1.		Preface/Preamble Page ii, iii revised
2.		Article 1, Definitions section for the following definition:

			Certificate of Authority (revised)
			Childrens Health Care Coverage Program (deleted)
			Comprehensive Orthodontic Treatment (revised)
			DHSS (revised)
			Dual Eligible (new)
			HCFA (deleted)
			Health Maintenance Organization (revised)
			New Jersey State Plan or State Plan (revised)
			NJ FamilyCare Plan H (revised)

		shall be amended as reflected in the relevant pages of Article 1 attached hereto and incorporated herein.
3.		Article 2, Conditions Precedent Sections A, G, G(1) and H shall be amended as reflected in Article 2, Sections A, G, G(1) , and H attached hereto and incorporated herein.
4.		Article 4, Provision of Health Care Services Sections 4.1.1(L); 4.1.1(R) (new); 4.1.2(A)9; 4.1.2(A)24; 4.1.2(A)27; 4.1.3(A)4; 4.1.3(A)7; 4.1.3(A)10; 4.1.6(A)14; 4.1.6(B)1; 4.1.7(B)2; 4.2.4(B)9 (new); 4.6.2(P); 4.6.2(Q)2; 4.6.4(C)4; 4.7.2(A)2; 4.7.2(A)8 (new); 4.7.2(A)9 (new); 4.7.4(B)9; 4.8.8(A)1(a); 4.8.8(A)2(a); 4.8.8(E)7; 4.8.8(1); 4.8.8(J)6; 4.8.8(K); 4.8.8(K)2, 3, 4; 4.8.8(L); 4.8.8(L)2, 3, 4; 4.8.8(M)3; 4.9.1(A); 4.9.1(B); 4.9.1(G)2; 4.9.1(M) (new); 4.9.2; 4.9.2(E) (deleted); and 4.9.3(B)3 (new) shall be amended as reflected in Article 4, Sections 4.1.1(L); 4.1.1(R); 4.1.2(A)9; 4.1.2(A)24; 4.1.2(A)27; 4.1.3(A)4; 4.1.3(A)7; 4.1.3(A)10; 4.1.6(A)14;

		4.1.6(B)1; 4.1.7(B)2; 4.2.4(B)9; 4.6.2(P); 4.6.2(Q)2; 4.6.4(C)4; 4.7.2(A)2; 4.7.2(A)8; 4.7.2(A)9; 4.7.4(B)9; 4.8.8(A)1(a); 4.8.8(A)2(a); 4.8.8(E)7; 4.8.8(1); 4.8.8(J)6; 4.8.8(K); 4.8.8(K)2, 3, 4; 4.8.8(L); 4.8.8(L)2, 3, 4; 4.8.8(M)3; 4.9.1(A); 4.9.1(B); 4.9.1(G)2; 4.9.1(M); 4.9.2; 4.9.2(E); and 4.9.3(B)3 attached hereto and incorporated herein.
5.		Article 5, Enrollee Services Sections 5.3.1(A)3; 5.3.2(G) (new); 5.5(G)1(b); 5.5(H); 5.5(J); 5.6(B) (deleted); 5.8.2(S); 5.10.2(D); 5.15.1(A), 5.15.2(B)9; 5.15.2(C)4; 5.16.2(A)1 and 5.16.2(A)12 shall be amended as reflected in Article 5, Sections 5.3.1(A)3; 5.3.2(G); 5.5(G)1(b); 5.5(H); 5.5(J); 5.6(B); 5.8.2(S); 5.10.2(D); 5.15.1(A); 5.15.2(B)9; 5.15.2(C)4; 5.16.2(A)1 and 5.16.2(A)12 attached hereto and incorporated herein.
6.		Article 6, Provider Information Sections 6.2(A)13 and 6.5(E) shall be amended as reflected in Article 6, Sections 6.2(A)13 and 6.5(E) attached hereto and incorporated herein.
7.		Article 7, Terms and Conditions Sections 7.2(B)7, 8, 11; 7.12(C)3; 7.14(A); 7.14(A)5, 7; 7.14(G)2; 7.16.2; 7.16.7(A)3; 7.20.8 (new); 7.21; 7.26(F); 7.30(A); 7.30(A)1; 7.30(A)3 (new); 7.37(A); 7.38.2(A)5 and 7.38.2(1) (new) shall be amended as reflected in Article 7, Sections 7.2(B)7, 8, 11; 7.12(C)3; 7.14(A); 7.14(A)5, 7; 7.14(G)2; 7.16.2; 7.16.7(A)3; 7.20.8; 7.21; 7.26(F); 7.30(A); 7.30(A)1; 7.30(A)3; 7.37(A); 7.38.2(A)5 and 7.38.2(1) attached hereto and incorporated herein.
8.		Article 8, Financial Provisions, Sections 8.2.1; 8.2.1(C); 8.3.2; 8.4.1; 8.4.1(A); 8.5.2.7; 8.5.4; 8.6; 8.7(C); 8.8(C) and 8.8(D) shall be amended as reflected in Article 8, Sections 8.2.1; 8.2.1(C); 8.3.2; 8.4.1; 8.4.1(A); 8.5.2.7; 8.5.4; 8.6; 8.7(C); 8.8(C) and 8.8(D) attached hereto and incorporated herein.

