Note: Portions of this exhibit indicated by [*] are subject to a confidential
treatment request, and have been omitted from this exhibit. Complete, unredacted
copies of this exhibit have been filed with the Securities and Exchange
Commission as part of the Company’s confidential treatment request.

INDEPENDENT PRACTICE ASSOCIATION PARTICIPATION AGREEMENT

COVER SHEET

General Information
IPA Name: Metcare of Florida, Inc
 
Federal Tax ID Number: 65-0879131
 
IPA UPIN:

Service Address
Service Address: 250 South Australian Ave., Ste 400
 
City: West Palm Beach
 
State: Florida
 
Zip: 33401
 
Contact Person Name:
 
Email Address:
 
Telephone Number: 561-805-8500
 
Facsimile (FAX) Number: 561-805-8501
 
County: Palm Beach

Billing Address
Billing Address: Same as Above
 
City:
 
State:
 
Zip:
 
Contact Person Name:
 
Email Address:
 
Telephone Number:
 
Facsimile (FAX) Number:

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For Humana Use Only
 
Nomination ¨ Yes    o No

INDEPENDENT PRACTICE ASSOCIATION PARTICIPATION AGREEMENT

This Independent Practice Association Participation Agreement ("Agreement") is
made and entered into by and between the party named on the signature page below
(hereinafter referred to as "IPA") and Humana Insurance Company, Humana Health
Insurance Company of Florida, Inc., Humana Medical Plan, Inc. and their
affiliates that underwrite or administer health plans (hereinafter referred to
as “Humana”).

RELATIONSHIP OF THE PARTIES

1.1
In performance of their respective duties and obligations hereunder, Humana and
IPA, and IPA’s respective employees and agents, are at all times acting and
performing as independent contractors, and neither party, nor their respective
employees and agents, shall be considered the partner, agent, servant, employee
of, or joint venturer with, the other party. Unless otherwise agreed to herein,
the parties acknowledge and agree that neither IPA nor Humana will be liable for
the activities of the other nor the agents and employees of the other, including
but not limited to, any liabilities, losses, damages, suits, actions, fines,
penalties, claims or demands of any kind or nature by or on behalf of any
person, party or governmental authority arising out of or in connection with:
(i) any failure to perform any of the agreements, terms, covenants or conditions
of this Agreement; (ii) any negligent act or omission or other misconduct; (iii)
the failure to comply with any applicable laws, rules or regulations; or (iv)
any accident, injury or damage to persons or property. Notwithstanding anything
to the contrary contained herein, IPA further agrees to and hereby does
indemnify, defend and hold harmless Humana from any and all claims, judgments,
costs, liabilities, damages and expenses whatsoever, including reasonable
attorneys' fees, arising from any acts or omissions in the provision by IPA of
medical services to Members. This provision shall survive termination or
expiration of this Agreement.

1.2
The parties agree that Humana’s affiliates whose Members receive services
hereunder do not assume joint responsibility or liability between or among such
affiliates for the acts or omissions of such other affiliates.

SERVICES TO MEMBERS

2.1
Subject at all times to the terms of this Agreement, IPA agrees to provide or
arrange for medical and related health care services to individuals designated
by Humana (herein referred to as “Members”) with an identification card or other
means of identifying them as Members covered under a self-funded or fully
insured health benefits plan to which IPA has agreed to participate as set forth
in the product participation list attachment.

2.2
IPA agrees to provide IPA’s services to individuals covered under other third
party payors’ (hereinafter referred to as “Payor” or “Payors”) health benefits
contracts (hereinafter referred to as "Plan" or “Plans”) and agrees to comply
with such Payors’ policies and procedures. For Covered Services rendered to such
individuals, IPA acknowledges and agrees that all rights and responsibilities
arising with respect to benefits to such individuals shall be subject to the
terms of the Payor Plan covering such individuals. Individuals covered under
such Plans will have an identification card as a means of identifying the Payor
Plan which provides coverage. Such identification cards will display the Humana
logo and/or name.

2.3
For Covered Services provided to those individuals identified in Section 2.2
above, Payor will make payments for Covered Services directly to IPA in
accordance with the terms and conditions of this Agreement and the rates set
forth in the payment attachment applicable to the Plan type of such individual.
IPA agrees that in no event, including, but not limited to, nonpayment by Payor,
or Payor’s insolvency, shall IPA bill, charge, collect a deposit from, seek
compensation, remuneration or reimbursement from, or have any recourse against
Humana for services provided by IPA to Plans’ members. This provision shall not
prohibit collection by IPA from Plans’ members for non-covered services and/or
member cost share amounts in accordance with the terms of the applicable member
Plan. Payors Plans will provide appropriate steerage mechanisms including
benefit designs and/or IPA directory and web site listings to ensure their
covered individuals will have incentives to utilize IPA’s services. All
obligations of IPA under this Agreement with respect to Humana’s Members shall
equally apply to the individuals identified in Section 2.2 above.

IPA_FL_08152006
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THIRD PARTY BENEFICIARIES

3.1
Except as is otherwise specifically provided in this Agreement, the parties have
not created and do not intend to create by this Agreement any rights in other
parties as third party beneficiaries of this Agreement, including, without
limitation, Members.

SCOPE OF AGREEMENT
 
4.1
This Agreement sets forth the rights, responsibilities, terms and conditions
governing: (i) the status of IPA and IPA’s employees, subcontractors and/or
independent contractors as health care providers (hereinafter referred to as
"Participating Providers") providing health care services; and (ii) IPA’s
provision of professional medical services (hereinafter referred to as "IPA
Services") to Members. All terms and conditions of this Agreement which are
applicable to “IPA” are equally applicable to each Participating Provider,
unless the context requires otherwise.

4.2
IPA represents and warrants that it is authorized to negotiate terms and
conditions of provider agreements, including this Agreement, and further to
execute such agreements for and on behalf of itself and its Participating
Providers. IPA further represents and warrants that Participating Providers will
abide by the terms and conditions of this Agreement, including each of IPA’s
employed, subcontracted or independently contracted IPAs. The parties
acknowledge and agree that nothing contained in this Agreement is intended to
interfere with or hinder communications between IPA and Members regarding the
Members’ medical conditions or treatment options, and IPA acknowledges that all
patient care and related decisions are the sole responsibility of IPA and Humana
does not dictate or control clinical decisions with respect to the medical care
or treatment of Members.

4.3
IPA acknowledges and agrees that with respect to self-funded groups, unless
otherwise provided herein, Humana’s responsibilities hereunder are limited to
provider network administration and/or claims processing.

SUBCONTRACTING PERFORMANCE

5.1
IPA shall provide directly, or through appropriate agreements with IPAs and
other licensed health care professionals and/or providers, IPA Services for
Members. It is understood and agreed that IPA shall maintain written agreements
with Participating Providers, if any, in a form comparable to, and consistent
with, the terms and conditions established in this Agreement. IPA’s downstream
provider agreements, if any, shall include terms and conditions which comply
with all applicable requirements for provider agreements under state and federal
laws, rules and regulations. In the event of a conflict between the language of
the downstream provider agreements and this Agreement, the language in this
Agreement shall control.

5.2
IPA shall provide Humana an executed letter of agreement (in a form
substantially similar to the form attached hereto as the letter of agreement
attachment) for each Participating Provider who is a IPA and who is
subcontracted or independently contracted with IPA prior to the provision of
services by such Participating Provider to Members. Such Participating
Providers, if any, who do not execute a letter of agreement may not participate
under this Agreement and may not be listed in Humana’s provider directories.

IPA_FL_08152006
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TERM AND TERMINATION
 

6.1
The term of this Agreement shall commence on _______________________, 20____
(the "Effective Date”). The initial term of this Agreement shall be for five (5)
years (hereinafter referred to as “Initial Term”). This Agreement shall
automatically renew for subsequent one (1) year terms unless either party
provides written notice of non-renewal to the other party at least ninety (90)
days prior to the end of the initial term or any subsequent renewal terms.

6.2
Notwithstanding anything to the contrary herein, after the Initial Term, either
party may terminate this Agreement without cause by providing to the other party
one hundred and twenty (120) days prior written notice of termination.

 

6.3
Humana may terminate this Agreement, or any individual Participating Provider,
immediately upon written notice to IPA, stating the cause for such termination,
in the event: (i) IPA's, or any individual Participating Provider's, continued
participation under this Agreement may adversely affect the health, safety or
welfare of any Member or brings Humana or its health care networks into
disrepute; (ii) IPA or any individual Participating Provider fails to meet
Humana’s credentialing or re-credentialing criteria; (iii) IPA or any individual
Participating Provider is excluded from participation in any federal health care
program; (iv) IPA or any individual Participating Provider voluntarily or
involuntarily seeks protection from creditors through bankruptcy proceedings or
engages in or acquiesces to receivership or assignment of accounts for the
benefit of creditors; or (v) Humana loses its authority to do business in total
or as to any limited segment of business, but then only as to that segment. 

6.4
In the event of a breach of this Agreement by either party, the non-breaching
party may terminate this Agreement upon at least sixty (60) days prior written
notice to the breaching party, which notice shall specify in detail the nature
of the alleged breach; provided, however, that if the alleged breach is
susceptible to cure, the breaching party shall have thirty (30) days from the
date of receipt of notice of termination to cure such breach, and if such breach
is cured, then the notice of termination shall be void of and of no effect. If
the breach is not cured within the thirty (30) day period, then the date of
termination shall be that date set forth in the notice of termination.
Notwithstanding the foregoing, any breach related to credentialing or
re-credentialing, quality assurance issues or alleged breach regarding
termination by Humana in the event that Humana determines that continued
participation under this Agreement may affect adversely the health, safety or
welfare of any Member or bring Humana or its health care networks into
disrepute, shall not be subject to cure and shall be cause for immediate
termination upon written notice to IPA.

6.5 
IPA agrees that the notice of termination or expiration of this Agreement shall
not relieve IPA’s obligation to provide or arrange for the provision of IPA
Services through the effective date of termination or expiration of this
Agreement.

POLICIES AND PROCEDURES

7.1
IPA agrees to comply with Humana’s quality assurance, quality improvement,
accreditation, risk management, utilization review, utilization management and
other administrative policies and procedures established and revised by Humana
from time to time and, in addition, those policies and procedures which are set
forth in Humana’s Physician Administration Manual, or its successor (hereinafter
referred to as the “Manual”), and bulletins or other written materials that may
be promulgated by Humana from time to time to supplement the Manual. The Manual
and updated policies and procedures may be issued and distributed by Humana in
electronic format. Paper copies may be obtained by IPA upon written request.
Revisions to such policies and procedures shall become binding upon IPA ninety
(90) days after such notice to IPA by mail or electronic means, or such other
period of time as necessary for Humana to comply with any statutory, regulatory
and/or accreditation requirements.

7.2
Humana shall maintain an authorization procedure for IPA to verify coverage of
Members under a Humana health benefits contract.

7.3
IPA agrees that it shall obtain preadmission authorization or provide admission
notification with respect to Member inpatient admissions. IPA recognizes that
failure to notify Humana of Member admission could result in limitation on
Humana's ability to administer Members’ benefits. In the event that IPA fails to
obtain preadmission authorization or notify Humana of a Member inpatient
admission, the IPA’s claim will be pended and may either not be paid (if it is
not Medically Necessary) or be subject to an administrative reduction in an
amount equal to a fifty percent (50%) of the allowed amount. IPA agrees it shall
not balance bill the Member for the amount of the reduction in payment. In the
event the reduction described herein is effected, the Member's Copayments, if
any, will be adjusted accordingly

IPA_FL_08152006
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CREDENTIALING AND PROFESSIONAL LIABILITY INSURANCE

8.1
Participation under this Agreement by IPA and Participating Providers is subject
to the satisfaction of all applicable credentialing and re-credentialing
standards established by Humana. IPA shall provide Humana, or its designee,
information necessary to ensure compliance with such standards at no cost to
Humana or its designee. IPA agrees to use electronic credentialing and
recredentialing processes when administratively feasible. IPA, as applicable,
and all Participating Providers providing IPA Services to Humana Members shall
be credentialed in accordance with Humana’s credentialing process prior to
receiving participating status with Humana.

