Document:

exv10w43

 

Exhibit 10.43

HHSC Contract No. 65M1015HPC

STATE OF TEXAS

COUNTY OF TRAVIS

AMENDMENT 6

TO THE AGREEMENT BETWEEN THE

HEALTH & HUMAN SERVICES COMMISSION

AND

AMERIGROUP TEXAS, INC.

FOR HEALTH SERVICES

TO THE

MEDICAID STAR+PLUS PROGRAM

IN THE

HARRIS SERVICE DELIVERY AREA

     THIS CONTRACT AMENDMENT (the “Amendment”) is entered into between the
HEALTH & HUMAN SERVICES COMMISSION (“HHSC”), an administrative agency within
the executive department of the State of Texas, and AMERIGROUP TEXAS, INC.
(“HMO”), a health maintenance organization organized under the laws of the
State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at 1200 E. Copeland Rd. Suite 200, Arlington, TX
76011 HHSC and CONTRACTOR may be referred to in this Amendment individually as
a “Party” and collectively as the “Parties.”

     The Parties hereby agree to amend their Agreement as set forth herein.

ARTICLE 1. PURPOSE.

Section 1.01 Authorization.

     This Amendment is executed by the Parties in accordance with
Article 15.2 of the Agreement.

Section 1.02 Effective Date.

     Except as otherwise provided in this Amendment, the provisions of this
Amendment are effective on May 1, 2004.

ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES

Section 2.01 Modification to Article 2, Definitions

	 	 	 	The following provisions amend and supplement the
definitions set forth in Article 2, Definitions, as follows:

               Court-ordered Commitment means a commitment of a
STAR +PLUS Member to a psychiatric facility for
treatment that is ordered by a court of law pursuant
to the Texas Health and Safety Code, Title VII,
Subtitle C, or a placement in a state-operated
facility as a condition of probation, as authorized by
the Texas Family Code.

	 	 	 	 	 
	HHSC Contract

	 	Page 1 of 6
	 	Effective Date: May 1, 2004

 

 

               Health-related Materials are materials that are
developed by the HMO or obtained from a third party
relating to the diagnosis or treatment of medical
conditions.

Section 2.02 Modification to Article 3, Plan Administrative and Human Resources
Requirements

	 	 	 	Article 3, Plan Administrative and Human Resources Requirements,
is amended by modifying Sections 3.4.1 through 3.4.4, as
follows:

               3.4.1 Prior to distribution to (1) Members, (2)
prospective Members, (3) providers within HMO’s network,
or (4) potential providers whom HMO intends to recruit as
network providers, and with the exception of
Health-related Materials, HMO must receive written
approval from HHSC for all written materials produced or
authorized by HMO containing information about the
STAR+PLUS Program. Health-related Materials do not need
to be submitted for review and approval. Per HHSC

request, and on an ad-hoc basis, HMOs will be required to
submit a list of Health-related Materials currently being
used, or used previously; HHSC may request the review of
selected materials from that list. HHSC will provide HMO
a reasonable amount of time to respond to such requests,
generally no less than 10 business days.

               3.4.2 Member materials must meet cultural and
linguistic requirements as stated in Article 8. Unless
otherwise required, Member materials must be written at a
4th - 6th grade reading comprehension level, and
translated into the language of any major population
group, except when HHSC requires HMO to use statutory
language (i.e., advance directives, medical necessity,
etc.).

               3.4.3 With the exception of Health-related
Materials, all plan materials regarding the STAR+PLUS
Program, including Member education materials, must be
submitted to HHSC for approval prior to distribution.
HHSC has fifteen (15) working days to review the
materials and recommend any suggestions or required
changes. If HHSC has not responded to HMO by the
fifteenth (15th) day, HMO may print and distribute these
materials. HHSC reserves the right to request HMO to
modify plan materials that are deemed approved and have
been printed or distributed. These modifications can be
made at the next printing unless substantial
non-compliance exists, as determined by HHSC. An
exception to the fifteen (15) working day timeframe may
be requested in writing by HMO for written provider
materials that require a quick turn-around time (e.g.,
letters). HHSC will review such requests within a
reasonable amount of time, generally within 5 working
days. MSC reserves the right to require revisions to
materials if inaccuracies are discovered or if changes
are required by changes in policy or law. These changes
can be made at the next printing unless substantial
non-compliance exists, as determined by HHSC.

