YH15-0006-02 AMENDMENT 1.PDF

Arizona Health Care Cost Containment System
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INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT
1. AMENDMENT it: 2. CONTRACT if: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM:
VH15-0006-02
1 C.26.15.005.3.00 OCTOBER 1, 2015 DFSM / DMS
5. CONTRACTOR/PROVIDER NAME AND ADDRESS:
Maricopa County Correctional Health Services
234 N. Central, Fifth Floor, Ste. 5000
Phoenix, Arizona 85004
6. PURPOSE: To revise rates and add HIPAA BAA.
1. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:
A. Change rates from Attachment A (SFY15) to the rates as shown in Attachment A (SFY16).
B. Change Quarterly Estimate of State Match Advance Payments from Attachment B (SFY15) to the
Estimates listed in Attachment B (SFY 16).
C. Add Business Associate Addendum to the IGA.
2. 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.
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SGNATURE PAGE
IN WITNESS THEREOF, the parties have executed this Agreement:
COUNTY: Arizona Health Care Cost Containment
System (AHCCCS):
Signature: Signature:
Printed Name: Steve Chucri Printed Name: Alice McLain, MBA
Title: Chairman, Maricopa County Board of Title: Procurement Manager
Supervisors
Date: Date:
ATTEST:
Signature:
Fran McCarroll, Clerk of the Board Date
In accordance with A.R.S. § 11-952, this Agreement In accordance with A.R.S. § 11-952, this
has been reviewed by the undersigned who has Agreement is in the proper form and is within the
determined that this Agreement is in the power and authority granted to AHCCCS under
appropriate form and is within the power and A.R.S. §§ 36-2943 et seq. and 36-2932 et seq.
authority granted to COUNTY.
COUNTY Attorney
Electronic Submission: An electronic or portable document file (PDF) copy of this amendment shall serve as the original.
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ATTACHMENT A
AHCCCS
Administrative Annual Cost Estimates for
Maricopa County Medicaid Eligible Inmates FFS Project IGA SFY16
State Federal
Claims Electronic Paper Total Fund Share Share
76% 24% 100% 50% 50%
Estimated total number of claims:
Physician & Emergency Transport/Hospital 2,200 700 2,900
DFSM Cost per Claim 2 $ 0.33 $ 0.39
OIG Cost per Claim 2$ 0.05 $ 0.05
ISD Cost per Claim 2$ 1.78 $ 1.78
Concurrent Review Average Cost
Estimated cost per case 3 $ 96.25
Estimated number of HSAG reviews 4 2
Claims Processing costs:
DFSM $720.75 $271.36 $992.10 $496.05 $496.05
010 $111.38 $35.44 $146.82 $73.41 $73.41
ISD $3,925.67 $1,249.08 $5,174.74 $2,587.37 $2,587.37
Total Claims Processing Costs $4,757.80 $1,555.88 $6,313.66 $3,156.83 $3,156.83
Direct DFSM Labor for Maricopa Co Medicaid Claims Processing 5 $0.00 $0.00 $0.00
Direct ISD Labor for Maricopa Co Medicaid Claims Processing 6 $7,000.00 $3,500.00 $3,500.00
Concurrent Review Estimated costs:
Cost for 2 reviews $192.50 $96.25 $96.25
Administrative Costs (see detail)
DBF Processing Personnel costs 7 $9,902.00 $4,951.00 $4,951.00
Postage @ $.0648/claim $187.82 $93.91 $93.91
Data Center Charges @ $.2108/claim 9 $611.34 $305.67 $305.67
Indirect at 10% $990.20 $495.10 $495.10
Total DBF Administrative Costs $11,691.36 $5,845.68 $5,845.68
Total Claims Processing Costs $25,197.52 $12,598.76 $12,598.76
DMS Eligibility Costs
Application Processing Costs - DMS ! 10 $25,000.00 $12,500.00 $12,500.00
Estimated Total Annual Costs for Program $50,197.52 $25,098.76 $25,098.76
Cost per Claim $17.24 $8.62 $8.62
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I Actual number of claims may be higher. Nurrber Includes, original, recoupment and adjustment claims.
2 Cost based on actual SFY14 expenditures and actual nunter of claims processed
'Average rate per contract. Actual costs w ill be a strict pass-through based on price negotiated
on new contract.
'Actual number may be higher or low er depending on Maricopa County Medicaid Inmate requirements.
5 Based on estimates of DFSM staff time required to process the claims.
'Estimate based on 40 hours at a rate of $175 per hour. WII only be billed for actual hours Incurred.
7 Based on estimates of DBF staff time required to rronitor funding activity and process payments.
Postage based on average cost per claim times nurrber of claims.
Data Center charges calculated based on average SFY14 costs
1, DMS Eligibility charges calculated at $100/deternination. Estimated 250 annual applications/determinations.