 
8.2
IPA shall maintain, at no expense to Humana, policies of comprehensive general
liability, professional liability, and workers' compensation coverage as
required by law, insuring IPA and IPA’s employees and agents against any claim
or claims for damages arising as a result of injury to property or person,
including death, occasioned directly or indirectly in connection with the
provision of IPA Services contemplated by this Agreement and/or the maintenance
of IPA’s facilities and equipment. Upon request, IPA shall provide Humana with
evidence of said coverage, of which minimum professional liability coverage
shall be two hundred and fifty thousand dollars ($250,000) per occurrence and
seven hundred and fifty thousand dollars ($750,000) in the aggregate, or as
required by state law. IPA shall provide Humana with written notice at least ten
(10) days prior to any cancellations and/or modifications in the coverage. IPA
shall within ten (10) business days following service upon IPA, or such other
period of time as may be required by any applicable law, rule or regulation,
notify Humana in writing of any Member lawsuit alleging malpractice involving a
Member.

PROVISION OF MEDICAL SERVICES

 
9.1
IPA shall provide Members all available medical services within the normal scope
of and in accordance with IPA’s: (a) licenses and certifications, and (b)
privileges to provide certain services based upon IPA’s qualifications as
determined by Humana. IPA agrees to comply with all requests for information
related to IPA’s qualifications in connection with Humana’s determination
whether to extend privileges to provide certain services and/or procedures to
Members. IPA shall not bill, charge, seek payment or have any recourse against
Humana or Members for any amounts related to the provision of IPA Services for
which Humana has notified IPA that privileges to perform such services have not
been extended.

 
9.2
IPA shall maintain all office medical equipment including, but not limited to,
imaging, diagnostic and/or therapeutic equipment (hereinafter referred to as
“Equipment”) in acceptable working order and condition and in accordance with
the Equipment manufacturer’s recommendations for scheduled service and
maintenance. Such Equipment shall be located in IPA’s office locations that
promote patient and employee safety. IPA shall provide Humana or its agents with
access to such Equipment for inspection and an opportunity to review all records
reflecting Equipment maintenance and service history. Such Equipment shall only
be operated by qualified technicians with appropriate training and required
licenses and certifications.

 

 
9.3
Equipment owned and/or operated by IPA shall comply with all standards for use
of such Equipment and technician qualifications established by Humana. IPA
agrees to comply with all requests for information related to Equipment and
IPA’s and/or IPA’s staff, qualifications for use of same. In the event: (i)
IPA’s Equipment fails to meet Humana’s standards; or (ii) IPA declines to comply
with Humana’s standards for use of Equipment, IPA agrees that it will not use
such Equipment while providing services to Members and shall not bill, charge,
seek payment or have any recourse against Humana or Members for any amounts for
services with respect to such Equipment.

 
STANDARDS OF PROFESSIONAL PRACTICE

10.1
IPA Services shall be made available to Members without discrimination on the
basis of type of health benefits plan, source of payment, sex, age, race, color,
religion, national origin, health status or disability. IPA shall provide IPA
Services to Members in the same manner as provided to their other patients and
in accordance with prevailing practices and standards of the profession.

IPA_FL_08152006
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MEDICAL RECORDS

11.1
IPA shall prepare, maintain and retain as confidential the medical records of
all Members receiving IPA Services, and Members’ other personally identifiable
health information received from Humana, in a form and for time periods required
by applicable state and federal laws, licensing requirements, accreditation and
reimbursement rules and regulations to which IPA is subject, and in accordance
with accepted medical practice. IPA shall obtain authorization of Members
permitting Humana, and/or any state or federal agency as permitted by law, to
obtain a copy and have access, upon reasonable request, to any medical record of
Member related to services provided by IPA pursuant to applicable state and
federal laws. Copies of such records for the purpose of claims processing shall
be made and provided by IPA at no cost to Humana or the Member.

11.2
IPA and Humana agree to maintain the confidentiality of information maintained
in the medical records of Members, and information obtained from Humana through
the verification of Member eligibility, as required by law. This Section 11
shall survive expiration or termination of this Agreement, regardless of the
cause.

GRIEVANCE AND APPEALS PROCESS/BINDING ARBITRATION

12.1
IPA shall cooperate and participate with Humana in grievance and appeals
procedures to resolve disputes that may arise between Humana and its Members.
IPA and Humana further agree that in the event they are unable to resolve
disputes that may arise with respect to this Agreement, IPA will first exhaust
any internal Humana administrative review or appeal procedures prior to
submitting any matters to binding arbitration.

12.2
In the event of a dispute between IPA and Humana which is not resolved as set
forth in Section 22 below, or which the parties cannot settle by mutual
agreement, the dispute shall be resolved by binding arbitration, conducted by a
single arbitrator selected by the parties from a panel of arbitrators proposed
by the American Arbitration Association (“AAA”). This applies, without
limitation, to any dispute arising out of the parties’ business relationship,
including allegations or claims involving violations of state or federal laws or
regulations. In the event the parties cannot agree on the arbitrator, then the
arbitrator shall be appointed by the AAA. The arbitration shall be conducted in
Ft. Lauderdale, Florida, in accordance with and subject to the Commercial
Arbitration Rules of the AAA then in effect, or under such other mutually agreed
upon guidelines. Judgment upon the award rendered in any such arbitration may be
entered in any court of competent jurisdiction, or application may be made to
such court for judicial acceptance and enforcement of the award, as applicable
law may require or allow. The submission of any dispute to arbitration shall not
adversely affect either party’s right to seek preliminary injunctive relief with
respect to an actual or threatened termination, repudiation or rescission of the
Agreement. Except as expressly set forth in Section 22 below, the costs of any
arbitration proceeding(s) hereunder shall be borne equally by the parties, and
each party shall be responsible for its own attorneys’ fees and such other costs
and expenses incurred related to the proceedings. Notwithstanding the preceding
sentence, in the event IPA is an individual practitioner or is a group practice
consisting of less than six (6) IPAs and is the prevailing party in the
arbitration, then Humana shall reimburse IPA any applicable filing fees or
arbitrator fees paid by IPA. Arbitrations hereunder shall be conducted solely
between IPA and Humana; class-based arbitration shall not be permitted. The
parties agree this Agreement is a transaction involving interstate commerce and
therefore that the Federal Arbitration Act, 9 U.S.C. §1 et seq. applies.

IPA_FL_08152006
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12.3
Notwithstanding anything to the contrary in Section 12.2 above, Section 12.2
shall not apply to any dispute between IPA and Humana: (i) which is subject to
resolution through either Section 7.10 or Section 7.11 of that certain
settlement agreement dated October 17, 2005 between Humana Inc. and Humana
Health Plan, Inc. and the representative plaintiffs, the signatory medical
societies, and class counsel (“MDL Settlement”); and (ii) for which IPA seeks
resolution pursuant thereto; provided, however, any dispute subject to
resolution under Section 7.11 of the MDL Settlement which does not result in a
binding determination on the parties pursuant to the terms of Section 7.11 and
for which IPA desires to continue to pursue shall be resolved by binding
arbitration in accordance with Section 12.2 of this Agreement. A description of
Sections 7.10 and 7.11 of the MDL Settlement are set forth in the Manual. All
final determinations rendered in accordance with Sections 7.10 or 7.11 of the
MDL Settlement are binding upon IPA and Humana. Notwithstanding anything to the
contrary in this Section 12.3 or in Section 22.1 below, at Humana's option,
Sections 7.10 or 7.11 or the MDL Settlement shall not apply to any physician,
including a Participating Provider, who has opted-out of the MDL Settlement.

 
USE OF IPA’S NAME

13.1
Humana may include the following information in any and all marketing and
administrative materials published or distributed in any medium: IPA’s name,
telephone number, address, office hours, type of practice or specialty, hospital
affiliation, Internet web-site address, and the names of Participating
Providers, including IPAs providing care at IPA’s office, and hospital
affiliation, board certification, and other education and training history, if
applicable, of Participating Providers. Humana will provide IPA with access to
such information or copies of such administrative or marketing materials upon
request.

13.2
IPA may advertise or utilize marketing materials, logos, trade names, service
marks, or other materials created or owned by Humana after obtaining Humana’s
written consent. IPA shall not acquire any right or title in or to such
materials as a result of such permissive use.

13.3
IPA agrees to allow Humana to distribute a public announcement of IPA’s
affiliation with Humana.

PAYMENT

14.1
IPA shall accept payment from Humana for those services for which benefits are
payable under a Member’s health benefits contract (hereinafter referred to as
“Covered Services”) provided to Member in accordance with the reimbursement
terms in the payment attachment. IPA shall collect directly from Member any
co-payment, coinsurance, or other member cost share amounts (hereinafter
referred to as "Copayments") applicable to the Covered Services provided and
shall not waive, discount or rebate any such Copayments. Payments made in
accordance with the payment attachment less the Copayments owed by Members
pursuant to their health benefits contracts shall be accepted by IPA as payment
in full from Humana for all Covered Services. This provision shall not prohibit
collection by IPA from Member for any services not covered under the terms of
the applicable Member health benefits contract. A reduction in payment as a
result of claims policies and/or processing procedures is not an indication that
the service provided is a non-covered service.

14.2
IPA agrees that payment may not be made by Humana for services rendered to
Members which are determined by Humana not to be Medically Necessary. “Medically
Necessary” (or “Medical Necessity”), unless otherwise defined by applicable law,
shall mean health care services that a physician, exercising prudent clinical
judgment, would provide to a patient for the purpose of preventing, evaluating,
diagnosing or treating an illness, injury, disease or its symptoms, and that are
(a) in accordance with generally accepted standards of medical practice; (b)
clinically appropriate, in terms of type, frequency, extent, site and duration,
and considered effective for the patient’s illness, injury or disease; and (c)
not primarily for the convenience of the patient, physician, or other health
care provider, and not more costly than an alternative service or sequence of
services at least as likely to produce equivalent therapeutic or diagnostic
results as to the diagnosis or treatment of that patient’s illness, injury or
disease. For these purposes, “generally accepted standards of medical practice”
means standards that are based on credible scientific evidence published in
peer-reviewed medical literature generally recognized by the relevant medical
community, physician specialty society recommendations and the views of
physicians practicing in relevant clinical areas and any other relevant factors.
IPA agrees that in the event of a denial of payment for IPA Services rendered to
Members determined not to be Medically Necessary by Humana, that IPA shall not
bill, charge, seek payment or have any recourse against Member for such
services. Notwithstanding the immediately preceding sentence, IPA may bill the
Member for services determined not to be Medically Necessary if IPA provides the
Member with advance written notice that: (a) identifies the proposed services,
(b) informs the Member that such services may be deemed by Humana to be not
Medically Necessary, and (c) provides an estimate of the cost to the Member for
such services and the Member agrees in writing in advance of receiving such
services to assume financial responsibility for such services.

IPA_FL_08152006
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14.3
IPA agrees that Humana may recover overpayments made to IPA by Humana by
offsetting such amounts from later payments to IPA, including, without
limitation, making retroactive adjustments to payments to IPA for errors and
omissions relating to data entry errors and incorrectly submitted claims or
incorrectly applied discounts. Humana shall provide IPA thirty (30) days advance
written notice of Humana’s intent to offset such amounts prior to deduction of
any monies due. If IPA does not refund said monies or request review of the
overpayments described in the notice within thirty (30) days following receipt
of notice from Humana, Humana may without further notice to IPA deduct such
amounts from later payments to IPA. Humana may make retroactive adjustments to
payments for a period not to exceed eighteen (18) months from original date of
payment or such other period as may be required by applicable law.

14.4
 In the event Humana has access to IPA’s, or a Participating Provider’s,
services through one or more other agreements or arrangements in addition to
this Agreement, Humana will determine under which agreement or arrangement
payment for Covered Services will be made.

14.5
Nothing contained in this Agreement is intended by Humana to be a financial
incentive or payment that directly or indirectly acts as an inducement for IPA
to limit Medically Necessary services.

