Exhibit 10.133


 


FIRST
AMENDMENT TO


PACIFICARE
OF CALIFORNIA


MEDICAL
GROUP/IPA SERVICES AGREEMENT


(PROFESSIONAL
CAPITATION)


 


This First Amendment to the PacifiCare Medical Group/IPA Services
Agreement (the “Amendment”) is effective January 1, 2002 by and between
PacifiCare of California, a California corporation (“PacifiCare”), and Prospect
Medical Group (“Medical Group”), with respect to the following facts:


 


RECITALS


 


A.                                   The parties have
previously entered into that certain PacifiCare Medical Group/IPA Services
Agreement effective January 1, 2001, (the “Agreement”).


 


B.                                     The parties desire
to amend the terms of the Agreement in the manner set forth herein.


 


NOW, THEREFORE, in consideration of the
foregoing, the parties hereto agree as follows:


 


1.                                       INCENTIVE
PROGRAMS.  Section 5.4.1,
Incentive Program Withhold, of the Agreement shall be deleted and replaced with
the following language.


 


5.4.1 Incentive Program Withhold.  PacifiCare shall establish a single withhold
from Medical Group’s monthly Capitation Payment for purposes of offsetting
potential deficits for the combined incentive programs.  The monthly incentive withhold shall
initially be *** per Member per month for the PacifiCare Commercial Health Plan
and Twenty Five Dollars ($25.00) per Member per month for the Secure Horizons
Health Plan.  The Incentive Program
Withhold shall not exceed *** per Member per month for the PacifiCare
Commercial Health Plan and *** per Member per month for the Secure Horizons
Health Plan.  Should the Incentive
Program Withhold exceed the Incentive Program Deficits, PacifiCare shall
prospectively adjust the withhold on a quarterly basis, based on Medical
Group’s experience under the combined incentive programs at the time of the
program settlements described below. 
Medical Group’s Incentive Program Withhold limits, as referenced above,
are based upon a calendar year.  To the
extent that Incentive Program Withhold amounts are decreased through the
quarterly settlement process, these amounts may be subsequently increased above
the stated withhold limits, provided that the average per member per month
Incentive Program Withhold for the calendar year does not exceed the stated
withhold limits.


 


2.                                       INCENTIVE
PROGRAMS.  Section 5.4.2,
Incentive Program Settlements, of the Agreement shall be deleted and replaced
with the following language.


 












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


 


1

















 


PacifiCare shall conduct combined settlements on a quarterly basis,
inclusive of a reserve allowance for incurred but not reported claims expense,
for all of the incentive programs for Managed Care Plans applicable to Medical
Group.  Surpluses and deficits under
each of the incentive programs shall be aggregated and offset against one
another, Payments shall be made to the Medical Group within seventy five (75)
days after the end of each calendar quarter. 
Should the withhold amount exceed that of the deficits in the Incentive
Program, PacifiCare will adjust the withhold amount to support the applicable
deficit in the Incentive Program.


 


PacifiCare will conduct a final calculation annually (the “Final
Calculation”) based on the contract calendar year.  The incentive program withhold described above shall be refunded
to the Medical Group at the time of the incentive program settlements, except
that Medical Group’s share of any incentive program deficits shall be deducted
from such refund.  Payments under the
combined incentive programs will be due from the owing party within one hundred
and eighty (180) days following the end of the contract calendar year for the
Final Calculation.  To the extent a
Medical Group deficit has been carried forward from a prior settlement period,
this deficit shall be offset against amounts due to Medical Group
hereunder.  In the event that claims for
providers were incurred during the contract calendar year in question but were
not paid until after the final calculation, such costs shall be carried forward
and applied to the subsequent contract calendar year’s incentive program as an
expense for that contract calendar year.


 


Incentive Program Compliance with State and Federal Law.  PacifiCare and Medical Group acknowledge and
agree that the payments which may be made directly or indirectly under the
incentive programs described in this Agreement are not made as an inducement to
reduce or limit Covered Services to any specific Member.  Medical Group acknowledges and agrees that
any payments which may be made directly or indirectly under physician incentive
programs Medical Group may utilize with respect to its Participating Providers
shall not be made as an inducement to reduce or limit Covered Services to any
specific Member.  Medical Group further
acknowledges and agrees that the incentive programs described in this Agreement
shall be subject to modification by PacifiCare during the term of this
Agreement in order to comply with changes in State and Federal Law, and Medical
Group further agrees to modify any physician incentive programs utilized with
respect to its Participating Providers to comply with such changes.


 


3.                                       PRODUCT
ATTACHMENT A, PACIFICARE COMMERCIAL HEALTH PLAN shall be deleted in its
entirety from the Agreement and replaced with the attached PRODUCT ATTACHMENT
A.


 


4.                                       PRODUCT
ATTACHMENT B, PACIFICARE COMMERCIAL POTNT-OF-SERVICE PLAN shall be deleted
in its entirety from the Agreement and replaced with the attached PRODUCT
ATTACHMENT B.


 


2

















 


5.                                       PRODUCT
ATTACHMENT C, SECURE HORIZONS HEALTH PLAN shall be deleted in its entirety
from the Agreement and replaced with the attached PRODUCT ATTACHMENT C.


 


6.                                       DIVISION
OF FINANCIAL RESPONSIBILITY shall be deleted in its entirety from the
Agreement and replaced with the attached DIVISION OF FINANCIAL RESPONSIBILITY.


 


7.                                       Use
of Defined Terms.  Terms utilized in
this Amendment shall have the same meaning set forth in the definitions to the
Agreement.


 


8.                                       Existing
Agreement Remains in Full Force and Effect.  Except as specifically amended by this Amendment, the Agreement
shall continue in full force and effect.


 


9.                                       Representations
and Warranties.  The parties to this
Agreement represent and warrant that they have read the Agreement and this
Amendment in their entirety; that they fully understand their rights and
obligations under this Agreement; that they have executed this Agreement freely
and voluntarily; that the Agreement, as amended, constitutes the entire
understanding and agreement between the parties.  The parties hereto further represent and warrant that they have
had the time and opportunity to consult with attorneys and financial advisors
of their choice in connection with the negotiation of this Amendment and the
parties’ decision to enter into this Amendment.  Neither party has relied upon the other party to determine the
reasonableness or enforceability of the terms of this Amendment.


 


IN WITNESS WHEREOF, the undersigned parties
hereby agree to this Amendment as of the dates set forth below.


