Exhibit 10. 186


 


HMO IPA/Medical Group Shared
Savings Provider Agreement, effective January 1, 2002, between Starcare Medical
Group Inc., dba Gateway Medical Group, Inc.


 


 












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


 

















 


BLUE SHIELD


 


HMO IPA/MEDICAL GROUP



SHARED SAVINGS PROVIDER AGREEMENT


 


1

















 


TABLE OF CONTENTS


 


	
  I.

  	
  DEFINITIONS

  	
   

  
	
   

  	
  1.1

  	
   

  	
  Agreement Year

  	
   

  
	
   

  	
  1.2

  	
   

  	
  Authorization

  	
   

  
	
   

  	
  1.3

  	
   

  	
  Benefit Program

  	
   

  
	
   

  	
  1.4

  	
   

  	
  Blue Shield Providers

  	
   

  
	
   

  	
  1.5

  	
   

  	
  Capitated Professional Services

  	
   

  
	
   

  	
  1.6

  	
   

  	
  Capitation

  	
   

  
	
   

  	
  1.7

  	
   

  	
  Copayments

  	
   

  
	
   

  	
  1.8

  	
   

  	
  Covered Services

  	
   

  
	
   

  	
  1.9

  	
   

  	
  Emergency Services

  	
   

  
	
   

  	
  1.10

  	
   

  	
  Evidence of Coverage

  	
   

  
	
   

  	
  1.11

  	
   

  	
  Group Provider

  	
   

  
	
   

  	
  1.12

  	
   

  	
  Group
  Service Area

  	
   

  
	
   

  	
  1.13

  	
   

  	
  Health
  Services Contract

  	
   

  
	
   

  	
  1.14

  	
   

  	
  Medically Necessary

  	
   

  
	
   

  	
  1.15

  	
   

  	
  Member

  	
   

  
	
   

  	
  1.16

  	
   

  	
  Primary Care Physician

  	
   

  
	
   

  	
  1.17

  	
   

  	
  Provider Manual

  	
   

  
	
   

  	
  1.18

  	
   

  	
  Shared Risk Services

  	
   

  
	
   

  	
  1.19

  	
   

  	
  Urgent Care Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  II.

  	
  OBLIGATIONS OF GROUP

  	
   

  
	
   

  	
  2.1

  	
   

  	
  Capitated
  Professional Services

  	
   

  
	
   

  	
  2.2

  	
   

  	
  Referrals For Other Covered Services

  	
   

  
	
   

  	
  2.3

  	
   

  	
  Availability

  	
   

  
	
   

  	
  2.4

  	
   

  	
  Standards For Provision of Care

  	
   

  
	
   

  	
  2.5

  	
   

  	
  Providers
  Not Meeting Standards

  	
   

  
	
   

  	
  2.6

  	
   

  	
  Group Service Contracts

  	
   

  
	
   

  	
  2.7

  	
   

  	
  Quality
  Improvement/Case Management/Utilization Management Programs

  	
   

  
	
   

  	
  2.8

  	
   

  	
  Right to Re-Assign Members

  	
   

  
	
   

  	
  2.9

  	
   

  	
  Outpatient
  Drug Formulary and Pharmacy Information

  	
   

  
	
   

  	
  2.10

  	
   

  	
  Reciprocity

  	
   

  
	
   

  	
  2.11

  	
   

  	
  Termination
  of Physician/Patient Relationship

  	
   

  
	
   

  	
  2.12

  	
   

  	
  Encounter Data and Other Reporting

  	
   

  
	
   

  	
  2.13

  	
   

  	
  Disclosures

  	
   

  
	
   

  	
  2.14

  	
   

  	
  Direct
  Access Programs

  	
   

  
	
   

  	
  2.15

  	
   

  	
  Addition of New Plan Benefit Programs

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  III.

  	
  PAYMENT OF PROVIDERS BY GROUP

  	
   

  
	
   

  	
  3.1

  	
   

  	
  Timely Group Payment

  	
   

  
	
   

  	
  3.2

  	
   

  	
  Failure To Make Payment

  	
   

  



 


2

















 


	
  IV.

  	
  PERFORMANCE
  OF DELEGATED FUNCTIONS

  	
   

  
	
   

  	
  4.1

  	
  Delegation

  	
   

  
	
   

  	
  4.2

  	
  Blue Shield Monitoring and Oversight

  	
   

  
	
   

  	
  4.3

  	
  Termination of Delegation

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  V.

  	
  OBLIGATIONS OF BLUE SHIELD

  	
   

  
	
   

  	
  5.1

  	
  Directory and Use of Names

  	
   

  
	
   

  	
  5.2

  	
  Provider Manual

  	
   

  
	
   

  	
  5.3

  	
  Blue Shield Reports

  	
   

  
	
   

  	
  5.4

  	
  Administrative Services

  	
   

  
	
   

  	
  5.5

  	
  Discretionary Blue Shield Incentive Programs

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  VI.

  	
  ELIGIBILITY OF BLUE SHIELD MEMBERS

  	
   

  
	
   

  	
  6.1

  	
  Identification
  Cards and Verification

  	
   

  
	
   

  	
  6.2

  	
  Verification
  of Eligibility

  	
   

  
	
   

  	
  6.3

  	
  Eligibility
  List and Modifications

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  VII.

  	
  COMPENSATION & FINANCIAL TERMS

  	
   

  
	
   

  	
  7.1

  	
  Capitation
  Payments

  	
   

  
	
   

  	
  7.2

  	
  Services Other Than Capitated Professional
  Services

  	
   

  
	
   

  	
  7.3

  	
  Copayments

  	
   

  
	
   

  	
  7.4

  	
  Stop Loss Coverage

  	
   

  
	
   

  	
  7.5

  	
  Shared
  Risk Programs

  	
   

  
	
   

  	
  7.6

  	
  Blue Shield POS Benefit Program

  	
   

  
	
   

  	
  7.7

  	
  Third Party Liens

  	
   

  
	
   

  	
  7.8

  	
  Groups Organized By Geographic Regions

  	
   

  
	
   

  	
  7.9

  	
  Purpose of Incentive Programs

  	
   

  
	
   

  	
  7.10

  	
  Blue
  Shield Timeliness Guarantee

  	
   

  
	
   

  	
  7.11

  	
  Encounter
  Data Submission Penalties

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  VIII.

  	
  PROTECTION OF MEMBERS

  	
   

  
	
   

  	
  8.1

  	
  Non
  Discrimination

  	
   

  
	
   

  	
  8.2

  	
  Credentialed
  Providers

  	
   

  
	
   

  	
  8.3

  	
  Charges to Members

  	
   

  
	
   

  	
  8.4

  	
  Protection
  of Members

  	
   

  
	
   

  	
  8.5

  	
  Benefits Determination

  	
   

  
	
   

  	
  8.6

  	
  Member
  Complaints and Grievances

  	
   

  
	
   

  	
  8.7

  	
  Medical Necessity Assistance

  	
   

  
	
   

  	
  8.8

  	
  Free Exchange of Information

  	
   

  
	
   

  	
  8.9

  	
  Insurance

  	
   

  



 


3

















 


	
  IX.

  	
  MEDICAL RECORDS & CONFIDENTIALITY

  	
   

  
	
   

  	
  9.1

  	
  Medical
  Records

  	
   

  
	
   

  	
  9.2

  	
  Confidentiality

  	
   

  
	
   

  	
  9.3

  	
  Member
  Access to Records

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  X.

  	
  COOPERATION WITH AUDITS &
  CERTIFICATIONS

  	
   

  
	
   

  	
  10.1

  	
  Disclosure
  of Records

  	
   

  
	
   

  	
  10.2

  	
  Site
  Evaluations

  	
   

  
	
   

  	
  10.3

  	
  Accreditation
  Surveys

  	
   

  
	
   

  	
  10.4

  	
  Compliance
  Monitoring

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  XI.

  	
  RESOLUTION
  OF DISPUTES

  	
   

  
	
   

  	
  11.1

  	
  Provider
  Dispute Resolution Procedure

  	
   

  
	
   

  	
  11.2

  	
  Arbitration
  of Disputes

  	
   

  
	
   

  	
  11.3

  	
  Cooperation
  With Member Disputes

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  XII.

  	
  TERM & TERMINATION

  	
   

  
	
   

  	
  12.1

  	
  Term

  	
   

  
	
   

  	
  12.2

  	
  Termination
  Without Cause

  	
   

  
	
   

  	
  12.3

  	
  Termination
  for Cause

  	
   

  
	
   

  	
  12.4

  	
  Notice and Cure Period

  	
   

  
	
   

  	
  12.5

  	
  Termination
  Not an Exclusive Remedy

  	
   

  
	
   

  	
  12.6

  	
  Effect of Termination

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  XIII

  	
  COMPLIANCE WITH LEGAL REQUIREMENTS

  	
   

  
	
   

  	
  13.1

  	
  Consistency
  with State Law

  	
   

  
	
   

  	
  13.2

  	
  Consistency
  with Federal Law

  	
   

  
	
   

  	
  13.3

  	
  Coordination
  of Benefits

  	
   

  
	
   

  	
  13.4

  	
  Timely Payment

  	
   

  
	
   

  	
  13.5

  	
  Disclosure
  of Provider Profiling

  	
   

  
	
   

  	
  13.6

  	
  Provider
  Terminations

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  XIV.

  	
  GENERAL PROVISIONS

  	
   

  
	
   

  	
  14.1

  	
  Waiver of Breach

  	
   

  
	
   

  	
  14.2

  	
  Amendments

  	
   

  
	
   

  	
  14.3

  	
  Entire Agreement

  	
   

  
	
   

  	
  14.4

  	
  Independent
  Contractors

  	
   

  
	
   

  	
  14.5

  	
  Notices

  	
   

  
	
   

  	
  14.6

  	
  Third Party Beneficiaries

  	
   

  
	
   

  	
  14.7

  	
  Assignment,
  Subcontracting, and Addition of PCPs

  	
   

  
	
   

  	
  14.8

  	
  Interpretation of Agreement

  	
   

  
	
   

  	
  14.9

  	
  Confidentiality/Trade Secrets

  	
   

  
	
   

  	
  14.10

  	
  Non-Solicitation

  	
   

  
	
   

  	
  14.11

  	
  Association
  Disclosure

  	
   

  



 


4

















 


	
  EXHIBIT A

  	
  Group Information and Benefit Programs

  	
   

  
	
  EXHIBIT B

  	
  Division of Financial Responsibilities

  	
   

  
	
  EXHIBIT C

  	
  Capitation

  	
   

  
	
  EXHIBIT C-l

  	
  Capitation Rates

  	
   

  
	
  EXHIBIT D

  	
  Shared Savings Programs

  	
   

  
	
  EXHIBIT
  D-1-

  	
  Shared
  Savings Fund Allocations

  	
   

  
	
  EXHIBIT
  D-2

  	
  Shared
  Savings Fund Allocations - Blue Shield 65 Plus

  	
   

  
	
  EXHIBIT
  D-3

  	
  Pharmacy
  Shared Savings Fund Allocations

  	
   

  
	
  EXHIBIT E

  	
  Blue Shield Allowable Rates

  	
   

  
	
  EXHIBIT F

  	
  Delegation Responsibilities

  	
   

  
	
   

  	
  Attachment
  I – Quality Management Requirements

  	
   

  
	
   

  	
  Attachment
  II – Utilization Management Requirements

  	
   

  
	
   

  	
  Attachment
  III – Credentialing/Delegation Requirements

  	
   

  
	
   

  	
  Attachment
  IV – Claims Processing Requirements

  	
   

  
	
  EXHIBIT G

  	
  Provider Incentive Program

  	
   

  
	
  EXHIBIT
  H-1

  	
  Blue
  Shield 65 Plus Provisions

  	
   

  
	
  EXHIBIT
  H-2

  	
  Blue
  Shield POS Provisions

  	
   

  
	
  EXHIBIT I

  	
  Professional Stop Loss Program

  	
   

  



 


5

















 


HMQ IPA/MEDICAL GROUP

SHARED SAVINGS PROVIDER AGREEMENT


 


This Agreement
is entered into between Starcare Medical Group, Inc. d.b.a. Gateway Medical Group, Inc., a California
corporation (hereinafter “Group”), and California Physicians’ Service, Inc.,
d.b.a.. Blue Shield of California, a California nonprofit corporation
(hereinafter ‘‘Blue Shield”). The Effective Date of this Agreement is January 1, 2002.


 


RECITALS


 


A.                                   Blue
Shield is licensed as a prepaid health care service plan under the Knox-Keene
Act of 1975 (“the Knox-Keene Act”);


 


B.                                     Blue
Shield contracts with individuals, employer groups and governmental entities to
provide or to arrange for the provision of covered HMO health care services to
Members of Blue Shield;


 


C.                                     Group
is organized as a legal entity as identified immediately following Group’s
signature on this Agreement and is licensed and qualified to provide or arrange
for the delivery of medical services to Members of Blue Shield, either directly
or through contracting providers; 


 


D.                                    Group
and Blue Shield desire that Group provide or arrange for the delivery of
services to Members in accordance with the terms of this Agreement; 


 


E.                                      Except
as specifically noted, this Agreement is applicable to members enrolled under
Blue Shield’s HMO Benefit Programs set forth in Exhibit A, attached
hereto.  This Agreement shall only apply
to Medicare beneficiaries enrolled in Blue Shield’s Medicare+Choice program
(“Blue Shield 65 Plus”) if such program is specifically identified in Exhibit
A.  It is not intended to and does not
supersede or amend any other agreement under which Group or Group Providers
provide professional services to Blue Shield’s PPO Members.


 


I. DEFINITIONS


 


For the purposes of this
Agreement, terms shall have the following meanings:


 


1.1                                 Agreement
Year: is the twelve month period beginning at 12:01 a.m. on the Effective
Date of this Agreement, and on each anniversary of the Effective Date.


 


1.2                                 Authorization:
is the procedure for obtaining the prior approval of Blue Shield, or its
delegatee (which may include Group), for the provision or referral of Covered
Services when such approval is required by Blue Shield.


 


6

















 


1.3                                 Benefit
Program: is a group or individual prepaid HMO benefit program offered by
Blue Shield through health services contracts (and riders thereto).  The Benefit Programs to which this Agreement
applies are set forth in Exhibit A, hereto.


 


1.4                                 Blue
Shield Providers(s): are those licensed healthcare providers, including
acute care hospitals (“Blue Shield Hospitals”), which have entered into
agreements with Blue Shield to provide Covered Services to Members.


 


1.5                                 Capitated
Professional Services: are those Covered Services which are described in
Exhibit B, hereto as the financial responsibility of Group. Capitated
Professional Services also include any Covered Services which are not listed in
Exhibit B., but which are customarily provided by IPAs, Medical Groups to their
patients.  Blue Shield may periodically
amend Capitated Professional Services to include any additional physician
and/or ancillary services which must be provided by law.


 


1.6                                 Capitation:
is the monthly payment made by Blue Shield to Group pursuant to Exhibit C,
hereto, which payment, along with applicable Copayments, is payment in full for
all Capitated Professional Services to Members.


 


1.7                                 Copayments:
refers to any copayments, deductibles, and coinsurance which are specifically
described as the financial responsibility of the Member for a Covered Service
in the applicable Health Services Contract and/or Evidence of Coverage in
effect as of the date of service. Any other amount which Group or Group
Provider may seek to recover from Members for Covered Services constitutes a
surcharge and is prohibited by both this Agreement and by the Knox-Keene Act.


 


1.8                                 Covered
Services: are the Medically Necessary healthcare services which
a Member is entitled to receive pursuant to the Health Services Contract and
Evidence of Coverage applicable to the Member. Except as otherwise provided in
the Member’s Health Services Contract and Evidence of Coverage, Covered
Services must generally be referred and authorized in conformity with the
Group’s and Blue Shield’s Utilization Management program.


 


1.9                                 Emergency
Services: are Covered Services to address a medical condition manifesting
itself by acute symptoms of sufficient severity (including severe pain) so as
to cause the prudent layperson to conclude that the absence of immediate
medical attention could reasonably be expected to result in: (i) placing the
Member’s health in serious jeopardy; (ii) serious impairment to bodily
functions; (c) serious dysfunction of any bodily organ or part. For Blue Shield
65 Plus Members, Emergency Services also include any other services defined as
emergency services in 42 C.F.R. §422.2.


 


1.10                           Evidence
of Coverage: is the document issued to the Member pursuant to California
law which describes the benefits, limitations and other features of the Benefit
Program in which the Member is enrolled.


 


1.11                           Group
Provider: is a physician (“Group Physician”), ancillary provider, or other
provider with whom Group has entered into a contract for the provision of
Capitated Professional Services.


 


7

















 


1.12                           Group
Service Area: is that aggregate geographic area determined by
and located within a thirty (30) mile radius from Group’s PCP designated
participating hospitals and including all zip codes containing a participating
PCP facility. A PCP facility refers to the Group’s principal and satellite
offices, if an integrated medical group, and to the offices of each of its
contracted or employed PCPs, if an IPA or medical foundation. The zip codes
describing the location of Group’s PCP facilities are set forth in Exhibit A.,
attached hereto. If subsequent to the Effective Date of this Agreement, Group
adds a new PCP, the Service Area and zip code list in Exhibit A, shall be
automatically amended if necessary to include the zip code in which the PCP
facility is located. The Group Service Area shall be used to determine in-area
from out-of-area services and to proscribe the maximum area in which Member’s
who select a Group PCP must live or work.


 


1.13                           Health
Services Contract: is the group or individual contract,
applicable to the Member, which sets forth the Benefit Program and the Covered
Services to which the Member is entitled, as well as the Member’s Copayment
obligation.


 


1.14                           Medically
Necessary: services or supplies means those medical services and
supplies which are provided in accordance with recognized professional medical
and surgical practices and standards which are determined to be: (a)
appropriate and necessary for the symptoms, diagnosis or treatment of the Member’s
medical condition; and (b) provided for the diagnosis and direct care and
treatment of such medical condition; and (c) not furnished primarily for the
convenience of the Member, the Member’s family, or the treating provider or
other provider; and (d) furnished at the most appropriate level which can be
provided consistent with generally accepted medical standards of care; and (e)
consistent with Blue Shield Medical Policy.


 


1.15                           Member:
is an individual who is, according to Blue Shield’s rules and policies,
eligible for and enrolled (or otherwise covered by Blue Shield as a newborn) in
a Blue Shield Benefit Program described in Exhibit A., and who has selected or
been assigned (either prospectively or retroactively) to a Group Primary Care
Physician as his/her primary care physician. Blue Shield retains final
authority to determine whether an individual is or is not a Member assigned to
a Group PCP.


 


1.16                           Primary Care
Physician (PCP): is a family practitioner, general practitioner, internist,
or pediatrician who has been employed or contracted by Group to provide primary
care services to Members and to be responsible for coordinating, referring, and
managing the delivery of Covered Services to the Member. A PCP shall include an
obstetrician-gynecologist who is qualified and has agreed with Group to serve
as a PCP, and may also include other specialists if approved in writing by Blue
Shield.


 


1.17                           Provider
Manual: refers to the manuals developed by Blue Shield which set
forth the operational rules and procedures applicable to the Group and Group
Providers. The Provider Manual will include the HMO Provider Manual, the HMO
Benefit Guidelines and the Blue Shield Medical Policy Manual.


 


8

















 


1.18                           Shared Savings
Services: refer to the Covered Services which are not Capitated
Professional Services and as to which the Group and Blue Shield share financial
responsibility under the Shared Savings Settlement set forth in Exhibit D.


 


1.19                           Urgent Care
Services: are those Covered Services (other than Emergency Services) which
are Medically Necessary to prevent serious deterioration of a Member’s health,
alleviate severe pain, or treat an illness or injury with respect to which
treatment can not reasonably be delayed. For Blue Shield 65 Plus Members,
Urgent Care Services, at a minimum, include all services which are defined by
Center for Medicare and Medicaid Services (CMS) as “Urgently Needed Services”.


 


II.
OBLIGATIONS OF GROUP


 


2.1                                 Capitated Professional Services.  Group shall provide or arrange for the provision of all Medically
Necessary Capitated Professional Services to Members and shall be fully
financially responsible for same. Such services shall be provided through Group
Providers who have been credentialed as required by this Agreement and as more
fully described in the Provider Manual. Without limiting the foregoing, Group
shall: (i) be financially responsible for Emergency and Urgent Care Services
provided by healthcare providers in addition to Group Providers, as set forth
in Exhibit B., (ii) refer Members, at Group’s cost and when Group Providers are
not available to provide Medically Necessary Capitated Services, to non-Group
Providers; (iii) provide all preventive health services to which a Member is
entitled under his/her Benefit Plan; and, (iv) make available to Members those
health education programs routinely provided fay Group and Group Providers at
no charge to their patients.


 


2.2                                 Referrals
For Other Covered Services.


 


(a)                                  Subject
to applicable Authorization requirements set forth to the Provider Manual,
Group shall, as Medically Necessary, refer Members to Blue Shield Providers
(including Blue Shield Hospitals) for those services which are Covered Services
but which are not Capitated Professional Services. Upon and following such
referral, Group shall coordinate the provision of such Covered Services to
Members and ensure continuity of care.


 


(b)                                 Group
shall utilize the organ transplant provider network established by Blue Shield
for the provision of selected organ transplants. Blue Shield shall, from time
to time, designate which transplant centers are to be utilized for specified
transplants.


 


(c)                                  In
addition, upon notice by Blue Shield to Group that Blue Shield has developed
other specialty networks for the provision of Covered Services that are not
Capitated Professional Services, Group shall utilize such applicable specialty
network(s) for the provision of such services to Members, unless (except for
the organ transplant provider network referred to above) Group demonstrates to
Blue Shield’s reasonable satisfaction that Group Providers are able to offer
comparable services of comparable quality and cost effectiveness to the
services to be offered by Blue Shield’s specialty network.


 


9

















 


2.3                                 Availability.


 


(a)                                  Group
shall ensure that routine Capitated Professional Services shall be available to
Members during normal physician business hours (generally, Monday through
Friday, 9:00 a.m. to 5:00 p.m.) and Emergency Services and telephone advice and
referral shall be available, as Medically Necessary, twenty-four (24) hours per
day, seven (7) days per week, three hundred sixty five (365) days per year.
Appointment, scheduling, and office waiting times shall be within the
applicable guidelines set forth in the Provider Manual. Capitated Professional
Services shall at all times during the term of this Agreement be made readily
available through PCP facilities located in the zip code areas set forth in
Exhibit A.


 


(b)                                 Group
shall ensure that each Group Physician maintains adequate on-call coverage
arrangements with another Group Physician to provide coverage for Members when
that Group Physician is temporarily unavailable. The provision of services to
Members by the on-call Group Physician shall be governed by the terms of this
Agreement.


 


(c)                                  Group
and Group Providers shall participate in all Benefit Programs set forth in
Exhibit A. Except for those PCPs who generally only serve, or generally do not
serve, geriatric patients in their practices, or pediatricians who serve only
pediatric patients, or OB/GYNs who serve only female patients, Group shall
ensure that each of its PCPs accepts all of the Members who select them during
such times that such PCP’s practice is open to new patients.


 


(d)                                 Group
shall ensure that at any given time, the practices of an adequate number of its
PCPs are open to Members to meet all access standards required by Blue Shield,
and its regulatory agencies. Each PCP, whether or not his/her practice is
closed to new patients, shall accept each Member (and such Member’s immediate
family members) who is or had been a patient of PCP at anytime during the two
(2) years immediately prior to such Member selecting physician as his/her PCP.
Without limiting the foregoing, Group shall ensure that at anytime that a PCP
is accepting new patients of other health care service plans, such PCP accepts
Members hereunder. In the event a PCP, during the term of this Agreement,
elects to close his/her practice to new Members, or cease to be a Group
Provider, Group shall give Blue Shield sixty (60) days prior written notice of
such closure.


 


(e)                                  Group
acknowledges that Blue Shield retains full authority to develop and
periodically modify its procedures for Member PCP selection and the assignment
of the Member to a Medical Group when the selected PCP is in multiple medical
groups. Group and its Group Providers shall cooperate with Blue Shield’s Member
PCP selection process and shall assist Members in selecting a PCP when requested
to do so by the Member or Blue Shield.


 


10

















 


(f)                                    In
providing Capitated Professional Services hereunder, Group shall comply with
all obligations of state and federal law relating to continuity of care and
continued access to terminated providers.


 


(g)                                 Group
shall, at all times during the term of this Agreement, maintain an adequate
network of Group Providers in number and type to comply with the requirements
of state and federal law and to ensure that Members have timely and reasonable
access to primary, specialty and ancillary care, as set forth in the Provider
Manual. All providers who are designated as Group Providers by Group and are
communicated to be such by Group to Blue Shield shall at all times be
reasonably available to Members as is appropriate.


 


2.4                                 Standards
For Provision of Care.


 


(a)                                  Group
and Group Providers shall maintain facilities and equipment which meet all
applicable legal requirements, including accessibility, and which otherwise comply
with the provider credentialing requirements developed by Blue Shield for such
providers, as more fully described in the Provider Manual. Accessibility shall
include compliance with the requirements of the Americans With Disabilities
Act.


 


(b)                                 To
assist Group in meeting Blue Shield requirements hereunder, Group shall,
through a duly designated representative, attend occasional provider
education/orientation sessions conducted by Blue Shield.


 


(c)                                  In
providing Capitated Professional Services hereunder Group shall utilize only
Group Providers who are credentialed and re-credentialed in accordance with
Blue Shield’s standards as set forth in the Provider Manual, unless the
Medically Necessary service is not available from a Group Provider. Group
and/or each Group Provider shall provide to Blue Shield, on request,
credentialing information, in such form as reasonably required by Blue Shield.


