AHCCCS - HOSPITALIZATION - AMENDMENT 2 - SIGNED.PDF

HCCCS

* Arizona Health Care Cost Contoinment System

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INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT

1, AMENDMENT #:

2

2. CONTRACT #:
YH16-0018-07
C-26-19-002-3-02

3. EFFECTIVE DATE OF AMENDMENT:

OCTOBER 1, 2020

4, PROGRAM:

DFSM/DMS

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 and to revise the terms of this agreement.

1. THE ABOVE REFERENCED CONTRACT IS HEREBY AMENDED AS FOLLOWS:

A. Change rates from Attachment A (SFY19) to the rates as shown in Attachment A (SFY21).

B. Change Quarterly Estimate of State Match Advance Payments from Attachment B (SFY19) to the
Estimates listed in Attachment B (SFY 21).

2. Pursuant to the Preamble of Agreement, this agreement is for the processing of Medicaid claims for
inpatient services, defined as an admission to a medical institution, as defined in 42 C.F.R. § 435.1010,
equal to or greater than 24 hours in a non-locked ward.

A. Add Section 7. Department Compliance with CMS Regulations.

7.1 The Department shall not impose requirements upon a medical institution that are

inconsistent with federal regulation and guidance issued by the Centers for Medicare and
Medicaid Services, including State Health Official Letter 16-007 and Survey & Certification
Letter 16-21-ALL REV.

B. Add Section 8. Consequences of Disallowance by CMS.

8.1 In the event the federal government disallows a claim by AHCCCS for federal financial

participation based on the Department's failure to comply with this Agreement, the
Department shall, within 30 days of written demand from AHCCCS, make a payment to
AHCCCS equal to the amount due to CMS as the result of the disallowance, including any
interest incurred as a result of an appeal of the disallowance. AHCCCS will consult with the

Department regarding an administrative appeal of a disallowance; however, AHCCCS has the

sole discretion on the decision whether to pursue an administrative appeal.

Electronic Submission: An electronic or portable document file (PDF) copy of this amendment shall serve as the original

Page 1 of 4

COUNTY: Maricopa

Signature:

Printed Name: Clint Hickman

Title: Chairman, Maricopa County Board of

IN WITNESS THEREOF, the parties have executed this Agreement:

Arizona Health Care Cost Containment
System (AHCCCS):

Signature: __ MegssfLaPorte (Oct 15, 2020 13:42 POT)

Printed Name: Meggan LaPorte, CPPO, MSW

Title: Chief Procurement Officer

Printed Name: Fran McCarroll - Clerk of the Board

In accordance with A.R.S. § 11-952, this Agreement
has been reviewed by the“Uhdersigned who has
determined that this” Agfeement is in the

Supervisors
Date: Date: _ Oct 15, 2020
ATTEST:
Signature:
Date

In accordance with ARS. § 11-952, this
Agreement is in the proper form and is within the
power and authority granted to AHCCCS under
A.R.S. §§ 36-2903 et seq. and 36-2932 et seq.

VM

Matthew J. Devlin (Oct 15, 2020 12:29 PDT)

Legal Counsel for AHCCCS

Page 2 of 4

AHCCCS
Administrative Annual Cost Estimates for

/ Maricopa County Medicaid Eligible Inmates FFS Project IGA SFY21

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YH16-0018-07
'C-26-19-002-3-02
Attachment A

Amendment 2

| it State Federal
Claims i Electronic | Paper | i Total Fund Share i Share
| | 97% | 3% Ld 100% 50% i 50%
[Estimated total number of claims: | | Lt i
Physician & Emergency Transport/Hospital L 1 2,651, i 1 2,742 Lal
DFSM Cost per Claim 25 0.65) | $ 075 | |
OIG Provider Enrollment Cost per Claim 2 $ 014 | §$ 0.14 | i
ISD Cost per Claim 2§ 1.59) $ 1.59 | |
Concurrent Review | Average Cost | |
Estimated cost per case 3 $ 127.95 I | | |
Estimated number of HSAG reviews 4 2 ! | | |
‘Claims Processing costs: | i |
DFSM $1,722.11 | $68.31 | $1,790.42 | $895.21 $895.21 |
OIG Provider Enrollment tot $382.41 $13.13 | $395.54 | $197.77 $197.77 |
IsD Loi $4,213.06 | $144.62 | $4,357.68 | $2,178.84 $2,178.84 |
State Accounting System Charges @ $0.1723/claim $456.82. $15.68 $472.50 $236.25 $236.25 |
Total Claims Processing Costs $6,774.40 | | $241.74 $7,016.14 | $3,508.06 $3,508.06 |
| Direct DFSM Labor for MDOC Medicaid Claims Processing 5 i | $0.00 $0.00 | $0.00
Direct ISD Labor for MDOC Medicaid Claims Processing el i i _$7,000.00 $3,500.00 $3,500.00 _
Concurrent Review Estimated costs: | |
Cost for 2 reviews : Loud il $255.90 $127.95 | $127.95
‘Administrative Costs (see detail) cl Ly | | i
DBF Paper Processing Personnel costs Lt i$ 7,537.68 $3,768.84 $3,768.84
Postage @ $.0545/claim 8 i $149.56 $74.78 $74.78
Data Center Charges @ $.7366/claim ba} i $2,019.82 | $1,009.91 | $1,009.94
OOD @ $.2960/claim i i $811.72 | $405.86 | $405.86 |
OALS @ $.0821/claim i $225.14 | $112.57 | $112.57 |
HRD @ $.0251/claim ia $68.76 | $34.38 $34.38 |
TIBCO @ $.3307/claim im | $908.84 | $453.42 | $453.42 |
Indirect at 10% | i i $1,171.96 $585.98 $585.98 |
‘Total Administrative Costs i | $12,891.48 $6,445.74 $6,445.74 |
[DMS Eligibility Costs | LI. |
Application Processing Costs - DMS i | i $1,575.00 $787.50 | $787.50 _
|Estimated Total Annual Costs for Program i Li Ld $28,738.52 $14,369.26 | $14,369.26 |
Cost per Claim {" an i $10.40 $5.20 | $5.20

* Actual number of claims may be higher. Number includes, original, recoupment and adjustment claims. |
2 Cost based on actual SFY 19 expenditures and actual nurber of claims processed |
® Average rate per contract. Actual costs willbe a strict pass-through based on price negotiated on contract. ul
Actual number may be higher or lower depending on Maricopa Co Medicaid inmate program requirements. I
® Based on estimates of DFSM staff time required to process the claims. it Li
* Estimate based on 40 hours al 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.
Postage based on average cost per claim times number of claims. id

* Data Center charges calculated based on average SFY 19 costs | in

© DMS Bigibilty charges calculated at $105/deterrination. Estimated 15 annual applications/determinations.
' Cost per claim does not include a cost for concurrent reviews i i

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Page 3 of 4

AHCCCS

Quarterly Estimate of State Match Advance Payments for Program Services

Maricopa County Medicaid Eligible FFS Project IGA SFY21

ATTACHMENT B

Estimate of Annual Dollar Value of Claims Paid
Average Federal Financial Participation Rate
‘Estimate of State Match Payments for Program Services for Current Year

Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS

Page 4 of 4

YH16-0018-07
'C-26-19-002-3-02 |

Amendment 2

| $ 2,150,000.00 |

81.56%

/§ 396,540.63 |

$ 99,135.00 |