COMPLETE_WITH_DOCUSIGN_YH08-0073_MARICOPA_CO.PDF
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INTERGOVERNMENTAL AGREEMENT
AMENDMENT
1.
AMENDMENT
20
2. AGREEMENT NUMBER:
YH08-0073
C-26-08-011-0-20
3. EFFECTIVE DATE OF AMENDMENT:
July 1, 2025
4. PROGRAM:
DFSM
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 update Point of Contact, AHCCCS’ address, revise rates for SFY2026 and extend services
from June 30, 2026 to June 30, 2027.
7.
The above referenced agreement is hereby amended as stated below:
A.
Section 2.1.8, of the Scope of Work, is updated as follows:
From: AHCCCS claims customer service support for the County and its contractors will be provided by
DFSM. Claims customer service support shall include an identified, dedicated customer service
representative(s), and compliance with customer service performance standards outlined below.
Contact Becky Fields at 602-417-4411.
To: AHCCCS claims customer service support for the County and its contractors will be provided by
DFSM. Claims customer service support shall include an identified, dedicated customer service
representative(s), and compliance with customer service performance standards outlined below.
Contact Lisa DeWitt at 602-417-4771.
B.
Section 5, Payment for Services of the Scope of work, Subsection 5.7, Administrative Services, the change
rates for SFY2026 (July 1, 2025 – June 30, 2026) is incorporated into this amendment as Attachment A.
C.
Section 6, Term of Agreement of the Scope of Work, Subsection, 6.1, the contract term is hereby extended
to June 30, 2027.
D.
Section 12, Notices of the Scope of Work, AHCCCS’ address is updated as follows:
From: 701 E. Jefferson Street, Mail Drop 5700
Phoenix, AZ 85034
To: 150 N. 18th Avenue, Mail Drop 15003
Phoenix, AZ 85007
These rates will remain the same until otherwise updated.
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8.
Except as provided for herein, all terms and conditions of the original agreement not heretofore changed and/or amended
remain unchanged and in full effect. In witness whereof the parties hereto sign their names in agreement.
9. Maricopa County Board of Supervisors
10. Arizona Health Care Cost Containment System
SIGNATURE OF AUTHORIZED INDIVIDUAL:
SIGNATURE:
TYPED NAME:
TYPED NAME:
Meggan LaPorte, MSW, CPPO
TITLE:
Chairman, County Board of Supervisors
TITLE:
Chief Procurement Officer
DATE:
DATE:
ATTEST:
TITLE: Clerk of the Board
DATE:
11. In accordance with state statutes, county rules, and bylaws,
this agreement has been reviewed by the undersigned who
has determined that this agreement is in appropriate form
and is within the power and authority granted to the county.
______________________________________________
Deputy County Attorney
Date: _________________________________________
In accordance with A.R.S. § 11-952, this Agreement has been reviewed by the
undersigned attorney of the agency, who has determined that the Agreement is
in the proper form and is within the powers and authority granted under the
laws of the State of Arizona to AHCCCS.
_____________________________________________________________
AHCCCS Legal Counsel
Date: _____________________________________________________
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10/1/2025
10/2/2025
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10/6/2025
Attachment A
Claims
Electronic
Paper
Total Fund
94%
6%
100%
Estimated total number of claims:
Physician & Emergency Transport/Hospital
1
19,837
1,205
21,042
DFSM Cost per Claim
2
$0.82
$0.95
DMPS Provider Enrollment Cost per Claim
2
$0.18
$0.18
ISD Cost per Claim
2
$2.00
$2.00
Concurrent Review
Average Cost
Estimated cost per case
3
$134.35
Estimated number of HSAG reviews
4
4
Claims Processing costs:
DFSM
$16,236.58
$1,139.77
$17,376.36
DMPS Provider Enrollment
$3,605.64
$219.02
$3,824.66
ISD
$39,722.30
$2,412.93
$42,135.23
State Accounting System Charges @ $0.2336/claim
$4,634.72
$237.92
$4,872.64
Total Claims Processing Costs
$64,199.24
$4,009.64
$68,208.89
Direct DFSM Labor for MDOC 100% State Claims Processing
117,629.82
Direct ISD Labor for MDOC 100% State Claims Processing
$14,000.00
Concurrent Review Estimated costs:
Cost for 4 reviews
$537.39
Administrative Costs (see detail)
