Exhibit
10.150


 


CaliforniaCare


 


MEDICAL SERVICES AGREEMENT


 


 












*** Confidential
Information omitted and filed separately with the Securities and Exchange
Commission.


 

















 


CALIFORNIACARE

MEDICAL SERVICES AGREEMENT


 


TABLE
OF CONTENTS


 


	
  I.

  	
  RECITALS

  	
   

  
	
   

  	
   

  	
   

  
	
  II.

  	
  DEFINITIONS

  	
   

  
	
   

  	
   

  	
   

  
	
  III.

  	
  RELATIONSHIP
  BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  IV.

  	
  PARTICIPATING
  MEDICAL GROUP SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  V.

  	
  BLUE CROSS
  SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  VI.

  	
  ELIGIBILITY LISTINGS

  	
   

  
	
   

  	
   

  	
   

  
	
  VII.

  	
  COMPENSATION
  TO PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  VIII.

  	
  ENROLLMENT PROTECTION

  	
   

  
	
   

  	
   

  	
   

  
	
  IX.

  	
  NON-CAPITATED SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  X.

  	
  OUTPATIENT
  PRESCRIPTION DRUG EXPENSE

  	
   

  
	
   

  	
   

  	
   

  
	
  XI.

  	
  QUALITY MANAGEMENT BONUS

  	
   

  
	
   

  	
   

  	
   

  
	
  XII.

  	
  BILLING
  FOR HMO-USA AWAY FROM HOME CARE SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  XIII.

  	
  TERM OF AGREEMENT,
  TERMINATION

  	
   

  
	
   

  	
   

  	
   

  
	
  XIV.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  XV.

  	
  CALIFORNIACARE
  MEMBER GRIEVANCE SYSTEM

  	
   

  
	
   

  	
   

  	
   

  
	
  XVI.

  	
  MISCELLANEOUS PROVISIONS

  	
   

  



 


EXHIBITS


 


	
  Exhibit A

  	
   

  	
  Covered Medical Services

  
	
   

  	
   

  	
   

  
	
  Exhibit A(1)

  	
   

  	
  Division of Financial Responsibilities

  
	
   

  	
   

  	
   

  
	
  Exhibit B

  	
   

  	
  CALIFORNIACARE Hospitals

  
	
   

  	
   

  	
   

  
	
  Exhibit C

  	
   

  	
  Administrative Responsibilities of
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
   

  	
   

  
	
  Exhibit D

  	
   

  	
  Capitation

  
	
   

  	
   

  	
   

  
	
  Exhibit E

  	
   

  	
  Physician Fee Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit F

  	
   

  	
  Non-Capitated Performance Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit G

  	
   

  	
  Compensation for Services to BLUE CROSS PLUS
  Members

  
	
   

  	
   

  	
   

  
	
  Exhibit G-1

  	
   

  	
  BLUE CROSS PLUS 1997 Baseline Capitation

  
	
   

  	
   

  	
   

  
	
  Exhibit H

  	
   

  	
  Outpatient Prescription Drug Performance
  Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit I

  	
   

  	
  Quality Management Bonus Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit J

  	
   

  	
  PARTICIPATING MEDICAL GROUP Facilities

  



 

















 


CALIFORNIACARE


 


MEDICAL SERVICES
AGREEMENT


 


This AGREEMENT is effective on January 1, 1997
between BLUE CROSS OF CALIFORNIA and Affiliates (jointly and severally “BLUE
CROSS”) and NORTHWEST ORANGE COUNTY MEDICAL GROUP, (“PARTICIPATING MEDICAL
GROUP”).


 


I.              RECITALS


 


1.01      BLUE CROSS is a
California Corporation licensed by the California Commissioner of Corporations
to operate a health care service plan pursuant to the Knox-Keene Health Care
Service Plan Act of 1975 and the Rules of the California Commissioner of
Corporations promulgated thereunder (California Health & Safety Code,
Sections 1340 to 1399.64 and California Code of Regulations, Sections 1300.43
to 1300.99, collectively, the “Knox-Keene Act”), including without limitation
to issue Benefit Agreements covering the provision of health care services and
to enter into agreements with PARTICIPATING MEDICAL GROUP.


 


1.02      PARTICIPATING
MEDICAL GROUP is a Professional Corporation, a legal entity organized under the laws of
the State of California and comprised of physicians who desire to provide and
arrange for health services to persons who are enrolled in BLUE CROSS’
CALIFORNIACARE programs.


 


II.            DEFINITIONS


 


2.01      “Adjusted Per
Member Per Month Non-Capitated Expense” means the PARTICIPATING MEDICAL GROUP’s Per
Member Per Month Non-Capitated Expense after adjustments for the PARTICIPATING
MEDICAL GROUP’s mix of Member age/sex and plan, and the PARTICIPATING MEDICAL
GROUP’s stop-loss and regional relativities for use in identifying the
PARTICIPATING MEDICAL GROUP’s Non-Capitated Performance Settlement.


 


2.02      “Affiliate” means a
corporation or other organization owned or controlled, either directly or
through parent or subsidiary corporations, by BLUE CROSS, or under common
control with BLUE CROSS.


 


2.03      “Age/Sex Factors” means the factors
used to adjust PARTICIPATING MEDICAL GROUP’s Per Member Per Month Non-Capitated
Expenses to account for cost variations attributable to the mix of Member age
and sex.


 


2.04      “Alternative
Birthing Center Services” means services rendered by an Alternative Birthing
Center.  Alternative Birthing Center
Services include related services such as equipment, surgical and anesthetic
supplies, oxygen and drugs, blood and blood processing, laboratory procedures and
diagnostic imaging.


 


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2.05      “Ambulance
Services” means transportation services provided by a licensed ambulance company.


 


2.06      “Attachment Point” is the point at
which no settlement shall be made if the PARTICIPATING MEDICAL GROUP’s Adjusted
Per Member Per Month Non-Capitated Expense equals or exceeds that amount.  The Attachment Point is shown in the
Non-Capitated Performance Settlement Schedule as set forth in Exhibit F.


 


2.07      “Away From Home
Care” means urgent care, Away from Home Emergency Care, routine care, and
follow-up care as defined in the HMO-USA member’s plan certificate or benefit
agreement.


 


2.08      “Benefit
Agreement(s)” means the written agreement(s) entered into between BLUE CROSS and
groups or individuals, under which BLUE CROSS provides, indemnifies, or
administers health benefits to persons enrolled in BLUE CROSS programs
including, but not limited to, the CALIFORNIACARE programs or the BLUE CROSS
PLUS program. “Benefit Agreement(s)” also mean arrangements established by BLUE
CROSS and/or one or more of its Affiliates, or by persons or entities utilizing
the BLUE CROSS Managed Care Network pursuant to a contract with BLUE CROSS
and/or one or more of its Affiliates. 
Subject to the terms hereof, BLUE CROSS and/or one or more of its Affiliates
may contract, on PARTICIPATING MEDICAL GROUP’s behalf, with Other Payors
wishing to utilize the services of the BLUE CROSS Managed Care Network,
incorporating the terms and conditions of this Agreement.


 


2.09      “BLUE CROSS Managed
Care Network” means the network of health care providers that have entered into
contracts with BLUE CROSS and/or one or more of its Affiliates pursuant to
which those providers have agreed to participate in the CALIFORNIACARE, BLUE
CROSS PLUS and other programs that are to be conducted pursuant to Benefit
Agreements.


 


2.10      “BLUE CROSS PLUS” means a point of
service option benefit plan offered by BLUE CROSS under which enrolled Members
may, at the time benefits are selected, elect to receive benefits from either a
CALIFORNIACARE provider or another licensed provider.


 


2.11      “CALIFORNIACARE” means direct care
prepayment plan(s) offered by BLUE CROSS.


 


2.12      “CALIFORNIACARE
Case Manager” means a CALIFORNIACARE employee charged with assisting PARTICIPATING
MEDICAL GROUPs in case management.


 


2.13      “CALIFORNIACARE
Coordinator” means an employee of PARTICIPATING MEDICAL GROUP as set forth in
Section 4.08B.


 


2.14      “CALIFORNIACARE
Hospital” means a hospital which has entered into an agreement with BLUE CROSS to
provide Hospital Services to Members.


 


2.15      “CALIFORNIACARE
Quality Management Representative” means an employee of BLUE CROSS responsible
for the CALIFORNIACARE Quality Management Program.


 


2.16      “Capitation” means a uniform
prepayment fee per Member per month, adjusted by age-sex, based on the Benefit
Agreement issued to each Subscriber and the services due thereunder.


 


2.17      “Capitation
Services” means all CALIFORNIACARE Covered Medical Services which are not
otherwise defined in this Agreement [ILLEGIBLE] the Division of Financial
Responsibilities (Exhibit A-1 hereto) as Non-Capitated Services.


 


2

















 


2.18      “Case Management Program” means a program
that assesses the Member’s medical needs and includes working with
PARTICIPATING MEDICAL GROUP and other Participating Providers to explore and
coordinate treatment alternatives that may (1) be more cost effective; (2)
result in better medical outcomes; (3) achieve benefit savings; and (4)
increase Member satisfaction.


 


2.19      “Case Management Stop-Loss Threshold” means the level at
which stop-loss under Section 9.03 herein shall apply to PARTICIPATING
MEDICAL GROUP’s Non-Capitated Performance Settlement.


 


2.20      “Covered Medical Services” means the services
and benefits covered under the Benefit Agreements.  A matrix of those services and benefits is set forth in Exhibit A
(incorporated by reference herein).


 


2.21      “Covered Persons” means Members,
enrollees, dependents and other beneficiaries who are covered by an Affiliate’s
Benefit Agreement or by an Other Payor.


 


2.22      “Customary and Reasonable Charges” (C&R) means:


 


A.    “Customary” means the fee that falls within
the range of prevailing fees charged by physicians and surgeons or other
licensed providers of the same service within the same area for the performance
of a specific service or procedure, and


 


B.    “Reasonable” means the fee that meets the
requirements of Customary and is justified, considering complications or
special circumstances with respect to the performed services or procedure.


 


C&R charges are determined by BLUE CROSS.


 


2.23      “Emergency” means a sudden unexpected onset of a medical
condition manifesting itself by acute symptoms of sufficient severity
(including, without limitation, sudden and unexpected severe pain) such that
the absence of immediate medical attention could reasonably result in any of
the following:


 


A.    Placing the patient’s health in serious
jeopardy,


 


B.    Serious impairment to bodily functions,


 


C.    Other serious medical consequences, or


 


D.    Serious and/or permanent dysfunction of any
bodily organ or part.


 


2.24      “Enrollment Protection” is a program to
limit PARTICIPATING MEDICAL GROUP’s risk with respect to any individual Member
who requires Capitation Services in excess of the limit of liability per
individual Member per calendar year, as set forth in Article VIII, ENROLLMENT
PROTECTION, below.


 


2.25      “Extension of Benefits” means extended
benefits which may be available to Members who are totally disabled on the date
of termination of their Benefit Agreement. 
Extended benefits shall have the meaning set forth in the group coverage
agreement applicable to the Member.


 


3

















 


2.26      “Health
Professional” means any of the following: A doctor of medicine or osteopathy,
licensed to practice medicine or osteopathy where the care is received, or a
dentist, an optometrist, a podiatrist or chiropodist, a clinical psychologist,
a chiropractor, a clinical social worker, a marriage family and child
counselor, a physical therapist, a speech pathologist, an audiologist, an
occupational therapist, a physician assistant, a registered nurse, a nurse
practitioner and/or nurse midwife providing services within the scope of
practice as defined by the appropriate clinical license and/or regulatory board.


 


2.27      “Hemodialysis
Services” means services rendered by a Medicare certified hemodialysis provider,
Hemodialysis Services include facility charges, use of facility equipment and
supplies, laboratory tests and drugs administered in conjunction with on-site
treatment.


 


2.28      “HMO-USA” means a nationwide
network of Blue Cross and Blue Shield Plan HMOs (Participating Plans) sponsored
by Blue Cross and Blue Shield Association (BCBSA).  BCBSA Participating Plan HMOs have entered into Agreements to provide
each other’s members with guest memberships, urgent care and Emergency care,
routine care, and follow-up care as pre-approved and authorized by BLUE CROSS
when the member is traveling away from his or her Home HMO-USA participating
plan.


 


2.29      “Home HMO” means the
participating plan in which a HMO-USA participating plan member is enrolled.


 


2.30      “Hospice Services” means services
rendered to terminally ill patients, by a Medicare certified hospice provider
that are (a) covered by a Benefit Agreement and (b) ordered or authorized by
PARTICIPATING MEDICAL GROUP.


 


2.31      “Hospital Services” means Medically
Necessary acute and sub-acute care inpatient and hospital outpatient services
and supplies which are both (a) covered by a Benefit Agreement, and (b) ordered
or authorized by a PARTICIPATING MEDICAL GROUP Physician.  Hospital Services do not include long-term
non-acute care.


 


2.32      “Host HMO” means any
participating plan in whose Service Area a HMO-USA participating plan member
temporarily stays except the member’s Home HMO.


 


2.33      “Independent
Practice Association” means an incorporated association of independent
physicians which has entered into an agreement with BLUE CROSS to provide and
arrange for health services to Members.


 


2.34      “Inpatient Hospital
Services” means services which include inpatient hospital days for semi-private
accommodations, or special treatment units, or private room accommodations if
specifically authorized as Medically Necessary by PARTICIPATING MEDICAL GROUP
Physician.


 


2.35      “Medically Necessary” means services or
supplies which, under the provisions of this Agreement, are determined to be:


 


A     Appropriate and
necessary for the symptoms, diagnosis or treatment of the medical condition;


 


B.    Provided for the
diagnosis or direct care and treatment of the medical condition;


 


C.    Within standards of
good medical practice within the organized medical community;


 


D.    Not primarily for
the convenience of the Member, the Member’s physician, or another provider; and


 


4

















 


E      The most
appropriate supply or level of service which can safely be provided.  For hospital stays, this means that acute
care as an inpatient is necessary due to the kinds of services the Member is
receiving or the severity of the Member’s condition, and that safe and adequate
care cannot be received as an outpatient or in a less intensified medical
setting.


 


2.36      “Member” means a Subscriber
or enrolled dependent covered by a Benefit Agreement.


 


2.37      “Member Months” means a count that
records one Member month for each month the Member is enrolled in the
CALIFORNIACARE program or the BLUE CROSS PLUS program.


 


2.38      “Non-Capitated
Expenses” means the actual expenses incurred by BLUE CROSS to provide
Non-Capitated Services to Members, as ordered, authorized or referred by
PARTICIPATING MEDICAL GROUP Physicians.


 


2.39      “Non-Capitated
Performance Settlement” means amount paid to PARTICIPATING MEDICAL GROUP
for managing Non-Capitated Services.


 


2.40      “Non-Capitated
Performance Settlement Schedule” means a schedule of PMPM Non-Capitated
Performance Settlement amounts associated with varying PMPM Non-Capitated
Expenses.  The Non-Capitated Performance
Settlement Schedule is set forth in Exhibit F.


 


2.41      “Non-Capitated
Services” means the designated services set forth in Article IX and Exhibit
A-1.


 


2.42      “Operations Manual” means the
CaliforniaCare PMG Operations Manual.