 


 


	
   

  	
  PACIFICARE OF CALIFORNIA,

  A California corporation

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
  Name:

  	
  Brian Jeffrey

  
	
   

  	
  Title:

  	
  Vice President, Network Management

  
	
   

  	
  Date:

  	
  12/7/??

  	
   

  
							



 


3

















 


	
   

  	
  PROSPECT MEDICAL GROUP

  A California professional corporation

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Peter G. Goll

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Name:

  	
  Peter
  G. Goll

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Title:

  	
  Senior
  Vice President

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  12-5-01

  	
   

  
							



 


4

















 


PRODUCT ATTACHMENT A


 


PACIFICARE COMMERCIAL HEALTH
PLAN


 


This Product Attachment A, along with the
Base Agreement, sets forth the specific terms and conditions which are
applicable to the PacifiCare Commercial Health Plan, as defined below.


 


ARTICLE l


DEFINITIONS


 


The following terms shall have the meaning
attributed below for purposes of the PacifiCare Commercial Health Plan, as
described in this Product Attachment A. 
Capitalized terms not otherwise defined herein shall have the meaning
assigned to them in the Base Agreement.


 


1.1                                 OPM
Agreement is the agreement between PacifiCare and the Federal Office of
Personnel Management for the provision of Covered Services to persons enrolled
in the PacifiCare Commercial Plan through their participation in the health
benefits programs for federal employees and their dependents.


 


1.2                                 Commercial
Plan Premium is the premium received by PacifiCare each month for
PacifiCare Commercial Plan Members, excluding amounts to pay broker and agent
commissions/compensation, Premium taxes and premiums for Supplemental Benefits.


 


1.3                                 PacifiCare
Commercial Plan is any and all of the various Managed Care Plans sold by
PacifiCare to individuals (excluding individuals eligible for the PacifiCare
Medicaid Plan and the Secure Horizons Health Plan) and employer groups,
associations with employer group participation and unions which purchase
benefits for their employees and their dependents.


 


1.4                                 Commercial
Plan Members are Medical Group Members enrolled in the PacifiCare
Commercial Plan.


 


1.5                                 Supplemental
Benefits are benefits offered under the PacifiCare Commercial Plan which
require separate premium, in addition to the Commercial Plan Premium, as
consideration for the additional benefits.


 


ARTICLE 2


DUTIES OF
MEDICAL GROUP


 


2.1                                 Provision
of Covered Services.  Medical Group
and its Participating Providers shall provide Covered Services to Commercial
Plan Members pursuant to the terms of the Base Agreement and this Product
Attachment A.


 


2.2                                 Compliance
with OPM Agreement.  Medical Group
shall comply with all requirements in the OPM Agreement which are applicable to
Medical Group as a subcontractor of PacifiCare as a result of this
Agreement.  Without limiting the
foregoing, Medical Group shall ensure that all


 


5

















 


provisions of the OPM Agreement, which are
applicable to Medical Group’s Participating Providers are included in Medical
Group’s subcontracts with its Participating Providers.  A copy of the OPM Agreement shall be
provided to Medical Group concurrent with the execution of this Agreement.


 


2.3                                 Compliance
with Subscriber Agreements for PacifiCare Commercial Plan.  Medical Group and its Participating
Providers shall comply with all requirements in Subscriber Agreements for the
PacifiCare Commercial Plan, which are applicable to Medical Group.  PacifiCare shall make good faith efforts to
notify Medical Group of any such requirements that are not otherwise reflected
in this Agreement.


 


ARTICLE 3


COMPENSATION


 


3.1                                 Age/Gender/Benefit
Adjusted Commercial Capitation. 
Capitation Payments to Medical Group for Commercial Plan Members shall
be made based upon a per Member per month base capitation rate (“Base
Capitation Rate”) adjusted to reflect the Medical Group Members’ age, gender,
and benefit plan participation.  The
Base Capitation Rate shall be *** per Commercial Plan Member per month for
Prospect North (PacifiCare DEC# 3948). 
The Base Capitation Rate shall be *** per Commercial Plan Member per
month for Prospect Central (PacifiCare DEC# 11276).  The Base Capitation Rate shall be *** per Commercial Plan Member
per month for Prospect South (PacifiCare DEC# 11277).  The Base Capitation Rate shall be *** per Commercial Plan Member
per month for Nuestra Familia Medical Group (PacifiCare DEC# 11315).  For the month of January 2002, the base
capitation using the November 2001 membership demographics, shall yield
*** per member per month.  Age/gender
adjustment factors are actuarially determined and are listed below.  Benefit adjustment factors are actuarially
determined and may take into consideration variations in benefit plan types,
copay and coinsurance levels. 
PacifiCare may change its benefit adjustment factors as needed to
support the differing plan types that it offers.  On an annual basis, PacifiCare may modify the benefit adjustment
factors based on actuarially determined changes.  The average capitation rate will vary during subsequent months as
a result of changes in the age, gender, and benefit plan participation of the
Medical Group’s Members for the applicable month.  The total monthly Capitation Payment shall also be adjusted in
the manner set forth in Article 5 of the Base Agreement.


 


The following are PacifiCare’s
age/gender adjustment factors:


 




	
  Child 0

  	
   

  	
  1.9939

  
	
  Child 1

  	
   

  	
  1.2664

  
	
  Child 2 - 9

  	
   

  	
  0.4730

  
	
  Child 10 - 17

  	
   

  	
  0.4375

  
	
  Female 18 - 19

  	
   

  	
  0.7395

  
	
  Female
  20 - 24

  	
   

  	
  1.4564

  






 


6

















 




	
  Female 25 - 29

  	
   

  	
  1.6593

  
	
  Female 30 - 34

  	
   

  	
  1.4785

  
	
  Female 35 - 39

  	
   

  	
  1.2495

  
	
  Female 40 - 44

  	
   

  	
  1.3095

  
	
  Female 45 - 49

  	
   

  	
  1.2221

  
	
  Female 50 - 54

  	
   

  	
  1.5869

  
	
  Female 55 - 59

  	
   

  	
  1.7404

  
	
  Female 60 - 64

  	
   

  	
  2.0135

  
	
  Female 65 plus

  	
   

  	
  2.0630

  
	
  Male 18 - 19

  	
   

  	
  0.3554

  
	
  Male 20 - 24

  	
   

  	
  0.4774

  
	
  Male 25 - 29

  	
   

  	
  0.5702

  
	
  Male 30 - 34

  	
   

  	
  0.6033

  
	
  Male 35 - 39

  	
   

  	
  0.7038

  
	
  Male
  40 - 44

  	
   

  	
  0.7700

  
	
  Male 45 - 49

  	
   

  	
  0.8742

  
	
  Male 50 - 54

  	
   

  	
  1.3235

  
	
  Male 55 - 59

  	
   

  	
  1.7024

  
	
  Male 60 - 64

  	
   

  	
  2.2284

  
	
  Male 65 plus

  	
   

  	
  2.3563

  






 


3.1.1                        Adjustment
for ISL Premium.  In calculating
Capitation Payments due to Medical Group, PacifiCare shall deduct the ISL
Premium amount set forth herein from the amounts otherwise due to Medical
Group, unless PacifiCare has approved of Medical Group’s opting out of
PacifiCare’s ISL Program.


