Exhibit
10.99


CaliforniaCare


 


MEDICAL
SERVICES AGREEMENT


 


Professional
Care IPA Medical Group, Inc.


 


 


 


 












*** Confidential
Treatment requested.


 

















 


CALIFORNIACARE

MEDICAL SERVICES AGREEMENT


 


TABLE OF CONTENTS


 


	
  I.

  	
  RECITALS

  	
   

  
	
   

  	
   

  	
   

  
	
  II.

  	
  DEFINITIONS

  	
   

  
	
   

  	
   

  	
   

  
	
  III.

  	
  RELATIONSHIP
  BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  IV.

  	
  PARTICIPATING
  MEDICAL GROUP SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  V.

  	
  BLUE CROSS
  SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  VI.

  	
  ELIGIBILITY
  LISTINGS

  	
   

  
	
   

  	
   

  	
   

  
	
  VII.

  	
  COMPENSATION
  TO PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  VIII.

  	
  ENROLLMENT
  PROTECTION

  	
   

  
	
   

  	
   

  	
   

  
	
  IX.

  	
  NON-CAPITATED
  SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  X.

  	
  OUTPATIENT
  PRESCRIPTION DRUG EXPENSE

  	
   

  
	
   

  	
   

  	
   

  
	
  XI.

  	
  QUALITY
  MANAGEMENT BONUS

  	
   

  
	
   

  	
   

  	
   

  
	
  XII.

  	
  BILLING
  FOR HMO-USA AWAY FROM HOME CARE SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  XIII.

  	
  TERM OF AGREEMENT,
  TERMINATION

  	
   

  
	
   

  	
   

  	
   

  
	
  XIV.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS

  AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  XV.

  	
  CALIFORNIACARE
  MEMBER GRIEVANCE SYSTEM

  	
   

  
	
   

  	
   

  	
   

  
	
  XVI.

  	
  MISCELLANEOUS
  PROVISIONS

  	
   

  



 


EXHIBITS


 


	
   

  	
  Exhibit A

  	
  Covered
  Medical Services

  
	
   

  	
  Exhibit A(1)

  	
  Division of
  Financial Responsibilities

  
	
   

  	
  Exhibit B

  	
  CALIFORNIACARE
  Hospitals

  
	
   

  	
  Exhibit C

  	
  Administrative
  Responsibilities of PARTICIPATING MEDICAL GROUP

  
	
   

  	
  Exhibit D

  	
  Capitation

  
	
   

  	
  Exhibit
  E

  	
  [Intentionally
  Omitted]

  
	
   

  	
  Exhibit F

  	
  Non-Capitated
  Performance Settlement Schedule

  
	
   

  	
  Exhibit G

  	
  Compensation
  for Services to BLUE CROSS PLUS Members

  
	
   

  	
  Exhibit G(1)

  	
  BLUE CROSS
  PLUS 1997 Baseline Capitation

  
	
   

  	
  Exhibit H

  	
  Outpatient
  Prescription Drug Settlement Schedule

  
	
   

  	
  Exhibit I

  	
  Quality
  Management Bonus Schedule

  
	
   

  	
  Exhibit J

  	
  PARTICIPATING
  MEDICAL GROUP Facilities

  
	
   

  	
  Exhibit K

  	
  Division
  of Responsibilities For Compliance Activities

  
	
   

  	
  Exhibit K(1)

  	
  Compliance
  Activity Performance Measurements

  



 

















 


CALIFORNIACARE


 


MEDICAL SERVICES AGREEMENT


 


This
AGREEMENT is effective on November 1, 1999 between BLUE CROSS OF
CALIFORNIA and Affiliates (jointly and severally “BLUE CROSS”) and Professional
Care IPA Medical Group, Inc., (“PARTICIPATING MEDICAL GROUP”).


 


I.                  RECITALS


 


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


 


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


 


II.                 DEFINITIONS


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


C&R charges are determined by BLUE CROSS.


 


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


 


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


 


B         Serious
impairment to bodily functions,


 


C.        Other
serious medical consequences, or


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


2.35         “Medically Necessary” means procedures, supplies, equipment or
services that BLUE CROSS determines to be:


 


(1)       Appropriate for the symptoms, diagnosis or treatment of the medical
condition; and


 


(2)       Provided for the diagnosis or direct care and treatment of the medical
condition; and


 


(3)       Within standards of good medical practice within the organized medical
community; and


 


(4)       Not primarily for the convenience of the Member’s physician, or another
provider, and


 


(5)       The most appropriate procedures, supplies, equipment or service which
can safely be provided.  The most
appropriate procedures, supplies, equipment or service or supply must satisfy
the following criteria: (i) there must be valid scientific evidence
demonstrating that the expected health benefits from the procedure, supply,
equipment or service are clinically significant and produce a greater
likelihood of benefit, without a disproportionately greater risk of harm or
complications, for the Member with the particular medical condition being
treated than other alternatives; and (ii) generally accepted forms of treatment
that are less invasive have been tried and found to be ineffective or are


 


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otherwise unsuitable; and (iii) for hospital stays acute care as an
inpatient is necessary due to the kind of services the Member is receiving or
the severity of the medical condition, and safe and adequate care cannot be
received as an outpatient or in a less intensified medical setting


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


2.64         “Urgent Care” means services to prevent serious
deterioration of an enrollee’s health resulting from unforeseen illness or
injury for which treatment cannot be delayed. 
For purposes of this Agreement, “Immediate Care” shall have the same
meaning as Urgent Care


 


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


 


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


 


III                 RELATIONSHIP
BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP


 


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


 


3.02         BLUE CROSS and PARTICIPATING MEDICAL GROUP agree that PARTICIPATING
MEDICAL GROUP Physicians shall maintain a physician-patient relationship with
each Member assigned to PARTICIPATING MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP shall be solely responsible to the
Member for treatment and medical care with respect to the provision of
Capitation Services and arrangements for Non-Capitated Services.  PARTICIPATING MEDICAL GROUP may freely
communicate with Members regarding the treatment options available to them,
including medication treatment options, regardless of benefit coverage
limitations.