 


2.43      “Other Payor” means persons or
entities utilizing the BLUE CROSS Managed Care Network pursuant to an agreement
with BLUE CROSS, including without limitation, other Blue Cross and/or Blue
Shield Plans, self-administered or self-insured programs providing health care
benefits, or employers or insurers.


 


2.44      “Out-of-Area
Emergency Services” means Emergency services which are rendered to a Member at a distance
of more than twenty (20) mile radius from the medical offices of PARTICIPATING
MEDICAL GROUP or the Satellite Facility to which the Member is assigned.  When PARTICIPATING MEDICAL GROUP is organized
as an Independent Practice Association, Out-of-Area Emergency Services are
those Emergency services which are rendered to a Member at a distance of more
than twenty (20) mile radius from a hospital designated in Exhibit B as a
Service Area hospital.  Out-of-Area
Emergency Services shall also include Out of Area urgently needed services to
prevent serious deterioration of a Member’s health resulting from unforeseen
illness or injury for which treatment cannot be delayed until the Member
returns to the Service Area.


 


2.45      “Outpatient
Hospital Services” means services which include the facility component of outpatient
surgery, pre-admission testing, laboratory and radiology services.


 


2.46      “Outpatient
Prescription Drug Expense” means the benefit amount paid by BLUE CROSS for a
Member’s covered outpatient prescription drugs.


 


2.47      “Outpatient
Prescription Drug Settlement” means an amount paid to PARTICIPATING MEDICAL
GROUP for managing Outpatient Prescription Drug Expenses.


 


2.48      “Outpatient
Prescription Drug Settlement Schedule” means a schedule of outpatient
prescription drug settlement amounts associated with varying Per Member per
Month Outpatient Prescription Drug Expenses. 
The Schedule is set forth in Exhibit H.


 


5

















 


2.49      “PARTICIPATING
MEDICAL GROUP Physician” means a duly licensed physician who is a
shareholder, partner, associate, contractor or employee of PARTICIPATING
MEDICAL GROUP.


 


2.50      “Per Member Per
Month (PMPM) Non-Capitated Expense” means the average monthly medical
Non-Capitated Expense per Member attributable to the PARTICIPATING MEDICAL
GROUP.


 


2.51      “Per Member Per
Month (PMPM) Outpatient Prescription Drug Expense” means the average
monthly Outpatient Prescription Drug Expenses per Member for PARTICIPATING
MEDICAL GROUP’s Members with outpatient prescription drug benefits.


 


2.52      “Plan Factors” means factors used
to adjust the PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations attributable to the mix of Member Benefit
Agreements.  The Non-Capitated Expense
Plan Factors include a durational factor for the durational plans.


 


2.53      “Primary Care
Physician” means the PARTICIPATING MEDICAL GROUP Physician responsible for
coordinating and controlling the delivery of Covered Medical Services to the
Member Primary Care Physicians include general and family practitioners,
internists and pediatricians, and such other specialists as BLUE CROSS may
approve in writing to be designated Primary Care Physicians.


 


2.54      “Quality Management
Committee” means a committee of physicians and other licensed health care
providers, at least fifty percent (50%) of whom participate in CALIFORNIACARE,
which meets regularly to review the Quality Management Program.


 


2.55      “Quality Management
Program” means a program which provides review by physicians and other health
professionals of the appropriateness and adequacy of the delivery of health
services.


 


2.56      “Related Hospital
Services” means services rendered to Members as part of, and concurrent with
Inpatient Hospital Services, Outpatient Hospital Services, Hemodialysis
Services, Skilled Nursing Facility Services, Alternative Birthing Center
Services and Hospice Services, including the use of facility equipment,
surgical and anesthetic supplies, oxygen and drugs except for take-home drugs,
blood and blood processing, laboratory procedures and diagnostic imaging.


 


2.57      “Referral Services” means Capitation
Services which are rendered to Members through a process established by
PARTICIPATING MEDICAL GROUP.


 


2.58      “Region Factor” means the factors
used to adjust PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations across BLUE CROSS corporate regions.


 


2.59      “Satellite
Facility” means a medical facility separate from PARTICIPATING MEDICAL GROUP’s
principal place of business, which is dependent upon, and responsible to,
PARTICIPATING MEDICAL GROUP.  It is a
facility that meets the CALIFORNIACARE Satellite Criteria set forth in the
Operations Manual and is approved by BLUE CROSS prior to being designated a
CALIFORNIACARE Satellite Facility.


 


2.60      “Service Area” means the
geographical area within a thirty (30) mile radius of the medical offices of
PARTICIPATING MEDICAL GROUP or any Satellite Facility to which the Member is
assigned, or, in the case of an Independent Practice Association, the medical
office of the PARTICIPATING MEDICAL GROUP Physician.  The designation of a particular geographical area shall not be
construed as giving PARTICIPATING MEDICAL GROUP an exclusive right to that
Service Area.


 


2.61      “Skilled Nursing
Facility Services” means inpatient and related services provided by a licensed skilled
nursing facility.  Skilled Nursing
Facility Services excludes custodial care.


 


6

















 


2.62      “Stop-Loss Factor” means the factor
used to adjust the PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations due to different Case Management Stop-Loss
thresholds.


 


2.63      “Subscriber” means an
individual who has qualified for and is covered under a Benefit Agreement.


 


2.64      “Urgent Care
Center” is a facility that meets CALIFORNIACARE’s Urgent Care Center criteria
as set forth in the Operations Manual, and is approved by BLUE CROSS prior to
being designated as a CALIFORNIACARE Urgent Care Center.


 


2.65      “Utilization
Management Program” means a program approved by BLUE CROSS and designed to review and
manage the utilization of Covered Medical Services.


 


III.           RELATIONSHIP
BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP


 


3.01      BLUE CROSS and
PARTICIPATING MEDICAL GROUP are independent entities.  Nothing in this Agreement shall be construed, or be deemed to
create, a relationship of employer and employee or principal and agent, or any
relationship other than that of independent parties contracting with each other
solely for the purpose of carrying out the provisions of this Agreement.


 


3.02      BLUE CROSS and
PARTICIPATING MEDICAL GROUP agree that PARTICIPATING MEDICAL GROUP Physicians
shall maintain a physician-patient relationship with each Member assigned to
PARTICIPATING MEDICAL GROUP. 
PARTICIPATING MEDICAL GROUP shall be solely responsible to the Member
for treatment and medical care with respect to the provision of Capitation
Services and arrangements for Non-Capitated Services.


 


3.03      Except as specifically
provided herein, nothing in this Agreement is intended to be construed, or be
deemed to create, any rights or remedies in any third party, including, but not
limited to, a Member or a provider of services, other than PARTICIPATING
MEDICAL GROUP.


 


3.04      PARTICIPATING
MEDICAL GROUP consents to the memorializing of its legal obligations with BLUE
CROSS and each particular Affiliate in one or more separate written agreements
that shall not alter the substance of those obligations.


 


3.05      PARTICIPATING MEDICAL
GROUP agrees that each arrangement by which PARTICIPATING MEDICAL GROUP
performs services for Covered Persons that utilize the BLUE CROSS Managed Care
Network shall constitute an independent legal relationship between
PARTICIPATING MEDICAL GROUP and that Affiliate or Other Payor.


 


3.06      PARTICIPATING
MEDICAL GROUP hereby expressly acknowledges its understanding that this
Agreement constitutes a contract between PARTICIPATING MEDICAL GROUP and BLUE
CROSS as an independent corporation, operating under a license with the Blue
Cross and Blue Shield Association, an association of independent Blue Cross and
Blue Shield Plans (the “Association”), permitting BLUE CROSS to use the Blue
Cross service mark in the State of California and that BLUE CROSS is not contracting
as the agent of the Association. 
PARTICIPATING MEDICAL GROUP further acknowledges and agrees that it has
not entered into this Agreement based upon representations by any person other
than BLUE CROSS and that no person, entity, or organization other than BLUE
CROSS, or the applicable Affiliate, shall be held accountable or liable to
PARTICIPATING MEDICAL GROUP for any of BLUE CROSS’, or the applicable
Affiliate’s, obligations to PARTICIPATING MEDICAL GROUP created under this
Agreement.  This section shall not
create any additional obligations whatsoever on the part of BLUE CROSS, other
than those obligations created under other provisions of this Agreement.


 


7

















 


IV.           PARTICIPATING
MEDICAL GROUP SERVICES AND RESPONSIBILITIES


 


PARTICIPATING MEDICAL GROUP and PARTICIPATING
MEDICAL GROUP Physicians agree as follows:


 


4.01      Provision of Services


 


A.    To promptly provide, arrange through
referral, or authorize all Capitation Services, and to authorize or arrange for
the provision of all Non-Capitated Services, and further, to accept full
financial responsibility for all Capitation Services provided, authorized or
arranged through referral, by PARTICIPATING MEDICAL GROUP in accordance with
the provisions of this Agreement.


 


B.    To provide a Primary Care Physician selected
by the Member to oversee the continuity of care for each Member who appears on
PARTICIPATING MEDICAL GROUP’s Eligibility Report.


 


C.    To maintain a sufficient number of Primary
Care Physicians to guarantee that there is the equivalent of at least one
full-time Primary Care Physician to each two thousand (2,000) Members served by
PARTICIPATING MEDICAL GROUP.  All
Primary Care Physicians shall be PARTICIPATING MEDICAL GROUP Physicians.


 


D.    To assure that privileges of PARTICIPATING
MEDICAL GROUP Physicians at CALIFORNIACARE Hospitals shall be adequate to meet
the requirements for the CALIFORNIACARE Hospital Services to which Members are
entitled under the terms of the Benefit Agreement(s).


 


E.     To engage the Referral Services of duly
licensed board certified consultants, specialists and duly certified allied
health professionals, responsible for delivering Covered Medical Services to
Members.  A list of all referral physicians
to whom PARTICIPATING MEDICAL GROUP refers Members for Referral Services shall
be provided to BLUE CROSS upon request.


 


F.     To ensure that all PARTICIPATING MEDICAL
GROUP Physicians and all PARTICIPATING MEDICAL GROUP employees responsible for
delivering Covered Medical Services to Members, continually meet all applicable
federal and state laws and regulations and all legal standards of care.


 


G.    That if BLUE CROSS determines in good faith
that any PARTICIPATING MEDICAL GROUP Physician(s):


 


(1)   does not meet the requirements specified herein;
or


(2)   that the health, safety or welfare of Members
is jeopardized by continuation of any PARTICIPATING MEDICAL GROUP Physician to
provide services to Members; or


(3)   if PARTICIPATING MEDICAL GROUP Physician(s)
furnishes false, incomplete, or inaccurate information to BLUE CROSS in the
application to participate; or


(4)   at any time during the term of this
Agreement, a PARTICIPATING MEDICAL GROUP Physician(s) suffers revocation,
termination or suspension of Physician’s medical license or medical staff privileges;
or


(5)   the ability of the PARTICIPATING MEDICAL
GROUP Physician(s) to perform the services covered by this Agreement is
otherwise impaired:


 


8

















 


PARTICIPATING MEDICAL GROUP warrants that
upon written request of BLUE CROSS said PARTICIPATING MEDICAL GROUP
Physician(s) shall be excluded from providing services to Members under this
Agreement.  PARTICIPATING MEDICAL GROUP
and PARTICIPATING MEDICAL GROUP Physician(s) may present to BLUE CROSS for
further consideration any additional information or explanation regarding
PARTICIPATING MEDICAL GROUP Physician’s compliance with the requirements set
forth herein.  However, BLUE CROSS
retains the right to make the final decision regarding a PARTICIPATING MEDICAL
GROUP Physician’s participation under this Agreement.


 


4.02      Accessibility and
Continuity of Care


 


A.    To promptly provide
or arrange for available and accessible Covered Medical Services for each
Member assigned to PARTICIPATING MEDICAL GROUP, in accordance with that
Member’s Benefit Agreement and this Agreement, and to provide those services in
and through facilities designated in Exhibit J (incorporated by reference
herein).


 


B.    That all Covered
Medical Services, (including consultation and Referral Services), ambulatory
care services, diagnostic laboratory, diagnostic imaging and therapeutic
radiology services, home health services and preventive health services, shall
be available to Members a minimum of forty (40) hours per week, except for
weeks including holidays.  The foregoing
services shall be available beyond normal business hours during additional
hours to be scheduled by PARTICIPATING MEDICAL GROUP


 


C.    To promptly
provide, arrange or authorize all Emergency services for each Member assigned
to PARTICIPATING MEDICAL GROUP. 
Authorization of any Emergency services, as set forth in
Section 2.23 herein, shall not be withheld by PARTICIPATING MEDICAL GROUP
regardless of whether PARTICIPATING MEDICAL GROUP is notified within
forty-eight (48) hours from the time such Emergency services were
rendered.  PARTICIPATING MEDICAL GROUP
shall comply with all requirements set forth in California Health and Safety
Code Section 1371.4(a) - (d).


 


D.    That PARTICIPATING
MEDICAL GROUP shall manage and facilitate access to Emergency services within a
twenty (20) mile radius of each Satellite Facility and PARTICIPATING MEDICAL
GROUP’s main facility at all times, twenty-four (24) hours a day, seven (7)
days a week.  In the event that
PARTICIPATING MEDICAL GROUP is an Independent Practice Association,
PARTICIPATING MEDICAL GROUP shall manage and facilitate access to Emergency
services within a twenty (20) mile radius of the Hospital(s) designated in
Exhibit B (incorporated by reference herein) as the CALIFORNIACARE Hospital(s)
within PARTICIPATING MEDICAL GROUP’s Service Area.


 


E.     To admit, or
authorize admission of, Members solely to the CALIFORNIACARE Hospitals listed
in Exhibit B, except (a) when Medically Necessary in an Emergency situation or
(b) when Covered Medical Services are not available in a CALIFORNIACARE
Hospital or (c) as otherwise required under Section 4.02F or (d) when
requested to do so in writing by the Member, with the written understanding
that admission to a hospital, other than those listed in Exhibit B, is not a
Covered Medical Service, except as stated above in this Section 4.02E.


 


F.     Notwithstanding
Section 4.02E, for those Members that require transplant services (solid
organ and bone marrow/stem cell) that are Covered Medical Services, PARTICIPATING
MEDICAL GROUP agrees to admit, or authorize the inpatient admission or
outpatient treatment of Members, solely at those CALIFORNIACARE Hospitals whose
transplant programs have been approved by BLUE CROSS and identified as such in
the Operations Manual.


 


9

















 


PARTICIPATING MEDICAL GROUP will provide
notification to BLUE CROSS of all potential transplant cases, including
deferred or denied cases, when such cases are considered by PARTICIPATING
MEDICAL GROUP’s Utilization Management Program Committee or other similar
PARTICIPATING MEDICAL GROUP functional committee, except for Emergencies, in
which case PARTICIPATING MEDICAL GROUP shall provide notification within two
(2) business days of the admission.  The
format of such notification is provided in the Operations Manual.


 


G     That in
circumstances where a Member requires specialized tertiary care or because of
bed unavailability in a CALIFORNIACARE Hospital, the Member must be admitted to
a non-CaliforniaCare in-area or out-of-area facility for Hospital Services,
then until the Member is transferred to a CALIFORNIACARE Hospital, the
PARTICIPATING MEDICAL GROUP will be financially responsible for care the same
as if care had been provided in a CALIFORNIACARE Hospital, and the
Non-Capitated Services arrangement as set forth in Article IX, of this
Agreement will apply.


