Exhibit 10.177


 


AMENDMENT


to the


PROVIDER SERVICES AGREEMENT


between


HEALTH NET INC., AFFILIATES


and


STARCARE MEDICAL GROUP DBA GATEWAY MEDICAL GROUP


 


The Provider Services
Agreement (“Agreement”), effective March 1, 1999, between StarCare Medical
Group, dba Gateway Medical Group, (“PPG”) and Health Net Inc., Affiliates
(“HNI”), subsequently amended July 1, 2000, and October 10, 2000, is hereby
amended effective February 1, 2002.


 


HNI and PPG hereby agree to
amend the Agreement as follows:


 


1.             All
references to the California Department of Corporations (“DOC”) shall hereby be
deleted and replaced by the California Department of Managed Health Care
(“DMHC”).


 


2.             Section
2.17. 
Quality Improvement Program.  shall be deleted in its entirety and replaced by the following:


 


2.17        Quality Improvement Program.  PPG
agrees to participate in and cooperate fully with the applicable Quality
Improvement Program and to comply with decisions rendered by HNI in connection
with a Quality Improvement Program.  The
quality of Contracted Services rendered to Members shall be monitored under the
Quality Improvement Program applicable to the particular Benefit Program.  PPG also agrees to provide medical and other
records within five (5) calendar days of receipt of written notice, and review
data and other information as may be required or requested under a Quality
Improvement Program, including reporting in accordance with, but not limited
to, the current Health Plan Employer Data and Information Set (HEDIS), or its
successor.  In the event that PPG’s
performance, including but not limited to, its structures, processes or
outcomes, is found to be unacceptable under any Quality Improvement Program,
HNI shall give written notice to PPG to correct the specified deficiencies
within the time period specified in the notice.  PPG shall correct such deficiencies within that time period.


 


PPG
recognizes the importance of the establishment of health care measurement
systems to evaluate, along with the continuum of care, the performance of hospitals,
physicians, and other healthcare providers. 
PPG agrees to support efforts to address quality, cost of care, access,
Member satisfaction and functional status through participation in the
development of valid performance measurement systems.  Performance measurement systems should examine process and
outcome and incorporate the following criteria:  standard indicators and definitions, uniform data, accuracy, and
state of the art risk adjustments.  PPG
is aware that participation in the development of performance measurement
systems may require the commitment of financial and human resources.


 


3.             Section
4.9.  Third
Party Recoveries, Workers’ Compensation.  shall be deleted in its entirety and
replaced by the following:


 


4.9          Third Party Recoveries, Workers’ Compensation.  In
the event PPG provides services to HNI Members for injuries resulting from the
acts of third parties, or resulting from work related injuries, PPG shall have
the right to recover from any settlement, award, or recovery from any responsible
third-party the value of Covered Services rendered pursuant to SB1471 and the
applicable provisions of the Coverage Certificate and as set forth in the
Operations Manual.  PPG shall notify HNI
of any third party payor and shall, upon request from HNI, provide HNI with an
accounting of all such sums recovered. 
In the event HNI has compensated PPG for such Covered Services, PPG
agrees to immediately refund such amounts paid to HNI.


 












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


 


1

















 


4.             Article
VI TERM AND TERMINATION. Section 6.1 Term is deleted in its entirety and
replaced as follows:


 


6.1          Term.  The term of this Amendment
shall commence February 1, 2002, and shall continue in effect for a period of
twenty-four (24) months (“Initial Term”). 
Thereafter, this Agreement shall automatically renew for successive
one-year (1) periods on the annual renewal date, unless terminated as set forth
herein.  The term of this Agreement
shall remain the same for all Benefit Programs covered hereunder.


 


5.             Article
VI TERM AND TERMINATION.  Section 6.2
Without Cause Termination is deleted in its entirety and replaced as follows:


 


6.2          Without Cause Termination.  After
the Initial Term either party may terminate this Agreement at the scheduled
renewal date upon one hundred twenty (120) days prior written notice to the
other party.  In the event HNI provides
PPG with such notice, HNI may, at its option, begin to transition Members
immediately under this Agreement to another Participating Provider after such
notice.


 


6.             Addendum
B, COMMERCIAL HEALTH MAINTENANCE ORGANIZATION (HMO) AND COMMERCIAL POINT OF
SERVICE (POS) BENEFIT PROGRAMS is deleted in its entirety and replaced with the
new Addendum attached hereto.


 


7              Addendum
B.2 DIVISION OF RESPONSIBILITY MATRIX OF HMO, PPG AND SHARED RISK/HOSPITAL
CAPITATED SERVICES COMMERCIAL HMO AND POINT OF SERVICE BENEFIT PROGRAMS is
deleted in its entirety and replaced with the new Addendum attached hereto.


 


8.             ADDENDUM I HEALTHY FAMILIES PROGRAM is added
and attached hereto.


 


Except as provided in this
Amendment, all other provisions of the Agreement between HNI and Provider not
inconsistent herewith shall remain in full force and effect.


 


IN WITNESS WHEREOF, the parties hereto have executed this Agreement by their officers duly
authorized to be effective on the date and year first written above.


 


	
  StarCare
  Medical Group Inc, dba

  Gateway Medical Group, Inc

  	
  Health Net
  Inc., Affiliates

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ Michael Olson

  	
   

  	
  /s/ Christopher Ciano

  	
   

  
	
  Michael Olson

  	
  Christopher Ciano

  
	
   

  	
   

  
	
  Director of Contracting

  	
  Senior Vice President &
  General Manager, South

  
	
   

  	
   

  
	
  2/11/02

  	
   

  	
  03-05-02

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
  33-0843838

  	
   

  	
   

  
	
  Federal Tax Identification
  Number

  	
   

  
					



 


2

















 


ADDENDUM B


 


COMMERCIAL HEALTH MAINTENANCE ORGANIZATION (HMO) AND

COMMERCIAL POINT OF SERVICE (POS) BENEFIT PROGRAMS


 


A.            GENERAL REIMBURSEMENT PROVISIONS.


 


1.             PPG understands and agrees that the
obligations of HNI set forth in this Addendum are only the obligations of
Health Net (hereafter “HMO”) and not the obligations of HNI or any other
Affiliate of HNI.  PPG shall be
compensated according to this Addendum B and this Addendum shall be applicable
to only those Commercial HMO and Commercial POS Members listed on the
applicable Capitation remittance summaries.