 


3.1.2                        Adjustment
for Experience-Rated Managed Care Plans. 
Capitation Payments for Experience Rated Plans shall be calculated
utilizing the following definitions and methodology:


 


(i)                                     An
“Experience-Rated Plan” is a non-federally-qualified plan in which the
Subscriber Group’s premium is partially deferred or adjusted to reflect the
actual medical costs incurred by Commercial Plan Members.


 


(ii)                                  The
“Net Actuarial Experience Rate” shall mean a rate calculated by the same method
used to determine premium for federally-qualified plans, except that trended
claims and utilization data may be considered to determine expected medical
costs and PacifiCare’s administrative retention may be adjusted to reflect
actuarial risk taken by the Subscriber Group instead of PacifiCare.


 


(iii)                               For
Experience-Rated Plans, Capitation Payments shall be calculated as a percent of
the Net Actuarial Experience Rate rather than based on a percent of the
Commercial Plan Premium.  The Net
Actuarial Experience Rate, like the Commercial Plan Premium, shall exclude
broker and agent commissions, premium taxes and premiums for Supplemental
Benefits.


 


7

















 


3.2                                 ISL
Program.  The ISL Deductible, ISL
Premium and ISL Coinsurance for the Commercial Plan shall initially be:


 


(i)                                     ISL
Deductible shall be zero dollars and zero cents ($0.00) per Commercial Plan
Member per calendar year.


 


(ii)                                  ISL
Premium shall be zero dollars and zero cents ($0.00) per Commercial Plan Member
per month.


 


(iii)                               ISL
Coinsurance shall be zero percent (0 %) of Cost of Care in excess of the ISL
Deductible.


 


If PacifiCare has approved of Medical Group’s
opt out of the ISL Program, the above amounts and percentages will reflect
“zero.”  In such event, Medical Group
shall be required to obtain ISL coverage from a third-party insurance carrier
in accordance with Section 5.6.5 of the Base Agreement.


 


3.3                                 Commercial
Hospital Incentive Program. 
PacifiCare shall establish and administer an annual Commercial Hospital
Incentive Program for the PacifiCare Commercial Plan (the “CHIP”).  The CHIP is designed to provide an incentive
for the efficient and effective use of Hospital Services, and shall be
calculated utilizing the terms defined below. 
All calculations for the CHIP shall be based upon Commercial Plan
Members, excluding Commercial POS Plan Members.


 


3.3.1                        Reinsurance
Program.  Claims under the
Reinsurance Program shall be valued at the Cost of Care as defined in this
Agreement.  The Reinsurance Deductible,
Reinsurance Premium and Reinsurance Coinsurance for the Commercial Plan shall
initially be:


 


(i)                                     Reinsurance
Deductible shall be
             dollars (            )
per Commercial Plan Member per
calendar year.


 


(ii)                                  Reinsurance
Premium shall be
             dollars (            )
of Commercial Plan Premium.


 


(iii)                               Reinsurance Coinsurance shall be *** of the
Cost of Care for amounts in excess of the Reinsurance Deductible but less than
*** and *** of the Cost of Care for amounts in excess of ***.


 


3.3.2                        CHIP Budget.  The CHIP Budget for
Commercial Plan Members shall be *** flat per Member per month, excluding Commercial POS Plan Members, less
PacifiCare Commercial Plan Reinsurance Premium, if any, and is subject to the
adjustments set forth in Article 5 of the Base


 


8

















 


Agreement
and the adjustments further specified below.


 


3.3.3                        CHIP
Expense.  CHIP Expense shall be
equal to the sum of the following:


 


(i)                                     Inpatient costs for Hospital Services rendered
to Commercial Plan Members, excluding Commercial POS Plan Members, by
Participating Providers, valued at the actual costs incurred by PacifiCare; plus,


 


(ii)                                  Other Hospital Services rendered to
Commercial Plan Members, excluding Commercial POS Plan Members, by
Participating Providers other than inpatient services, valued at actual costs
incurred by PacifiCare; plus,


 


(iii)                               The
actual amount paid for Hospital Services which are rendered by
non-Participating Providers; minus,


 


(iv)                              Amounts paid by PacifiCare under the
Reinsurance Program, if any; minus


 


(v)                                 Any and all amounts received from third
parties for Hospital Services provided to Commercial Plan Members, excluding
Commercial POS Plan Members, through coordination of benefits, work-related
accidents or injuries, stop-loss and reinsurance payments and Member
Copayments.


 


3.3.4                        CHIP Surplus.  In
the event the CHIP Expense is less than the CHIP Budget, the surplus shall be
allocated as follows:


 


*** to Medical Group


*** to PacifiCare


 


3.3.5                        CHIP Deficit.  In the event the CHIP Expense is greater than the
CHIP Budget, the deficit shall be allocated as follows:


 


*** to Medical Group, limited to $2.00 per Member per month


*** to PacifiCare


 


3.3.6                        Settlements and Reconciliation. 
Interim settlements and the final settlement and reconciliation of the
CHIP shall be performed by PacifiCare as provided in Article 5 of the Base
Agreement.