 


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


 


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


 


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


 


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


 


IV.                PARTICIPATING MEDICAL GROUP SERVICES AND RESPONSIBILITIES


 


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


 


4.01         Provision of Services.


 


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


 


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


 


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


 


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


 


E         To
engage the Referral Services of duly licensed board certified consultants,
specialists and duly certified and licensed allied health professionals,
responsible for delivering Covered Medical Services to Members.  A list of all referral physicians and other
providers to whom PARTICIPATING MEDICAL GROUP refers Members for Referral
Services shall be provided to BLUE CROSS upon request.  PARTICIPATING MEDICAL GROUP shall provide
BLUE CROSS with revised copies of its form of agreements between PARTICIPATING
MEDICAL GROUP and its contracted Referral Service providers and PARTICIPATING
MEDICAL GROUP Physicians, as such are updated


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


4.02         Accessibility and Continuity of Care.


 


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


 


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


 


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


 


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


 


9

















 


Emergency services within a twenty (20) mile radius of the Hospital(s)
designated in Exhibit B (incorporated by reference hereof as the CALIFORNIACARE
Hospital(s) within PARTICIPATING MEDICAL GROUP’s Service Area


 


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


 


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


 


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


 


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


 


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


 


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


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


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


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


 


10

















 


(5)       Members may directly access PARTICIPATING MEDICAL GROUP Physicians in
the following specialties without the prior authorization of PARTICIPATING
MEDICAL GROUP’s Utilization Management Program:


 


(a)           Dermatology


(b)           Allergy


(c)           Obstetrics/Gynecology


(d)           Ear, Nose and Throat


 


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


 


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


 


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


 


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


 


4.03         Utilization/Quality Management and Grievance Procedures.


 


To cooperate with BLUE CROSS’ administration of its internal quality of
care review and grievance procedures. 
The parties acknowledge and agree that authority to perform Utilization
Management Program activities and Quality Management Program activities under
this Agreement is a delegation of BLUE CROSS authority pursuant to Sections
1370 and 1370.1 of the Health and Safety Code, and all or part of this
authority may be revoked at any time. 
The scope of delegated authority shall be as set forth in the
Utilization Management Program guidelines and the Quality Management Program
guidelines issued by BLUE CROSS and provided to PARTICIPATING MEDICAL
GROUP.  The proceedings of the
Utilization Management and Quality Management Committees shall be strictly
confidential between BLUE CROSS and PARTICIPATING MEDICAL GROUP and are subject
to the protections set forth in Sections 1370 and 1370. 1


 


4.04         Quality Management Program.


 


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


 


A.       The
Quality Management Program shall


 


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


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


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


 


11

















 


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


 


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


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


(3)       Incident identification and risk management.


(4)       Member grievance resolution.


(5)       General and focused health care audits


(6)       Development and implementation of appropriate recommendations.


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


 


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


 


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


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


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


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


 


D.       PARTICIPATING
MEDICAL GROUP shall:


 


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


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


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


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


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


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


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


 


12

















 


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


 


4.05         Utilization Management Program.


 


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


 


A.       The
Utilization Management Program shall


 


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


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


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


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


(5)       Work closely with CALIFORNIACARE Hospitals.


(6)       Encompass inpatient, outpatient, and ancillary care.


(7)       Utilize prospective, concurrent, and retrospective review.


(8)       Assure that all adverse utilization review decisions are made by a
licensed physician, and no denial of a requested service shall be made except
by a licensed physician, experienced in the area being reviewed.  Denial decisions shall be provided to
Members in writing.


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


 


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


 


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


 


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


 


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


 


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


 


C.        PARTICIPATING
MEDICAL GROUP shall:


 


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


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


(3)       Provide the CALIFORNIACARE Medical Director (or the Medical Director’s
clinical designee) with a schedule designating the time and place of all
Utilization Management Committee meetings that relate to Members, in order that
he or she shall in the Medical


 


13

















 


Director’s discretion, attend.  The CALIFORNIACARE Medical Director shall
notify the PARTICIPATING MEDICAL GROUP in advance of his or her attendance and
shall not be excluded from any deliberation on activities related to Members


 


4.06         Records and Reserves.


 


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


 


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


 


(1)       Balance sheets


(2)       Statements of revenues and expenses


(3)       Statements of cash flow


 


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


 


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


 


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


 


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


 


4.07         Insurance Programs or Policies.


 


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


 


14

















 


 


A.       Professional
Liability Insurance


 


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


 


B.        Other
Insurance


 


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


 


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


 


4.08         Administrative Responsibilities.


 


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


 


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


 


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


 


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


 


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


 


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


 


15

















 


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


 


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


 


F.        To
provide BLUE CROSS, on a monthly basis, all ambulatory encounter data
electronically as described in the Operations Manual.


 


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


 


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


 


I.         To
provide at least ninety (90) days advance written notice to BLUE CROSS whenever
(a) a PARTICIPATING MEDICAL GROUP Physician who is a Primary Care Physician is
no longer a PARTICIPATING MEDICAL GROUP Physician; or (b) a Satellite Facility
closes, relocates or is unable to serve Members.


 


J.         To
provide at least sixty (60) days prior written notification to BLUE CROSS of
any of the following:


 


(1)       A non-Primary Care Physician’s termination of his/her affiliation with
PARTICIPATING MEDICAL GROUP or a PARTICIPATING MEDICAL GROUP provider.


 


(2)       The termination of a non-Primary Care Physician by PARTICIPATING MEDICAL
GROUP or a PARTICIPATING MEDICAL GROUP provider.


 


4.09         Payments and Member Billing.


 


A        To
accept the monthly Capitation payment from BLUE CROSS as payment in  full for Capitation Services (including
all Referral Services) provided or arranged hereunder, and not to seek
additional payments or compensation from Members for Covered Medical
Services.  The foregoing restriction
shall not apply to co-payments, which may be collected by PARTICIPATING MEDICAL
GROUP in accordance with the applicable provisions of the Benefit Agreement(s),
nor shall it apply to billings and collections with respect to non-Covered
Medical Services rendered to Members by PARTICIPATING MEDICAL GROUP.  However, to the extent that the
PARTICIPATING MEDICAL GROUP’s billing office is aware of the Member’s payment
responsibility, PARTICIPATING MEDICAL GROUP agrees to advise the Member of that
payment responsibility prior to rendering any service requiring a co-payment,
or any non-Covered Medical Service.


 


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


 


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


 


16

















 


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


 


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


 


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


 


4.10         Membership.


 


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


 


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


 


C.        PARTICIPATING
MEDICAL GROUP agrees that, in the event a Member who is covered for workers’
compensation benefits by a workers’ compensation carrier affiliated with BLUE
CROSS, seeks services for a work-related illness or injury, PARTICIPATING
MEDICAL GROUP shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.  In the event
that PARTICIPATING MEDICAL GROUP elects to treat such Member, PARTICIPATING
MEDICAL GROUP shall complete a Doctor’s First Report of Injury as defined in
the California Labor Code.  As payment
for such medical services rendered, PARTICIPATING MEDICAL GROUP agrees to
accept, as payment in full, compensation in accordance with the then current
Blue Cross of California Prudent Buyer Plan Participating Physician Agreement
fee schedule for the applicable region. 
PARTICIPATING MEDICAL GROUP further agrees that, in the event such
Member requires medical services in connection with such work-related illness
or injury beyond the treatment provided at the initial visit, PARTICIPATING
MEDICAL GROUP shall refer such Member only to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.