SUBMISSION OF CLAIMS

15.1
IPA shall submit all claims to Humana or its designee, as applicable, using the
Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) compliant
837 electronic format, or a CMS 1500 and/or UB-92, or their successors, within
one hundred eighty (180) days from the later of: (i) the date of service; or
(ii) the date of IPA’s receipt of the explanation of benefits from the primary
payor when Humana is the secondary payor; provided, however, all claims under
self-insured plans must be submitted within ninety (90) days of the date of
service. Notwithstanding the foregoing, self-insured plans may specify a shorter
period of time in which claims must be submitted. Humana may, in its sole
discretion, deny payment for any claim(s) received by Humana after the later of
the dates specified above. IPA acknowledges and agrees that Members shall not be
responsible for any payments to IPA except for applicable Copayments and
non-covered services provided to such Members

 
15.2
Humana will process IPA claims which are accurate and complete in accordance
with Humana’s normal claims processing procedures and applicable state and/or
federal laws, rules and regulations with respect to the timeliness of claims
processing. Such claims processing procedures may include, without limitation,
automated systems applications which identify, analyze and compare the amounts
claimed for payment with the diagnosis codes and which analyze the relationships
among the billing codes used to represent the services provided to Members.
These automated systems may result in an adjustment of the payment to the IPA
for the services or in a request, prior to payment, for the submission for
review of medical records that relate to the claim. A reduction in payment as a
result of claims policies and/or processing procedures is not an indication that
the service provided is a non-covered service. In no event may IPA bill a member
for any amount adjusted in payment.

15.3
IPA shall use best efforts to submit all claims to Humana by electronic means
available and accepted as industry standards that are mutually agreeable, and
which may include claims clearinghouses or electronic data interface companies
used by Humana. IPA acknowledges that Humana may market certain products that
will require electronic submission of claims in order for IPA to participate.

IPA_FL_08152006
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COORDINATION OF BENEFITS

16.1
When a Member has coverage, other than with Humana, which requires or permits
coordination of benefits from a third party payor in addition to Humana, Humana
will coordinate its benefits with such other payor(s). In all cases, Humana will
coordinate benefits payments in accordance with applicable laws and regulations
and in accordance with the terms of its health benefits contracts. When
permitted to do so by such laws and regulations and by its health benefits
contracts, Humana will pay the lesser of: (i) the amount due under this
Agreement; (ii) the amount due under this Agreement less the amount payable or
to be paid by the other payor(s); or (iii) the difference between allowed billed
charges and the amount paid by the other payor(s). In no event, however, will
Humana, when its plan is a secondary payor, pay an amount, which, when combined
with payments from the other payor(s), exceeds the rates set out in this
Agreement; provided, however, if Medicare is the primary payer, Humana will, to
the extent required by applicable law, regulation or Centers for Medicare and
Medicaid Services (“CMS”) Office of Inspector General (“OIG”) guidance, pay IPA
an amount up to the amount Humana would have paid, if it had been primary,
toward any applicable unpaid Medicare deductible or coinsurance.

NO LIABILITY TO MEMBER FOR PAYMENT

17.1
IPA agrees that in no event, including, but not limited to, nonpayment by
Humana, Humana’s insolvency or breach of this Agreement, shall IPA or any
Participating Provider bill, charge, collect a deposit from, seek compensation,
remuneration or reimbursement from, or have any recourse against Members or
persons other than Humana (or the payor issuing the health benefits contract
administered by Humana) for Covered Services provided by IPA. This provision
shall not prohibit collection by IPA from Member for any non-covered service
and/or Copayments in accordance with the terms of the applicable Member health
benefits contract.

17.2
IPA further agrees that: (i) this provision shall survive the expiration or
termination of this Agreement regardless of the cause giving rise to expiration
or termination and shall be construed to be for the benefit of the Member; (ii)
this provision supersedes any oral or written contrary agreement now existing or
hereafter entered into between IPA and Member or persons acting on their behalf;
and (iii) this provision shall apply to all employees, agents, trustees,
assignees, subcontractors, and independent contractors of IPA, and IPA shall
obtain from such persons specific agreement to this provision.

17.3
Any modification to this Section 17 shall not become effective unless approved
by the Commissioner of Insurance, in the event such approval is required by
applicable state law or regulation, or such changes are deemed approved in
accordance with state law or regulation.

ACCESS TO INFORMATION

18.1
IPA agrees that Humana, or any state or federal regulatory agency as required by
law, shall have reasonable access and an opportunity to examine IPA’s financial
and administrative records as they relate to services provided to Members during
normal business hours, on at least seventy-two (72) hours advance notice, or
such shorter notice as may be imposed on Humana by a federal or state regulatory
agency or accreditation organization.

NEW PRODUCT INTRODUCTION

19.1
From time to time during the term of this Agreement, Humana may develop or
implement new products. Should Humana offer participation in any such new
product to IPA, IPA shall be provided with ninety (90) days' written notice
prior to the implementation of such new product. If IPA does not object in
writing to its participation in such new product within such ninety (90) day
notice period, IPA shall be deemed to have accepted participation in the new
product. In the event IPA objects to its participation in a new product, the
parties shall confer in good faith to reach agreement on the terms of IPA’s
participation. If agreement on such new product cannot be reached, such new
product shall not apply to this Agreement. Humana may in its discretion,
establish, develop, manage and market provider networks in which IPA may not be
selected to participate.

IPA_FL_08152006
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ASSIGNMENT AND DELEGATION

20.1
The assignment by IPA of this Agreement or any interest hereunder shall require
notice to and the written consent of Humana. As used in this paragraph, the term
“assignment” shall also include a change of control in IPA’s practice by merger,
consolidation, transfer, or the sale of thirty-three percent (33%) or more stock
or other ownership interest in IPA’s practice. Any attempt by IPA to assign this
Agreement or any interest hereunder without complying with the terms of this
paragraph shall be void and of no effect, and Humana, at its option, may elect
to terminate this Agreement upon thirty (30) days written notice to IPA, without
any further liability or obligation to IPA. Humana may assign this Agreement in
whole or in part to any purchaser of or successor to the assets or operations of
Humana, or to any affiliate of Humana, provided that the assignee agrees to
assume Humana’s obligations under this Agreement. Upon notice of an assignment
by Humana, IPA may terminate this Agreement upon thirty (30) days written notice
to Humana.

COMPLIANCE WITH REGULATORY REQUIREMENTS

21.1
IPA acknowledges, understands and agrees that this Agreement may be subject to
the review and approval of state regulatory agencies with regulatory authority
over the subject matter to which this Agreement may be subject. Any modification
of this Agreement requested by such agencies or required by applicable law or
regulations shall be incorporated herein as provided in Section 23.10, of this
Agreement.

21.2
IPA and Humana agree to be bound by and comply with the provisions of all
applicable state and/or federal laws, rules and regulations. The alleged failure
by either party to comply with applicable state and/or federal laws, rules or
regulations shall not be construed as allowing either party a private right of
action against the other in any court, administrative or arbitration proceeding
in matters in which such right is not recognized or authorized by such law or
regulation.  IPA and Participating Providers agree to procure and maintain for
the term of this Agreement all license(s) and/or certification(s) as is required
by applicable law and Humana’s policies and procedures. IPA shall notify Humana
immediately of any changes in licensure or certification status of IPA or
Participating Providers. If IPA or any individual Participating Provider
violates any of the provisions of applicable state and/or federal laws, rules
and regulations, or commits any act or engages in conduct for which IPA’s or
Participating Providers’ professional licenses are revoked or suspended, or
otherwise is restricted by any state licensing or certification agency by which
IPA or Participating Providers are licensed or certified, Humana may immediately
terminate this Agreement or any individual Participating Provider.

DISPUTE RESOLUTION/LIMITATIONS ON PROCEEDINGS

22.1
IPA may contest the amount of the payment, denial or nonpayment of a claim only
within a period of eighteen (18) months following the date such claim was paid,
denied or not paid by the required date by Humana. In order to contest such
payments, IPA shall provide to Humana, at a minimum, in a clear and acceptable
written format, the following information: Member name and identification
number, date of service, relationship of the Member to the patient, claim
number, name of the provider of the services, charge amount, payment amount, the
allegedly correct payment amount, difference between the amount paid and the
allegedly correct payment amount, and a brief explanation of the basis for the
contestation. Humana will review such contestation(s) and respond to IPA within
thirty (30) days of the date of receipt by Humana of such contestation.
Notwithstanding the foregoing, in the event the claims contestation is subject
to resolution under Section 7.11 of the MDL Settlement, IPA may elect to pursue
resolution thereunder in lieu of the contestation procedure set forth in this
Section 22.1; provided, however, any commencement of an appeal under Section
7.11 shall be brought within the eighteen (18) month timeframe set forth in this
Section 22.1 or shall otherwise be barred. Further, in the event IPA fails to
exercise the contestation rights set forth in this Section 22.1, IPA shall not
be entitled to pursue an appeal under Section 7.10 of the MDL Settlement.

IPA_FL_08152006
9
 

 

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22.2
In the event of a determination, following either the review of the claims
contestations by Humana, or following the arbitration proceedings described in
Section 12.2 above, that the claims in dispute, in the aggregate, were processed
and paid correctly, IPA shall, upon request of Humana, reimburse Humana for its
costs in reviewing the claims contestations and reprocessing the claims and, in
the event the matter was submitted by either party for arbitration, the costs
and expenses, and attorneys fees incurred by Humana that are attributable to the
arbitration proceeding. In the event of a determination, following either the
review of the claims contestations by Humana or following the arbitration
proceedings described in Section 12.2 above, that the claims in dispute, in the
aggregate, were not processed and paid correctly by Humana, Humana shall, upon
request of IPA, reimburse IPA’s costs in preparing the claims contestation
submission to Humana, and, in the event the matter was submitted by either party
for arbitration, the costs and expenses, and attorneys fees incurred by IPA that
are attributable to the mediation or arbitration proceeding.

MISCELLANEOUS PROVISIONS

23.1
SEVERABILITY. If any part of this Agreement should be determined to be invalid,
unenforceable, or contrary to law, that part shall be reformed, if possible, to
conform to law, and if reformation is not possible, that part shall be deleted,
and the other parts of this Agreement shall remain fully effective.

23.2
GOVERNING LAW. This Agreement shall be governed by and construed in accordance
with the applicable laws of the State of Florida. The parties agree that
applicable state and/or federal laws and/or regulations may make it necessary to
include in this Agreement specific provisions relevant to the subject matter
contained herein. Such state law provisions, if any, are set forth in the state
law coordinating provisions attachment hereto. Such federal law provisions, if
any, are set forth in the Medicare Advantage provisions attachment hereto. The
parties agree to comply with any and all such provisions and in the event of a
conflict between the provisions in the state law coordinating provisions
attachment and/or the Medicare Advantage provisions attachment and any other
provisions in this Agreement, the provisions in those attachments, as
applicable, shall control. In the event that state and/or federal laws and/or
regulations enacted after the Effective Date expressly require specific language
be included in this Agreement, such provisions are hereby incorporated by
reference without further notice by or action of the parties and such provisions
shall be effective as of the effective date stated in such laws, rules or
regulations.

23.3
WAIVER. The waiver, whether express or implied, of any breach of any provision
of this Agreement shall not be deemed to be a waiver of any subsequent or
continuing breach of the same provision. In addition, the waiver of one of the
remedies available to either party in the event of a default or breach of this
Agreement by the other party shall not at any time be deemed a waiver of a
party's right to elect such remedy at any subsequent time if a condition of
default continues or recurs.

23.4
NOTICES. Any notices, requests, demands or other communications, except notices
of changes in policies and procedures pursuant to Section 7, required or
permitted to be given under this Agreement shall be in writing and shall be
deemed to have been given: (i) on the date of personal delivery; or (ii)
provided such notice, request, demand or other communication is received by the
party to which it is addressed in the ordinary course of delivery: (a) on the
third day following deposit in the United States mail, postage prepaid or by
certified mail, return receipt requested; (b) on the date of transmission by
facsimile transmission; or (c) on the date following delivery to a nationally
recognized overnight courier service, each addressed to the other party at the
address set forth below their respective signatures to this Agreement, or to
such other person or entity as either party shall designate by written notice to
the other in accordance herewith. Humana may also provide such notices to IPA by
electronic means to the e-mail address of IPA set forth on the Cover Sheet to
this Agreement or to other e-mail addresses IPA provides to Humana by notice as
set forth herein. Unless a notice specifically limits its scope, notice to any
one party included in the term “IPA” or “Humana” shall constitute notice to all
parties included in the respective terms.

