STATE OF CONNECTICUT DEPARTMENT OF SOCIAL SERVICES
CONTRACT AMENDMENT
Amendment Number:
10
Contract #:
093-HUS-FCHP-1
Contract Period:
08/11/2001 – 01/31/2005
Contract Name:
FIRSTCHOICE HEALTHPLANS OF CONNECTICUT, INC.
Contractor Address:
116 Washington Avenue, North Haven, CT 06473
Contract number 093-HUS-FCHP-1 by and between the Department of Social Services (the “Department”) and Firstchoice Health Plan of CT (the “Contractor”) for the provision of services under the HUSKY B program as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8 and 9 is hereby further amended as follows:
1.
Paragraph 1 of Part I as amended by Amendments 1, 2, 3, 4, 5, 6, 7, 8 and 9 is further amended to extend the contract end date from September 30, 2004 and January 31, 2005.
2.
Part II ‘GENERAL CONTRACT TERMS FOR MCOs” dated December 12, 2003 remain unchanged and in full force and effect.
3.
Appendix I as amended by Amendment 9 is deleted in its entirety and replaced with Appendix I attached hereto and incorporated herein by reference. The effective dates for Appendix I are 10/01/04 through 01/31/05.
ACCEPTANCES AND APPROVALS
This document constitutes an amendment to the above numbered contract. All provisions of that contract and prior amendments, except those explicitly changed or described above by this amendment, shall remain in full force and effect.
CONTRACTOR
DEPARTMENT
FirstChoice HealthPlans of Connecticut, Inc.
Department of Social Services
Thaddeus Bereday 9/29/04
_Michael P. Starkowski 9/30/04_
Signature (Authorized Official) Date
Signature (Authorized Official) Date
Thaddeus Bereday Secretary
_Michael P. Starkowski Deputy Commissioner
Signature (Authorized Official) Title
Signature (Authorized Official) Title
OFFICE OF THE ATTORNEY GENERAL
Attorney General (as to form) Date
( ) This contract does not require the signature of the Attorney General pursuant to an agreement between the Department and the Office of the Attorney General dated:
APPENDIX I – Amendment
First Choice Health Plan of Connecticut
HUSKY B Capitation Rate 10/01/04 – 01/31/05
1
186 – 300% FPL: $159.05
APPENDIX A – Amended
Plan Name FirstChoice
Capitation Rates 10/01/04 – 01/31/05
Fairfield
Hartford
Litchfield
Middlesex
New Haven
New London
Tolland
Windham
Under One
$
580.21
$
656.41
$
654.49
$
775.69
$
652.17
$
648.96
$
783.92
$
628.96
Ages 1 to 14
$
110.68
$
119.48
$
119.14
$
140.71
$
118.75
$
118.14
$
142.19
$
116.49
Male – Ages
$
137.60
$
149.72
$
149.29
$
175.78
$
148.82
$
148.11
$
177.57
$
146.21
15 to 39 Female – Ages
$
224.72
$
250.37
$
249.64
$
296.11
$
248.76
$
247.51
$
299.28
$
241.27
15-39 Male – Ages 40
$
245.89
$
274.99
$
274.16
$
325.75
$
273.20
$
271.82
$
329.24
$
264.65
and over Female – Ages
$
236.35
$
264.07
$
263.28
$
312.80
$
262.35
$
261.01
$
316.18
$
254.22
40 and over
2
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