 


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


 


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


 


17

















 


compensate PARTICIPATING MEDICAL GROUP in accordance with the terms of
this Agreement for services provided to Covered Persons of any such Other
Payor.  If BLUE CROSS contracts with
another Knox-Keene licensed health care service plan to permit access to the
Managed Care Network.  BLUE CROSS will
notify all affected participating providers in the service area by mail
identifying such health care service plan. 
When an Other Payor utilizes the Managed Care Network, such Other Payor
shall comply with the terms of this Agreement.


 


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


 


4.11         Compliance Activities


 


A.       PARTICIPATING
MEDICAL GROUP acknowledges that BLUE CROSS is responsible for the performance
of certain activities (“Compliance Activities”) related to medical services in
order to comply with applicable state and federal laws and accreditation and
certification requirements of managed care organization oversight agencies,
including, but not limited to, the California Department of Corporations
(“DOC”), the National Committee for Quality Assurance (“NCQA”) and the Health
Care Financing Administration (“HCFA”) if applicable.  PARTICIPATING MEDICAL GROUP understands that BLUE CROSS may
delegate responsibility for some or all Compliance Activities (“Delegated
Compliance Activities”) to qualified PARTICIPATING MEDICAL GROUPs.


 


B.        Delegation
of Compliance Activities


 


(1)       BLUE CROSS hereby authorizes PARTICIPATING MEDICAL GROUP to perform, and
PARTICIPATING MEDICAL GROUP agrees to perform on BLUE CROSS’ behalf, the
Delegated Compliance Activities delineated in the Division of Responsibilities
For Compliance Activities, Exhibit K (incorporated by reference herein).


 


(2)       BLUE CROSS retains primary responsibility for Compliance Activities that
are not specifically delegated to PARTICIPATING MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP shall cooperate
and comply with BLUE CROSS’ performance of such activities, as necessary.


 


(3)       If PARTICIPATING MEDICAL GROUP attains and maintains NCQA Physician
Organization Certification (“POC”), or other certification deemed acceptable by
BLUE CROSS during the term of this Agreement, BLUE CROSS agrees to exempt
PARTICIPATING MEDICAL GROUP from predelegation, annual, and follow-up onsite
audits of Delegated Compliance Activities, except to the extent those Delegated
Compliance Activities must be monitored by BLUE CROSS as required by any
regulatory agency having jurisdiction over BLUE CROSS.  PARTICIPATING MEDICAL GROUP shall supply
written evidence of such POC certification to BLUE CROSS no less than once every
twelve (12) months and upon renewal PARTICIPATING MEDICAL GROUP shall
immediately notify BLUE CROSS in the event such certification is revoked or is
not renewed


 


18

















 


(4)       Notwithstanding any delegation of credentialing or recredentialing
activities to PARTICIPATING MEDICAL GROUP, BLUE CROSS retains the right to
approve, suspend or deny any Health Professional from providing services to
Members under this Agreement.


 


C.        Compliance
Activities Performance Measurement


 


(1)       PARTICIPATING MEDICAL GROUP agrees to comply with the Compliance
Activity Performance Measurements indicated in Exhibit K (1) (incorporated by
reference herein) for each listed Compliance Activity Standard for which it is
delegated responsibility.


 


(2)       PARTICIPATING MEDICAL GROUP shall submit all required written
documentation demonstrating compliance with the Compliance Activity Performance
Measurement, as delineated in Exhibit K(1). 
Such materials must be submitted to the appropriate BLUE CROSS contact
person as indicated in Exhibit K (1) by the deadlines set forth therein.  PARTICIPATING MEDICAL GROUP will be
monitored for compliance with meeting submission time frames.


 


(3)       PARTICIPATING MEDICAL GROUP agrees to give BLUE CROSS a continuing right
of access to PARTICIPATING MEDICAL GROUP’s records and information pertaining
to Delegated Compliance Activities as necessary to evaluate ongoing
qualification for delegation, and to copy those records and information as
needed.


 


D.       Corrective
Actions and Revocation of Delegation


 


(1)       In the event that BLUE CROSS determines that PARTICIPATING MEDICAL GROUP
is in breach of the terms of this Section 4.11 and/or that PARTICIPATING
MEDICAL GROUP fails to satisfactorily fulfill its responsibilities for performing
any Delegated Compliance Activity, BLUE CROSS may, in addition to any other
available remedy


 


(a)           Require that PARTICIPATING MEDICAL GROUP submit, within thirty (30)
calendar days of request, a  corrective
plan of action acceptable to BLUE CROSS and adhere to such plan; or


 


(b)           Revoke PARTICIPATING MEDICAL GROUP’s delegation status, in whole or in
part, by giving thirty (30) calendar days prior written notice to PARTICIPATING
MEDICAL GROUP.


 


(2)       In the event BLUE CROSS determines that continued performance by
PARTICIPATING MEDICAL GROUP of any Delegated Compliance Activity poses a risk
of physical, mental, emotional, or financial harm to a Member, BLUE CROSS may
revoke the delegation of such Compliance Activity, immediately upon written
notice to PARTICIPATING MEDICAL GROUP.


 


(3)       BLUE CROSS retains the right to modify Exhibits K and K(1) on an annual
basis or as may be reasonably necessary or required to comply with applicable
laws or regulations or the accreditation requirements of regulatory agencies
and managed care organization oversight bodies.  In any such event, BLUE CROSS shall provide PARTICIPATING MEDICAL
GROUP with written notice.