 


(d)                                 Group
represents and warrants that during the term of this Agreement, each physician
through whom it will provide Capitated Professional Services hereunder shall:
(i) maintain a current, unrestricted license to practice medicine in
California; and, (ii) maintain such staff privileges with at least one Blue
Shield Hospital as necessary for physician to provide services to Members
hereunder; and, (iii) be certified and eligible to participate in the Medicare
Program. Group further represents and warrants that: (iv) each non- physician
Group Provider shall maintain a current and unrestricted license to practice
his/her profession or provide the contracted service; and, (v) use of any
physician extender shall be in strict compliance with the rules of the
California Medical Board.


 


(e)                                  Each
Group Physician shall authorize each hospital at which he/she maintains staff
privileges to notify Blue Shield should any disciplinary or other action of any
kind be initiated against such physician which could result in any suspension,
reduction, or modification of his/her hospital privileges.


 


11

















 


2.5                                 Providers
Not Meeting Standards. Group shall promptly notify Blue Shield
as of the date Group knows that a Group Physician no longer meets any of Blue
Shield’s credentialing criteria as set forth in the Provider Manual.


 


2.6                                 Group Service Contracts. Group shall provide to Blue Shield a
written list of its Group Providers, and each month notify Blue Shield of any
additions or deletions to such list (including any notices of termination of
Group Providers), in addition to which Group shall provide Blue Shield with
immediate notice of termination of Group Providers. Further, Group shall
provide timely response to reasonable periodic requests from Blue Shield for
verification of the current list of Group Providers. Group’s contracts with
Group Providers shall be in writing and shall ensure that such providers: (a)
seek payment for the provided services only from Group and under no
circumstances seek payment from the Member or from Blue Shield; (b) under no
circumstances balance bill or surcharge Members for Covered Services (including
in the event of Group and/or Blue Shield’s insolvency); (c) maintain and
disclose such records to Blue Shield and to Governmental Officials as set forth
in Article IX hereof; (d) permit Government Officials and Blue Shield to
inspect its offices, records, and facilities as set forth in Article X; (e)
cooperate with and participate in Blue Shield’s and Group’s quality improvement
and utilization management programs and Member grievance and appeal procedures;
and, (f) maintain such professional and general business liability insurance as
set forth in Article VIII hereof. Upon Blue Shield’s request, Group’s form of
provider contract(s), along with the executed signature pages to such
contracts, shall be provided to Blue Shield. Group may maintain the
confidentiality of its payment rates (other than bonus/withhold/shared risk or
savings arrangements), provided that such does not result in concealment or
misunderstanding of other terms and provisions of the contract. Upon Blue
Shield’s request, such contracts shall be promptly amended to contain any
provisions required to be contained in provider contracts by either the
Department of Corporations (“DMHC”), CMS, or any other governmental agency.


 


2.7                                 Quality Improvement/ Case Management/ Utilization Management
Programs. Group and Group Providers shall fully cooperate with and
participate in Blue Shield’s quality improvement and utilization management
programs, including its peer review functions, authorization procedures, and quality
improvement committees, as described in the Provider Manual. Group shall
immediately notify Blue Shield of those Members and cases which Group has
identified as requiring additional resources and case management (see Provider
Manual for commonly referred diagnoses and conditions) and shall cooperate in
the management of these cases. Group and Group Providers shall fully cooperate
with Blue Shield with regard to the Health Employer Data Information Sets
(HEDIS) measurements and HEDIS audits, guideline development, preventive
services utilization, disease/risk management, clinical service monitoring and
quality improvement studies and initiatives. Group and Group Providers shall
comply with Blue Shield’s Medical Policy, The quality improvement and quality
management obligations of Blue Shield are not delegated to Group; however,
Group shall have its own fully functional Quality Management Program, as
described in Attachment 1 to Exhibit F hereto, that is cooperative with and
integrated into the Blue Shield Quality Management Program. Group shall comply
with and accept as final, the decisions of the Blue Shield quality improvement
and utilization


 


12

















 


management
program, and pending resolution of any dispute through the dispute resolution
process, comply with the decisions of the Blue Shield quality improvement and
utilization management program.


 


2.8                                 Right to Re-Assign Members. Blue Shield reserves the right to
re-assign Members from Group to another medical group contracting with Blue
Shield, or from a Group Physician to another Group Physician, or to limit or
deny the assignment or selection of new Members to Group or a Group Physician
Provider; (i) during any termination notice period; or (ii) if Blue Shield
determines that Capitated Professional Services are not being properly provided
to, or arranged for, such Members as required by this Agreement and that such
failure poses an immediate threat to the Members health and safety. In the
event that Blue Shield takes any action permitted by this Paragraph 2.8, this
Agreement shall continue in effect unless terminated by either party as set
forth in Article XII of the Agreement.


 


2.9                                 Outpatient Drug Formulary and Pharmacy Information.


 


(a)                                  Group
and Group Providers shall comply with the outpatient drug formulary, drug prior
authorization requirements, and pharmacy benefit design (including maximum
supplies, use of generics, and mail order for maintenance drugs), as adopted
and periodically modified by Blue Shield and as set forth in the Provider
Manual.


 


(b)                                 In
the event that Blue Shield provides to Group computerized or electronic data
regarding prescriptions obtained by Members and drugs supplied, Group agrees
that such information is provided for the limited and restricted purpose of
utilization management. Under no circumstances may Group copy or share such
data with others, or utilize such data, in whole or in part, directly or
indirectly, to negotiate rebates, discounts, or contracts with pharmaceutical
manufacturers or other suppliers of pharmaceuticals.


 


(c)                                  Group
acknowledges that Blue Shield and its designees retain sole authority to
perform, in relationship to outpatient pharmacy, claims processing, formulary
development, a prior authorization program, selection and contracting of a
pharmacy network, and determination of pharmacy benefit design.


 


2.10                           Reciprocity.


 


(a)                                  Group
shall participate in the statewide Blue Shield health services delivery network
and shall accept referrals of Blue Shield members (members of Blue Shield who
are not Members hereunder) and/or provide Emergency Services to such members,
when such members are the financial responsibility of other Blue Shield medical
groups. Except as Group and the other medical group to which such Blue Shield
member is assigned agree, Group shall accept as compensation for such services,
the rates set forth in Exhibit E. (the “Blue Shield Allowable Rates”) minus the
Blue Shield member’s applicable Copayment.


 


13

















 


(b)                                 In
the event that a Member receives Emergency Services or Urgent Care Services
from or Group refers a Member for Capitated Professional Services to a
healthcare provider who is neither a Group Provider nor a provider who is
obligated to accept the compensation described in subpart (a) above, but with
whom Blue Shield has negotiated Compensation rates, then Blue Shield, at
Group’s request, may compensate such provider for the Capitated Professional
Services provided to the Member and deduct the amount of such payment from any
amount then or thereafter owed by Blue Shield to Group. This provision is
intended for specific occasional services only and Blue Shield shall have no
obligation hereunder to compensate providers contracted to Group in the event
of Group’s default in compensating such providers.


 


(c)                                  Affiliates.
In the event that Group or a Group Provider provides services to an individual
who is not a member of Blue Shield, but who is entitled to coverage for or
payment of the services so provided by virtue of enrollment in a health plan of
an Affiliate of Blue Shield, then Group and Group Providers agree to render
services and to accept payment of the Blue Shield Allowable Rates (Exhibit E.)
from the Affiliate as full and complete payment for such services less any
copayment, coinsurance or deductible owed by the individual under the Affiliate
health plan. Group agrees to look solely to the Affiliate and not to Blue
Shield for payment for such services. For purposes of this Paragraph, “Affiliate”
means an organization that is: (i) wholly owned by Blue Shield, or, (ii) under
common ownership or control with Blue Shield (a sister corporation), or, (iii)
a joint venturer with Blue Shield in an enterprise under which the Affiliate is
obligated to provide coverage for/pay for the services in question.


 


2.11                           Termination
of Physician/Patient Relationship.


 


(a)                                  Group
or a Group Provider may terminate the professional relationship with a Member
only with Blue Shield’s consent and in accordance with the procedures set forth
in the Provider Manual. In the event a Group Provider terminates his/her
relationship with a Member, Group shall assist the Member in selecting another
Group Provider for the provision of Capitated Professional Services.


 


(b)                                 In
no event may either Group or a Group Provider terminate the professional
relationship with a Member because of such Member’s medical condition, or the
amount, variety, or cost of Covered Services that are required by the Member.


 


(c)                                  Group
acknowledges that a Member may request transfer between PCPs, and between Blue
Shield medical groups, in accordance with the Member’s applicable Health
Services Contract and Evidence of Coverage. As appropriate, Group agrees to
accept the transfer of a Blue Shield member to Group at the request of Blue
Shield.


 


(d)                                 Notwithstanding
the foregoing, when the consent of CMS or any other governmental agency to the
termination of a physician-patient relationship is


 


14

















 


required
pursuant to the rules and regulations governing the Medicare Program or any
other governmental program, neither Group nor a Group Provider may terminate
the physician-patient relationship with a Blue Shield 65 Plus Member or such
other Member without first obtaining the consent of Blue Shield, CMS, or as
applicable, the other governmental agency.


 


2.12                           Encounter
Data and Other Reporting. Group shall submit to Blue Shield such
encounter/claims data (“Encounter Data”) as set forth in and in accordance with
the requirements set forth in the Provider Manual. Group also shall provide to
Blue Shield such data regarding Group turn-around time for authorizations and
other administrative services as set forth in the Provider Manual.


 


2.13                           Disclosures.


 


(a)                                  In
addition to the notice obligation set forth in Paragraph 2.5, Group shall
notify Blue Shield immediately in writing when it becomes aware of the
occurrence of any of the following events: (i) Group’s or a Group Provider’s
liability insurance is canceled, terminated, not renewed, or materially
modified; (ii) Group or a Group Provider has become a defendant in a lawsuit
filed by a Member or is required or agrees to pay damages to a Member for any
reason; (iii) an act of nature or any event occurs which has a materially adverse
effect on Group’s ability to perform its obligations hereunder; (iv) a petition
is filed to declare Group bankrupt or for reorganization under the bankruptcy
laws of the United States or a receiver is appointed over all or any portion of
the Group’s assets; or (v) Group is sued, or suit is threatened in writing, by
a healthcare provider for nonpayment of compensation; or (vi) any other
situation arises which could reasonably be expected to materially affect
Group’s ability to carry out its obligations under this Agreement. Group shall
also provide Plan with thirty (30) days’ advance notice of any proposed
material change in the ownership of Group, a change in its management services
organization (if any), or the sale of all or substantially all of the assets of
the Group and obtain Plan’s prior approval of same, which approval shall not be
unreasonably withheld.


 


(b)                                 Annually,
within sixty (60) days following the end of Group’s fiscal year or thirty days
following such information being available to Group, Group shall provide to
Blue Shield a copy of its most recent annual income statement, balance sheet,
and statement of cash flow, which shall be prepared in accordance with
generally accepted accounting principles and shall be certified by Group’s
chief executive officer or chief financial officer. Group shall provide a copy
of any audited financial statements it may have to Blue Shield. A narrative or
work sheet describing the calculation of Group’s IBNR shall accompany the
submitted financial statements. The information set forth in this paragraph
shall also be provided by Group to Blue Shield in the event there is an actual
or proposed change in ownership of Group. Group shall also, upon request,
provide Blue Shield with copies of quarterly financial statements, which shall
include a balance sheet, statement of income and


 


15

















 


statement of
cash flow prepared in accordance with generally accepted accounting principles.


 


(c)                                  Group
shall provide Blue Shield with monthly claims reports required by Blue Shield
in order to comply with state and federal law and to ensure compliance by Group
with the requirements of Article III, hereof.


 


(d)                                 Blue
Shield agrees that it shall treat as confidential all financial information
provided by Group in accordance with subparts (b) and (c) of this section
unless such information is publicly available, and shall not disclose such
information to others except as required by law or as requested by Blue
Shield’s regulators.


 


2.14                           Direct
Access Programs. Group shall participate in and comply with the
Access+ and CareDirect program requirements as set forth in the Provider
Manual.


 


2.15                           Addition
of New Plan Benefit Programs. In the event that Blue Shield
develops one or more new Benefit Programs and requests that Group agree to
amend this Agreement to add such new Benefit Program(s) to this Agreement,
Group shall in good faith consider such request and make best efforts to
resolve all matters (including the new Benefit Program compensation) so that a
finalized amendment to this Agreement may be executed within thirty (30) days
of Blue Shield’s request.


 


2.16                           Acceptance
of Members. Group shall accept all Members who select or who are assigned
to Group or Group PCPs and who live or work within the Group Service Area. This
requirement shall not apply to Members with whom the Group’s relationship was
terminated in accordance with section 2.11 hereof. Blue Shield shall undertake
reasonable efforts in accordance with a standard of good faith to assure that
Members who select or are assigned to Group or Group PCPs live or work within
the Group Service Area.


 


III. PAYMENT OF PROVIDERS BY GROUP


 


3.1                                 Timely
Group Payment. Group shall process claims from and pay its Group
Providers and other healthcare providers for Capitated Professional Services
(including without limitation the Emergency Services or Urgent Care Services
which are Group’s responsibility hereunder) in a timely fashion as set forth in
Paragraph 13.4 hereof. If Group delegates to a subcontractor (either a
management company, claims administrator, subcontracted capitated provider,
etc.) the obligation to process claims on Group’s behalf, then Group shall: (i)
immediately notify Blue Shield of such delegation, including any change in the
delegated entity, and, (ii) require that the subcontractor comply with the
claims payment procedure requirements set forth in this Agreement.


 


3.2                                 Failure
To Make Payment.


 


(a)                                  In
the event that Group occasionally fails to pay a Group Provider or other healthcare
provider for Capitated Professional Services within the time frames


 


16

















 


set forth in
this Agreement, and Blue Shield reasonably determines that such amount is due
and payable by Group, Blue Shield may, after notice to Group, pay the amount
due, and deduct and offset such payment from any amount then or thereafter
payable by Blue Shield to Group.


 


(b)                                 In
the event of Group’s continued or repeated failure to compensate Group
Providers or other healthcare providers within the time limits required by this
Agreement as set forth in Section 13.4, Blue Shield may elect to pay claims on
behalf of Group and offset the amount of such payments, along with a monthly
administrative fee (not to exceed 10% of monthly Capitation) from any amounts
then or thereafter owed by Blue Shield to Group, including capitation. Prior to
any such action, Blue Shield shall have provided Group with written notice of
the repeated failures and an opportunity to cure the noncompliance.


 


(c)                                  Group
acknowledges that any such direct payments to Group Providers by Blue Shield
constitute partial mitigation of damages incurred by Blue Shield for Group’s
failure to perform its obligations under this Agreement.


 


IV. PERFORMANCE OF DELEGATED FUNCTIONS


 


4.1                                 Delegation.
Blue Shield delegates to Group the responsibilities set forth in Exhibit F,
attached hereto, and Group agrees to accept and perform such delegated
responsibilities in full compliance with the delegation criteria and standards
for performance of delegated activities set forth in Exhibit F, and the
Provider Manual. Responsibility for all functions not so delegated is retained
by Blue Shield. With respect to matters delegated, Blue Shield retains final
authority and responsibility, including without limitation, the determination
of the Medical Necessity of Covered Services, the determination as to which
services are Covered Services, and the determination as to who is or is not a
Member.


 


4.2                                 Blue Shield Monitoring and Oversight. Group acknowledges Blue
Shield’s responsibility to monitor Group’s compliance with the delegation
criteria and standards and agrees to cooperate with Blue Shield’s monitoring of
such compliance, as set forth in Exhibit F, and the Provider Manual.


 


4.3                                 Termination of Delegation.


 


(a)                                  In
the event that Blue Shield is dissatisfied for any reason with Group’s
performance of delegated activities, Blue Shield may, in its sole discretion,
modify Group’s status (with respect to all or a particular delegated activity)
from fully delegated to delegated with corrective action. Such notice of
delegation with corrective action shall set forth the deficiencies perceived by
Blue Shield in Group’s performance of delegated activities, and Group shall
have ninety (90) days to correct such deficiencies to the reasonable
satisfaction of Blue Shield. In the event such deficiencies are not corrected
to the reasonable satisfaction of Blue Shield, Blue Shield may, in its sole


 


17

















 


discretion, terminate
the delegation or extend the period given Group to correct such deficiencies.


 


(b)                                 In
lieu of the notice of delegation with corrective action and opportunity to
correct deficiencies, as set forth in Paragraph 4.3(a) above, Blue Shield may
at anytime within its sole discretion, terminate all or portions of the
delegation granted to Group hereunder by providing no less than sixty (60) days
prior written notice. Blue Shield may also terminate all or portions of the
delegation granted to Group hereunder if Blue Shield determines, after
consultation with Group, that Group either no longer meets all criteria or is
not performing (or is reasonably not likely to perform) the delegated
activities in full compliance with the standards. In such event, Blue Shield
shall give to Group no less than thirty (30) days prior notice of such
termination of delegation, and if Group, during such notice period, cures such
deficiencies to Blue Shield’s reasonable satisfaction, Blue Shield may, in its
sole discretion, withdraw such termination. The reduction amount set forth in
Exhibit F. is intended solely as a penalty and will cease when Group has
demonstrated successful implementation of the corrective action plan.


 


(c)                                  Upon
termination of all or part of the delegation pursuant to this Article IV, Blue
Shield may, in its sole discretion, reduce the Capitation amount otherwise
payable to Group hereunder by a per member amount as set forth in Exhibit F.
for each delegated service, which amount is not intended to represent the
portion of the capitation amounts that are allocated to cover the cost of
performance of the delegate service by Group nor an estimate of the costs
incurred by Blue Shield as a result of the termination of such delegation;
rather, the amounts set forth in Exhibit F. are intended as a penalty for
Group’s failure to meet the standards established for performance of the
delegated service.


 


V.
OBLIGATIONS OF BLUE SHIELD


 


5.1                                 Directory
and Use of Names.


 


(a)                                  Blue
Shield shall develop a directory of Primary Care Physicians and certain
specialists and other healthcare providers participating in Blue Shield which
shall be distributed to Members. Blue Shield may provide a draft of such
directory to Group and Group may, within five (5) working days thereafter, submit
to Blue Shield, any additions, deletions, or modifications to be included in
the directory. Group, on behalf of itself and each of its Group Providers,
agrees that the following information may be included in Blue Shield’s
marketing materials, Blue Shield publications provided to present or potential
Members and subscriber groups, and in other written or electronic information
sources provided to present or potential Members and subscriber groups: (i)
Group’s name, address, phone number; (ii) the names, addresses, phone numbers,
areas of practice of its Group Providers (and other provider specific
information); and, (iii) such other types of information regarding


 


18

















 


Group and
Group Providers which are reasonable to include in directories, marketing
materials, or publications. Group and Group Providers agree that in the event
this Agreement is terminated, or the listing information is or becomes
incorrect or incomplete. Blue Shield will have no obligation to correct,
delete, or update such listing information until such time as Blue Shield, in
its sole discretion, issues a new directory, marketing material, or Blue Shield
publication.


 


(b)                                 Except
as provided in subpart (a) above, neither Blue Shield nor Group shall use the
other’s name, trademark(s), or service mark(s), without the other’s prior
written consent, which consent shall not be unreasonably withheld.


 


5.2                                 Provider Manual. Blue
Shield shall develop a Provider Manual, and Group and Group Providers shall
comply with its provisions. Blue Shield may, in its discretion, periodically
modify the Provider Manual by written notice to Group. “the Provider Manual, as
so amended, is incorporated herein by reference. To the extent of any conflict
between this Agreement and the Provider Manual, the terms of this Agreement
shall govern. In the event Group reasonably concludes that a change in the
Provider Manual would have an adverse financial impact on the Group, then Group
and Blue Shield shall confer in good faith regarding the change.


 


5.3                                 Blue Shield Reports. Blue
Shield shall provide to Group such reports regarding utilization and other
matters as set forth from time to time in the Provider Manual.


 


5.4                                 Administrative Services. Blue
Shield shall perform those services incident to the administration of a health
care service plan including, but not limited to, the processing of enrollment
applications, assignment of Members to PCPs, and the administration of claims
for Covered Services which are not Capitated Professional Services or Capitated
Hospital Services.


 


5.5                                 Discretionary Blue Shield Incentive Programs. Blue Shield
may periodically, in its sole discretion, develop, modify, and/or terminate
programs to reward and encourage the quality, efficiency, or responsiveness of
Blue Shield medical groups. Any such discretionary incentive programs shall be
described in Exhibit G. hereto, Commencing on the Effective Date, and until
terminated or modified by Blue Shield, Blue Shield shall pay to Group such
incentive fees as provided in Blue Shield’s Provider Incentive Program, as
described in Exhibit G.


 


VI. ELIGIBILITY OF BLUE SHIELD MEMBERS


 


6.1                                 Identification Cards and Verification.
Blue Shield shall issue identification cards to Members as set forth in the
Provider Manual. Production of such identification cards shall be indicative of
a person’s status as a Member, but shall not be conclusive of such status. Blue
Shield shall provide or shall make available to Group in formats that may be
accessed by Group electronically or telephonically, information regarding
Member status and Group/Primary Care Physician selection.


 


19

















 


6.2                                 Verification
of Eligibility. As set forth in the Provider Manual, Group and
Group Providers shall verify the eligibility of Members and provide services to
individuals claiming eligibility but whose name does not appear on Blue
Shield’s Eligibility List. Verification of eligibility shall not limit the
rights of Blue Shield to retroactively adjust eligibility, as set forth in
Paragraph 6.3 of this Agreement.


 


6.3           Eligibility List and Modifications.


 


(a)                                  Blue
Shield shall provide to Group on a monthly basis within ten days of the start
of the month, a member eligibility report and a member eligibility change
report, as further described in the Provider Manual. These reports shall be
submitted to the Group electronically, unless both Blue Shield and the Group
agree that it may be submitted in writing. Blue Shield shall attempt to
discourage retroactive cancellation or retroactive addition of Members.
However, Blue Shield may make exceptions as may be necessary for administrative
or business reasons. Subsequent Capitation to Group will be adjusted to reflect
the retroactive addition or deletion of Members. With the exception of
retroactive changes for Members enrolled in Blue Shield 65 Plus and those
Members enrolled through CalPERS and FEHBP, retroactive additions or deletions
shall not exceed ninety (90) days.


 


(b)                                 In
the event Blue Shield retroactively deletes a Member and Group has provided
Capitated Services to such deleted Member during the period of retroactive
deletion, Blue Shield shall compensate Group for such services only if Group
has unsuccessfully billed the Member through two (2) billing cycles. The amount
owed by Blue Shield for such Covered Services provided during the period of
retroactive deletion shall be the Blue Shield Allowable Rates set forth in
Exhibit E., net of any Copayments. Notwithstanding the foregoing, Blue Shield
shall have no obligation to compensate Group for such services in the event
that such Member is covered during the period of retroactive deletion by
another health care service plan, insurer, or third party payor (including
Medicare).


 


(c)                                  In
the event a person is retroactively added as a Member, Blue Shield’s financial
responsibility shall be the payment of Capitation for the period of retroactive
addition. Any payments collected from such Member by Group or Group Providers
for Covered Services hereunder, other than applicable Copayments, shall be
refunded to the Member.


 


VII. COMPENSATION & FINANCIAL TERMS


 


7.1          Capitation Payments.


 


(a)                                  Blue
Shield shall pay Group, on a monthly basis, the applicable Capitation set forth
in Exhibit C. Such Capitation shall be paid for Members not enrolled in the
Blue Shield 65 Plus Benefit Program no later than the twentieth (20th) day of
the month. Capitation shall be paid for Members who are enrolled in Blue


 


20

















 


Shield’s Blue
Shield 65 Plus Benefit Program no later than the later occurring of the
twentieth (20th) day of the month or five (5) business days following the date
Blue Shield receives the CMS capitation payment for such Members.


 


(b)                                 Medicare
Primary. For those Members for whom Medicare is primary, Group or Group
Providers shall bill Medicare as the primary payor for Medicare covered
benefits. For such Members, Blue Shield shall pay a reduced Capitation as set
forth in Exhibit C., and Group shall be financially responsible for all
Capitated Professional Services (including those which are not Medicare
benefits) which are Covered Services for said Members.  In addition, neither Group nor Group
Providers may charge or collect from such Members the Member’s Medicare
coinsurance and deductible. The Medicare Primary Member, however, shall be
responsible for his/her applicable Copayment set forth in the applicable Health
Services Contract and Evidence of Coverage.


 


(c)                                  The
Capitation paid shall be for all Members eligible on the first (1st) day of the
month for which the Capitation is to be paid, who have chosen a Group physician
as their PGCP. Group shall accept payment of Capitation in accordance with this
Agreement, and applicable Copayments and coordination of benefits collections,
as payment in full for all Capitated Professional Services, administrative
services, and other services rendered by Group pursuant to this Agreement.


 


(d)                                 In
the event this Agreement terminates on a day other than the last day of a
month, Blue Shield may pro-rate the Capitation due for said month based on the
number of days in said month covered by the Agreement to the total number of
calendar days in said month.


 


7.2                                 Services Other Than Capitated Professional
Services.


 


(a)                                  In
the event that Group provides Emergency Services, Urgent Care Services, or
authorized Covered Services to Blue Shield’s HMO members who are not Members
hereunder (and for whom such services are not the financial responsibility of
another capitated Blue Shield medical group), Group shall bill Blue Shield for
the provision of such services as set forth in the Provider Manual. Blue Shield
shall pay Group for the services described in this Paragraph 7.2 at the rates
set forth in Exhibit E., minus any applicable Copayment. All such billings shall
be delivered to Blue Shield within sixty (60) days of the date of service. Blue
Shield may deny payment for any bills not received by Blue Shield within one
hundred eighty (180) days of the date of service and in such event, neither
Group nor Group Providers may bill the Member for such services.