               3.4.4 With the exception of Health-related
Materials, HMO must send HHSC-approved English versions
of HMO’s Member Handbook, Member Provider Directory,
newsletters, individual Member letters, and any written
information that applies to Medicaid-specific services to
TDHS for TDHS to translate into Spanish. TDHS must
provide the written and approved translation into Spanish
to HMO no later than 15

	 	 	 	 	 
	HHSC Contract

	 	Page 2 of 6
	 	Effective Date: May 1, 2004

 

 

working days after receipt of the English version by
HHSC. HMO must incorporate the approved translation
into their materials. If TDHS has not responded to
HMO by the fifteenth day, HMO may print and
distribute these materials. HHSC reserves the right
to require revisions to materials if inaccuracies
are discovered or if changes are required by changes
in policy or law. These changes can be made at the
next printing, unless substantial non-compliance
exists, as determined by HHSC. HMO has the option to
use the TDHS translation unit or their own
translators for health education materials not
containing Medicaid-specific information and for
other marketing materials such as billboards, radio
spots, and television and newspaper advertisements.

Section 2.03 Modification to Article 4, Fiscal, Financial, Claims, and
Insurance Requirements

	 	 	 	Article 4, Fiscal, Financial, Claims, and Insurance
Requirements, is amended by modifying Sections 4.10.3 and
4.10.6, respectively, as follows:

               4.10.3 HMO and claims processing subcontractors
must comply with HHSC’s Texas Medicaid Managed Care
Claims Manual (Claims Manual), as amended or
modified. The Claims Manual is incorporated herein
by reference and contains HHSC’s claims processing
and reporting requirements. HHSC will provide the
HMO reasonable notice of changes to the Claims
Manual. For purposes of this section only,
“reasonable notice” will generally mean 60 days
advance written notice of systems changes and 30
days advance written notice of other changes, unless
in HHSC’s sole discretion, changes in federal or
state laws, rules, regulations, or policies warrant
a shorter time period for notice.

               4.10.6 All provider clean claims must be
adjudicated (finalized as paid or denied
adjudicated) within 30 days from the date the claim
is received by HMO. HMO must pay providers interest
on a claim that is not adjudicated within 30 days
from either: (1) the date the HMO receives the clean
claim, or (2) the date the claim becomes clean. HMO
must pay providers interest at an 18% annual rate,
calculated daily for the full period in which the
clean claim remains unadjudicated beyond the 30-day
claims processing deadline. HMO must comply with the
Texas Medicaid Managed Care Claims Manual to
determine the principal amount for the interest
payment computation. HMO will be held to a minimum
performance level of 90% of all clean claims paid or
denied within 30 days of receipt and 99% of all
clean claims paid or denied within 90 days of
receipt. Failure to meet these performance levels is
a default under this contract and could lead to
damages or sanctions as outlined in Article 17. The
performance levels are subject to changes, if
required to comply with federal and state laws or
regulations.

Section 2.04 Modification to Article 5, Statutory, Regulatory, and Compliance
Requirements

	 	 	 	Effective February 15, 2004, Article 5, Statutory,
Regulatory, and Compliance Requirements, is amended by
adding new Section 5.1.4, and by modifying Sections 5.6.1
and 5.6.2, respectively, as set forth below. The attached
HUB monthly reporting form replaces the quarterly reporting
form included in Attachment B to the Agreement :

	 	 	 	 	 
	HHSC Contract

	 	Page 3 of 6
	 	Effective Date: May 1, 2004

 

 

               5.1.4 In accordance with Texas Government Code
§2262.003, HMO understands that acceptance of funds
under this contract acts as acceptance of the
authority of the State Auditor’s Office, or any
successor agency, to conduct an audit or
investigation in connection with those funds. HMO
further agrees to cooperate fully with the State
Auditor’s Office or its successor in the conduct of
the audit or investigation, including providing all
records requested. HMO will ensure that this clause
concerning the authority to audit funds received
indirectly by subcontractors through HMO and the
requirement to cooperate is included in any
subcontract it awards.

               5.6 HISTORICALLY UNDERUTILIZED BUSINESS

               5.6.1 In accordance with Texas Government Code
Chapter 2161 and 1 TAC § 111.11 et seq. and §392.100
state agencies are required to make a good faith
effort to assist Historically Underutilized
Businesses (HUBs) in receiving contract awards issued
by the State. The goal of this program is to promote
full and equal business opportunity for all
businesses in contracting with the state. It is
HHSC’s intent that all contractors make a good faith
effort to subcontract with HUBs during the
performance of their contracts.

               Important Note: The Health and Human Services
Commission has concluded that HUB subcontracting
opportunities may exist in connection with this
contract. See Appendix B to the Agreement for the
following instructions and form: “Grant/Subcontract
Applications Client Services HUB Subcontracting Plan
Instructions” (C-IGA) and “Determination of Good
Faith Effort for Grant Contracts” (C-DGFE). If an
approved HUB Subcontracting Plan is not already on
file with HHSC, the HMO shall submit a completed
C-DGFE with the signed contract or renewal.