 


19

















 


4.12         To provide BLUE CROSS, within seven (7) days of its request, a  description of any policies and
procedures related to economic profiling utilized by PARTICIPATING MEDICAL
GROUP.  PARTICIPATING MEDICAL GROUP
further agrees to comply with the requirements of the Knox-Keene Act related to
economic profiling, including Health and Safety Code Section 1367.02(c)


 


V.                 BLUE CROSS SERVICES AND RESPONSIBILITIES


 


BLUE CROSS agrees:


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


20

















 


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


 


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


 


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


 


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


 


VI                 ELIGIBILITY
LISTINGS


 


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


 


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


 


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


 


(1)       duplicate copies of paper reports,


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


(3)       duplicate reports for prior months


 


21

















 


C.        BLUE
CROSS will discourage retroactive cancellation by an employer group of more
than ninety (90) days from BLUE CROSS applicable monthly billing process
date.  However, when no services have
been rendered, BLUE CROSS may make occasional exceptions due to legitimate
administrative processing requirements. 
Notwithstanding any retroactive cancellation of a Member by an employer
group of more than ninety (90) days, BLUE CROSS shall not be entitled to any
refund of Capitation payments made for such Member beyond the ninety (90) day
period.  BLUE CROSS will attempt to
discourage retroactively adding any Member after the applicable billing is
reconciled.  In the event BLUE CROSS
finds it necessary to assign, up to ninety (90) days retroactively, a new
Member to PARTICIPATING MEDICAL GROUP, Capitation payment for that Member shall
be made, and PARTICIPATING MEDICAL GROUP agrees to be responsible for all
Covered Medical Services due that Member under the terms of the Member’s
Benefit Agreement which were provided or arranged by PARTICIPATING MEDICAL
GROUP, from the date the Member was assigned.


 


D.       In the
event care is provided to an ineligible person, based on an erroneous or
delayed Eligibility Report, BLUE CROSS shall be financially responsible for all
care provided by PARTICIPATING MEDICAL GROUP prior to the time PARTICIPATING
MEDICAL GROUP received notice of that person’s ineligibility and, on the
condition that PARTICIPATING MEDICAL GROUP shall supply BLUE CROSS with
evidence that PARTICIPATING MEDICAL GROUP has unsuccessfully sought payment for
all or a portion of the charges from the ineligible person, or the person
having legal responsibility for the ineligible person, through two billing
cycles, or through a period of sixty (60) days, whichever is greater.  In that event, BLUE CROSS’ responsibility
for physician compensation shall be measured as set forth in the then current
Blue Cross of California Prudent Buyer Plan Participating Physician fee
schedule for the applicable region or the actual billed amount, whichever
is less.  The obligations of BLUE CROSS
under this Subsection D shall be conditioned upon (1) the exercise of
prudent judgment by PARTICIPATING MEDICAL GROUP, evidenced by reasonable
efforts to contact BLUE CROSS for verification of the eligibility of each
Member prior to providing or arranging Covered Medical Services, and (2)
submission to BLUE CROSS of both the claim and evidence of its unsuccessful
collection efforts within twelve (12) months of the date of service.


 


VII.               COMPENSATION TO PARTICIPATING MEDICAL GROUP


 


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


 


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


 


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


 


22

















 


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


 


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


 


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


 


7.05         PARTICIPATING MEDICAL GROUP agrees to be responsible for professional
and facility charges, as described in Exhibit A(1) (incorporated by reference
herein).


 


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


 


7.07         Transplant Services.


 


For those transplant Professional Capitation Services, including without
limitation, bone marrow/stem cell and solid organ for which PARTICIPATING
MEDICAL GROUP is financially responsible (ie, professional component),
PARTICIPATING MEDICAL GROUP shall pay for such services at the applicable rate
negotiated by BLUE CROSS for professional transplant services or at the rate
negotiated by PARTICIPATING MEDICAL GROUP. 
If such payment has been made by BLUE CROSS, PARTICIPATING MEDICAL GROUP
shall remit payment to BLUE CROSS within forty-five (45) days of BLUE CROSS
written request or BLUE CROSS may adjust subsequent Capitation payments to
offset such payment amount.


 


VIII.             ENROLLMENT
PROTECTION


 


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


 


8.02         For PARTICIPATING MEDICAL GROUPs with less than two thousand (2,000)
Members on the effective date of this Agreement, the liability of PARTICIPATING
MEDICAL GROUP for expenses


 


23

















 


for Capitation Services rendered to any single Member during the
calendar year shall be limited to the first SIX THOUSAND DOLLARS ($6,000.00) of
such expenses.


 


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


 


A.       The liability of PARTICIPATING MEDICAL GROUP
for expenses for Capitation Services rendered to any single Member during the
calendar year, shall be limited to the first *** of Capitation Services
expenses, which have been incurred by PARTICIPATING MEDICAL GROUP for that Member,
or


 


B.        The liability of PARTICIPATING MEDICAL GROUP
for expenses for Capitation Services rendered to any single Member during the
calendar year, shall be limited to the first TWENTY-FIVE THOUSAND DOLLARS
($25,000.00) of Capitation Services expenses which have been incurred by
PARTICIPATING MEDICAL GROUP for that Member.


 


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


A.  o  B  ý  (Check one).


 


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


 


8.05         The total expenses of PARTICIPATING MEDICAL
GROUP for Capitation Services rendered to any single Member during the calendar
year shall be calculated according to the then current Blue Cross of California
Prudent Buyer Plan Participating Physician Agreement fee schedule for the
applicable region.  In the event the
foregoing calculation for any given procedure results in a figure greater than
the actual cost of the procedure as billed by a third party, then the actual
cost for that procedure shall be deemed to be the amount actually paid by
PARTICIPATING MEDICAL GROUP.


 


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


 


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


 


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


 


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


 


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


 


8.07         PARTICIPATING MEDICAL GROUP shall maintain
records necessary to evidence having reached the Enrollment Protection
level.  After reaching the Enrollment
Protection level with


 


24

















 


regard to any Member, during the reminder of the calendar year
PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for one hundred percent
(100%) of services rendered, or provided, to that Member by PARTICIPATING
MEDICAL GROUP, calculated in accordance with Sections 8.02, 8.03, 8.04, 8.05
and 8.06 Reimbursement to PARTICIPATING MEDICAL GROUP for Enrollment Protection
shall be made by BLUE CROSS in accordance with the lesser of (i) actual billed
charges: (ii) the then current Blue Cross of California Prudent Buyer Plan
Participating Physician Agreement fee schedule for the applicable region,
(ii) the rate negotiated between BLUE CROSS and the provider of service; or
(iv) the amount actually paid by PARTICIPATING MEDICAL GROUP.  Such reimbursement shall be made on a
monthly basis, within forty-five (45) working days of submission of complete
and accurate documentation by PARTICIPATING MEDICAL GROUP.  Services which are not set forth in the then
current Blue Cross of California Prudent Buyer Plan Participating Physician
Agreement fee schedule for the applicable region shall be reimbursed by
BLUE CROSS at the actual charges paid by PARTICIPATING MEDICAL GROUP.


 


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


 


IX.               NON-CAPITATED
SERVICES


 


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


 


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


 


A        Inpatient Hospital Services (exclusive of
professional charges).