 


(b)                                 Notwithstanding
the foregoing subpart (a), in the event that Blue Shield is not the primary
payor, Group shall not make any demand for payment from Blue Shield until all
primary sources of payment have been pursued. Blue Shield’s obligation
hereunder with respect to such Covered Services provided to members who are not
Members hereunder, shall be limited to the amount, if


 


21

















 


any, which
when added to the amount obtained by Group from such primary payors, equals the
amount of compensation to which Group is entitled under this Agreement for such
services.


 


7.3                                 Copayments.
Group shall collect and retain, as additional compensation, the Member’s
applicable Copayment for Covered Services provided. Such Copayment obligation
shall not be waived by Group or Group Providers.


 


7.4                                 Stop Loss
Coverage. During the term of this Agreement, Group shall either obtain
professional stop loss coverage through Blue Shield under the terms and
conditions set forth in Exhibit I attached hereto or shall obtain professional
stop loss coverage from a third party insurer acceptable to Blue Shield. Upon
request, certificates and other proof of such coverage shall be provided to
Blue Shield. Group shall provide Blue Shield with timely notice of cancellation
of coverage or change in carrier. If Group elects to have Blue Shield provide
such stop loss coverage, by so indicating on the Signature Page hereto, Blue
Shield shall provide and charge Group for stop loss coverage as set forth in
Exhibit I.


 


7.5                                 Shared Savings Programs.


 


(a)                                  Blue
Shield shall establish a Shared Savings Program pursuant to which Blue Shield
and Group share savings for the cost of Covered Shared Savings Services
provided to Members during the Agreement Year. The provisions of the Shared
Savings Program for Members who are enrolled in Benefit Programs other than
Blue Shield 65 Plus are set forth in Part A of Exhibit D. The provisions of the
Shared Savings Program for Blue Shield 65 Plus Members are set forth in Part B
of Exhibit D.


 


(b)                                 Blue
Shield shall establish a Pharmacy Shared Savings Fund Program pursuant to which
Blue Shield and Group share savings for the cost of Covered Outpatient
Prescription Drug services provided to Blue Shield 65 Plus Members during the
Agreement Year, the provisions of the Pharmacy Shared Savings Fund Program are
set forth in Part C, of Exhibit D.


 


(c)                                  Blue
Shield may offset any amount owed to Blue Shield by Group under a Shared
Savings Program, Pharmacy Shared Savings Fund, or other risk sharing or
incentive agreement (regardless of year owed or under which agreement owed)
from any amount, other than Capitation and Professional Stop Loss Program
payments made pursuant to Exhibit I , owed by Blue Shield to Group under this
or any other agreement between Blue Shield and Group.


 


(d)                                 In
the event that Group has contracted with a provider for services at rates which
are more favorable than the rates obtained by Blue Shield and a Shared Savings
Service is provided by such provider to a Member hereunder. Group shall make
best efforts to cooperate with Blue Shield to obtain such more favorable rate
for the provision of such Shared Savings Service to such Member.


 


22

















 


(e)                                  In
the event Group wishes to dispute Blue Shield determinations regarding the
Shared Savings Program settlements, it shall notify Blue Shield in writing
within sixty (60) days following such settlement determination, and if such
dispute is not resolved by the parties. Group may request arbitration as set
forth in Article XI.


 


7.6                                 Blue Shield POS Benefit Program. 
This Agreement shall apply to Blue Shield POS Benefit Programs only if
so indicated on Exhibit A, attached hereto. Compensation to Group for Members
enrolled in a Blue Shield POS Benefit Program shall be as described in Exhibit
H-2 attached hereto. Blue Shield may offset surpluses in the POS Out-of-Network
Funds settlements against any deficits in any other risk or incentive agreement.
Blue Shield shall not offset any deficits in the POS Out-of- Network Funds
settlements against any other amounts owed to Group by Blue Shield.


 


7.7                                 Third Party Liens.  In the event a Member seeks and obtains a
recovery from a third party or a third party’s insurer for injuries caused to
that Member, and only to the extent permitted by the Member’s Evidence of
Coverage and by California law, Group shall have the right to assert a third
party lien for and to recover from the Member the reasonable value of Capitated
Professional Services provided to the Member by Group for the injuries caused
by the third party. Group’s pursuit and recovery under third party liens shall
be conducted in strict accordance with the procedures set forth in the Provider
Manual. Blue Shield shall similarly have the right to assert a lien for and
recover for payments made by Blue Shield for such injuries. Group shall
cooperate with Blue Shield in identifying such third party liability claims and
in providing such information, within such time frames, as set forth in the
Provider Manual.


 


7.8                                 Groups Organized By Geographic Regions. In the event that Blue
Shield and Group have agreed that Group will provide services to Members in
specified multiple geographic regions, such regions shall be described in
Exhibit A., and Blue Shield shall pay Group Capitation based upon the region in
which the Member selects a Group PCP. Shared Savings settlements shall be
determined on a region by region basis, with any amounts owed by Blue Shield to
Group for one region(s) offset by any amounts owed by Group to Blue Shield for
any other regions). Incentive programs, as referred to in Paragraph 5.5, shall
be determined on Group-wide (not a regional) basis.


 


7.9                                 Purpose of Incentive Programs. The parties understand and agree
that any payments made directly or indirectly to the Group under the incentive
provisions set forth in this Agreement, including the Shared Savings Program
(Paragraph 7.5) and the Discretionary Blue Shield Incentive Programs (Paragraph
5,5), are not made as an inducement to reduce or limit Medically Necessary
Covered Services to any specific Member.


 


7.10                           Blue Shield Timeliness Guarantee. Except for reasons not
attributable to Blue Shield (e.g., natural disaster), in the event that Blue
Shield fails to:


 


(i)                                     Provide
to Group a Member eligibility list on or before the 10th day of each month,
Blue Shield shall, as a penalty, pay to Group ten cents ($0.10) for each


 


23

















 


Member, as the
number of Members are determined by the list once provided. If the list is
provided by the 10th day of the month, no penalty is payable even if the list
is incomplete or is subsequently corrected; and.


 


(ii)                                  Pay
monthly Capitation to Group within the time limits required by this Agreement,
Blue Shield shall pay interest on the unpaid Capitation until paid, at the Bank
of America prime rate plus two percent (2%) per annum. Such interest is not
payable if Capitation is paid within such time limits, regardless of whether
such Capitation is incomplete or subsequently corrected.


 


7.11                           Encounter Data Submission Penalties. Based on Blue Shield’s quarterly
determinations and following no less than thirty (30) days prior notice to
Group, Blue Shield may withhold a portion of Group’s Capitation, as set forth
in Exhibit C., in the event that Blue Shield determines that a significant
portion (as described in the Provider Manual) of the monthly Encounter Data
which Group is obligated to provide (Paragraph 2.12) has not been delivered to
Blue Shield within the prior quarter. If at the quarterly determination next
following such withhold, Blue Shield determines that Group has satisfactorily
delivered to Blue Shield the previously non-delivered Encounter Data, such
withheld Capitation shall be paid to Group, without interest. In the event that
Group does not deliver such Encounter Data to Blue Shield prior to such
quarterly determination. Blue Shield shall be entitled to retain such withheld
Capitation and will continue to deduct from the Group’s Capitation and retain
such deductions as described in Exhibit C. from each quarter’s Capitation. If
at a later date Group resumes the timely and complete submission of encounter
data as required by this Agreement, then Blue Shield will cease deducting these
penalties from Group’s Capitation beginning as of the month in which compliance
is demonstrated by Group.


 


VIII.
PROTECTION OF MEMBERS


 


8.1                                 Non-discrimination.
Except as otherwise provided in this Agreement, Group and Group Providers shall
make Capitated Services available to Members in the same manner, in accordance
with the same standards, and with no less availability as Group and Group
Providers provide services to their other patients. Group and Group Providers
shall not discriminate against any Member in its provision of Covered Services
on account of race, sex, color, religion, national origin, ancestry, age,
physical or mental handicap, health status, disability, need for medical care,
sexual preference, or veteran’s status, or status as a Member of Blue Shield.


 


8.2                                 Credentialed
Providers. In providing Capitated Services hereunder, and except
as otherwise provided in Paragraph 2.4, Group shall utilize only Group
Providers who are credentialed and re-credentialed in accordance with Blue Shield’s
standards as set forth in the Provider Manual. Group and/or each Group Provider
shall provide to Blue Shield, on request, credentialing information, in such
form as reasonably required by Blue Shield.


 


24

















 


8.3                                 Charges
to Members.


 


(a)                                  In
no event, including but not limited to nonpayment by Blue Shield or Group, or
Blue Shield’s or Group’s insolvency or breath of this Agreement (or breach by
Group of its agreement with Group Provider), shall Group and Group Providers
bill, charge, collect a deposit from, impose a surcharge on, seek compensation,
remuneration or reimbursement from or have any recourse against. Members or an
individual responsible for their care for Covered Services. Nor shall Group or
a Group Provider seek payment from Members or individuals responsible for their
care, for payments for Covered Services denied by Blue Shield or Group because
such bill or claim was not timely or properly submitted, or because the
rendered services were not Medically Necessary or Authorized, Whenever Blue
Shield receives notice of a violation of this Paragraph 8.3, it shall take
appropriate action (including without limitation the right to reimburse the
Member the amount of any payment and offset the amount of such payment from any
amounts then or thereafter owed by Blue Shield to Group).


 


(b)                                 Group
and Group Providers shall not bill or collect from a Member any charges in
connection with Non-Covered Services, non-Authorized services, or services
determined not to be Medically Necessary unless Group, or as applicable, the
Group Provider, has first obtained a written acknowledgment from the Member
that such services are either not Covered Services, not Authorized, or not
Medically Necessary, and that the Member, or the Member’s legal representative,
is financially responsible for the cost of such services. Such acknowledgment
shall be obtained prior to the time that such services are provided to the
Member and shall be in such form as meets the applicable requirements set forth
in the Provider Manual.


 


(c)                                  Group
agrees that, in the event of Blue Shield’s insolvency or other cessation of
operations, Covered Services to Members will continue through the period for
which their premiums have been paid, and Covered Services to Members confined
in an inpatient facility on the date of insolvency or other cessation of
operations will continue until the Member’s discharge.


 


(d)                                 The
provisions of this Paragraph 8.3 shall: (i) survive the termination of this
Agreement (and any agreement between Group and Group Provider) regardless of
the cause giving rise to termination and shall be construed to be for the
benefit of Members; and, (ii) supersede any oral or written contrary agreement
(now existing or hereafter entered into) between the Group or Group Provider
and the Member.


 


(e)                                  The
provisions of this Paragraph 8.3 shall be incorporated into any agreement
between the Group and its contracted healthcare providers. This Paragraph 8.3
shall not be changed without the prior approval of the appropriate government
regulatory agency.


 


8.4                                 Protection
of Members. In the event that Blue Shield or a Member notifies
Group that a Group Provider (or physician providing coverage for such Group
Provider), or another provider who provided Capitated Professional Services to
the Member is billing, suing, or otherwise attempting to collect (“Collection”)
payment


 


25

















 


from the
Member or person responsible for the Member’s care, other than Copayments, Group
shall immediately take all reasonable and appropriate actions to stop such
Collection. In the event that Group is unable to timely stop such Collection,
as determined by Blue Shield, Blue Shield may take any steps it deems
appropriate, including payment of the claim, to stop such Collection. In such
event, Blue Shield may deduct and offset such payment from any amount then or
thereafter payable by Blue Shield to Group.


 


8.5                                 Benefits
Determination. All final decisions regarding coverage are
reserved to Blue Shield, and Group shall refer Members who have inquiries or
disputes regarding such coverage to Blue Shield for response and resolution.
This provision, however, does not and shall not be construed to prohibit any
physician from providing any medical treatment, or other advice which such
physician believes to be in the best interest of the patient.


 


8.6                                 Member Complaints and Grievances. Group shall
promptly notify Blue Shield of receipt of any claims, including professional
liability claims filed or asserted by a Member against Group or a Group
Provider. Group shall cooperate with Blue Shield in identifying, processing,
and resolving all Member grievances and other complaints, in accordance with
Blue Shield’s complaint/grievance process and time limits set forth in the
Provider Manual, as well as in accordance with such time limits as required by
state and/or federal law, Group shall comply with Blue Shield’s resolution of
any such complaints or grievances including specific findings, conclusions and
orders of the Department of Corporations.


 


8.7                                 Medical
Necessity Assistance. In all cases where the Group and/or a
Group Provider has made a determination regarding the Medical Necessity of a
medical service requested or provided to a Member, Group shall, upon the
request of Blue Shield, assist Blue Shield in determining the Medical Necessity
of such service and provide relevant medical records to Blue Shield and
participate in any grievance, arbitration, and/or other proceedings in which
such Medical Necessity determination is an issue. Moreover, Group agrees to
cooperate with and abide by the Medical Necessity determination of any external
review entity to which Blue Shield is either obligated by law to submit such
disputes or for which Blue Shield has implemented a program to submit such
disputes to external review.


 


8.8                                 Free Exchange of Information. No provision of this Agreement
shall be construed to prohibit, nor shall any provision in any contract between
Group and its employees or subcontractors prohibit, the free, open and
unrestricted exchange of any and all information of any kind between health
care providers and Members regarding the nature of the Member’s medical
condition, the health care treatment options and alternatives available and
their relative risks and benefits, whether or not covered or excluded under the
Member’s health plan, and the Member’s right to appeal any adverse decision
made by Group or Blue Shield regarding coverage of treatment which has been
recommended or rendered. Moreover, Group shall not penalize nor sanction any
health care provider in any way for engaging in such free, open and
unrestricted communication with a Member nor for advocating for a particular
service on a Member’s behalf.


 


26

















 


8.9          Insurance.


 


(a)                                  Group
and Group Providers shall maintain professional liability (malpractice)
insurance and general liability insurance coverage in the minimum amount of One
Million Dollars ($1,000,000) per occurrence and Three Million Dollars
($3,000,000) annual aggregate per physician per year for all physicians who are
partners, associates or employees of Group and warrants that all physicians
with which Group contracts will carry professional liability coverage in the
same amount. If Group or its Group Providers or subcontracts have a claims made
malpractice insurance policy, then they agree to keep the policy in effect for
at least five (5) years past any termination of this Agreement or purchase
extended reporting coverage (tail insurance).


 


(b)                                 Each
Group Provider who is not a physician shall maintain insurance as set forth
above, but with commercially reasonable policy limits appropriate to the risk
being insured.


 


(c)                                  Group
and Group Providers shall maintain Workers’ Compensation insurance covering all
employees of Group or, as applicable, of Group Provider.


 


(d)                                 Group
shall notify Blue Shield and provide evidence to Blue Shield at the time of any
amendment, change or modification to such insurance coverage and at any time on
reasonable request by Blue Shield during the term of this Agreement.


 


IX.  MEDICAL RECORDS & CONFIDENTIALITY


 


9.1                                 Medical Records.
Group and Group Providers shall maintain the usual and customary records for
Members in the same manner as for other patients of Group and Group Providers.
Group will require that all Group Physicians establish and maintain in an
accurate and timely manner for each Member who has obtained care from such
physician a medical record which is organized in a manner which contains such
demographic and clinical information as is necessary, in the opinion of the
Blue Shield medical director and the Group medical director, to provide
documentation as to the medical problems and medical services provided to the
Member. Such record shall include a historical record of diagnostic and
therapeutic services recommended or provided by, or under the direction of, the
provider. Such records shall be in such a form as to allow trained health
professionals, other than the provider, to readily determine the nature and
extent of the Member’s medical problem and the services provided and permit
peer review of the care provided. Such records shall, on request, and within
reasonable time requirements, be made available without charge to Blue Shield
and its designated agents. Without limiting the foregoing, Group shall, without
charge, transmit Member’s medical records information to a Member’s other
providers, to Government Officials, and to Blue Shield for purposes of
utilization management, quality improvement and other Blue Shield
administrative purposes. Upon termination of this Agreement, or the re-


 


27

















 


assignment or
transfer of Members, one copy of such records shall be provided without charge
to the Member’s new medical group upon request.


 


9.2                                 Confidentiality. Group and Group Providers
shall comply with all applicable state and federal laws regarding privacy and
confidentiality of medical information and records, including mental health
records. Group and Group Providers shall develop policies and procedures to
ensure that Member medical records are not disclosed in violation of Cal.
Civ. Code §§ 56, et seq. To the extent Group receives, maintains or
transmits medical or personal information of Members electronically, Group
shall comply with all state and federal laws relating to the protection of such
information including, but not limited to, the Health Insurance Portability and
Accountability Act (HIPAA) provisions on security and confidentiality and any CMS
regulations or directives relating to Medicare beneficiaries.


 


9.3                                 Member
Access to Records. Group and Group Providers shall ensure that
Members have access to their medical records in accordance with the
requirements of state and federal law.


 


X. COOPERATION WITH AUDITS &
CERTIFICATIONS


 


10.1        Disclosure of Records.


 


(a)                                  Group
and each Group Provider shall comply with all provisions of the Omnibus
Reconciliation Act of 1980 regarding access to books, documents, and records.
Without limiting the foregoing, Group shall maintain such records and provide
such information to Blue Shield as well as to DMHC, CMS, any Peer Review
Organization (“PRO”) with which Blue Shield contracts as required by CMS, the
U.S. Comptroller General, their designees and any other governmental officials
entitled to such access by law (collectively, “Governmental Officials”) as
required by law and as may be necessary for compliance by Blue Shield with the
provisions of all state and federal laws governing Blue Shield. Blue Shield and
Government Officials shall have access to, and copies of, at reasonable time
upon request, the medical records, books, charts, and papers relating to the
Provider’s provision of health care services to Members, the cost of such
services, and payment received by the Provider from the Member (or from others
on their behalf), and to the financial condition of the provider. Such records
described herein shall be maintained at least six (6) years from the end of
each Agreement Year, and, if this Agreement is applicable to Blue Shield 65
Plus , six (6) years from the close of CMS’ fiscal year in which the contract
was in effect (or for a particular record or group of records, a longer time
period when or DMHC requests such longer record retention and Group is notified
of such request by Blue Shield), and in no event for a shorter period than as
may be required by the Knox-Keene Act and the regulations promulgated
thereunder. All records of Group/Providers shall be maintained in accordance
with the


 


28

















 


general
standards applicable to such book or record keeping and shall be maintained
during any governmental audit or investigation.


 


(b)                                 Group
shall, on request, disclose to Government Officials the method and amount of compensation
or other consideration to be received by it from Blue Shield or payable by
Group to its subcontractors. Group shall maintain and make available to
Government Officials:  (i) its
subcontracts, and (ii) compensation/financial records relating to such
subcontracts and compensation from Blue Shield.


 


(c)                                  Upon
forty-eight (48) hours notice, Group shall make any records of its quality
improvement and utilization review activities pertaining to Members and
provider credentialing files available to Blue Shield’s quality and utilization
review committee. Such sharing of records between the two committees shall be
in accordance with, and limited to, Sections 1157 of the California Evidence
Code and 1370 of the California Health and Safety Code and shall not be
construed as a waiver of any rights or privileges conferred on either party by
those statutes.


 


(d)                                 Blue
Shield, at its sole cost and expense, and with reasonable prior notice to
Group, may from time to time audit the books and records of Group as they
relate to its services, claims payments, authorization turn-around times,
reporting, and billings under this Agreement.


 


10.2                     Site Evaluations. Group and Group Providers shall
permit Government Officials and Blue Shield to conduct periodic site evaluations
and inspections of their facilities and records. In the event that Government
Officials or Blue Shield find any deficiencies in such facilities or records,
Group, or Group Provider, as applicable, shall have thirty (30) days to
substantially correct such deficiencies which are identified by such Government
Officials or Blue Shield.


 


10.3                     Accreditation
Surveys. Group and Group providers shall cooperate in the manner
described in Paragraphs 10.1 and 10.2 hereof with respect to surveys and site
evaluations relating to accreditation of Blue Shield by NCQA or any other
accrediting organization. Further, Group agrees to implement any changes
reasonably required as a result of all such surveys.


 


10.4                     Compliance Monitoring.
Group shall cooperate with Blue Shield in the performance of any monitoring,
studies, evaluations analyses or surveys required by Government Officials or
accrediting organizations of Group’s performance of services hereunder.


 


XI. RESOLUTION OF DISPUTES


 


11.1                     Provider
Dispute Resolution Procedure. Blue Shield and Group agree to meet and
confer in good faith to resolve any disputes that arise under this Agreement,
except for dispute relating to the procedure whereby this Agreement may be
terminated, which disputes shall be governed exclusively by Paragraph 11.2
hereof. If such disputes remain unresolved, they may be referred to the Blue
Shield


 


29

















 


Provider
Dispute Resolution Committee. Disputes may be submitted in writing addressed to
Blue Shield Dispute Resolution Committee, Attn: Network Manager, Provider
Services, P. O. Box 629011, El Dorado Hills, CA 95762-9011. Disputes referred
to the Blue Shield Provider Dispute Resolution Committee shall be decided
within thirty (30) days of referral. If such disputes cannot be resolved by the
Blue Shield Provider Dispute Resolution Committee, Blue Shield and Group agree
to submit the dispute to binding arbitration pursuant to Section 11.2 of this
Agreement. Group further agrees that the procedures set forth in this Paragraph
11.1 may be used in the event that a Group Provider has a dispute with Group.
Pursuit by Group of a dispute through the processes described in this Article
XI, shall not modify nor relieve Group of any obligations to continue to
provide services to Members in accordance with and to comply with all terms of
this Agreement.


 


11.2                           Arbitration
of Disputes. If any dispute, controversy, or misunderstanding (other
than a claim of medical malpractice) arises between the parties to this
Agreement which exceeds the jurisdiction of Small Claims Court, which was not
resolved in the Provider Dispute Resolution procedure set forth in Paragraph
11.1, and which may directly or indirectly concern or involve any term,
covenant, or condition hereof, the parties shall settle the dispute by final
and binding arbitration in San Francisco, Los Angeles, San Diego or Sacramento,
California, whichever city is closest to the Group. Arbitration shall be
conducted under the Commercial Rules of the American Arbitration Association.
The arbitration decision shall be binding on both parties. It is agreed that
the arbitrator shall be bound by applicable state and federal law and that the
arbitrator shall issue written findings of fact and conclusions of law. The
arbitrator shall have no authority to award damages or provide a remedy which
would not be available to such prevailing party in a court of law nor shall the
arbitrator have the authority to award punitive damages. The cost of the
arbitration shall be shared equally by Group and Plan. Each party shall be
responsible for its own attorneys’ fees.


 


11.3                           Cooperation
With Member Disputes. Group and Group Providers shall cooperate
in the Member grievance and appeals process as described in the Provider
Manual.


 


XII. TERM
&. TERMINATION


 


12.1                           Term. When executed by both parties, this
Agreement shall become effective as of the Effective Date, and shall continue
in effect for three (3) years thereafter, unless earlier terminated as set
forth below. Unless either party notifies the other party at least one hundred
eighty (180) days prior to the expiration of said initial three (3) year term,
this Agreement shall, following expiration of the initial term, continue in
effect for additional one (1) year terms until terminated as set forth below.


 


12.2                           Termination
Without Cause. Either party may terminate this Agreement at anytime
without cause by giving to the other party at least one hundred eighty (180)
calendar days written notice of termination


 


30

















 


12.3                           Termination for Cause.
Either party may, subject to the cure period set forth in Paragraph 12.4,
terminate this Agreement for material cause after written notice as set forth
hereinafter. The following shall constitute a material cause for termination:


 


(a)                                  By
Group if: (i) Blue Shield fails to pay Group the Capitation due to Group
hereunder within twenty (20) days of such payment’s due date; or, (ii)
revocation of Blue Shield’s license necessary for the performance of this
Agreement; or, (iii) Blue Shield breaches any material term, covenant, or
condition of this Agreement.


 


(b)                                 By
Blue Shield if: (i) the filing of bankruptcy by a parent or subsidiary or
substantial deterioration in the financial condition of a parent, affiliate or
subsidiary, or, (ii) Group fails to provide quality medical services consistent
with the standards set forth in this Agreement and in the Provider Manual; or,
(iii) Group breaches any material term, covenant, or condition of this
Agreement.


 


Notwithstanding
any provision of Paragraph 12.4 to the contrary, Blue Shield may immediately
terminate this Agreement in the event that Group is excluded from participation
in Medicare or Group fails to maintain all insurance required herein, or if
Blue Shield, after consultation with Group, determines in good faith that
continuation of this Agreement may reasonably be expected to jeopardize the
health, safety, or welfare of Members, or if Blue Shield reasonably determines,
after consulting with Group, that Group is likely to be financially unable to
provide and/or pay for, in a competent and timely manner, Capitated
Professional Services.


 


12.4                           Notice and Cure
Period. A party seeking to terminate this Agreement for material breach
shall notify the other party in writing of the nature of the breach and the
other party shall have thirty (30) days from the receipt of such notice to cure
or otherwise eliminate such cause. If the other party does not remedy the
breach, to the reasonable satisfaction of the non-breaching party, this
Agreement shall terminate at the end of the thirty (30) day period.


 


12.5                           Termination
Not an Exclusive Remedy. The termination of this Agreement by either
party pursuant to this Article XII is not an exclusive remedy and such
terminating party retains whatever rights in law or equity as may be necessary
to enforce its rights under this Agreement.


