AHCCCS - AMENDMENT - C-26-08-011-0-15 BOS.PDF

“AHCCCS

*" Arizona Health Care Cost Containment System

INTERGOVERNMENTAL AGREEMENT
AMENDMENT

41. AMENDMENT | 2. AGREEMENT NUMBER:

15 YHO8-0073
C-26-08-011-0-15

3. EFFECTIVE DATE OF AMENDMENT:

4, PROGRAM:

July 1,2022 DFSM

5. CONTRACTOR/PROVIDER NAME AND ADDRESS:

Maricopa County onbehalf of
Correctional Health Services
234 N. Central, Suite 5000
Phoenix, AZ 85004

6. PURPOSE: To revise rates for SFY2023.

7. The above referencedagreement is hereby amendedas stated below:

A. Pursuant toSection 5, Payment for Services, Subsection 5.7, Administrative Services, change rates for

SFY2023 (July 1, 2022 — June 30, 2023) are hereby incorporated to this amendment as Attachment A.

These rates will remain the same until otherwise updated.

NOTE: Please return scanned copy to: Toni Cota, Procurement Specialist at: gnntonia,cota@azaheccs. gov

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 on behaif of Correctional Health
Services

10. Arizona Health Care Cost Containment System

SIGNATURE OF AUTHORIZED INDIVIDUAL: SIGNATURE:

Alalr—

Meggan LaPorte (Sep 20, 2022 10:00 PDT)

TYPED NAME: TYPED NAME:

Meggan LaPorte, MSW, CPPO
TITLE: TITLE:

Chairman, County Boardof Supervisors Chief Procurement Officer

DATE: DATE:

Sep 20, 2022

11. Inaccordance 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 Js withIn the power and authority granted to the county.

12. tmaccordance with § A.R.S. 14-952, this amendment Is in proper form and
is within the power and authority granted to the administration under §
A.R.S. 36-2903 et seq. and §36-2932 et seq.

9 fei) 22
Date: Date: Sep 49, 2022
BY. C* = Nicole Fries Ah 2022 10:34 PDT)
Deputy County Attorney Nicole Fries, Associate General Counsel for the administration

AHCCCS - Attachment A
Administrative Annual Cost Estimates for
Maricopa County Corrections 100% State IGA SFY23 - Contract C-26-0-011-0-15

Claims Electronic Paper Total Fund
88% 12% 100%
Estimated total number of claims:
Physician & Emergency Transporl/Hospitail ‘ 47,000 2,400 19,400
DFSM Cost per Claim 2¢ 078 §¢ 0.90
DMPS Provider Enrollment Cost per Claim an 017. §$ 0.17
ISD Cost per Claim 2¢§ 1.91 $ 4.91 .
Concurrent Review Average Cost
Estimated cost per case 8g 127.95
Estimated number of HSAG reviews 4 4

Claims Processing costs:

DFSM $13,251,90 $2,161.98 $15,413.88

BMPS Provider Enrollment $2,942.83 $415.46 $3,358.29

ISD $32,420,38 $4,576.99 $36,997.37

State Accounting System Charges @ $0.2336/claim $3,971.88 $473.87 $4,445.75

Total Claims Processing Costs $52,586.99 $7,628.30 $60,215.28

Direct DFSM Labor for MDOC 100% State Claims Processing 5 112,028.40
Direct ISD Labor for MDOC 100% State Claims Processing 8 $14,000.00
Concurrent Review Estimated costs:

Cost for 4 reviews $511,80
Administrative Costs (see detail)

DBF Paper Processing Personnel costs 7 $ 40,693.44

Postage @ $.0820/claim 8 $1,591.26

Data Center Charges @ $.7717/claim 8 $14,976.93

OOD @ $,3524/ciaim $6,837.05

OGC @ $.0977/claim $1,896.28

HRD @ $.0299/claim $579.24

TIBCO @ $.1349/claim $2,617.87

Indirect at 10% $3,918.61
Total Administrative Costs $ 43,104.68
DMPS Eligibility Costs
Application Processing Costs - DMPS 10 $0.00
Estimated Total Annual Costs for Program $229,860.17
Cost per Claim $11.82

L i
5 Actual number of ciaims may be higher. Number includes, original, recoupment and adjustment claims,

2 Cost based on aclual expenditures and actual number of clalms processed

+ average rate per contract. Actual costs will pe a strict pass-through based on price negotialed on contract.
4 Actual number may de higher or lower depending on MOOG 100% State program requirements,

5 Based on estimates of DFSM staff time required to process the claims,

® Estimate based on 80 hours at a rate of $175 per hour. Will only be billed for actual hours incurred.

7 Based on eslimates of DBF staff time required to monitor funding activity and process payments.

® Postage based on average cost per claim times number of claims.

° Data Genler charges calculated based on average costs

‘© DMPS Eligibility charges calculated al $108/deiemmination. Estimated 0 annual applications/determinations,

AHCCCS DBF 9/13/2022 12:06 PM CAUserst\AMCotaDocuments\tGAs\inmate Hospitalizalion\FY23\MDOC 100% State SFY23