 


2.             Benefit Programs.  This Addendum B is applicable
to the following Benefit Programs:


•      Commercial HMO


•      Standard HMO


•      Flex Funded HMO


•      Small Group HMO


•      Individual HMO


•      AIM


•      Medicare Supplement


•      Commercial POS


 


3.             Compensation for PPG Capitated Services.  As
compensation for rendering PPG Capitated Services.  HMO shall pay PPG Capitation as set forth in this Addendum B for
each Commercial HMO and Commercial POS Member eligible to receive services from
PPG during any particular month. 
Capitation shall be payable on a per Member per month (PMPM) basis.  Capitation shall be computed on the basis of
the most current information available and shall be paid by HMO by wire
transfer on or before the fifteenth (15th) day of each month or the first
business day following the fifteenth if the fifteenth is a holiday or on a
weekend.  Each Capitation payment shall
be accompanied by a remittance summary. 
The remittance summary identifies the total Capitation payable and those
Commercial HMO and Commercial POS Members for whom Capitation is being
paid.  In the event of a Capitation
error, resulting in an overpayment or underpayment to PPG, HMO shall adjust
subsequent Capitation to offset such error.


 


4.             Compensation to Other Providers of PPG Capitated
Services.  PPG shall compensate all providers who
render PPG Capitated Services to Commercial HMO and Commercial POS Members
assigned to PPG.  In the event that PPG
does not process and pay eligible claims submitted to PPG for Capitated
Services within applicable time limits, HMO may pay such claims at the lesser
of HMO’s contract rate with such provider, if any, PPG’s subcontract terms, or
provider’s billed charges.  HMO shall
deduct any such claim amounts paid from PPG’s Capitation, as set forth in the
Operations Manual.


 


5.             Contracted Services.  PPG
and Member Physicians shall render Contracted Services which are not PPG
Capitated Services to Members covered under this Addendum B and shall be
compensated on a fee-for-service basis at the rates set forth in Addendum
E.  PPG shall submit claims in
accordance with the terms of this Agreement and State and federal law.


 


6.             Withhold Fund and Determination of Maximum Downside of
Shared Risk Deficits.  Notwithstanding any provision in this
Agreement or in any Addendum hereto to the contrary.  PPG’s total downside liability for all Shared Risk Budget
deficits shall not exceed twenty percent (20%) of PPG’s gross annual
Capitation.  Any and all Withhold Fund
amounts as set forth herein shall be applied to offset such total downside
liability.


 


3

















 


B.            STANDARD HMO.


 


1.             Professional Captation Rates.


 


1.1          Capitation Rales.  PPG Capitation for Standard HMO
Members shall be determined on a monthly basis by multiplying the following
normalized PMPM rates by the age, sex and benefit plan factors set forth in
Addendum B for each assigned Member. 
Normalized rates represent the PMPM prior to the adjustment for PPG’s
assigned Members age, sex and benefit plan. 
Actual PPG gross Capitation shall fluctuate from month to month to the
extent that PPG’s age, sex and benefit plan mix fluctuates.


 




	
  Standard

  HMO Capitation

  
	
  February
  1, 2002, through December 31, 2002, $*** PMPM

  
	
  January
  1, 2003, $*** PMPM

  






 


2.             Professional Slop Loss Program.  PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage


 


3.             Shared Risk Program.  PPG shall
participate in an incentive program for Shared Risk Services which shall reward
PPG for effectively coordinating such care. 
Under this Program, a budget shall be established for Shared Risk
Services, and the actual cost of such services shall be compared to the budget.


 


3.1          Shared Risk Budget.  HMO
shall fund the Shared Risk Budget for Members, with normalized rates.  These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum B.  Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and
benefit plan mix fluctuates.


 




	
  Standard

  HMO Shared Risk Budget

  
	
  January
  1, 2002, through December 31, 2002, $46.00 PMPM

  
	
  January
  1, 2003, $*** PMPM

  






 


3.2          Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct *** of PPG’s Capitation for Standard HMO Members and place such amount
in the Withhold Fund as described in the Agreement.


 


In the event
the shared risk claims exceed the shared risk budget at the interim settlement date, HMO may, at its sole
discretion, withhold from PPG’s gross monthly capitation up to *** of PPG’s
monthly capitation and may continue such withhold until the final shared risk
settlement.  The withheld amount shall
be placed in the Withhold Fund as described in the Agreement.  If there is a deficit at the time of final
settlement, HMO may at it’s sole discretion, continue to withhold up to *** of
PPG’s capitation for Standard HMO Members and place such amount in the Withhold
Fund as described in this agreement.


 


Each Reconciliation Period,
HMO shall calculate Shared Risk Claims in accordance with the Operations Manual
and compare such claim cost to the corresponding Shared Risk Budget.  HMO shall perform both an interim and final
settlement.  In the event that such
claims are less than the Shared Risk Budget for the Interim Period, PPG’s share
of the settlement shall be ***, subject to Section 4.3 of this Agreement.


 


4

















 


Shared Risk
Claims with dates of service within the Reconciliation Period, and paid by March 31 of the following year shall
be used in the calculation.  Shared Risk
Services incurred within the Reconciliation Period but paid after March 31 of
the following year will be included in the next Reconciliation Period
calculation.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk program,
those excess funds shall be paid to PPG by April 30 of the following year.


 


3.3          Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a) *** of the Shared Risk Budget surplus, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3 of the Agreement, the
Shared Risk Budget surplus shall be offset against any amounts payable by
PPG.  Any surplus remaining shall be
paid to PPG by April 30 of the following year.


 


3.4          Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit, PPG’s share of the deficit shall be
limited to the lesser of (a) *** of the Shared Risk Budget deficit, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3, of the Agreement any
amounts payable by PPG shall be offset against the Withhold Fund and any other
amounts payable by HMO.


 


In the event a deficit
remains in the Shared Risk Program after such offset, such deficit shall be
carried forward to be applied against future years Shared Risk Program
surpluses and withhold funds.


 


3.5          Shared Risk Reinsurance.  PPG
shall participate in the Shared Risk Reinsurance Program.  The cost to PPG for such participation shall
be calculated as follows:


 


(a)           Out-of-Area Emergency and Urgently Needed Services:  *** of Shared Risk Budget.


 


Out-of-Area Emergency and
Urgently Needed Services are reimbursed *** of allowed amount, and the
remaining *** shall be charged against the Shared Risk Budget.


 


(b)           In-Area Shared Risk Services: 
*** of Shared Risk Budget.


 


The cost of In-Area Shared
Risk Services utilized by a Member in a Reconciliation Period shall be charged
against the Shared Risk Budget as follows: 
*** of any amount over ***.


 


4.             AIDS.  On a network wide basis,
reinsurance programs shall be established by HMO to cover the payment of
expenses incurred in the treatment of Members who have been diagnosed with
Acquired Immune Deficiency Syndrome (“AIDS Members”).