 
23.5
CONFIDENTIALITY. IPA agrees that the terms of this Agreement and information
regarding any dispute arising out of this Agreement are confidential, and agrees
not to disclose the terms of this Agreement nor information regarding any
dispute arising out of this Agreement to any third party without the express
written consent of Humana, except pursuant to a valid court order, or when
disclosure is required by a governmental agency. Notwithstanding anything to the
contrary herein, the parties acknowledge and agree that IPA may discuss the
payment methodology included herein with Members requesting such information.

IPA_FL_08152006
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23.6
COUNTERPARTS, HEADINGS AND CONSTRUCTION. This Agreement may be executed in one
or more counterparts, each of which shall be deemed an original, and all of
which together constitute one and the same instrument. The headings in this
Agreement are for reference purposes only and shall not be considered a part of
this Agreement in construing or interpreting any of its provisions. Unless the
context otherwise requires, when used in this Agreement, the singular shall
include the plural, the plural shall include the singular, and all nouns,
pronouns and any variations thereof shall be deemed to refer to the masculine,
feminine or neuter, as the identity of the person or persons may require. It is
the parties desire that if any provision of this Agreement is determined to be
ambiguous, then the rule of construction that such provision is to be construed
against its drafter shall not apply to the interpretation of the provision.

23.7
INCORPORATION OF ATTACHMENTS. All attachments attached hereto are incorporated
herein by reference.

23.8
FORCE MAJEURE. Neither party to this Agreement shall be deemed to breach its
obligations under this Agreement if that party's failure to perform under the
terms of this Agreement is due to an act of God, riot, war or natural disaster.

23.9
ENTIRE AGREEMENT. This Agreement, including the attachments, addenda and
amendments hereto and the documents incorporated herein, constitutes the entire
agreement between Humana and IPA with respect to the subject matter hereof, and
it supersedes any prior or contemporaneous agreements, oral or written, between
Humana and IPA.

23.10
MODIFICATION OF AGREEMENT.  This Agreement may be amended in writing as mutually
agreed upon by IPA and Humana. In addition, Humana may amend this Agreement upon
ninety (90) days' written notice to IPA. Failure of IPA to object in writing to
such amendment during the ninety (90) day notice period shall constitute
acceptance of such amendment by IPA.

23.11
MATERIAL ADVERSE CHANGES. Notwithstanding anything to the contrary in Sections
6, 7.1, 19.1, 23.10 or the payment attachment, in the event Humana makes a
material adverse change in the terms of this Agreement it shall provide at least
ninety (90) days written notice to IPA of such change; except where a shorter
notice period is required to comply with applicable law or regulation. If IPA
objects to the change that is the subject of the notice, then IPA must within
thirty (30) days of the date of the notice give written notice of termination of
this Agreement which notice shall be effective at the end of the notice period
of the material adverse change; provided, however, if Humana provides written
notice within sixty-five (65) days of the date of the original notice of the
material adverse change that it will not implement such change as to IPA, then
IPA’s notice of termination shall be of no force or effect.

CONTRACTING LIMITATIONS

24.1
Unless otherwise agreed to in writing by Humana, IPA and its affiliated
companies agree not to enter into any risk contract (including global, full and
limited risk and capitated contracts) with any other health maintenance
organization, health insurance company, health benefits organization, prepaid
health plan or similar entity providing prepaid health services and/or any
affiliated companies thereof and who underwrite, administer, market or otherwise
participate in the Medicare Advantage (formerly known as Medicare+Choice)
program and have a contract with the Centers for Medicare and Medicaid Services
covering the following counties in the State of Florida, specifically: Martin,
St. Lucie, Okeechobee and Glades counties (“Medicare Advantage Competitor”).
Failure to comply with the provisions of this paragraph will constitute cause
for termination of the Agreement.

24.2
IPA represents and warrants that the execution, delivery and performance of the
terms of the “Contracting Limitations” provision does not and will not
constitute a breach of any other contract to which IPA is subject.

IPA_FL_08152006
11
 

 

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24.3
The parties agree that this “Contracting Limitations” Section 24 does not in any
way: (a) require IPA to terminate his/her/its relationship with any Medicare
Advantage Competitor or patient; or (b) restrict IPA’s ability to treat
patients, including those currently enrolled in a Medicare Advantage Competitor,
on a self-pay and/or out-of-network and/or emergency basis; or (c) apply or
relate to any of IPA’s contractual relationships with health maintenance
organizations, health insurance companies, health benefits organizations,
prepaid health plans or similar entities providing coverage for health services
and/or any affiliated companies thereof as they apply to commercial or
self-insured programs or plans.

24.4
The parties hereby agree that this “Contracting Limitations” Section 24 shall
terminate on December 31, 2013 (the “Contracting Limitations Termination Date”)

NON-SOLICITATION
 
25.1
IPA acknowledges that Humana has invested and will invest substantial resources
including funds, time, effort and goodwill in building a roll of Medicare
Advantage Members to be treated by IPA or IPA Participating Provider. Therefore,
IPA agrees that IPA and or any of IPA’s Participating Providers, employees,
principals or financially related entities, shall not solicit, persuade, induce,
coerce or otherwise cause the disenrollment of any Medicare Advantage Member at
any time, directly or indirectly. If thirty-five (35) or more Medicare Members
assigned to an individual IPA Participating Provider disenroll from Humana due
to IPA’s directly or indirectly soliciting, persuading, inducing, coercing or
otherwise causing the disenrollment of such Medicare Advantage Members to be
treated by IPA or IPA's Participating Provider, employees, principals or other
financially related entity under some other prepaid health care benefit plan
other than Humana's, IPA shall pay Humana the amount of three thousand dollars
($3,000.00) for each disenrolled Medicare Advantage Member who is treated by
IPA, or any of IPA’s Participating Provider, employees, principals or any
financially related entity. IPA hereby agrees to agree that this amount is not a
penalty and constitutes liquidated damages in as much as the actual damages are
not and cannot be ascertained at the time of the execution of this Agreement.
IPA understands that this liquidated damages clause does not apply to or require
payment from the Medicare Advantage Members under any circumstance. IPA further
acknowledges and agrees that in the event of termination of this Agreement, the
amount calculated by Humana herein as liquidated damages shall be deducted from
any amount Humana may owe IPA including, but not limited to any surplus amount
owed for services rendered by IPA to Members as per the Payment Attachment
referenced in this Agreement.

 
25.2
Humana agrees with IPA that this paragraph shall not be applicable in the case
of any Medicare Advantage Member who disenrolls and is treated by IPA or anyone
else as a private patient (i.e. the Medicare Advantage Member does not enroll in
another Medicare Advantage plan.) In addition, Medicare Advantage Members who
were patients prior to IPA’s participation as a Humana Participating Provider
under this Agreement or any other prior participating agreement with Humana, are
excluded from this provision, if the IPA can furnish documentation to Humana in
the form of a list of his/her patients prior to becoming a Humana Participating
Provider. IPA has the obligation to and agrees to notify Humana immediately of
the name of any Medicare Advantage Member of former Medicare Advantage Member
treated by IPA or IPA Participating Provider or any other person covered by this
provision. This paragraph shall survive for twelve (12) months following the
termination or expiration of this Agreement, except in the event that IPA
terminates this Agreement for material breach of this Agreement by Humana, which
material breach is finally adjudicated by a court of competent jurisdiction or
is finally adjudicated by an arbitrator through binding arbitration conducted in
accordance with Section 12.

 
HUMANA CONTRACTING LIMITATIONS
 
26.1
[*]

26.2
[*]

IN WITNESS WHEREOF, the parties have the authority necessary to bind the
entities identified herein and have executed this Agreement to be effective as
of the Effective Date.

IPA_FL_08152006
12
 

 

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IPA/AUTHORIZED SIGNATORY   HUMANA          
Signature:_________________________________
 
Signature: _________________________________
         
Printed Name:________________________________
 
Printed Name:________________________________
          Title: ____________________________________   Title:
____________________________________          
Date:____________________________________
 
Date: ____________________________________
 

 
Address For Notice:

IPA:
 
HUMANA:
     
250 South Australian Ave., Ste 400
 
3501 SW 160th Ave
West Palm Beach FL 33401
 
Miramar, FL 33027
   
Attn: Provider Contracting
         
Copy to:
   
Humana Inc.
   
P.O. Box 1438
   
Louisville, Kentucky 40201-1438
   
Attn: Law Department

IPA_FL_08152006
13
 

 

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PRODUCT PARTICIPATION LIST
ATTACHMENT

IPA agrees to participate in the health benefits plan(s) selected below, whether
self-funded or fully insured, that are offered or administered by Humana.

Health Benefits Plan (Check only those which apply)

Commercial HMO Plans
X
       
Commercial HMO Choice Plans
 
X
     
Commercial PPO Plans
 
X
     
Commercial POS Plans
 
X      
Commercial EPO Plans
 
X 
     
Medicare PPO Plans
 
X
     
Medicare HMO Plans
 
X 
     
Medicare POS Plans
 
X
     
Medicaid HMO Plans
 
N/A 
     
Traditional Plans
    
X 

IPA_FL_08152006
14
 

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IPA INFORMATION
ATTACHMENT

(To be provided by IPA prior to execution of this Agreement.)

The following information is to be listed below for IPA and each Participating
Provider: address, phone number, fax number, tax identification number, contact
person, area of specialty, office hours, and area hospitals where IPA and
Participating Providers have admitting privileges and the corresponding hospital
privilege category.

This Agreement is limited to IPA and Participating Providers located in the
following counties in the state of Florida:

Central Region: Marion, Sumter, Lake and Polk

Gulf Coast: Lee, Charlotte, Collier, Manatee and Sarasota

Treasure Coast: Martin, St. Lucie, Okeechobee and Glades

IPA_FL_08152006
15
 

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LETTER OF AGREEMENT
ATTACHMENT

WHEREAS, Humana Insurance Company, Humana Health Insurance Company of Florida,
Inc., Humana Medical Plan, Inc., and their affiliates who underwrite or
administer health plans (hereinafter referred to as "Humana") and Metcare of
Florida, Inc. (hereinafter referred to as "IPA") entered into a IPA
Participation Agreement (hereinafter "Agreement") on ___________________, AND

WHEREAS, IPA and Humana agreed to be bound by the terms and conditions of the
Agreement, AND

WHEREAS, the undersigned IPA (hereinafter referred to as "Participating
Provider") is a member of IPA, and a Participating Provider pursuant to the
Agreement between IPA and Humana , AND

WHEREAS, Participating Provider acknowledges and agrees that the joinder of the
Humana companies above shall not be construed as imposing joint responsibility
or cross guarantee between or among Humana companies.

NOW, THEREFORE, the parties hereby agree as follows:

Participating Provider agrees to abide by all of the terms and conditions set
forth in the Agreement, and to abide by all Humana policies and procedures
established and revised from time to time by Humana including, but not limited
to, quality assurance, quality improvement, risk management, utilization
management, credentialing and recredentialing, and grievances/appeals.

Participating Provider unconditionally authorizes Humana and IPA to share
information, including but not limited to credentialing, recredentialing,
quality management and utilization management information as related to
treatment of individuals covered under those Humana health benefits plans
covered under the Agreement (hereinafter "Members"). However, it is understood
expressly that the information shall not be shared with anyone not a party to
the Agreement, unless required by law or pursuant to prior written consent of
Participating Provider.

Participating Provider acknowledges that Participating Provider has been
provided an opportunity to read the Agreement, all of the terms of which are
hereby incorporated by reference.

Participating Provider further agrees that payment to IPA or Participating
Provider, as applicable, from Humana, less any Copayments owed by the Member, is
payment in full for health care services provided or arranged for Members in
accordance with the applicable Member health benefits contract and the terms and
conditions of this Agreement. Participating Provider shall look solely to IPA
for payment and agrees that payments made by Humana to IPA for Covered Services
rendered to Members by Participating Provider constitutes payment in full to
Participating Provider.