 


12.6                           Effect of
Termination. As of the date of termination, this Agreement shall be
considered of no further force or effect whatsoever, and each of the parties
shall be relieved and discharged herefrom, except that:


 


(a)                                  Termination
shall not affect any rights or obligations hereunder which have previously
accrued, or shall hereafter 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.


 


31

















 


(b)                                 Group
shall, at Blue Shield’s option, continue rendering Capitated Professional
Services after the termination of this Agreement to Members assigned to Group
at the capitation rates in effect immediately prior to the date of termination,
for the duration of the contracts in effect with Blue Shield through which
Members are enrolled with Blue Shield, or until such time as Blue Shield has
arranged for an alternative source of services for each such Member from other
contracting providers.


 


(c)                                  Group
shall, in the event of Blue Shield’s insolvency, continue rendering Capitated
Professional Services to any Member who is an inpatient of a hospital until
such Member’s discharge or transfer to another appropriate facility.


 


(d)                                 The
following paragraphs of this Agreement shall survive the termination of this
Agreement, whether such termination is the result of rescission or otherwise; Paragraphs
2.9(b), 3.1, 5.1, 8.3, 8.4, 8.6, 8.7, 8.8, 10.1, 11.1, 11.2, 14.9, and 14.10.


 


XIII. COMPLIANCE WITH LEGAL REQUIREMENTS


 


13.1                           Consistency
with State Law. This Agreement is subject to the requirements of
Chapter 2.2 of Division 2 of the California Health & Safety Code (the
Knox-Keene Act) and of Subchapter 5.5 of Chapter 3 of Title 10 of the
California Administrative Code. Any provision required to be in this Agreement
by either of the above Codes shall bind Blue Shield and Group, whether or not
provided in this Agreement. Group shall require that Group Providers similarly
comply with all applicable provisions of the Act and Rules.


 


13.2                           Consistency with Federal Law. If this Agreement applies to Blue
Shield 65 Plus, Group shall comply and Group shall require that its Group
Providers comply with the statutes and regulations and CMS instructions which
govern Blue Shield’s Agreement with CMS. Moreover, Group and Group Providers
shall comply with the additional obligations set forth in Exhibit H-1 hereto.
Group also agrees that, to the extent ERISA statutes and regulations apply to
the claims payment and Member complaint functions performed by Group, Group and
Group Providers shall comply with all such requirements.


 


13.3                           Coordination
of Benefits. Group agrees that coordination of benefits, benefit
determinations under the Medicare Secondary Payor rules, and Workers’
Compensation recoveries shall be conducted by Group in accordance with the
procedures set forth in the Provider Manual.


 


13.4                           Timely
Payment. In making payments to Group Providers and other providers for
Capitated Professional Services as set forth in Article III, hereof, Group
shall comply and shall cause all subcontractors to whom claims payment
obligations are delegated to comply with the timeliness requirements set forth
in applicable state and


 


32

















 


federal law,
including, but not limited to, Section 1371 of the Knox-Keene Act and any
applicable CMS rules and regulations.


 


13.5                           Disclosure
of Provider Profiling. Group shall, upon request from Blue Shield and
as further described in the Provider Manual, provide Blue Shield with
information regarding any “economic profiling” of Group Providers by Group in
order to permit Blue Shield to comply with the provisions of Section 1367.02 of
the Knox-Keene Act. Further, to the extent that group utilizes ‘‘economic
profiling” as defined in Section 1367.02, Group shall provide copies of
economic profiling information to Group Providers in accordance with the
requirements of Section 1367.02.


 


13.6                    Provider
Terminations. In the event that a subcontract with a Group Provider is
denied, suspended or terminated, Group shall provide the provider with written
notice of the reason for the action as required by state and federal law,
including any standards and profiling data Group used to evaluate the provider,
the number and mix of similar health care providers that Group needs (if
applicable), and notice of the provider’s right to appeal the action, including
notice of the process and timing to request a hearing. In the event Group
terminates a contract with a Group Provider for deficiencies in the quality of
care provider, Group shall give notice of the action to the appropriate
licensing and disciplinary bodies.


 


13.7                           Financial
Solvency Reporting The Group shall, as further described in the Provider
Manual, submit Quarterly and Annual reports to the Department of Managed Health
Care in compliance with the legal requirements of Subchapter 5.5 of Chapter 3
of Title 28, California Code of Regulations §1300.75.4.2.


 


13.8                           Blue
Shield Reporting Requirements Blue Shield shall submit Quarterly and Annual
reports to the Department of Managed Health Care in compliance with the legal
requirements of Subchapter 5.5 of Chapter 3 of Title 28, California Code of
Regulations § 1300.75.4.3.


 


XIV.
GENERAL PROVISIONS


 


14.1                           Waiver
of Breach. The waiver of any breach of this Agreement by either party
shall not constitute a continuing waiver of any subsequent breach of either the
same or any other provisions of this Agreement.


 


14.2                           Amendments.
Except as provided in this Paragraph 14.2 and in Paragraphs 1.5 and 5.2, this
Agreement may be amended only by mutual, written consent of Blue Shield and
Group’s duly authorized representatives. Notwithstanding the foregoing, or if
Blue Shield’s legal counsel determines in good faith that this Agreement must
be modified to be in compliance with applicable federal or state law or to meet
the requirements of accreditation organizations which accredit Blue Shield and
its providers, Blue Shield may amend this Agreement by delivering to Group (the
“Notice Date”) a copy of the modifications (the “Legally-Required
Modifications”) along with the reasons therefore, and such modification(s)
shall be deemed accepted by Group and an amendment to this Agreement if Group
does not, within thirty (30) days following said Notice Date, deliver to Blue
Shield its written objection of such Legally-Required


 


33

















 


Modification(s).
In the event that Group timely objects to such Legally-Required Amendment, such
amendment shall nevertheless become effective as of the date set forth in said
amendment, and Group, in the event Group and Blue Shield cannot resolve Group’s
objection, may terminate this Agreement on ninety (90) days prior written
notice to Blue Shield.


 


14.3                           Entire
Agreement. This Agreement, all attachments and Exhibits referenced in
this Agreement and attached hereto, and the Provider Manual, as amended from
time to time, are incorporated herein by reference, and constitute the entire
understanding between the parties relating to the subject matter hereof. This
Agreement does not supersede or modify any agreement between the parties
pertaining to Blue Shield’s PPO Benefit Programs, including without limitation,
any Physician Member Application and Agreement between the parties or between
Blue Shield and Group physicians.


 


14.4                           Independent Contractors. In the performance of each
party’s work, duties, and obligations pursuant to this Agreement, each of the
parties shall at all times be acting and performing as an independent
contractor, and nothing in the Agreement shall be construed or deemed to create
a relationship of employer and employee or partner or joint venturer or principal
and agent. Each party agrees to indemnify, defend and hold harmless the other
party from any claims, causes of action or costs, including reasonable
attorneys’ fees, arising out of the indemnifying parties alleged or actual
negligence or otherwise improper performance of its obligations hereunder.


 


14.5                           Notices. Any notices or other communication made or
contemplated by this Agreement to be in writing shall be deemed to have been
received by the party to whom it is addressed three (3) days after it is
deposited in the United States mail, certified postage prepaid, return receipt
requested, or the date of delivery by Federal Express or similar commercial
courier service, and addressed as set forth in Exhibit A., or to such other
address as either party from time to time informs the other in writing.
Further, notice may be given during normal business hours by facsimile
transmission to the number set forth in Exhibit A. which shall be deemed
received upon facsimile transmission confirmation, or by personal delivery to
the address set forth in Exhibit A. which shall be deemed received upon receipt
of a signature from the person or office at the designated address.


 


14.6                           Third
Party Beneficiaries. Except as set forth in Paragraph 2.10, neither
Members nor any other third parties are intended by the parties hereto to be
third party beneficiaries under this Agreement, and no action to enforce the
terms of this Agreement may be brought against either party by any person who
is not a party hereto.


 


14.7                           Assignment, Subcontracting, and Addition of PCPs.


 


(a)                                  Neither
Blue Shield nor Group shall assign, transfer, or subcontract its rights,
duties, or obligations under this Agreement without the prior written consent
of the other party.


 


34

















 


(b)                                 For
purposes of providing services to Members hereunder, Group may not add as PCPs
any physician whose principal medical office is located outside the postal zip
codes set forth as PCP Zip Codes in Exhibit A., without Blue Shield’s prior
written consent, which consent may be granted or withheld by Blue Shield in its
sole discretion.


 


14.8                           Interpretation of Agreement. In the
event of any ambiguity in this Agreement, this Agreement shall be interpreted
according to its fair intent and not for or against any one party on the basis
of which party drafted the Agreement. This Agreement shall be governed in all
respects, whether as to validity, construction, capacity, performance or
otherwise, by the laws of the State of California and such federal laws as are
applicable to Blue Shield. If for any reason any provision of this Agreement is
held invalid, the remaining provisions shall remain in full force and effect.
The captions herein are for convenience only and shall not affect the meaning
or interpretation of the Agreement.


 


14.9                           Confidentiality/Trade Secrets. The compensation terms
of this Agreement and all terms relating to compensation shall be confidential.
Group shall not disclose such terms (other than to Government Officials) except
with the prior written consent of Blue Shield. However, nothing herein shall
prohibit Group or Group Providers from disclosing to Members and others the
method by which they are compensated (e.g., capitation, fee-for-service, etc.);
it is the precise compensation amounts for which confidential treatment is
required by this provision.


 


14.10                     Non-Solicitation.
During the term of this Agreement, and for one (1) year thereafter, neither
Group nor Group Providers shall solicit, induce, or encourage any Member to
disenroll from Blue Shield or select another health care service plan for
healthcare services. Notwithstanding the foregoing, Group and Group Providers
shall be entitled to freely communicate with Members regarding any aspect of
their health status or treatment.


 


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


 


IN WITNESS
WHEREOF, the parties have caused this Agreement to be executed by their
authorized representatives.


 


35

















 


	
  BLUE SHIELD OF CALIFORNIA

  	
   

  	
  GATEWAY MEDICAL GROUP,

  INC.

  
	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Lisa Farnan

  	
   

  	
   

  	
  Signature:

  	
  /s/ Mike
  Olson

  
	
   

  	
   

  	
   

  	
   

  
	
  Print Name:

  	
  Lisa Farnan

  	
   

  	
   

  	
  Print Name:

  	
  Mike Olson

  
	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  VP, Provider Relations

  	
   

  	
   

  	
  Title:

  	
  Contracting
  /Network Development Director

  
	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  4-5-02

  	
   

  	
   

  	
  Date:

  	
  April 3,
  2002

  
												



 


36

















 


GROUP’S
TAX ID #: 33-0843838


 


	
  GROUP IS A:

  	
  ý

  	
   IPA

  	
   

  	
  Ltd.
  Knox-Keene Licensee

  
	
   

  	
   

  	
   Integrated
  Medical Group

  	
   

  	
  Other
  (Specify):

  
	
   

  	
   

  	
   Foundation

  	
   

  	
   

  



 


IN
RESPECT TO THE PROFESSIONAL STOP LOSS COVERAGE (AND APPLICABLE CHARGES BY
PLAN), THE GROUP ELECTS AS FOLLOWS:


 


The Professional Stop Loss
Coverage set forth in Schedule I:


 


o
Will Participate                ý
Will NOT Participate


 


37

















 


Exhibit
A


 


HMO IPA/Medical Group Agreement



GROUP INFORMATION & BENEFIT PROGRAMS


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


1.                                       Address
for Notice:


 


	
  If to Blue Shield

  	
   

  	
  If to Group

  
	
  Blue Shield
  of California

  	
   

  	
  Gateway
  Medical Group, Inc.

  
	
  6701 Center
  Drive West

  	
   

  	
  710 N.
  Euclid Street

  
	
  Los Angeles,
  CA 90045

  	
   

  	
  Anaheim, CA
  92801

  
	
  Attn:  Regional Executive

  	
   

  	
  Attn: C.E.O.

  
	
  Fax No.:
  310-670-2329

  	
   

  	
  Fax No:
  714-490-1975

  



 


2.                                       (a)           Group Regions:
not applicable


 


(b)                                 Zip
Codes (By Group Regions, if applicable)*: see attached Exhibit A-l


 


3.                                       Benefit
Programs: This Agreement is applicable to the following Benefit Programs:


 


(1)                                  Commercial Group,
Point of Service and Individual Plans, including Healthy Families            ý Yes o
No


 


(2)                                  Blue Shield 65 Plus
(Medicare+ Choice)                                                                                         
ý Yes o
No


 


(3)                                  Other
(Describe)


	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*                                         For
Blue Shield 65+, Members will be permitted to select Group and its Primary Care
Physicians if they reside anywhere within the Medicare contract service area in
which Group is located, in accordance with Medicare guidelines.


 


***Confidential Treatment Requested


 


***


 


38

















 


Exhibit A-1


HMO IPA/Medical Group Agreement

SERVICE AREA


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


The Service Area outlined in
this Exhibit A-1 may be updated periodically to reflect changes in Group
Provider locations and/or Zip Code additions or deletions identified by Blue
Shield or the U.S. Postal Service.


 


	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  
	
  Alhambra

  	
   

  	
  91801-04

  	
   

  	
  Corona Del Mar

  	
   

  	
  92625

  	
   

  	
  Irvine

  	
   

  	
  92618-20

  	
   

  
	
   

  	
   

  	
  91841,91896

  	
   

  	
  Costa Mesa

  	
   

  	
  92626-28

  	
   

  	
   

  	
   

  	
  92623,92697

  	
   

  
	
   

  	
   

  	
  91899

  	
   

  	
  Covina

  	
   

  	
  91722-24

  	
   

  	
   

  	
   

  	
  92709-10

  	
   

  
	
  Aliso Viejo

  	
   

  	
  92656,92698

  	
   

  	
  Culver City

  	
   

  	
  90230-33

  	
   

  	
  La Canada Flintridge

  	
   

  	
  91011-12

  	
   

  
	
  Altadena

  	
   

  	
  91001, 91003

  	
   

  	
  Cypress

  	
   

  	
  90630

  	
   

  	
  La Crescenta

  	
   

  	
  91224

  	
   

  
	
  Alta Loma

  	
   

  	
  91701,91737

  	
   

  	
  Dana Point

  	
   

  	
  92629

  	
   

  	
  La Habra

  	
   

  	
  90631-33

  	
   

  
	
  Anaheim

  	
   

  	
  92801-08

  	
   

  	
  Diamond Bar

  	
   

  	
  91765

  	
   

  	
  La Mirada

  	
   

  	
  90637-39

  	
   

  
	
   

  	
   

  	
  92812

  	
   

  	
  Downey

  	
   

  	
  90239-42

  	
   

  	
  La Puente

  	
   

  	
  91744

  	
   

  
	
   

  	
   

  	
  92814-17

  	
   

  	
  Duarte

  	
   

  	
  91009-10

  	
   

  	
   

  	
   

  	
  91746-47

  	
   

  
	
   

  	
   

  	
  92825, 92850

  	
   

  	
  East Irvine

  	
   

  	
  92650

  	
   

  	
   

  	
   

  	
  91749

  	
   

  
	
   

  	
   

  	
  92899

  	
   

  	
  El Monte

  	
   

  	
  91731-32

  	
   

  	
  La Verne

  	
   

  	
  91750

  	
   

  
	
  Arcadia

  	
   

  	
  91006-07

  	
   

  	
   

  	
   

  	
  91734-35

  	
   

  	
  Ladera Ranch

  	
   

  	
  92694

  	
   

  
	
   

  	
   

  	
  91066, 91077

  	
   

  	
  El Segundo

  	
   

  	
  90245

  	
   

  	
  Laguna Beach

  	
   

  	
  92651-52

  	
   

  
	
  Artesia

  	
   

  	
  90701-02

  	
   

  	
  Foothill Ranch

  	
   

  	
  92610

  	
   

  	
  Laguna Hills

  	
   

  	
  92653-54

  	
   

  
	
  Atwood

  	
   

  	
  92811

  	
   

  	
  Fountain Valley

  	
   

  	
  92708, 92728

  	
   

  	
  Laguna Niguel

  	
   

  	
  92607,92677

  	
   

  
	
  Azusa

  	
   

  	
  91702

  	
   

  	
  Fullerton

  	
   

  	
  92831-38

  	
   

  	
  Lake Forest

  	
   

  	
  92630

  	
   

  
	
  Baldwin Park

  	
   

  	
  91706

  	
   

  	
  Garden Grove

  	
   

  	
  92840-46

  	
   

  	
  Lakewood

  	
   

  	
  90711-15

  	
   

  
	
  Bell

  	
   

  	
  90201

  	
   

  	
  Gardens

  	
   

  	
  90247-49

  	
   

  	
  Lawndale

  	
   

  	
  90260-61

  	
   

  
	
  Bellflower

  	
   

  	
  90706-07

  	
   

  	
  Glendale

  	
   

  	
  91201-10

  	
   

  	
  Lomita

  	
   

  	
  90717

  	
   

  
	
  Bell Gardens

  	
   

  	
  90202

  	
   

  	
   

  	
   

  	
  91221-22

  	
   

  	
  Long Beach

  	
   

  	
  90801-10

  	
   

  
	
  Beverly Hills

  	
   

  	
  90211-12

  	
   

  	
   

  	
   

  	
  91225-26

  	
   

  	
   

  	
   

  	
  90813-15

  	
   

  
	
  Brea

  	
   

  	
  92821-23

  	
   

  	
  Glendora

  	
   

  	
  91740-41

  	
   

  	
   

  	
   

  	
  90822

  	
   

  
	
  Buena Park

  	
   

  	
  90620-24

  	
   

  	
  Guasti

  	
   

  	
  91743

  	
   

  	
   

  	
   

  	
  90831-35

  	
   

  
	
  Burbank

  	
   

  	
   

  	
   

  	
  Hacienda Hghts

  	
   

  	
  91745

  	
   

  	
   

  	
   

  	
  90840, 90842

  	
   

  
	
  Carson

  	
   

  	
  90745-90747

  	
   

  	
  Harbor City

  	
   

  	
  90710

  	
   

  	
   

  	
   

  	
  90844-48

  	
   

  
	
   

  	
   

  	
  90749

  	
   

  	
  Hawaiian Grdns

  	
   

  	
  90716

  	
   

  	
   

  	
   

  	
  90853, 90888

  	
   

  
	
  Cerritos

  	
   

  	
  90703

  	
   

  	
  Hawthorne

  	
   

  	
  90250-51

  	
   

  	
  Los Alamitos

  	
   

  	
  90720-21

  	
   

  
	
  Chino

  	
   

  	
  91708, 91710

  	
   

  	
  Hermosa Beach

  	
   

  	
  90254

  	
   

  	
  Los Angeles

  	
   

  	
  90001-23

  	
   

  
	
  Chino Hills

  	
   

  	
  91709

  	
   

  	
  Huntington Bch

  	
   

  	
  92605, 92615

  	
   

  	
   

  	
   

  	
  90026-48

  	
   

  
	
  City of Industry

  	
   

  	
  91714-16

  	
   

  	
   

  	
   

  	
  92646-49

  	
   

  	
   

  	
   

  	
  90050-63

  	
   

  
	
  Claremont

  	
   

  	
  91711

  	
   

  	
  Huntington Prk

  	
   

  	
  90255

  	
   

  	
   

  	
   

  	
  90065-66

  	
   

  
	
  Compton

  	
   

  	
  90220-24

  	
   

  	
  Inglewood

  	
   

  	
  90301-13

  	
   

  	
   

  	
   

  	
  90068-72

  	
   

  
	
  Corona

  	
   

  	
  91718

  	
   

  	
   

  	
   

  	
  90397-98

  	
   

  	
   

  	
   

  	
  90074-76

  	
   

  
	
   

  	
   

  	
  92877-83

  	
   

  	
  Irvine

  	
   

  	
  92602-04

  	
   

  	
   

  	
   

  	
  90078-83

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  92606, 92612

  	
   

  	
   

  	
   

  	
  90086-89

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  92614, 92616

  	
   

  	
   

  	
   

  	
  90091

  	
   

  



 












***Confidential Treatment
Requested


 


39

















 


	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  	
  CITY NAME

  	
   

  	
  ZIP CODE

  	
   

  
	
  Los Angeles

  	
   

  	
  90093-94

  	
   

  	
  Placentia

  	
   

  	
  92870-71

  	
   

  	
  Yorba Linda

  	
   

  	
  92885-87

  	
   

  
	
   

  	
   

  	
  90096-97

  	
   

  	
  Playa Del Rey

  	
   

  	
  90293, 90296

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90099

  	
   

  	
  Pomona

  	
   

  	
  91766-69

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90101-103

  	
   

  	
   

  	
   

  	
  91797, 91799

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90174

  	
   

  	
  Rancho Santa Margarita

  	
   

  	
  92688

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90185

  	
   

  	
  Rancho Cucamonga

  	
   

  	
  91729-30

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lynwood

  	
   

  	
  90262

  	
   

  	
  Rancho Palos Verdes

  	
   

  	
  90275

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Manhattan Bch

  	
   

  	
  90266-67

  	
   

  	
  Redondo Beach

  	
   

  	
  90277-78

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Maywood

  	
   

  	
  90270

  	
   

  	
  Riverside

  	
   

  	
  92503, 92505

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Marina Del Rey

  	
   

  	
  90295

  	
   

  	
  Rosemead

  	
   

  	
  91770-72

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Midway City

  	
   

  	
  92655

  	
   

  	
  Rowland Heights

  	
   

  	
  91748

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Mira Loma

  	
   

  	
  91752

  	
   

  	
  San Dimas

  	
   

  	
  91773

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Mission Vlejo

  	
   

  	
  92690-92

  	
   

  	
  San Gabriel

  	
   

  	
  91775-76

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Monrovia

  	
   

  	
  91016-17

  	
   

  	
   

  	
   

  	
  91778

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Montbello

  	
   

  	
  90640

  	
   

  	
  San Juan Cap.

  	
   

  	
  92675, 92693

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Montclair

  	
   

  	
  91763

  	
   

  	
  San Pedro

  	
   

  	
  90731-34

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Monterey Park

  	
   

  	
  91754-56

  	
   

  	
  Santa Ana

  	
   

  	
  92701-07

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Montrose

  	
   

  	
  91020-21

  	
   

  	
   

  	
   

  	
  92711-12

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Mount Wilson

  	
   

  	
  91023

  	
   

  	
   

  	
   

  	
  92735, 92799

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  North Hills

  	
   

  	
  91393

  	
   

  	
  San Marino

  	
   

  	
  91108,91118

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Newport Beach

  	
   

  	
  92658-63

  	
   

  	
  Santa Fe Springs

  	
   

  	
  90670-71

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Newport Coast

  	
   

  	
  92657

  	
   

  	
  Silverado

  	
   

  	
  92676

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Norco

  	
   

  	
  92860

  	
   

  	
  Seal Beach

  	
   

  	
  90740

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Norwalk

  	
   

  	
  90650-52

  	
   

  	
  Sierra Madre

  	
   

  	
  91024-25

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90659

  	
   

  	
  South El Monte

  	
   

  	
  91733

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Ontario

  	
   

  	
  91758

  	
   

  	
  South Gate

  	
   

  	
  90280

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91761-62

  	
   

  	
  South Pasadena

  	
   

  	
  91030-31

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91764, 91798

  	
   

  	
  Stanton

  	
   

  	
  90680

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orange

  	
   

  	
  92856-57

  	
   

  	
  Sun Valley

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  92859

  	
   

  	
  Sunset Beach

  	
   

  	
  90742

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  92862-69

  	
   

  	
  Surfside

  	
   

  	
  90743

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Palos Verdes

  	
   

  	
  90274

  	
   

  	
  Temple City

  	
   

  	
  91780

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Paramount

  	
   

  	
  90723

  	
   

  	
  Torrance

  	
   

  	
  90501-10

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pasadena

  	
   

  	
  90150-51

  	
   

  	
  Trabuco Canyon

  	
   

  	
  92678-79

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91101-07

  	
   

  	
  Tustin

  	
   

  	
  92780-82

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91109-10

  	
   

  	
  Upland

  	
   

  	
  91784-86

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91114-17

  	
   

  	
  Venice

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91121

  	
   

  	
  Villa Park

  	
   

  	
  92861

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91123-26

  	
   

  	
  Walnut

  	
   

  	
  91788-89

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91129,91131

  	
   

  	
   

  	
   

  	
  91795

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91175, 91182

  	
   

  	
  West Covina

  	
   

  	
  91790-93

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91184-89

  	
   

  	
  Westminster

  	
   

  	
  92683-85

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  91191

  	
   

  	
  Whittier

  	
   

  	
  90601-10

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pico Rivera

  	
   

  	
  90660-62

  	
   

  	
   

  	
   

  	
  90612

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  90665

  	
   

  	
  Wilmington

  	
   

  	
  90744, 90748

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


40

















 


Exhibit
B


 


HMO IPA/Medical Croup Agreement


DIVISION OF FINANCIAL RESPONSIBILITIES-


for Members other than Blue Shield 65 Plus
Members


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


Pursuant to the disclosure
requirements as set forth in Subchapter 5.5 of Chapter 3 of Title 28,
California Code of Regulations § 1300.75.4.1 (a) the attached Division of
Financial Responsibility (DOFR), informs Group of the allocation of financial
risk assumed under the contract. The matrix details the responsibility for
medical expenses, including physician, institutional and ancillary costs, which
will be allotted to the group, the hospital, the plan and any shared risk
funds.


