Exhibit 10.32.6
HHSC XXXXXXXX XX. 000-00-000-X
XXXXX XX XXXXX
XXXXXX OF XXXXXX
AMENDMENT #11
TO THE AGREEMENT BETWEEN THE
HEALTH & HUMAN SERVICES COMMISSION
AND
AMEIGROUP TEXAS, INC
FOR HEALTH SERVICES
TO THE
MEDICAID STAR+PLUS PROGRAM
IN THE
XXXXXX COUNTY 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 0000 X. XXXXXXXX XX. XXXXX 000, XXXXXXXXX, XX 00000. HHSC
and HMO 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 AUTHORIZATION.
This Amendment is executed by the Parties in accordance with Article 15.2
of the Agreement.
SECTION 1.02 EFFECTIVE DATE.
Except as specified below, the Effective Date of this Agreement is January
1, 2006.
ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES
SECTION 2.01 MODIFICATION TO ARTICLE 6, SCOPE OF SERVICES
Article 6, Scope of Services, is amended by the addition of the following
provision to the end of the article:
6.20 COORDINATION WITH MEDICARE ADVANTAGE PLAN
6.20.1 As a STAR+PLUS contractor, HMO will:
6.20.1.1 Market to its STAR+PLUS members to encourage enrollment in the
Medicare Advantage/Special Needs Plan offered by the same organizational
entity as the STAR+PLUS plan, thereby providing an integrated source of
coverage for members who choose this option.
6.20.1.2 Receive and pass through a monthly premium per month covering all
co pays and deductibles to the Medicare Advantage/Special Needs Plan to:
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6.20.1.2.1 Pay Medicare providers full payment for covered services,
eliminating the need for the provider to file an additional claim for
Medicaid, and eliminating the need for "cross over" claims processing.
6.20.1.2.2 Require in its credentialing with network providers an agreement
that they will not file additional claims for Medicaid deductible or co pay
reimbursement and that they will not balance xxxx persons covered under
this agreement.
6.20.1.3 Send to the state the monthly file of STAR+PLUS members who are
enrolled in the Medicare Advantage/Special Needs Plan operated by the
STAR+PLUS entity.
6.20.1.4 Transmit Medicare encounter data on persons covered under this
agreement in a format provided by HHSC.
6.20.1.5 Assure that network providers serving the MA/SNP plan will be
informed and educated to not file claims against Medicaid for persons
covered under this agreement. Provider contracts must include this
requirement.
6.20.2 HHSC Responsibilities
6.20.2.1 Receive and record Medicare Advantage/Special Needs Plan
enrollment information from the HMO.
6.20.2.2 Include in the monthly premium an amount to cover all co pay and
deductible costs for STAR+PLUS members enrolled in the Medicare
Advantage/Special Needs Plan offered by the same organizational entity
offering STAR+PLUS.
6.20.2.3 Make payments for those persons identified on the enrollment file
submitted by the HMO in the same timeframes as payment of capitation
payments under the STAR+PLUS Medicaid Managed Care program.
SECTION 2.02 MODIFICATION OF ARTICLE 13, PAYMENT PROVISIONS
Article 13, Payment Provisions, is amended by the addition of the following
provision to the end of the article:
13.7 CAPITATION FOR MEDICARE ADVANTAGE ENROLLEES
13.7.1 HHSC will establish, through negotiation with plans participating,
the per member per month amount for STAR+PLUS members enrolled in the
Medicare Advantage/Special Needs Plan (MA/SNP) offered by the same
organizational entity each fiscal year. The STAR+PLUS HMO will be notified
by August 1 of each year of the amount payable for the following State
Fiscal Year. For SFY 2006 the per member per month amount will be $80.00
pre member per month. Members will be prospectively recognized as eligible
for payment under this addendum. Members enrolled after submission of the
enrollment file and the first of the month will not be covered for the
first month of MA/SNP enrollment but will be eligible for the following and
succeeding months
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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 HMO HAVE EACH CAUSED THIS AMENDMENT TO BE
SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE.
HEALTH & HUMAN SERVICES COMMISSION AMERIGROUP TEXAS, INC.
By: By: /s/ Xxxxxxx X. Xxxxxxx
--------------------------------- ------------------------------------
Xxxxxx Xxxxxxx Xxxxxxx X. Xxxxxxx
Executive Commissioner Printed Name and Title
Date: Date: 12/12/05
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