COMPLETE_WITH_DOCUSIGN_YH16-0018-07__IGA_AME.PDF
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INTERGOVERNMENTAL AGREEMENT (IGA)
AMENDMENT
1. AMENDMENT #:
7
2. AGREEMENT #:
YH16-0018-07
C-26-19-002-3-07
3. EFFECTIVE DATE OF AMENDMENT:
July 1, 2024
4. PROGRAM:
DFSM/DMPS
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 the SFY25 rates for this agreement.
7. THE ABOVE REFERENCED AGREEMENT IS HEREBY AMENDED AS FOLLOWS:
A.
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 incorporated for SFY25.
B.
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 incorporated for SFY25.
C.
These rates will remain the same until otherwise updated.
Electronic Submission: An electronic or portable document file (PDF) copy of this amendment shall serve as the original.
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.
Signature:
Name and Title:
Date:
12. In accordance with § A.R.S. 11-952, 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.
Signature:
Name and Title: Nicole Fries, Chief Deputy General Counsel
Date:
Docusign Envelope ID: 41C91017-05B7-4013-A3D2-6E26632F631F
10/17/2024
10/18/2024
Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
Davina Bressler
10/18/2024
ATTACHMENT A
Amendment 7 YH16-0018-07 / C-26-19-002-3-07
State
Federal
Claims
Electronic
Paper
Total Fund
Share
Share
98%
2%
100%
50%
50%
Estimated total number of claims:
Physician & Hospital
1
4,500
75
4,575
DFSM Cost per Claim
2
0.86
$
0.99
$
DMPS Provider Enrollment Cost per Claim
2
0.19
$
0.19
$
ISD Cost per Claim
2
2.10
$
2.10
$
Concurrent Review
Average Cost
Estimated cost per case
3
140.75
$
Estimated number of HSAG reviews
4
2
Claims Processing costs:
DFSM
$3,858.64
$74.32
$3,932.96
$1,966.48
$1,966.48
DMPS Provider Enrollment
$856.88
$14.28
$871.16
$435.58
$435.58
ISD
$9,440.05
$157.33
$9,597.38
$4,798.69
$4,798.69
State Accounting System Charges @ $0.2570/claim
$1,156.52
$19.28
$1,175.80
$587.90
$587.90
Total Claims Processing Costs
$15,312.09
$265.21
$15,577.30
$7,788.65
$7,788.65
Direct DFSM Labor for Maricopa Co Medicaid Inmate Claims Processing
5
-
$0.00
$0.00
Direct ISD Labor for Maricopa Co Medicaid Inmate State Claims Process
6
$7,000.00
$3,500.00
$3,500.00
Concurrent Review Estimated costs:
Cost for 2 reviews
$281.50
$140.75
$140.75
Administrative Costs (see detail)
DBF Paper Processing Personnel costs
7
10,138.06
$
$5,069.03
$5,069.03
Postage @ $.0902/claim
8
$412.78
$206.39
$206.39
Data Center Charges @ $.8489/claim
9
$3,883.58
$1,941.79
$1,941.79
OOD @ $.3877/claim
$1,773.58
$886.79
$886.79
OGC @ $.1075/claim
$491.92
$245.96
$245.96
HRD @ $.0328/claim
$150.26
$75.13
$75.13
TIBCO @ $.1484/claim
$679.10
$339.55
$339.55
Indirect at 10%
$1,752.92
$876.46
$876.46
Total Administrative Costs
19,282.20
$
$9,641.10
$9,641.10
DMPS Eligibility Costs
Application Processing Costs - DMPS
10
$1,100.00
$550.00
$550.00
Estimated Total Annual Costs for Program
$43,241.00
$21,620.50
$21,620.50
Cost per Claim
$9.40
$4.70
$4.70
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 Maricopa County Medicaid Inmate program requirements.
5 Based on estimates of DFSM staff time required to process the claims.
6 Estimate based on 40 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 $110/determination. Estimated10 annual applications/determinations.
AHCCCS
Administrative Annual Cost Estimates for
Maricopa County Medicaid Eligible Inmates FFSV Project IGA SFY25
AHCCCS DBF 10/16/2024 1:18 PM
C:\Users\AMCota\Downloads\Maricopa Co Medicaid Inmate Rate SFY25
Docusign Envelope ID: 41C91017-05B7-4013-A3D2-6E26632F631F
Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
ATTACHMENT B
Amendment 7 YH16-0018-07 /C-26-19-002-3-07
AHCCCS
Quarterly Estimate of State Match Advance Payments for Program Services
Maricopa County Medicaid Eligible FFSV Project IGA SFY25
Estimate of Annual Dollar Value of Claims Paid
3,200,000.00
$
Average Federal Financial Participation Rate
77.45%
Estimate of State Match Payments for Program Services for Current Year
721,600.00
$
Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS
180,400.00
$
Docusign Envelope ID: 41C91017-05B7-4013-A3D2-6E26632F631F
Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
Certificate Of Completion
Envelope Id: 41C9101705B74013A3D26E26632F631F
Status: Completed
Subject: Please Docusign This Document - YH16-0018-07
Source Envelope:
Document Pages: 3
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
Status: Original
10/17/2024 9:41:00 AM
Holder: anntonia cota
anntonia.cota@azahcccs.gov
Location: DocuSign
Security Appliance Status: Connected
Pool: StateLocal
Storage Appliance Status: Connected
Pool: Arizona Health Care Cost Containment
System
Location: DocuSign
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Timestamp
Nicole Fries
nicole.fries@azahcccs.gov
Deputy General Counsel
Security Level: Email, Account Authentication
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Signature Adoption: Pre-selected Style
Using IP Address: 174.206.169.119
Signed using mobile
Sent: 10/17/2024 9:42:21 AM
Viewed: 10/17/2024 9:45:05 AM
Signed: 10/17/2024 9:45:20 AM
Electronic Record and Signature Disclosure:
Accepted: 10/11/2023 4:56:52 PM
ID: 79297826-f052-44dd-8316-a1f63a43e041
Company Name: Carahsoft OBO Arizona Health Care Cost Containment System
Meggan LaPorte
Meggan.LaPorte@azahcccs.gov
Chief Procurement Officer
AHCCCS
Security Level: Email, Account Authentication
(None)
Signature Adoption: Uploaded Signature Image
Using IP Address: 13.86.232.74
Sent: 10/17/2024 9:45:22 AM
Viewed: 10/18/2024 11:44:52 AM
Signed: 10/18/2024 11:45:01 AM
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Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
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Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
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
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send you paper copies of any such documents from our office to you, you will be charged a
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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
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speed at which we can complete certain steps in transactions with you and delivering services to
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Electronic Record and Signature Disclosure created on: 2/9/2023 8:44:33 AM
Parties agreed to: Nicole Fries
Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D
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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
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body of such request you must state your email address, full name, mailing address, and
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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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if you consent to receiving notices and disclosures exclusively in electronic format as described
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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
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Docusign Envelope ID: B0280A85-072F-401C-AABA-C612EBA64E2D