 


	
  SERVICES

  	
   

  	
  MEDICAL GROUP

  	
   

  	
  SHARED SAVINGS

  	
   

  	
  BLUE SHIELD

  	
   

  
	
  PREVENTIVE SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Health Education/Promotion

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Immunizations/Serum

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Routine Physical Exams

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Vision/Hearing Screenings

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEALTH CARE PROFESSIONAL (OUTPATIENT AND OFFICE)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Allergy Testing/Serum

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Amniocentesis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Biofeedback

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Chiropractic (Non-Rider Benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Diagnosis, Therapy, Treatment &  Triage

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Within Service Area or
  at nearest designated trauma center

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Outside Service Area – (or designated trauma center)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Commercial Members

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Office Visit Supplies (Splints, Casts, Bandages, Dressings, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Office Visits/Consultation/Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Pathology/Radiology/Anesthesia (including Dental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Patient Counseling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Podiatry

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Pre-and Post-Transplant Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Acute Detox

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •      Psychiatric/Substance Abuse for Commercial Members whose benefits have
  not been renewed since 7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance Abuse – Commercial Members whose benefits renew
  or become effective on or
  after 7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Urgent Care Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEALTH CARE PROFESSIONAL (INPATIENT)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Diagnosis, Treatment &  Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Within Service Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Outside Service Area – Commercial Members

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












***all references to division
of financial responsibility have been deleted.


 


41

















 


	
  SERVICES

  	
   

  	
  MEDICAL
  GROUP

  	
   

  	
  SHARED
  SAVINGS

  	
   

  	
  BLUE
  SHIELD

  	
   

  
	
  •      Pathology/Radiology/Anesthesia

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Transplant (all inclusive
  case notes)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Transplant (physician fees
  excluded from case rate payment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Urgent Care Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Visits/Consultations/Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FACILITY SERVICES (INPATIENT)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Within
  Service Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Outside
  Service Area – Commercial Members

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Facility and Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Acute Detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse for Commercial Members whose benefits have not been renewed since
  7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse- Commercial Members whose benefits renew or become effective on or
  after 7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Take Home Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Transplant

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Urgent Care Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FACILITY SERVICES (OUTPATIENT)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Chemotherapy/Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Diagnostic Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Within
  Service Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Emergency Services Outside
  Service Area – Commercial Members

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Endoscopic Studies not
  performed in physician’s office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      False Labor OB Check at
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Fetal Genetic Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Fetal Monitoring

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Invasive Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Lab/Radiology/Ancillary Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Lithotripsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Other Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Pre and Post Transplant
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Pre-admission Testing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse Day Treatment for Commercial Members whose benefits have not been
  renewed since 7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse Day Treatment- Commercial Members whose benefits renew or become
  effective on or after 7-1-00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse O/P Counseling for Commercial Members whose benefits have not been
  renewed since 7-1-00

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Psychiatric/Substance
  Abuse O/P Counseling –Commercial Members whose benefits renew or become
  effective on or after 7-1 -00.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Radiation Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •      Renal Dialysis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 











***all references to division
of financial responsibility have been deleted.


 


42

















 


	
  SERVICES

  	
   

  	
  MEDICAL
  GROUP

  	
   

  	
  SHARED
  SAVINGS

  	
   

  	
  BLUE
  SHIELD

  	
   

  
	
  •

  	
  Surgery/Surgical
  Procedures (Including Laser)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Urgent Care
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PREGNANCY AND MATERNITY CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Alternate
  Birth Center

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Normal
  Delivery/C-Section

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Prenatal/Postnatal
  Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FAMILY PLANNING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Abortions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Counseling

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Infertility
  (Diagnostics/Treatment - Limited Benefits)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Tubal
  Ligation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Vasectomy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES (For Repair of
  Accident/Injury Only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Blood
  Transfusions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Blood/Blood
  Products (Autologous)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Blood/Blood
  Products from Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Clotting
  Factors

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SKILLED NURSING FACILITY CARE (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INSTITUTIONAL HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Professsional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Facility
  Take Home Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Outpatient
  Prescription Drugs

  (Excluding Take Home and Injectables)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Therapeutic
  Injections/Injectables; provided in MD office or Outpatient Setting
  (excluding those meeting criteria to qualify as Shared Savings Responsibility
  as defined in the Provider Manual and all Childhood Immunizations first
  recommended for use by  the
  American Academy of Pediatrics on or after 1-01-01 and Prevnar®).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Therapeutic
  Injections/Injectables provided in MD office or Outpatient Setting that meet
  criteria to qualify as Shared Savings Responsibility as defined in the
  Provider Manual 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  All
  Childhood Immunizations first recommended for use by the American Academy of
  Pediatrics on or after 1-01-01 and Prevnar®.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Therapeutic
  Injections/lnjectables; provided for self-administration as home use, either
  through contracted Alternate Care Services Provider, a Plan contracted
  pharmacy or Home Health Agency.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Implanted
  Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Lenses and
  Frames Incident to Cataract Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Non-Cataract
  Related Rx Lenses and Frames

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 











***all references to division
of financial responsibility have been deleted.


 


43

















 


	
  SERVICES

  	
   

  	
  MEDICAL
  GROUP

  	
   

  	
  SHARED
  SAVINGS

  	
   

  	
  BLUE
  SHIELD

  	
   

  
	
  •

  	
  Vision
  Screening

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH CARE (HHC) & HOME HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Agency Visit

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Home Medical
  Equipment (HME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Medical
  Supplies/IV Solutions Associated with HHC Treatment Blue Shield

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Physician
  Home Visit

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Licensed Per
  Diem Hospice

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  REHAB THERAPY

  (PT, ST, OT, RT, Cardiac)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OTHER SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Colostomy/Ostomy
  Supplies/Parental/Enteral Nutritional Supplements (OP)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Diabetic
  glucose testing machines, insulin pump & syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Disposable
  Diabetic Testing Supplies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Insulin

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Orthotics/Prostheses
  (External) - Commercial - $50 or Under

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Orthotics/Prostheses
  (External) - Commercial -Over $50

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Surgically
  Implanted Devices

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OPTIONAL BENEFITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Acupuncture
  Rider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Chiropractic
  Rider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Dental Rider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Outpatient
  Prescription Drug Rider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Hearing Aids

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Infertility
  Rider (Gifts, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Podiatric
  Rider.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
  Vision Rider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


 


This is intended  only as a summary guide of financial responsibility as  stated in the  contract. It is not possible to list all medical
services. If you have any  questions
as to the financial responsibility for a service not listed above, Blue Shield
follows Medicare  guidelines for
all product lines. Services covered under  Medicare Part A are Shared Savings Fund responsibility and services
covered under Medicare Part B are Group responsbility.


 











***all references to division
of financial responsibility have been deleted.


 


44

















 


Exhibit B


 


HMO IPA/Medical Group Agreement


DIVISION OF FINANCIAL RESPONSIBILITIES-


for Blue Shield 65 Plus Members


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


Pursuant
to the disclosure requirements as set forth in Subchapter 5.5 of Chapter 3 of
Title 28, California Code of Regulations § 1300.75.4.1 (a) the attached
Division of Financial Responsibility (DOFR), informs Group of the allocation of
financial risk assumed under the contract. The matrix details the
responsibility for medical expenses, including physician, institutional and
ancillary costs, which will be allotted to the group, the hospital, the plan
and any shared risk funds.


 


A.                                    Inpatient
Services, Ambulatory Surgery and Major Diagnostic Procedures


 


This heading
includes facility and all ancillary/non-professional charges for Covered
Services provided to inpatient and day surgery patient in a licensed facility,
including inpatient hospital acute, sub-acute or skilled nursing facility
services, including room and board and ancillary services. It includes facility
and ancillary/non-professional charges related to ambulatory surgery or
ambulatory diagnostic/therapeutic procedures (e.g., endoscopy, bronchoscopy,
laparoscopy, angiography, etc.) requiring a surgical or other specialized suite
or general anesthesia. It includes pre-operative and pre-admission testing. It
includes Covered Services provided by facilities other than Hospital and
services provided by Out-of-Area providers upon referral.


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1.

  	
   

  	
  Acute
  Hospital Care (Semi-private rooms)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  Intensive
  Care Units and Coronary Care Units

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.

  	
   

  	
  Hospital
  Surgical Unit

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.

  	
   

  	
  Sub Acute
  Hospital Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.

  	
   

  	
  Skilled
  Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6.

  	
   

  	
  Hospice

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.

  	
   

  	
  Inpatient
  Medications

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  8.

  	
   

  	
  Surgically
  Implanted Prosthesis

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  9.

  	
   

  	
  Nursing
  Services (including special duty)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  10.

  	
   

  	
  Lithotripsy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  11.

  	
   

  	
  Discharge
  Medications (5 days)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  12.

  	
   

  	
  Ambulatory
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  13.

  	
   

  	
  Psychiatric
  Day Treatment or partial hospitalization

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  14.

  	
   

  	
  Psychiatric
  and Substance Abuse Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  15.

  	
   

  	
  Medical Detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  16.

  	
   

  	
  Observation
  Stay

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












***all references to division
of financial responsibility have been deleted.


 


45

















 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  17.

  	
   

  	
  Prolonged
  obstetrical monitoring

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  Inpatient Hospital with IV

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b -
  Outpatient Hospital without IV

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c -
  Physician Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


B.                                    In Area Emergency Room Services


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1.

  	
   

  	
  Emergency
  Roam / Treat & Release

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Facility
  /Ancillary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - ER
  Physician

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c - HBP
  Professional (Pathologist and Radiologist)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  Emergency
  Room—Within 24-hours of admission

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Facility
  /Ancillary

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - ER
  Physician

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c - HBP Professional
  (Pathologist and Radiologist)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


C.                                    Professional Services Including Hospital Based
Physicians and other Specialty Physicians (Hospital based physicians are
defined as Radiologists and Pathologists)


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1.

  	
   

  	
  Anesthesiologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Surgical
  / Other Procedure Anesthesia Inpatient and Outpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Pain
  Management / Inpatient and Outpatient.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  Radiologist—Diagnostic
  Interpretation, Interventional Procedures and Radiation Therapy including
  Implants

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  Inpatient (includes ambulatory surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b -
  Outpatient Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c -
  Physician Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.

  	
   

  	
  Pathologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  Anatomical Pathology Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  1 - Inpatient (includes ambulatory surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  2 - Outpatient Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  3 - Physician Office including Pap Smears 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Clinical
  Laboratory Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  1 - Pre-Admission

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  2 - Inpatient (includes ambulatory surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  3 - Outpatient Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  4 - Physician Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.

  	
   

  	
  Neurologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  Inpatient EEG, EMG and NCS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b -
  Outpatient EEG, EMG and NCS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.

  	
   

  	
  Nephrologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Dialysis
  Professional Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Other
  Professional Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 











***all references to division
of financial responsibility have been deleted.


 


46

















 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  6.

  	
   

  	
  Cardiologist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Inpatient and Hospital Outpatient
  Diagnostic Procedures (e.g. ECG, treadmill, holter, echocardiogram, wall
  motion, thallium scan, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b- Outpatient Diagnostic Procedures (e.g.
  ECG, treadmill, holter echocardiogram, wall motion, thallium scan, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c - Physician Office Diagnostic Procedures
  (e.g. ECG, treadmill, holter monitor, echocardiogram, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.

  	
   

  	
  Pulmonology
  / Respiratory Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Inpatient Diagnostic Services (e.g.,
  PFT/Blood Gas/Apnea  Eval/etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Outpatient Hospital Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c- Physician Office Diagnostic Procedure

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  8.

  	
   

  	
  Interventional
  Professional Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Interventional Cardiology (e.g. PTCA,
  angiography, percutaneous, valvuloplasty, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Interventional Gastroenterology (e.g.
  ERCP, endoscopy, percutaneous, biopsy, drainage, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  c - Interventional Radiology (angioplasty,
  embolization, etc.)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  d - Bronchoscopy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


D.                                    Laboratory,
X-Ray and Diagnostic Procedures (Technical Components)


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1.

  	
   

  	
  Pre-admission
  and inpatient laboratory, x-ray, ECG and other diagnostic services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  ER
  laboratory, x-ray, ECG and other diagnostic services—treat & release

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.

  	
   

  	
  ER
  laboratory, x-ray, ECG and other diagnostic services (within 24-hour
  admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.

  	
   

  	
  a -
  Outpatient cytology and pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b -
  Inpatient cytology and pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.

  	
   

  	
  Non-invasive
  outpatient diagnostic procedures including outpatient x-rays chest and
  skeletal x-rays, CT scans and MRIs. Ultrasound, echocardiogram, nuclear
  medicine, cardiac stress testing, EKG, holter monitor, EEG, EMG, mammography

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6.

  	
   

  	
  Invasive
  outpatient diagnostic treatment services (e.g. angiography, endoscopy). This
  excludes outpatient radiology and pathology services.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.

  	
   

  	
  Inpatient
  diagnostic procedures including CT, MRI/NMR, ultrasound, nuclear medicine,
  EKG/ECG, holter monitor, EEG, echocardiogram, EMG including nerve conduction
  studies, mammography.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 











***all references to division
of financial responsibility have been deleted.


 


47

















 


E.                                      Physician
Services (not including those services described under Section C)


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1.

  	
   

  	
  Primary care
  office visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  Outpatient
  specialty consultations and interpretations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.

  	
   

  	
  Inpatient
  primary care and consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.

  	
   

  	
  Office
  surgical procedures

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.

  	
   

  	
  Physician
  office outpatient ECG services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6.

  	
   

  	
  Office
  laboratory

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.

  	
   

  	
  Outpatient
  chest and skeletal x-rays

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  8.

  	
   

  	
  Office
  visual examinations—includes routine ophthalmology and optometric care
  including tonometry.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  9.

  	
   

  	
  Office
  hearing evaluation (excluding hearing aids)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  10.

  	
   

  	
  Emergency
  Room Physician Fees

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  11.

  	
   

  	
  Routine physical
  exams and evaluation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  12.

  	
   

  	
  Allergy
  testing and serum

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


F.                                      Other
Professional and Ancillary Services


 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  1. *

  	
   

  	
  Home Health
  Care (professional medication, supplies) and respite care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2.

  	
   

  	
  Durable
  Medical Equipment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  3.

  	
   

  	
  Orthotics/Prosthetics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  4.

  	
   

  	
  Supplies
  (except as used in physicians’ office)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5.

  	
   

  	
  Health
  Education Programs (including literature and course offerings):

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a - Programs
  offered by Hospital as inpatient or outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - Programs
  offered in physicians’ office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  6.

  	
   

  	
  Dietary
  counseling and education

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b - outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  7.

  	
   

  	
  Professional
  psychiatric services and mental health counseling services including
  alcoholism and CD rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  8.

  	
   

  	
  Professional services for medical detox

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  9.

  	
   

  	
  Social
  services and discharge planning

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  10.

  	
   

  	
  Physical
  rehabilitation services, including physical, occupational, speech therapy and
  rehabilitation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  a -
  inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
  b -
  outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 











***all references to division
of financial responsibility have been deleted.


 


48

















 


	
   

  	
   

  	
   

  	
   

  	
  Shared

  Savings

  	
   

  	
  Group

  	
   

  	
  Blue

  Shield

  	
   

  
	
  11.

  	
   

  	
  Blood and
  blood derivatives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  12.

  	
   

  	
  Dialysis
  (Tech. Fac., Supp. & Meds)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  a -
  inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  b-
  outpatient technical/facility

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  b -
  outpatient professional

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  13.

  	
   

  	
  Medical
  transportation

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  !4.

  	
   

  	
  Cardiac
  Rehabilitation

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  a -
  inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  b -
  outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  15.

  	
   

  	
  Facility
  component for fluorescein angiography and all treatments with lasers

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  16.

  	
   

  	
  Chemotherapy
  treatment including medications and administration not including oncologist
  professional fees

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  a -
  inpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  b -
  outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  17.

  	
   

  	
  Other
  services considered to be customarily a hospital inpatient service

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  18.

  	
   

  	
  Radiation
  therapy technical (facility component)

  a - inpatient

  b - outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  19.

  	
   

  	
  Facility
  component of outpatient hospital Respiratory Therapy (including oxygen and
  pulmonary function testing)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  20.

  	
   

  	
  Self
  administered injectable medications **

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Erythropoietin
  (Epogen, Procrit), Granulocyte - CSF, Growth hormone (Humatrope, Protropin),
  Interferon Beta-1b (Betaseron), Interferon Alpha-2b (Intron A), Filgrastim
  (Neupogen), Calcitionin (Calcimar), Leuprolide (Lupron), Imitrex

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  21.

  	
   

  	
  Outpatient
  Pharmacy

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  22.

  	
   

  	
  Refractions
  and eye glasses

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  23.

  	
   

  	
  Out-of-Area
  Services (Emergent and Urgent Only)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  a-
  Professional

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  b - Facility

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 












*Note: Home
Health Care which is in lieu of outpatient care or ambulatory care (i.e.
Chemotherapy, transfusions and neuro-rehab), will remain the financial
responsibility of the provider responsible for that outpatient care or
ambulatory care service as stated in the Matrix Financial Responsibility.


 


**Note: Self
injectable medications that are commonly and routinely administered safely,
subcutaneously or intramuscularly, in a non-institutional environment by the
Member or Member’s caregiver are payable by Blue Shield provided Group has
received prior authorization from Blue Shield’s Medical Management Department.
The self injectable nature of such medication will ordinarily be noted in
standard references. The drug must be readily available from a community or
chain pharmacy. If authorization is not obtained and the self injectable
medication is a Covered Service, then Group shall be financially responsible
for the difference in price between Blue


 


***all references to division
of financial responsibility have been deleted.


 


49

















 


Shield’s contracted rates and the amount owed to  the non-authorized provider.  If authorization is not obtained and the
self injectable medication is not a Covered Service, then Group shall be
financially responsible for the entire cost of the medication.


 


G.                                    Excluded
Situations and Procedures—Any service not covered pursuant to the Evidence
of Coverage.


 


In the event
financial responsibility for a service is not established in this Matrix,
services generally paid for under Medicare Part B will be considered a
Capitated Professional Service. Services generally paid for under Medicare Part
A will be considered a Shared Savings Service and will be paid from the
Shared Savings Fund by Blue Shield as described in Exhibit D.


 


50

















 


Exhibit
C

HMO IPA/Medical Group Agreement


 


CAPITATION


 


Gateway Medical
Group, Inc.


Effective Date: January 1, 2002


 


CAPITATION
PAYMENTS


 


Pursuant to Article VII of the
Agreement, Blue Shield shall pay to Group, based upon the Member’s Benefit
Program, the monthly per member per month (PMPM) Capitation set forth in
Exhibit C-l hereto. Capitation for non-Blue Shield 65 Plus Members is a
specified dollar rate based upon the Member’s benefit plan design, including
copayment levels and age/sex category. Per Exhibit C-l, the capitation rate for
each member is a product of the Member’s age/sex category multiplied by the
corresponding base rate multiplied by the applicable co-pay adjustment factor.
The sum of the individual capitation rates for assigned Members will be added
to determine the Group’s aggregate Capitation payable for any given month.
Capitation for Blue Shield 65 Plus Members is a percentage of the Medicare
premium received by Blue Shield from CMS for the basic medical benefits for
such Members and excludes any premium paid by CMS, the Member or an Employer
Group for rider benefits that are not the financial responsibility of Group.


 


Information on
actuarial cost and utilization assumptions, as required by Subchapter 5.5 of
Chapter 3 of Title 28, California Code of Regulations § 1300.75.4.1(a) is
further described in the Provider Manual and is updated at least annually. The
information presented therein regarding cost and utilization is provided by way
of example only and is based broadly on historical data in Blue Shield’s
possession. It is not a statement of fact or opinion of what will actually
occur and is not offered as an accurate predictor of the experience of any
specific Group. It is not intended to reflect the actual cost or utilization
incurred by any specific Group, does not predict the actual costs to any
specific group or patient mix, and has not been risk adjusted in any way
(capitation adjustments for age, sex and benefit plan design are reflected in
this Exhibit C.). Group recognizes that its actual utilization and unit costs
will likely differ from the examples given and could be higher or lower. Group
should not rely on this information in evaluating its own financial risk, but,
rather, should review its own patient mix, utilization and cost information as
well as other available information, consult with its own financial and
actuarial advisors in evaluating the information contained herein, and make its
own independent business judgment in deciding to enter into the financial risk
arrangements under the Agreement based on its own independent assessment.


 


ENCOUNTER DATA SUBMISSION PENALTIES


 


In the event
that Group fails to comply with the encounter data submission requirements
described in Paragraph 2.12 hereof, then the amounts to be deducted or withheld
from Group Capitation on a monthly basis as provided in Paragraph 7.11 hereof
are identified in Exhibit C-1 as “Penalties for Deficient Encounter Data
Submission”.


 


###


 












***Confidential Treatment
Requested


 


51

















 


Exhibit C
- l


 


HMO IPA/Medical Group Agreement


 


CAPITATION RATES


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002-December 31,
2002


 


As
of 01/01/02, the effective net yield (which includes the deduction for Stop
Loss, if applicable) for  the
following PMPMs and factors are *** for  the
HMO Group, *** for HMO IFP, *** for POS, and *** pmpm in aggregate, based on
the 08/01/200l membership.


 


The
actual capitation payment for each month will be calculated based on the actual
member mix for each age/sex/copay level category.


 


A.
MEMBERS OTHER THAN BLUE SHIELD 65 PLUS MEMBERS


 


	
  Age & Sex Categories and Capitation Fees

  	
   

  	
  Benefit/Rate Adjustment

  	
   

  
	
  Category

  	
   

  	
  Age/Sex Adjusted Capitation (PMPM)

  	
   

  	
  Office Visit Copay Factor

  	
   

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  Group

  (non-POS)

  	
   

  	
  IFP

  (non-POS)

  	
   

  	
  POS

  (In-network)

  	
   

  	
  Office Visit

  Copay **

  	
   

  	
  Factor

  	
   

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.081

  	
   

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.071

  	
   

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.061

  	
   

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.052

  	
   

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.043

  	
   

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.034

  	
   

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.026

  	
   

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.017

  	
   

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.009

  	
   

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.001

  	
   

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.994

  	
   

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.986

  	
   

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.979

  	
   

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.972

  	
   

  
	
  F

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.965

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.958

  	
   

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.951

  	
   

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.944

  	
   

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.937

  	
   

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.930

  	
   

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.923

  	
   

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.917

  	
   

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.910

  	
   

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.903

  	
   

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.897

  	
   

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.890

  	
   

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.858

  	
   

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.825

  	
   

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.793

  	
   

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.760

  	
   

  
	
  M

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.728

  	
   

  



 












* = Medicare Primary


** For any copayment amount not
listed, the factor for the next lesser copayment amount shall apply.


*** Confidential Treatment
Requested


 


52

















 


Effective Date: January 1, 2003-December 31,
2003 & thereafter until amended


 


As
of 01/01/03, the effective net yield (which includes the deduction for Stop
Loss,  if applicable) for the
following PMPMs and factors are *** for the HMO Group. *** for HMO IFP, *** for
POS, and *** pmpm in aggregate, based on the 08/01/2001 membership.


The
actual capitation payment for each month will be calculated based on the actual
member mix for each age/sex/copay level category.


 


A. MEMBERS OTHER THAN BLUE SHIELD 65 PLUS
MEMBERS


 


	
  Age & Sex Categories and Capitation Fees

  	
   

  	
  Benefit/Rate Adjustment

  	
   

  
	
  Category

  	
   

  	
  Age/Sex Adjusted Capitation (PMPM)

  	
   

  	
  Office Visit Copay Factor

  	
   

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  Group

  (non-POS)

  	
   

  	
  IFP

  (non-POS)

  	
   

  	
  POS

  (In-network)

  	
   

  	
  Office Visit

  Copay **

  	
   

  	
  Factor

  	
   

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.081

  	
   

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.071

  	
   

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.061

  	
   

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.052

  	
   

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.043

  	
   

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.034

  	
   

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.026

  	
   

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.017

  	
   

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.009

  	
   

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  1.001

  	
   

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.994

  	
   

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.986

  	
   

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.979

  	
   

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.972

  	
   

  
	
  F

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.965

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.958

  	
   

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.951

  	
   

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.944

  	
   

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.937

  	
   

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.930

  	
   

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.923

  	
   

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.917

  	
   

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.910

  	
   

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.903

  	
   

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.897

  	
   

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.890

  	
   

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.858

  	
   

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.825

  	
   

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.793

  	
   

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.760

  	
   

  
	
  M

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0.728

  	
   

  



 












* = Medicare
Primary


**For any
copayment amount not listed, the factor for the next lesser copayment amount
shall apply.


 


53

















 


The preceding
capitation rates do not apply to Members enrolled through the Healthy Families
Program. For Healthy Family Program Members, the following capitation rates
shall apply:


 


	
  Age 0 –
  11.99 months

  	
  ***PMPM

  
	
   

  	
   

  
	
  Age 1 year –  18 years 11.99 mos.

  	
  ***PMPM

  
	
   

  	
   

  
	
  Age 19 –
  years – 44 years 11.99 mos.

  	
  ***PMPM

  
	
   

  	
   

  
	
  Age 45 years
  +

  	
  ***PMPM

  



 


B. Blue Shield 65 Plus Members – Basic
Capitation


 


*** of the Monthly
CMS Capitation received by Blue Shield from CMS and *** of the actual Monthly
Blue Shield 65 Plus Premium (as described below) which Blue Shield determines,
according to its actuarial standards and methodology, to be for a benefit that
is included in the Member’s basic benefit plan and for which Group bears
financial risk. Blue Shield will retain 100% of premiums collected for benefits
considered supplemental to the basic benefit plan (as described below). Blue
Shield may make monthly retroactive adjustments to reflect any retroactive
adjustments made by CMS to the Monthly CMS Capitation.