 


H.    To use a referral
request process by which Capitation Services are to be rendered by Health
Professionals other than the Member’s Primary Care Physician, including
PARTICIPATING MEDICAL GROUP Physicians or other Health Professionals who do not
belong to PARTICIPATING MEDICAL GROUP. 
This process shall assure that:


 


(1)   All Health
Professionals who provide Referral Services follow appropriate billing procedures.


(2)   That the Health
Professional must look only to PARTICIPATING MEDICAL GROUP for payment of
Covered Medical Services and shall not bill the Member, except for applicable
co-payments and for non-Covered Medical Services.


(3)   Primary Care Physicians
who determine that a referral is necessary, may issue a referral without the
prior authorization of PARTICIPATING MEDICAL GROUP’s Utilization Management
Program to physicians in the following specialties: Cardiology, Dermatology,
Endocrinology, Ear, Nose and Throat, Gastroenterology, General Surgery,
Hematology, Neurology, Obstetrics-Gynecology, Oncology, Ophthalmology,
Orthopedic Surgery, Podiatry, Routine Laboratory, Routine X-ray and Urology.


(4)   For referrals to
specialists or providers, or services other than those listed in (3) above,
PARTICIPATING MEDICAL GROUP shall review and issue an authorization or denial
of a request for referral within five (5) business days of receipt of such
request or admission to hospital.


 


I.      That visits to the
Member’s home within the PARTICIPATING MEDICAL GROUP Service Area, by a Primary
Care Physician, shall occur as necessary within that Physician’s discretion.


 


J.     To assure that
Members shall not be subject to discrimination in access to Covered Medical
Services.


 


K.    That PARTICIPATING
MEDICAL GROUP facilities shall be reasonably accessible to the physically
handicapped.


 


L.     To provide health
education and wellness programs for Members within the guidelines indicated in
the “CaliforniaCare Health Education and Wellness Manual.” Programs are to be
delivered in accordance with these guidelines which provide for disease
prevention and management and the promotion of healthier life-styles.


 


10

















 


4.03      Utilization/Quality
Management and Grievance Procedures


 


To cooperate with BLUE CROSS’ administration
of its internal quality of care review and grievance procedures.  The parties acknowledge and agree that
authority to perform Utilization Management Program activities and Quality
Management Program activities under this Agreement is a delegation of BLUE
CROSS authority pursuant to Sections 1370 and 1370.1 of the Health and Safety
Code, and all or part of this authority may be revoked at any time.  The scope of delegated authority shall be as
set forth in the Utilization Management Program guidelines and the Quality
Management Program guidelines issued by BLUE CROSS and provided to
PARTICIPATING MEDICAL GROUP.  The
proceedings of the Utilization Management and Quality Management Committees
shall be strictly confidential between BLUE CROSS and PARTICIPATING MEDICAL
GROUP and are subject to the protections set forth in Sections 1370 and 1370.1.


 


4.04      Quality Management
Program.


 


To adopt and maintain a Quality Management
Program consistent with BLUE CROSS standards and approved by BLUE CROSS.  This program will cover all Covered Medical
Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members
PARTICIPATING MEDICAL GROUP agrees to allow on-site review of its Quality Management
Program by BLUE CROSS staff.


 


A     The Quality
Management Program shall:


 


(1)   Provide for Quality
Management review by PARTICIPATING MEDICAL GROUP Physicians and other Health
Professionals.


(2)   Provide for review
of all services provided to Members by PARTICIPATING MEDICAL GROUP.


(3)   Stress health
outcomes by providing health education and wellness programs for Members.


 


B.    The Quality
Management Program shall include, but not be limited to the following
activities:


 


(1)   Credentialing and
recredentialing of all PARTICIPATING MEDICAL GROUP Physicians and allied Health
Professional providers.


(2)   Credentialing and
recredentialing of all Health Professionals or providers under contract with or
employed by PARTICIPATING MEDICAL GROUP.


(3)   Incident identification
and risk management.


(4)   Member grievance
resolution.


(5)   General and focused
health care audits.


(6)   Development and
implementation of appropriate recommendations.


(7)   Documentation of
remedial procedures for instances of inappropriate or substandard service(s)
and/or failure to provide needed Medically Necessary Covered Medical
Service(s).


 


C.    BLUE CROSS shall
validate PARTICIPATING MEDICAL GROUP’s development and implementation of the
Quality Management Program through regular audit activities as follows:


 


(1)   The CALIFORNIACARE
Quality Management Department shall review PARTICIPATING MEDICAL GROUP’s
Quality Management Program on an annual basis through a scheduled on-site
audit.


(2)   The CALIFORNIACARE
Quality Management Representative shall notify PARTICIPATING MEDICAL GROUP of
any deficiencies or areas needing improvement.


(3)   PARTICIPATING
MEDICAL GROUP shall take corrective action to eliminate any deficiencies in
areas needing improvement within a reasonable period of time.


 


11

















 


(4)   BLUE CROSS shall
conduct follow-up reviews as necessary


 


D     PARTICIPATING
MEDICAL GROUP shall:


 


(1)   Make available to
BLUE CROSS summaries of all minutes and notes from any and all Quality
Management Committees and/or activities which specifically relate to Members.


(2)   Provide BLUE CROSS
with access to all PARTICIPATING MEDICAL GROUP Quality Management data directly
or indirectly relating to Members.


(3)   Make available to
BLUE CROSS all composite Quality Management Program data which include Members
in the composite data set and provide such detail as is available regarding
those Members.


(4)   Make known to BLUE
CROSS any and all adverse actions taken against a PARTICIPATING MEDICAL GROUP
Physician when such action is the result of deficiencies in quality of medical
care.


(5)   Provide the
CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee)
with a schedule designating the time and place of all Quality Management
Committee meetings that relate to Members, in order that he or she shall, in
the Medical Director’s discretion, attend. 
The CALIFORNIACARE Medical Director shall notify the PARTICIPATING
MEDICAL GROUP in advance of his or her attendance and shall not be excluded
from any deliberation on activities related to Members.


(6)   Permit BLUE CROSS
to evaluate and utilize the data obtained from the CALIFORNIACARE Quality
Management Program in a manner that satisfies BLUE CROSS’ requirements for
quality assurance, for BLUE CROSS internal use only.


(7)   Implement any
necessary changes in procedures, in order to fully comply with all quality
assurance standards, as mutually agreed by the parties, and provide BLUE CROSS
with the minutes of Quality Management Committee meetings and reviews that
relate to Members.


(8)   Report to BLUE
CROSS quarterly on activities or actions of PARTICIPATING MEDICAL GROUP’s
Quality Management Committee as such activities or actions relate to Members.


 


4.05      Utilization
Management Program.


 


To adopt and maintain a Utilization Management
Program consistent with BLUE CROSS standards and approved by BLUE CROSS.  This program will cover all Covered Medical
Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members.  PARTICIPATING MEDICAL GROUP agrees to allow
on-site review of Utilization Management Program by BLUE CROSS.


 


A.    The Utilization
Management Program shall:


 


(1)   Include the
development and implementation of appropriate recommendations.


(2)   Include
documentation of remedial procedures for instances of inappropriate or
substandard services(s) and or failure to provide Medically Necessary Covered
Medical Services.


(3)   Assure that
PARTICIPATING MEDICAL GROUP’s primary consideration is the quality of services
rendered to Members.


(4)   Assure that all
services provided to Members are Medically Necessary.


(5)   Work closely with
CALIFORNIACARE Hospitals.


(6)   Encompass
inpatient, outpatient and ancilary care.


(7)   Utilize prospective
concurrent and retrospective review.


(8)   Assure that all
adverse utilization review decisions are made by a licensed physician, and no
denial of a requested service shall be made except by a licensed physician,


 


12

















 


experienced in the area being reviewed.  Denial decisions shall be provided to
Members in writing.


(9)   Permit BLUE CROSS
to have access to all PARTICIPATING MEDICAL GROUP Utilization Management data
directly or indirectly relating to Members.


 


B.    BLUE CROSS shall
validate PARTICIPATING MEDICAL GROUP’s development and implementation of the Utilization
Management Program through regular audit activities as follows:


 


(1)   The CALIFORNIACARE
Quality Management Department shall review PARTICIPATING MEDICAL GROUP’
Utilization Management Program on an annual basis through a scheduled on-site
audit.


(2)   The CALIFORNIACARE
Quality Management Representative shall notify PARTICIPATING MEDICAL GROUP of
any deficiencies or areas needing improvement.


(3)   PARTICIPATING
MEDICAL GROUP shall take corrective action to eliminate any deficiencies in
areas needing improvement within a reasonable period of time.


(4)   BLUE CROSS shall
conduct follow-up reviews as necessary.


 


C.    PARTICIPATING
MEDICAL GROUP shall:


 


(1)   Make available to
BLUE CROSS summaries of all minutes and notes from any and all Utilization
Management Committees and/or activities which relate to Members.


(2)   Make available to
BLUE CROSS upon request all composite Utilization Management data which include
Members in the composite data set and provide such detail as is available
regarding those Members.


(3)   Provide the
CALIFORNIACARE Medical Director (or the Medical Director’s clinical designee)
with a schedule designating the time and place of all Utilization
Management Committee meetings that relate to Members, in order that he or she
shall, in the Medical Director’s discretion, attend.  The CALIFORNIACARE Medical Director shall notify the
PARTICIPATING MEDICAL GROUP in advance of his or her attendance and shall not
be excluded from any deliberation on activities related to Members.


 


4.06      Records and Reserves.


 


A.    BLUE CROSS shall
have access at reasonable times upon demand to the books, records and papers of
PARTICIPATING MEDICAL GROUP relating to the services PARTICIPATING MEDICAL
GROUP provides to Members, to the cost thereof, and to payments PARTICIPATING
MEDICAL GROUP receives from Members or others on their behalf.  PARTICIPATING MEDICAL GROUP shall maintain
such records and provide such information to BLUE CROSS and the Commissioner of
Corporations as may be necessary for BLUE CROSS’ compliance with the
requirements of the Knox-Keene Act. 
PARTICIPATING MEDICAL GROUP shall maintain such records for at least
five (5) years, and such obligations shall not be terminated upon a termination
of this Agreement, whether by rescission or otherwise.


 


B.    PARTICIPATING
MEDICAL GROUP agrees to provide BLUE CROSS with audited financial statements of
PARTICIPATING MEDICAL GROUP no later than three (3) months after the end of its
fiscal year, and BLUE CROSS shall maintain strict confidentiality of said
records.  Audited financial statements
shall illustrate net operating surplus or profit (after taxes).  Documents shall include the following.


 


(1)   Balance sheets


(2)   Statements of
revenues and expenses


(3)   Statements of cash
flow


 


13

















 


PARTICIPATING MEDICAL GROUP further agrees
that BLUE CROSS shall have the right to require audited financial statements,
in addition to the latest fiscal year, at any time, upon request, with
reasonable notice, if BLUE CROSS pays for the audit.


 


C.    To maintain
financial reserves adequate to cover all risks assumed by PARTICIPATING MEDICAL
GROUP hereunder, including, but not limited to, unanticipated claims for
Referral Services that are the potential responsibility of PARTICIPATING
MEDICAL GROUP.


 


D.    That all
information shall be provided to each party to this Agreement pursuant to
procedures designed to protect the confidentiality of patient medical records
in accordance with applicable legal requirements, recognized standards of
professional practice and generally accepted procedures followed by health
maintenance organizations (HMOs).


 


E.     Upon termination of
this Agreement, PARTICIPATING MEDICAL GROUP shall, upon advance written notice
from BLUE CROSS, make available to BLUE CROSS and permit BLUE CROSS to copy the
medical records of each Member who has been assigned to PARTICIPATING MEDICAL
GROUP.


 


4.07      Insurance Programs
or Policies.


 


PARTICIPATING MEDICAL GROUP agrees to
maintain professional liability insurance, or other risk protection program,
acceptable as defined under A. and B. below to BLUE CROSS.  Notification by PARTICIPATING MEDICAL GROUP
of cancellation or material modification of the coverage under such
professional liability insurance or other risk protection program is to be made
to BLUE CROSS within thirty (30) days prior to any cancellation or
modification.  Copies of the agreements
or documents evidencing professional liability insurance or other risk
protection required under this section shall be provided to BLUE CROSS
upon execution of this Agreement.


 


A.    Professional
Liability Insurance


 


The coverage to be provided under this
section shall be in minimum amounts of ONE MILLION DOLLARS ($1,000,000.00)
for any one (1) incident, THREE MILLION DOLLARS ($3,000,000.00) annual aggregate.  PARTICIPATING MEDICAL GROUPs which are
organized as Independent Practice Associations shall ensure that PARTICIPATING
MEDICAL GROUP Physicians maintain professional liability insurance in minimum
amounts of ONE MILLION DOLLARS ($1,000,000.00) for any one incident and THREE
MILLION DOLLARS ($3,000,000.00) annual aggregate.  Furthermore, PARTICIPATING MEDICAL GROUPs organized as
Independent Practice Associations shall maintain directors and officers
liability in minimum amounts of ONE MILLION DOLLARS ($1,000,000.00) for any one
incident, ONE MILLION DOLLARS ($1,000,000.00) annual aggregate.


 


B.    Other Insurance


 


(1)   General Liability
Insurance.  In addition to
Subsection A., above, PARTICIPATING MEDICAL GROUP shall also maintain a
policy or program of comprehensive general liability insurance (or other risk
protection) with minimum coverage including no less than ONE HUNDRED THOUSAND
DOLLARS ($100,000.00) for PARTICIPATING MEDICAL GROUP’s property, together with
combined single limit bodily injury and property damage insurance of not less
that SIX HUNDRED THOUSAND DOLLARS ($600,000.00).


 


(2)   Workers’
Compensation.  PARTICIPATING MEDICAL GROUP’s
employees shall be covered by Workers’ Compensation Insurance in an amount and
form meeting all requirements of applicable provisions of the California Labor Code.


 


14

















 


4.08      Administrative
Responsibilities


 


A.    To comply with all
CALIFORNIACARE administrative policies and procedures in the areas listed in
Exhibit C (incorporated by reference herein) and as set forth in the Operations
Manual (incorporated by reference herein) and to comply with all applicable
state and federal laws and regulations relating to the delivery of Covered
Medical Services.


 


B.    To provide a CALIFORNIACARE
Coordinator who will create a liaison with BLUE CROSS and assist Members in
accordance with the procedures set forth in the Operations Manual, and who will
be available to Members during all regular office hours of PARTICIPATING
MEDICAL GROUP for the purpose of assisting Members to resolve any problems
which may arise or be perceived by the Member.


 


C.    To notify BLUE
CROSS within Fifteen (15) days concerning:


 


(1)   Any material change
in the bylaws, membership, ownership or officers of PARTICIPATING MEDICAL GROUP
which might affect BLUE CROSS or this Agreement.


 


(2)   Any legal or
governmental action initiated against a PARTICIPATING MEDICAL GROUP Physician
or against PARTICIPATING MEDICAL GROUP which might affect BLUE CROSS or this
Agreement including, but not limited to, any change in PARTICIPATING MEDICAL
GROUP Physician(s) licensure, insurance, certification, malpractice,
disciplinary experience or physical or mental health status.