DBF Paper Processing Personnel costs
$11,356.73
Postage @ $.0861/claim
$1,812.23
Data Center Charges @ $.8103/claim
$17,049.96
OOD @ $.3700/claim
$7,786.52
OGC @ $.1026/claim
$2,159.62
HRD @ $.0314/claim
$659.67
TIBCO @ $.1416/claim
$2,981.41
Indirect at 10%
$4,380.61
Total Administrative Costs
$48,186.77
DMPS Eligibility Costs
Application Processing Costs - DMPS
$0.00
Estimated Total Annual Costs for Program
$248,562.87
Cost per Claim
$11.79
1 Actual number of claims may be higher. Number includes, original, recoupment and adjustment claims.
2 Cost based on actual expenditures and actual number of claims processed
3 Average rate per contract. Actual costs will be a strict pass-through based on price negotiated on contract.
4 Actual number may be higher or lower depending on MDOC 100% State program requirements.
5 Based on estimates of DFSM staff time required to process the claims.
6 Estimate based on 80 hours at a rate of $175 per hour. Will only be billed for actual hours incurred.
7 Based on estimates of DBF staff time required to monitor funding activity and process payments.
8 Postage based on average cost per claim times number of claims.
9 Data Center charges calculated based on average costs
10 DMPS Eligibility charges calculated at $105/determination. Estimated 0 annual applications/determinations.
10
8
9
7
5
6
Maricopa County Corrections 100% State IGA SFY26
AHCCCS
Administrative Annual Cost Estimates for
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Status: Completed
Subject: Please Docusign This Document YH08-0073
Source Envelope:
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Signatures: 2
Envelope Originator:
Certificate Pages: 5
Initials: 0
anntonia cota
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-07:00) Arizona
801 E. Jefferson St.
Phoenix, AZ 85034
anntonia.cota@azahcccs.gov
IP Address: 64.207.219.136
Record Tracking
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10/1/2025 3:12:56 PM
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anntonia.cota@azahcccs.gov
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Pool: Arizona Health Care Cost Containment
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Michael Kielsky
Michael.Kielsky@azahcccs.gov
Deputy General Counsel
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Electronic Record and Signature Disclosure:
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ID: 9decbdf1-722b-4553-a17a-231996b787d6
Company Name: Carahsoft OBO Arizona Health Care Cost Containment System
Meggan LaPorte
Meggan.LaPorte@azahcccs.gov
Chief Procurement Officer
AHCCCS
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(None)
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Using IP Address: 20.245.184.185
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Tracey Thomas
Tracey.Thomas@azahcccs.gov
Procurement Manager
AHCCCS
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Electronic Record and Signature Disclosure
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ELECTRONIC RECORD AND SIGNATURE DISCLOSURE
From time to time, Arizona Health Care Cost Containment System (we, us or Company) may be
required by law to provide to you certain written notices or disclosures. Described below are the
terms and conditions for providing to you such notices and disclosures electronically through the
DocuSign system. Please read the information below carefully and thoroughly, and if you can
access this information electronically to your satisfaction and agree to this Electronic Record and
Signature Disclosure (ERSD), please confirm your agreement by selecting the check-box next to
‘I agree to use electronic records and signatures’ before clicking ‘CONTINUE’ within the
DocuSign system.
Getting paper copies
At any time, you may request from us a paper copy of any record provided or made available
electronically to you by us. You will have the ability to download and print documents we send
to you through the DocuSign system during and immediately after the signing session and, if you
elect to create a DocuSign account, you may access the documents for a limited period of time
(usually 30 days) after such documents are first sent to you. After such time, if you wish for us to
send you paper copies of any such documents from our office to you, you will be charged a
$0.00 per-page fee. You may request delivery of such paper copies from us by following the
procedure described below.
Withdrawing your consent
If you decide to receive notices and disclosures from us electronically, you may at any time
change your mind and tell us that thereafter you want to receive required notices and disclosures
only in paper format. How you must inform us of your decision to receive future notices and
disclosure in paper format and withdraw your consent to receive notices and disclosures
electronically is described below.