 


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


 


C.        Hemodialysis Services (exclusive of
professional charges).


 


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


 


E.        Related Hospital Services.


 


F.        Skilled Nursing Facility Services.


 


G.        Ambulance Services.


 


H.       Home Health Services.


 


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


 


25

















 


J.         ***
of expenses related to Out-of-Area Emergency Services (Facility and
Professional Expenses).


 


K.       Durable Medical Equipment and prosthetic
devices.


 


L.        Hospice Services.


 


M.      *** of the average wholesale price (AWP)
related to chemotherapy drugs (intravenously administered) and injectable
medications (excluding take-home insulin).


 


N.       Mammography Services.


 


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


 


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


 


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


 


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


 


9.03         Case Management Stop-Loss.


 


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


 


B.        For
PARTICIPATING MEDICAL GROUPs with enrollment of *** or more Member Months for
the calendar year, the Case Management Stop-Loss Threshold for an individual
Member shall be *** of Non-Capitated Expenses incurred during that calendar
year.


 


For PARTICIPATING MEDICAL GROUPs with enrollment of less than *** Member
Months, the Case Management Stop-Loss Threshold shall be *** of Non-Capitated Expenses incurred during
that calendar year.


 


26

















 


C.        Authorized
expenses for Member’s Non-Capitated Services, up to the Case Management
Stop-Loss Threshold specified above will be accrued toward PARTICIPATING
MEDICAL GROUP’s PMPM Non-Capitated Expenses. Additionally, *** of expenses
between the applicable Case Management Stop-loss Threshold and *** incurred by
an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses.  Non-Capitated
expenses greater than *** for any individual Member will not be included in
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.


 


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


 


9.04         Calculating PARTICIPATING MEDICAL GROUP PMPM Non-Capitated Expenses.


 


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


 


BLUE CROSS shall accrue Non-Capitated Expenses by each PARTICIPATING
MEDICAL GROUP by the calendar year the services were incurred and paid through
one hundred and twenty (120) days (April 30) after year-end.  Beginning in year two (2) of this Agreement,
any claims received after calculation of the final Non-Capitated Performance
Settlement will be charged to the following year’s Non-Capitated Expenses.  Any Non-Capitated Service admissions,
including, but not limited to, inpatient hospital, skilled nursing facility,
hospice and alternative birthing center admissions that occur in one calendar
year and extend into the next year shall accrue to the year the admission
occurred.  Notwithstanding the
aforementioned, any claims for Non-Capitated Services or Shared Risk Services
(as defined in the CALIFORNIACARE Medical Services Agreement in effect for
years prior to the Initial Term of this Agreement) paid after the
April 30th immediately following the effective date hereof will be charged
to the Non-Capitated Expense for the first calendar year, or portion thereof,
of this Agreement.


 


9.05         Non-Capitated Performance Settlement Schedule.


 


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


 


27

















 


9.06         Calculating the Non-Capitated Performance Settlement.


 


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


 


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


 


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


 


B.        Non-Capitaled
Performance Settlement.


 


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


 


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


 


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


 


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


 


28

















 


X                  OUTPATIENT PRESCRIPTION DRUG EXPENSE


 


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


 


The Outpatient Prescription Drug Expense (“OPDE”) shall include only
those amounts paid by BLUE CROSS to pharmacies or pharmacists to provide
covered outpatient prescription drugs to Members assigned to PARTICIPATING
MEDICAL GROUP.  Any rebates or other
similar arrangements between BLUE CROSS and manufacturers/vendors shall not be
considered in determining the Outpatient Prescription Drug Expense Target, the
OPDE, or the Outpatient Prescription Drug Settlement.


 


BLUE CROSS shall accrue OPDE for each
PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and
paid through one hundred and twenty (120) days after year-end.  Beginning in year two (2) of this Agreement,
any claims received after calculation of the final Outpatient Prescription Drug
Settlement will be charged to the following year’s OPDE.  Notwithstanding the aforementioned, any
claims for outpatient prescription drug services incurred prior to the Initial
Term of this Agreement paid after the April 30th immediately following the
effective date hereof and if applicable, for subsequent years, will be charged
to the OPDE for the first calendar year of this Agreement, or portion thereof


 


10.02       Outpatient Prescription Drug Settlement
Schedule.


 


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


 


10.03       Calculating the Outpatient Prescription Drug
Settlement.


 


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


 


A.       Outpatient Prescription Drug Settlement


 


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


 


B.        Formulary Utilization Incentive.


 


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


 


The amount of the Outpatient Prescription Drug Settlement and Formulary
utilization incentive will be based on the applicable PMPM Settlement
calculation under Exhibit H multiplied by


 


29

















 


PARTICIPATING MEDICAL GROUP’s Member Months for Members with outpatient
prescription drug benefits.  Within
forty-five (45) working days after April 30.  BLUE CROSS will pay any Outpatient Prescription Drug Settlement
that is due PARTICIPATING MEDICAL GROUP for the previous year.


 


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


 


XI.               QUALITY
MANAGEMENT BONUS


 


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


 


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


 


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


 


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


 


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


 


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


 


30

















 


All medical services rendered at PARTICIPATING MEDICAL GROUP or
Satellite Facilities and all Referral Services rendered to members of HMO-USA
participating plans, due to unavailability of the required services at
PARTICIPATING MEDICAL GROUP, shall be paid by BLUE CROSS.  For services PARTICIPATING MEDICAL GROUP
provides directly to members of HMO-USA participating plans, BLUE CROSS shall
reimburse PARTICIPATING MEDICAL GROUP at PARTICIPATING MEDICAL GROUP’s invoiced
amount, not to exceed reimbursement in accordance with the then current Blue
Cross of California Prudent Buyer Plan Participating Physician Agreement fee
schedule for the applicable region. 
For Referral Services, PARTICIPATING MEDICAL GROUP may instruct
providers of Referral Services to bill BLUE CROSS directly or, such providers
may bill PARTICIPATING MEDICAL GROUP, in which case, PARTICIPATING MEDICAL
GROUP shall be reimbursed by BLUE CROSS. 
In all cases, PARTICIPATING MEDICAL GROUP or provider of Referral
Services shall note on the claim that services were rendered to a member of an
HMO-USA participating plan.  Neither
PARTICIPATING MEDICAL GROUP nor provider of Referral Services shall bill
members of HMO-USA participating plans.


 


12.02       BLUE CROSS agrees to pay PARTICIPATING MEDICAL GROUP within forty-five
(45) working days of receipt of a completed professional services claim form
for authorized services rendered to members of HMO-USA participating
plans.  Any claim under the HMO-USA Away
From Home Care Program which would otherwise be the responsibility of BLUE
CROSS under this Agreement shall be the responsibility of PARTICIPATING MEDICAL
GROUP if such claim is not submitted to BLUE CROSS within twelve (12) months of
the date of service.