 


3.4                                 Commercial Health Plan Pharmacy Incentive and
Upside Sharing Programs.  PacifiCare shall establish and administer a
Pharmacy Upside Sharing Program for the 2002 calendar year and ongoing for the
PacifiCare Commercial Health Plan (the “PIP”). 
The PIP is designed to provide an incentive for the efficient and
effective use of Outpatient Pharmacy Supplemental Benefits for Commercial
Health Plan Members.  PacifiCare shall
provide Medical Group with monthly reports on the PIP (no later than the
twentieth (20th) calendar day following the applicable month) which shall
include data showing the applicable Member, Participating


 


9

















 


Provider and pharmaceutical
prescribed for the applicable Member. 
The PIP shall be calculated as follows:


 


3.4.1                        Outpatient Pharmacy Supplemental Benefits shall be the benefits made available by PacifiCare under the PacifiCare
Supplemental Pharmacy Benefit, as defined in the applicable Subscriber
Agreement.


 


3.4.2                        PIP Budget shall
equal *** of the premium received by PacifiCare for Outpatient Pharmacy
Supplemental Benefits for Commercial Health Plan Members plus *** per
Commercial Health Plan Member per month, which amount is established as a
credit for rebates received annually from pharmaceutical manufacturers.  This credit may or may not reflect the total
pharmaceutical manufacturer rebate revenues received by PacifiCare.  The PIP Budget shall be retained by
PacifiCare for purposes of administering the PIP.


 


3.4.3                        PIP Expense shall equal the expense incurred for the provision of Outpatient
Pharmacy Supplemental Benefits during the applicable period.


 


3.4.4                        PIP Surplus.  In the event the PIP Expense
is less that the PIP Budget, *** of the surplus shall be allocated to the
Medical Group


 


3.4.5                        PIP Deficit.  In the event that the PIP
Expense is greater that the PIP Budget, Fifty Percent of the deficit shall be
allocated to the Medical Group not to exceed *** per Commercial Plan Member per
Month.


 


IN WITNESS WHEREOF, the parties hereto have executed this Product
Attachment A.


 


 


	
   

  	
  PACIFICARE
  OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice
  President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  12/7/01

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  PROSPECT
  MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Peter G. Goll

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Senior
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  12-5-01

  	
   

  
								



 


10

















 


PRODUCT ATTACHMENT B


 


PACIFICARE COMMERCIAL
POINT-OF-SERVICE PLAN


 


This Product Attachment B, along with Product Attachment A and the Base
Agreement, sets forth the terms and conditions which are applicable to the
PacifiCare Commercial Point-of-Service Plan, as defined below.


 


ARTICLE 1


DEFINITIONS


 


The following terms shall have the meaning
attributed below for purposes of the PacifiCare Commercial Point-of-Service
Plan, as described in this Product Attachment B.  Capitalized terms not otherwise defined herein shall have the
meaning assigned to them in the Base Agreement.


 


l.l                                       Commercial
Plan Premium is the premium received by PacifiCare each month for
PacifiCare Commercial Plan Members, excluding amounts to pay broker and agent
commissions/compensation, Premium taxes and premiums for Supplemental Benefits.


 


1.2                                 In-Network
Services are Covered Services received by Commercial POS Plan Members which
are (a) provided or arranged by Medical Group pursuant to the PacifiCare
Commercial Plan; (b) received from a
non-contracting Provider following an authorization from Medical Group; (c) Emergency
Services; and (d) Urgently Needed Services.


 


1.3                                 ln-Network
Hospital Services are Hospital Services received by Commercial POS Plan
Members which are (a) provided or arranged by Medical Group pursuant to the
PacifiCare Commercial Plan; (b) received from a non-contracting Provider
following an authorization from Medical Group; (c) Emergency Services; and (d)
Urgently Needed Services.


 


1.4                                 Out-of-Network
Services are Covered Services, excluding Emergency Services and Urgently
Needed Services, which are received by Commercial POS Plan Members without the
prior authorization of Medical Group.


 


1.5                                 PacifiCare
Commercial Point-of-Service (“POS”) Plan is any PacifiCare Commercial Plan,
as defined in Product Attachment A, under which Members are entitled to coverage
for both In-Network Services and Out-of-Network Services.


 


1.6                                 Commercial
POS Plan Members are Medical Group Members enrolled in the PacifiCare
Commercial POS Plan.


 


1.7                                 POS
Plan Premium is the sum of the In-Network Premium and the Out-of-Network Premium,
as defined below:


 


11

















 


1.7.1                        In-Network
Premium is the Commercial Plan Premium, as defined in Product Attachment B,
billed or accounted for by PacifiCare for coverage of In-Network Services under
the PacifiCare Commercial POS Plan.


 


1.7.2                        Out-of-Network
Premium is the Commercial Plan Premium, as defined in Product Attachment A,
billed or accounted for by PacifiCare (or an insurance company or self-insured
employer which has assumed the risk for the Out-of-Network Services), for
coverage of Out-of-Network Services under the PacifiCare Commercial POS Plan.


 


ARTICLE 2


DUTIES OF
MEDICAL GROUP


 


2.1                                 Covered
Services.  Medical Group and its
Participating Providers shall provide or arrange Covered Services to Commercial
POS Plan Members under same terms and conditions as Commercial Plan Members.


 


2.2                                 Reciprocity:
Reimbursement for Out-of-Network Services. 
If any of Medical Group’s Participating Providers provides
Out-of-Network Services to a Commercial POS Plan Member, such Medical Group
Participating Provider shall bill PacifiCare or the payor responsible for
payment for Out-of-Network Services for such services and agrees to accept full
payment at the Cost of Care.  Neither
Medical Group nor its Participating Providers shall encourage Members to
receive Covered Services from non-Participating Providers.  Medical Group shall include the requirements
of this Section in all subcontracts with its Participating Providers.


 


ARTICLE 3


COMPENSATION


 


3.1                                 Capitation
Payments for Commercial POS Plan Members. 
For Commercial POS Plan Members, PacifiCare will pay Medical Group ***
of the Capitation Payment for Commercial Plan Members, subject to the
adjustments set forth in Article 5 of the Base Agreement and the adjustments
set forth below in this Section. 
Capitation Payments for Commercial POS Plan Members will be based on a
percentage of the In-Network Premium only. 
The payment described in this Section is payment in full for
In-Network Services, except for Copayments, coordination of benefits, third
party recoveries and payments under the PacifiCare POS Control Program set
forth below.


 


3.1.1                        Premium
Adjustments.  The Commercial Plan
Premium and benefits may be amended for each Subscriber Agreement upon the
annual renewal date of each Subscriber Agreement at the sole discretion of
PacifiCare.