               5.6.2 In accordance with Article 12.11, HMO is
required to submit HUB monthly reports in the format
set forth in Appendix B to the Agreement. CONTRACTOR
must submit retroactive monthly reports for months,
beginning December 2003.

               If HMO decides after the award to subcontract
any part of the contracted work, the HMO shall notify
HHSC Health Plan Manager prior to entering into any
subcontract. The HMO shall comply with the good faith
effort requirements relating to developing and
submitting a modified HUB Subcontracting Plan.

Section 2.05 Modification of Article 6, Scope of Services

	 	 	 	Article 6, Scope of Services, is amended by modifying Section 6.6.11, as
follows:

               6.6 BEHAVIORAL HEALTH CARE SERVICES — SPECIFIC
REQUIREMENTS

               6.6.11 HMO must provide inpatient psychiatric
Covered Services to Members under the age of 2I who
have been ordered to receive the services by a court
of competent jurisdiction under the provisions of
Title VII, Subtitle C of the Texas Health and Safety
Code, relating to court-ordered commitments to
psychiatric facilities, or a placement in a

	 	 	 	 	 
	HHSC Contract

	 	Page 4 of 6
	 	Effective Date: May 1, 2004

 

 

state-operated facility as a condition of probation,
as authorized by the Texas Family Code.

Section 2.06 Modification of Article 7, Provider Network Requirements

	 	 	 	Article 7, Provider Network Requirements, is amended by
modifying Section 7.2.8.10, as follows:

               7.2.8.10 All provider clean claims must be
adjudicated (finalized as paid or denied adjudicated)
within 30 days from the date the claim is received by
HMO. HMO must agree to pay the provider interest in
accordance with Section 4.10.6 for clean claims that
are not adjudicated within 30 days.

Section 2.07 Modification of Article 12, Reporting Requirements

	 	 	 	Effective February 15, 2004, Article 12, Reporting
Requirements, is amended by modifying Sections 12.2.9, and
12.11, as follows:

               12.2.9 Claims Reports. HMO must comply with
Claims Reports submission requirements specified in
HHSC’s Texas Medicaid Managed Care Claims Manual. The
reports must be submitted to HHSC in a format
specified within the Texas Medicaid Managed Care
Claims Manual and/or report templates provided by
HHSC.

               12.11 HMO must submit monthly reports
documenting HMO’s HUB program efforts and
accomplishments in a format provided by HHSC.

Section 2.08 Modification of Article 13, Payment Provisions

	 	 	 	Article 13, Payment Provisions, is amended by modifying
Section 13.1.2; furthermore, Section 13.2.4 is deleted in its
entirety, and new Section 13.2.6 is added, as follows:

               13.1.2 The capitation amount by Member risk
group has been calculated to be less than the amount
payable for providing the same services for an
actuarially equivalent population in the regular
Medicaid fee-for-service program. The monthly
capitation payments, effective September 1, 2003, are
as follows:

	 	 	 	 	 
	 	 	Monthly Capitation
	Member Risk Group
	 	Amounts

	CBA Waiver Clients- Dual Eligible
	 	$	1503.36	 
	CBA Waiver Clients- Medicaid Only
	 	$	3614.67	 
	Other Community Clients- Dual Eligible
	 	$	152.54	 
	Other Community Clients- Medicaid Only
	 	$	700.61	 
	Nursing Facility Clients- Dual Eligible
	 	$	152.54	 
	Nursing Facility Clients- Medicaid Only
	 	$	700.61	 

13.2 EXPERIENCE REBATE TO STATE

	 	 	 	 	 
	HHSC Contract

	 	Page 5 of 6
	 	Effective Date: May 1, 2004

 

 

     13.2A [deleted]

     13.2.6 Interest on any experience rebate owed to
HHSC shall be charged beginning on the date that the
first and/or second settlements are overdue to the
date of the respective payment. In addition, if any
adjusted amount is owed to HHSC at the final
settlement date, then interest is charged on the
adjusted amount owed beginning on the second
settlement date to the date of the final settlement
payment. Interest charged shall be calculated on an
annual and simple basis using the current Prime
Rate(s) established by the federal government.

ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES

     The Parties contract and agree that the terms of the Agreement will remain
in effect and continue to govern except to the extent modified in this
Amendment.

     By signing this Amendment, the Parties expressly understand and agree that
this Amendment is hereby made a part of the Agreement as though it were set out
word for word in the Agreement.