 


(3)   Any other situation
that may interfere with PARTICIPATING MEDICAL GROUP’s or PARTICIPATING MEDICAL
GROUP Physician’s duties and obligations under this Agreement.


 


D.    To obtain BLUE
CROSS’ prior written approval for any literature related to CALIFORNIACARE and
intended for Members.


 


E.     To continually meet
all criteria for PARTICIPATING MEDICAL GROUPs, set forth in the Operations
Manual, and to continually meet all criteria for Satellite Facilities (if
applicable) set forth in the Operations Manual.


 


F.     To provide BLUE
CROSS, on a monthly basis, all ambulatory encounter data either directly or
through PARTICIPATING MEDICAL GROUP’s billing agent in the file format as shown
in the Operations Manual.


 


G.    To comply with BLUE
CROSS programs related to the management of pharmaceutical expenses.


 


H.    That all financial
terms of this Agreement shall be and remain confidential and shall not be
disclosed to any third party, except as required by law or as required to
supply information required by any financial institution.


 


4.09      Payments and Member
Billing.


 


A.    To accept the monthly
Capitation payment from BLUE CROSS as payment in full for Capitation Services
(including all Referral Services) provided or arranged hereunder, and not to
seek additional payments or compensation from Members for Covered Medical
Services.  The foregoing restriction
shall not apply to co-payments, which may be collected by


 


15

















 


PARTICIPATING MEDICAL GROUP in accordance
with the applicable provisions of the Benefit Agreement(s), nor shall it apply
to billings and collections with respect to non-Covered Medical Services
rendered to Members by PARTICIPATING MEDICAL GROUP.  However, to the extent that the PARTICIPATING MEDICAL GROUP’s
billing office is aware of the Member’s payment responsibility, PARTICIPATING
MEDICAL GROUP agrees to advise the Member of that payment responsibility prior
to rendering any service requiring a co-payment, or any non-Covered Medical
Service.


 


If PARTICIPATING MEDICAL GROUP should receive
any surcharge or payment from a Member, in addition to those permissible
charges set forth above, PARTICIPATING MEDICAL GROUP shall promptly refund the
full amount thereof to the Member.


 


B.    To never charge any
Member for any health service which has been deemed not Medically Necessary or
not appropriate after utilization review by PARTICIPATING MEDICAL GROUP, unless
the Member specifically requests the service and acknowledges in writing that
the service is not a Covered Medical Service under the Member’s Benefit
Agreement.


 


C.    That BLUE CROSS and
PARTICIPATING MEDICAL GROUP respectively acknowledge that the authority and
responsibility for coordination of benefits shall be carried out in accordance
with the provisions set forth in the Benefit Agreements and the Operations
Manual.


 


D.    That PARTICIPATING
MEDICAL GROUP shall promptly notify, in writing, the CALIFORNIACARE Case
Management Department of all cases that reach the Enrollment Protection or Case
Management Stop-Loss levels specified herein.


 


E.     To pay all Health
Professionals and hospitals who have rendered authorized Referral Services or
Out-of-Area Emergency Services to Members, within forty-five (45) working days
following receipt of a clean, undisputed claim, consistent with the regulations
of the Commissioner of Corporations governing BLUE CROSS.


 


4.10      Membership.


 


A.    To accept any and
all Members who select PARTICIPATING MEDICAL GROUP until such time as
PARTICIPATING MEDICAL GROUP shall have provided ninety (90) days prior written
notice to BLUE CROSS that it has reached its maximum capacity as set forth in
Section 16.08 herein, or that it anticipates reaching such maximum within
ninety (90) days from the date of the notice to BLUE CROSS.  The maximum capacity of PARTICIPATING
MEDICAL GROUP designated in Section 16.08 shall be reduced only upon
ninety (90) days written notice to BLUE CROSS. 
The parties acknowledge their understanding that enrollment from
individual accounts, or changes in selection of PARTICIPATING MEDICAL GROUP by
Members, are not entirely within the control of BLUE CROSS.


 


B.    That PARTICIPATING
MEDICAL GROUP will not request, demand, require or otherwise seek the transfer
or removal of any Member from the care of PARTICIPATING MEDICAL GROUP, based on
that Member’s need of, or utilization of, Medically Necessary services.


 


C.    PARTICIPATING
MEDICAL GROUP agrees that, in the event a Member who is covered for workers’
compensation benefits by a workers’ compensation carrier affiliated with BLUE
CROSS, seeks services for a work-related illness or injury, PARTICIPATING
MEDICAL GROUP shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.  In the event
that PARTICIPATING MEDICAL GROUP elects to treat such Member, PARTICIPATING
MEDICAL GROUP shall complete a Doctor’s First Report of Injury as defined in
the California


 


16

















 


Labor Code. 
As payment for such medical services rendered, PARTICIPATING MEDICAL
GROUP agrees to accept, as payment in full, compensation in accordance with the
fee schedule set forth in Exhibit E of the Agreement (incorporated by
reference herein) PARTICIPATING MEDICAL GROUP further agrees that, in the event
such Member requires medical services in connection with such work-related
illness or injury beyond the treatment provided at the initial visit,
PARTICIPATING MEDICAL GROUP shall refer such Member only to a provider that
participates in the Prudent Buyer Comp provider network or the CalCare Comp
provider network, whichever is applicable.


 


D.    That unless agreed
to in writing by BLUE CROSS, this Agreement shall not apply to organized
physician groups (including, but not limited to, Independent Practice
Associations) that PARTICIPATING MEDICAL GROUP acquires, manages or affiliates
with subsequent to the effective date of this Agreement.


 


E.     When the BLUE CROSS
Managed Care Network is utilized by an Affiliate or Other Payor, PARTICIPATING
MEDICAL GROUP agrees to provide services to Covered Persons of that Affiliate
or Other Payor in accordance with the terms of this Agreement.  BLUE CROSS shall compensate PARTICIPATING
MEDICAL GROUP in accordance with the terms of this Agreement for services
provided to Covered Persons of any such Other Payor.  When an Other Payor utilizes the Managed Care Network, such Other
Payor shall comply with the terms of this Agreement.


 


In the event the BLUE CROSS Managed Care
Network is to be utilized by an Other Payor that has operational requirements
that are materially different from those required under this Agreement, BLUE
CROSS agrees to notify PARTICIPATING MEDICAL GROUP in writing thirty (30) days
prior to the commencement of such utilization. 
PARTICIPATING MEDICAL GROUP may decline to provide services to such
Other Payor by providing written notice of such decision to BLUE CROSS within
ten (10) days of receipt of notice by BLUE CROSS referenced above.


 


17

















 


V.            BLUE CROSS SERVICES
AND RESPONSIBILITIES


 


BLUE CROSS agrees:


 


5.01      To perform, or
arrange for the performance of, all necessary accounting and enrollment
functions with respect to marketing and administering the CALIFORNIACARE
program, and to issue an identification card to each Subscriber or to each
Subscriber and one additional eligible Member covered under a two-party or
family contract as described in the Operations Manual.


 


5.02      To provide
PARTICIPATING MEDICAL GROUP with Member Eligibility Reports, as set forth in
Article VI.


 


5.03      That, to the extent
compatible with its obligations to BLUE CROSS hereunder, PARTICIPATING MEDICAL
GROUP reserves the right to provide professional services to persons who are
not Members.


 


5.04      To provide
PARTICIPATING MEDICAL GROUP with claims paid and Non-Capitated Services data as
described in the Operations Manual.


 


5.05      To make trained
personnel available to PARTICIPATING MEDICAL GROUP to assist in Quality
Management activities, the establishment of procedures for pre-admission
medical review and concurrent medical review of Members who require, or may
require, hospitalization.


 


5.06      To notify
PARTICIPATING MEDICAL GROUP of any CALIFORNIACARE Group Benefit Agreements
between BLUE CROSS and employers, government agencies, or any other groups,
which may substantially affect enrollment at PARTICIPATING MEDICAL GROUP.


 


5.07      To undertake
reasonable efforts, in accordance with a standard of good faith, to assure that
Members assigned to PARTICIPATING MEDICAL GROUP will live or work within the
Service Area defined in this Agreement. 
However, BLUE CROSS reserves the right to assign any Members to
PARTICIPATING MEDICAL GROUP at the Member’s open enrollment period, or when the
Member changes residence, or when BLUE CROSS determines such transfer to be in
the Member’s best interest due to special circumstances under the terms of the
Member’s Benefit Agreement.


 


5.08      To exercise
reasonable efforts to negotiate special rates with hospitals and other
providers who contract with BLUE CROSS to render Non-Capitated Services to
Members and to pay hospitals in accord with those agreements.


 


5.09      To notify and
consult with PARTICIPATING MEDICAL GROUP with respect to the development of any
material changes, as determined by BLUE CROSS, or amendments to the Benefit
Agreements, and to obtain PARTICIPATING MEDICAL GROUP’s consent to changes that
BLUE CROSS believes may materially affect PARTICIPATING MEDICAL GROUP, except
for changes required by law.  The
foregoing consent will not be unreasonably withheld by PARTICIPATING MEDICAL
GROUP, so long as Capitation payments are adjusted as mutually agreed to
reflect any additional services which may be required due to any amendment or
change in Member benefits.


 


5.10      To accept sole
responsibility for filing reports, obtaining approvals, and complying with the
applicable laws and regulations of state, federal, and other regulatory
agencies having jurisdiction over BLUE CROSS, on the condition that
PARTICIPATING MEDICAL GROUP cooperates in providing BLUE CROSS with any
information and assistance reasonably required.  PARTICIPATING MEDICAL GROUP is not required to provide
information which is confidential in any other existing contract of
PARTICIPATING MEDICAL GROUP.


 


18

















 


5.11      That nothing
contained in this Agreement is intended to interfere with the professional
relationship between any Member and the Member’s PARTICIPATING MEDICAL GROUP
Physician(s).


 


5.12      To collect, or
arrange to have collected, all premiums, Member payments and other items of
income to which BLUE CROSS is entitled under its group and individual contracts
or otherwise, except for (a) co-payments, (b) payments for non-Covered Medical
Services, (c) coordination of benefits payments for professional services which
may be collected by PARTICIPATING MEDICAL GROUP under the conditions set forth
in the Member’s Benefit Agreement, and (d) third party liability payments for
professional services.  Pursuant to the
Benefit Agreement(s) BLUE CROSS may hold a lien on third party liability
payments in the amount of benefits paid by BLUE CROSS and the value of medical
care provided under CALIFORNIACARE for the treatment of the illness, injury or
condition for which a third party is liable. 
BLUE CROSS shall assign to PARTICIPATING MEDICAL GROUP that portion of
any such lien related to professional services rendered under this Agreement by
PARTICIPATING MEDICAL GROUP. 
PARTICIPATING MEDICAL GROUP’s methods of collection of such payments
shall be conducted in a reasonable and nonegregious manner and only proper
legal procedures may be used to enforce such payment.


 


5.13      To consult with
PARTICIPATING MEDICAL GROUP regarding any material changes, as determined by
BLUE CROSS, in operating procedures and policies, as set forth in the
Operations Manual, and to provide PARTICIPATING MEDICAL GROUP with an
opportunity to comment on any policy and procedural changes which may have a
substantial impact on PARTICIPATING MEDICAL GROUP.


 


VI.           ELIGIBILITY
LISTINGS


 


6.01      Eligibility
listings of Members of employer groups who have personally selected, or been
assigned to, PARTICIPATING MEDICAL GROUP shall be provided in the following
manner:


 


A.    BLUE CROSS shall
maintain, update and distribute monthly, Member Eligibility Reports listing the
persons who are eligible to receive Covered Medical Services during the
applicable month.


 


B.    PARTICIPATING
MEDICAL GROUP shall receive a copy of the Eligibility Reports at PARTICIPATING
MEDICAL GROUP’s main site.  Should
PARTICIPATING MEDICAL GROUP request reports in an electronic format, paper
reports will continue to be provided for an additional ninety (90) days
only.  As described in the Operations
Manual, BLUE CROSS will charge a fee of between Fifty Dollars ($50.00) and Five
Hundred Dollars ($500.00) per report, for each of the following:


 


(1)   duplicate copies of
paper reports,


(2)   copies of paper
reports delivered in addition to reports in electronic format after the ninety
(90) day parallel reporting period (tape, diskette, NDM or other electronic
medium),


(3)   duplicate reports
for prior months.


 


C.    BLUE CROSS will
discourage retroactive cancellation by an employer group of more than ninety
(90) days from BLUE CROSS’ applicable monthly billing process date.  However, when no services have been
rendered, BLUE CROSS may make occasional exceptions due to legitimate
administrative processing requirements. 
Notwithstanding any retroactive cancellation of a Member by an employer
group of more than ninety (90) days, BLUE CROSS shall not be entitled to any
refund of Capitation payments made for such Member beyond the ninety (90) day
period.  BLUE CROSS will attempt to
discourage retroactively adding any Member after the applicable billing is
reconciled.  In the event BLUE CROSS
finds it


 


19

















 


necessary to assign, up to ninety (90) days
retroactively, a new Member to PARTICIPATING MEDICAL GROUP Capitation payment
for that Member shall be made, and PARTICIPATING MEDICAL GROUP agrees to be
responsible for all Covered Medical Services due that Member under the terms of
the Member’s Benefit Agreement which were provided or arranged by PARTICIPATING
MEDICAL GROUP, from the date the Member was assigned.


 


D.    In the event care
is provided to an ineligible person, based on an erroneous or delayed
Eligibility Report, BLUE CROSS shall be financially responsible for all care
provided by PARTICIPATING MEDICAL GROUP prior to the time PARTICIPATING MEDICAL
GROUP received notice of that person’s ineligibility and, on the condition that
PARTICIPATING MEDICAL GROUP shall supply BLUE CROSS with evidence that
PARTICIPATING MEDICAL GROUP has unsuccessfully sought payment for all or a
portion of the charges from the ineligible person, or the person having legal
responsibility for the ineligible person, through two billing cycles, or
through a period of sixty (60) days, whichever is greater.  In that event, BLUE CROSS’ responsibility
for physician compensation shall be measured as set forth in Exhibit E or the
actual billed amount, whichever is less. 
The obligations of BLUE CROSS under this Subsection D shall be
conditioned upon the exercise of prudent judgment by PARTICIPATING MEDICAL
GROUP, evidenced by reasonable efforts to contact BLUE CROSS for verification
of the eligibility of each Member prior to providing or arranging Covered
Medical Services.


 


VII.          COMPENSATION TO
PARTICIPATING MEDICAL GROUP


 


7.01      Exhibits D, G and
G-1 (all incorporated by reference herein), set forth Capitation payments for
new and renewing business.  The
applicable Capitation payment for each Member assigned to PARTICIPATING MEDICAL
GROUP, shall be paid monthly, prorated in accordance with Member eligibility.


 


Such Capitation payment shall be adjusted for
Member age, sex and Benefit Agreement in accordance with age, sex and plan
relativities that have been developed by BLUE CROSS based upon actuarial
assumptions and BLUE CROSS’ utilization experience.  BLUE CROSS reserves the right to adjust such relativity factors,
upon contract renewal, based upon BLUE CROSS’ experience.


