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4° Arizona Health Care Cost Containment System asaaaaeaaaosaaaaaaaaaaaamomaaeaaaoasaoaaaoaaaooaa 00000000000000000 00000 0800000 00010000a ea a 00aeaaeaaaaaaaeoaaaaaaaaaaafaaeoes INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 1. AMENDMENT#: 2. CONTRACT #: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM: YH15-0006-02 2 C.26.15.005.3.00 OCTOBER 1, 2017 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. 1. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS: A. Change rates from Attachment A (SFY16) to the rates as shown in Attachment A (SFY18). B. Change Quarterly Estimate of State Match Advance Payments from Attachment B (SFY16) to the Estimates listed in Attachment B (SFY 18). 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. Page 1 of 6 SIGNATURE PAGE IN WITNESS THEREOF, the parties have executed this Agreement: COUNTY: Arizona Health Care Cost Containment System (AHCCCS): Signature: Signature: Printed Name: Steve Churcri Printed Name: Alice McLain, MBA Title: Chairman, Maricopa County Board of Title: Procurement Manager Supervisors Date: Date: ATTEST: Signature: Printed Name: 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. §§ 36.72903 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. Page 2 of 6 ATTACHMENT A AHCCCS Administrative Annual Cost Estimates for Maricopa County Medicaid Eligible Inmates FFS Project IGA SFY18 YH15-0006-02 State Federal Claims Electronic Paper Total Fund Share Share 96% 4% 100% 50% 50% Estimated total number of claims: Physician & Emergency Transport/Hospital 3,725 175 3,900 DFSM Cost per Claim 0.70 OIG Cost per Claim 0.15 ISD Cost per Claim 1.41 Concurrent Review Average Cost Estimated cost per case 3 $ 96.75 Estimated number of HSAG reviews 2 Claims Processing costs: DFSM $2,267.61 $123.11 $2,390.72 $1,195.36 $1,195.36 OIG $559.55 $26.29 $685.84 $292.92 $292.92 ISD $5,252.35 $246.75 $5,499.10 $2,749.55 $2,749.55 State Accounting System Charges @ $0.1350/claim $502.73 $23.61 $526.34 $263.17 $263.17 Total Claims Processing Costs $8,582.24 $419.76 $9,002.00 $4,501.00 $4,501.00 Direct DFSM Labor for MCC Claims Processing $0.00 $0.00 Direct ISD Labor for MCC Claims Processing 6 $7,000.00 $3,500.00 $3,500.00 Concurrent Review Estimated costs: Cost for 2 reviews $193.50 $96.75 $96.75 Administrative Costs (see detail) DBF Paper Processing Personnel costs $8,061.76 $4,030.88 $4,030.88 Postage @ $.0605/claim $235.90 $117.95 $117.95 Data Center Charges @ $.4931/claim $1,923.00 $961.50 $961.50 Indirect at 10% $806.18 $403.09 $403.09 Total DBF Administrative Costs $11,026.84 $5,513.42 $5,513.42 DMS Eligibility Costs Application Processing Costs - DMS $23,000.00 $11,500.00 $11,500.00 ' Estimated Total Annual Costs for Program $50,222.34 ' $25,111.17 , $25,111.17 'Cost per Claim $12.83 $6.41 $6.41 Page 3 of 6 1 Actual nunrber of claims may be higher. Nurrber includes, original, recoupment and adjustrrent claims. 2 Cost based on actual SFY17 expenditures and actual number of claims processed 3 Average rate per contract. Actual costs w ill be a strict pass-through based on price negotiated on new contract. 4 Actual number may be higher or low er depending on Maricopa Co Medicaid Inmate program requirerrents. 5 Based on estimates of DFSM staff tine required to process the claim ° Estimate based on 40 hours at a rate of $175 per hour. Wll only be billed for actual hours incurred. 7 Based on estimates of DBF staff time required to monitor funding activity and process payrrents. 8 Postage based on average cost per claim tins number of claims. 9 Data Center charges calculated based on average SFY17 costs , 1° DMS Eligibility charges calculated at $100/determination. Estimated 230 annual applications/determinations. 11 Cost per claim does not include a cost for concurrent reviews Page 4 of 6 ATTACHMENT B AHCCCS Quarterly Estimate of State Match Advance Payments for Program Services Maricopa County Medicaid Eligible FFS Project IGA SFY18 YH15-0006-02 Estimate of Annual Dollar Value of Claims Paid $ 2,585,000.00 ,Average Federal Financial Participation Rate 80.74% Estimate of State Match Payments for Program Services for Current Year 497,871.00 Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS 125,000.00 Page 5 of 6 END OF DOCUMENT Page 6 of 6