 


The “Monthly
CMS Capitation” refers to the monthly premium payment made by CMS to Blue
Shield as payment to Blue Shield for the provision of services to the Blue
Shield 65 Plus Members enrolled in Blue Shield.


 


The “Monthly
Blue Shield 65 Plus Premium Payments” refers those additional premium payments
which Blue Shield receives directly from the member or from the employer group
for basic benefit plan provisions.


 


“Supplemental
Benefits” are benefits offered to enhance the basic benefit provided by Blue
Shield in the Member’s county of residence. Additional premiums (beyond the
base plan premium, if applicable) are collected from Members and employer
groups for such benefits. Group shall have no financial responsibility for the
administration and/or delivery of such benefits.


 


C. PENALTIES FOR DEFICIENT ENCOUNTER DATA
SUBMISSION If minimum submission requirements are not
met, as defined in the Provider Manual, and are not corrected within a thirty
(30) day notice period, Group shall be subject to a penalty of three percent
(3%) of the Group’s commercial capitation payment and, if applicable, one
percent (1%) of the Group’s Blue Shield 65 Plus capitation payment for the
period(s) in question from the monthly capitation payments until the deficiency
is corrected.


 


###


 


54

















 


Exhibit
D


 


HMO IPA/Medical Group Agreement


 


SHARED SAVINGS PROGRAMS


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


A.                                    COMMERCIAL
MEMBERS


 


FUNDING: For Members other than
those enrolled in Blue Shield 65 Plus plans and Blue Shield POS Benefit
Programs, Blue Shield will allocate to a Shared Savings Fund a per Member per
month amount set forth in Exhibit D-l for all Members assigned to Group,
subject to retroactive adjustments either upward or downward due to retroactive
changes in membership, [See Exhibit H-2 for provisions relating to Blue Shield
POS Benefit Programs and POS Shared Savings Funds.]


 


CHARGING OF PAYMENTS: Blue
Shield shall charge against the Shared Savings Fund all payments made by Blue
Shield for such Members during the annual term of the Agreement which are
designated as Shared Savings Services in Exhibit B, less payments received by
Blue Shield as a result of third-party reimbursement, Workers’ Compensation
recoveries and coordination of benefits payments. Blue Shield shall include any
payments for Shared Savings Services which are paid prior to the date of the
settlement, as well as a reasonable allowance, as determined by Blue Shield’s
actuaries, for incurred but not paid (1BNP) claims. Any costs for Shared
Savings Services not included in any annual settlement shall be carried forward
and included in the Shared Savings settlement for the succeeding Agreement
Year. In addition, if this Agreement is replaced or superseded any other
agreement between the parties which contained a risk sharing arrangement for
similar services; then the following shall also be charged against the Shared
Savings Fund described herein: (i) any deficit in the final settlement of that
risk sharing arrangement and, (ii) any claims for risk services which were
incurred but not included in the settlement of the risk arrangement in the
prior agreement. Blue Shield shall provide
sufficient detail in the annual settlement, so that Group can determine the
IBNP amount by Agreement Year.


 


SHARED SAVINGS
FUND SETTLEMENT: The Shared Savings Fund shall be settled on an annual basis,
within one hundred eighty (180) days following the end of each annual term of
the Agreement (being a 120 day claims run out and a 60 day determination
period). In the event of termination of the Agreement for any reason, final settlement
of the Shared Savings Fund shall be performed one hundred fifty (150) days
after the date of termination and any amounts due from Blue Shield to Group
shall be paid within thirty (30) days thereafter.


 


Surplus: If the total actual cost of Shared Savings
Services is less than the total allocation to the Shared Savings Fund, then
Group shall be entitled to *** of the amount by which the allocation exceeds
the costs, minus any carry forward resulting from deficits from previous
Agreement years. However, Group’s share of
the surplus in any Agreement Year


 












*** Confidential Treatment
Requested


 


55

















 


shall be limited to thirty percent (30%) of
the total allocation to the Shared Savings Fund for that Agreement Year.


 


Deficit: If the total actual cost of Shared
Savings services is more than the total allocation to the Shared Savings Fund,
then *** of the amount by which the actual costs exceed the total allocation, not to exceed *** of the total allocation to the
Shared Savings Fund for that Agreement Year, shall be allocated to
Group and shall be handled as follows: (i) the excess may be deducted from any
other settlements or payments, except capitation and Professional Stop Loss
Program payments made pursuant to Exhibit I, due to Group from Blue Shield,
and, (ii) any remaining amounts shall be carried forward into future Agreement
years and shall be deducted from any Shared Savings payments to Group in future
years.


 


SUMMARIES
& SETTLEMENTS: Blue Shield shall provide to Group a Shared Savings Program
quarterly Report and a Shared Savings Annual Settlement, as further described
in the Provider Manual.


 


B.                                     BLUE SHIELD 65 PLUS MEMBERS


 


FUNDING: For Members enrolled
in Blue Shield 65 Plus plans, Blue Shield will allocate to a Shared Savings
Fund a per Member per month percentage amount set forth in Exhibit D-2 for all
Members assigned to Group, subject to retroactive adjustments either upward or
downward due to retroactive changes in membership.


 


CHARGING OF
PAYMENTS: Blue Shield shall charge against the Shared Savings Fund all payments
made by Blue Shield for such Members during the annual term of the Agreement
which are designated as Shared Savings Services in Exhibit B, less payments
received by Blue Shield as a result of third-party reimbursement, Workers’
Compensation recoveries and coordination of benefits payments. Blue Shield
shall include any payments for Shared Savings Services which are paid prior to
the date of the settlement, as well as a reasonable allowance, as determined by
Blue Shield’s actuaries, for incurred but not paid (IBNP) claims. Any costs for
Shared Savings Services not included in any annual settlement shall be carried
forward and included in the Shared Savings settlement for the succeeding Agreement
Year. In addition, if this Agreement is replaced or superceded any other
agreement between the parties which contained a risk sharing arrangement for
similar services; then the following shall also be charged against the Shared
Savings Fund described herein: ( I ) any deficit in the final settlement of
that risk sharing arrangement and, (ii) any claims for risk services which were
incurred but not included in the settlement of the risk arrangement in the
prior agreement. Blue Shield shall provide sufficient
detail in the annual settlement, so that Group can determine the IBNP amount by
Agreement Year.


 


SHARED SAVINGS FUND SETTLEMENT: The Shared Savings Fund shall be
settled on an annual basis, within one hundred eighty (180) days following the
end of each annual term of the Agreement (being a 120 day claims run out and a
60 day determination period). In the event of termination of the Agreement for
any reason, final settlement of the Shared Savings


 


 


56

















 


Fund shall be
performed one hundred fifty (150) days after the date of termination and any
amounts due from Blue Shield to Group shall be paid within thirty (30) days
thereafter.


 


Surplus: If the total actual cost of Shared
Savings Services is less than the total allocation to the Shared Savings Fund,
then Group shall be entitled to *** of the amount by which the allocation
exceeds the costs, minus any carry forward resulting from deficits from
previous Agreement years. However, Group’s
share of the surplus for any Agreement Year shall be limited to *** of the
Capitation paid to the Group for Members enrolled in Blue Shield 65 Plus plans
in that Agreement Year.


 


Deficit: If the total actual cost of Shared
Savings Services is more than the total allocation to the Shared Savings Fund,
then *** of the amount by which the actual costs exceed the total allocation, not to exceed *** of the Capitation paid to the Group
for Members enrolled in Blue Shield 65 Plus plans in that Agreement Year,
shall be allocated to Group and shall be handled as follows: (i) the excess may
be deducted from any other settlements or payments, except capitation and
Professional Stop Loss Program payments made pursuant to Exhibit I, due to
Group from Blue Shield, and, (ii) any remaining amounts shall be carried
forward into future Agreement years and shall be deducted from any Shared
Savings payments to Group in future years.


 


SUMMARIES & SETTLEMENTS:
Blue Shield shall provide to Group a Shared Savings Program Quarterly Report
and a Shared Savings Annual Settlement, as further described in the Provider
Manual.


 


C.                                    PHARMACY
SHARED SAVINGS FUND


 


FUNDING: For Members enrolled
in Blue Shield 65 Plus, Blue Shield will allocate to a separately administered
Pharmacy Shared Savings Fund a per member per month percentage amount as set
forth in Exhibit D-3 for all Members assigned to Group. All membership is
subject to retroactive adjustments either upward or downward due to retroactive
changes in membership.


 


CHARGING OF PAYMENTS: Blue
Shield will charge against the Pharmacy Shared Savings Fund the actual cost
paid by Blue Shield for outpatient prescription drug services provided to
assigned members, as well as a reasonable allowance, as determined by Blue
Shield’s actuaries, for incurred but not paid (IBNP) outpatient prescription
drug claims. Pharmacy costs include the ingredient cost for Covered Services
rendered to Members for which the Pharmacy Shared Savings Fund is financially
responsible per Exhibit B, professional dispensing fees paid to participating
pharmacies, less associated pharmacy co-payment revenue. Any costs for
outpatient prescription drug services not included in any annual settlement
shall be carried forward and included in the Pharmacy Risk Fund settlement for
the succeeding Agreement Year. In addition, if this Agreement is replaced or


 


57

















 


superceded any other agreement
between the parties which contained a risk sharing arrangement for similar
services; then the following shall also be charged against the Shared Savings
Fund described herein: ( I ) any deficit in the final settlement of that risk
sharing arrangement and, (ii) any claims for risk services which were incurred
but not included in the settlement of the risk arrangement in the prior
agreement. Blue Shield shall provide
sufficient detail in the annual settlement, so that Group can determine the
IBNP amount by Agreement Year.


 


PHARMACY RISK
FUND SETTLEMENT: The Pharmacy Shared Savings Fund shall be settled on an annual
basis, within one hundred eighty (180) days following the end of each annual
term of the Agreement (being a 120 day claims run out and a 60 day
determination period). In the event of termination of the Agreement for any
reason, final settlement of the Pharmacy Risk Fund shall be performed one
hundred fifty (150) days after the date of termination and any amounts due from
Blue Shield to Group shall be paid within thirty (30) days thereafter.


 


Surplus: If the total actual cost of
outpatient prescription drugs is less than the total allocation to the Pharmacy
Risk Fund, then Group shall be entitled to *** of the amount by which the
allocation exceeds the costs, minus any carry forward resulting from deficits
from previous Agreement years. However,
Group’s share of the surplus for any Agreement Year shall be limited to *** of
the total allocation to the Pharmacy Risk Fund for that Agreement Year.


 


Deficit: If the total actual cost of Pharmacy
Shared Savings services is more than the total allocation to the Pharmacy Shared
Savings Fund, then *** of the amount by which the actual costs exceed the total
allocation, not to exceed *** of the total
allocation to the Pharmacy Risk Fund for that Agreement Year, shall
be allocated to Group and shall be handled as follows: (i) the excess may be
deducted from any other settlements or payments, except capitation and
Professional Stop Loss Program payments made pursuant to Exhibit I, due to
Group from Blue Shield, and, (ii) any remaining amounts shall be carried
forward into future Agreement years and shall be deducted from Pharmacy Shared
Savings Payments to Group in future years.


 


SUMMARIES
& SETTLEMENTS: Blue Shield shall provide to Group, as further described in
the Provider Manual, on a quarterly basis, a summary of the Pharmacy Shared
savings expenses along with a comparison to the Pharmacy Shared Savings Funding
and utilization data pertaining to the cost of prescriptions written on a
physician specific basis. Blue Shield shall also provide to Group a Shared
Savings Annual Settlement.


 


58

















 


Exhibit
D- l


 


HMO IPA/Medical Group Agreement


 


SHARED SAVINGS FUND ALLOCATIONS


 


Gateway Medical
Group, Inc.


 


Effective Date: January l, 2002-December 31,
2002


 


As of 01/01/2002, the effective net yield for
the following PMPMs is *** for the HMO Group and IFP combined, based on the
08/01/2001 membership.


 


The actual allocation to Shared Saving Fund
for each month will be calculated based on the actual member mix for each
age/sex category.


 


MEMBERS OTHER THAN BLUE SHIELD 65 PLUS
MEMBERS


 


	
  Age & Sex Categories and Shared Savings Allocations

  
	
  Category

  	
   

  	
  Shared Savings Allocation (PMPM)

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  Group

  (non-POS)

  	
   

  	
  IFP

  (non-POS)

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  



 












* = Medicare Primary.


*** Confidential Treatment
Requested


 


59

















 


Effective Date: January 1, 2003-Decetnber 31,
2003, & thereafter until amended


 


As
of 01/01/2003 the effective net yield for the following PMPMs is *** for the
HMO Group and IFP combined, based on the 08/01/2001 membership.


 


The
actual allocation to Shared Saving Fund for each month will be calculated based
on the actual member mix for each age/sex category.


 


MEMBERS
OTHER THAN BLUE SHIELD 65 PLUS MEMBERS


 


	
  Age & Sex Categories and Shared Savings Allocations

  
	
  Category

  	
   

  	
  Shared Savings Allocation (PMPM)

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  Group

  (non-POS)

  	
   

  	
  IFP

  (non-POS)

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (M)*

  	
   

  	
  ***

  	
   

  	
  ***

  



 












* Medicare Primary.


 


60

















 


Exhibit
D-2


 


HMO IPA/Medical Group Agreement 


 


SHARED SAVINGS FUND ALLOCATIONS


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002-December 31,
2002 & thereafter until amended


 


BLUE SHIELD 65 PLUS MEMBERS


 


*** of the Monthly CMS
Capitation received by Blue Shield from CMS and *** of the monthly premium
received by Blue Shield from the Member or from an Employer Group which Blue
Shield determines, according to its actuarial standards and methodology, to be
for a benefit that is designated as a Shared Savings Service in Exhibit B.


 


 


61

















 


Exhibit
D-3


 


HMO IPA/Medical Group Agreement


 


PHARMACY SHARED SAVINGS FUND ALLOCATIONS


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002-December 31,
2002 & thereafter until
amended


 


BLUE SHIELD 65 PLUS MEMBERS


 


*** of the Monthly CMS Capitation received by Blue Shield from CMS and
*** of the monthly premium received by Blue Shield from the Member or from an
Employer Group which Blue Shield determines, according to its actuarial
standards and methodology, to be for outpatient prescription drug services.


62

















 


Exhibit
E


 


HMO IPA/Medical Group Agreement



BLUE SHIELD ALLOWABLE RATES


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


The following
shall constitute Blue Shield Allowable Rates to be paid to Group or Group
Providers for Reciprocity (Paragraph 2.10), Retroactive Deletions (Paragraph
6.3(b)), and Services Other Than Capitated Professional Services (Paragraph
7.2):


 


The lesser of
*** of the Blue Shield PPO Physician Allowances in effect on the date of
service, or the amount paid by the Group (or Group Provider) for the services,
if any, (excluding Capitation payment), minus the Member’s/individual’s
applicable copayment, coinsurance or deductible. Further detail regarding Blue
Shield’s proprietary fee schedule is provided upon request.


 


vvv


 


 


 


63

















 


Exhibit
F


 


HMO IPA/Medical Group Agreement



DELEGATION RESPONSIBILITIES


 


Gateway Medical Group,
Inc.


 


Effective Date: January 1, 2002


 


1.                                 Delegation
Responsibilities & Penalties. The capitation amounts paid to Group by
Blue Shield as set forth in Paragraph 7.1 (a) of this Agreement are based on
Blue Shield’s expectation that the Group accepts and will perform delegation of
the requirements set forth as Group’s responsibility in Attachments I, II, III
and IV of this Exhibit F. The quality improvement and quality management
obligations of Blue Shield are not delegated to Group; however, Group shall have
its own fully functional Quality Management Program, as described in Attachment
1, that is cooperative with and integrated into the Blue Shield Quality
Management Program. In accordance with paragraph 4.3 (c) of this Agreement, the
net monthly capitation penalty reduction for any de-delegated function shall be
as follows:


 


	
   

  	
   

  	
  Commercial

  	
   

  	
  Blue
  Shield 65 Plus

  	
   

  
	
  UM/Professional

  	
   

  	
  3.0

  	
  %

  	
  3.0

  	
  %

  
	
  UM/Shared
  Savings

  	
   

  	
  3.0

  	
  %

  	
  3.0

  	
  %

  
	
  Credentialing

  	
   

  	
  .5

  	
  %

  	
  .5

  	
  %

  
	
  Claims
  Processing

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Non contracted only penalty

  	
   

  	
  .7

  	
  %

  	
  .7

  	
  %

  
	
  All Claims penalty

  	
   

  	
  7.0

  	
  %

  	
  7.0

  	
  %

  
	
  Non contracted only payment withhold*

  	
   

  	
  8.5

  	
  %

  	
  8.5

  	
  %

  
	
  All Claims payment withhold*

  	
   

  	
  85.0

  	
  %

  	
  85.0

  	
  %

  



 












*Subject to actual claims paid
experience.


 


Dedelegation penalties for Claims Processing do not apply in cases
where Blue Shield participates in joint administration of claims processing on
Group’s premises, however, Group shall reimburse Blue Shield for Blue Shield’s
cost of providing on site assistance and shall provide workstations and
equipment as required.


 


2.                                       Delegation
Criteria and Standards.  Blue Shield
has developed and adopted delegation criteria and standards for performance of
delegated activities for the delegation of utilization management, medical
records audits, credentialing, professional site reviews, and claims
processing.  These criteria and
standards as set forth in the Provider Manual and this Exhibit F, may be
modified from time to time by Blue Shield. Group warrants to Blue Shield that
it meets the criteria for the activities, and is willing to, and capable of,
performing such delegated activities in full compliance with the standards.
Group shall promptly notify Blue Shield in


 


64

















 


writing,
within no less than seven (7) business days, in the event it ceases, in whole
or in part, to meet such criteria.


 


3.                                       Blue
Shield Monitoring and Oversight. Blue Shield shall be entitled to conduct
audits of Group’s compliance with the criteria and standards. Group shall
provide reasonable access during regular business hours to its claims, claims
supporting documentation, Member inquiry files, credentialing files, clinical
and medical records of Members as applicable and reasonably necessary to
evaluate Group’s performance of its delegated activities. In the event Group
has insufficient data and records relating to Members to permit Blue Shield to
evaluate a particular activity under review, then Group shall provide
sufficient documents and information on non-Members, with all non-Member
identifying information deleted to preserve the confidentiality of such
information, in order to permit Blue Shield to evaluate Group’s performance of
such activity. Group shall participate in an annual evaluation and quarterly
meetings between Blue Shield and Group staff. 
In addition, Group shall provide to Blue Shield periodic reports on
delegated activities as set forth in the Provider Manual. Group shall take such
corrective actions as requested by Blue Shield through the audit review process
within such time lines as established by Blue Shield.


 


4.                                       Shared
Savings Service Authorization/Medical Policy.  When authorization responsibility for Shared Savings Services is
delegated to Group, Group shall pre-authorize Shared Savings Services (or, as
appropriate, retroactively authorize Emergency Services) and shall provide a
copy of such authorization to Blue Shield within seven (7) days following the
authorization. Group shall provide to Blue Shield weekly reports setting forth
authorizations granted and denied, as set forth in the Provider Manual. All
utilization management and authorizations of Group shall be consistent with
Blue Shield’s Medical Policy.


 


5.                                       Blue
Shield Request for Records, Files and Reports Related to Delegated
Credentialing and Recredentialing. Blue Shield shall be entitled to conduct
audits of Group’s compliance with the criteria and standards of Delegated
Credentialing and Recredentialing. 
Group shall provide reasonable access during regular business hours to
credentialing files, as reasonably necessary to evaluate Group’s performance of
it’s delegated activities.  Group shall
submit copies of credentialing/recredentialing files for review by
governmental, accrediting and regulatory review agencies. Submission of
documents by Group will be within the required timeframe of the requesting
agency. Group shall participate in an annual evaluation and quarterly meetings
between Blue Shield and Group staff. In addition, Group shall provide to Blue
Shield periodic reports on delegated activities as set forth in the Provider Manual.  Group shall take such corrective actions as
requested by Blue Shield through the audit review process within such time
lines as established by Blue Shield.


 


65

















 


ATTACHMENT
I TO EXHIBIT F


 


BLUE SHIELD OF CALIFORNIA

QUALITY MANAGEMENT (QM) REQUIREMENTS*


 


	
  QI Standard Per BSC

  	
   

  	
  Activities
  Performed by Group

  	
   

  	
  Group
  Reporting Frequency to BSC

  	
   

  	
  BSC
  Oversight

  
	
  1.  Program
  Structure

  	
   

  	
  •   Written QM Program

  •   QM Program accountable to
  Governing Body.

  •   Program evaluated annually
  and updated.

  •   Designated physician has
  substantial involvement.

  •   QM committee meets quarterly,
  at a minimum.

  •   Annual QM work plan.

  •   Annual QM evaluation.

  	
   

  	
  •    Submit QM Program annually.

  •   Submit workplan annually.

  •   Submit program evaluation annually.

  	
   

  	
  1   Review
  and approval of:

  •   Program

  •   Work plan

  •   Annual evaluation

  •   QI Policies

  •   QI Procedures

  •   Clinical Guidelines

  •   Access Guidelines

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.  Program
  Operations

  	
   

  	
  •   Provider QI Committee
  recommends policy decisions, reviews QI activities, institutes needed actions
  and ensures follow-up.

  •   Contemporaneous, signed and
  dated minutes.

  •   Physicians actively
  participate in QI program.

  •   QI program coordinates
  monitoring activity throughout organization.

  	
   

  	
  •   Group policies and procedures
  related to QI submitted annually and any updates and changes submitted
  quarterly.

  •   Annual Report to include
  monitoring activities and results, and improvements.

  	
   

  	
  •   Annual on-site assessment to
  include review of minutes

  •   Annual review of monitoring
  reported to BSC’s QI/UM Committee.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.  Health
  Services Contracts

  	
   

  	
  •   Negotiate contracts with
  subcontractors if written prior approval obtained from BSC.

  •   Include in contract
  w/subcontracted vendors the requirement that the subcontracted vendor is
  obligated to participate in and be compliant with the BSC QI process and
  findings.

  	
   

  	
   

  	
   

  	
  Prospective
  review and approval of BSC contract for appropriate contract language

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.  Availability
  of Primary Care Practitioners

  	
   

  	
  •   Access studies

  •   Keep BSC aware of closed PCP
  practices.

  •   Keep BSC aware of changes in
  status of contracted providers.

  	
   

  	
   

  	
   

  	
  •   Review of open/closed panels

  •   Monitoring of patient
  geographic access to PCP and specialists offices

  •   Monitoring of appropriate
  referrals to out-of-network providers

  •   Review of patient complaint
  trends re: access and availability to care and services.

  •   Review of results of access
  studies

  



 












*Quality Management is not a
delegatable function and therefore not subject to de-delegation.


 


66

















 


	
  QI Standard per BSC

  	
   

  	
  Activities
  Performed by Group

  	
   

  	
  Group
  Reporting

  Frequency to BSC

  	
   

  	
  BSC
  Oversight

  
	
  5.  Accessibility
  of Services – BSC is Responsible for Establishing access Guidelines for:

  •        Wait times

  •        Appointments

  •        After-hours care

  •        Telephone access;

  •        Access for referrals to
  specialty care

  •        Development of access
  study design, methodology and tools

  	
   

  	
  •        Participate in BSC’s
  access surveys. 

  •        Schedule member
  appointments based on access guidelines

  •        Perform internal IPA/MG
  access study. 

  	
   

  	
  •        Quarterly access study
  results as performed by IPA/MG

  	
   

  	
  •        Access Study Data
  results

  •        Review Group’s Access
  Guidelines

  •        Review of access-related
  patient complaints

  •        Trend reports of member
  complaints re access

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.  Member
  Satisfaction

  	
   

  	
  Participate
  in Group’s Member Satisfaction Surveys.

  	
   

  	
  Quarterly

  	
   

  	
  •        Review of member
  complaint data.

  •        Review of member survey
  data.

  •        Review of BSC’s
  disenrollment for quality of care issues data.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.  Health
  Management Systems – BSC Designs population-based programs to identify and
  manage chronic conditions of BSC members.

  	
   

  	
  •   Data collection

  •   Program implementation as
  provided by BSC

  •   Provider & staff
  education as provided by BSC

  	
   

  	
  •   Annual submission of program
  design.

  •   Annual submission of BSC
  member participation list.

  	
   

  	
  •        Review by BSC of all provider-based
  chronic care initiatives.

  •        Reconciliation of member participation
  list against BSC list of members assigned to Group with those chronic
  conditions being addressed, to ensure identification of all potentially
  eligible members.

  •        Verification with individual providers
  of participation in the chrome care initiatives.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  8.  Clinical
  Practice Guidelines — acute and chronic services.

  	
   

  	
  •   Adopts BSC guidelines

  •   Disseminates guidelines to
  providers.

  •   Measures performance against
  no less than 2 high-volume, high-risk problem-prone guidelines annually.

  •   Submits for review to BSC
  individually developed guidelines and/or chosen industry established
  guidelines for review.

  	
   

  	
  •   Annual submission of guidelines.

  •   Submission of results of
  review of performance measurement against guidelines to be included in the
  annual report.

  	
   

  	
  •        BSC annual assessment to
  include process of  guideline
  development, performance measurement, and distribution.

  •        BSC to review and approve
  all guidelines.

  



 












* Quality Management is not a delegatable function and therefore not
subject to de-delegation.


 


67

















 


	
  QI Standard per BSC

  	
   

  	
  Activities
  Performed by Group

  	
   

  	
  Group
  Reporting

  Frequency to BSC

  	
   

  	
  BSC
  Oversight

  
	
  9.  Scope
  and Content of non-preventive clinical QI issues.  BSC identifies meaningful clinical issues for plan-wide
  monitoring and review.

