vanguard Health Holding Company I, LLC, Vanguard Health Systems, Inc. and U.S. Bank National
Association, as trustee under the Senior Subordinated Indenture referred to below (the “Trustee”).

WITNESSETH

                        WHEREAS, the Issuers and the existing Guarantors have heretofore executed and delivered to the Trustee an indenture (as
amended, supplemented or otherwise modified, the “Senior Subordinated Indenture”), dated as of September 23, 2004 providing for the issuance of 9% Senior Subordinated Notes due 2014 (the “Senior Subordinated Notes”);

                        WHEREAS, Section 4.16 of the Senior Subordinated Indenture provides that under certain circumstances the New Guarantor shall
execute and deliver to the Trustee a supplemental indenture pursuant to which the New Guarantor shall unconditionally guarantee all of the Issuers’ Obligations under the Senior Subordinated Notes and the Senior Subordinated Indenture on the terms and conditions
set forth herein (the “Note Guarantee”); and

                        WHEREAS, pursuant to Section 9.01 of the Senior Subordinated Indenture, the Trustee and the Issuers are authorized to execute
and deliver this Supplemental Senior Subordinated Indenture.

                        NOW, THEREFORE, in consideration of the foregoing and for other good and valuable consideration, the receipt of which is
hereby acknowledged, the New Guarantor, the Issuers and the Trustee mutually covenant and agree for the equal and ratable benefit of the Holders of the Senior Subordinated Notes as follows:

                        1.         DEFINED TERMS.  Defined terms used herein without definition shall
have the meanings assigned to them in the Senior Subordinated Indenture.

                        2.         AGREEMENT TO GUARANTEE.  The New Guarantor hereby agree, jointly and
severally with all existing Guarantors (if any), to provide an unconditional Guarantee on the terms and subject to the conditions set forth in Article 12 of the Senior Subordinated Indenture and to be bound by all other applicable provisions of the Senior
Subordinated Indenture and the Senior Subordinated Notes and to perform all of the obligations and agreements of a Guarantor under the Senior Subordinated Indenture.  The Guarantee of the New Guarantor shall be subordinated to Senior Debt as provided in the
Senior Subordinated Note Indenture

1

                        3.         NO RECOURSE AGAINST OTHERS.  No past, present or future director,
manager, officer, employee, incorporator, stockholder or member of the Issuers, any parent entity of the Issuers or any Subsidiary, as such, will have any liability for any obligations of the Issuers or the Guarantors under the Senior Subordinated Notes, this Senior
Subordinated Indenture, the Note Guarantees or for any claim based on, in respect of, or by reason of, such obligations or their creation.  Each Holder of Senior Subordinated Notes by accepting a Senior Subordinated Note waives and releases all such
liability.  The waiver and release are part of the consideration for issuance of the Senior Subordinated Notes.  The waiver may not be effective to waive liabilities under the federal securities laws.

                        4.         NOTICES.  All notices or other communications to the New Guarantor
shall be given as provided in Section 14.02 of the Senior Subordinated Indenture.

                        5.         RATIFICATION OF INDENTURE; SUPPLEMENTAL INDENTURES PART OF
INDENTURE.  Except as expressly amended hereby, the Senior Subordinated Indenture is in all respects ratified and confirmed and all the terms, conditions and provisions thereof shall remain in full force and effect.  This Supplemental Senior Subordinated
Indenture shall form a part of the Senior Subordinated Indenture for all purposes, and every holder of Senior Subordinated Notes heretofore or hereafter authenticated and delivered shall be bound hereby.

                        6.         GOVERNING LAW.  THIS INDENTURE, THE NOTES AND THE SENIOR SUBORDINATED
NOTE GUARANTEES SHALL BE GOVERNED BY, AND CONSTRUED IN ACCORDANCE WITH, THE LAWS OF THE STATE OF NEW YORK.

                        7.         COUNTERPARTS.  The parties may sign any number of copies of this
Supplemental Senior Subordinated Indenture.  Each signed copy shall be an original, but all of them together represent the same agreement.

                        8.         EFFECT OF HEADINGS.  The Section headings herein are for convenience
only and shall not affect the construction hereof.

                        9.         TRUSTEE MAKES NO REPRESENTATION.  The Trustee makes no representation
as to the validity or sufficiency of this Supplemental Indenture.

2

                        IN WITNESS WHEREOF, the parties hereto have caused this Supplemental Indenture to be duly executed and attested, all as of
the date first above written.

Dated: March 24, 2009

                                               
BHS PHYSICIANS ALLIANCE FOR ACE, LLC

                                               
(formerly known as VHS Acquisition Company Number

                                               
2, LLC)

                                               
By:/s/ James H. Spalding                      

                                               
Name: James H. Spalding

                                               
Title: Senior Vice President

                                               
VANGUARD HEALTH HOLDING COMPANY II, LLC

                                               
By:/s/ James H. Spalding                      

                                               
Name: James H. Spalding

                                               
Title: Senior Vice President

                                               
VANGUARD HOLDING COMPANY II, INC.

                                               
By:/s/ James H. Spalding                      

                                               
Name: James H. Spalding

                                               
Title: Senior Vice President

                                               
VANGUARD HEALTH HOLDING COMPANY I, LLC

                                               
By:/s/ James H. Spalding                      

                                               
Name: James H. Spalding

                                               
Title: Senior Vice President

                                               
VANGUARD HEALTH SYSTEMS, INC.

                                               
By:/s/ James H. Spalding                      

                                               
Name: James H. Spalding

                                               
Title: Senior Vice President

3

                                               
U.S. BANK NATIONAL ASSOCIATION

                                               
as Trustee

                                               
By:/s/ Richard Prokosch                      

                                               
Name: Richard Prokosch

                                               
Title: Vice President

4VANGUARD HEALTH SYSTEMS, INC.