Participating Provider further agrees that in the event of termination or
expiration of the Agreement, or in the event IPA is dissolved for whatever
reason, Participating Provider shall continue to provide health care services
under the terms and conditions of the Agreement and Humana agrees to continue to
pay Participating Provider in accordance with the fee-for-service payment
arrangements stated in the payment attachment of the Agreement, for a period of
one hundred and eighty (180) days after notice of dissolution of IPA or the
effective date of termination or expiration of the Agreement, during which time
a new IPA agreement may be negotiated between Humana and the individual
Participating Provider. Humana may terminate such Participating Provider
participation at any time after dissolution of IPA or termination or expiration
of the Agreement upon written notice to Participating Provider.

HUMANA
 
PARTICIPATING PROVIDER
         
Signature: _________________________________
 
Signature: _________________________________
 
Print Name: ________________________________
 
Print Name: ________________________________
 
Date: ____________________________________
 
Date: ____________________________________
 

IPA_FL_08152006
16
 

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Ownership Disclosure Form

IPA:

Metcare of Florida, Inc

--------------------------------------------------------------------------------

(Must be indentical to the name shown on the Cover Sheet.)

STATUS:

__________________________________ 
 
Sole Proprietorship
     
__________________________________ 
 
Professional Association
     
__________________________________ 
 
Partnership or Limited Liability Company
     
______________X_________________________________
 
Corporation

List names and addresses of all principals and indicate percent of ownership, if
applicable. (“Principal” means any shareholder, officer, director, partner,
member, manager, joint venturer or anyone else having an ownership in or
managerial control over IPA.) Attach additional sheets if necessary.

 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 
   
 
 
 
 
 

IPA_FL_08152006
17
 

 

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Note: Portions of this exhibit indicated by [*] are subject to a confidential
treatment request, and have been omitted from this exhibit. Complete, unredacted
copies of this exhibit have been filed with the Securities and Exchange
Commission as part of the Company’s confidential treatment request.

Percentage of Premium Payment Attachment

I: PAYMENT FOR MEMBERS ASSIGNED TO IPA PRIMARY CARE PHYSICIAN(S)

A:
PAYMENT AND FUNDING ARRANGEMENTS

Humana agrees to pay IPA for Covered Services provided to Medicare HMO Members
who have been assigned to IPA Primary Care Physician(s) according to the payment
arrangement set forth below. IPA agrees that the payment arrangements and rates
set out in below and as further identified below shall apply for Covered
Services rendered to Humana Members. The following table sets out the risk
shared between Humana and IPA of any surplus/deficit in the Funds.

 
 
Total % of
 Premium 
Allocation**
 
Part A
Fund Split 
IPA/HUMANA*
 
Part B 
Fund
IPA/HUMANA*
 
Stop-Loss
Fund Split 
IPA/HUMANA*
 
PRODUCT
                         
Medicare HMO
(Applicable for Calendar Year 2008)
   

[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
Medicare HMO
(Applicable for Calendar Year 2009)
   

[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
Medicare HMO
(Applicable for Calendar Year 2010)
   

[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
Medicare HMO
(Applicable for Calendar Year 2011 and thereafter)
   

[*]

%
 

[*]%/[*]

%
 

[*]%/[*]

%
 

[*]%/[*]]

%

*
Percentage of surplus or deficit allocated to IPA/Humana as described herein.

**
Percentage of premium as described below in Section B.

--------------------------------------------------------------------------------

B. PERCENT OF PREMIUM CALCULATION METHODOLOGY

I. The Medicare HMO percentage of premium shall be based on the income Humana
collects from CMS and any premium from Member for each Member assigned to IPA
Primary Care Physician.

II. In the event Humana changes the benefits offered under Humana's health care
benefit plans, all payments, allocations, fundings and tables established or
provided for under this Attachment shall be increased or decreased as may be
required in order to directly reflect the actuarial change.

C. FUND DESCRIPTIONS

1. Part A Fund

A Part A Fund shall be established which will consist of the "Part A Revenue"
and "Part A Expenses". The fund shall be calculated as follows:

Part A Fund Revenue

Part A Fund Revenue shall consist of amounts equal to the appropriate funding as
outlined in the Funding Table for those Medicare and Medicaid Members for each
product covered under this Agreement multiplied by the number of Members
assigned to IPA Primary Care Physician in each category covered under this
Agreement. Such amounts shall be credited to the Part A Fund as "Part A
Revenue".

Part A Fund Expenses

Part A Fund Expenses shall consist of amounts equal to the claims and/or
capitation paid to providers by Humana for Covered Services provided to Members
assigned to IPA Primary Care Physician, plus an actuarially determined amount
for claims incurred but not reported or paid (IBNR) and a catastrophic withhold
amount as calculated by Humana for Part A Expenses.

Part A Expenses include, but are not limited to, costs identified for inpatient
hospital (medical and surgical services), inpatient hospital psychiatric
services, selected outpatient surgery procedures at Humana contracted
facilities, skilled nursing home services, applicable disease management
programs, home health care services, and the cost of stop-loss coverage if
provided by Humana. Part A Expenses also include the cost of other Covered
Services or costs which may be determined to be Part A Expenses by Humana in the
normal course of business

2. Part B Fund

A Part B Fund shall be established to pay for Part B Expenses. The fund shall be
calculated as follows:

Part B Fund Revenue

Part B Fund Revenue shall consist of amounts equal to the appropriate funding as
outlined in the Funding Table for those Medicare and Medicaid Members for each
product covered under this Agreement multiplied by the number of Members
assigned to IPA Primary Care Physician in each category covered under this
Agreement. Such amounts shall be credited to the Part B Fund as "Part B
Revenue". The funding is LESS amounts that may be paid by Humana to IPA Primary
Care Physician as a primary care capitation and amounts allocated to the
Pharmacy Fund, if the Pharmacy Fund is carved out of the Part B Fund.

Part B Fund Expenses

Part B Fund Expenses shall consist of amounts equal to the claims and/or
capitation paid to providers by Humana for Covered Services provided to Members
assigned to IPA Primary Care Physician, plus an actuarially determined amount
for claims incurred but not reported or paid (IBNR).

--------------------------------------------------------------------------------

Part B Expenses are all costs for Covered Services not defined as Part A
Expenses. Part B Expenses include, but may not be limited to, hospital based
physician fees, specialists fees, hospital outpatient services, costs for
applicable disease management programs, outpatient prescription drugs and the
cost for stop-loss coverage if provided by Humana. Part B Expenses also include
the cost of other Covered Services or costs which may be determined to be Part B
Expenses by Humana in the normal course of business or as may be determined by
CMS to be a Part B Covered Service.

Payment for IPA Primary Care Physician Services - Capitation

IPA agrees and shall accept as payment in full a primary care capitation payment
for Medicare HMO Members which will be mailed to IPA for medical services on or
about the 15th day of each month. The capitation shall be based on a mutually
agreed upon amount on an actuarial equivalent for primary care services. The
primary care capitation shall be carved out of the Part B Revenue Fund as
defined above.

Payment for IPA Specialist Physician Services

IPA agrees to accept as payment in full Humana's Fee Schedule, or Humana’s or
IPA’s Capitation Payment as applicable, or IPA's usual and customary charges,
whichever is less, less any Co-payments owed by the Member, for Covered Services
provided to Members. Such cost of IPA capitation or fee-for-service
reimbursement will be expensed against the Part A and Part B Funds as described
above.

3.  Stop-Loss Coverage

IPA shall provide and maintain a Stop-Loss program, at IPA expense, providing
protection against excessive Part A and/or Part B costs for Members as required
by any applicable state or federal laws, rules and regulations. The Stop-Loss
program shall be funded directly by IPA, in its sole discretion, and not as a
carve-out from the capitation allocated to the Part A and Part B Funds, with a
stop loss insurance carrier on terms and conditions reasonably acceptable to
IPA.

4. Settlement, Reconciliation and Distribution of Funds

The aforementioned Part A and Part B Funds (the “Funds”) shall be settled and
reconciled as follows:

At the close of each month, after the fourth (4th) month of this Agreement, any
Part A and/or Part B surpluses shall be offset by any Part A and or Part B
deficits. Any resulting net surplus shall be paid the IPA on or about the end of
the following month. Any resulting net deficit shall be paid to Humana upon
notification by Humana of such deficits. In the event the deficit is not paid,
the deficit amount will be offset against future IPA payments.

Prior to the distribution of monies from any of the Funds, an actuarially
justified reserve for incurred but not reported or paid (IBNR) and catastrophic
withhold calculation claim costs will be calculated by Humana and such IBNR and
catastrophic withhold calculation amounts will be held in the Funds. Upon
termination, final reconciliation of the amounts funded and claims satisfied
will be made twelve (12) months following the contract termination date (the
“Final Settlement”). IPA will be responsible for any net Fund deficits resulting
from the Final Settlement and shall reimburse Humana the amount of any such
deficits within thirty (30) days of receipt of notice of such deficits. If the
Final Settlement shows that the Funds have a positive net balance, the balance
will be distributed to the IPA within thirty (30) days after such final
settlement.

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Distribution of Settlement is outlined in the Funding Table above.

Notwithstanding anything to the contrary in this Agreement, IPA has the right to
dispute only that portion of the Final Settlement amount distributed that is
applicable to claims contested in accordance with Section 22.2 of this Agreement
for a period of up to forty-five (45) calendar days from receipt of such Final
Settlement calculation. Regardless of any dispute, Humana agrees to pay any
undisputed Final Settlement surplus amounts within forty-five (45) days of the
Final Settlement calculation identified above and IPA agrees to pay any
undisputed Final Settlement deficits amounts to Humana within forty-five (45)
days of the Final Settlement calculation above. In the event of such dispute,
the parties agree to work toward a mutually agreeable resolution. In order for
contestations by IPA to be accepted for review by Humana, IPA must submit those
contestations in Humana’s defined format and according to Humana’s specific
guidelines. Failure to comply with Humana’s guidelines and formatting
requirements will result in denial of such contestations without review and will
be considered as if contestations were never submitted. If the IPA contests the
payment of a claim as set forth herein, then the IPA shall provide at a minimum
the following information: Member name and identification number, date of
service, relationship of the Member-patient to the Member who completed the
application for health care benefits coverage with Humana, claim number, name of
the provider of medical services, charge amount, payment amount, the allegedly
correct payment amount, difference between the amount paid and the allegedly
correct payment amount and a brief explanation of the basis for the
contestation.

The parties acknowledge and agree that Humana’s decision on any contestation of
claims in the Final Settlement will be final. In the event Humana’s review of a
contestation results in Humana’s identification of the need to readjudicate
identified claim(s), such amounts recovered will be credited to the applicable
Primary Care Physician Fund when such readjudication by Humana is complete.
However, IPA agrees to pay to Humana any deficits identified in Humana’s review
of the contestation within thirty (30) days of receipt of Humana’s written
response to the contestation identified above. Failure to contest the amount of
Final Settlement distribution within the time specified above shall result in
the waiver of IPA’s right to contest such Final Settlement distribution.

5. Method of Calculation

Personnel from Humana will be available to IPA to explain the methodology
employed in any calculation permitted or required hereunder. In addition, the
Manual contains general principals to be employed in calculations and
illustrative examples. The parties understand that the method of calculation may
change if that is necessary to make the results more accurate.

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PAYMENT ATTACHMENT
 
1.  REIMBURSEMENT
 
A. Commercial Plan(s)

IPA agrees to accept as payment in full from Humana for Covered Services
rendered to Members of commercial plan(s) covered by this Agreement, the lesser
of IPA’s billed charges or the amount specified below, less any Copayments due
from Members.

Service:
Reimbursement:
   
Drugs & Biologicals
100 % of Humana’s 201-544 fee schedule
   
All other services
100 % of Humana’s 006-333 fee schedule

 
For any claims for Covered Services rendered to such Members that are billed
under codes not listed on Humana’s (006-333) fee schedule, IPA agrees to accept
as payment in full from Humana for such Covered Services one hundred percent
(100%) of Humana’s (005-333) fee schedule or IPA’s billed charges, whichever is
less, less any Copayments due from Members.

For services of a physician extender, IPA agrees and shall require the physician
extender to agree to accept as payment in full from Humana for Covered Services
rendered to Members of commercial plan(s) covered by this Agreement, eighty
percent (80%) of Humana’s (006-333) fee schedule or IPA’s billed charges,
whichever is less, less any Copayments due from Member.  For any claims for
Covered Services rendered to such Members that are billed under codes not listed
on Humana’s (006-333) fee schedule, IPA agrees and shall require the physician
extender to agree to accept as payment in full from Humana for such Covered
Services eighty percent (80%) of Humana’s (005-333) fee schedule or IPA’s billed
charges, whichever is less, less any Copayments due from Members.