 


7.02      Capitation shall be
paid in consideration for providing Capitation Services and arranging
Non-Capitated Services for each Member assigned to PARTICIPATING MEDICAL GROUP,
and in consideration for all Capitation Services arranged through referral for
Members by PARTICIPATING MEDICAL GROUP. 
The Capitation payment shall be made by the tenth of each month and
shall be computed on the basis of the most current group and individual
information available.  In the event
that an error is made in the computation of the Capitation payment, resulting
in an overpayment or underpayment to PARTICIPATING MEDICAL GROUP, BLUE CROSS
reserves the right to adjust subsequent Capitation payments to PARTICIPATING
MEDICAL GROUP to offset such overpayment or underpayment.


 


Each Capitation payment shall be accompanied
by a remittance summary.  The remittance
summary identifies the total Capitation amount payable, including retroactivity
and identifies those Members whose retroactivity had a financial impact on the
total Capitation payment.  A complete
listing of Members that are eligible for Capitation Services is provided in the
monthly Eligibility Report, as set forth in Article VI.


 


7.03      PARTICIPATING
MEDICAL GROUP agrees that in no event shall any allowable co-payment or
reimbursement amount, or sum thereof, due PARTICIPATING MEDICAL GROUP, exceed
the cost to PARTICIPATING MEDICAL GROUP of providing the service or item which
was billed.


 


20

















 


7.04      PARTICIPATING
MEDICAL GROUP agrees to continue to provide or arrange for all Covered Medical
Services and benefits to any Member, or former Member, who is eligible for
coverage under the Extension of Benefits provision of the Benefit Agreements,
in exchange for the then current Capitation amount per Member per month of the
Benefit Agreement type under which the Member is, or was, enrolled.  Under the circumstances described in this
Section 7.04 BLUE CROSS shall be financially responsible for Non-Capitated
Services.


 


7.05      PARTICIPATING
MEDICAL GROUP agrees to be responsible for professional and technical charges,
as described in Exhibit A-1 (incorporated by reference herein), for laboratory,
radiology and diagnostic testing procedures and diagnostic imaging examinations
rendered to Members, as a part of, and concurrent with benefits set forth in
this Agreement, whether billed by the hospital or by a qualified health
professional.


 


7.06      In the event a
referral provider has not been reimbursed for authorized Referral Services or
that any other provider has not been reimbursed by PARTICIPATING MEDICAL GROUP
as required under their agreement for services provided to Members within
forty-five (45) working days following receipt of a clean, undisputed claim,
then after notice BLUE CROSS shall, have the option to pay a clean and
uncontested claim and deduct such payment (including any interest payable under
Health & Safety Code Section 1371), plus an administrative charge
equal to ten percent (10%) of the claim amount, from any money due from BLUE
CROSS to PARTICIPATING MEDICAL GROUP. 
If a total of five (5) or more instances occur where any provider
associated with PARTICIPATING MEDICAL GROUP bills a Member in violation of this
Agreement during any calendar year, BLUE CROSS may, in its sole discretion,
suspend the assignment of new Members to PARTICIPATING MEDICAL GROUP until such
time as PARTICIPATING MEDICAL GROUP has rectified the problem to BLUE CROSS’
satisfaction.


 


VIII.        ENROLLMENT
PROTECTION


 


8.01      Enrollment
Protection is a program designed to limit PARTICIPATING MEDICAL GROUP’s
liability for Capitation Services expense.


 


8.02      For PARTICIPATING
MEDICAL GROUPs with less than two thousand (2,000) Members, on the effective
date of this Agreement, the liability of PARTICIPATING MEDICAL GROUP for
expenses for Capitation Services rendered to any single Member during the
calendar year shall be limited to the first SIX THOUSAND DOLLARS ($6,000.00) of
such expenses.


 


8.03      If PARTICIPATING
MEDICAL GROUP’s assigned CALIFORNIACARE and BLUE CROSS PLUS enrollment is two
thousand (2,000) or more Members, on the effective date of this Agreement,
PARTICIPATING MEDICAL GROUP agrees to accept risk under either
Subsection A or Subsection B, as indicated below.


 


A.    The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first EIGHT
THOUSAND DOLLARS ($8,000.00) of Capitation Services expenses, which have been
incurred by PARTICIPATING MEDICAL GROUP for that Member, or


 


B.    The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first
TWENTY-FIVE THOUSAND DOLLARS (S25,000.00) of Capitation Services expenses which
have been incurred by PARTICIPATING MEDICAL GROUP for that Member.


 


PARTICIPATING MEDICAL GROUP hereby elects to
accept risk pursuant to Section 8.03.


 


21

















 


(Check one)


A     ý


B     o


 


8.04      Notwithstanding Section 8.02 or 8.03
above, the liability of PARTICIPATING MEDICAL GROUP for expenses for Capitation
Services for Members who have been diagnosed as having Acquired Immune
Deficiency Syndrome (AIDS) shall be limited to FIFTEEN HUNDRED DOLLARS ($1,500.00)
for any Member who has been diagnosed as having AIDS according to the most
current criteria established by the Center for Disease Control (CDC) at the
time of the diagnosis.


 


8.05      The total expenses of PARTICIPATING MEDICAL
GROUP for Capitation Services rendered to any single Member during the calendar
year shall be calculated according to the fee schedule set forth in
Exhibit E.  In the event the foregoing
calculation for any given procedure results in a figure greater than the actual
cost of the procedure as billed by a third party, then the actual cost for that
procedure shall be deemed to be the amount actually paid by PARTICIPATING
MEDICAL GROUP.


 


8.06      Expenses in connection with the following
services shall not be included as Capitation Services expenses incurred by
PARTICIPATING MEDICAL GROUP in reaching the Enrollment Protection level:


 


A.    Services rendered in connection with Workers’
Compensation cases.


 


B.    Services for which payment is obtained from
third-party sources.


 


C.    Services for which payment is obtained from
BLUE CROSS through any coverage other than CALIFORNIACARE.


 


All co-payments applicable to Capitation
Services rendered to Members shall be subtracted from Capitation Services
expenses.  When the PARTICIPATING
MEDICAL GROUP is capitated by two coverages for one Member, the PARTICIPATING
MEDICAL GROUP agrees to coordinate all related co-payments under the
Coordination of Benefits rules in the Member’s Benefit Agreement.


 


8.07      PARTICIPATING MEDICAL GROUP shall maintain
records necessary to evidence having reached the Enrollment Protection
level.  After reaching the Enrollment
Protection level with regard to any Member, during the remainder of the
calendar year PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for one hundred
percent (100%) of services rendered, or provided, to that Member by
PARTICIPATING MEDICAL GROUP, calculated in accordance with Sections 8.02, 8.03,
8.04, 8.05 and 8.06.  Reimbursement to
PARTICIPATING MEDICAL GROUP for Enrollment Protection shall be made by BLUE CROSS
in accordance with the lesser of actual billed charges or the fee
schedule set forth in Exhibit E, on a monthly basis, within forty-five
(45) working days of submission of complete and accurate documentation by
PARTICIPATING MEDICAL GROUP.  Services which
are not set forth in Exhibit E shall be reimbursed by BLUE CROSS at the actual
charges paid by PARTICIPATING MEDICAL GROUP.


 


8.08      PARTICIPATING MEDICAL GROUP and BLUE CROSS
acknowledge and agree that PARTICIPATING MEDICAL GROUP limitations of liability
as set forth in this Article VIII shall be conditioned upon submission of
clean undisputed claims to BLUE CROSS no later than twelve (12) months after
the date of the service rendered to Members. 
Any claims under the Enrollment Protection program which would otherwise
be the responsibility of BLUE CROSS under this Agreement shall be the financial
responsibility of PARTICIPATING MEDICAL GROUP if a clean undisputed claim is
not submitted within twelve (12) months of the date of service.  For the purpose of this Agreement, a clean
claim shall mean a claim that meets all BLUE CROSS requirements with respect to
back-up information.


 


22

















 


IX.           NON-CAPITATED
SERVICES


 


9.01      Non-Capitated
Services, as defined in this Article, shall include Covered Medical Services,
as set forth in the applicable Benefit Agreement and as authorized or referred
by PARTICIPATING MEDICAL GROUP.


 


The Covered Medical Services encompassed in
Non-Capitated Services are delineated in Exhibit A(1) and include, but are not
limited to:


 


A.    Inpatient Hospital
Services (exclusive of professional charges).


 


B.    Outpatient Hospital
Services (exclusive of professional charges).


 


C.    Hemodialysis
Services (exclusive of professional charges).


 


D.    In-Area Emergency
Room Facility Services (exclusive of professional charges).


 


E.     Related Hospital
Services.


 


F.     Skilled Nursing
Facility Services.


 


G.    Ambulance Services.


 


H.    Home Health
Services.


 


I.      Alternative
Birthing Center Services (exclusive of professional charges).


 


J.     Ten percent (10%)
of expenses related to Out-of-Area Emergency Services (Facility and
Professional Expenses).


 


K.    Durable Medical
Equipment and prosthetic devices.


 


L.     Hospice Services.


 


M.   Fifty percent (50%)
of the average wholesale price (AWP) related to chemotherapy drugs
(intravenously administered) and injectable medications administered during a
visit to the physician’s office (excluding take-home insulin).


 


N.    Mammography
Services.


 


23

















 


 


9.02      Billing for
Non-Capitated Services shall be as follows:


 


A.    The provider of
Non-Capitated Services may bill BLUE CROSS directly, in which case, BLUE CROSS
shall reimburse said provider within forty-five (45) working days following
receipt of a clean, undisputed claim accompanied by an authorization from
PARTICIPATING MEDICAL GROUP; or


 


B.    The provider of
Non-Capitated Services may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for reimbursement.  BLUE CROSS shall reimburse PARTICIPATING
MEDICAL GROUP within forty-five (45) working days following BLUE CROSS’s
receipt of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the
condition that such claim shall be submitted to BLUE CROSS no later than twelve
(12) months after the date of service. 
This section shall only apply for the following Non-Capitated
Services:  mammography services, DME,
prosthetics and injectable medications (including chemotherapy drugs and
infused substances).


 


In either case described above, BLUE CROSS
shall pay contracting providers at the rate negotiated between BLUE CROSS and
said provider.  In the case of
non-contracting providers, BLUE CROSS shall pay the lesser of: the actual
billed charges, or the maximum allowable rate according to the BLUE CROSS
Customary and Reasonable charges, or the rate arranged for by a CALIFORNIACARE
Case Manager.


 


9.03      Case Management
Stop-Loss.


 


A     The Case Management
Program is a program in which a Member’s medical needs are assessed by PARTICIPATING
MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and
coordinate treatment alternatives. 
PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case
Manager prior to the Member achieving the applicable Case Management Stop-Loss
Threshold, as described below.


 


B.    For PARTICIPATING
MEDICAL GROUPs with enrollment of Twenty-Four Thousand (24,000) or more Member
Months for the calendar year, the Case Management Stop-Loss Threshold for an
individual Member shall be SIXTY THOUSAND DOLLARS ($60,000.00) of Non-Capitated
Expenses.


 


For PARTICIPATING MEDICAL GROUPs with
enrollment of less than Twenty-Four Thousand (24,000) Member Months, the Case
Management Stop-Loss Threshold shall be THIRTY-FIVE THOUSAND DOLLARS ($35,000.00)
of Non-Capitated Expenses.


 


C.    Authorized expenses
for Member’s Non-Capitated Services, up to the Case Management Stop-Loss
Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expenses. 
Additionally, ten percent (10%) of expenses between the applicable Case
Management Stop-loss Threshold and ONE HUNDRED AND FIFTY THOUSAND DOLLARS
($150,000) incurred by an individual Member will be accrued toward
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.  Non-Capitated expenses greater than ONE
HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) for any individual Member will
not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.


 


24

















 


D.    The Case Management
Stop-loss Thresholds described above will apply to Members whose treatment
includes transplants (solid organ and bone marrow/stem cell), except in those
cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as
described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to
provide such notice, all of that Member’s Non-Capitated Expenses will be
included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.


 


9.04      Calculating
PARTICIPATING MEDICAL GROUP PMPM Non-Capitated Expenses.


 


The Non-Capitated Expenses shall include
actual expenses incurred by BLUE CROSS to provide Non-Capitated Services to
Members, as authorized or referred by the PARTICIPATING MEDICAL GROUP. Expenses
above the Case Management Stop-Loss Threshold, as set forth in
Section 9.03, and expenses incurred by Members or former Members covered
under the Extension of Benefits provision of the Benefit Agreements are
excluded from PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses for purposes
of determining the Non-Capitated Performance Settlement.


 


BLUE CROSS shall accrue Non-Capitated
Expenses by each PARTICIPATING MEDICAL GROUP by the calendar year the services
were incurred and paid through one hundred and twenty (120) days
(April 30) after year-end.  Beginning in year two (2) of this Agreement, any claims received
after calculation of the final Non-Capitated Performance Settlement will be
charged to the following year’s Non-Capitated Expenses. Any Non-Capitated
Services treatments that begin in one calendar year and extend into the next
year shall accrue to the year the treatment began. Notwithstanding the
aforementioned, any claims for Non-Capitated Services or Shared Risk Services
(as defined in the CALIFORNIACARE Medical Services Agreement in effect for
years prior to 1997) paid after April 30, 1997 will be charged to the 1997
Non-Capitated Expense.


 


PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense is the quotient of PARTICIPATING MEDICAL GROUP’s
Non-Capitated Expenses divided by PARTICIPATING MEDICAL GROUP’s calendar year
Member Months.


 


BLUE CROSS shall provide PARTICIPATING
MEDICAL GROUP with quarterly reports advising them of their Non-Capitated
Expenses. The Operations Manual describes the PARTICIPATING MEDICAL GROUP
reports.


 


9.05      Non-Capitated
Performance Settlement Schedule.


 


Non-Capitated Performance Settlement
Schedule shall mean a schedule that will be the basis for determining
the Non-Capitated Performance Settlement. This schedule presents BLUE
CROSS’s prior year aggregate PMPM Non-Capitated Expenses adjusted by factors to
account for medical inflation. Exhibit F (incorporated by reference herein)
sets forth the Non-Capitated Performance Settlement Schedule.


 


9.06      Calculating the
Non-Capitated Performance Settlement.


 


A.    PARTICIPATING
MEDICAL GROUP’s Adjusted PMPM Non-Capitated Expense.


 


PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expenses is the quotient of PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses divided by the composite of PARTICIPATING MEDICAL GROUP’s
Age/Sex, Plan, Stop-Loss and Region Factors.


 


25

















 


The PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense is adjusted to account for the PARTICIPATING MEDICAL
GROUP’s mix of Members and make the PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses comparable to the Non-Capitated Performance Settlement
Schedule, as set forth in Exhibit F.


 


B.    Non-Capitated
Performance Settlement.


 


If the PARTICIPATING MEDICAL GROUP’s Adjusted
PMPM Non-Capitated Expense is equal to or greater than the Attachment Point,
the PARTICIPATING MEDICAL GROUP will not receive a Non-Capitated Performance
Settlement. If the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated
Expense is less than the Attachment Point, the PARTICIPATING MEDICAL GROUP will
receive a Non-Capitated Performance Settlement.