 


4.1          AIDS Reinsurance.  Professional, institutional,
and pharmacy costs for AIDS Members shall be the financial responsibility of
HMO, as set forth in the Operations Manual. 
Additionally, the pharmacy cost for HIV drugs shall be the financial
responsibility of HMO under this Program. 
PPG shall receive prior authorization from HMO for an elective inpatient
admission of an AIDS Member.  In
addition, PPG shall provide HMO with timely notification of any urgent/emergent
admission of any AIDS Member who is receiving anti-viral home treatments, or of
any AIDS Member who is receiving total parenteral nutrition.  For purposes of this paragraph, timely
notification is within twenty-four (24) hours of an admission or the initial
treatment.  In the event PPG fails to
notify HMO as set forth in this paragraph, AIDS related claims for such Members
shall not be eligible for payment under this Program.


 


4.3          AIDS Reinsurance Premium.  The
Reinsurance Program rates, as set forth


 


5

















 


below, shall be  deducted from PPG’s Capitation:


	
  •

  	
   

  	
  AIDS Reinsurance effective
  February 1, 2002 thru May 31, 2002

  	
   

  	
  - *** PMPM

  
	
  •

  	
   

  	
  AIDS Reinsurance effective
  June 1, 2002

  	
   

  	
  - *** PMPM

  



 


5.             Flex Funded HMO.  Flex Funded HMO Members, (those
enrolled in a benefit program which is fully or partially self-funded) shall
not be subject to a Dual Risk Program not to a Shared Risk Program.  PPG Capitation, Professional Stop Loss and
Reinsurance Programs shall be as set forth above.


 


C.            SMALL GROUP HMO.


 


1.                             Professional Capitation
Rates.


 


1.1          Capitation Rates.  PPG Capitation for Small Group
HMO Members shall be determined on a monthly basis by multiplying the following
normalized PMPM rates by the age, sex and benefit plan factors set forth in
Addendum B for each assigned Member. 
Normalized PMPM rates represent the PMPM prior to the adjustment for
PPG’s assigned Members’ age, sex and benefit plan.  Actual PPG gross Capitation shall fluctuate from month to month
to the extent that PPG’s age, sex and benefit plan mix fluctuates.


 




	
  Small Group

  HMO Capitation

  
	
  Effective
  February 1, 2002, through December 31, 2002, *** PMPM

  
	
  Effective
  January 1, 2003, *** PMPM

  






 


2.             Professional Stop Loss Program.  PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage.


 


3.             Shared Risk Budget.  HMO
shall fund the Shared Risk Budget for Members with normalized rates.  These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum B.  Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and
benefit plan mix fluctuates.


 




	
  Small Group

  HMO Shared Risk Budget

  
	
  Effective
  January 1, 2002, through December 31, 2002, *** PMPM

  
	
  Effective
  January 1, 2003, *** PMPM

  






 


3.2          Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct *** of PPG’s Capitation for Small Group HMO Members and place such
amount in the Withhold Fund as described in the Agreement.


 


In the event
the shared risk claims exceed the shared risk budget at the interim settlement date, HMO may, at its sole
discretion, withhold from PPG’s gross monthly capitation up to five percent
(5%) of PPG’s monthly capitation and may continue such withhold until the
final shared risk settlement.  The
withheld amount shall be placed in the Withhold Fund as described in the
Agreement.  If there is a deficit at the
time of final settlement, HMO may at it’s sole discretion, continue to withhold
up to *** of PPG’s capitation for Small Group HMO Members and place such amount
in the Withhold Fund as described in this agreement.


 


Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk


 


6

















 


Budget.  HMO shall perform both an interim and final
settlement.  In the event that such
claims are less than the Shared Risk Budget for the Interim Period, PPG’s share
of the settlement shall be *** subject to Section 4.3 of this Agreement.


 


Shared Risk
Claims with dates of service within the Reconciliation Period, and paid by March 31 of the following year, shall
be used in the calculation.  Shared Risk
Services incurred within the Reconciliation Period but paid after March 31 of
the following year will be included in the next Reconciliation Period
calculation.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall be paid to PPG by April 30 of the following
year.


 


3.3          Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limned to the lesser of (a) *** of the Shared Risk Budget surplus, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3 of the Agreement, the
Shared Risk Budget surplus shall be offset against any amounts payable by PPG.  Any surplus remaining shall be paid to PPG
by April 30 of the following year.


 


3.4          Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit, PPG’s share of the deficit shall be
limited to the lesser of (a) *** of the Shared Risk Budget deficit, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3, of the Agreement,
any amounts payable by PPG shall be offset against the Withhold Fund -and any
other amounts payable by HMO.


 


In
the event a deficit remains in the Shared Risk Program after such offset, such
deficit shall be carried forward to be applied against future years Shared Risk
Program surpluses and withhold funds.


 


3.5          Shared Risk Reinsurance.  PPG
shall participate in the Shared Risk Reinsurance Program.  The cost to PPG for such participation shall
be calculated as follows:


 


(a)           Out-of-Area Emergency and Urgently Needed
Services:  *** of Shared Risk Budget.


 


Out-of-Area
Emergency and Urgently Needed Services are reimbursed at *** of allowed amount,
and the remaining *** shall be charged against the Shared Risk Budget.


 


(b)           In-Area Shared Risk Services:  *** of Shared Risk Budget.


 


The
cost of in-area Shared Risk Services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as follows:  *** of any amount over ***.


 


4.             AIDS Reinsurance Premium.  As
further defined in Section B.4 of this Addendum B, the Reinsurance Program
rates, as set forth below, shall be deducted from PPG’s Capitation:


	
  •

  	
   

  	
  AIDS Reinsurance effective
  February 1, 2002 thru May 31, 2002

  	
   

  	
  - *** PMPM

  
	
  •

  	
   

  	
  AIDS Reinsurance effective
  June 1, 2002

  	
   

  	
  - *** PMPM

  



 


7

















 


D.    INDIVIDUAL HMO.


 


1.             Professional Capitation Rates.


 


1.1          Capitation Rates.  PPG Capitation for Individual
HMO Members shall be determined on a monthly basis by multiplying the following
normalized PMPM rates by the age, sex and benefit plan factors set forth in
Addendum B for each assigned Member. 
Normalized PMPM rates represent the PMPM prior to the adjustment for
PPG’s assigned Members’ age, sex and benefit plan.  Actual PPG gross Capitation shall fluctuate from month to month
to the extent that PPG’s age, sex and benefit plan mix fluctuates.