11 Cost per claim does not include a cost for concurrent reviews
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Ao IACHIVIE s
AHCCCS
Quarterly Estimate of State Match Advance Payments for Program Services
Maricopa County Medicaid Eligible FFS Project IGA SFY16
SFY15 Annual Dollar Value of Claims Paid $ 1,275,000.00
Average Federal Financial Participation Rate 77.92%
Estimate of State Match Payments for Program Services for Current Year $ 281,520.00
Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS $ 70,380.00
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BUSINESS ASSOCIATE ADDENDUM
Amended 2016
This Addendum is made part of this Contract between the Arizona Health Care Cost Containment System
("AHCCCS") and the Contractor, referred to as "Business Associate" in this Addendum.
AHCCCS and Business Associate agree that the underlying Contract shall comply with the Administrative
Simplification requirements of the Health Insurance Portability and Accountability Act of 1996 ("HIPAA"), as set
forth in Title 45, Parts 160 and 164 of the Code of Federal Regulations (the "CFR"), as amended. In the event of
conflicting terms or conditions, this Addendum shall supersede the underlying Contract.
1. DEFINITIONS
The following terms used in this Addendum shall have the same meaning as those terms in the HIPAA rules set
forth in Title 45, Parts 160 and 164 of the CFR: Breach, Data Aggregation, Designated Record Set, Disclosure,
Health Care Operations, Individual, Minimum Necessary, Notice of Privacy Practices, Protected Health
Information, Required by Law, Secretary, Security Incident, Subcontractor, Unsecured Protected Health
Information, and Use.
2. OBLIGATIONS AND ACTIVITIES OF BUSINESS ASSOCIATE
Business Associate agrees to:
2.1. Not use or disclose protected health information ("PHI") other than as permitted or required by this
Addendum or as required by law;
2.2. Use appropriate safeguards, and comply with Subpart C of 45 CFR Part 164 with respect to electronic PHI,
to prevent use or disclosure of protected health information other than as provided for by this
Addendum;
2.3. Report to AHCCCS any use or disclosure of PHI not provided for by this Addendum of which it becomes
aware, including breaches of unsecured protected health information as required at 45 CFR §164.410,
and any security incident of which it becomes aware in the following manner;
2.3.1. Reporting. Business Associate shall report to AHCCCS any use or disclosure of PHI that is not
authorized by the Contract, by law, or in writing by AHCCCS. Business Associate shall make an
initial report to the AHCCCS Privacy Official not more than twenty-four (24) hours after
Business Associate learns of such unauthorized use or disclosure. The initial report shall
include all of the following information to the extent known to the Business Associate at the
time of the initial report:
A. A description of the nature of the unauthorized use or disclosure, including the number
of individuals affected by the unauthorized use or disclosure;
B. A description of the PHI used or disclosed;
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C. The date(s) on which the unauthorized use or disclosure occurred;
D. The date(s) on which the unauthorized use or disclosure was discovered;
E. Identify the person(s) who used or disclosed the PHI in an unauthorized manner;
F. Identify the person(s) who received PHI disclosed in an unauthorized manner;
G. A description of actions, efforts, or plans undertaken by the Business associate to
mitigated the harm of the unauthorized disclosure;
H. A description of corrective actions undertaken or planned to prevent future similar
unauthorized use or disclosure;
I. An assessment of whether a breach, as defined in 45 CFR 164.402, including, if
necessary, an assessment of the probability of harm, and
J. Such other information, as may be reasonably requested by the AHCCCS Privacy Official.
Business Associate shall provide AHCCCS with supplemental reports promptly as new
information becomes available, as assessments and action plans are developed, and as action
plans are implemented. In any event, Business Associate shall provide a comprehensive
written report including all of the information listed above no later than twenty (20) days after
discovery of the unauthorized use or disclosure.
2.3.2. Mitigation. Business Associate agrees to mitigate, to the extent practicable, any harmful effect
that is known to Business Associate of a use or disclosure of PHI by Business Associate in
violation of the requirements of the Contract.
2.3.3. Sanctions. Business Associate shall have and apply appropriate sanctions against any
employee, subcontractor or agent who uses or discloses AHCCCS PHI in violation of this
Addendum or applicable law.
2.4. In accordance with 45 CFR §164.502(e)(1)00 and §164.308(b)(2), if applicable, ensure that any
subcontractors that create, receive, maintain or transmit PHI on behalf of the Business Associate agree
to the same restrictions, conditions and requirements that apply to the Business Associate with respect
to such information;
2.5. Make available PHI in a designated record set to AHCCCS as necessary to satisfy AHCCCS' obligations
under 45 CFR §164.524;
2.6. Make any amendment(s) to PHI in a designated record set as directed or agreed to by AHCCCS pursuant
to 45 CFR §164.526, or take other measures as necessary to satisfy AHCCCS' obligations under 45 CFR
§164.526;
2.7. Maintain and make available the information required to provide an Accounting of Disclosures to AHCCCS
as necessary to satisfy AHCCCS' obligations under 45 CFR §164.528;
2.8. To the extent Business Associate is to carry out one of more of AHCCCS' obligations under Subpart E of 45
CFR Part 164, comply with the requirements of Subpart E that apply to AHCCCS in the performance of
such obligation(s); and
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2.9. Make its internal practices, books and records available to AHCCCS and the Secretary for purposes of
determining compliance with the HIPAA rules.