 


The PMPM Non-Capitated Performance Settlement
is determined by allocating a portion of the difference between the Attachment
Point and the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated
Expense. The proportion of the difference allocated to the PMPM Non-Capitated
Performance Settlement is according to the Non-Capitated Performance Settlement
Schedule, set forth in Exhibit F. The PMPM Non-Capitated Performance Settlement
amount multiplied by the PARTICIPATING MEDICAL GROUP’s calendar year Member
Months determines the total Non-Capitated Performance Settlement.


 


Within forty-five (45) working days after
April 30, BLUE CROSS shall pay the Non-Capitated Performance Settlement if
a Non-Capitated Performance Settlement amount is due to the PARTICIPATING
MEDICAL GROUP.


 


Notwithstanding the above, in the event this
Agreement is terminated, BLUE CROSS shall calculate the Non-Capitated
Performance Settlement in accordance with this Article IX and shall pay
PARTICIPATING MEDICAL GROUP a preliminary Non-Capitated Performance Settlement
equal to eighty percent (80%) of any amount due PARTICIPATING MEDICAL GROUP
based upon this calculation. Twelve (12) months following the calculation and
payment of the preliminary Non-Capitated Performance Settlement, BLUE CROSS
shall calculate a final Non-Capitated Performance Settlement in accordance with
this Article IX and shall pay any amount due PARTICIPATING MEDICAL GROUP,
less any amounts paid at the time of preliminary Non-Capitated Performance
Settlement. In the event monies paid PARTICIPATING MEDICAL GROUP at the time of
the preliminary Non-Capitated Performance Settlement exceed the final
Non-Capitated Performance Settlement, PARTICIPATING MEDICAL GROUP shall
reimburse BLUE CROSS any amounts owed within forty-five (45) working days of
notification from BLUE CROSS.


 


X.            OUTPATIENT
PRESCRIPTION DRUG EXPENSE


 


10.01    Calculating PARTICIPATING MEDICAL GROUP PMPM
Outpatient Prescription Drug Expenses (“PMPM OPDE”).


 


The Outpatient Prescription Drug Expense
(“OPDE”) shall include expenses incurred by BLUE CROSS to provide covered
outpatient prescription drugs to Members assigned to PARTICIPATING MEDICAL
GROUP.


 


BLUE CROSS shall accrue OPDE for each
PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and
paid through one hundred and twenty (120) days after year-end. Beginning in
year two (2) of this Agreement, any claims received after calculation of the
final Outpatient Prescription Drug Settlement will be charged to the following
year’s OPDE. Notwithstanding the aforementioned, any claims for outpatient
prescription drug services incurred


 


26

















 


prior to 1997 but paid after the final
Non-Capitated Performance Settlement calculation for 1996 and if applicable,
for subsequent years, will be charged to the following year’s OPDE.


 


PARTICIPATING MEDICAL GROUP’s PMPM OPDE is
the quotient of PARTICIPATING MEDICAL GROUP’s OPDE divided by the PARTICIPATING
MEDICAL GROUP’s calendar year Member Months for Members with outpatient
prescription drug benefits.


 


BLUE CROSS shall provide PARTICIPATING
MEDICAL GROUP with quarterly reports advising them of their OPDE. Report
formats are described in the Operations Manual.


 


10.02    Outpatient
Prescription Drug Settlement Schedule.


 


The Outpatient Prescription Drug Settlement
Schedule set forth at Exhibit H (incorporated by reference herein) will be
the basis for determining PARTICIPATING MEDICAL GROUP’s Outpatient Prescription
Drug Settlement.


 


10.03    Calculating the
Outpatient Prescription Drug Settlement.


 


If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is
less than the Outpatient Prescription Drug Expense Target, the PARTICIPATING
MEDICAL GROUP will receive an Outpatient Prescription Drug Settlement. If the
PARTICIPATING MEDICAL GROUP’s PMPM Outpatient Prescription Drug Expense is
equal to or greater than the Outpatient Prescription Drug Expense Target, the
PARTICIPATING MEDICAL GROUP will not receive an Outpatient Prescription Drug
Settlement.


 


A.    Outpatient
Prescription Drug Settlement.


 


The PMPM Outpatient Prescription Drug
Settlement is determined by allocating a portion of the difference between the
OPDE Target, and the PARTICIPATING MEDICAL GROUP’s PMPM Outpatient Prescription
Drug Expense. The proportion of the difference allocated to the PMPM Outpatient
Prescription Drug Settlement is determined in accordance with the Outpatient
Prescription Drug Schedule, set forth in Exhibit H.


 


B.    Formulary Utilization
Incentive.


 


If PARTICIPATING MEDICAL GROUP’s use of the
BLUE CROSS Outpatient Prescription Drug Formulary (the “Formulary”) is equal to
or greater than ninety-five percent (95%), as described in Exhibit H, and
PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an
additional $0.10 PMPM will be added to PARTICIPATING MEDICAL GROUP’s PMPM
Outpatient Prescription Drug Settlement.


 


The amount of the Outpatient Prescription
Drug Settlement and Formulary utilization incentive will be based on the
applicable PMPM Settlement calculation under Exhibit H multiplied by
PARTICIPATING MEDICAL GROUP’s Member Months for Members with outpatient
prescription drug benefits. Within forty-five (45) working days after
April 30, BLUE CROSS will pay any Outpatient Prescription Drug Settlement
that is due PARTICIPATING MEDICAL GROUP for the previous year.


 


Notwithstanding the above, in the event this
Agreement is terminated, BLUE CROSS shall calculate the Outpatient Prescription
Drug Settlement in accordance with this Article X and shall pay
PARTICIPATING MEDICAL GROUP a preliminary Outpatient Prescription Drug
Settlement equal to eighty percent (80%) of any amount due PARTICIPATING
MEDICAL GROUP based upon this calculation. Twelve (12) months following the
calculation and payment of the preliminary Outpatient Prescription Drug
Settlement, BLUE CROSS shall calculate a final


 


27

















 


Outpatient Prescription Drug Settlement in
accordance with this Article X and shall pay any amount due PARTICIPATING
MEDICAL GROUP, less any amounts paid at the time of preliminary Outpatient
Prescription Drug Settlement. In the event monies paid PARTICIPATING MEDICAL
GROUP at the time of the preliminary Outpatient Prescription Drug Settlement
exceed the final Outpatient Prescription Drug Settlement, PARTICIPATING MEDICAL
GROUP shall reimburse BLUE CROSS any amounts owed within forty-five (45)
working days of notification from BLUE CROSS.


 


XI.           QUALITY MANAGEMENT BONUS


 


Blue Cross will evaluate PARTICIPATING
MEDICAL GROUP’s Quality Management Program and Member quality of care using a
scorecard.  PARTICIPATING MEDICAL GROUP
will be notified of the scorecard parameters and scoring methodology prior to
the start of each year, as described in the Operations Manual.


 


PARTICIPATING MEDICAL GROUP must meet minimum
eligibility criteria to receive a scorecard score and therefore to be eligible
for a Quality Management Bonus. These criteria include a minimum of 12,000
Member months for a calendar year and submission to BLUE CROSS of all necessary
encounter data.


 


A Quality Management Bonus will be paid if
PARTICIPATING MEDICAL GROUP’s performance on the scorecard is average or above
average. No Quality Management Bonus will be paid if PARTICIPATING MEDICAL
GROUP’s scorecard performance is below average. BLUE CROSS will notify
PARTICIPATING MEDICAL GROUP of the scorecard results sixty (60) days following
the end of the calendar year.


 


The Quality Management Bonus paid to
PARTICIPATING MEDICAL GROUP, should a payment be due in accordance with the
PMPM Quality Management Bonus Schedule shown in Exhibit I (incorporated by
reference herein), will be made by the fifteenth of June following the end
of the calendar year for which it is based.


 


XII.         BILLING FOR HMO-USA
AWAY FROM HOME CARE SERVICES


 


12.01    PARTICIPATING
MEDICAL GROUP agrees to render or refer urgent care, Emergency services,
follow-up care and routine services, as Host HMO to out-of-state members of
HMO-USA participating plans, when such care is prearranged by BLUE CROSS.
Urgent care as it relates to the HMO-USA Away From Home Care Program means
outpatient medical care which the Host HMO determines is required for an
unexpected illness or injury that is not life threatening, but which cannot
reasonably be postponed until the HMO-USA participating plan member returns to
the service area of the member’s Home HMO.


 


All medical services rendered at
PARTICIPATING MEDICAL GROUP or Satellite Facilities and all Referral Services
rendered to members of HMO-USA participating plans, due to unavailability of
the required services at PARTICIPATING MEDICAL GROUP, shall be paid by BLUE
CROSS. For services PARTICIPATING MEDICAL GROUP provides directly to members of
HMO-USA participating plans.  BLUE CROSS
shall reimburse PARTICIPATING MEDICAL GROUP at PARTICIPATING MEDICAL GROUP’s
invoiced amount, not to exceed reimbursement in accordance with Exhibit E of
this Agreement For Referral Services. 
PARTICIPATING MEDICAL GROUP may instruct providers of Referrral Services
to bill BLUE CROSS directly or, such providers may bill PARTICIPATING MEDICAL
GROUP, in which case, PARTICIPATING MEDICAL GROUP shall be reimbursed by BLUE
CROSS. In all cases, PARTICIPATING MEDICAL GROUP or provider of Referral
Services shall note on the claim that services were


 


28

















 


rendered to a member of an HMO-USA
participating plan. Neither PARTICIPATING MEDICAL GROUP nor provider of
Referral Services shall bill members of HMO-USA participating plans.


 


12.02    BLUE CROSS agrees
to pay PARTICIPATING MEDICAL GROUP within forty-five (45) working days of
receipt of a completed professional services claim form for authorized services
rendered to members of HMO-USA participating plans.


 


XIII.        TERM OF AGREEMENT,
TERMINATION


 


13.01    This Agreement
shall be in effect for a one year period
(the “Initial Term”) from the date noted on page 1.  Unless written notice of intent not to renew or of intent to
modify this Agreement is provided at least one hundred twenty (120) days prior
to completion of the Initial Term or any subsequent renewal period, this
Agreement shall renew upon the same terms and conditions for consecutive one
year periods each year thereafter.


 


13.02    Should this
Agreement be terminated pursuant to Section 13.01 above, PARTICIPATING
MEDICAL GROUP agrees to continue to provide Capitation Services and to arrange
Non-Capitated Services for all Members assigned to PARTICIPATING MEDICAL GROUP,
including any Members who become eligible during the notice period set forth in
Section 13.01 above; and to provide these services consistent with the
terms and conditions of the applicable Benefit Agreements.  In such case, Capitation Services rendered
to Members shall be compensated at the applicable rates set forth in Exhibit E,
until the annual anniversary dates of the Benefit Agreements of Members
assigned to PARTICIPATING MEDICAL GROUP.


 


In the event this Agreement is terminated,
BLUE CROSS shall have the right, but not the obligation, to directly pay any
bills for expenses for Referral Services rendered to Members assigned to
PARTICIPATING MEDICAL GROUP which remain outstanding on the date of
termination. BLUE CROSS shall immediately be notified in writing of all such
outstanding bills for Referral Services and BLUE CROSS shall have the right to
set off the amount of such payments against any amount due PARTICIPATING
MEDICAL GROUP for Capitation and Non-Capitated Services pursuant to
Article IX, or any other payments due PARTICIPATING MEDICAL GROUP.


 


The right to set off such payments against
any amounts due under this Agreement shall be in addition to any other rights
BLUE CROSS may have under this Agreement, or in law or in equity.


 


13.03    Termination of this
Agreement shall not affect any rights or obligations hereunder which shall have
previously accrued, or shall thereafter arise, with respect to any occurrence
prior to termination, and such rights and obligations shall continue to be
governed by the terms of this Agreement.


 


Without limiting the foregoing, if this Agreement
is terminated, PARTICIPATING MEDICAL GROUP shall continue to provide and be
compensated under the terms of this Agreement for Covered Medical Services
provided to each Member who is under the care of PARTICIPATING MEDICAL GROUP at
the time of that termination, until the services being rendered to that Member
are completed or reasonable and medically appropriate provision is made for the
assumption of such services by another contracting provider.


 


29

















 


13.04    In the event of a
material breach of this Agreement the party claiming the breach shall give
written notice to the other, with registered or certified mail. The notice
shall specify the breach with as much detail as possible. The party receiving
the notice shall then have thirty (30) days to commence curing the breach. If
the breach is not cured to the satisfaction of the complaining party within
sixty (60) days after the notice is received by the other party, this Agreement
shall terminate at the end of the sixtieth (60th) day or. if the breach is by
PARTICIPATING MEDICAL GROUP, BLUE CROSS may in the alternative freeze
enrollment of PARTICIPATING MEDICAL GROUP and/or withhold fifteen percent (15%) of the Capitation until such breach is cured to BLUE CROSS’
satisfaction.


 


XIV.        ARBITRATION OF
DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP


 


14.01    PARTICIPATING
MEDICAL GROUP and BLUE CROSS agree to meet and confer in good faith to resolve
any problems or disputes that may arise under this Agreement.


 


14.02    Any problem or
dispute arising under this Agreement and/or concerning the terms of this
Agreement that is not satisfactorily resolved under Section 14.01 shall be
arbitrated.  The arbitration shall be
initiated by either party making a written demand for arbitration on the other
party. Arbitration shall be conducted by the American Arbitration Association
(AAA) under the Commercial Rules of the AAA. 
The arbitration shall also be subject to California Code of Civil
Procedure, Title Nine, Section 1280, et.
seq., unless otherwise mutually agreed. The parties agree that the
decision of the arbitrator shall be final and binding as to each of them,
except to the extent that California or Federal law provide for the review of
arbitration proceedings.  Issues as to
whether malpractice was committed by a physician shall not be subject to
Arbitration by the AAA unless otherwise agreed in writing by the parties and
the AAA.


 


14.03    Arbitration Fee.  In all cases submitted to AAA, the parties
agree to share equally the AAA administrative fee as well as the arbitrator’s
fee, if any, unless otherwise assessed by the arbitrator. The administrative
fee shall be advanced by the initiating party.


 


14.04    Enforcement of
Award. The parties agree that the arbitrator’s award may be enforced in any
court having jurisdiction thereof by the filing of a petition to enforce said
award. Costs of filing may be recovered by the party that initiates the action
to have an award enforced.


 


14.05    Alternative Dispute
Settlement Techniques.  Should
the parties, prior to submitting a dispute to arbitration, desire to utilize
other impartial dispute settlement techniques, such as mediation or
fact-finding, a joint request for such services may be made to the AAA, or the
parties may initiate such other procedures as they may mutually agree upon.


 


14.06    Limitation. Nothing contained
herein is intended to create, nor shall it be construed to create, any right of
any Member to independently initiate the arbitration procedure established in
this Article. This limitation shall not prevent BLUE CROSS from initiating such
procedures as the representative of its Members, or PARTICIPATING MEDICAL GROUP
from initiating such procedures on behalf of Members for whom they have assumed
responsibility for the provision of Capitation Services, and for arranging
Non-Capitated Services provided that in any such case BLUE CROSS or
PARTICIPATING MEDICAL GROUP, respectively, shall be considered the initiating
party for the purposes of Section 14.03 hereof.


 


14.07    Each party hereto
agrees to notify the other at the earliest reasonable time in the event of any
dispute which may be arbitrated, and in the event either party becomes aware of
facts or circumstances which indicate a reasonable possibility of litigation with
any third person or entity, and which are relevant to any rights, obligations,
or other responsibilities under this Agreement.