 


XIII              TERM
OF AGREEMENT, TERMINATION


 


13.01       This Agreement shall be in effect for a three (3) year period (the
“Initial Term”) from the date noted on page 1. 
Unless written notice of intent not to renew or of intent to modify this
Agreement is provided at least one hundred twenty (120) days prior to
completion of the Initial Term or any subsequent renewal period, this Agreement
shall renew upon the same terms and conditions for consecutive one year periods
each year thereafter.


 


13.02       In the event this Agreement is terminated, PARTICIPATING MEDICAL GROUP
agrees to continue to provide Professional Capitation Services and to arrange
Institutional Capitation Services and Risk Fund Services for all Members assigned
to PARTICIPATING MEDICAL GROUP, including any  Members
who become eligible during the notice period set forth in Section 12.01
above, and to provide these services consistent with the terms and conditions
of the applicable Benefit Agreements. 
In such cases, Capitation Services rendered to Members Shall be
compensated at the applicable rates set forth in the then current Blue Cross of
California Prudent Buyer Plan Participating Physician fee schedule for the
applicable region, until the services being rendered to that Member are
completed or reasonable and medically appropriate provision is made for the
assumption of such services by another contracting provider, but in no event
later the annual anniversary dates of the Benefit Agreements of Members assigned
to PARTICIPATING MEDICAL GROUP.  The
foregoing anniversary date limitation shall not apply with respect to the
continuation of services, as required under Section 1373.95 of the
California Health and Safety Code


 


In the event this Agreement is terminated, any and all outstanding
deficits owed to BLUE CROSS under this Agreement shall be immediately due and
payable, and BLUE CROSS may offset the entire such deficit against any and all
amounts then due or thereafter due to PARTICIPATING MEDICAL GROUP under this
Agreement or any other agreement with PARTICIPATING MEDICAL GROUP


 


31

















 


13.03       Termination of this Agreement shall not affect any rights or obligations
hereunder which shall have previously accrued, or shall thereafter arise, with
respect to any occurrence prior to termination, and such rights and obligations
shall continue to be governed by the terms of this Agreement.  Without limiting the foregoing, if this Agreement
is terminated, at BLUE CROSS’ sole discretion, PARTICIPATING MEDICAL GROUP
shall continue to provide and be compensated under the terms of this Agreement
for Covered Medical Services provided to Members who at the time of termination
are undergoing a course of treatment from a PARTICIPATING MEDICAL GROUP
Physician for an acute condition, serious chronic condition, high-risk
pregnancy, or a pregnancy that has reached the second or third trimester.  For cases involving an acute condition or a
serious chronic condition, such services may continue for up to ninety (90)
days or a longer period if necessary for a safe transfer to another
CALIFORNIACARE participating medical group physician as determined by BLUE
CROSS in consultation with the PARTICIPATING MEDICAL GROUP Physician,
consistent with good professional practice. 
For pregnancy cases as specified above, such services will continue
until postpartum services related to the delivery are completed or for a longer
period if necessary for a safe transfer to another CALIFORNIACARE participating
medical group physician, consistent with good professional practice.


 


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


 


XIV              ARBITRATION OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP


 


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


 


14.02       Any problem or dispute arising under this Agreement and/or concerning
the terms of this Agreement that is not satisfactorily resolved under
Section 13.01 shall be arbitrated The arbitration shall be initiated by
either party making a written demand for arbitration on the other party.  Arbitration shall be conducted by the
American Arbitration Association (AAA) under the Commercial Rules of the AAA.  The arbitration shall also be subject to
California Code of Civil Procedure, Title Nine, Section 1280, et. seq.,
unless otherwise mutually agreed.  The
parties agree that the decision of the arbitrator shall be final and binding as
to each of them, except to the extent that California or Federal law provide
for the review of arbitration proceedings. 
BLUE CROSS waives any right to pursue, on a class basis, any such
problem or dispute against PARTICIPATING MEDICAL GROUP, and PARTICIPATING
MEDICAL GROUP waives any right to pursue, on a class basis, any such problem or
dispute against BLUE CROSS.  Issues as
to whether malpractice was committed by a physician shall not be subject to
Arbitration by the AAA unless otherwise agreed in writing by the parties and
the AAA.


 


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


 


32

















 


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


 


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


 


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


 


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


 


14.08       With respect to settlements and/or bonuses under Articles IX, X or XI
hereof, PARTICIPATING MEDICAL GROUP shall review such payment and/or the
settlement statement prepared by BLUE CROSS and shall within forty-five (45)
days of receipt notify BLUE CROSS in writing of any problem or discrepancy;
otherwise the right to challenge the calculation and/or amount of the
settlement or bonus shall be deemed waived by PARTICIPATING MEDICAL GROUP.


 


XV               CALIFORNIACARE MEMBER GRIEVANCE SYSTEM


 


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


 


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


 


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


 


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


 


33

















 


XVI.             MISCELLANEOUS PROVISIONS


 


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


 


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


 


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


 


Except as provided above, BLUE CROSS and PARTICIPATING MEDICAL GROUP
each reserve the right to control the use of their respective names and all
symbols, trademarks or service marks presently existing, or later
established.  In addition, except as
provided above, neither BLUE CROSS nor PARTICIPATING MEDICAL GROUP shall use
the other party’s name, symbols, trademarks or service marks in advertising or
promotional materials, or otherwise, without the prior written consent of that
party, and shall cease any such usage immediately upon written notice of the
party or on termination of this Agreement, whichever first occurs.  Any prohibition, restriction or limitation
on advertising hereunder shall comply with the requirements of the Knox-Keene
Act, including Health and Safety Code Section 1395.5.


 


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


 


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


 


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


 


16.07       Notices.  Any notice required to be given pursuant to
the terms of this Agreement shall be in writing, and shall be either personally
delivered, or sent by registered or certified mail, in the United States Postal
Service, return receipt requested, postage prepaid, addressed to BLUE CROSS or
PARTICIPATING MEDICAL GROUP at the applicable address below.  The notice shall be effective on the date
received.


 


	
  If to BLUE CROSS:

  	
   

  	
  Blue Cross of California

  
	
   

  	
   

  	
  21555
  Oxnard Street Woodland Hills, CA 91367

  
	
   

  	
   

  	
   

  
	
  If
  to PARTICIPATING MEDICAL GROUP

  



 


34

















 


16.08       Maximum Capacity.  The
Maximum Capacity of PARTICIPATING MEDICAL GROUP during the term of this
Agreement shall be 25,000 Members.