     IN WITNESS HEREOF, HHSC and the CONTRACTOR have each caused this Amendment
to be signed and delivered by its duly authorized representative.

	 	 	 	 	 	 	 
	 	 	AMERIGROUP TEXAS, INC.	 	HEALTH & HUMAN SERVICES COMMISSION
	 
	 	 	 	 	 	 
	By:

	 	/s/ Eric M. Yoder
	 	By:
	 	/s/ Albert Hawkins
	

	 	
 
	 	 	 	
 
	

	 	Eric M. Yoder
	 	 	 	Albert Hawkins
	

	 	President & CEO
	 	 	 	Executive Commissioner
	 
	 	 	 	 	 	 
	Date: April 6, 2004	 	Date: April 26, 2004

	 	 	 	 	 
	HHSC Contract	 	Page 6 of 6	 	Effective Date: May 1,
2004

 

Exhibit 10.43

HHSC Contract No. 65M1015HPC

STATE OF TEXAS

COUNTY OF TRAVIS

AMENDMENT 8

TO THE AGREEMENT BETWEEN THE

HEALTH & HUMAN SERVICES COMMISSION

AND

AMERIGROUP TEXAS, INC.

FOR HEALTH SERVICES

TO THE

MEDICAID STAR+PLUS PROGRAM

IN THE

HARRIS SERVICE DELIVERY AREA

     THIS CONTRACT AMENDMENT (the “Amendment”) is entered into between the
HEALTH & HUMAN SERVICES COMMISSION (“HHSC”), an administrative agency within
the executive department of the State of Texas, and AMERIGROUP TEXAS, INC.
(“HMO”), a health maintenance organization organized under the laws of the
State of Texas, possessing a certificate of authority issued by the Texas
Department of Insurance to operate as a health maintenance organization, and
having its principal office at 1200 E. Copeland Rd. Suite 200, Arlington, TX
76011. HHSC and CONTRACTOR may be referred to within this Amendment
individually as a “Party” and collectively as the “Parties.”

     The Parties hereby agree to amend their
Agreement as set forth herein.

ARTICLE 1. PURPOSE.

Section 1.01 Purpose

     The purpose of this Amendment is to revise the monthly capitation rates,
as last defined by Section 2.08 of Amendment 6 to the Agreement of the Parties.
The Centers for Medicare and Medicaid (“CMS”) did not approve the monthly
capitation rates set forth in Section 2.08 of Amendment 6, thereby making the
section invalid and unenforceable by operation of law.

Section 1.02 Authorization.

     This Amendment is executed by the Parties in accordance with Article 15.2 of
the Agreement.

Section 1.03 Effective Date.

     This Amendment is effective May 1, 2004.

ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES

Section 2.01 Modification of Article 13, Payment Provisions

     Section 13.1.2 is deleted in its entirety and replaced as follows:

     13.1.2 The following table represents the
monthly capitation rates applicable to the dates
specified below:

	 	 	 	 	 
	HHSC Contract

	 	Page 1 of 2
	 	Effective Date: May 1, 2004

 

 

	 	 	 	 	 	 	 	 	 	 	 	 	 
	 	 	Monthly Capitation	 	Monthly Capitation	 	Monthly Capitation
	 	 	Rate	 	Rate	 	Rate
	 	 	Effective	 	Effective	 	Effective
	SDA
	 	9/1/03 to 6/30/04
	 	7/1/04 to 7/31/04
	 	8/1/04 to 8/31/04

	CBA Waiver Clients- Dual
Eligible
	 	 	1,503.34	 	 	 	1,503.34	 	 	 	1,503.34	 
	CBA Waiver Clients- Medicaid
Only
	 	 	3,556.95	 	 	 	4,191.76	 	 	 	3,614.66	 
	Other Community Clients- Dual
Eligible
	 	 	152.55	 	 	 	152.55	 	 	 	152.55	 
	Other Community Clients-
Medicaid Only
	 	 	684.88	 	 	 	857.91	 	 	 	700.61	 
	Nursing Facility Clients- Dual
Eligible
	 	 	152.55	 	 	 	152.55	 	 	 	152.55	 
	Nursing Facility Clients-
Medicaid Only
	 	 	684.88	 	 	 	857.91	 	 	 	700.61	 

ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES

     The Parties contract and agree that the terms of the Agreement will
remain in effect and continue to govern except to the extent modified in
this Amendment.

     By signing this Amendment, the Parties expressly understand and agree
that this Amendment is hereby made a part of the Agreement as though it were
set out word for word in the Agreement.

