EX-10.4 5 a32316exv10w4.txt EXHIBIT 10.4 EXHIBIT 10.4 PURSUANT TO CALIFORNIA GOVERNMENT CODE SECTION 6254(q) WHICH REQUIRES PROVIDER CONTRACTS ENTERED INTO BY THE CALIFORNIA MEDICAL ASSISTANCE COMMISSION TO REMAIN CONFIDENTIAL FOR ONE YEAR AND FOR RATE TERMS TO REMAIN CONFIDENTIAL FOR FOUR YEARS, CONFIDENTIAL TREATMENT HAS BEEN REQUESTED FOR THE BULK OF THIS DOCUMENT. STATE OF CALIFORNIA STANDARD AGREEMENT AMENDMENT STD 213 A(DHS Rev 7/04) [X] CHECK HERE IF ADDITIONAL PAGES ARE ADDED 17 PAGES AGREEMENT NUMBER AMENDMENT NUMBER 05-45908 A-02 REGISTRATION NUMBER: ______________ 1. This Agreement is entered into between the State Agency and Contractor named below: STATE AGENCY'S NAME (Also referred to as CDHS, DHS, or the State) California Department of Health Services CONTRACTOR'S NAME (Also referred to as Contractor) Molina Healthcare of California Partner Plan, Inc. 2. The term of this Agreement is June 30, 2005 through December 31, 2007 3. The maximum amount of this Agreement is: Seventy Three Million, Thirty-three Thousand Dollars $73,033,000 4. The parties mutually agree to this amendment as follows. All actions noted below are by this reference made a part of the Agreement and incorporated herein: 1) Amendment effective date: December 7, 2006 2) Purpose of amendment: To extend the Contract through December 31, 2007; to remove some aid codes; to amend the Non-Contracting Emergency Service Providers language; to remove Medicare Part D as a Covered Service; to amend the Alcohol and Substance Abuse Treatment Services language and to add its related Attachment 10-C; to add the Erectile Dysfunction language and to add its related Attachment 10-D; to amend Attachment 10-B; to amend the Grievance language; to amend the enrollment capacity; to add the Confidential Contract Terms language; to add the Federal False Claim Act Compliance language; and to adjust rates and the encumbrances/amounts payable accordingly. 3) EXHIBIT A, ATTACHMENT 8 PROVIDER COMPENSATION ARRANGEMENTS, SECTION 13 NON-CONTRACTING EMERGENCY SERVICE PROVIDERS, IS AMENDED TO READ: (Continued on next page) All other terms and conditions shall remain the same. IN WITNESS WHEREOF, THIS AGREEMENT HAS BEEN EXECUTED BY THE PARTIES HERETO. ----------------------------------------------------------------------------------------------------- CONTRACTOR CALIFORNIA DEPARTMENT OF GENERAL SERVICES CONTRACTOR'S NAME (If other than an individual, state whether a USE ONLY corporation, partnership, etc.) MOLINA HEALTHCARE OF CALIFORNIA PARTNER PLAN, INC. BY (Authorized Signature) DATE SIGNED (Do not type) 12/9/06 /s/ Stephen T. O'Dell ---------------------------------------- PRINTED NAME AND TITLE OF PERSON SIGNING Stephen T. O'Dell, President ADDRESS One Golden Shore Drive Long Beach, CA 90802 STATE OF CALIFORNIA AGENCY NAME California Department of Health Services BY (Authorized Signature) DATE SIGNED (Do not type) 2/6/07 /s/ Stan Rosenstein ---------------------------------------- PRINTED NAME AND TITLE OF PERSON SIGNING Stan Rosenstein, Deputy Director, Medical Care Services Exempt per: [ ] Welfare and Institutions ADDRESS Code section 14087.55(c) 1501 Capitol Avenue, 6th Floor, MS 4000, PO Box 997413 [X] Welfare and Institutions Sacramento, CA 95899-7413 Code section 14089.8(b) -----------------------------------------------------------------------------------------------------