 




	
  Individual

  HMO Capitation

  
	
  Effective
  February 1, 2002, through December 31, 2002, *** PMPM

  
	
  Effective
  January 1, 2003, *** PMPM

  






 


2.             Professional Stop Loss Program.  PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage.


 


3.             Shared Risk Program.  PPG
shall participate in an incentive program for Shared Risk Services, which shall
reward PPG for effectively coordinating such care.  Under this Program, a budget shall be established for Shared Risk
Services, and the actual cost of such services shall be compared to the budget.


 


3.1          Shared Risk Budget.  HMO
shall fund the Shared Risk Budget for Members, with normalized rates.  These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan-factors as set forth in
Addendum B.  Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and
benefit plan mix fluctuates.


 




	
  Individual

  HMO Shared Risk Budget

  
	
  Effective January 1, 2002, through December 31, 2002, *** PMPM

  
	
  Effective
  January I, 2003, *** PMPM

  






 


3.2          Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program.  HMO shall deduct *** of PPG’s Capitation for
Individual HMO Members and place such amount in the Withhold Fund as described
in the Agreement.


 


In the event
the shared risk claims exceed the shared risk budget at the interim settlement date, HMO may, at its sole
discretion, withhold from PPG’s gross monthly capitation up to five percent
(5%) of PPG’s monthly capitation and may continue such withhold until the final
shared risk settlement.  The withheld
amount shall be placed in the Withhold Fund as described in the Agreement.  If there is a deficit at the time of final
settlement, HMO may at it’s sole discretion, continue to withhold up to five
percent (5%) of PPG’s capitation for Individual HMO Members and place such
amount in the Withhold fund as described in this agreement.


 


Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget.  HMO shall perform
both an interim and final settlement. 
In the event that such claims are less than the Shared Risk Budget for
the Interim Period, PPG’s share of the settlement shall be seventy-five percent
(75%), subject to Section 4.3 of this Agreement.


 


Shared
Risk Claims with dates of service within the Reconciliation Period, and paid by
March 31 of the following year, shall be used in the calculation.  Shared Risk Services incurred within the
Reconciliation Period but paid after March 31 of the following year will be
included in the next Reconciliation Period calculation.  In the event any amounts remain in the
Withhold Fund following the


 


8

















 


reconciliation of any shared
risk program, those excess funds shall be paid to PPG by April 30 of the
following year.


 


3.3          Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a) *** of the Shared Risk Budget surplus, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3 of the Agreement, the
Shared Risk Budget surplus shall be offset against any amounts payable by PPG.  Any surplus remaining shall be paid to PPG
by April 30 of the following year.


 


3.4          Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit, PPG’s share of the deficit shall be
limited to the lesser of (a) *** of the Shared Risk Budget deficit, or (b) an
amount not to exceed *** of the annual gross PPG Capitation.  Subject to Section 4.3, of the Agreement,
any amounts payable by PPG shall be offset against the Withhold Fund and any
other amounts payable by HMO.


 


In
the event a deficit remains in the Shared Risk Program after such offset, such
deficit shall be carried forward to be applied against future years Shared Risk
Program surpluses and withhold funds.


 


3.5          Shared Risk Reinsurance.  PPG
shall participate in the Shared Risk Reinsurance Program.  The  cost
to PPG for such participation shall be calculated as follows:


 


(a)           Out-of-Area Emergency and Urgently Needed
Services:  *** of Shared Risk Budget.


 


Out-of-Area
Emergency and Urgently Needed Services are reimbursed at eighty percent (80%)
of allowed amount, and the remaining *** shall be charged against the Shared
Risk Budget.


 


(b)           In-Area Shared Risk Services:  *** of Shared Risk Budget.


 


The
cost of in-area Shared Risk services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as follows:  *** of any amount over ***.


 


4.             AIDS Reinsurance Premium.  As
further defined in Section B.4 of this Addendum B, the Reinsurance Program
rates, as set forth below, shall be deducted from PPG’s Capitation:


	
  •

  	
   

  	
  AIDS Reinsurance effective
  February 1, 2002 thru May 31, 2002

  	
   

  	
  - *** PMPM

  
	
  •

  	
   

  	
  AIDS Reinsurance effective
  June 1, 2002

  	
   

  	
  - *** PMPM

  



 


E.             ACCESS FOR INFANTS AND MOTHERS.  The
Access for Infants and Mothers (“AIM”) Program provides health care coverage to
low-income women, pursuant to state law, who are pregnant but without insurance
for such pregnancy.  The AIM Program is
funded by the State through Proposition 99 Cigarette and Tobacco Tax
Revenue.  At such time PPG is certified
by the State for participation in the AIM Program, PPG shall provide Covered
Services for AIM Members as set forth in the Operations Manual.


 


1.             Compensation.  HMO shall pay PPG a flat fee of
*** for each adult AIM Member to cover the professional services related to the
birth of an infant.  In addition to this
flat fee, HMO shall pay PPG *** PMPM for each adult AIM Member enrolled in the
AIM Program.  HMO shall pay PPG *** PMPM
during the first year of life for each infant AIM Member and *** PMPM during
the second year of life.


 


9

















 


2.             Reinsurance Programs.  PPG’s
professional stop loss level shall be per AIM Member.  The professional stop loss level shall be provided to the PPG for
AIM Members at no cost.  All other terms
and conditions of the Agreement regarding Professional Stop Loss shall apply to
AIM Members.


 


AIM
Members shall not be included in the AIDS Reinsurance Program or the Transfer
Reinsurance Program.


 


3.             Shared Risk Programs.  HMO
shall be solely responsible for all Shared Risk services and for pharmacy benefit
costs of AIM Members.


 


F.             MEDICARE SUPPLEMENT.  The
Medicare Supplement Benefit Programs are provided to Members who have primary
coverage through Medicare.  Capitation
for Members enrolled in such Benefit Programs compensates PPG for Copayments
that would be normally a Member’s responsibility under Medicare.


 


1.             Capitation Rates.  PPG Capitation rates for
Medicare Supplement Members shall be at the following PMPM levels, subject to
age, sex and benefit plan factors set forth in Addendum B:


 




	
  Medicare

  Supplement HMO

  	
   

  	
  Medicare

  Supplement POS

  
	
  $***
  PMPM

  	
   

  	
  $***
  PMPM

  






 


2.             Reinsurance Programs. 
Medicare Supplement Members shall not be included in the Professional
Stop Loss Program, the AIDS Reinsurance Program or the Transfer Reinsurance
Program.


 


3.             Shared Risk Program.  HMO
shall be solely responsible for all Shared Risk Services and for pharmacy
benefit costs of Medicare Supplement Members.