     IN WITNESS HEREOF, HHSC and the CONTRACTOR have each caused this
Amendment to be signed and delivered by its duly authorized representative.

	 	 	 	 	 	 	 
	AMERIGROUP TEXAS, INC.
	 	HEALTH & HUMAN SERVICES COMMISSION
	 
	 	 	 	 	 	 
	By:

	 	/s/ Eric M. Yoder
	 	By:	 	 
	

	 	
 
	 	 	 	
 
	

	 	Dr. Eric M. Yoder
	 	 	 	Albert Hawkins
	

	 	President and CEO
	 	 	 	Exectuive Commissioner
	 
	 	 	 	 	 	 
	Date:

	 	June 11, 2004
	 	Date:	 	 
	

	 	 	 	 	 	
 

	 	 	 	 	 
	HHSC Contract

	 	Page 2 of 2
	 	Effective Date: May 1, 2004<PAGE>
                                                                               .
                                                                               .
                                                                               .

                                                                    EXHIBIT 4.01

[NUMBER CGI LOG0]               [CELERITY LOGO]                    [SHARES LOGO]

<TABLE>
<S>                                     <C>                       <C>                            <C>
THIS CERTIFICATE IS TRANSFERABLE IN                     CELERITY GROUP, INC.                     SEE REVERSE FOR
RIDGEFIELD PARK, NJ AND NEW YORK, NY    INCORPORATED UNDER THE LAWS OF THE STATE OF DELAWARE     CERTAIN DEFINITIONS

                                                                                                 CUSIP 15101G 10 0
</TABLE>

THIS CERTIFIES that

is the owner of

     FULLY PAID AND NON-ASSESSABLE SHARES OF COMMON STOCK, $.0001 PAR VALUE
                                 PER SHARE, OF
                              CELERITY GROUP, INC.

transferable on the books of the Corporation in person or by duly authorized
attorney upon surrender of this certificate properly endorsed.

      This certificate is not valid unless countersigned by the Transfer Agent.

      WITNESS the facsimile seal of the Corporation and the facsimile signatures
      of its duly authorized officers.

                             (CERTIFICATE OF STOCK)

Dated

     /s/ John Goodman                       /s/ David J. Shimmon
     -------------------                    ------------------------------------
     SECRETARY                              CHAIRMAN AND CHIEF EXECUTIVE OFFICER

                                     [SEAL]

COUNTERSIGNED:
      MELLON INVESTOR SERVICES LLC
           TRANSFER AGENT

BY
               AUTHORIZED SIGNATURE

<PAGE>

                              CELERITY GROUP, INC.

      The following abbreviations, when used in the inscription on the face of
this certificate, shall be construed as though they were written out in full
according to applicable laws or regulations:

<TABLE>
<S>                                           <C>
TEN COM -  as tenants in common               UNIF GIFT MIN ACT  -  _______Custodian_________
TEN ENT -  as tenants by the entireties                             (Cust)           (Minor)
JT TEN  -  as joint tenants with right of                           under Uniform Gifts to Minors
           survivorship and not as tenants                          Act___________
           in common                                                     (State)
</TABLE>

     Additional abbreviations may also be used though not in the above list.

For Value Received, _________________ hereby sell, assign and transfer unto

PLEASE INSERT SOCIAL SECURITY OR OTHER
   IDENTIFYING NUMBER OF ASSIGNEE
[                                    ]

________________________________________________________________________________
  (PLEASE PRINT OR TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)
________________________________________________________________________________

________________________________________________________________________________

__________________________________________________________________________Shares
of the Common Stock represented by the within certificate, and do hereby
irrevocably constitute and appoint
________________________________________________________________________Attorney
to transfer the said shares on the books of the within named Corporation with
full power of substitution in the premises.

Dated ______________________________

                  ______________________________________________________________
                  NOTICE:  THE SIGNATURE TO THIS ASSIGNMENT MUST CORRESPOND WITH
                           THE NAME AS WRITTEN UPON THE FACE OF THE CERTIFICATE
                           IN EVERY PARTICULAR, WITHOUT ALTERATION OR
                           ENLARGEMENT OR ANY CHANGE WHATEVER.

        SIGNATURE(S) GUARANTEED    _____________________________________________
                                   THE SIGNATURE(S) MUST BE GUARANTEED BY AN
                                   ELIGIBLE GUARANTOR INSTITUTION (BANKS,
                                   STOCKBROKERS, SAVINGS AND LOAN ASSOCIATIONS
                                   AND CREDIT UNIONS WITH MEMBERSHIP IN AN
                                   APPROVED SIGNATURE GUARANTEE MEDALLION
                                   PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15.

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