EXHIBIT 10.1

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION

DIVISION OF BUSINESS AND FINANCE

SECTION A: CONTRACT

	

 1. AMENDMENT NUMBER:

     3

		
2.  CONTRACT NO.:

      YH09-0001-07

		
3.  EFFECTIVE DATE OF CONTRACT:

      May 1, 2009

		
4.  PROGRAM:

      DHCM - ACUTE

	

 5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

VHS Phoenix Health Plan, LLC

 7878 N. 16th Street, Suite 105

 Phoenix, Arizona  85020

	

 6. PURPOSE OF AMENDMENT:  To amend Section B, Capitation Rates, effective May 1, 2009.

	
7.

	
 

	
THE CONTRACT REFERENCED ABOVE FOLLOWS

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
To amend Section B, Capitation Rates, effective May 1, 2009.

	
 

	
 

	
NOTE:  Please sign and date all copies and then return one executed original to:    
               Mark Held

                                                                                                                                
Sr. Procurement Specialist

                                                                                                                                
AHCCS Contracts

                                                                                                                                
701 E. Jefferson St., MD 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.  SIGNATURE OF AUTHORIZED REPRESENTATIVE:

	
 

	
10.  SIGNATURE OF AHCCCSA CONTRACTING OFFICER:

	
     /a/ Nancy Novick

	
 

	
       /s/ Pat Wathimson for Michael Veit

	
 

	
 

	
 

	
TYPED NAME:      NANCY NOVICK

	
 

	
MICHAEL VEIT

	
TITLE:                    CHIEF EXECUTIVE OFFICER

	
 

	
CONTRACTS & PURCHASING ADMINISTRATOR

	
DATE: 4/6/09

	
 

	
DATE: 3-30-09

SECTION B: CAPITATION RATES

The Contractor shall provide services as described in this contract. In consideration for these services, the Contractor

 will be paid Contractor-specific rates per member per month for the term May 1, 200 through September 30,

 2009. See attached revised rates.

61

	

ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM

 CAPITATION RATE SUMMARY – ACUTE RATES

 Phoenix Health Plan

 5/1/2009-9/30/2009

	
 

	
Title XIX and KidsCare Rates 1:

	
TANF

 <1, M/F

	
TANF

 1-13, M/F

	
TANF

 14-44, F

	
TANF

 14-44, M

	
TANF

 45+, M/F

	
SSI

 w/ Med

	
SSI

 w/o Med

	
SFP

	
Maternity

 Delivery

 Supplement

	
Non-MED

	
MED

	
4

	
Apache/Coconino/Mohave/Navajo

	
$474.47

	
$111.58

	
$273.18

	
$157.95

	
$409.52

	
$161.19

	
$776.11

	
$19.02

	
$6,248.22

	
$578.66

	
$1,434.36

	
6

	
Yavapai

	
$507.50

	
$116.03

	
$270.46

	
$180.56

	
$427.88

	
$141.69

	
$758.61

	
$18.30

	
$6,871.52

	
$627.38

	
$1,160.64

	
8

	
Gila/Pinal

	
$578.37

	
$108.22

	
$256.73

	
$172.31

	
$358.20

	
$139.85

	
$737.91

	
$12.43

	
$6,594.24

	
$487.17

	
$1,673.46

	
10

	
Pima

	
$493.42

	
$101.61

	
$239.36

	
$127.59

	
$408.04

	
$146.24

	
$772.28

	
$21.96

	
$6,627.59

	
$492.92

	
$1,356.27

	
12

	
Maricopa

	
$550.49

	
$117.35

	
$241.92

	
$151.74

	
$422.47

	
$158.80

	
$749.25

	
$18.79

	
$6,694.65

	
$630.48

	
$1,423.69

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
PPC Rates:

	
TANF

 <1, M/F

	
TANF

 1-13, M/F

	
TANF

 14-44, F

	
TANF

 14-44, M

	
TANF

 45+, M/F

	
SSI

 w/ Med

	
SSI

 w/o Med

			
Non-MED

	
MED

	
4

	
Apache/Coconino/Mohave/Navajo

	
$1,190.99

	
$62.12

	
$264.37

	
$215.09

	
$439.52

	
$135.86

	
$405.68

			
$1,127.75

	
$7,407.25

	
6

	
Yavapai

	
$1,210.79

	
465.92

	
$262.35

	
$223.35

	
$442.10

	
$133.86

	
$407.50

			
$1.116/81

	
$7,418.82

	
8

	
Gila/Pinal

	
$1,200.37

	
$66.67

	
$253.25

	
$212.60

	
$444.30

	
$134.33

	
$407.29

			
$1,100.13

	
$7,521.76

	
10

	
Pima

	
$1,195.05

	
$56.40

	
$248.23

	
$197.36

	
$440.40

	
$132.96

	
$408.89

			
$889.79

	
$7,402.50

	
12

	
Maricopa

	
$1,221.70

	
$66.27

	
$256.92

	
$225.36

	
$448.09

	
$133.45

	
$426.87

			
$1,323.84

	
$7,696.96

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
Other Rates:

	
Option 1

 Transplant

	
Option 2

 Transplant

									
	
4

	
Apache/Coconino/Mohave/Navajo

	
$40.00

	
$40.00

									
	
6

	
Yavapai

	
$40.00

	
$40.00

									
	
8

	
Gila/Pinal

	
$40.00

	
$40.00

									
	
10

	
Pima

	
$40.00

	
$40.00

									
	
12

	
Maricopa

	
$40.00

	
$40.00

									
	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

	
 

1. Rates have been adjusted for $50,000 Reinsurance Deductible

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