 


G.            COMMERCIAL POS.


 


1.             Commercial POS Benefit Program.  Under
a POS Benefit Program, Members may elect, at the time of obtaining each Covered
Service, to utilize:  (i) HMO coverage
through PPG; (ii) coverage by self-referring to any PPO Provider; or (iii)
indemnity coverage for self-referring to non-Participating Providers in accordance
with Benefit Program requirements.  Standard
HMO Members, Small Group HMO Members, Individual HMO Members, Medicare
Supplemental HMO Members and Flex Funded HMO Members may be eligible for
Commercial POS Benefit Programs.


 


2.             Definitions.


 


2.1          In-Network Services.  PPG
Capitated Services and Shared Risk Services provided or arranged through PPG.


 


2.2          Out-of-Network Services.  In
accordance with Benefit Program requirements, Covered Services provided as a
result of a Member’s self-referral to a PPO or HMO Provider or to a
non-Participating Provider. 
Out-of-Network Services may be provided in area or out of area.


 


3.             Compensation.  Compensation to PPG for
Commercial POS Members shall include: 
a) PPG professional Capitation for In-Network professional services, b)
any surplus resulting from the Professional Out-of-Network Shared Risk Program,
and c) any surplus resulting from the Institutional In-Network and
Out-of-Network Shared Risk Program.


 


10

















 


3.             Professional Capitation Rate.  PPG
shall be compensated for rendering professional In-Network Services to
Commercial POS Members at the PMPM amounts set forth for Commercial HMO
Members, less a *** Withhold (Professional Capitation).  This Withhold shall partially fund the
Professional Out-of-Network Budget.


 


Effective
January 1, 2003, PPG shall be compensated for rendering professional In-Network
Services to Commercial POS Members at the PMPM amounts set forth for Commercial
HMO Members, less a *** Withhold (Professional Capitation).  This Withhold shall partially fund the
Professional Out-of-Network Budget.


 


5.             Professional Out-of-Network Risk Sharing Program.  The
budget for this Program shall be equal to the sum of the following two
components:  1) The Professional
Out-of-Network Withhold as described in Section 4 above, and 2) an amount equal
to *** of the Commercial POS Professional Capitation prior to withhold.


 


Each
year, HMO shall settle the risk sharing program by calculating the difference
between the budget and the actual claims. 
If a surplus remains, PPG’s share shall be fifty percent not to exceed
*** of PPG’s annual gross capitation, subject to Section 4.3.  PPG shall not be subject to any downside.


 


6.             Institutional Shared Risk Program.


 


6.1          POS Shared Risk Budgets.  The
budgets shall be determined for each Commercial POS population:  Standard POS, Small Group POS and, at a
later date, Individual POS Members. 
Each Budget shall cover In-Network, Out-of-Network and Out-of-Area
Shared Risk Services.  Each of the
normalized Shared Risk Budgets shall be equal to the normalized HMO Shared Risk
Budget, or institutional capitation PMPM, if applicable, and multiplied by
***.  Actual Shared Risk Budget shall
fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.


 


	
  Standard POS Shared Risk

  + 10%=

  	
   

  	
  Small
  Croup POS

  Shared Risk

  + 10%=

  	
   

  	
  Individual
  POS

  Shared Risk

  + 10%=

  	
   

  
	
  Effective January 1, 2002 through December
  31, 2002, $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  
	
  Effective January 1, 2003, *** PMPM

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  



 


6.2          POS Shared Risk Administration.  Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget.  HMO shall perform
both an interim and final settlement. 
In the event any amounts remain in the Withhold Fund following the
reconciliation of any shared risk program, those excess funds shall be paid to
PPG by April 30 of the following year. 
In the event that such claims are less than the Shared Risk Budget for
the Interim Period, PPG’s share of the settlement shall be seventy-five percent
(75%), subject to Section 4.3 of this Agreement.


 


Shared Risk
Claims with dates of service within the Reconciliation Period and paid by March 31 of the following year shall
be used in the calculation.  Shared Risk
Services incurred within the Reconciliation Period but paid after March 31 of
the following year will be included in the next Reconciliation Period calculation.


 


6.3          POS Shared Risk Budget Surplus.  In
the event of a POS Shared Risk Budget surplus, PPG’s share of the surplus shall
be limited to the lesser of (a) *** or (b) an amount not to exceed *** of the
annual gross PPG Capitation.


 


11

















 


6.4          POS Shared Risk Budget Deficit.  In
the event of a POS Shared Risk Budget deficit, PPG shall not be liable for the
deficit.


 


6.5          POS Shared Risk Reinsurance.  PPG
shall participate m the POS Shared Risk Reinsurance Program, which provides
reinsurance for In-Network and Out-of-Network services.  The cost to PPG for the POS Shared Risk
Reinsurance Program shall be calculated as follows:


 


(a)           Out-of-Area Emergency and Urgently Needed Services:  ***% of POS Shared Risk Budget.


 


Out-of-Area
Emergency and Urgently Needed Services shall be reimbursed at eighty percent (80%) of cost, and the
remaining *** of the cost shall be charged against the POS Shared Risk Budget.


 


(b)           In-Network and Out-of-Network POS Shared Risk Services:  ***% of POS Shared Risk Budget.


 


The
cost of In-Network and Out-of-Network POS Shared Risk Services during the
Reconciliation Period shall be charged against the POS Shared Risk Budget as
follows:  *** of any amount over ***


 


7.             Professional Stop Loss Program.  The
Professional Stop Loss Program includes coverage for In-Network Services, an
optional program, as well as for Out-of-Network Services, a program in which
PPG’s participation is required.


 


(a)           In-Network Professional Stop Loss. PPG elects not to participate in the
Professional Stop Loss Program.  PPG
shall provide HMO with proof of Professional Stop Loss coverage.


 


(b)           Out-of-Network Professional Stop Loss. PPG’s Out-of-Network Professional
Stop Loss threshold shall be *** per Commercial POS Member during the calendar
year.  The cost to PPG for the
Out-of-Network Professional Stop Loss program shall be *** PMPM, which, shall
be deducted from PPG’s Out-of-Network Risk Sharing Budget.


 


8.             AIDS Reinsurance.  As
further defined in Section B.4 of this Addendum, the AIDS Reinsurance rate
shall be *** PMPM, which shall be deducted from PPG’s Capitation and *** PMPM
shall be deducted from PPG’s Professional Out-of-Network Risk Sharing
Budget.  For the subsequent years, these
deductions shall fluctuate to correspond with the Professional Out-of-Network
Withhold percentage change.