Consequences of changing your mind
If you elect to receive required notices and disclosures only in paper format, it will slow the
speed at which we can complete certain steps in transactions with you and delivering services to
you because we will need first to send the required notices or disclosures to you in paper format,
and then wait until we receive back from you your acknowledgment of your receipt of such
paper notices or disclosures. Further, you will no longer be able to use the DocuSign system to
receive required notices and consents electronically from us or to sign electronically documents
from us.
All notices and disclosures will be sent to you electronically
Electronic Record and Signature Disclosure created on: 2/9/2023 8:44:33 AM
Parties agreed to: Michael Kielsky
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Unless you tell us otherwise in accordance with the procedures described herein, we will provide
electronically to you through the DocuSign system all required notices, disclosures,
authorizations, acknowledgements, and other documents that are required to be provided or made
available to you during the course of our relationship with you. To reduce the chance of you
inadvertently not receiving any notice or disclosure, we prefer to provide all of the required
notices and disclosures to you by the same method and to the same address that you have given
us. Thus, you can receive all the disclosures and notices electronically or in paper format through
the paper mail delivery system. If you do not agree with this process, please let us know as
described below. Please also see the paragraph immediately above that describes the
consequences of your electing not to receive delivery of the notices and disclosures
electronically from us.
How to contact Arizona Health Care Cost Containment System:
You may contact us to let us know of your changes as to how we may contact you electronically,
to request paper copies of certain information from us, and to withdraw your prior consent to
receive notices and disclosures electronically as follows:
To contact us by email send messages to: anthony.flot@azahcccs.gov
To advise Arizona Health Care Cost Containment System of your new email address
To let us know of a change in your email address where we should send notices and disclosures
electronically to you, you must send an email message to us at anthony.flot@azahcccs.gov and in
the body of such request you must state: your previous email address, your new email
address. We do not require any other information from you to change your email address.
If you created a DocuSign account, you may update it with your new email address through your
account preferences.
To request paper copies from Arizona Health Care Cost Containment System
To request delivery from us of paper copies of the notices and disclosures previously provided
by us to you electronically, you must send us an email to anthony.flot@azahcccs.gov and in the
body of such request you must state your email address, full name, mailing address, and
telephone number. We will bill you for any fees at that time, if any.
To withdraw your consent with Arizona Health Care Cost Containment System
To inform us that you no longer wish to receive future notices and disclosures in electronic
format you may:
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i. decline to sign a document from within your signing session, and on the subsequent page,
select the check-box indicating you wish to withdraw your consent, or you may;
ii. send us an email to anthony.flot@azahcccs.gov and in the body of such request you must state
your email, full name, mailing address, and telephone number. We do not need any other
information from you to withdraw consent.. The consequences of your withdrawing consent for
online documents will be that transactions may take a longer time to process..
Required hardware and software
The minimum system requirements for using the DocuSign system may change over time. The
current system requirements are found here: https://support.docusign.com/guides/signer-guide-
signing-system-requirements.
Acknowledging your access and consent to receive and sign documents electronically
To confirm to us that you can access this information electronically, which will be similar to
other electronic notices and disclosures that we will provide to you, please confirm that you have
read this ERSD, and (i) that you are able to print on paper or electronically save this ERSD for
your future reference and access; or (ii) that you are able to email this ERSD to an email address
where you will be able to print on paper or save it for your future reference and access. Further,
if you consent to receiving notices and disclosures exclusively in electronic format as described
herein, then select the check-box next to ‘I agree to use electronic records and signatures’ before
clicking ‘CONTINUE’ within the DocuSign system.
By selecting the check-box next to ‘I agree to use electronic records and signatures’, you confirm
that:
You can access and read this Electronic Record and Signature Disclosure; and
You can print on paper this Electronic Record and Signature Disclosure, or save or send
this Electronic Record and Disclosure to a location where you can print it, for future
reference and access; and
Until or unless you notify Arizona Health Care Cost Containment System as described
above, you consent to receive exclusively through electronic means all notices,
disclosures, authorizations, acknowledgements, and other documents that are required to
be provided or made available to you by Arizona Health Care Cost Containment System
during the course of your relationship with Arizona Health Care Cost Containment
System.
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