  	
   

  	
  •   Adopts BSC guidelines.

  •   Educates group providers in
  the application and use of the BSC established processes.

  	
   

  	
  •   Annual submission of
  guidelines.

  •   Submission of results of
  review of performance measurement against guidelines to be included in the
  annual report.

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  10. Clinical Measurement
  Activities: 

   

  •  Data collection

  •  Measurement

  •  Data analysis

  •  Intervention & Implementation 

   

  Related to:

  •  Primary care services

  •  High-volume specialty services 

  •  Behavioral Health 

  •  services

  •  Institutional services

  •  Over/under utilization monitoring

  •  Issues that affect continuity and coordination
  of care and service.

  	
   

  	
  •   Identify Group key clinical
  areas for study development 

  •   Data collection 

  •   Data analysis 

  •   Recommend and develop interventions 

  	
   

  	
  •   Prior to study implementation

  •   On-going reports during
  implementation of  study

  •   Clinical activity findings
  reported no less than quarterly

  	
   

  	
  •   Prospective review and
  approval of clinical measurement activities

  •   Quarterly review of
  monitoring activity results

   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  11. Intervention
  & follow-up for clinical issues

  	
   

  	
  •   Implementation of action plan
  to immediate care and service.

  •   Evaluate affects of actions
  taken.

  	
   

  	
  •   Prior to study
  implementation.

  •   On-going reports during
  implementation of study.

  •   Clinical activity findings
  reported no less than quarterly

  	
   

  	
  •   Prospective review and
  approval of clinical measurement activities

  •   Quarterly review of
  monitoring activity results

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  12. Effectiveness
  of QI Program and Demonstration of Required Improvements

  	
   

  	
  •   Group to participate in QI
  program by submission of required data. Group responsible for maintaining
  separate QI program for group function and issues.

  	
   

  	
  •   Annual QI program eval.

  •   QI meeting minutes

  •   QI quarterly reporting on
  activities listed in QI Plan

  	
   

  	
  •   Submission of QI annual
  evaluation.

  



 












* Quality Management is not a
delegatable function and therefore not subject to de-delegation.


 


68

















 


	
  QI Standard per BSC

  	
   

  	
  Activities
  Performed by Group

  	
   

  	
  Group
  Reporting

  Frequency to BSC

  	
   

  	
  BSC
  Oversight

  
	
  13. Grievance
  process/ Complaint handling &  reporting

  	
   

  	
  Group to
  coordinate with BSC for communication and management of Grievance and Appeals
  resolution.

  	
   

  	
   

  	
   

  	
  •   Annual review of Group’s
  complaint policies & procedures

  •   Quarterly review of complaint
  log

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  14. QI
  oversight

  	
   

  	
  Group to
  participate in BSC QI process by implementation. submission and evaluation of
  required audits and provision of data as needed for evaluation of processes
  and function.

  	
   

  	
   

  	
   

  	
  •  Pre-delegation on-site audit

  •   Annual on-site audit

  •   Committee meeting minutes

  •   On-going review of Group
  delegation activities.

  



 












*Quality Management is not a
delegatable function and therefore not subject to de-delegation.


 


69

















 


ATTACHMENT
II TO EXHIBIT F


 


BLUE SHIELD OF CALIFORNIA


UTILIZATION MANAGEMENT (UM) REQUIREMENTS


 


	
  UM Standard per BSC

  	
   

  	
  Activities
  Delegated to Group

  	
   

  	
  Group

  Reporting

  Frequency to

  BSC

  	
   

  	
  BSC
  Oversight

  
	
  1    UM
  program Structure & Process:

  •   Programs

  •   Work Plan

  •   Annual Eval

  	
   

  	
  Compose
  written UM Program description Work Plan and Plan Evaluation as outlined in
  BSC Delegation Standards.

  	
   

  	
  Annual

  	
   

  	
  Review and
  submission, annually, of:

  •   UM Program

  •   UM Work plan

  •   UM Annual Eval.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.   Prior-authorization

  	
   

  	
  Conduct
  prior authorization according to time frames description as outlined in BSC
  Delegation Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of referrals

  •   Inter-Rater Reliability
  Studies

  •   Authorization and Denials

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.   Concurrent
  review

  	
   

  	
  Conduct
  concurrent review according to time frames description as outlined in BSC
  Delegation Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of concurrent
  review decisions

  •   Bed day report

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4    Case
  Management – Coordination of care and services required to assure appropriate
  and timely intervention and care for chronic conditions, high risk, out of
  area, out of network cases, and difficult cases.

  	
   

  	
  Conduct case
  management according to time frames description as outlined in BSC Delegation
  Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of case
  management files

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.   Discharge
  Planning

  	
   

  	
  Conduct
  discharge planning according to time description as outlined in BSC
  Delegation Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of discharge
  planning cases

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  6.   DME

  	
   

  	
  Conduct DME
  according to time frames description as outlined in BSC Delegation Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of DME
  authorization and denials

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  7.   Homeo
  Health

  	
   

  	
  Conduct DME
  according to time frames description as outlined in BSC Delegation Standards.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Retro-review of home health
  authorization and denials

  •   Review trends in QI reporting
  and patient complaints

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  8.   Institutional
  Reporting

  	
   

  	
  Conduct
  concurrent review and monitoring for appropriateness and submission of
  reports/encounter data for all admits.

  	
   

  	
  Monthly to
  BSC.

  	
   

  	
  Assure
  institutional report is sent to accountable Health Plan monthly

  



 


70

















 


	
  UM Standard per BSC

  	
   

  	
  Activities
  Delegated to Group

  	
   

  	
  Group

  Reporting

  Frequency to

  BSC

  	
   

  	
  BSC
  Oversight

  
	
  9.   Decision
  Criteria

  •    Medical appropriateness

  •    LOS

  •    Catastrophic Case Management

  	
   

  	
  •   Development of criteria.

  •   Day-to-day monitoring of
  criteria in the in-patient and ambulatory settings.

  	
   

  	
  Frequency of
  reporting to BSC will be no less than quarterly.

  	
   

  	
  •   Annual review of evidence of
  adoption of criteria

  •   Inter-rater reliability study

  •   Bed day report

  •   Catastrophic case report

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  10. Standards
  for UM Decision-making

  •    Pre-authorizations 

  •    Referrals

  •    Expedited referrals

  •    Denials for medical
  necessity

  •    Retrospective review

  •    Concurrent review

  	
   

  	
  •   Day-to-day accounting of
  in-patient review

  •   Referrals management

  •   Medical necessity
  decision-making for patients receiving care in in-patient and ambulatory
  settings within the industry and BSC defined parameters.

  	
   

  	
  Frequency of
  reporting to BSC will be no lees than quarterly.

  	
   

  	
  •   Review of denial letters for
  appropriate regulatory language and timeframes

  •   Retro-review of
  authorizations/ referrals/ denials for medical necessity

  •   Bed day report

  •   Inter-rater reliability study.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  11  OOA
  Patient Management

  	
   

  	
  •   Day-to-day case management of
  out-of-area patients in in-patient and ambulatory settings when group is
  capitated for OOA management with BSC notification; BSC to manage when shared
  savings.

  	
   

  	
  Frequency of
  reporting to BSC will be concurrent, weekly, but in all cases no less than
  quarterly.

  	
   

  	
  •   Bed day report

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  12. Technology
  Assessment

  	
   

  	
  Group is
  responsible to report and coordinate authorization requests for care that is
  considered experimental and/or investigational. Group is responsible for the
  adherence to BSC P&Ps regarding the authorization of new technology and
  coordination of benefits interpretation.

  	
   

  	
  Concurrent

  	
   

  	
  •   Review of IPA/MG submitted
  denials for appropriateness and compliance with BSC P&Ps

  •   Review of Appeals overturned

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  13. Continuity
  of Care.

  	
   

  	
  Group
  responsible for the development of P&P and ongoing day-to-day management
  of continuity of care issues as needed and in compliance with current
  regulatory requirements and BSC criteria.

  	
   

  	
   

  	
   

  	
  •   Review and approval of
  submitted P&Ps

  •   Annual review of utilization
  Management minutes of IPA/MG

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  14. Behavioral
  Health Management

  	
   

  	
  Day to day
  case management of BH cases is the responsibility of the group.  The group is further responsible for the coordination
  and continuity of care related to mental health care issues.

  	
   

  	
   

  	
   

  	
  •   Review and approval of
  submitted P&Ps

  •   Annual review of Utilization
  Management minutes of IPA/MG

  •   Medical Records review PCPs
  with >50 members, every other year

  



 


71

















 


	
  UM Standard per BSC

  	
   

  	
  Activities
  Delegated to Group

  	
   

  	
  Group

  Reporting

  Frequency to

  BSC

  	
   

  	
  BSC
  Oversight

  
	
  15. Benefit
  Development Interpretation

  	
   

  	
  Compliance
  with benefit interpretation as provided by BSC.

  	
   

  	
  Concurrent
  submission of ALL denials.

  	
   

  	
  Concurrent
  review of denials.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  16. Oversight
  of Delegated UM activities

  	
   

  	
  Preparation,
  maintenance, and availability of all documents that demonstrate UM/QM
  activity in keeping with regulatory compliance.

  	
   

  	
  At least
  quarterly.

  	
   

  	
  Quarterly
  audits.

  



 


72

















 


ATTACHMENT
III TO EXHIBIT F


 


BLUE SHIELD OF CALIFORNIA


CREDENTIALING/DELEGATION REQUIREMENTS


 


	
  Standard
  per BSC

  	
   

  	
  Delegateable

  Status

  	
   

  	
  Activities Delegated to Group

  	
   

  	
  Group

  Reporting

  Frequency to

  BSC

  	
   

  	
  BSC Oversight

  
	
  1.   Credentialing
  structure & process:

  •    Policies & procedures

  •    Committee/Review body

  	
   

  	
  Non-delegateable
  establishment of standards

  	
   

  	
  Development
  & implementation of relevant policies and procedures:

  •    Scope

  •    Criteria

  •    Decision-making

  •    Committee/review body

  •    Protection of provider
  rights

  •    Medical Director or
  designee’s responsibilities

  •    Peer Review/Disciplinary
  Action

  •    Documentation of Agreement

  •    Initial evaluation 

  •    Oversight organization
  retains right of approval/disapproval

  	
   

  	
  Annual

  	
   

  	
  Review of
  annual submission of:

  •    Policies and Procedures

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2    Appointment
  process

  	
   

  	
  Non-delegateable
  establishment of standards

  	
   

  	
  •    Completion of application

  •    Primary source verification

  •    Verification of information
  from monitoring organizations

  •    Identification of sanction
  activity

  	
   

  	
  Group
  submits at least quarterly reports of which providers have been appointed or
  declined for appointment by the Credentials Committee

  	
   

  	
  BSC performs
  at least annual onsite review of a sampling of initial credentialing files
  and committee minutes.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.   Reappointment
  process

  	
   

  	
  Non-delegateable
  establishment of standards

  	
   

  	
  •    Primary source verification

  •    Review of information from
  monitoring organizations within 180 days of credentialing

  •    PCP Performance appraisal
  which includes: member complaints, QI results, UM reports, and member
  satisfaction (optional)

  •    Reappointment is performed
  at least every two years.

  	
   

  	
  Group
  submits at least quarterly reports of which providers have been re-appointed
  or declined for re-appointment by the Credentials Committee

  	
   

  	
  BSC performs
  at least annual on-site review of a sampling of re-credentialing files and
  committee minutes.

  



 


73

















 


	
  Standard
  per BSC

  	
   

  	
  Delegateable

  Status

  	
   

  	
  Activities Delegated to Group

  	
   

  	
  Group

  Reporting

  Frequency to

  BSC

  	
   

  	
  BSC Oversight

  
	
  4.   Office
  Site Visits

  	
   

  	
  Non-delegateable
  establishment of standards

  	
   

  	
  •    Initial office site visit
  for potential PCP’S and QS/Gyn’s which includes evaluation of medical record
  keeping practices

  •    At the time of
  recredentialing, an office site visit for high volume PCP’s which includes

  •    Evaluation of medical record
  keeping practices

  	
   

  	
  N/A

  	
   

  	
  BSC performs
  at least annual review of:

  •    Policies & procedures
  describing office site visits

  Initial and
  re-appointment files to assess evidence of office site visits

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5.
  Credentialing file maintenance

  	
   

  	
  Non-delegateable
  establishment of standards

  	
   

  	
  •    Maintenance of individual
  provider credentialing/ recredentialing files.

  •    Submission of copy of
  provider credentialing recredentialing file at the request of BSC

  	
   

  	
  As requested
  for governmental, accreditation and regulatory review.

  	
   

  	
  BSC performs
  at least annual review of:

  •    Policies & procedures
  describing submission of files upon request of BSC for the purposes of
  meeting governmental, accrediting and regulatory agency review requests.

  BSC requests
  for copy of credentialing recredentialing file for review by governmental,
  accrediting and regulatory agency review will be within the required time
  frame of requesting agency.

  



 


74

















 


ATTACHMENT
IV TO EXHIBIT F


 


BLUE SHIELD OF CALIFORNIA

CLAIMS

PROCESSING REQUIREMENTS


 


	
  Standard per BSC

  	
   

  	
  Activities
  Delegated to Group

  	
   

  	
  Group
  Reporting

  Frequency to BSC

  	
   

  	
  BSC
  Oversight

  
	
  1. Payment 

  •    Timeliness

  •    Payment Accuracy

  •    Denials

  	
   

  	
  Payment/processing
  of claims for all services which are the Group’s responsibility per this
  agreement and state or federal regulations.

  	
   

  	
  Monthly

  	
   

  	
  Monthly
  report review.

  Periodic audits

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2. Claims
  Forwarding

  	
   

  	
  Forwarding
  of claims which are not the group’s payment responsibility within industry
  standard of 8 calendar days.

  	
   

  	
  None

  	
   

  	
  As required.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.
  Self-Monitoring and Reporting

  	
   

  	
  Internal
  quality assurance testing procedures. Monthly report submission per industry
  standard format.

  	
   

  	
  Monthly

  	
   

  	
  Monthly
  report review. 

  Periodic
  audits

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  4.
  Sub-delegation of claims processing through capitation. (This does not refer
  to a TPA or management company arrangement for Group’s entire claims
  processing.)

  	
   

  	
  Continued
  compliance with all requirements. Monitor sub-delegated claim shops employing
  all means used by Blue Shield or government regulators in their oversight. If
  sub-capitated organization engages a TPA or management company, those must be
  audited by Group.

  	
   

  	
  Monthly
  including breakout of sub-capitated entities.

  	
   

  	
  Periodic
  audits

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  5. Audits
  and Audit Preparation and Follow-Up (for CMS, DMHC, BSC)

  	
   

  	
  Preparation
  including producing accurate claims universe lists, providing detailed
  information in a standard questionnaire, selecting and retrieving requested
  documents; claims, back-up records, checks/payment confirmation, and written
  corrective action plans in accordance with BSC instructions.

  	
   

  	
  As requested

  	
   

  	
  Periodic
  audits 

  Random
  focused audits 

  Focused
  reviews

  



 


75

















 


Exhibit
G


 


HMO IPA/Medical Group Agreement


 


PROVIDER INCENTIVE PROGRAM


 


Group shall not participate in
the Blue Shield Provider Incentive Program.


 












*** Confidential Treatment
Requested


76

















 


Exhibit
H-1


 


HMO IPA/Medical Group Agreement


 


BLUE SHIELD 65 Plus PROVISIONS


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


Group and Group Physicians
specifically agree to serve Blue Shield 65 Plus Members pursuant to the terms
and conditions of this Agreement and the following requirements:


 


1.                                       This
Agreement shall apply to Blue Shield 65 Plus Members who are enrolled in Blue
Shield’s Medicare+ Choice Plan.


 


2.                                       DEFINITIONS – The following definitions
shall apply for Blue Shield 65 Plus Members in addition to the Definitions set
forth in Article I of the Agreement:


 


A.            “Emergency Medical
Condition” shall mean a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that a prudent
layperson, with an average knowledge of health and medicine, could reasonably
expect the absence of immediate medical attention to result in (1) serious
jeopardy to the health of the individual or, in the case of a pregnant woman,
the health of the woman or her unborn child; or (2) serious impairment to
bodily functions; or (3) serious dysfunction of any bodily organ or part.


 


B.            “Emergency
Services” shall mean those medical and hospital services required that are
(i) furnished by a Physician qualified to furnish emergency services; and (ii)
needed to evaluate or stabilize an Emergency Medical Condition.


 


C.            “Member” shall
mean a Medicare beneficiary who is enrolled in the Health Plan’s Medicare+Choice
program (“Blue Shield 65 Plus Choice Plan”) who is assigned to a Group
Physician and Hospital.


 


D.            “Urgently Needed
Services” will mean medical services received outside of the Service Area
which are, in the judgment of a prudent layperson, required without delay in
order to prevent serious deterioration of Enrollee’s health as a result of an
illness or injury.


 


3.                                       OBLIGATIONS OF GROUP – The Obligation set
forth in Article II, Paragraph 2.6 of the Agreement is modified to add the
following at the end of current text of Paragraph 2.6 and shall apply to Blue
Shield 65 Plus Members:


 


“Group will
comply and have its Group Providers comply with state and federal laws and
regulations including but not limited to physician incentives, and stop


 












*** Confidential Treatment
Requested


 


77

















 


loss insurance
requirements. Group shall include in its contracts with Group Providers all
provisions required by federal and state laws, including the BBA and related
regulations. Group shall ensure that, on or before December 31, 1999, all
contracts with Group Providers comply with all applicable Medicare+Choice
regulations as described in this Exhibit H and as outlined in the Provider
Manual. Further, to the extent Group subcapitates other provider organisations
and the contracts with such organizations delegate to the organization
responsibility for claims processing, including the right to pay or deny
claims, Group’s contracts with such Group Providers shall require that they
comply with the provisions of this Exhibit H-l. Further, Group shall comply
with the provisions set forth in Exhibit F of this Agreement and in the
Provider Manual.”


 


The Obligation
set forth in Article II, Paragraph 2.12 of the Agreement is modified to add the
following at the end of the current text of Paragraph 2.12 and shall apply to
Blue Shield 65 Plus Members:


 


“Submission
of Electronic Encounter Data. Group agrees to furnish Blue Shield with
complete encounter data for Capitated Professional Services rendered to Members
in the HCFA 1500 format.  The encounter
data will be furnished to Blue Shield through Electronic Data Interchange and
shall be received by Blue Shield ninety (90) days following the date of
service. Group also agrees to furnish medical records that may be required to
obtain any additional information or corroborate the encounter data. Group
further agrees to have its CEO attest and certify the completeness and
truthfulness of the encounter data submitted. Failure by Blue Shield to receive
encounter data within stipulated time frame will result in Group receiving
reduced compensation as described in Paragraph 7.11 of this Agreement as well
as grounds for termination of this Agreement.”


 


4.                                       COMPLIANCE WITH LEGAL REQUIREMENTS – In addition
to the requirements set forth in Article XIII of the Agreement, the following
new Paragraphs shall also apply:


 


“13.7        Provider
Terminations. If Blue Shield terminates a Group Provider without cause,
Blue Shield must provide Group at least sixty (60) days notice. If Group
terminates a Group Provider without cause, Group must provide Blue Shield at
least sixty (60) days notice.


 


“13.8        Medicare+Choice.
Group will comply and have its Group Providers comply with state and federal
laws and regulations including but not limited to physician incentives, and
stop loss insurance requirements. Group shall submit to Blue Shield on an
annual basis descriptive information regarding its Physician Incentive Plan
(PIP) as required by CMS. Group shall submit such information utilizing the CMS
PIP Disclosure Forms. Group shall include in its contracts with Group Providers
all provisions required by federal and state laws, including the BBA and
related regulations. Group shall ensure that, on or before December 31, 1999, all
contracts with Group Providers comply with all applicable


 


78

















 


Medicare+Choice
regulations as described in this Amendment and as outlined in the Provider
Manual.


 


Group
understands that payments made by Blue Shield are, in whole or in part, derived
from federal funds, and therefore provider and its subcontractors are subject
to certain laws that are applicable to individuals and entities receiving
federal funds. Group agrees to comply with all applicable Medicare laws,
regulations and CMS instructions including Title VI of the Civil Rights Act of
1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act
of 1975, the Americans with Disabilities Act, and to require their
subcontractors to do the same. Group agrees to include the requirements of this
section in its contracts or subcontracts with other Participating Providers or
entities.


 


In making
payments to Group Physicians and other Group Providers for Covered Services,
Group shall comply with the timeliness requirements set forth in applicable
federal law, including, but not limited to, any applicable CMS rules and
regulations.


 


13.9         CMS Participation
Requirements. Group is prohibited from employing or contracting with an
individual who is excluded from participation in Medicare for the provision of
any of the following: healthcare services, utilization review services, medical
social work services and administrative services. In the event Group fails to
comply with the above, Blue Shield reserves the right to pass through to the
Group any sanctions imposed by CMS for violation of this prohibition.


 


13.10       Organization
Determination Process. Blue Shield may delegate the process of utilization
management to the Group. If such delegation occurs, Group shall comply with
Medicare regulations and CMS instructions pertaining to timely organization
determinations by Group as to whether to provide, deny, reduce or discontinue a
Covered Service to a Member. Such determinations shall be made in accordance
with procedures and instructions set forth in the Provider Manual. Group shall
submit to Blue Shield on a monthly basis a report which tracks the requests for
organization determinations and expedited reviews and the timeframe within
which decisions were made by Group. This section is subject to change as
determined by CMS regulations, policies and instructions.


 


13.11       Private Contract.
Group understands that Blue Shield is prohibited by CMS from paying capitation
to, or including in its network, any provider that has entered into a private
contract with a Member for the provision of services. Blue Shield reserves the
right to terminate any such provider from its network. Further, if the provider
so terminated was a Group Physician, Blue Shield shall have the right to reduce
Group’s capitation by the amount of any capitation that was paid either
directly or indirectly to such provider(s). This provision shall remain in
effective for a period of two (2) years from the time that all direct contracts
between provider and Member have been terminated.


 


79

















 


13.12       Health Assessment.
Blue Shield must conduct a health assessment of all Members within ninety (90)
days of the effective date of Member’s enrollment with Blue Shield. Group
agrees to cooperate in such health assessment process.


 


13.13       Utilization Management
Plan. Prior to the execution of this Agreement, and if utilization
management functions are delegated to Group by Blue Shield, Group will provide
Blue Shield with a written Utilization Management Plan for the purpose of
review and approval by Blue Shield. Group shall notify Blue Shield within
thirty (30) days of any changes involving the rules, regulations, authorities
and responsibilities for the Utilization Management Plan, which shall be
subject to reasonable approval thereof by Blue Shield. The Utilization
Management Plan shall include procedures approved by Blue Shield to identity,
assess, establish, and implement a treatment plan for Members who have complex
or serious medical conditions, and for direct access of Members to services as
mandated by the BBA and related regulations. Group agrees to comply with Blue
Shield’s Medical Policies. All Group denial letters shall be reviewed and
approved by Blue Shield. Group agrees to cooperate with Blue Shield in
furnishing the required reports identified in the Provider Manual.”


 


5.                                       PLAN QUALITY IMPROVEMENT – Following
Paragraph 2.7 of the Agreement, the following provisions shall also apply.


 


“Blue Shield retains
responsibility for Quality Improvement and Quality Management Programs. Quality
Improvement and Quality Management Programs are not delegated to Group. Group
however agrees to comply with Blue Shield’s Quality Improvement Program for
both hospital and office based care. Blue Shield’s Quality Improvement Program
shall be developed in consultation with Blue Shield Providers to ensure that
practice guidelines of quality improvement and quality management pursuant to
Medicare regulations and CMS instructions are met. Group agrees to maintain a
Quality Management Program which states that Group will review on a
prospective, concurrent and retrospective basis the quality, appropriateness,
level of care and utilization of Group Providers. The Quality Management
Program will include among others an annual evaluation, annual quality
management goals, proposed quality management studies, a description of the
quality management committee and frequency of meetings. Group shall notify Blue
Shield of any changes to the Quality Management Plan which shall be subject to
prior approval by Blue Shield.”


 


6.                                       PROVIDER
MANUAL – In Article V. of the Agreement, the following provisions shall be
added to the end of Paragraph 5.2:


 


Precedence. The Provider Manual and all revisions
thereto shall be consistent with the laws and regulations governing the
Medicare+Choice program, the regulations established by CMS, the Knox-Keene Act
and the provisions of this Agreement. In the event of any conflict or
inconsistency between the Provider Manual, the Agreement, and/or any of the
cited state or federal laws and


 


80

















 


regulations,
the provision which governs shall be determined by apply the following order of
precedence: the BBA, CMS regulations and instructions, the Knox-Keene Act and
regulations, the Agreement and, then, the Provider Manual.


 


vvv


 


81

















 


Exhibit
H-2


 


HMO IPA/Medical Group Agreement


 


BLUE SHIELD POS PROVISIONS


 


Gateway Medical Group,
Inc.


 


Effective Date: January 1, 2002


 


This Exhibit implements the
Blue Shield HMO POS Benefit Program (“BSC POS”) pursuant to which BSC POS
Members may receive Covered Services on either an In-Network Services or
Out-of-Network Services basis (as defined below).


 


1.                                       Definitions.
In addition to the definitions set forth in the Agreement, the following
definitions apply to this Exhibit H-2:


 


(a)                                  BSC
POS Member refers to a Member enrolled in the BSC HMO POS Benefit Program.


 


(b)                                 In-Network
Services refers to Covered Services which are not Out-of-Network Services.