3. PERMITTED USES AND DISLOSURES BY BUSINESS ASSOCIATE
3.1. Business Associate may only use or disclosure PHI as necessary to perform the services and obligations
set forth in the underlying Contract;
3.2. Business Associate may use or disclose protected health information as required by law;
3.3. Business Associate agrees to make uses and disclosures and requests for protected health information
consistent with AHCCCS' Minimum Necessary Policy, located at www.azahcccs.gov ;
3.4. Business Associate may not use or disclose protected health information in a manner that would violate
Subpart E of 45 CFR Part 164 if done by AHCCCS, except for the specific uses and disclosures set forth
below in (3.5 and 3.6);
3.5. Business Associate may use protected health information for the proper management and administration
of the Business Associate or to carry out the legal responsibilities of the Business Associate; and
3.6. Business Associate may provide data aggregation services relating to the health care operations of
AHCCCS.
4. PROVISIONS FOR AHCCCS TO INFORM BUSINESS ASSOCIATE OF PRIVACY PRACTICES AND RESTRICTIONS
4.1. AHCCCS shall notify Business Associate of any limitation(s) in the AHCCCS Notice of Privacy Practices
(found at www.azahcccs.gov ) under 45 CFR §164.520, to the extent that such limitation may affect
Business Associate's use or disclosure of PHI;
4.2. AHCCCS shall notify Business Associate of any changes in, or revocation of, the permission by an
individual to use or disclose his or her PHI, to the extent that such changes may affect Business
Associate's use or disclosure of PHI; and
4.3. AHCCCS shall notify Business Associate of any restriction on the use or disclosure of PHI that AHCCCS has
agreed to or is required to abide by under 45 CFR 164.522, to the extent that such restriction may affect
Business Associate's use or disclosure of PHI.
5. TERM AND TERMINATION
5.1. Term: This Addendum is effective upon the effective date of the underlying Contract and shall terminate
on the date AHCCCS terminates the contract for cause as authorized in paragraph (b) of this Section, or
for any other reason permitted under the contract, whichever is sooner.
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5.2. Termination for Cause: Business Associate authorizes termination of the Contract by AHCCCS if AHCCCS
determines that Business Associate has breached a material term of this Addendum and Business
Associate has not cured the breach or ended the violation within the time specified by AHCCCS.
5.3. Obligations of Business Associate Upon Termination: Upon termination, cancellation, expiration or other
conclusion of the Contract, Business Associate, with respect to PHI received from AHCCCS, or created,
maintained, or received by Business Associate on behalf of AHCCCS, shall:
5.3.1. Retain only that PHI which is necessary for Business Associate to continue its proper
management and administration or to carry out its legal responsibilities;
5.3.2. Destroy or return to AHCCCS all remaining PHI that the Business Associate still maintains in any
form;
5.3.3. Continue to use appropriate safeguards and comply with Subpart C of 45 CFR Part 164 with
respect to electronic PHI to prevent use or disclosure of the PHI, other than as provided for in
this Section, for as long as Business Associate retains the PHI;
5.3.4. Not use or disclose the PHI retained by Business Associate other than for the purposes for
which such protected health information was retained and subject to the same conditions set
out in this Addendum that applied prior to termination; and
5.3.5. Destroy or return to AHCCCS the PHI retained by Business Associate when it is no longer
needed by Business Associate for its proper management and administration or to carry out its
legal and contractual responsibilities.
5.4. Survival: The obligations of Business Associate under this Section shall survive the termination of the
Contract.
6. INDEMNIFICATION AND MISCELLANEOUS
6.1. Indemnification: Each party (as "Indemnitor") agrees to defend, indemnify, and hold harmless the other
party (as "Indemnitee") from and against any and all claims, losses, liability, costs, or expenses (including
reasonable attorney's fees) (hereinafter collectively referred to as "Claims") arising out of bodily injury of
any person (including death) or property damage, but only to the extent that such Claims which result in
vicarious/derivative liability to the lndennnitee are caused by the act, omission, negligence, misconduct,
or other fault of the lndemnitor, its officers, officials, agents, employees, or volunteers.
6.2. Regulatory References: A reference in this Addendum to a section in the HIPAA rules means the section
as in effect or as amended.
6.3. Amendment: The parties agree to take such action as is necessary to amend this Addendum from time to
time as is necessary for compliance with the requirements of the HIPAA rules or any other applicable law.
6.4. Interpretation: Any ambiguity in this Addendum shall be interpreted to permit compliance with the
HIPAA rules.
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END OF DOCUMENT
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