B. Medicare PPO Plan(s)

IPA agrees to accept as payment in full from Humana for Covered Services
rendered to Members of Medicare PPO plan(s) covered by this Agreement, one
hundred percent (100%) of Humana’s (005-333) fee schedule or IPA's billed
charges, whichever is less, less any Copayments due from Member.

For services of a physician extender, IPA agrees and shall require the physician
extender to agree to accept as payment in full from Humana for Covered Services
rendered to  Members of Medicare Advantage plan(s) covered by this Agreement,
eighty percent (80%) of Humana’s (005-333) fee schedule or IPA’s billed charges,
whichever is less, less any Copayments due from Member.

C. Medicare HMO and POS Plan(s)

See Percentage of Premium Payment Attachment
 

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D. Traditional Plan(s)

IPA agrees to accept as payment in full from Humana for Covered Services
rendered to Members of traditional plan(s) covered by this Agreement, one
hundred percent (100%) of Humana’s (005-333) fee schedule, or IPA’s billed
charges, whichever is less, less any Copayments due from Members.

For services of a physician extender, IPA agrees and shall require the physician
extender to agree to accept as payment in full from Humana for Covered Services
rendered to Members of commercial plan(s) covered by this Agreement, eighty
percent (80%) of Humana’s (005-333) fee schedule or IPA’s billed charges,
whichever is less, less any Copayments due from Member.  

2. Fee Schedule Description

201-544 Fee Schedule:

Humana’s injectable fee schedule (201-544) uses a percentage of the CMS Average
Sales Price (ASP) or another industry standard as the basis of the 201-544 fee
schedule. The fee schedule includes the following administration codes: 90465,
90466, 90467, 90468, 90471, 90472, 90473, and 90474. Notwithstanding anything to
the contrary in the Agreement, in the event the basis for the schedule is
changed from a percentage of ASP to another basis, then Humana will provide
ninety (90) days advance notice to IPA, of the new basis. The list of codes and
associated fees are reviewed and updated quarterly to reflect market pricing.
These quarterly updates, if any, as well as any change in the basis may result
in fees being adjusted either upwardly or downwardly. These updates shall be
incorporated in the Humana injectable fee schedule (201-544) without notice to
IPA, but will be made available to IPA, upon request.

006-333 Fee Schedule:

Humana’s (006-333) fee schedule is based upon a modified version of the 2007
Medicare Resource Based Relative Value Scale (“RBRVS”) fee schedule and payment
systems, including the site-of-service payment differential. Various percentages
are applied by Humana to the fees in the schedule for specific Current
Procedural Terminology (“CPT”) and Healthcare Common Procedure Coding System
(“HCPCS”) codes or ranges of CPT and HCPCS codes.

Humana may modify schedule (006-333) to include codes and/or fees for services
that are not included in this fee schedule (hereinafter “Gap Codes”). In most
cases, the Gap Codes are adjusted by Humana using the relative value unit
(“RVU”) multiplied by Medicare’s conversion factor and geographic factor to
assign the fee at the same percentage applied by Humana for other codes within
that code range.

Additionally, Humana may incorporate new CPT and HCPCS codes into schedule
(006-333). The fee attributable to such code(s) will be determined by applying
the same percentage as Humana applied to other codes within such code range to
that code’ s RBRVS which is current as of the date of creation of the code.

Humana will also modify the fee for a code if the RVU for the code changes as
herein described. RVU increases for a code will be measured by dividing the
revised Total RVU by the prior Total RVU. “Total RVU” means the sum of all three
RVU components, physician work, overhead and malpractice. If the resulting
quotient is 1.25 or greater or .75 or lesser, the revised fee for such code will
be determined by applying the same percentage as Humana applied to other codes
within such code range to that code’s RBRVS which is current as of the date of
publication of the revised RVU.

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Periodic updates for new CPT codes, HCPCS codes and/or Gap Codes, or for
modifications of fees resulting from adjustments to a code’s RVU as specified
above, shall be incorporated into schedule (006-333) without notice to IPA, but
will be available to IPA upon request. Humana may make other adjustments and
modifications to this fee schedule. In such cases, Humana will provide IPA a
ninety (90) day written notice prior to implementation of any other
modifications and adjustments to schedule (006-333).

005-333 Fee Schedule:

Humana’s (005-333) fee schedule is based on the RBRVS fee schedule and payment
systems, including the site-of-service payment differential, in effect as of the
effective date of this Agreement and will change thereafter to reflect the
annual updates to the schedule made by the Centers for Medicare and Medicaid
Services (“CMS”). Additionally, Humana will adjust the schedule to include and
assign fees for services which are not covered by RBRVS. A list of those Humana
adjusted codes and fees will be available to IPA upon request.

Such annual updates by CMS and any corresponding adjustments by Humana shall be
incorporated herein without notice to the IPA, but will be available to the IPA
upon request. Humana may make other adjustments and modifications to the fee
schedule. In such cases, Humana will provide to IPA a ninety (90) day written
notice prior to implementation of any other modifications and adjustments to the
fee schedule.

D. Fee Schedule Samples

Humana has provided a representative sample of these fee schedules to IPA prior
to IPA’s execution of this Agreement, and thereafter will supply a sample upon
written request by IPA. IPA hereby acknowledges receipt of fee schedule sample.

3.  IPA EXTENDERS

IPA agrees that in the event that IPA employs, subcontracts or dependently
contracts with or uses the services of a physician extender (that is a physician
assistant, advanced registered nurse practitioner, certified registered nurse
anesthetist, certified nurse midwife, certified surgical assistant, certified
registered nurse first assistant or such other similarly situated individual)
who will be providing services to Humana Members under the supervision of IPA,
IPA shall notify Humana in writing, upon execution of this Agreement and at any
time during the term of this Agreement when such physician extenders are
employed, subcontracted, or independently contracted with IPA, and the specific
services that such physician extenders will be performing, prior to the
provision of services to any Humana Member. IPA represents that physician
extenders employed by or under contract with IPA will comply with the terms and
conditions of this Agreement, maintain professional liability coverage and are
appropriately licensed as required by applicable state and federal laws, rules
and regulations. IPA acknowledges and agrees Humana retains the right to
approve, suspend and/or terminate participation under this Agreement of any
physician extender who will be providing services to Humana Members.

4. SPECIFIC REFERRALS

IPA and other Participating Providers acknowledge and agree that certain
referrals are required to be made to specific providers designated by Humana.
The specific referral providers include but are not limited to:
 
Services:
 
Vendor Entity:
Laboratory
 
Humana’s Current Participating Providers
Mental Health
 
Humana’s Current Participating Providers
Vision
 
Humana’s Current Participating Providers
Podiatry
 
Humana’s Current Participating Providers
Dental
 
Humana’s Current Participating Providers
Chiropractic
 
Humana’s Current Participating Providers
Hearing
 
Humana’s Current Participating Providers
Admitting
 
Humana’s Current Participating Providers
Home Health/Infusion/DME
 
Humana’s Current Participating Providers

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IPA and other Participating Providers further acknowledge and agree that such
specific providers may be changed or added to upon written notice by Humana to
IPA.

5. MISCELLANEOUS 

IPA understands that Humana may market or administer products that contain
variable Copayment amounts due from the Member for Covered Services based on the
medical specialty of certain physicians and the unit costs or reimbursement
rates provided for in provider participation agreements. IPA agrees to
participate in such products and to bill and accept as payment in full for
Covered Services rendered to Members in such products the reimbursement rates
set forth above less any Copayment amounts due from the Member.

In circumstances where the Member's Copayment for a Covered Service is equal to
or greater than the rate set forth herein for that service, IPA agrees to accept
as payment in full for the service the Member's Copayment, not to exceed the
rates set forth herein. Furthermore, in such cases, IPA agrees to refund to
Member the difference, if any, between the Copayment collected from the Member
and such rate.

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HMO PROVISIONS
ATTACHMENT

The following provisions apply solely to commercial HMO and/or Medicare
Advantage HMO products and plans, as applicable.

I.
Services to Members.  In the event IPA provides a Member a non-covered service
or refers a Member to an out-of-network provider without pre-authorization from
Humana, IPA shall, prior to the provision of such non-covered service or
out-of-network referral, inform the Member: (i) of the service(s) to be provided
or referral(s) to be made; (ii) that Humana will not pay or be liable
financially for such non-covered service(s) or out-of-network referral(s); and
(iii) that Member will be responsible financially for non-covered service(s)
and/or out-of-network referral(s) that are requested by the Member.

II.
Continuity of Care. Subject to and in accordance with all applicable state
and/or federal laws, rules and/or regulations, treatment following termination
or expiration of this Agreement must continue until the Member: (i) has been
evaluated by a new participating provider who has had a reasonable opportunity
to review or modify the Member's course of treatment, or until Humana has made
arrangements for substitute care for the Member; and (ii) until the date of
discharge for Members hospitalized on the effective date of termination or
expiration of this Agreement. IPA agrees to accept as payment in full from
Humana for Covered Services rendered to such Members, the rates set forth in the
payment attachment, less any Copayments due from such Members.

III.
Medical Records. Upon request from Humana or a Member, IPA shall transfer a
complete copy of the medical records of any Member transferred to another IPA
and/or facility for any reason, including termination or expiration of this
Agreement. The copy and transfer of medical records shall be made at no cost to
Humana or the Member and shall be made within a reasonable time following the
request, but in no event more than five (5) business days, except in cases of
emergency where the transfer shall be immediate. IPA agrees that such timely
transfer of medical records is necessary to provide for the continuity of care
for Members. IPA agrees to pay court costs and/or legal fees incurred by Humana
or the Member to enforce the terms of this provision.

IV.
Acquisitions. In the event IPA acquires, through an asset acquisition, merger,
consolidation, lease or other means, or enters into a management agreement to
manage the practice(s) of IPA(s) or IPA group(s) in Marion, Sumter, Lake, Polk,
Lee, Charlotte, Collier, Manatee, Sarasota, Martin, St Lucie, Okeechobee and
Glades counties, and such practices or groups have in effect an agreement with
Humana to provide services to Humana’s Members at rates which are more favorable
to Humana than those contained herein, the rates of such acquired practices or
groups shall survive and shall not be adjusted to reflect the rates contained in
this Agreement unless agreed to in writing by both Humana and IPA.

V.
Equal Access.  IPA agrees to accept Humana Members as patients within the normal
scope of IPA’s medical practice. If, due to overcapacity, IPA closes his/her
practice to new patients, such closure will apply to all prospective patients
without discrimination or regard to payor or source of payment for services.
Should IPA subsequently reopen his/her practice to new patients, IPA agrees to
accept Humana Members seeking assignment and/or referral to IPA’s practice to
the same extent and in the same manner as all other non-Humana patients seeking
IPA’s services.

VI.
IPA Responsibilities. 

A. Services

IPA agrees to be responsible twenty-four (24) hours a day, seven (7) days a week
for providing Covered Services for Members including, but not limited to,
prescribing, directing and monitoring all urgent and emergency care for Members.

IPA agrees to provide Humana upon request a written description of its
arrangements for emergency and urgent care and service coverage in the event of
unavailability due to vacation, illness, and after regular office hours. IPA
shall ensure that all IPAs providing such coverage are contracted and
credentialed IPAs with Humana. IPA will ensure that all IPAs providing such
coverage render services under the same terms and conditions and in compliance
with all provisions of this Agreement. Compensation to IPAs for "on call"
coverage will be the responsibility of IPA.
 

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In the event that emergency or urgent care services are needed by a Member
outside the service area, IPA agrees to monitor and authorize the out-of-area
care to provide direct care as soon as the Member is able to return to the
service area for treatment without medically harmful or injurious consequences.

B. Specific Referrals 

Except in the case of a medical emergency, IPA agrees to use its best efforts to
admit, refer, and cooperate with the transfer of Members for Covered Services
only to providers designated, specifically approved by or under contract with
Humana.

In addition, IPA acknowledges and agrees that certain Members may have health
benefits contracts that limit coverage to certain types of participating
providers. For such Members, referrals are required to be made to specific
providers designated by Humana.