 


3.1.2                        Adjustment
for 1SL Premium.  In calculating
Capitation Payments due to the Medical Group for Commercial POS Plan Members,
PacifiCare shall deduct eighty percent (80%) of the ISL Premium amount set
forth in Section 3.2 of Product Attachment A from the amounts otherwise
due to Medical Group, unless PacifiCare has approved of Medical Group’s opt out
of PacifiCare’s ISL Program.


 


12

















 


3.2                                 Commercial
POS Control Program.  PacifiCare
shall establish and administer an annual Control Program for the PacifiCare
Commercial Point-of-Service Plan (“Commercial POS Control Program”).  The Commercial POS Control Program is
designed to provide an incentive for the efficient and effective use of
In-Network Hospital Services and to control Out-of-Network Services, and shall
be calculated in accordance with the following provisions.


 


3.2.1                        Definitions.  The following terms shall have the meaning
attributed below for purposes of the Commercial POS Control Program.


 


(i)                                     POS
Plan Budget shall equal the CHIP Budget, plus the POS Capitation Withhold,
plus fifty percent (50%) of the Out-of-Network Premium, less PacifiCare POS
Control Program Reinsurance Premium, if any.


 


(ii)                                  POS
Plan Costs shall mean the following:


 


(a)          Claims paid for
In-Network Hospital Services incurred during the current period, calculated at
the actual amount paid; plus,


 


(b)         Claims paid for
Out-of-Network Services incurred during the current period, calculated at the
actual amount paid; plus,


 


(c)          Claims paid for
In-Network Hospital Services and Out-of-Network Services incurred but not
included in prior period Commercial POS Control Program calculations,
calculated at the actual amount paid; minus,


 


(d)         Any and all amounts
received from third party liability and coordination of benefit recoveries for
In-Network Hospital Services and Out-of-Network Services that are received
during the period of calculation.


 


(iii)                               Budget
Surplus.  The amount, if any, by
which the POS Plan Budget exceeds the POS Plan Costs for any calendar year.


 


(iv)                              Budget
Deficit.  The amount, if any, by
which the POS Plan Costs exceeds the POS Plan Budget for any calendar year.


 


(v)                                 Capitation
Restoration Amount.  The difference
between (a) the amount Medical Group would have received if Medical Group’s
Capitation Payments for Commercial POS Plan Members had been determined by
multiplying the percentage set forth in Section 3.1 of Product Attachment
A by the In-Network Premium and (b) the actual capitation paid to Medical Group
for Commercial POS Plan Members for the relevant contract year.


 


3.2.2                        POS
Control Program Reinsurance.  Unless
PacifiCare has approved of Medical Group’s opt out of POS reinsurance (“POS
Control Program Reinsurance”), PacifiCare


 


13

















 


shall provide reinsurance (the “Commercial POS Control Program
Reinsurance”) in order to provide protection for the Commercial POS Plan Budget
when Cost of Care for POS In-Network Hospital Services and Out-of-Network
Medical Group and Hospital Services (“Out-of-Network Services”) exceeds a
specified dollar amount per Medical Group Member per calendar year (the
“Commercial POS Control Program Reinsurance Deductible”).  Costs for In-Network Hospital Services and
Out-of-Network Services that exceed the Commercial POS Control Program
Reinsurance Deductible shall be considered an expense against the Commercial
POS Plan Budget, of which surpluses and deficits are shared between PacifiCare
and Medical Group as noted below.


 


3.2.3                        Reinsurance
Program.  Claims under the POS
Control Program Reinsurance shall be valued at *** per acute inpatient day, ***
per skilled nursing facility day, and *** for all other claims.  The Reinsurance Deductible and Reinsurance
Premium for the Commercial POS Plan shall initially be:


 


(i)                                     Reinsurance
Deductible shall be
            
(        ) per Commercial Plan Member
per calendar year.


 


(ii)                                  In-Network
Reinsurance Premium shall be
            
(        ) of the Commercial Plan
Reinsurance Premium amount set forth in Section 3.3.1 of Product
Attachment A.


 


(iii)                               Out-of-Network
Reinsurance Premium shall be
            
(        ) of the Commercial Plan
Reinsurance Premium amount set forth in Section 3.3.1 of Product
Attachment A.


 


If PacifiCare has approved of Medical Group’s
opt out of the Reinsurance Program, the above amounts and percentages will
reflect “zero.”  In such event, Medical
Group shall be required to obtain reinsurance coverage from a third-party
insurance carrier in accordance with Section 5.6.5 of the Base Agreement.


 


3.2.4                        Documentation.  PacifiCare shall provide Medical Group with
a list of In-Network Hospital Services claim payments and Out-of-Network claim
payments in support of computation and accuracy of POS Plan Costs, third party
liability and coordination of benefit recoveries, assumptions and data
supporting the POS Plan Budget, the Budget Surplus, and the Budget Deficit and
the Capitation Restoration Amount.


 


3.2.5                        Budget Surplus
Reconciliation.  Medical Group shall
receive *** of the Budget Surplus, until such time as Medical Group has
received the applicable Capitation Restoration Amount.  If the Budget Surplus exceeds the Capitation
Restoration Amount, then PacifiCare and Medical Group shall each be entitled to
*** of the remaining Budget Surplus.


 


14

















 


3.2.6                        Budget Deficit
Reconciliation.  In the event of a
Budget Deficit, Medical Group shall not be responsible for making any payments
under the PacifiCare POS Control Program. 
However, *** of the Budget Deficit amount shall be considered a Medical
Group obligation for purposes of offsetting surpluses under other incentive
programs under the Agreement.


 


3.3                                 Adjustment of Rates.  Capitation
Payments for Commercial POS Plan Members and the POS Plan Budget may be
prospectively adjusted on an annual basis to reflect actual experience under
the Commercial POS Plan; provided, however, that in no event shall the amount
of any increase or decrease to such Capitation Payments be greater than ten
(10) percentage points in any given year.


 


IN WITNESS WHEREOF, the parties hereto have executed this Product
Attachment B.


 


 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  12/7/01

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  PROSPECT MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Peter G. Goll

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Senior Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  12/5/01

  	
   

  
							



 


15

















 


PRODUCT ATTACHMENT C


 


SECURE HORIZONS HEALTH PLAN


 


This Product Attachment C, along with the
Base Agreement, sets forth the terms and conditions which are applicable to the
Secure Horizons Health Plan, as defined below.