 


I.              Pharmacy Shared Risk Program.  Not
applicable.  PPG does not participate in
Pharmacy Shared Risk Program.


 


J.             Immunizations:  PPG
assumes financial responsibility for immunization under the capitation rate set
forth in this Addendum.  New
immunizations approved by American Academy of Pediatrics, after the effective
date of the Agreement, shall be reimbursed at rates that are negotiated based
on experiential data, which shall be mutually agreed upon by HMO and PPG.


 


12

















 


ADDENDUM B.2


 


DIVISION OF RESPONSIBILITY

MATRIX OF HMO, PPG AND SHARED RISK/HOSPITAL CAPITATED SERVICES


 


COMMERCIAL HMO AND POINT OF SERVICE BENEFIT
PROGRAMS


 


The following matrix
outlines the division of financial responsibility between HMO, PPG and
Hospital.  The matrix is intended only
as a summary guide.  The applicable
Subscriber’s Certificate should be consulted for an accurate and complete
description of Covered Services and the Provider Operations Manual for
clarification.


 


MATRIX EFFECTIVE 2/1/2002


 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Storage and Collection of
  Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient Professional
  Component Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Detox Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Inpatient Detox
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Drugs, including Epogen,
  Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COSMETIC SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Medically
  Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


13

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  DENTAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DIAGNOSTIC
  TESTING - Outpatient
  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – Out of
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS – In
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPITAL
  BASED PHYSICIANS -Inpatient, Ambulatory Surgery or
  Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


14

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTABLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IN PATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF &
  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE
  ADMISSION -
  Outpatient Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (within 72 hrs. or related
  admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation Therapy-Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical/Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation Therapy-Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical/facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


15

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  RADIOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Related to a Hospital Stay:

  Surgical Supplies, Equipment, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Related to an Outpatient Office Visit:

  Splints, Casts, Bandages, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Chem Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY  –
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY: 
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Exams and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


16

















 


ADDENDUM I


 


HEALTHY FAMILIES PROGRAM


 


PPG
understands and agrees that the obligations of HNI set forth in this Addendum
shall be the obligations of HEALTH NET of California, (HEALTH NET), an
Affiliate of HNI, and not the obligations of HNI or any other Affiliate of HNI.


 


HEALTH
NET entered into an agreement with the California Managed Risk Medical
Insurance Board (“MRMIB”) to arrange for the provision of Covered Services to
persons who are eligible under the California Children’s Health Insurance
Program (aka and hereinafter “Healthy Families Program”) and enrolled in, or
otherwise assigned to HEALTH NET, on a prepaid basis.  The Healthy Families Program is a government sponsored health
care program administered by the State of California, funded in part by federal
funds, and arranged by HMOs and their participating providers.


 


Notwithstanding
any provision in the Agreement to the contrary, PPG understands and agrees that
PPG shall arrange and provide health care services to Healthy Families Members
in accordance with the benefits and program requirements of the Healthy
Families Agreement.  PPG understands
that Evidence of Coverage documents are subject to change and approval by MRMIB
and PPG hereby agrees to arrange and provide health care services in accordance
with such changes.


 


A.    GENERAL PROVISIONS


 


1.             Provision of Covered Services.  PPG
shall arrange Covered Services for assigned Members.  For the purposes of this Addendum, “Covered Services” means those
health care services, supplies and items set that are specified as being
covered under the Healthy Families Agreement. 
PPG shall ensure that it and its Participating Providers arrange Covered
Services for Members, in accordance with the following, each of which is hereby
incorporated by reference as if set out in full herein:


 


1.1           The terms and conditions of this Addendum and the Agreement.


 


1.2           The terms and conditions of HEALTH NET’s Healthy Families Agreement with
MRMIB, and the applicable Evidence of Coverage.


 


1.3           HEALTH NET’s Healthy Families policies and procedures and provider
bulletins.


 


1.4           Healthy Families Program regulations and statutes.


 


1.5           All laws applicable to PPG or HEALTH NET.


 


1.6           HEALTH NET’s Utilization Management Program and Quality Management
Program.


 


1.7           Standards requiring services to be provided in the same manner, and with
the same availability, as services are rendered to other patients.


 


1.8           No less than the minimum clinical quality of care and performance
standards that are professionally recognized and/or adopted, accepted or
established by HEALTH NET


 


1.9           The most recent recommendations of the American Academy of Pediatrics
(AAP) with regard to Recommendations for Preventative Pediatric Health Care, or
other preventative care standards mandated by MRMIB


 


2.             Reports and Information.  PPG
and its Participating Providers shall provide HEALTH NET,


 


17

















 


within the time requested by
HEALTH NET, with all such reports and information as HEALTH NET may require to
allow it to meet the reporting requirements under the Healthy Families
Agreement or any applicable law.  Such
reporting obligations include, but are not limited to, monthly reporting to
HEALTH NET of referrals of Members to the following programs:  California Children’s Services, referrals of
Members with possible Serious Emotional Disturbance to the County Mental Health
Department, and alcohol and drug treatment referrals to Managed Health Network.


 


3.             Carve-out of California
Children’s Services (CCS) Program services.  Health care services to treat
CCS-eligible conditions are “carved out” of HEALTH NET’s coverage obligations
under the Healthy Families Agreement. 
However, PPG and us Participating Providers are required to identify and
timely refer Members with possible CCS-eligible conditions to the County CCS
Program.  Upon referral, the
Participating Provider shall inform the Member’s parent or guardian.  The CCS Program requires eligible children
to be treated at CCS-certified facilities by CCS-paneled providers.  The CCS Program may require transfer to CCS-certified
facilities with CCS-paneled providers. 
The CCS Program is financially responsible for payment of health care
costs to treat a CCS-eligible condition. 
The parties understand and agree that HEALTH NET is not financially
responsible for payment of services related to CCS-eligible conditions.


 


4.             Referral of Members having possible mental health
conditions to Managed Health Network.  PPG and its Participating
Providers are required to identify and timely refer Members with possible
mental health conditions (other than Serious Emotional Disturbance as set out
in the following section) to HEALTH NET’s affiliate and subcontractor, Managed
Health Network.  Managed Health Network
is financially responsible for payment of treatment of covered mental health
services.


 


5.             Services for Members with Serious Emotional Disturbance
(SED).  Health care services to treat SED are the
responsibility of the County Mental Health Department.  However, PPG and its Participating Providers
are required to identify and timely refer Members with possible SED to the
County Mental Health Department.  Upon
referral, the Participating Provider shall inform the Member’s parent or
guardian.  The County Mental Health
Department is responsible for the provision and payment of health care costs to
treat SED.