 


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


 


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


 


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


 


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


 


16.13       Governing Law.  This
Agreement and the rights and obligations of the parties hereunder shall be
construed and interpreted and enforced in accordance with, and governed by, the
laws of the State of California, and the United States and all regulations
promulgated pursuant thereto.  Any
provisions required to be in this Agreement by any of the above laws and
regulations shall bind BLUE CROSS and PARTICIPATING MEDICAL GROUP whether or
not expressly provided in this Agreement.


 


	
  BLUE
  CROSS OF CALIFORNIA

  	
   

  	
  PARTICIPATING
  MEDICAL GROUP;

  
	
   

  	
   

  	
   

  	
  Professional Care IPA Medical Group, Inc.

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Barry Ford

  	
   

  	
   

  	
  Signature:

  	
  /s/ Rick Shinto

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Barry
  Ford

  	
   

  	
   

  	
  Name:

  	
  Rick Shinto

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice
  President

  	
   

  	
   

  	
  Title:

  	
   

  	
   

  
	
   

  	
  Network
  Development & Management

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  11-1-99

  	
   

  	
   

  	
  Date:

  	
  10/11/99

  	
   

  



 


35

















 


EXHIBIT A


 


COVERED
MEDICAL SERVICES


 


I.              Medical and Surgical Services


 


A.    Physician’s
services at the


 


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


 


(2)   Hospital or
Skilled Nursing Facility


 


B.    Professional
services of an anesthetist or anesthesiologist


 


C.    Diagnostic
X-ray examinations


 


D.    Laboratory
tests


 


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


 


F.     Professional
services of other participating Health Professionals


 


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


 


II.            Psychiatric Care Benefits


 


A.    Inpatient
Visits


 


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


 


B.    Outpatient
Visits or Sessions


 


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


 


III.           Covered Preventive Care Benefits


 


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


 


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


 


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


 


C.    Pediatric
and adult immunizations.


 


D.    Eye
examinations.


 


A-1

















 


E.     Infertility
studies for Members aged 18 or over.


 


F.     Ear
examinations.


 


G.    Health
education services as follows:


 


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


 


(2)   Instruction in personal health care measures.


 


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


 


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


 


I.      Allergy
testing and administration of injections.


 


A-2

















 


EXHIBIT A(1)


CALIFORNIACARE


 


DIVISION
OF FINANCIAL RESPONSIBILITIES


 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY
  TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE:
  Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHETICS,
  Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  EYE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  ARTIFICIAL INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD
  AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  CHEMICAL DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*     As set
forth in the applicable Benefit Agreement


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


 


A(1)-1

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY
  DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHIROPRACTIC
  (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In
  Conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DENTAL
  SERVICES

  (accidental injury to sound natural teeth
  and dental work necessary for the construction of non-dental structures)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  DURABLE MEDICAL EQUIPMENT (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*     As set
forth in the applicable Benefit Agreement


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


 


A(1)-2

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMPLOYMENT
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ENDOSCOPIC
  STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXPERIMENTAL
  PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FAMILY
  PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FETAL
  MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENETIC
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  **
  HEALTH EVALUATIONS / PHYSICALS

  (required by third party or outside agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
    *
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING
  SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*     As set
forth in the applicable Benefit Agreement.


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


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


 


A(1)-3

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEPATITIS
  B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME
  HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE
  (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics /
  Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedic
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  HOSPITALIZATI0N / INPATIENT SERVICES,
  SUPPLIES & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area
  (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE
  CARE - In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set
forth in the applicable Benefit Agreement


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


A(1)-4

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA MONITOR (DME)

  (in conjunction with or concurrent with
  authorized inpatient admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * 
  INFERTILITY(Diagnosis/ Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  * Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFUSION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Infused Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLE MEDICATIONS: Outpatient

  (excluding take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LABORATORY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient / Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MAMMOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set forth in the applicable Benefit
Agreement


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


 


A(1)-5

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  NUTRITIONIST
  / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OBSTETRICAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ORGAN
  TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  OUTPATIENT DIAGNOSTIC SERVICES &
  TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Primary
  Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CAT
  Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2-D
  Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EKG
  (aka: ECG)c

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set
forth in the applicable Benefit Agreement


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


 


A(1)-6

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics
  / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set forth in the applicable Benefit
Agreement


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


 


A(1)-7

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  SURGERY: Professional Component continued

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary
  Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation
  Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PEDIATRIC
  SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICAL
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PODIATRY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREADMISSION
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PRE-EXISTING
  PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set forth in the applicable Benefit
Agreement


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


 


A(1)-8

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIATION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RECONSTRUCTIVE
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REHABILITATION
  SERVICES

  (Physical Therapy, Occupational Therapy,
  Speech Therapy, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ROUTINE
  PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SKILLED
  NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SPECIALIST
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*     As set
forth in the applicable Benefit Agreement


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


 


A(1)-9

















 


	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGICAL
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TEMPORO-MANDIBULAR
  JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Dental
  Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  (for the diagnosis and medically necessary
  correction)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous
  Blood Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT
  CARE: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT
  CARE: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION
  SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Medically
  Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lenses
  / Frames (covered by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Contact
  lenses (fitting only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*      As set forth in the
applicable Benefit Agreement


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


 


A(1)-10

















 


EXHIBIT B


 


CALIFORNIACARE
HOSPITALS


 


B-1

















 


EXHIBIT C


 


ADMINISTRATIVE
RESPONSIBILITIES OF PARTICIPATING MEDICAL GROUP


 


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


 


A.    PROFESSIONAL SERVICES ADMINISTRATION


 


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


 


Outside Referrals - Control, process and report encounter information


 


Ancillary - Control, process and report encounter information


 


B.    INSTITUTIONAL SERVICES ADMINISTRATION


 


Preadmission certification process


 


Medical Review of claims


 


Length-of-stay (monitoring and control)


 


C.    UTILIZATION REVIEW


 


D.    PEER REVIEW, EDUCATION AND CREDENTIALING


 


E.     QUALITY MANAGEMENT


 


F.     GRIEVANCE PROCEDURE COMPLIANCE


 


G.    MONITOR AND REVISE SPECIALIST/OTHER REFERRAL
CONTRACTS


 


H.    PATIENT EDUCATION


 


I.      CASE MANAGEMENT


 


C-1

















 


EXHIBIT D


 


CAPITATION


 


•              If
PARTICIPATING MEDICAL GROUP selects the Section 8.03A Enrollment
Protection level of ***, once PARTICIPATING MEDICAL GROUP reaches *** Members
at the beginning of the calendar year PARTICIPATING MEDICAL GROUP will receive
an additional payment of
$                             PMPM.