 


ARTICLE 1


DEFINITIONS


 


The following terms shall have the meaning
attributed below for purposes of the Secure Horizons Health Plan, as described
in this Product Attachment C. 
Capitalized terms not otherwise defined herein shall have the meaning
assigned to them in the Base Agreement.


 


1.1                                 HCFA
is the Health Care Financing Administration, an administrative agency of the
United States Government, responsible for administering the Medicare program.


 


1.2                                 HCFA
Agreement is the Medicare + Choice contract between PacifiCare and HCFA.


 


1.3                                 Medicare
is the Hospital Insurance Plan (Part A) and the Supplementary Medical Insurance
Plan (Part B) provided under Title XVIII of the Social Security Act, as
amended.


 


1.4                                 Monthly
HCFA Payment is the revenue received by PacifiCare each month from HCFA, as
determined by HCFA, for providing Covered Services to Secure Horizons Members.


 


1.5                                 Secure
Horizons Health Plan is the prepaid health plan operated by PacifiCare
pursuant to the HCFA Agreement, which provides Covered Services to individuals
(including retirees) eligible to receive Medicare benefits.


 


1.6                                 Secure
Horizons Members are Medical Group Members enrolled in the Secure Horizons
Health Plan.


 


1.7                                 Secure
Horizons Revenue is the Monthly HCFA Payment for Medical Group Members
enrolled in the Secure Horizons Health Plan, less payments for broker
and agent commissions/compensation (when applicable), premium taxes and amounts
used to fund the Market Specific Benefit Program (as defined below).


 


ARTICLE 2


DUTIES OF
MEDICAL GROUP


 


2.1                                 Compliance
with HCFA Agreement and Federal Medicare Law.  Medical Group shall comply with all requirements in the HCFA
Agreement, which are applicable to Medical Group as a subcontractor of
PacifiCare as a result of this Agreement. 
Without limiting the foregoing, Medical Group shall ensure that all provisions
of the HCFA Agreement, which are applicable


 


16

















 


to Medical Group’s Participating Providers as
a subcontractor of PacifiCare are included in Medical Group’s subcontracts with
its Participating Providers.  A copy of
the HCFA Agreement shall be made available to Medical Group concurrent with the
execution of this Agreement.  Medical
Group and its Participating Providers shall comply with Title XVIII of the
Social Security Act and the regulations adopted thereunder by HCFA for the
Medicare program.


 


2.2                                 Medicare
Participation Standards.  Medical
Group shall require that all of its Participating Providers who provide
services to Secure Horizons Members meet the standards for participation and
all applicable requirements for providers of health care services under the
Medicare program.  In addition, Medical
Group shall require that all facilities and offices utilized by Medical Group
and its Participating Providers to provide or arrange Covered Services to Secure
Horizons Members shall comply with facility standards established by HCFA.


 


2.3                                 Specific
Provisions Pertaining to Benefits, Coverage and Beneficiary Protections.  Without limiting any of Medical Group’s
other obligations under this Agreement, Medical Group specifically agrees to
comply with the following policies and procedures:


 


(i)                                     PacifiCare’s
policies pertaining to the collection of Copayments which prohibit the
collection of Copayments for routine injections, routine immunizations, flu
immunizations, and the administration of pneumococcal/pneumonia vaccine.


 


(ii)                                  PacifiCare’s
policies pertaining to pre-certification which provide that Secure Horizons
Members may directly access a provider for mammography and influenza
vaccinations and women’s health specialists for routine and preventative health
care.


 


(iii)                               PacifiCare’s
policies pertaining to complex and serious conditions, which provide for
procedures to identify, assess and establish treatment plans for persons with
complex or serious medical conditions.


 


(iv)                              PacifiCare’s
policies pertaining to enrollment and assessment of new Secure Horizons Members
including requirements to conduct a health assessment of all new Secure
Horizons Members within ninety (90) days of the effective date of their
enrollment.


 


2.4                                 Confidentiality
of Medical Records.  Medical Group
shall establish and maintain procedures and controls so that no information
contained in its records or obtained from HCFA or from others in carrying out
the terms of this Agreement shall be used by or disclosed by it, its agents,
officers, or employees except as provided in Section 1106 of the Social
Security Act, as amended, and regulations prescribed thereunder.


 


2.5                                 Submission
of Data.  Medical Group shall
cooperate with PacifiCare in submitting to the Secretary of Health and Human
Services statistical data pertaining to Covered Services provided by Medical
Group, enrollment and disenrollment data and any other reports the Secretary
may reasonably require to carry out its functions under the Medicare + Choice


 


17

















 


program.


 


2.6                                 Advance
Directives.  Medical Group shall
document all Secure Horizons Member patient records with respect to the
existence of an Advance Directive in compliance with the Patient
Self-Determination Act (Section 4751 of the Omnibus Reconciliation Act of
1990), as amended, and other appropriate laws. 
For purposes of this Agreement, an Advance Directive is a Member’s
written instructions, recognized under State law, relating to the provision of
health care when the Member is not competent to make health care decisions as
determined under State law.  Examples of
Advance Directives are living wills and durable powers of attorney for health
care.


 


2.7                                 Non-Discrimination.  Medical Group understands that HCFA requires
compliance with the provisions of this Section as a condition for
participation in the Secure Horizons Health Plan.  Medical Group and its Participating Providers shall not
unlawfully discriminate against any of their employees or applicants for
employment or against any Members on the basis of race, color, creed, national
origin, ancestry, religion, sex, marital status, age (except as provided by
law), sexual orientation, gender identity, or physical or mental handicap,
including HIV status.  Medical Group and
its Participating Providers shall ensure that the evaluation and treatment of
their employees and applicants for employment and of Members are free of such
discrimination.  Medical Group and its
Participating Providers shall comply with Title VI of the Civil Rights Act of
1964, as amended (42 U.S.C. Section 2000d et. seq.), Section 504 of
the Rehabilitation Act of 1973, as amended (29 U.S.C. Section 794) and the
regulations thereunder, Title IX of the Education Amendments of 1972, as amended
(20 U.S.C. Section 1681 et. seq.), the Age Discrimination Act of 1975, as
amended (42 U.S.C. Section 6101 et. seq.), Section 654 of the Omnibus
Budget Reconciliation Act of 1981, as amended (42 U.S.C. Section 9849),
the Americans With Disabilities Act (P.L. 101-365) and all implementing
regulations, guidelines and standards as are now or may be lawfully adopted
under the above statutes.


