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ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM ADMINISTRATION DIVISION OF BUSINESS AND FINANCE INTERGOVERNMENTAL AGREEMENT AMENDMENT I AMENDMENT 2. CONTRACT NUMBER: 3. EFFECTIVE DATE OF AMENDMENT: 4. PROGRAM: NUMBER: 08 YHO5-0024-01 October 1,2013 DMS C-26-05-009-2-04 5. CONTRACTOR/PROVIDER NAME AND ADDRESS: Maricopa County on behalf of Correctional Health Services 234 N. Central, Suite 5000 Phoenix, AZ 85004 6. PURPOSE: To revise language, rates and extend the term of the agreement for an additional twelve month period. 7. The above referenced contract is hereby amended as stated below: A. Page 9, Replace Paragraph 3.6.3 Contract Term: with the following language: The effective date of this agreement is upon signature of both parties with an initial term of one (1) year. The parties reserve the right to extend the agreement for additional one-year terms or any portion thereof. Therefore this agreement is extended for the period October 1,2013 - September 30, 2014. B. Revise rates shown in Attachment A for SFY2014. 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. 10. ARIZONA HEALTH CARE COST CONTAINMENT SYSTEM MARICOPA COUNTY on behalf of CORRECTIONAL HEALTH SERVICES SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE: 7(. 6 i 11 , _ L , TYPED NAME: TYPED NAME: DENNY BARNEY .../MEGGAN HARLEY TITLE: TITLE: CHAIRMAN, COUNTY BOARD OF SUPERVISORS PROCUREMENT AND CONTRACTS MANAGER DATE: DATE: JANUARY 29, 2014 11. IN ACCORDANCE WITH STATE STATUTES, COUNTY RULES, 12. IN ACCORDANCE WITH § A.R.S. 11-952, THIS AMENDMENT IS IN PROPER AND BYLAWS, THIS AGREEMENT HAS BEEN REVIEWED BY THE FORM AND IS WITHIN THE POWER AND AUTHORITY GRANTED TO THE UNDERSIGNED WHO HAS DETERMINED THAT THIS ADMINISTRATION UNDER § A.R.S 36-2903 FT SEQ. AND §36-2932 ET SEQ. AGREEMENT IS IN APPROPRIATE FORM AND IS WITHIN THE POWER AND AUTHORITY GRANTED TO THE COUNTY. 3) - DATED THIS DAY OF I , 2014 DATED THIS DAY OF .2014 C ... BY LEGAL COUNSEL • dFfIE ADMINIS - AT1ON DEPUTY COUNTY ATTORNEY YHO5-0024-91 AHCCCS ATTACHMENT A Administrative Annual Cost Estimates for MDOC Medicaid Eligible Inmates FFS Project IGA SFY14 State Federal Claims Electronic Pa per Total Fund Share Share 94% 6% 100% 50% 50% Estimated total number of claims: Physician & Emergency Transport/Hospital 800 50 850 DFSM Cost per Claim 0.68 $ 0.80 OIG Cost per Claim 0.14 $ 0.14 ISD Cost per Claim 3.16 $ 3.21 Concurrent Review Average Cost Estimated cost per case 2 $ 96.25 Estimated number of HSAG reviews 3 2 Claims Processing costs: DFSM $547.59 $40.04 $587.63 $293.82 $293.82 OIG $110.11 $6.88 $116.99 $58.50 $58.50 ISD $2,529.32 $160.75 $2,690.06 $1,345.03 $1,345.03 Total Claims Processing Costs $3,187.02 $207.67 $3,394.68 $1,697.34 $1,697.34 Direct DFSM Labor for MDOC Medicaid Claims Processing Direct1SD Labor for MDOC Medicaid Claims Processing $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 Paper Processing Personnel costs $9,443.00 $4,721.50 $4,721.50 Postage @ $.0824/claim 4 $70.05 $35.03 $35.03 Data Center Charges @ $.37/claim 5 $314.50 $157.25 $157.25 Indirect at 10% $944.30 $472.15 $472,15 Total DBF Administrative Costs $10,771.85 $5,385.93 $5,385.93 Total Claims Processing Costs $21,359.03 $10,679.52 $10,679.52 DMS Eligibility Costs Application Processing Costs - DMS 6 $8,330.00 $4,165.00 $4,165.00 Estimated Total Annual Costs for Program $29,689.04 $14,844.52 $14,844.52 Cost per Claim 7 $34.71 $17.36 $17.36 Actual number of claims may be higher. Number Includes original, recoupment and adjustment claims 2 Average rate per contract Actual costs will be a strict pass-through based on price negotiated on new contract. 3 Actual number may be higher or lower depending on MDOC Medicaid Inmate requirements. 4 Postage based on average cost per claim times number of claims. 5 Data Center charges calculated based on average SFY13 costs 7 Cost per claim does not include a cost for concurrent reviews DMS Eligibility charges calculated at 598/determination. Estimated 85 annual applications/determinations.