9.

Appendix, Section A, Reports

			A.4.1 Provider Network File, Attachment A;
			A.4.3 Network Accessibility Analysis A.5, B;
			A.7.2 Fraud and Abuse added Section C to table;
			A.7.3 Table 1 Medicaid Enrollment by Primary Care Provider revised
			A.7.11 Table 9 Semi Annual Utilization and Medical Expenditures Summary;
			A.7.18 Table 16 Ratio of Prior Authorizations Denied to Requested;
			A.7.21 Contractor Financial Reporting Manual for Medicaid/NJ FamilyCare Rate Cell Grouping Costs revised;

shall be amended as reflected in Appendix, Section A, A.4.1; A.4.3; A.7.2, A.7.3; A.7.11; A.7.18 and A.7.21 attached hereto and incorporated herein.

10.

Appendix, Section B, Reference Materials

			B.3.2 Data File Resource Guide;
			B.4.15 Hysterectomy and Sterilization Procedures and Consent Forms
	shall be amended as reflected in Appendix, Section B, B.3.2 and B.4.15 attached hereto and incorporated herein.

11.

Appendix, Section C, Capitation Rates shall be revised as reflected in SFY 2006 Capitation Rates attached hereto and incorporated herein.

All other terms and conditions of the October 1, 2000 contract and subsequent amendments remain unchanged except as noted above.

The contracting parties indicate their agreement by their signatures.

AMERIGROUP						State of New Jersey Department
New Jersey, Inc.						of Human Services
BY:						BY: Ann Clemency Kohler
TITLE: President & CEO						TITLE: Director, DMAHS
DATE: 5/26/06						DATE:
APPROVED AS TO FORM ONLY
Attorney General
State of New Jersey
BY:
Deputy Attorney General
DATE:

CONTRACT

BETWEEN

STATE OF NEW JERSEY

DEPARTMENT OF HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

AND

                                                                                 , CONTRACTOR

Amended 7/1/2006

STATE OF NEW JERSEY
DEPARTMENT OF HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
AND

                                                            

CONTRACT TO PROVIDE SERVICES

This comprehensive risk and non-risk contract is entered into this                      day of                     , and is effective on the                      day of                      between the Department of Human Services, which is in the executive branch of state government, the state agency designated to administer the Medicaid program under Title XIX of the Social Security Act, 42 U.S.C. 1396 et seq. pursuant to the New Jersey Medical Assistance Act, N.J.S.A. 30:4D-l et seq. and the State Child Health Insurance Program under Title XXI of the Social Security Act, 42 U.S.C. 1397aa et seq., pursuant to the Childrens Health Care Coverage Act, PL 1997, c.272 (also known as NJ KidCare), pursuant to Family Care Health Coverage Act, P.L. 2005, c.156 (also known as NJ FamilyCare) whose principal office is located at P.O. Box 712, in the City of Trenton, New Jersey hereinafter referred to as the Department and                                                                                 , a federally qualified/ state defined health maintenance organization (HMO) which is a New Jersey, profit/nonprofit corporation, certified to operate as an HMO by the State of New Jersey Department of Banking and Insurance and whose principal corporate office is located at                                         , in the City of                                                                                 , County of                     , New Jersey, hereinafter referred to as the contractor.