 


2.8                                 Termination
of HCFA Agreement.  In the event the
HCFA Agreement is terminated or not renewed, the provisions of this Agreement
relating to the Secure Horizons Health Plan shall automatically terminate
unless otherwise agreed by HCFA and PacifiCare.


 


ARTICLE 3


COMPENSATION


 


3.1                                 Capitation
Payments for Secure Horizons Members. 
Capitation Payments for Secure Horizons Members shall be thirty seven
and five tenths percent (37.5%) of the Secure Horizons Revenue per Secure
Horizons Member per month, plus zero dollars and zero cents ($0.00) for each
Secure Horizons Member for whom PacifiCare has received a monthly member
premium, subject to the adjustments set forth in Article 5 of the Base
Agreement and the adjustments set forth below in this Section.


 


3.1.1                        Adjustment
for ISL Premium.  In calculating
Capitation Payments due to Medical Group, PacifiCare shall deduct the ISL
Premium amount set forth herein from the


 


18

















 


amounts otherwise due to Medical Group, unless PacifiCare has approved
of Medical Group’s opting out of PacifiCare’s ISL Program.


 


3.2                                 ISL Program.  The ISL Deductible, ISL Premium
and ISL Coinsurance for the Secure Horizons Plan shall initially be:


 


(i)                                     ISL Deductible shall be zero dollars and zero
cents ($0.00) per Secure Horizons Member per calendar year.


 


(ii)                                  ISL Premium shall be zero percent (0%) of the
Secure Horizons Revenue.


 


(iii)                               ISL Coinsurance shall be zero percent (0%) of
the Cost of Care in excess of the ISL Deductible.


 


If PacifiCare has approved of Medical Group’s opt out of the ISL
Program, the above amounts and percentages will reflect “zero.” In such event, Medical
Group shall be required to obtain ISL coverage from a third-party insurance
carrier in accordance with Section 5.6.5 of the Base Agreement.


 


3.3                                 Secure Horizons Hospital Incentive Program. 
PacifiCare shall establish and administer an annual Hospital Incentive
Program for the Secure Horizons Health Plan (the “SHIP”).  The SHIP is designed to provide an incentive
for the efficient and effective use of Hospital Services, and shall be
calculated utilizing the terms defined below.


 


3.3.1                        Reinsurance Program. 
Claims under the Reinsurance Program shall be valued at the Cost of Care
as defined in this Agreement.  The
Reinsurance Deductible, Reinsurance Premium and Reinsurance Coinsurance for the
Secure Horizons Plan shall initially be:


 


(i)                                     Reinsurance Deductible shall be
             
(         ) per Secure Horizons
Member per calendar year.


 


(ii)                                  Reinsurance Premium shall be
             
percent (       %) of the Secure Horizons
Revenue.


 


(iii)                               Reinsurance
Coinsurance shall be *** of the Cost of Care for amounts in excess of the
Reinsurance Deductible but less than *** and *** of the Cost of Care for amounts in excess of ***.


 


3.3.2                        SHIP Budget.  The SHIP Budget for Secure
Horizons Members shall be forty nine percent (49.0%) of the Secure Horizons
Revenue per Secure Horizons Member per Month, subject to the adjustments set
forth in Article 5 of the Base Agreement and further specified below, less
PacifiCare Secure Horizons Plan Reinsurance Premium, if any.


 


19

















 


3.3.3                        SHIP
Expense.  SHIP Expense shall be
equal to the sum of the following:


 


(i)                                     Inpatient
costs for Hospital Services rendered to Secure Horizons Members by
Participating Providers valued at the actual costs incurred by PacifiCare; plus.


 


(ii)                                  Other
Hospital Services rendered to Secure Horizons Members by Participating
Providers other than inpatient services, valued at actual costs incurred by
PacifiCare; plus.


 


(iii)                               The
actual amount paid for Hospital Services, which are rendered by non-Participating
Providers; minus.


 


(iv)                              Amounts
paid by PacifiCare under the Reinsurance Program, if any; minus.


 


(v)                                 Any
and all amounts received from third parties for Hospital Services provided to
Secure Horizons Members through coordination of benefits, work-related
accidents or injuries, stop-loss and reinsurance payments and Medical Group
Member Copayments.


 


3.3.4                        SHIP
Surplus.  In the event the SHIP
Expense is less than the SHIP Budget, the surplus shall be allocated as
follows:


 


*** to Medical
Group


*** to PacifiCare


 


3.3.5                        SHIP
Deficit.  In the event the SHIP
Expense is greater than the SHIP Budget, the deficit shall be allocated as
follows:


 


*** to Medical
Group,


*** to
PacifiCare


 


3.3.6                        Settlements
and Reconciliation.  Interim
settlements and the final settlement and reconciliation of the SHIP shall be
performed by PacifiCare as provided in Article 5 of the Base Agreement.


 


3.4                                 Market-Specific
Benefit Program.  PacifiCare may
establish, at its sole discretion, an annual Market-Specific Benefit Program
(the “MSBP”).  The MSBP is designed to
provide an incentive to control costs for certain additional benefits (the
“MSBP Benefits”) offered to Secure Horizons Members, as defined in the
applicable Subscriber Agreement, for the purpose of enhancing the marketability
of the Secure Horizons Health Plan.  The
MSBP may include the following additional benefits and may be amended from time
to time by PacifiCare to reflect changes in the benefits:


 


Dental Benefits


Immunosuppressive Drugs


 


20

















 


Outpatient Pharmacy Benefits


Respite Care


 


PacifiCare shall retain *** of the Monthly
HCFA Payment (the “MSBP Budget”) and add to it *** per Secure Horizons Plan
Member per month, which amount is established as a credit for rebates received
from pharmaceutical manufacturers.  This
credit may or may not reflect the total pharmaceutical manufacturer rebate
revenues received by PacifiCare for purposes of funding and administering the
MSBP.  The MSBP shall be calculated as
follows:


 


3.4.l                           MSBP
Benefits shall be the additional benefits listed above in this
Section and made available under the Secure Horizons Health Plan as
defined in the applicable Subscriber Agreement.


 


3.4.2                        MSBP
Expense shall equal the expense incurred for the provision of MSBP Benefits
during the applicable period.


 


3.4.3                        MSBP
Surplus.  In the event the MSBP
Expense is less than the MSBP Budget, fifty percent (50%) of the surplus shall
be allocated to Medical Group.