C. Disease/Case Management Programs

IPA agrees to participate in Humana’s disease/case management programs as they
are developed and implemented.

D. Humana First

IPA agrees to participate in Humana’s twenty-four (24) hours nurse call program,
HumanaFirst, or any such successor program.
 
E. Hospitalist Programs

IPA agrees to cooperate with and participate in Humana’s hospitalist programs
where applicable, as they are developed and implemented.

F. Transplant Programs

Upon request by Humana, IPA agrees to cooperate with and participate in Humana’s
organ and tissue transplant programs as they are developed and implemented.

G. Health Improvement Studies

IPA agrees to participate in Humana’s health improvement studies as they are
developed and implemented.

H. Quality Improvement Activities

IPA agrees to cooperate with Humana’s quality improvement activities and, upon
request by Humana, to participate in Humana’s quality improvement activities as
they are developed and implemented.

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MEDICARE ADVANTAGE PROVISIONS

The following additional provisions relate specifically to Medicare Advantage
products and plans and are hereby incorporated by reference into the Agreement.

a)
IPA agrees to: (i) abide by all federal and state laws regarding
confidentiality, privacy and disclosure of medical records or other health and
enrollment information, (ii) ensure that medical information is released only in
accordance with applicable state or federal law, or pursuant to court orders or
subpoenas, (iii) maintain all Member records and information in an accurate and
timely manner, and (iv) allow timely access by Members to the records and
information that pertain to them.

b)
Humana and IPA agree that Humana will process all claims for Covered Services
which are accurate and complete within thirty (30) days from the date of
receipt.

c)
IPA agrees that in no event, including, but not limited to, nonpayment by
Humana, Humana’s insolvency or breach of this Agreement, shall IPA bill, charge,
collect a deposit from, seek compensation, remuneration or reimbursement from,
or have any recourse against Members or persons other than Humana (or the payor
issuing the health benefits contract administered by Humana) for Covered
Services provided by IPA for which payment is the legal obligation of Humana.
This provision shall not prohibit collection by IPA from Member for any
non-covered service and/or Copayments in accordance with the terms of the
applicable Member health benefits contract. IPA further agrees that: (i) this
provision shall survive the expiration or termination of this Agreement
regardless of the cause giving rise to expiration or termination and shall be
construed to be for the benefit of the Member; (ii) this provision supersedes
any oral or written contrary agreement now existing or hereafter entered into
between IPA and Member or persons acting on their behalf; and (iii) this
provision shall apply to all employees, agents, trustees, assignees,
subcontractors, and independent contractors of IPA, and IPA shall obtain from
such persons specific agreement to this provision.

d)
IPA agrees to cooperate with Humana in its efforts to monitor compliance with
its Medicare Advantage contract(s) and/or Medicare Advantage rules and
regulations and to assist Humana in complying with corrective action plans
necessary for Humana to comply with such rules and regulations.

e)
IPA agrees that nothing in the Agreement shall be construed as relieving Humana
of its responsibility for performance of duties agreed to through its Medicare
Advantage contracts existing now or entered into in the future with CMS.

f)
IPA agrees to comply with and be subject to all applicable Medicare program
laws, rules and regulations, reporting requirements, and CMS instructions as
implemented and amended by CMS. This includes, without limitation, federal and
state regulatory agencies’ including, but not limited to, HHS, the Comptroller
General or their designees rights to evaluate, inspect and audit IPA’s
operations, books, records, and other documentation and pertinent information
related to IPA’s obligations under the Agreement, as well as all other federal
and state laws, rules and regulations applicable to individuals and entities
receiving federal funds. IPA further agrees HHS', the Comptroller General's, or
their designees right to inspect, evaluate and audit any pertinent information
for any particular contract period will exist through ten (10) years from the
final date of the contract period between Humana and CMS or from the date of
completion of any audit, whichever is later, and agrees to cooperate, assist and
provide information as requested by such entities.

 

g)
IPA agrees to retain all contracts, books, documents, papers and other records
related to the provision of services to Medicare Advantage Members and/or as
related to IPA’s obligations under the Agreement for a period of not less than
ten (10) years from: (i) each successive December 31; or (ii) the end of the
contract period between Humana and CMS; or (iii) from the date of completion of
any audit, whichever is later.

h)
IPA agrees in the event certain identified activity(ies) have been delegated to
IPA under the Agreement, any sub-delegation of the noted activity(ies) by IPA
requires the prior written approval of Humana. Notwithstanding anything to the
contrary in the Agreement, Humana will monitor IPA’s performance of any
delegated activity(ies) on an ongoing basis and hereby retains the right to
modify, suspend or revoke such delegated activity(ies) in the event Humana
and/or CMS determines, in their discretion, that IPA is not meeting or has
failed to meet its obligations under the Agreement related to such delegated
activity(ies). In the event that Humana has delegated all or any part of the
claims payment process to IPA under the Agreement, IPA shall comply with all
prompt payment requirements to which Humana is subject. Humana agrees that it
shall review the credentials of IPA or, if Humana has delegated the
credentialing process to IPA, Humana shall review and approve IPA’s
credentialing process and audit it on an ongoing basis.

1

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i)
IPA agrees to comply with Humana’s policies and procedures.

j)
IPA agrees to maintain full participation status in the federal Medicare
program. This also includes all of IPA’s employees, subcontractors, and/or
independent contractors who will provide services, including, without
limitation, health care, utilization review, medical social work, and/or
administrative services under the Agreement.

k)
IPA agrees that payment from Humana for services rendered to Humana’s Medicare
Advantage Members is derived, in whole or in part, from federal funds received
by Humana from CMS.

l)
IPA agrees to disclose to Humana, upon request and within thirty (30) days or
such lesser period of time required for Humana to comply with all applicable
state or federal laws, all of the terms and conditions of any payment
arrangement that constitutes a “physician incentive plan” as defined by CMS
and/or any federal law or regulation. Such disclosure should identify, at a
minimum, whether services not furnished by the physician/provider are included,
the type of incentive plan including the amount, identified as a percentage, of
any withhold or bonus, the amount and type of any stop-loss coverage provided
for or required of the physician/provider, and the patient panel size broken
down by total group or individual physician/provider panel size, and by the type
of insurance coverage (i.e., Commercial HMO, Medicare Advantage HMO, Medicare
PPO, and Medicaid HMO).

m)
IPA agrees that in the event of Humana’s insolvency or termination of Humana’s
contract with CMS, benefits to Members will continue through the period for
which premium has been paid and benefits to Members confined in an inpatient
facility will continue until their discharge.

n)
IPA agrees to provide or arrange for continued treatment, including, but not
limited to, medication therapy, to Medicare Advantage Members upon expiration or
termination of the Agreement. In accordance with all applicable state and
federal laws, rules and/or regulations, treatment must continue until the
Member: (i) has been evaluated by a new participating provider who has had a
reasonable opportunity to review or modify the Medicare Advantage Member’s
course of treatment, or until Humana has made arrangements for substitute care
for the Medicare Advantage Member; and (ii) until the date of discharge for
Medicare Advantage Members hospitalized on the effective date of termination or
expiration of the Agreement. IPA agrees to accept as payment in full from Humana
for Covered Services rendered to Humana’s Medicare Advantage Members, the rates
set forth in the payment attachment which are applicable to such Member.

o)
IPA agrees to cooperate with the activities and/or requests of any independent
quality review and improvement organization utilized by and/or under contract
with Humana as related to the provision of services to Medicare Advantage
Members.

p)
IPA agrees to cooperate with Humana’s health risk assessment program.

q)
IPA agrees to provide to Humana accurate and complete information regarding the
provision of Covered Services by IPA to Members (“Data”) on a complete CMS 1500
or UB 92 form, or their respective successor forms as may be required by CMS, or
such other form as may be required by law when submitting claims and encounters
in an electronic format, or such other format as is mutually agreed upon by both
parties. The Data shall be provided to Humana on or before the last day of each
month for encounters occurring in the immediately preceding month, or such
lesser period of time as may be required in the Agreement, or as is otherwise
agreed upon by the parties in writing. The submission of the Data to Humana
and/or CMS shall include a certification from IPA that the Data is accurate,
complete and truthful. In the event the Data is not submitted to Humana by the
date and in the form specified above, Humana may, in its sole option, withhold
payment otherwise required to be made under the terms of the Agreement until the
Data is submitted to Humana.

2

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r)
IPA agrees not to collect or attempt to collect copayments, coinsurance,
deductibles or other cost-share amounts from any Humana Medicare Advantage
Member who has been designated as a Qualified Medicare Beneficiary (“QMB”) by
CMS.

s)
IPA agrees to maintain written agreements with employed and contracted health
care providers and health care professionals providing services under the
Agreement in a form comparable to, and consistent with, the terms and conditions
of the Agreement. IPA’s downstream provider agreements shall include terms and
conditions which comply with all applicable requirements for provider agreements
under state and federal laws, rules and regulations including, without
limitation, the Medicare Advantage rules and regulations to which Humana is
subject. In the event of a conflict between the language of the downstream
provider agreements and the Agreement, the language in the Agreement shall
control.

3

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STATE LAW COORDINATING PROVISIONS
ATTACHMENT

FLORIDA

[Please note that none of the provisions of this attachment apply to any
Medicare line(s) of business covered by this Agreement.]

Humana and IPA agree that the following provisions are incorporated into the
Agreement solely to the extent specifically required to ensure compliance with
applicable Florida laws, rules and regulations.
 
Term and Termination

 
1
This Agreement may be terminated upon issuance of an order by the Office of
Insurance Regulation (“OIR”) requiring such termination pursuant to section
641.234, The issuance of such an order by the OIR will not affect the
termination of the entire Agreement which shall remain in full force and effect
with respect to Humana Health Insurance Company of Florida, Inc. and/or Humana
Insurance Company and product lines contemplated in the Agreement to which this
provision is made a part.

 
2
As required under Florida Statute §641.315, IPA shall provide the OIR and Agency
for Health Care Administration (“AHCA”) with sixty (60) days notice of any
intended termination of the Agreement Humana shall also provide sixty (60) days
advance written notice to the IPA at the address listed in the “Notice” Article
of this Agreement, and to the OIR before canceling, without cause, this
Agreement with IPA. Nonpayment for goods or services rendered by IPA to Humana
or any of its Members shall not be a valid reason for avoiding such sixty (60)
day advance notice of cancellation. Upon receipt by Humana of a sixty (60) day
cancellation notice, Humana, if requested by the IPA, may terminate the contract
in less than sixty (60) days if Humana is not financially impaired or insolvent.

 
3
Humana and IPA hereby acknowledge and agree that the provisions stated in the
previous paragraph do not relieve the IPA of any of their other obligations
under this Agreement that are not inconsistent with the foregoing, including
without limitation, any obligation IPA has to provide more than sixty (60) days
notice of cancellation of this Agreement to Humana.

 
4
In the event that this Agreement expires and/or is terminated for whatever
reason, IPA shall continue Member(s)’ course of treatment at the payment rates
set out in the payment attachment, including, but not limited to medication
therapy, until the earlier of the following occurrence: (i) the expiration of
six (6) months past the effective date of expiration or termination; or (ii) the
Member(s) has been evaluated by a new Participating Physician and the new
Participating Physician has had a reasonable opportunity to review or modify
Member(s)’ course of treatment; or (iii) the completion of the Member’s course
of treatment which the Member began prior to the effective date of expiration or
termination of this Agreement; or (iv) for those Members who are pregnant, until
completion of postpartum care.

Grievance and Appeals/Binding Arbitration/Dispute Resolution

 
5
IPA shall post in its facility reception areas, a notice to Members on the
process for resolving complaints with Humana. Such notice shall include the
Florida Agency for Health Care Administration (AHCA), the Florida Subscriber
Assistance Program and the Florida Office of Insurance Regulation respective
addresses and toll-free telephone numbers for filing complaints. In addition,
IPA will make Humana’s Grievance Department address and telephone number
available to Members upon request.

 
6
Physician acknowledges and agrees that in the event it is unable to resolve
directly disputes that may arise with Humana, IPA will exhaust all internal
Humana administrative appeal, grievance or other dispute resolution mechanisms
prior to the submission of any unresolved disputes to a third party.