 


30

















 


XV.         CALIFORNIACARE MEMBER GRIEVANCE
SYSTEM


 


15.01    In the event a
Member perceives a problem which the CALIFORNIACARE Coordinator is unable to
satisfactorily resolve, the Member shall be advised to complete a Grievance
Form and submit it to the CALIFORNIACARE Coordinator. The grievance shall be
reviewed and resolved if possible, by the PARTICIPATING MEDICAL GROUP’s Quality
Management Committee.


 


15.02    PARTICIPATING
MEDICAL GROUP shall maintain a log of all grievances heard by PARTICIPATING
MEDICAL GROUP’s Quality Management Committee filed by Members who are assigned
to PARTICIPATING MEDICAL GROUP and shall, on a quarterly basis, forward a copy
of each grievance to the CALIFORNIACARE Quality Management Representative.


 


15.03    PARTICIPATING
MEDICAL GROUP shall provide a written response to Member within fifteen (15)
working days of receipt of grievance. 
In the event a grievance cannot be resolved by the PARTICIPATING MEDICAL
GROUP’s Quality Management Committee to the complaining Member’s satisfaction
within fifteen (15) working days of receipt, the Member may appeal to BLUE
CROSS using the procedures in the Member’s Benefit Agreement and in the
Operations Manual.  In the event that
the Member appeals to BLUE CROSS, PARTICIPATING MEDICAL GROUP agrees to provide
BLUE CROSS with a response to the grievance and the pertinent medical records
within ten (10) days from the date of such request by BLUE CROSS.


 


15.04    The Member shall be
notified of the disposition of the complaint by BLUE CROSS within fifteen (15)
working days of making the appeal.


 


XVI.        MISCELLANEOUS
PROVISIONS


 


16.01    Amendment. This Agreement or
any part or section of it may be amended at any time during the term of
the Agreement by mutual written consent of duly authorized representatives of
BLUE CROSS and PARTICIPATING MEDICAL GROUP.


 


16.02    Assignment. BLUE CROSS and
PARTICIPATING MEDICAL GROUP, pursuant to mutual written agreement, may assign
rights and duties established under this Agreement, provided that no such
assignment shall adversely affect the rights or duties of Members or be in
conflict with the requirements of state or federal laws or regulations under
which BLUE CROSS is licensed or regulated.


 


16.03    Marketing,
Advertising and Publicity. BLUE CROSS shall have the right to use the name
of PARTICIPATING MEDICAL GROUP for purposes of informing Members and prospective
Members of the identity of PARTICIPATING MEDICAL GROUP.


 


Except as provided above, BLUE CROSS and
PARTICIPATING MEDICAL GROUP each reserve the right to control the use of their
respective names and all symbols, trademarks or service marks presently existing,
or later established. In addition, except as provided above, neither BLUE CROSS
nor PARTICIPATING MEDICAL GROUP shall use the other party’s name, symbols,
trademarks or service marks in advertising or promotional materials, or
otherwise, without the prior written consent of that party, and shall cease any
such usage immediately upon written notice of the party, or on termination of
this Agreement, whichever first occurs.


 


16.04    Sole Agreement. This Agreement
with its Exhibits and the Operations Manual, represents the entire agreement
between the parties hereto and supersedes any and all prior or contemporaneous,
written or oral agreements representations or understandings.


 


31

















 


16.05    Independent Contractors. PARTICIPATING
MEDICAL GROUP shall furnish care or other benefits to Members as an independent
contractor, and BLUE CROSS shall not be liable for any claim or demand on
account of damages arising out of, or in connection with, any injuries suffered
by any Member while receiving care from, or care authorized by, PARTICIPATING
MEDICAL GROUP or any of its Member Physicians.


 


16.06    Severability.  If any term, provision, covenant or
condition of this Agreement is held by a court of competent jurisdiction to be
invalid, void or unenforceable, the remainder of the provisions hereof shall
remain in full force and effect and shall in no way be affected, impaired, or
invalidated as a result of such decision.


 


16.07    Notices. Any notice which
is required or permitted to be given pursuant to this Agreement shall be in
writing and shall either be personally delivered, or sent by registered or
certified mail, in the United States Postal Service, return receipt requested,
postage prepaid, addressed to each party at its principal office or at the
address provided in writing to the other. 
Notices shall be effective when received.


 


16.08    Maximum Capacity.  The Maximum Capacity of PARTICIPATING
MEDICAL GROUP during the term of this Agreement shall be 10,000 Members.


 


16.09    Knox-Keene Act.  BLUE CROSS is subject to the requirements of
the Knox-Keene Act and any provision required to be in this Agreement
thereunder shall bind BLUE CROSS and PARTICIPATING MEDICAL GROUP, whether or
not expressly provided in this Agreement.


 


16.10    Solicitation of
Members.  The business relationship
between BLUE CROSS and its Members, and BLUE CROSS and the employer groups with
which it contracts, shall be deemed the property of BLUE CROSS.  Similarly, all lists of Members accepted by
PARTICIPATING MEDICAL GROUP under the provisions of this Agreement and of the
employer groups to which they belong, shall be deemed the property of BLUE
CROSS. During the term of this Agreement or any renewal thereof, and for a
period of one (1) year from the date of termination, PARTICIPATING MEDICAL
GROUP agrees and will require its PARTICIPATING MEDICAL GROUP.  Physicians and all other contracted Health
Professionals to agree, that they will not, within the service area of BLUE
CROSS: (1) interfere with BLUE CROSS’ contract and/or property rights; (2)
advise or counsel any Member or employer groups to disenroll from BLUE CROSS;
(3) solicit such Member or employer group to become enrolled with any other
health maintenance organization, preferred provider organization or any other
similar hospitalization or medical payment plan or insurance company; or (4)
disclose proprietary BLUE CROSS information. 
This section shall not apply to general mailings unless the
mailings specifically target BLUE CROSS Members and as long as the mailings do
not violate the intent of this section.


 


16.11    Confidentiality.  PARTICIPATING MEDICAL GROUP and BLUE CROSS
agree to keep confidential, except as otherwise required by applicable law or
this Agreement, the terms and conditions of this Agreement and any amendments
thereto.  Violation of the above shall
be deemed a material breach.


 


16.12    Waiver.  The waiver by either party of a failure to
perform any covenant or condition set forth in this Agreement shall not act as
a waiver of performance for a subsequent breach of the same or any other
covenant or condition set forth in this Agreement.


 


32

















 


16.13    Governing Law. This Agreement
shall be construed and enforced in accordance with the laws of the State of
California.


 


	
  BLUE
  CROSS OF CALIFORNIA

  	
   

  	
  NORTHWEST
  ORANGE COUNTY MEDICAL

  GROUP, INC.

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Ferial Bahremand

  	
   

  	
   

  	
  Signature:

  	
  /s/ Pratibha Patel

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Ferial Bahremand

  	
   

  	
   

  	
  Name:

  	
  Pratibha Patel, MD

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice President

  	
   

  	
   

  	
  Title:

  	
  President

  	
   

  
	
   

  	
  Network Development
  & Management

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  3/3/97

  	
   

  	
   

  	
  Date:

  	
  2/10/97

  	
   

  



 


33

















 


EXHIBIT A


 


COVERED MEDICAL SERVICES


 


I.              Medical and Surgical Services


 


A.    Physician’s
services at the


 


(1)   Physician’s office;
the Member shall pay any copayment directly to the physician for each such
visit


 


(2)   Hospital or Skilled
Nursing Facility


 


B.    Professional
services of an anesthetist or anesthesiologist


 


C.    Diagnostic X-ray
examinations


 


D.    Laboratory tests


 


E.     Radiation therapy
in Physician’s office, including use of X-ray, radium, cobalt and other
radioactive substances


 


F.     Professional
services of other participating Health Professionals


 


G.    Professional
services of a physician at the Member’s home when the Member is too ill or
disabled to be seen during regular office hours.  The Member shall pay the amounts set forth in the Member’s
Benefit Agreement to the physician for each such visit.


 


II.            Psychiatric Care
Benefits


 


A.    Inpatient Visits


 


Physician’s hospital visits shall be limited
as set forth in the Member’s Benefit Agreement during each calendar year and
the Member shall pay the amounts set forth in the Member’s Benefit Agreement to
the physician for each such visit.


 


B.    Outpatient Visits
or Sessions


 


Outpatient care shall be provided for
short-term evaluation of the Member’s condition when such care is ordered by
the attending PARTICIPATING MEDICAL GROUP Physician. Charges and limitations as
set forth in the Member’s Benefit Agreement. This care shall not include visits
for psychoanalysis.


 


III.           Covered Preventive
Care Benefits


 


The following services shall be provided when
performed by, authorized by. or deemed appropriate by the Member’s Primary Care
Physician. The Member shall pay any copayment listed in the Member’s Benefit
Agreement directly to the physician for each service performed.


 


A.    Well baby care
through age 2 years, including immunizations.


 


B.    Scheduled physical
examinations as set forth in the Member’s Benefit Agreement.


 


C.    Pediatric and adult immunizations.


 


D.    Eye examinations.


 


A-1

















 


E.     Infertility studies for Members aged 18 or
over.


 


F.     Ear examinations.


 


G.    Health education services as follows:


 


(1)   Health education services and education in
the appropriate use of health services and in the contribution each Member can
make to the maintenance of his/or her own health.


 


(2)   Instruction in personal health care measures.


 


(3)   Information about services provided, including
recommendations on generally accepted medical standards for use and frequency
of such services.


 


H.    Services such as pre- and
post-hospitalization planning; referral to services provided through community
health and social welfare agencies and related family counseling for the
physical, emotional and economic impact of illness and disability.


 


I.      Allergy testing and administration of
injections.


 


A-2

















 


EXHIBIT A(1)

CALIFORNIACARE


 


DIVISION OF FINANCIAL RESPONSIBILITIES


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ALLERGY TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  AMBULANCE: Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ANESTHETICS, Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ARTIFICIAL EYE

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  ARTIFICIAL INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ARTIFICIAL LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  BLOOD AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Autologous Blood
  Donation

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  CHEMICAL DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*      As set forth in the applicable Benefit
Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-1

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CHEMOTHERAPY DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Chemotherapy Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CHIROPRACTIC (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  In Conjunction with Home
  Health

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  DENTAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  (accidental injury to sound
  natural teeth and dental work

  necessary for the construction of non-dental structures)

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  DURABLE
  MEDICAL EQUIPMENT (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMERGENCY ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMERGENCY ADMISSIONS:
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMERGENCY ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*      As set forth in the
applicable Benefit Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-2

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	 

	
   

  	
  EMERGENCY ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMPLOYMENT PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ENDOSCOPIC STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EXPERIMENTAL PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  FAMILY PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  FETAL MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  GENETIC TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEALTH EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  **

  	
  HEALTH EVALUATIONS / PHYSICALS

  (required by third party or
  outside-agency)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   *

  	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
									



 












*      As set forth in the
applicable Benefit Agreement.


**   Routine physical
examinations or tests which do not directly treat an actual illness, injury or
condition unless authorized by a Primary Care Physician, except in no event
will any physical examination or test required by employment or government
authority, or at the request of a third party such as a school, camp or sport
affiliated organization be covered.


*** All references to the division of financial
responsibility have been deleted.


 


A(1)-3

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HOSPICE (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HOSPITAL BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Obstetrics
  / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Orthopedic Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  HOSPITALIZATION / INPATIENT SERVICES; SUPPLIES
  & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Out-of-Area (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  
								



 












*      As set forth in the applicable Benefit
Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-4

















 


	 
	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	 
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMEDIATE CARE

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  INFANT APNEA MONITOR (DME)

  (in conjunction with or concurrent with authorized
  inpatient admission)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OUTPATIENT INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  INFERTILITY(Diagnosis / Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Inpatient Facility
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  INFUSION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Infused Substances

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  INJECTABLE MEDICATIONS: Outpatient

  (excluding take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  LABORATORY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  MAMMOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
									



 












*      As set forth in the
applicable Benefit Agreement


 


*** All references to the division of financial
responsibility have been deleted.


 


A(1)-5

















 


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  MENTAL HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  NUTRITIONIST / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OBSTETRICAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES,
  DRESSINGS etc.

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ORGAN TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *

  	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Primary Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Specialty Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY
  COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  These services include, but are not limited to
  the following:

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CAT Scan

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  2-D Echo

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EKG (aka: ECG)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  
								



 












*      As set forth in the
applicable Benefit Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-6

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component
  for:

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OUTPATIENT SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component
  for:

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  
									



 












*      As set forth in the applicable Benefit
Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-7

















 


 


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PEDIATRIC SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PHYSICAL THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PHYSICIAN VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  To Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  To Skilled Nursing
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  To Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PHYSICIAN OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Specialty Visits

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PODIATRY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PREADMISSION TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PRE-EXISTING PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*      As set forth in the applicable Benefit
Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-8

















 


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PREGNANCY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PROSTHETIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  RADIATION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  RADIOLOGY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  RECONSTRUCTIVE SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  REHABILITATION SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  (Short Term: Physical Therapy,
  Occupational Therapy, Speech Therapy, Cardiac Therapy)

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic or
  Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  ROUTINE PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  SKILLED NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  SPECIALIST CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*      As set forth in the applicable Benefit
Agreement


 


*** All references to the
division of financial responsibility have been deleted.


 


A(1)-9

















 


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  SURGICAL SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Dental Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  (for the diagnosis and medically necessary
  correction)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Autologous Blood
  Donations

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  URGENT CARE: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  URGENT CARE: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  VISION SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Lenses / Frames (covered
  by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Contact lenses (fitting
  only)

  	
   

  	
  ***

  	
   

  	
  ***

  



 












*      As set
forth in the applicable Benefit Agreement


 


*** All references to the division of financial
responsibility have been deleted.


 


A(1)-10

















 


EXHIBIT C


 


ADMINISTRATIVE RESPONSIBILITIES OF PARTICIPATING MEDICAL
GROUP


 


This exhibit lists the areas in which PARTICIPATING
MEDICAL GROUP and PARTICIPATING MEDICAL GROUP Physicians will have
administrative responsibility. The extent and type of responsibility to be
undertaken will be agreed upon by the PARTICIPATING MEDICAL GROUP and BLUE
CROSS through an annual audit process.