 


3.4.4                        MSBP
Deficit.  In the event the MSBP
Expense is greater than the MSBP Budget, fifty percent (50%) of the deficit
shall be allocated to Medical Group, not to exceed three dollars ($3.00) per
member per month


 


3.4.5                        Settlements.  The calculations in this Section and
settlements shall be performed in accordance with the procedures specified in
Article 5 of the Base Agreement.


 


3.5                                 Collection
of Charges From Third Parties When Medicare Is Not the Primary Payor.  Medical Group shall accept Capitation
Payments from PacifiCare as payment in full for Covered Services provided to
Secure Horizons Members; provided, however, when Medicare is not the primary
payor for Covered Services, such as when the Secure Horizons Member is entitled
to payment from another third party or for payment for a workers’ compensation
claim, or from other primary insurance coverage maintained by Secure Horizons
Member, Medical Group shall make no demand upon PacifiCare for reimbursement
under the Individual Stop-Loss Program until all primary sources of payment
have been pursued and it is determined that full payment cannot be obtained
within ten (10) months from the date of the provision of Covered Services.


 


21

















 


IN WITNESS WHEREOF, the parties hereto have executed this Product
Attachment C.


 


 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  12/7/01

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  PROSPECT MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Peter G. Goll

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Senior Vice President

  	
   

  
	
   

  	
   

  
	
   

  	
  Date:

  	
   12-5-01

  	
   

  
								



 


22

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES
AGREEMENT


(PROFESSIONAL CAPITATION)


 


DIVISION OF FINANCIAL
RESPONSIBILITY


 


(This Exhibit is an
integral part of this Agreement)


 


The following matrix outlines the division of financial responsibility
between PacifiCare, Medical Group and the Hospital Incentive Program, the
intent being to clarify Covered Services categories in order to provide for
accurate administration.  The matrix
serves as a model under which broad Covered Service categories suggest the
appropriate financial responsibility for Covered Services not specifically
listed.  The applicable Subscriber
Agreement and Evidence of Coverage should be consulted for an accurate and
complete description of Covered Services and the Provider Manual for
administrative clarification.  Member
benefit information should be verified prior to the provision of services.


 


Division of Financial
Responsibility


 


	
  KEY:  M - Opt-out to Medicare
  benefit for Hospice

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  
	
  Allergy
  - Serum - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Allergy
  - Testing & Tx - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Ambulance
  (Air and Ground) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Amniocentesis
  - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Anesthesiology
  - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Autologous
  Blood Services - OP - Fac &  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Biofeedback
  (Medically Necessary) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Detox) - IP &  OP -
  Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Detox) - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - IP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - IP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - IP - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - IP - Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - OP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - OP - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemical
  Dependency (Rehab) - OP - Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemotherapy
  (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemotherapy
  (Including Chemotherapy Drugs - Inject/Oral) - OP - Fac & Prof -SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chemotherapy
  - IP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chiropractic
  - Medical - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chiropractic
  - Supplemental - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Circumcision
  - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


23

















 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  
	
  Diagnostic
  Tests - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DME
  - IP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DME,
  Ostomy/Colostomy Supplies, Prosthetics/Orthotics - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency
  Room - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Emergency
  Room - OP - E.R. Phys.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Endoscopic
  Studies - IP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Endoscopic
  Studies - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Endoscopic
  Studies - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Abortions - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Abortions - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Contraceptive Devices - Insertion - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Contraceptive Devices - Non-Rx (eg. Norplant/IUD) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Contraceptive Devices - Prescription - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - GIFT/ZIFT/IVF - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Infertility Procedures - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Infertility Procedures - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Infertility Testing - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Sterilization - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Sterilization - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Family
  Planning - Sterilization - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Fetal
  Monitoring - OP - Fac &  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health
  Education - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Health
  Eval/Physical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing
  Aids/Molds - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hearing
  Screening (Audiologic Evaluation) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hemodialysis/Dialysis
  - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hemodialysis
  / Dialysis - OP - Fac (including all drugs)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Home
  Health Care / Homebound Infusion Therapy - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hosp
  Based Phys Interpretative Serv Incl Radiology & Pathology - IP & OP -
  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospice
  Services (Medicare) - IP - Fac & Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospice
  Services - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Hospitalization
  Services - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Immunizations
  & Inoculations (Medically Necessary) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Injectables
  - Not Part of Outpatient Pharmacy Benefits - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory/Pathology
  (Diagnostic Only) - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory/Pathology
  (Diagnostic Only) - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory/Pathology
  - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Lithotripsy
  - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Lithotripsy
  - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Med/Surg
  Supplies (casts, splints, bandages) - Office - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Medication
  - Prescription - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental
  Health (Crisis Intervention) - OP - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH: AB88 Benefits (Mental Health Parity applies to CO only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP & OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP & OP - Prof- CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH: Secure Horizons and Commercial (non AB88 Benefits)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


24

















 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  
	
  MENTAL
  HEALTH: Secure Horizons and Commercial (non AB88 Benefits)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP and OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP and OP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP and OP - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Mental Health - IP and OP - Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Observation
  Room - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Oral
  Surgery / Denial Services - Accident & Injury Only - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Oral
  Surgery / Dental Services - Accident & Injury Only - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Out
  of Area - IP & OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Out
  of Area - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient
  Surgery - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Outpatient
  Surgery - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Physician
  Services (All Professional Services) - IP &
  OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Prosthetics
  - Surgical Implants - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation
  Therapy - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiation
  Therapy - OP - Fac and/ or freestanding facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology
  (Diagnostic Only) - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology
  (Diagnostic Only) - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Radiology
  - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Reconstructive
  Surgery - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Reconstructive
  Surgery - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Rehabilitation
  - Cardiac/OT/PT/RT/ST - OP- Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Rehabilitation
  - Cardiac/OT/PT/RT/ST - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Skilled
  Nursing Facility - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Sleep
  Studies - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TMJ
  - Evaluation (excludes dental exams/treatment) - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Transfusions
  - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Transplants-
  IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Transplants
  - IP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Urgent
  Care - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision
  Medical Treatment - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision
  - Refraction for Contact Lenses/Frames - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision
  Care Materials - Contact Lenses/Frames (non-cataract) - OP - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Vision
  Care Materials - Contact Lenses/Frames (non-cataract) - OP - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 












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


 


25