 


•              If
PARTICIPATING MEDICAL GROUP selects the Section 8.03B Enrollment
Protection level of ***, once PARTICIPATING MEDICAL GROUP reaches *** at the
beginning of the calendar year PARTICIPATING MEDICAL GROUP will receive an
additional payment of
$                        PMPM.


 


D-1

















 


EXHIBIT F


 


NON-CAPITATED
PERFORMANCE SETTLEMENT SCHEDULE


For Non-Capitated Medical Services


 


Based on Plan C.
*** Stop Loss. Age/Sex Factor = 1 00 and Regional Factor = 1 00


 


Non-Capitated Performance
Settlement Calculation Method:


 


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


 


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


 


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


 


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


 


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


 




	
  Payment Bands

  	
   

  	
  Non-Capitated
  Expense Ranges

  (PMPM Non-Capitated Expense)

  	
   

  	
  Multiplier

  	
   

  	
  Minimum
  Payment Amount

  	
   

  
	
   

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1

  	
   

  	
  $

  	
  ***

  	
   

  	
  >

  	
  $

  	
  ***

  	
   

  	
  0

  	
  %

  	
  $

  	
  0.00

  	
   

  
	
  2

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
  * 

  	
  25

  	
  %

  	
  $

  	
  0.00

  	
   

  
	
  3

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  40

  	
  %

  	
  $

  	
  0.33

  	
   

  
	
  4

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  55

  	
  %

  	
  $

  	
  0.66

  	
   

  
	
  5

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  65

  	
  %

  	
  $

  	
  1 59

  	
   

  
	
  6

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  75

  	
  %

  	
  $

  	
  2.45

  	
   

  
	
  7

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  65

  	
  %

  	
  $

  	
  3.44

  	
   

  
	
  8

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  50

  	
  %

  	
  $

  	
  4.30

  	
   

  
	
  9

  	
   

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  40

  	
  %

  	
  $

  	
  4.96

  	
   

  
	
  10

  	
   

  	
  <

  	
  $

  	
  ***

  	
   

  	
  $

  	
  ***

  	
   

  	
  0

  	
  %

  	
  $

  	
  5.49

  	
   

  
															






 












*
Attachment Point


 


Example of  Non-Capitated
Performance Settlement Calculation


 


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


 


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


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


 


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


$27.63 -
$26.63 = $1.00


 


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


$1.00 x 65%
= $0.65


 


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


$0.65 +
$1.59 = $2.24  PMPM Non-Capitated
Performance Settlement


 


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


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


 


F-1

















 


EXHIBIT G


 


COMPENSATION
FOR SERVICES TO BLUE CROSS PLUS MEMBERS


 


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


 


I          DEFINITIONS


 


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


 


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


 


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


 


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


 


	
  Baseline
  Capitation Payment

  	
   

  	
  =
  A

  
	
   

  	
   

  	
   

  
	
  Expenses
  for Out-of-Network Services

  (Modified to allow for IBNR)

  	
   

  	
  =
  B

  
	
   

  	
   

  	
   

  
	
  In-Network
  Utilization Factor

  	
   

  	
  =
  C

  
	
   

  	
   

  	
   

  
	
  C
  =

  	
  A

  	
   

  	
   

  	
   

  
	
   

  	
  A+B

  	
   

  	
   

  	
   

  



 


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


 


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


 


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


 


G-1

















 


II         COMPENSATION FOR SERVICES TO BLUE CROSS PLUS
MEMBERS


 


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


 


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


 


B.    PARTICIPATING
MEDICAL GROUP may earn Supplemental Capitation Payments by achieving an
In-Network Utilization Factor greater than 0.42 in any calendar quarter, as set
forth in Exhibit G(1).  For any calendar
quarter in which PARTICIPATING MEDICAL GROUP achieves an In-Network Utilization
Factor of 0.42 or above, BLUE CROSS shall make a Supplemental Capitation
Payment in accordance with Exhibit G(1) due sixty (60) working days after the
end of such calendar quarter. 
PARTICIPATING MEDICAL GROUP shall review such payment and/or the
settlement statement prepared by BLUE CROSS and shall within forty-five (45)
days of receipt notify BLUE CROSS in writing of any problem or discrepancy,
otherwise the right to challenge the calculation and/or amount of the
Supplemental Capitation Payment shall be deemed waived by PARTICIPATING MEDICAL
GROUP.


 


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


 


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


 


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


 


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


 


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


 


G-2

















 


EXHIBIT G(1)


 


BLUE
CROSS PLUS 1997 BASELINE CAPITATION


 


•              If PARTICIPATING MEDICAL GROUP selects the
Section 8.03A Enrollment Protection level of ***, once PARTICIPATING
MEDICAL GROUP reaches *** Members at the beginning of the calendar year
PARTICIPATING MEDICAL GROUP will receive an additional payment of $
             PMPM.


 


•              If
PARTICIPATING MEDICAL GROUP selects the Section 8.03B Enrollment
Protection level of ***, once PARTICIPATING MEDICAL GROUP reaches ***) Members
at the beginning of the calendar year PARTICIPATING MEDICAL GROUP will receive
an additional payment of $
             PMPM.


 


G(1) -1

















 


EXHIBIT H


 


OUTPATIENT
PRESCRIPTION DRUG SETTLEMENT SCHEDULE


 


	
  PMPM
  Outpatient Prescription Drug Expense Target:

  	
   

  	
  $***PMPM

  



 


	
  PMPM Expense Range

  	
   

  	
  Settlement
  Calculation

  
	
  Greater than $***

  	
   

  	
  $0.00

  
	
  $9.60 to $***

  	
   

  	
  ($*** - PMPM OPDE) x 45%

  
	
  $8.75 to $***

  	
   

  	
  ($1*** - PMPM OPDE) x 50%

  
	
  Less than $***

  	
   

  	
  $***  PMPM

  



 


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


 


	
  Formulary
  Utilization:

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

  



 


H-1

















 


EXHIBIT I


 


QUALITY MANAGEMENT BONUS SCHEDULE


 


	
  Quality Management Scorecard
  Rating

  	
   

  	
  PMPM
  Quality Bonus Settlement

  
	
  Below Average

  	
   

  	
  $***

  
	
  Average

  	
   

  	
  $***

  
	
  Above Average

  	
   

  	
  $***

  



Where:


 


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


 


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


 


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


 


I-1

















 


EXHIBIT J


 


PARTICIPATING
MEDICAL GROUP FACILITIES


 


J-1

















 


EXHIBIT K


 


DIVISION OF
RESPONSIBILITIES FOR COMPLIANCE ACTIVITIES


 


K-1

















 


EXHIBIT K(1)


 


COMPLIANCE
ACTIVITY PERFORMANCE MEASUREMENTS


 


K(1)-1