COMPLETE_WITH_DOCUSIGN_ARIZONA_HEALTH_CARE_C.PDF

INTERGOVERNMENTAL AGREEMENT (IGA) AMENDMENT 
 
 
1. AMENDMENT #: 
6 
2. AGREEMENT #: 
YH16-0018-07 
C-26-19-002-3-06 
3. EFFECTIVE DATE OF AMENDMENT: 
July 1, 2023 
4. PROGRAM: 
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 the SFY24 rates for this agreement.   
 
7. THE ABOVE REFERENCED AGREEMENT IS 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 
SFY24.    
  
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 SFY24.    
 
 
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. 
 
 
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 County 
Arizona Health Care Cost Containment 
System (AHCCCS): 
Signature:    
 
Signature:    
 
Printed Name:    
 
Printed Name: Meggan LaPorte, CPPO, MSW 
Title: Chairman, Maricopa County Board of 
Supervisors 
Title: Chief Procurement Officer 
Date:    
 
Date:    
 
DocuSign Envelope ID: 294241CB-D57C-49E1-8DFF-EA22FCEAAAA8
1/12/2024
DocuSign Envelope ID: 75084883-9B42-4F5A-8946-0B59E48C89EF

In accordance with A.R.S. § 11-952, this Agreement 
has been reviewed by the undersigned who has 
determined that this Agreement is in the 
appropriate form and is within the power and 
authority granted to COUNTY. 
 
County Attorney 
In    accordance    with    A.R.S.    §    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. 
Nicole Fries, Deputy General Counsel for 
AHCCCS 
DocuSign Envelope ID: 294241CB-D57C-49E1-8DFF-EA22FCEAAAA8
1/11/2024
DocuSign Envelope ID: 75084883-9B42-4F5A-8946-0B59E48C89EF
1/26/2024

Attachment A
YH16-0018-07 / C-26-19-002-3-06 Amendment 6
State 
Federal
Claims
Electronic
Paper
Total Fund
Share
Share
98%
2%
100%
50%
50%
Estimated total number of claims:
   Physician & Emergency Transport/Hospital
1
3,570
55
3,625
                 
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
2
Claims Processing costs:
DFSM
$2,922.04
$52.02
$2,974.06
$1,487.03
$1,487.03
DMPS Provider Enrollment
$648.89
$10.01
$658.90
$329.45
$329.45
ISD
$7,148.69
$110.13
$7,258.82
$3,629.41
$3,629.41
State Accounting System Charges @ $0.2336/claim
$834.10
$10.86
$844.96
$422.48
$422.48
Total Claims Processing Costs
$11,553.72
$183.02
$11,736.74
$5,868.37
$5,868.37
Direct DFSM Labor for Maricopa Co Medicaid Inmate Claims Processing
5
-
                     
$0.00
$0.00
Direct ISD Labor for Maricopa Co Medicaid Inmate Claims Processing
6
$7,000.00
$3,500.00
$3,500.00
Concurrent Review Estimated costs:
   Cost for 2 reviews
$268.70
$134.35
$134.35
Administrative Costs (see detail)
   DBF Paper Processing Personnel costs
7
9,598.26
$          
$4,799.13
$4,799.13
   Postage @ $.0861/claim
8
$312.20
$156.10
$156.10
   Data Center Charges @ $.8103/claim
9
$2,937.28
$1,468.64
$1,468.64
OOD @ $.3700/claim
$1,341.42
$670.71
$670.71
OGC @ $.1026/claim
$372.04
$186.02
$186.02
HRD @ $.0314/claim
$113.64
$56.82
$56.82
TIBCO @ $.1416/claim
$513.62
$256.81
$256.81
   Indirect at 10%
$1,518.84
$759.42
$759.42
Total Administrative Costs
16,707.30
$        
$8,353.65
$8,353.65
DMPS Eligibility Costs
Application Processing Costs - DMPS
10
$1,575.00
$787.50
$787.50
Estimated Total Annual Costs for Program 
$37,287.75
$18,643.86
$18,643.86
Cost per Claim 
$10.22
$5.11
$5.11
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 Co Medicaid Inmate program requirements.
5 Based on estimates of DFSM staff time required to process the claims.
6 Estimate based on 10 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 10 annual applications/determinations.
AHCCCS
Administrative Annual Cost Estimates for
Maricopa County Medicaid Eligible Inmates FFSV Project IGA SFY24
 AHCCCS DBF  1/9/2024    10:43 AM
C:\Users\AMCota\Documents\IGAs\Inmate Hospitalization\Amendments\SFY Rates Updates\YH16-0018-07\Maricopa Co Medicaid Inmate Rate SFY24
DocuSign Envelope ID: 294241CB-D57C-49E1-8DFF-EA22FCEAAAA8
DocuSign Envelope ID: 75084883-9B42-4F5A-8946-0B59E48C89EF

YH16-0018-07 / C-26-19-002-3-06 Amendment 6
Estimate of Annual Dollar Value of Claims Paid 
2,300,000.00
$      
Average Federal Financial Participation Rate
79.43%
Estimate of State Match Payments for Program Services for Current Year
473,110.00
$         
Quarterly Estimate of State Match Advance Payments for Program Services to AHCCCS
118,277.50
$         
ATTACHMENT B
AHCCCS
Quarterly Estimate of State Match Advance Payments for Program Services
 Maricopa County Medicaid Eligible FFSV Project IGA SFY24
DocuSign Envelope ID: 294241CB-D57C-49E1-8DFF-EA22FCEAAAA8
DocuSign Envelope ID: 75084883-9B42-4F5A-8946-0B59E48C89EF