 


6.             Cultural and Linguistic Services.  PPG
and its Participating Providers shall: 
(1) not require or encourage Members to utilize family members or
friends as interpreters; (2) record the language needs of Members in the
medical record; and (3) document Member request or refusal of interpreter
services in the Member’s medical record. 
PPG and its Participating Providers shall arrange interpreter services
for Members either through telephone language services or face-to-face
interpreters.  PPG and its Participating
Providers are encouraged to directly make these interpretive services
available, however, HEALTH NET’s Member Services Department is available to
provide certain interpretive assistance to facilitate Member-provider
communications upon request.


 


7.             Initial Health Assessments.  PPG
and its Participating Providers shall offer an initial health assessment to
their assigned members within 120 days of their enrollment in HEALTH NET’s
Healthy Families Plan.


 


8.             Eligibility.  Eligibility and commencement of
enrollment under Healthy Families is determined by MRMIB.  Commencement of coverage can occur at any
day of a month.


 


9.             Copayments.  Copayments are subject to a
$250 annual limitation and PPG and its Participating Providers are encouraged
to make extended payment arrangements available to Members experiencing an
inability to pay a required copayment.


 


B.            REIMBURSEMENT PROVISIONS


 


1.             PPG shall be compensated according to this
Addendum I and this Addendum shall be applicable to only those Healthy Families
listed on the Commercial HMO remittance summaries.  HNI will modify this Addendum I to reflect a new rate structure
for adults, pending federal approval of expanding this program to parents


 


2.             Compensation for PPG
Capitated Services.  As compensation for rendering PPG Capitated
Services.  HEALTH NET shall pay PPG
Capitation as set forth in this Addendum I for each Healthy Families


 


18

















 


Member to receive services
from PPG during any particular month. 
Capitation shall be payable on a per Member per month (PMPM) basis.  Capitation shall be computed on the basis of
the most current information available and shall be paid by HEALTH NET by wire
transfer on or before the fifteenth (15th) day of each month or the first
business day following the fifteenth if the fifteenth is a holiday or on a
weekend.  Each Capitation payment shall
be accompanied by a remittance summary. 
The remittance summary identifies the total Capitation payable and those
Healthy Families Members for whom Capitation is being paid.  In the event of a Capitation error,
resulting in an overpayment or underpayment to PPG, HEALTH NET shall adjust
subsequent Capitation to offset such error.


 


3.             Compensation to Other
Providers of PPG Capitated Services.  PPG shall compensate all
providers who render PPG Capitated Services to Healthy Families Members
assigned to PPG.  In the event that PPG
does not process and pay eligible claims submitted to PPG for Capitated
Services within applicable time limits. 
HEALTH NET may pay such claims at the lesser of HEALTH NET’S contract
rate with such provider, if any, PPG’s subcontract terms or provider’s billed
charges.  HEALTH NET shall deduct any
such claim amounts paid from PPG’s Capitation, as set forth in the Operations
Manual.


 


4.             Contracted Services.  PPG
and Member Physicians shall render Contracted Services which are not PPG
Capitated Services to Members covered under this Addendum I and shall be
compensated on a fee-for-service basis at one hundred percent of the Medi-Cal
Fee Schedule.  PPG shall submit claims
in accordance with the terms of this Agreement and State and federal law.


 


5.             Withhold Fund and
Determination of Maximum Downside of Shared Risk Deficits. 
Notwithstanding any provision in this Agreement or in any Addendum
hereto to the contrary.  PPG’s total downside
liability for all Shared Risk Budget deficits shall not exceed *** of PPG’s
gross annual Capitation.  Any and all
Withhold Fund amounts, if applicable, as set forth herein shall be applied to
offset such total downside liability.


 


6.             Newborns.  PPG
shall provide Covered Services to a child born to a Member for the month of
birth and the following month.  For a
child born in the month immediately preceding the mother’s membership.  PPG shall provide Covered Services to the
child during the mother’s first month of enrollment.  No additional Capitation Compensation will be made to PPG for the
child for such periods under these circumstances.


 


7.             Professional Capitation
Rates.


 


7.1           Capitation Rates.  PPG
Capitation for Healthy Families Members shall be determined on a monthly basis
by multiplying the number of members by the flat capitation amount set forth in
Addendum I.


 




	
  Healthy Families Capitation

  
	
  ***
  PMPM

  






 


8.             Professional Stop Loss.  PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage.


 


9.             Shared Risk Program.  PPG
shall participate in an incentive program for Shared Risk Services, which shall
reward PPG for effectively coordinating such care.  Under this Program, a budget shall be established for Shared Risk
Services, and the actual cost of such services shall be compared to the budget


 


9.1           Shared Risk Budget. 
HEALTH NET shall fund the Shared Risk Budget for Members, with
normalized rates.  These normalized
rates shall be adjusted for PPG’s assigned Members by the age, sex and benefit
plan factors as set forth in Addendum B. 
Actual Shared Risk Budget shall fluctuate from month to month to the
extent that PPG’s age, sex and benefit plan mix fluctuates.


 




	
  Healthy Families Shared Risk Budget

  
	
  January
  1, 2002, through December 31, 2002, *** PMPM

  
	
  January
  1, 2003, $49.00 PMPM

  






 


19

















 


9.2           Shared Risk Administration.  Each
Reconciliation Period, HEALTH NET shall calculate Shared Risk Claims in
accordance with the Operations Manual and compare such claim cost to the
corresponding Shared Risk Budget. 
HEALTH NET shall perform both an interim and final settlement.  In the event that such claims are less than
the Shared Risk Budget for the Interim Period, PPG’s share of the settlement
shall be seventy-five percent (75%), subject to Section 4.3 of this Agreement.


 


Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period calculation.  In the event any amounts remain in the
Withhold Fund following the reconciliation of any shared risk program those
excess funds shall be paid to PPG by April 30 of the following year.


 


9.3           Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus. 
PPG’s share of the surplus shall be limited to the lesser of (a) *** of
the Shared Risk Budget surplus, or (b) an amount not to exceed *** of the
annual gross PPG Capitation.  Subject to
Section 4.3 of the Agreement, the Shared Risk Budget surplus shall be offset
against any amounts” payable by PPG. 
Any surplus remaining shall be paid to PPG by April 30 of the following
year.


 


9.4           Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit. 
PPG’s share of the deficit shall be limited to the lesser of (a) *** of
the Shared Risk Budget deficit, or (b) an amount not to exceed *** of the
annual gross PPG Capitation.  Subject to
Section 4.3, of the Agreement, any amounts payable by PPG shall be offset
against the Withhold Fund and any other amounts payable by HEALTH NET.


