AHCCCS HOSPITALIZATION AMENDMENT 4 .PDF

HCCCS

“Arizona Health Care Cost Containment System

ee  Y

INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT

4. AMENDMENT ff: 2, CONTRACT #: 3, EFFECTIVE DATE OF AMENDMENT: 4, PROGRAM;
YH16-0018-07
4 C-26-19-002-4-02 OCTOBER 1, 2022 DFSM/DMPS

5, CONTRACTOR/PROVIDER NAME AND ADDRESS:

Maricopa County
c/o Correctional Health Services
234 N. Central, Fifth Floor, Suite 5000
Phoenix, AZ 85004

6, PURPOSE: To revise rates for this agreement.

7.1 THE ABOVE REFERENCED CONTRACT [S HEREBY AMENDED AS FOLLOWS;

A. Pursuant to Section 4.4, AHCCCS Rights and Obligations, Subsection 4.4.1, Eligibility Decision 4.4.1.1,

Attachment A, Administrative Annual Cost Estimates for Maricopa County, Is hereby Incorporated for SFY23.

B. Pursuant to Section 4.5, County's Rights and Obligation, Subsection 4.5.2, Advance Payment for Medical

Services and Administrative Costs by the County, Attachment B, Quarterly Estimate of State Match Advance

Payments, Is hereby Incorporated for SFY23.

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.

Electronic Submission: An electronic or portable document file (PDF} copy of this amendment shall serve as the original
IN WITNESS THEREOF, the parties have executed this Agreement:

COUNTY: Maricopa Arizona Health Care Cost Containment
System (AHCCCS):
Signature: Signature: MepgantaPparte Mov, 2072 13:14 POT)
Printed Name: Printed Name: Meggan LaPorte, CPPO, MSW
Title: Chairman, Maricopa County Board of Title: Chief Procurement Officer
Supervisors
Date: Date: Nov 4, 2022

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ATTEST:

Signature: Printed Name:
Date

Title: Clerk of the Board

In accordance with A.R.S. § 11-952, this Agreement In accordance with ARS, § 11-952, this
has been reviewed by the undersigned who has Agreement Is in the proper form and is within the
determined that thls Agreement is In the power and authority granted to AHCCCS under
appropriate form and Is within the power and A.R.S, §§ 36-2903 et seq. and 36-2932 et seq.
authority granted to COUNTY.
COUNTY Attorney Davy an Bren shen” Nicole Fries, Associate General Counsel for
AHCCCS

Page 2 of 4

Attachment A
YH16-0018-07 / C-26-19-002-3-04 Amendment 4

AHCCCS
Administrative Annual Cost Estimates for
Maricopa County Medicaid Eligible Inmates FFSV Project IGA SFY23

State Federal
Claims Electronic Paper Total Fund Share Share
93% 1% 100% 50% 50%
Estimated total number of claims:
Physiclan & Emergency Transport/Hospital ‘ 2,480 1650 2,300

DFSM Cost per Claim 2s 0.78 $ 0,90
DMPS Provider Enrollment Cost per Clalm 2 ¢ 0.47 $ 017
ISD Cost per Claim 191 8

Concurrent Review Average Cost
Estimated cost per case 3 § 127,95
Estimated number of HSAG reviews 4 2

Claims Processing costs:

DFSM $1,675.98 $1436.12 $1,814.40 $905.55 $905.55
DMPS Provider Enrollment $372.18 $25.98 $398.16 $199.08 $199.08
IsD $4,100.22 $286.06 $4,386.28 $2,193.14 $2,193.14
State Accounting System Charges @ $0.2336/claim $502.34 $29.62 $531,96 $265.98 $265.98
Total Claims Processing Costs $6,650.72 $476.78 $7,127.50 $3,663,75 $3,563.75
Direct DFSM Labor for Maricopa Co Medicald inmate Claims Proce * - $0.00 $0.00
Direct ISD Labor for Maricopa Co Medicaid Inmate Claims Process ° $7,000.00 $3,600.00 $3,500.00
Concurrent Review Estimated costs:
Cost for 2 reviews $255.90 $127.95 $127.95
Administrative Costs (see detail)
DBF Paper Processing Personnel costs 7 $ 9,054.78 $4,627.39 $4,527.39
Postage @ $.0820/clain 8 $188.66 $94.33 $94,393
Data Center Charges @ $.7717/claim 8 $1,774.80 $887.45 $887.45
OOD @ $.3624/claim $810.58 $405.28 $406.29
OGC @ $.097 7/claim $224.82 $112.44 $112.44
HRD @ $.0299/claim $68.66 $34.33 $34.33
TIBCO @ $.1349/claim $310.38 $166.19 $4186.19
Indirect at 10% $1,243.28 $621.64 $621.64
Total Administrative Costs $ 43,876.06 $6,838.03 $6,838.03
DMPS Eligibility Costs
Application Processing Costs - DMPS. e $4,575.00 $787.50 $787.50
Estimated Total Annual Costs for Program $29,634.46 $14,847.23 $14,817.23

st per Clalm

Actual number of claims may be higher, Number Includes, original, recoupment and adjustment claims.

? Gost based on aclval expenditures and actual number of claims processed

* Average rate per contract. Actual costs will be a stricl pass-through based on price negoliated on contract.

4 Aclual number may be higher or lower depending on Maricopa Co Medicaid inmate program requirements.

® Based on estimales of DFSM staff time required lo process the claims.

® Esitmale based on 10 hours at a rale of $176 per hour, Will only be billed for acluaf hours incurred,

7 Based on estimates of DBF slaif time required to monitor funding activity and process paymants,

* Postage based on average cost per claim Umes number of claims,

® Data Center charges calculated based on average costs

© OMPS Eligibility chargos calculaled at $405/delermination, Estmated 10 annuat appiicattons/dalerminations,

AHCCCS DBF 11/2/2022 4:12PM C:lUsers\AMCotalDocuments\iGAsiinmate Hospitalization\F Y23\VH 16-0019-07\Maricopa Co Medicald inmate Rate SFY23

ATTACHMENT B
YH16-0018-07 / C-26-16-002-3-03 Amendment 4

AHCCCS
Quarterly Estimate of State Match Advance Payments for Program Services
Maricopa County Medicaid Eligible FFSV Project IGA SFY23

Estimate of Annual Dollar Value of Claims Paid §  2,400,000,00
Average Federal Financial Participation Rate 81.39%
Estimate of State Match Payments for Program Services for Current Year $ 446,640.00

Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS $ 111,660.00