 


(c)                                  BSC
POS Institutional Services are those Covered Services provided to a BSC POS
Member, which are identified in the Division of Financial Responsibility
(Exhibit B.) as Shared Savings (other than Outpatient Prescription Drugs).


 


(d)                                 BSC
POS Professional Services are Covered Services provided to a BSC POS Member
which are defined as Capitated Professional Services in Paragraph 1.5 of the
Agreement.


 


(e)                                  Out-of-Network
Services refers to Covered Services provided to a BSC POS Member on the
basis of the Member’s self-referral, other than: (i) Services provided by the
Member’s PCP (or physician providing on-call coverage for such PCP); (ii)
Emergency or Urgent Care Services not requiring authorization under Blue
Shield’s utilization management rules; or, (iii) Services not requiring a PCP
referral or authorization from Blue Shield and/or Group or which Members, in
general, have a right to self-refer.


 


2.                                       Financial
Responsibility. The Capitation payable to Group pursuant to Exhibit C shall
cover, and Group shall be financially responsible for: (i) all BSC POS
Professional Services which are In-Network Services; and, (ii) all
Out-of-Network BSC POS Professional Services provided by Group Providers. Except
as otherwise provided herein, Blue Shield shall be financially responsible for
Out-of-Network BSC POS Professional Services provided by providers who are not
Group Providers.  Those BSC POS
Professional Services which are Blue Shield’s financial responsibility
hereunder will be included in the POS Out-of-Network Professional


 












*** Confidential Treatment
Requested


 


82

















 


Fund settlement described in
Paragraph 8 of this Exhibit H-2. Those BSC POS Out-of-Network Institutional
Service which are the financial responsibility of Blue Shield, will be included
in the POS Out-of-Network Institutional Fund settlement described in Paragraph
9 of this Exhibit H-2. Covered BSC POS In-Network Institutional Services which
are identified as Shared Savings Services in Exhibit B will be included in the
POS In-Network Shared Savings Fund settlement described in Paragraph 7 of this
Exhibit H-2. Covered outpatient prescription drug services which are Blue
Shield’s responsibility will be included in the Pharmacy Shared Savings Fund
settlement described in Exhibit D.


 


3.             Administrative
Services. As set forth in the Provider Manual, Blue Shield shall advise
Group as to which Members are BSC POS Members. In addition:


 


(a)                                  Following
Blue Shield’s receipt of a claim for BSC POS Professional Services, Blue
Shield, within such time frames as set forth in the Provider Manual, shall
provide a copy of such claim to Group. Thereafter, and within such time frames
as set forth in the Provider Manual, Group shall make an initial determination,
and so advise Blue Shield in writing, as to which of such claims are for
In-Network Services, which are for Out-of-Network Services provided by a Group
Provider, and which are for Out-of-Network Services provided by other than a
Group Provider.


 


(b)                                 In
the event that Group (rather than Blue Shield) receives a claim for BSC POS
Professional Service which it determines to be for Out-of-Network Services
provided by other than a Group Provider, Group shall, within such time frames
as set forth in the Provider Manual, provide Blue Shield with a copy of the
claim and its initial determination.


 


(c)                                  In
the event a Group Provider refers a BSC POS Member for a Covered Service on an
In-Network basis, but the Group Provider, rather than the Member, fails to
comply with Group’s utilization management requirements, such Covered Service
shall be deemed an In-Network Service, and the Member’s financial
responsibility shall be limited to the applicable Copayment for In-Network
Services. The Group may refuse to compensate a Group Provider for such services
to the extent permitted in its contract with the Group Provider providing the
service.


 


(d)                                 Blue
Shield may, on its own initiative, or in the event a BSC POS Member or a provider
disputes Group’s initial determinations made pursuant to this Paragraph 3,
adjudicate whether a service was an In-Network or Out-of-Network Service and if
an Out-of-Network Service, whether or not provided by a Group Provider. Blue
Shield may also, at its expense and upon reasonable notice to Group,
periodically audit Group’s initial determinations made pursuant to this
Paragraph 3. Group shall cooperate with such audits and adjudications and
provide such information and documentation regarding its initial determinations
as reasonably requested by Blue Shield.


 


83

















 


Subject to the
Dispute Resolution provisions in this Agreement, Blue Shield’s determination
shall be binding upon Group. Subject to such dispute resolution procedures: (i)
In the event that Blue Shield determines that it has erroneously paid for
services as Out-of-Network Services from non-Group Providers, which were, in
fact, In-Network Services (or Out-of-Network Services provided by Group Providers),
such amounts shall within ninety (90) days following notice by Blue Shield to
Group of such determination (and the completion of any requested dispute
resolution procedures) be refunded to Blue Shield by Group and Blue Shield may,
in its sole discretion, off-set such amounts from any monies owed to Group by
Blue Shield; and (ii) In the event that Blue Shield determines that Group has
erroneously paid for BSC POS Professional Services as In-Network Services or
Out-of-Network Services provided by Group Providers which were, in fact,
Out-of-Network Services provided by non-Group Providers, Blue Shield shall
within ninety (90) days after such determination, or within ninety (90) days
after such determination is made through the requested dispute resolution
procedures, refund the amounts so paid to Group.


 


(e)                                  Summaries
& Settlements: Blue Shield shall provide to Group on a quarterly basis
a summary of the funding and expenses in the Shared Savings Program.


 


4.                                       Additional
Group Payment Responsibility. Notwithstanding any provision of this Exhibit
H-2 to the contrary, Group shall be financially responsible for Out-of-Network
Covered Services provided by Non-Group Providers to the extent such services
were obtained by the BSC POS Member on an Out-of-Network basis as a direct
result of Group’s failure, on an In-Network basis, to timely provide or arrange
for such Covered Services for the BSC POS Member. Such services shall be
excluded from the POS Out-of-Network Fund settlement.


 


5.                                       Group
Cooperation with Out-of-Network Providers. In the event that a BSC POS
Member elects to obtain Out-of-Network Services, Group shall cooperate with the
provider of such Out-of-Network Services to ensure coordination and continuity
of care and, upon request of such provider of Out-of-Network Services (and with
the BSC POS Member’s written authorization), provide copies of the BSC POS
Member’s relevant medical records to such provider.


 


6.                                       Coordination
of Benefits for Out-of-Network Claims. Blue Shield is solely entitled to
collect and retain any and all third party liens, coordination of benefits, or
any other payments obtained from third party payments for Out-of-Network
Services provided to BSC POS Members by non-Group Providers.  Any funds received by Blue Shield for POS
Out-of-Network services shall be credited by Blue Shield in the POS
Out-of-Network Fund settlement described in Paragraph 7 of this Exhibit H-2.


 


7.                                       POS
In-Network Shared Savings Fund Settlement. Blue Shield shall establish a
POS In-Network Shared Savings Fund as follows.


 


84

















 


a.               Funding:
For BSC POS Members Blue Shield will allocate to a POS In-Network Shared
Savings Fund a per Member per month amount set forth in Schedule 1 to this
Exhibit H-2 for all Members assigned to Group, subject to retroactive
adjustments either upward or downward due to retroactive changes in membership.


 


b.              Charging
of Payments: Blue Shield shall charge against the POS In-Network Shared
Savings Fund all payments made by Blue Shield for such BSC POS Members during
the annual term of the Agreement for In-Network services which are designated
as Shared Savings Services in Exhibit B, less payments received by Blue Shield
as a result of third-party reimbursement, Workers’ Compensation recoveries and
coordination of benefits payments. Blue Shield shall include any payments for
Shared Savings Services which are paid prior to the date of the settlement, as
well as a reasonable allowance, as determined by Blue Shield’s actuaries, for
incurred but not paid (IBNP) claims. Any costs for Shared Savings Services not
included in any annual settlement shall be carried forward and included in the
Shared Savings settlement for the succeeding Agreement Year. Blue Shield shall provide sufficient detail in the
annual settlement, so that Group can determine the IBNP amount by Agreement
Year.


 


c.               POS
In-Network Shared Savings Fund Settlement: The POS In-Network Shared
Savings Fund shall be settled on an annual basis, within one hundred eighty
(180) days following the end of each annual term of the Agreement (being a one
hundred twenty (120) day claims run out and a sixty (60) day determination
period). In the event of termination of the Agreement for any reason, final
settlement of the POS In-Network Shared Savings Fund shall be performed one
hundred fifty (150) days after the date of termination and any amounts due from
Blue Shield to Group shall be paid within thirty (30) days thereafter.


 


d.              If
the total actual cost of Shared Savings services is less than the total
allocation to the POS In-Network Shared Savings Fund, then Group shall be
entitled to *** of the amount by which the allocation exceeds the costs, minus
any carry forward resulting from deficits from previous Agreement years. However, Group’s share of the surplus for any
Agreement Year shall be limited to *** of the total allocation to the POS
In-Network Shared Savings Fund for that Agreement Year.


 


e.               If
the total actual cost of Shared Savings services is more than the total
allocation to the POS In-Network Shared Savings Fund, then *** of the amount by
which the actual costs exceed the total allocation, not to exceed *** of the total allocation to the POS In-Network Shared
Savings Fund for that Agreement Year, shall be allocated to Group
and shall be handled as follows: (i) the excess may be deducted from any other
settlements or payments, except Capitation and Professional Stop Loss Program
payments


 


85

















 


made pursuant
to Exhibit 1, due to Group from Blue Shield, and, (ii) any remaining amounts
shall be carried forward into future Agreement Years and shall be deducted from
any  Shared Savings payments to
Group in future years.


 


8.                                       POS
Out-of-Network Professional Fund Settlement. Blue Shield shall establish a
POS Out-of-Network Professional Fund.


 


a.               Funding
of Out-of-Network Professional Fund - Blue Shield will allocate on a
monthly basis the amounts set forth in Schedule 1 to this Exhibit H-2 for all
BSC POS Members assigned to Group, subject to retroactive adjustments due to
retroactive changes in members (the “POS Out-of-Network Professional Budget”).


 


b.              Allocation
of POS Out-of-Network Professional Expenses - The POS Out-of-Network
Professional Fund shall be charged for all Covered Out-of-Network Professional
services which are paid by Blue Shield for BSC POS Members assigned to Group
(the “POS Out-of-Network Professional Expenses”).


 


c.               Timing
of POS Out-of-Network Professional Fund Settlement – On an Agreement year
basis, Blue Shield shall perform a reconciliation of the POS Out-of-Network
Professional Fund. Such settlement shall be performed within one hundred twenty
(120) days following the end of the Agreement Year. Any amounts due from Blue
Shield to Group shall be paid within sixty (60) days thereafter. In the event
of termination of the Agreement for any reason, final settlement of the POS
Out-of-Network Professional Fund shall be performed one hundred fifty (150)
days after the date of termination and any amounts due from Blue Shield to
Group shall be paid within thirty (30) days thereafter.


 


d.              Out-of-Network
Professional Fund Surplus – For any Agreement Year in which the POS
Out-of-Network Professional Budget exceeds the POS Out-of-Network Professional
Expenses, IPA shall be entitled to *** of the POS Out-of-Network Professional
Fund surplus, minus any POS Out-of-Network Professional Fund or POS
Out-of-Network Institutional Fund deficit carried forward from a previous
Agreement Year. However, Group’s share of the
POS Out-of-Network Professional Fund surplus for any Agreement Year shall be
limited to *** of the Capitation paid to Group for POS Members in that
Agreement Year.


 


e.               Out-of-Network
Professional Fund Deficit – For any Agreement Year in which the POS
Out-of-Network Professional Expenses exceed the POS Out-of- Network
Professional Budget, Blue Shield shall offset any out-of-network Professional
deficit against any out-of-network Institutional surplus. If a deficit results,
Blue Shield shall carry such deficit forward into future Agreement Years and
the deficit carryover shall be offset against any Out-of-Network Professional
or Institutional Fund Surpluses in future years. (However, the deficit amount carried forward for the current Agreement
Year shall be limited to fifteen percent (15%) of the Capitation paid to Group
for POS Members in that


 


86

















 


Agreement Year.) In
the event the Deficit carried forward exceeds the Surplus in a future year, the
remaining deficit shall continue to be carried forward and offset against any
Surpluses in subsequent years.


 


9.                                       POS
Out-of-Network Institutional Fund Settlement. Blue Shield shall establish a
POS Out-of-Network Institutional Fund.


 


a.               Funding
of Out-of-Network Institutional Fund - Blue Shield will allocate on a
monthly basis the amounts set forth in Schedule 1 to this Exhibit H-2 for all
BSC POS Members assigned to Group, subject to retroactive adjustments due to
retroactive changes in members (the “POS Out-of-Network Institutional Budget”).


 


b.              Allocation
of POS Out-of-Network Institutional Expenses - The POS Out-of-Network
Institutional Fund shall be charged for all Covered Out-of-Network
Institutional services which are paid by Blue Shield for BSC POS Members
assigned to Group (the “POS Out-of-Network Institutional Expenses”).


 


c.               Timing
of POS Out-of-Network Institutional Fund Settlement – On an Agreement Year
basis, Blue Shield shall perform a reconciliation of the POS Out-of-Network
Institutional Fund. Such settlement shall be performed within one hundred
twenty (120) days following the end of the Agreement Year. Any amounts due from
Blue Shield to Group shall be paid within sixty (60) days thereafter. In the
event of termination of the Agreement for any reason, final settlement of the
POS Out-of-Network Institutional Fund shall be performed one hundred fifty
(150) days after the date of termination and any amounts due from Blue Shield
to Group shall be paid within thirty (30) days thereafter.


 


d.              Out-of-Network
Institutional Fund Surplus – For any Agreement Year in which the POS
Out-of-Network Institutional Budget exceeds the POS Out-of-Network
Institutional Expenses, IPA shall be entitled to 50% of the POS Out-of-Network
Institutional Fund surplus minus any POS Out-of-Network Professional Fund or
POS Out-of-Network Institutional Fund deficit carried forward from a previous
Agreement year. However, Group’s share of the
POS Out-of-Network Institutional Fund surplus in any Agreement Year shall be
limited to thirty-five percent (35%) of the Capitation paid to Group for POS
Members in that Agreement Year.


 


e.               Out-of-Network
Institutional Fund Deficit – For any Agreement Year in which the POS
Out-of-Network Institutional Expenses exceed the POS Out-of-Network
Institutional Budget, Blue Shield shall offset any out-of-network Institutional
deficit against any out-of-network Professional surplus. If a deficit results,
Blue Shield shall carry such deficit forward into future Agreement Years and
the deficit carryover shall be offset against any Out-of-Network Professional
or Institutional Fund Surpluses in future years. (However, the deficit amount carried forward for the current Agreement
Year shall be limited to fifteen percent (15%) of the Capitation paid to Group
for POS Members in that


 


87

















 


Agreement Year.) In
the event the Deficit carried forward exceeds the Surplus in a future year, the
remaining deficit shall continue to be carried forward and offset against any
Surpluses in subsequent years.


 


vvv


 


88

















 


Exhibit
I


 


HMO IPA/Medical Group Agreement


 


PROFESSIONAL STOP LOSS PROGRAM


 


Gateway Medical
Group, Inc.


 


Effective Date: January 1, 2002


 


A.                                   Commencement
of Stop Loss Program:


 


If, as set
forth on the Signature Page to the Agreement, Group elects to participate in
this Stop Loss Program, this Exhibit I is added to the HMO Medical Agreement
(the “Agreement”) between Group and Blue Shield. The Stop Loss Program set
forth in this Exhibit I commences with respect to Capitated Professional
Services provided to Members on the following date:


 


	
       

  	
  The
  Effective Date of the Agreement

  
	
   

  	
   

  
	
   

  	
  OR,

  
	
   

  	
   

  
	
       

  	
  [Specify
  Date]

  	
          

  	
  , 19

  	
   

  	
   

  



 


The
commencement date for this Stop Loss Program shall not cause either a
modification of the Agreement Year, as set forth in the Agreement, nor, if the
initial time period covered by the Stop Loss Program is less than a full
Agreement Year, a proration of the Attachment Level set forth below.


 


Notwithstanding
any provision of the Agreement or this Exhibit I to the contrary, Blue Shield
shall have no obligation to permit Group to commence the Stop Loss Program
other than as of the first day of an Agreement Year.


 


B.                                     Termination
or Modification of Stop Loss Program:


 


(1)                                  Group
may at anytime, without terminating the Agreement and by no less than sixty
(60) days prior written notice to Blue Shield, terminate this Stop Loss Program
and (delete this Exhibit from the Agreement), provided that Group provides to
Blue Shield, in conjunction with such termination notice, a certificate of
insurance demonstrating that Group has (or will have as of the effective date
of such termination) stop loss coverage in compliance with Paragraph 7.4 of the
Agreement. In the event of such termination, the Stop Loss Attachment Level
described below will not be prorated.


 


(2)                                  Blue
Shield may, without terminating the Agreement and by no less than sixty (60)
days prior written notice to Group, terminate this Stop Loss Program as to
Group (and delete this Exhibit from the Agreement) as of midnight of the last
day of the Agreement Year.


 












*** Confidential Treatment
Requested


 


89

















 


(3)                                  Blue
Shield may, by no less than sixty (60) days prior written notice to Group,
modify the provisions of this Stop Loss Program, including without limitation
the Stop Loss Program Charges specified below. Such modification shall be
effective as of the first day of the Agreement Year which immediately follows
the Agreement Year in which such notice is given.


 


C.                                     Stop
Loss Program:


 


(1)                                  For
the Stop Loss Program Charges set forth in Part D below, Blue Shield shall
reimburse Group for eighty percent (80%) of that portion of the Allowable Costs
(as described herein) of Capitated Professional Services provided during any
one (1) Agreement Year to any one (1) Member which exceeds the Attachment Level
and which are Group’s financial responsibility under the Agreement.


 


(2)                                  In
addition to the defined terms of the Agreement, the following terms have the
following meanings for this Stop Loss Program:


 


(i)                                     The
Attachment Level is ten thousand dollars ($10,000) of Allowable Costs
incurred by Group for the provision of Capitated Professional Services to any
one (1) Commercial Member (including POS Members) in any one (1) Agreement
Year.  The Attachment Level is fifteen
thousand dollars ($15,000) of Allowable Costs incurred by Group for the
provision of Capitated Professional Services to any one (1) Blue Shield 65 Plus
Member in any one (1) Agreement Year.


 


(ii)                                  Allowable
Costs (both for determining the Attachment Level and Stop Loss Program
reimbursement after the Attachment Level is reached) are the lesser of the
amount actually paid (other than capitation payments) by Group for such
Capitated Professional Services, or ninety percent (90%) of the Blue Shield’s
PPO Physician Allowances in effect at the time. Allowable Costs are reduced by:
(a) the Member’s applicable Copayments; and (b) any amount for which Group is
entitled to reimbursement or payment from any other source.


 


(3)                                  Group
shall submit to Blue Shield any claims for Stop Loss Program reimbursement
within ninety (90) days of the end of the Agreement Year in which the services,
for which Stop Loss Program reimbursement is claimed, were provided. Blue
Shield may deny any claims not submitted within said time period. Claims shall
be in such form, containing such information, and provided to Blue Shield as
set forth in the Provider Manual.


 


90

















 


(4)                                  Stop
Loss Program reimbursement is provided only for Capitated Professional Services
which are provided to an eligible Member in conformity with the terms and
conditions of the Agreement, including, without limitation, any provisions
requiring Authorizations and case management program notification and
cooperation. Without limiting the foregoing, Stop Loss Program reimbursement is
not paid for any monetary compensation payable to a Member for any reason,
including Group’s negligence in providing or arranging or failing to provide
services.


 


(5)                                  Group
shall promptly notify Blue Shield of all cases for which the Attachment Level
is reached or for which it is reasonably likely that the Attachment Level will
be reached.


 


(6)                                  Group
shall, as a condition of such Stop Loss Program reimbursement, provide to Blue
Shield all information necessary for Blue Shield to determine its Stop Loss
Program obligation hereunder.


 


(7)                                  Stop
Loss Program reimbursement shall be payable by Blue Shield at the later
occurring of: (i) the date of the Shared Savings Settlement described in
Exhibit D to the Agreement; or, (ii) ninety (90) days following the timely,
complete, and uncontested submission to Blue Shield of Group’s Stop Loss
Program reimbursement claim.


 


(8)                                  Blue
Shield reserves the right to audit Group’s Stop Loss Program claims and other
information provided pursuant to this Exhibit I. In the event such audit
determines that there has been an underpayment in Stop Loss Program
reimbursement, Blue Shield shall pay to Group the amount of such underpayment
within forty-five (45) working business days thereafter. In the event such
audit determines that there has been an overpayment in Stop Loss Program
reimbursement, Group shall pay to Blue Shield the amount of such overpayment
within forty-five (45) working business days thereafter.  Alternatively, Blue Shield may, at its
election, offset such overpayment from any amount then or thereafter owed by
Blue Shield to Group.


 


D.                                    Stop
Loss Program Charges to Group:


 


As
reimbursement to Blue Shield for the Stop Loss Program coverage provided
pursuant to this Exhibit, Blue Shield shall deduct from Capitation payable to
Group pursuant to the Agreement, the following per Member per Month (PMPM)
amounts:


 


	
  Commercial

  	
   

  	
  *** pmpm

  
	
  Point of
  Service (POS)

  	
   

  	
  *** pmpm

  
	
  Blue Shield
  65 Plus

  	
   

  	
  *** of
  Group’s Capitation Amount

  



 


vvv


 


91

















 


Exhibit H-2, Schedule I

HMO IPA/Medical Group Agreement

POS Funds Allocations

Gateway Medical Group, Inc.


 


Effective Date: January 1, 2002-December 3l,
2002


 


As
of 01/01/2002, the effective net yield (which includes the deduction for Stop
Loss, if applicable) for  the
following PMPMs are ***  for  the POS In-network Shared Saving, *** for
POS Out-of-network Professional, and *** for the POS Out-of-network
Institutional, based on the 08/01/2001 membership.


 


The
actual allocation to POS Fund for each month will be calculated based on the
actual member mix for each age/sex  category.


 


Members
Other Than Blue Shield 65 Plus  Members


 


	
  Age &
  Sex Categories and POS Fund Allocations

  
	
  Category

  	
   

  	
  POS Fund
  Allocation (PMPM)

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  IN-NETWORK

  SHARED SAVINGS

  	
   

  	
  OUT-OF-NETWORK

  PROFESSIONAL

  	
   

  	
  OUT-OF-NETWORK

  INSTITUTIONAL

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (M) *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (M) *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












* = Medicare Primary


 


*** Confidential Treatment Requested


 


92

















 


Effective
Date: January 1, 2003-December 31, 2003 & thereafter until amended


 


As
of 01/01/2003, the effective net yield (which includes the deduction for Stop
Loss, if applicable) for the following PMPMs are *** for the POS In-network
Shared Saving, *** for POS Out-of-network Professional, and *** for the POS
Out-of-network Institutional, based on the 08/01/2001 membership.


 


The
actual allocation to POS Fund for each month will be calculated based on the
actual member mix for  each
age/sex category.


 


Members
Other Than Blue Shield 65 Plus Members


 


	
  Age &
  Sex Categories and POS Fund Allocations

  
	
  Category

  	
   

  	
  POS Fund
  Allocation (PMPM)

  
	
  Sex

  	
   

  	
  Age

  	
   

  	
  IN-NETWORK

  SHARED SAVINGS

  	
   

  	
  OUT-OF-NETWORK

  PROFESSIONAL

  	
   

  	
  OUT-OF-NETWORK

  INSTITUTIONAL

  
	
  F

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  F

  	
   

  	
  65 + (M) *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  0 - 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  2 - 6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  7 - 18

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  19 - 21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  22 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (NM)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  M

  	
   

  	
  65 + (M) *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












* = Medicare Primary


 


vvv


 


93

















 


Summation Of Blue
Shield Negotiations; 2 Year Commercial Deal (2002, 2003), 1 Year Senior (2002
Only)


 


Commercial HMO Group
and IFP


 


	
  Description

  	
   

  	
  2001 Rate

  	
   

  	
  2002 Rate

  	
   

  	
  % ­

  	
   

  	
  2003 Rate

  	
   

  	
  % ­

  	
   

  	
  Comments

  
	
  Commercial
  Professional, HMO Group

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Institutional, HMO Group

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  HMO Group, Global Funding

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Professional, HMO IFP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Institutional, HMO IFP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  ***

  	
   

  	
  ***

  
	
  Commercial
  HMO IFP, Global Funding

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 


Commercial POS


 


	
  Description

  	
   

  	
  2001 Rate

  	
   

  	
  2002 Rate

  	
   

  	
  % ­

  	
   

  	
  2003 Rate

  	
   

  	
  % ­

  	
   

  	
  Comments

  
	
  Cap Splits, In Network/Out of Network

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Professional, POS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Professional, POS Out Of Network Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Global
  Professional for POS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Institutional, POS, In Network

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Commercial
  Institutional, POS, Out-of-Network

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Global
  Institutional for POS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Global POS
  (Professional and Insitutional)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 


Medicare+Choice/Blue
Shield 65+


 


	
  Description

  	
   

  	
  2001 Rate

  	
   

  	
  2002 Rate

  	
   

  	
  % ­

  	
   

  	
  2003 Rate

  	
   

  	
  % ­

  	
   

  	
  Comments

  
	
  Senior
  Professional

  	
   

  	
  *** of CMS; none of monthly premium

  	
   

  	
  *** of CMS; none of monthly premium

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Senior
  Institutional

  	
   

  	
  *** of CMS; none of monthly premium

  	
   

  	
  *** of CMS + *** of member premium

  	
   

  	
  ***  + member premium funding

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Senior
  Global Funding

  	
   

  	
  *** of CMS only

  	
   

  	
  *** of CMS, + *** of member premium

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***