 


In the event a deficit remains in the Shared Risk Program after such
offset, such deficit shall be carried forward to be applied against future
years Shared Risk Program surpluses and withhold funds.


 


9.5           Shared Risk Reinsurance.  PPG
shall participate in the Shared Risk Reinsurance Program.  The cost to PPG for such participation shall
be calculated as follows:


 


(a)           Out-of-Area Emergency and Urgently Needed
Services:  ***  of Shared Risk Budget.


 


Out-of-Area
Emergency and Urgently Needed Services are reimbursed at eighty percent (80%)
of allowed amount, and the remaining *** shall be charged against the Shared
Risk Budget.


 


(b)           In-Area Shared Risk Services:  *** of Shared Risk Budget.


 


The
cost of In-Area Shared Risk Services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as follows:  *** of any amount over ***.


 


10.           AIDS Reinsurance Programs.  On a
network wide basis, reinsurance programs shall be established by HEALTH NET to
cover the payment of expenses incurred in the treatment of Members who have
been diagnosed with Acquired Immune Deficiency Syndrome (“AIDS Members”).


 


10.1         AIDS Reinsurance. 
Professional, institutional, and pharmacy costs for AIDS Members shall
be the financial responsibility of HEALTH NET, as set forth in the Operations
Manual.  Additionally, the pharmacy cost
for HIV drugs shall be the financial responsibility of HEALTH NET under this
Program.  PPG shall receive prior
authorization from HEALTH NET for an elective inpatient admission of an AIDS
Member.  In addition, PPG shall provide
HEALTH NET with timely notification of any urgent/emergent admission of any
AIDS Member who is receiving anti-viral home treatments, or of any AIDS Member
who is receiving total parenteral nutrition. 
For purposes of this paragraph, timely notification is within
twenty-four (24) hours of an admission or the initial treatment.  In the event PPG fails


 


20

















 


to
notify HEALTH NET as set forth in this paragraph, AIDS related claims for such
Members shall not be eligible for payment under this Program.


 


10.3         AIDS Reinsurance Premium.  The
Reinsurance Program rates, as set forth below, shall be deducted from PPG’s
Capitation:


	
  •

  	
   

  	
  AIDS Reinsurance effective
  February 1, 2002 thru May 31, 2002

  	
   

  	
  - *** PMPM

  
	
  •

  	
   

  	
  AIDS Reinsurance effective
  June 1, 2002

  	
   

  	
  - *** PMPM

  



 


11.           Immunizations:


 


11.1         Immunizations: 
Claims for immunizations approved by the American Academy of Pediatrics
and administered by PPG shall be submitted to HNI using the HCFA 1500 forms and
billed using the appropriate CPT-4 codes. 
Compensation shall be the lesser of a) the PPG’s billed charges; b) the
Average Wholesale Price (AWP) as established by First Databank and as reflected
in HNI’s database which is updated semi-annually, less *** or c) the lowest
acquisition cost provided through services made available by HNI.  AWP reimbursement is based on the lowest AWP
for the specific antigen.  Multi-dose vials
shall be reimbursed on a per dose basis.


 


21

















 


ADDENDUM I.1


 


AGE, SEX AND BENEFIT FACTORS


 


The age, sex and benefit plan
factors shall be developed by HEALTH NET based upon actuarial assumptions
consistent with existing actuarial assumptions and HEALTH NET’s utilization
experience.  Such factors, as updated
approximately every three years to reflect changing demographic and utilization
patterns, shall be forwarded to PPG and are incorporated into this Agreement by
reference.


 


A.            Age, Sex and Benefit Plan Factors for PPG Capitation
and Shared Risk Budgets:


 


A.1          Age, Sex Factors for PPG Capitation and Hospital Capitation/Shared Risk
Budgets.


 




	
  Sex

  	
   

  	
  Age

  	
   

  	
  Inst

  Factor

  
	
  Child

  	
   

  	
  0

  	
   

  	
  5.228

  
	
   

  	
   

  	
  1

  	
   

  	
  0.644

  
	
   

  	
   

  	
  2 – 4

  	
   

  	
  0.406

  
	
   

  	
   

  	
  5 – 9

  	
   

  	
  0.296

  
	
   

  	
   

  	
  10 – 14

  	
   

  	
  0.338

  
	
   

  	
   

  	
  15 – 19

  	
   

  	
  0.607

  






 


A.2          Benefit Plan Factors for PPG Capitation and Hospital Capitaion/Shared
Risk Budgets


 


Healthy
Families




	
  Plan

  	
   

  	
  Inst

  Factor

  
	
  9Y

  	
   

  	
  0.9334

  
	
  TBA

  	
   

  	
   

  
	
  TBA

  	
   

  	
   

  






 


22

















 


ADDENDUM I.2


 


DIVISION OF RESPONSIBILITY

MATRIX OF HMO, PPG AND SHARED RISK/HOSPITAL CAPITATED SERVICES


 


HEALTHY FAMILIES PROGRAM


 


The following matrix outlines
the division of financial responsibility between HMO, PPG and Hospital.  The matrix is intended only as a summary
guide.  The applicable Subscriber’s
Certificate should be consulted for an accurate and complete description of
Covered Services and the Provider Operations Manual for clarification.  CCS-eligible services are excluded from HMO
Risk Services.


 


MATRIX EFFECTIVE 2/1/2002


 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS – Drugs-Children 0-21 years

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Drugs-Adults 21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Facility Component-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Facility Component-Adults 21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Professional Component-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS – Professional Component-Adults 21 and
  older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  In
  Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Out
  of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD
  PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Autologous/Homologous Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Drugs, including Epogen, Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


23

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  COSMETIC
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DIAGNOSTIC
  TESTING - Outpatient
  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – Out of
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS – In
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •       Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


24

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  HOSPITAL
  BASED PHYSICIANS –

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Inpatient,
  Ambulatory Surgery or Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTABLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF & GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY – Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL HEALTH – Inpatient-Serious Emotional
  Disturbances (SED)-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL HEALTH – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL HEALTH – Outpatient-Serious Emotional Disturbance(SED)-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


25

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  PATHOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE
  ADMISSION –
  Outpatient Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (within 72 hrs. or related
  admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Related to a Hospital Stay:

  Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Related to an Outpatient Office Visit:

  Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Chem, Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY: 
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


26

















 


	
   

  	
   

  	
  PPG

  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/

  HOSPITAL

  CAPITATED

  SERVICES

  
	
  TRANSPLANTS (Non-experimental)-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS (Non-experimental)-Adults 21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS-Children
  0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS-Adults
  21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Exams

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


27