 


A.            PROFESSIONAL
SERVICES ADMINISTRATION


 


Professional Services - Schedule, control,
process and report encounter information


 


Outside Referrals - Control, process and
report encounter information


 


Ancillary - Control, process and report
encounter information


 


B.            INSTITUTIONAL
SERVICES ADMINISTRATION


 


Preadmission certification process


 


Medical Review of claims


 


Length-of-stay (monitoring and control)


 


C.            UTILIZATION REVIEW


 


D.            PEER REVIEW,
EDUCATION AND CREDENTIALING


 


E.             QUALITY MANAGEMENT


 


F.             GRIEVANCE PROCEDURE
COMPLIANCE


 


G.            MONITOR AND REVISE
SPECIALIST/OTHER REFERRAL CONTRACTS


 


H.            PATIENT EDUCATION


 


I.              CASE MANAGEMENT


 












*** Confidential
Treatment requested


 


C-1

















 


CALIFORNIACARE HEALTH PLANS


 


SCHEDULE D


 


1997 AGE/SEX ADJUSTED CAPITATION


 


ODN: NORTHWEST ORANGE COUNTY MEDICAL GROUP, INC. FOR
DURATIONALS


 


PLAN IC - DURATION YEAR 1 PROFESSIONAL CAPITATION


BASED ON $21.91 PMPM


 


	
  AGE    BAND

  	
   

  	
  MALE

  	
   

  	
  FEMALE

  	
   

  
	
  < 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  1 - 4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5 - 14

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  15 - 19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  20 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 +

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 + MP *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      EMPLOYER INSURANCE
IS SECONDARY PAYER TO MEDICARE


 


ENROLLMENT
PROTECTION THRESHOLD OF  $6,000 @ $0.00
PMPM


 


1

















 


	
  Effective December 1, 1996

  	
   

  	
  Blue Cross of California

  
	
   

  	
   

  	
  Prudent Buyer Plan

  



 


EXHIBIT E


 


PHYSICIAN PAYMENT STRUCTURE


 


AREA 5


 


Blue Cross of California
establishes and, from time to time, revises unit values based on observed
charge patterns by CPT-4 procedure code. The maximum allowable for physician
claims shall be calculated using the unit values as in effect, multiplied by
the following conversion factors: *


 


CONVERSION FACTORS


 




	
  Anesthesia Medicine

  	
  ***

  
	
   

  	
   

  
	
  Pathology

  	
   

  
	
  CPT
  codes 88100-88399

  	
  ***

  
	
  All
  other CPT codes

  	
  ***

  
	
   

  	
   

  
	
  Radiology

  	
  ***

  
	
   

  	
   

  
	
  Surgery

  	
   

  	
   

  
	
  CPT-4
  codes 59400-59622

  	
  ***

  
	
  All
  other CPT-4 codes

  	
  ***

  
			






 












*      When PHYSICIAN does not
submit claims electronically in a format specified by BLUE CROSS, a handling
fee of $0.50 per OCR scannable claim and $1.00 per paper claim will be deducted
from payment due PHYSICIAN. PHYSICIAN will not charge Members for the handling
fee.


 


REIMBURSEMENT FOR HCPCS LEVEL II CODES


 


Pharmacy (including infusion
therapy drugs): Maximum Allowable reimbursement based on Average
Wholesale Price (AWP) according to published market data (such as Drug Topics Red Book, American Druggist Blue Book, or
Medispan). Oral prescription drugs dispensed in the physician’s
office will be denied as not payable, and the Member may not be billed by
physician.


 


Durable Medical Equipment,
Supplies (including, but not limited to, infusion therapy supplies),
Prosthetics and Orthotics: Maximum Allowable Reimbursement not to
exceed the lesser of the average retail price or the Medicare regional
allowable reimbursement rates applied to California for the appropriate code
ranges. The average retail price will be determined annually from claims data
and/or external data. Reimbursement rates will be based on whether the
equipment is new, used or rented as identified by the CPT code modifier. Codes
not identified by modifier will be considered as rentals.


 


All other HCPCS Codes: For all other
HCPCS codes the Maximum Allowable will be determined by Blue Cross using claims
data and/or external data.


 












*** Confidential
Treatment requested


 

















 


EXHIBIT F


 


NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE


For Non-Capitated Medical Services


 


Based on Plan C,
$60.000 Stop Loss, Age/Sex Factor = 1.00 and Regional Factor = 1.00


 


Non-Capitated Performance
Settlement Calculation Method:


 


1)     Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.


 


2)     Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value of
the payment band


 


3)     Multiply the result
from Step 2 by the multiplier column for the payment band


 


4)     Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement


 


5)     Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the Non-Capitated Performance Settlement


 


	
  Payment Bands

  	
   

  	
  Non-Capitated
  Expense Ranges

  (PMPM Non-Capitated Expense)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Low

  	
   

  	
  High

  	
   

  	
  Multiplier

  	
   

  	
  Minimum
  Payment Amount

  	
   

  
	
  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0%

  	
   

  	
  ***

  	
   

  
	
  2

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  25%

  	
   

  	
  ***

  	
   

  
	
  3

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40%

  	
   

  	
  ***

  	
   

  
	
  4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  55%

  	
   

  	
  ***

  	
   

  
	
  5

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65%

  	
   

  	
  ***

  	
   

  
	
  6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  75%

  	
   

  	
  ***

  	
   

  
	
  7

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65%

  	
   

  	
  ***

  	
   

  
	
  8

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  50%

  	
   

  	
  ***

  	
   

  
	
  9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40%

  	
   

  	
  ***

  	
   

  
	
  10

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0%

  	
   

  	
  ***

  	
   

  
											



 












* Attachment Point


 


Example of Non-Capitated
Performance Settlement Calculation


 


Assume:  PARTICIPATING MEDICAL GROUP has an PMPM Non-Capitated Expense of
$26.63; and there are 100,000 member months


 


(1)   Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.


The PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expense of $26.63 falls between the low and high values of
payment band 5


(2)   Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value
for the payment band $27.63 - $26.63 = $1.00


(3)   Multiply the result
from Step 2 by the multiplier for the payment band. $1.00 x 65% = $0.65


(4)   Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement. $0.65 +
$1.59 = $2.24 PMPM Non-Capitated Performance Settlement


(5)   Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the Non-Capitated Performance Settlement.


 


$2.24 PMPM Non-Capitated
Performance Settlement x 100,000 member months = $224,000 Non-Capitated
Performance Settlement


 


F-1

















 


EXHIBIT G


 


COMPENSATION FOR SERVICES TO BLUE CROSS PLUS MEMBERS


 


In consideration for the mutual promises herein set
forth, PARTICIPATING MEDICAL GROUP and BLUE CROSS hereby agree as follows:


 


I.              DEFINITIONS


 


A.    “Advance
Supplemental Capitation Payment” means a supplemental Capitation payment
apportioned monthly and paid in advance of the date it is earned. Advance
Supplemental Capitation Payments are subject to recoupment by BLUE CROSS if not
actually earned prior to the end of the calendar quarter.


 


B.    “Baseline
Capitation Payment” means the monthly Capitation payment for each Member
covered by a BLUE CROSS PLUS Benefit Agreement and assigned to PARTICIPATING
MEDICAL GROUP.


 


C.    “In-Network
Services” means those services which are provided, arranged by, referred or
authorized by PARTICIPATING MEDICAL GROUP for BLUE CROSS PLUS Members and which
would be CALIFORNIACARE Capitation Services if they had been rendered under the
Agreement to a CALIFORNIACARE Member.


 


D.    “In-Network
Utilization Factor” means the quotient of the Baseline Capitation Payment,
divided by the sum of Baseline Capitation Payments plus expenses for Out-of-
Network Services, modified each calendar quarter to allow for incurred but not
reported expenses (IBNR) based on BLUE CROSS’s overall BLUE CROSS PLUS
experience, as follows:


 


	
  Baseline Capitation Payment

  	
   

  	
  = A

  
	
   

  	
   

  	
   

  
	
  Expenses for Out-of-Network Services

  	
   

  	
  = B

  
	
  (Modified to allow for IBNR)

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  In-Network Utilization Factor

  	
   

  	
  = C

  



 


	
  C = 

  	
  A

  	
   

  
	
  A + B

  	
   

  



 


E.     “Non-Participating
Provider” means a Health Professional, hospital, emergency facility,
skilled nursing facility, ambulance service, home health agency, or Alternate
Birthing Center that has rendered services to a BLUE CROSS PLUS Member without
authorization from the PARTICIPATING MEDICAL GROUP to which the Member is
assigned.


 


F.     “Out-of-Network
Services” means those services rendered to BLUE CROSS PLUS Members by a
Non-Participating Provider, and which would be Capitation Services if rendered
by PARTICIPATING MEDICAL GROUP under the Agreement to CALIFORNIACARE Members,
except for Out-of-Area Emergency Services


 


 


G-1

















 


G     “Supplemental
Capitation Payment” means a Capitation payment per BLUE CROSS PLUS Member
per month, which may be earned based on the In-Network Utilization Factor as
set forth in Exhibit G-1.


 


G-2

















 


II.            COMPENSATION FOR SERVICES TO BLUE CROSS PLUS
MEMBERS


 


The parties agree that the terms of Exhibit D
of the Agreement shall apply only to CALIFORNIACARE Members. BLUE CROSS shall
compensate PARTICIPATING MEDICAL GROUP for services to BLUE CROSS PLUS Members
as follows:


 


A.    BLUE CROSS shall
pay a Baseline Capitation Payment per Member per month in the amounts set forth
in Exhibit G-1, adjusted to account for age and sex characteristics of the
Member, and Member Benefit Agreement.


 


B.    PARTICIPATING
MEDICAL GROUP may earn Supplemental Capitation Payments by achieving an
In-Network Utilization Factor greater than 0.42 in any calendar quarter, as set
forth in Exhibit G-1. For any calendar quarter in which PARTICIPATING MEDICAL
GROUP achieves an In-Network Utilization Factor of 0.42 or above, BLUE CROSS
shall make a Supplemental Capitation Payment in accordance with Exhibit G-1 due
sixty (60) working days after the end of such calendar quarter.


 


C.    PARTICIPATING
MEDICAL GROUP may elect to receive advance Supplemental Capitation Payments
prior to the time PARTICIPATING MEDICAL GROUP’s In-Network Utilization Factor
is known, i.e., during the applicable calendar quarter. However, if at the end
of such calendar quarter, PARTICIPATING MEDICAL GROUP’s In-Network Utilization
Factor is below 0.42, then BLUE CROSS shall have the right to set off the
amount of advance Supplemental Capitation Payments made during such quarter
from Capitation payments due PARTICIPATING MEDICAL GROUP in subsequent months.


 


D.    BLUE CROSS shall
calculate the In-Network Utilization Factor on a PARTICIPATING MEDICAL GROUP
specific basis for each PARTICIPATING MEDICAL GROUP with 1200 or more BLUE
CROSS PLUS Member Months for the applicable calendar quarter. All PARTICIPATING
MEDICAL GROUPs with 450 to 1199 BLUE CROSS PLUS Member Months, for the
applicable calendar quarter, will be pooled for determining the In-Network
Utilization Factor.  All PARTICIPATING
MEDICAL GROUPS with fewer than 450 BLUE CROSS PLUS Member Months, for the
applicable calendar quarter, will be grouped into a second pool for determining
the In-Network Utilization Factor.


 


E.     Total claims for
Out-of-Network Expenses rendered to any single BLUE CROSS PLUS Member during
the calendar year shall be limited to 140% of the Enrollment Protection level
selected by PARTICIPATING MEDICAL GROUP for CALIFORNIACARE and BLUE CROSS PLUS
Members under Article VIII, Sections 8.02 or 8.03 of the Agreement.


 


F.     The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered
during the calendar year to any single Member enrolled in BLUE CROSS PLUS shall
be limited to the applicable Enrollment Protection amount defined in Sections
8.02, 8.03 and 8.04. Expenses considered under Enrollment Protection shall
include expenses incurred by PARTICIPATING MEDICAL GROUP.  Expenses for out-of-network services are not
included.


 


G.    BLUE CROSS may
complete an audit of BLUE CROSS PLUS capitation payments within six (6) months
after the end of the calendar year to reconcile any annual over or
underpayments.


 


G-3

















 


CALIFORNIACARE
HEALTH PLANS


 


SCHEDULE G-l


 


1997
AGE/SEX ADJUSTED CAPITATION FOR NEW AND RENEWING EMPLOYER GROUPS


 


ODN:
NORTHWEST ORANGE COUNTY MEDICAL GROUP, INC.


 


PLAN ZA
PROFESSIONAL CAPITATION BASED ON $16.96 PMPM (1)


 


	
  AGE BAND

  	
   

  	
  MALE

  	
   

  	
  FEMALE

  	
   

  
	
       
  <  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
    1
  -   4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
    5
  - 14

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  15 - 19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  20 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 +

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 + MP *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      EMPLOYER
INSURANCE IS SECONDARY PAYER TO MEDICARE


 


ENROLLMENT
PROTECTION THRESHOLD OF $6,000 @ $0.00 PMPM


 




	
  INUF

  	
   

  	
  SUPPLEMENTAL

  CAPITATION PAYMENT (2)

  	
   

  
	
  0 < = .42

  	
   

  	
  ***

  	
   

  
	
  .42 < .48

  	
   

  	
  ***

  	
   

  
	
  .48 < .55

  	
   

  	
  ***

  	
   

  
	
  .55 < .65

  	
   

  	
  ***

  	
   

  
	
  .65 < .80

  	
   

  	
  ***

  	
   

  
	
  > .80

  	
   

  	
  ***

  	
   

  






 


(1)   BASELINE
CAPITATION AMOUNT IS EQUAL TO FIFTY PERCENT (50%) OF THE TOTAL CAPITATION
PAYMENT.


(2)   SUPPLEMENTAL
CAPTATION PAYMENT AMOUNT IS EXPRESSED AS A PERCENT OF THE TOTAL CAPITATION
PAYMENT AND INCLUDES ANY ADVANCE SUPPLEMENTAL CAPITATION PAYMENT ALREADY PAID.


 


1

















 


EXHIBIT H


 


OUTPATIENT PRESCRIPTION DRUG SETTLEMENT SCHEDULE


 


	
  PMPM Outpatient Prescription Drug Expense Target:

  	
  *** PMPM

  



 


	
  PMPM Expense Range

  	
   

  	
  Settlement
  Calculation

  	
   

  
	
  Greater than
  $10.45

  	
   

  	
  ***

  	
   

  
	
  $9.60 to $10.45

  	
   

  	
  (*** - PMPM OPDE
  ) x 45%

  	
   

  
	
  $8.75 to $9.59

  	
   

  	
  (*** - PMPM OPDE ) x 50%

  	
   

  
	
  Less than $8.75

  	
   

  	
  *** PMPM

  	
   

  



 


If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less
than the OPDE Target, an additional $0.10 PMPM will be due to PARTICIPATING
MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal
to or greater than 95%.


 


Formulary
Utilization:          Is the quotient of
the number of prescriptions for Members with outpatient prescription drug
benefits assigned to PARTICIPATING MEDICAL GROUP using drugs listed in the Blue
Cross of California Outpatient Prescription Drug Formulary divided by the total
number of prescriptions for Members with outpatient prescription drug benefits
assigned to PARTICIPATING MEDICAL GROUP.


 












*** Confidential
Treatment requested


 


H-1

















 


EXHIBIT I


 


QUALITY MANAGEMENT BONUS SCHEDULE


 


	
  Quality Management Scorecard
  Rating

  	
   

  	
  PMPM
  Quality Bonus Settlement

  	
   

  
	
  Below Average

  	
   

  	
  ***

  	
   

  
	
  Average

  	
   

  	
  ***

  	
   

  
	
  Above Average

  	
   

  	
  ***

  	
   

  



 


Where:


 


“Average” is the numeric average of all
PARTICIPATING MEDICAL GROUP scorecard scores plus or minus one standard
deviation.


 


“Above Average” is a score that is greater than one
standard deviation above the numeric average of all PARTICIPATING MEDICAL GROUP
scorecard scores.


 


“Below Average” is a score that is less than one
standard deviation below the numeric average of all PARTICIPATING MEDICAL GROUP
scorecard scores.


 












*** Confidential
Treatment requested


 


I-1