WHEREAS, the contractor is engaged in the business of providing prepaid, capitated comprehensive health care services pursuant to N.J.S.A. 26:2J-1 et seq. as well as non-risk administrative services for certain beneficiary groups; and

WHEREAS, the Department, as the state agency designated to administer a program of medical assistance for eligible persons under Title XIX of the Social Security Act (42 U.S.C. Sec. 1396, et seq., also known as Medicaid), for eligible persons under the Family Care Health Coverage Act (P.L. 2005, c.156) and for children under Title XXI of the Social Security Act (42 U.S.C. Sec. 1397aa, et seq., also known as State Child Health Insurance Program), is authorized pursuant to the federal regulations at 42 C.F.R. 434 to provide such a program through an HMO and is desirous of obtaining the contractors services for the benefit of persons eligible for Medicaid/NJ FamilyCare; and

WHEREAS, the Division of Medical Assistance and Health Services (DMAHS), is the Division within the Department designated to administer the medical assistance program, and the Departments functions as regards all Medicaid/NJ FamilyCare program benefits provided through the contractor for Medicaid/NJ FamilyCare eligible enrolled in the contractors plan.

NOW THEREFORE, in consideration of the contracts and mutual covenants herein contained, the Parties hereto agree as follows:

1.

PREAMBLE

Governing Statutory and Regulatory Provisions: This contract and all renewals and modifications are subject to the following laws and all amendments thereof: Title XIX and Title XXI of the Social Security Act, 42 U.S.C. 1396 et. seq., 42 U.S.C. 1397aa et seq., the New Jersey Medical Assistance Act and the Medicaid, and NJ KidCare and NJ FamilyCare State Plans approved by CMS (N.J.S.A. 30:4D- 1 et seq.; 8 et seq.); federal and state Medicaid and State Child Health Insurance, and NJ FamilyCare regulations, other applicable federal and state statutes, and all applicable local laws and ordinances.

Care Managementa set of enrollee-centered, goal-oriented, culturally relevant, and logical steps to assure that an enrollee receives needed services in a supportive, effective, efficient, timely, and cost-effective manner. Care management emphasizes prevention, continuity of care, and coordination of care, which advocates for, and links enrollees to, services as necessary across providers and settings. Care management functions include 1) early identification of enrollees who have or may have special needs, 2) assessment of an enrollees risk factors, 3) development of a plan of care, 4) referrals and assistance to ensure timely access to providers, 5) coordination of care actively linking the enrollee to providers, medical services, residential, social, and other support services where needed, 6) monitoring, 7) continuity of care, and 8) follow-up and documentation.

Centers for Medicare and Medicaid Services (CMS)formerly the Health Care Financing Administration (HCFA) within the U.S. Department of Health and Human Services.

Certificate of Authoritya license granted by the New Jersey Department of Banking and Insurance to operate an HMO in compliance with N.J.S.A. 26:2J-l et. seq.

Children with Special Health Care Needsthose children who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type and amount beyond that required by children generally.

Chronic Illnessa disease or condition of long duration (repeated inpatient hospitalizations, out of work or school at least three months within a twelve-month period, or the necessity for continuous health care on an ongoing basis), sometimes involving very slow progression and long continuance. Onset is often gradual and the process may include periods of acute exacerbation alternating with periods of remission.

Clinical Peera physician or other health care professional who holds a non-restricted license in New Jersey and is in the same or similar specialty as typically manages the medical condition, procedure, or treatment under review.

CNM or Certified Nurse Midwifea registered professional nurse who is legally authorized under State law to practice as a nurse-midwife, and has completed a program of study and clinical experience for nurse-midwives or equivalent.

CNP or Certified Nurse Practitionera registered professional nurse who is licensed by the New Jersey Board of Nursing and meets the advanced educational and clinical practice requirements beyond the two to four years of basic nursing education required of all registered nurses.