 

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IPA has the right to dispute reimbursement of a claim for a period of up to
twelve (12) months from the date such claim was paid or denied by Humana. In the
event of such a dispute, the parties agree to work toward a mutually agreeable
resolution of such dispute. IPA shall provide at a minimum the following
information if the IPA contests the payment of a claim as set out herein: Member
name and identification number, date of service, relationship of the
Member-patient to the Member who completed the application for health benefits
coverage with Humana, claim number, name of the IPA of medical and related
health care services, charge amount, payment amount, the allegedly correct
payment amount, difference between the amount paid and the allegedly correct
payment amount and a brief explanation of the basis for the contestation. Humana
will review such contestation(s) and respond to Group within thirty (30) days of
the date of receipt by Humana of such contestation. The parties agree to use
their best efforts to negotiate a mutually agreeable resolution within the sixty
(60) day period following submission of the claim contestation to Humana. In the
event the parties are unable to come to a mutually agreeable resolution within
the above noted sixty (60) day time period, either party may submit such
disputed claims to binding arbitration as stated below. Failure to contest the
amount of any claim hereunder within the time specified above shall result in a
waiver of IPA’s right to contest such claim amount distributed.

In the event IPA continues to dispute or contest the payment or denial of a
claim for Covered Services rendered Members, following the parties attempts to
negotiate a mutually agreeable resolution, IPA may submit such claims payment
disputes or contestations to the claim dispute resolution program established
under §408.7057, Florida Statutes as provided for and in accordance with the
specific terms and limitations set forth thereunder. The parties agree that the
date a claim is paid or denied by Humana, or its designee, is the ‘final
determination’ of Humana for purposes of any claims payment disputes that may be
submitted to the Florida claim dispute resolution program hereunder. IPA
acknowledges and agrees that should IPA continue to dispute the payment or
denial of a claim for Covered Services following submission to the above noted
Florida claim dispute resolution program, such unresolved claims disputes are
subject to the binding arbitration provision set forth below. IPA further
acknowledges and agrees that all other disputes under this Agreement are subject
to the binding arbitration provision set forth below.

Notwithstanding the above and subject to Sections 21.1and 21.2 above, IPA may
elect to submit such unresolved claim payment disputes or contestations for a
claim for Covered Services rendered to Members to binding arbitration as set
forth below. Should IPA elect to submit such unresolved claim disputes or
contestations to binding arbitration, IPA acknowledges and agrees that such
submission to binding arbitration is the final and exclusive remedy for such
unresolved claim payment disputes or contestations.

Subject to this section, in the event of a dispute between IPA and Humana which
is not resolved as set forth above or which the parties cannot settle by mutual
agreement, the dispute shall be resolved by binding arbitration, conducted by a
single arbitrator selected by the parties from a panel of arbitrators proposed
by the American Arbitration Association (“AAA”). This applies, without
limitation, to any dispute arising out of the parties’ business relationship,
including allegations or claims involving violations of state or federal laws or
regulations. In the event the parties cannot agree on the arbitrator, then the
arbitrator shall be appointed by the AAA. The arbitration shall be conducted in
Broward County, Florida, in accordance with and subject to the Commercial
Arbitration Rules of the AAA then in effect, or under such other mutually agreed
upon guidelines. Judgment upon the award rendered in any such arbitration may be
entered in any court of competent jurisdiction sitting in Florida or Kentucky or
application may be made to such court for judicial acceptance and enforcement of
the award, as applicable law may require or allow. The submission of any dispute
to arbitration shall not adversely affect any party’s right to seek preliminary
injunctive relief with respect to an actual or threatened termination,
repudiation or rescission of the Agreement. The cost of any arbitration
proceeding(s) hereunder shall be borne equally by the parties. Each party shall
be responsible for its own attorneys’ fees and such other costs and expenses
incurred related to the proceedings. Arbitration proceeding(s) hereunder shall
be conducted solely between IPA and Humana, class-based arbitration shall not be
permitted. The parties agree that in the event an issue or dispute is submitted
by either party to the binding arbitration process set forth herein, the result
will be the final and exclusive remedy and by submission to binding arbitration,
the parties waive other remedies that may be available at law. The parties agree
this Agreement is a transaction involving interstate commerce and therefore that
the Federal Arbitration Act, 9 U.S.C. §1 et seq. applies.

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Claims Submission and Payment

 
7
IPA agrees to submit all claims eligible for payment as provided under this
Agreement within: (i) one hundred eighty (180) days from the date of service or
date of discharge from an inpatient facility, as applicable, for primary
insurers; and (ii) ninety (90) days following the date of final determination by
the primary insurer for secondary insurers. Humana may, at its sole discretion,
deny payment for any such claim(s) received after the above noted time periods.
IPA acknowledges and agrees that at no time shall Members be responsible for any
payments in addition to applicable Copayments for Covered Services provided to
such Members. In the event the payment is denied as described herein, the
Member’s Copayment, if any, shall be adjusted accordingly.

In accordance with requirements for requests for refund of overpayments of
claims established under Florida law, IPA shall be notified in writing by Humana
of any monies IPA may owe Humana, for any reason, and Hospital shall have: (i)
forty (40) days from receipt of such notification to refund overpayments of
claims due to Humana under this Agreement; or (ii) thirty-five (35) days from
receipt of such notification to contest or deny the request. The IPA’s
contestation or denial of overpayment of claims owed must be in writing and must
state the specific reason for contesting or denying. IPA agrees that as the
mutually agreed upon method of reconciliation for requests for refund of
overpayment of claims amounts due hereunder, Humana may deduct monies that
otherwise may be due and payable to Humana from any outstanding monies that
Humana may, for any reason, owe IPA, if: (a) IPA agrees in writing to the offset
of monies; or (b) IPA does not appropriately respond to a request for refund of
overpayments as indicated hereunder within the above noted time periods. The
parties agree that requests for refund of overpayments of claims are limited to
the thirty (30) month period following the date the claim was paid, except in
cases of fraud. 

Notwithstanding anything to the contrary in this Agreement and subject to
requests for refund of overpayments of claims, IPA agrees that Humana may make
retroactive adjustments to the payments made in accordance with the payment
arrangements outlined in the payment attachment for changes in enrollment and/or
eligibility and other business reasons including, but not limited to, claims
payment errors, data entry errors, capitation errors and incorrectly submitted
claims. Excluding government programs, including without limitation any Medicare
Advantage plan and/or Medicaid HMO plan, offered or administered by Humana and
governed under federal laws, rules and regulations, and programs not otherwise
governed under Florida law, the parties agree that retroactive adjustments to
payments made to IPA for changes in enrollment and/or eligibility status are
limited to the one (1) year period following the date the claim was paid or
denied.  

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Amendment

To Independent Practice Association Participation Agreement
 
This AMENDMENT is entered into this __ day of__________________, 2008 by and
between Metcare of Florida, Inc (herein referred to as “IPA”) and Humana Medical
Plan, Inc., Humana Health Insurance Company Of Florida, Inc., and, Humana
Insurance Company, and their affiliates who underwrite or administer health
benefit plans (collectively, “HUMANA”).

WHEREAS, the parties entered into an Independent Practice Association
Participation Agreement effective ______________________, (“Agreement”);

WHEREAS, the parties desire to further amend the terms of the Agreement:

NOW, THEREFORE, for good and valuable consideration, the receipt and sufficiency
of which are hereby acknowledged by the parties, the parties hereto agree as
follows:

 
1.
The Letter Of Credit Attachment, attached hereto, is hereby added to the
Agreement.

 
The effective date of this Amendment shall be ______________________. 

ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.

IN WITNESS WHEROF, the parties have executed the Amendment the day and year
first above written.

IPA
   
HUMANA
 

By:
      
By:
    

Print Name:
      
Print Name:
   

Title:
     
Title:
   

Date:
     
Date:
   

Tax ID#: 65-0879131
Humana Medical Plan, Inc.
 
Humana Health Insurance Co. of FL, Inc.
 
Humana Insurance Company

 
Amendment
1 of 3
 
June 19, 2008
   
IPA_FL_08152006
   

 

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Amendment

To Independent Practice Association Participation Agreement
 
Letter of Credit
Attachment

Metcare of Florida Inc (herein referred to as IPA) shall provide HUMANA, by
September 1, 2008, with an irrevocable standby letter of credit initially in the
amount of one million dollars ($1,000,000.00) (“Letter of Credit Amount”), a
copy of which shall be attached hereto as Attachment A1. The Letter of Credit
Amount shall be reviewed quarterly and may be adjusted with HUMANA’s approval.
In the event the Letter of Credit Amount is to be increased or decreased as a
result of the review described above, IPA shall cause to be issued a new or
amended Letter of Credit to HUMANA for its written approval. The then current
Letter of Credit shall not expire until such new or amended Letter of Credit is
delivered to HUMANA and HUMANA has issued its written approval.

Each Letter of Credit, and any drawing instructions contained therein, shall be
in form and substance satisfactory to HUMANA and in HUMANA’s name, shall be
irrevocable, shall be drawn on a financial institution acceptable to HUMANA, and
shall be payable at sight and after the date of issuance at such financial
institution or a branch or office thereof when accompanied by a written
statement or drawing certificate signed by an authorized representative of
HUMANA in the a form described in the Letter of Credit.

In the event HUMANA has received notice of cancellation or non-renewal from the
issuer of the Letter of Credit within ninety (90) days prior to the expiration
date of the Letter of Credit, or within ninety (90) days prior to the expiration
date of any succeeding renewal period pertaining to a Letter of Credit, IPA
shall have three (3) business days to obtain a renewal or a replacement Letter
of Credit issued in accordance with the terms hereof. In the event that a
renewed or replacement Letter of Credit is not provided by IPA to HUMANA within
such time period, HUMANA may immediately draw down the entire amount, or balance
thereof, of the Letter of Credit. In addition, such failure to renew or replace
the Letter of Credit shall constitute a breach and default by IPA under this
Agreement, and HUMANA may thereafter terminate this Agreement effective upon the
earlier of the expiration date of the Letter of Credit or ninety (90) days
notice to IPA, and hold all proceeds of the Letter of Credit until completion of
the final settlement.

In the event HUMANA at any time draws down the Letter of Credit, IPA shall,
within three (3) business days of the satisfaction of the draw by the issuer,
replenish the Letter of Credit by an amount equal to the amount of the draw. In
the event that the Letter of Credit is not replenished in such amount within
such time period, HUMANA may immediately draw down the balance of the Letter of
Credit. In addition, such failure to replenish the Letter of Credit shall
constitute a breach and default by IPA under this Agreement, and HUMANA may
thereafter terminate this Agreement effective upon the earlier of the expiration
date of the Letter of Credit or ninety (90) days following the end of the three
(3) business day period described above, and hold all proceeds until completion
of final settlement under the terms of this Agreement.
 
Amendment
2 of 3
 
June 19, 2008
   
IPA_FL_08152006
   

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Amendment

To Independent Practice Association Participation Agreement

If at any time HUMANA determines that the total financial deficits attributable
to IPA under this Agreement exceeds the Letter of Credit Amount, HUMANA shall
give written notice to IPA of such deficits, together with its calculations
thereof, IPA shall have ten (10) business days following such notice to increase
the Letter of Credit Amount by an amount equal to the amount of the deficit
which is in excess of the Letter of Credit Amount. In the event IPA does not
increase the Letter of Credit by such amount within the ten (10) business day
period described above, such failure shall constitute a breach and default by
IPA under this Agreement, and HUMANA may draw upon the entire amount of the
Letter of Credit and hold all proceeds until completion of final settlement
under the terms of this Agreement and thereafter may terminate this Agreement
effective upon the earlier of the expiration date of the Letter of Credit or
upon ninety (90) days written notice of termination to IPA

Notwithstanding anything to the contrary in this Agreement, HUMANA may upon
written notice to IPA upon the failure of IPA to provide a Letter of Credit, or
replacement or amendment thereof, or to replenish a drawn upon Letter of Credit,
as required under this Agreement, and without prejudice to any other rights of
HUMANA stated herein, offset any part or all of IPA payments from HUMANA under
the terms of this Agreement up to the Letter of Credit Amount.
 
Amendment
3 of 3
 
June 19, 2008
   
IPA_FL_08152006
   

 

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