Exhibit 10.174


 


Health Net Medicare+Choice (M+C)

Addendum to Provider Agreement


 


This Addendum or
Exhibit (the “Addendum”) is entered into by Health Net and StarCare Medical
Group dba Gateway Medical Group (“Provider”) effective October 1, 1999 and is
intended to amend the agreement between Health Net and Provider to add language
required by HCFA for participation as a Medicare+Choice contracted provider or
organization.


 


Whereas, HCFA
requires specific contract language be incorporated into contracts and subcontracts
to comply with the provisions of the Balanced Budget Act of 1997;


 


Whereas, Provider
wishes to provide services to Medicare beneficiaries who elected to enroll in
Health Net, and Health Net wishes Provider to provide services to such Medicare
beneficiaries;


 


Whereas, Provider
agrees to the addition of the following language as an Addendum to the
agreement between Health Net and Provider which shall apply to Health Net
Seniority Plus Members.


 


NOW, THEREFORE,
the parties agree as follows:


 


I. DEFINITIONS


 


1.1.         Downstream
Providers means a health care provider who or which is contracted with Provider to
render services to Members.


 


1.2.         Health
Care Financing Administration (HCFA) means the agency within the Department of
Health and Human Services that administers the Medicare Program.


 


1.3.         Member
means
an individual who has enrolled in or elected coverage in Health Net Seniority
Plus, an M+C Organization.


 


II. ACCESS:  RECORDS AND FACILITIES


 


Provider agrees:


 


2.1.         To give the Department of Health and Human
Services (HHS), and the General Accounting Office (GAO) or their designees the
right to audit, evaluate, inspect books, contracts, medical records, patient
care documentation, other records of subcontractors, or related entities for
the later of six (6) years, or for periods exceeding six (6) years, for reasons
specified in the federal regulation.


 


2.2.         To safeguard the privacy of any information
that identifies a particular Member and to maintain such records in an accurate
and timely manner.


 












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


 


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III. ACCESS: BENEFITS
& COVERAGE


 


Provider agrees:


 


3.1.         To not discriminate based on health status.


 


3.2.         To pay for emergency and urgently needed
services consistent with federal regulations, if such services are Provider’s
liability.


 


3.3          To pay for renal dialysis services for
Members temporarily outside the service area, if such services are Provider’s
liability.


 


3.4.         To direct access to mammography screening
and influenza vaccinations.


 


3.5.         To not collect any co-payment or other cost
sharing for influenza vaccine and pneumoccal vaccines.


 


3.6.         To direct access to in-network women’s
health specialist for women for routine and preventative services.


 


3.7.         To have approved procedures to identify,
assess and establish a treatment plan for Members with complex or serious
medical conditions.


 


3.8.         To provide access to benefits in a manner
described by HCFA.


 


IV. MEMBER PROTECTIONS


 


Provider agrees;


 


4.1.         To work with Health Net in conducting a
health assessment of all new Members within ninety (90) days of the effective
date of enrollment.


 


4.2.         To provide all covered benefits to Members
in a manner consistent with professionally recognized standards of health care.


 


4.3.         To comply with all confidentiality and
Member record accuracy requirements.


 


4.4          To hold harmless and protect Members from
incurring financial liabilities that are the legal obligation of Health Net or
Provider.  In no event, including but
not limited to, nonpayment or breach of an agreement by Health Net, Provider,
or any intermediary, shall Provider bill, charge, collect a deposit from or
receive other compensation or remuneration from a Member.  Provider shall not take any recourse against
a Member, or a person acting on behalf of a Member, for services provided.  This provision also does not prohibit (i)
collection of applicable coinsurance, deductibles, or co-payments, as specified
in the Evidence of Coverage, or (ii) collection of fees for non-covered
services, provided the Member was informed in advance of the cost and elected
to have non-covered services rendered.


 


4.5.         To protect Members who are hospitalized from
loss of benefits through the date of discharge or through the period of time
HCFA premiums are paid.


 


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V. DELEGATION


 


Provider agrees:


 


5.1.         To maintain delegated functions consistent
with Health Net’s requirements and compliant with M+C’s regulations and Health
Net’s policy and procedures as set forth in the Health Net Seniority Plus
Participating Provider Group Operations Manual.


 


5.2.         To comply with any applicable delegation
requirements between Health Net and Provider.


 


VI. PAYMENT AND FEDERAL FUNDS


 


Provider agrees:


 


6.1.         To include specific payment and incentive
arrangements in agreements with all Downstream Providers.


 


6.2.         To pay claims promptly according to HCFA
standards and comply with all payment provisions of state and federal law.  HCFA requires non-contracted provider claims
to be paid within thirty (30) days of receipt and contracted provider claims to
be paid within sixty (60) days of receipt.


 


6.3.         That Members health services are being paid
for with Federal funds, and as such, payments for such services are subject to
laws applicable to individuals or entities receiving Federal funds.


 


VII. REPORTING AND DISCLOSURE


 


Provider agrees:


 


7.1.         To submit to Health Net all data, including
medical records, necessary to characterize the content and purpose of each
encounter with Member.


 


7.2.          To submit and
certify the completeness and truthfulness of all encounter data.


 


VIII. QUALITY ASSURANCE / QUALITY
IMPROVEMENT


 


Provider Agrees:


 


8.1.         To cooperate with an independent quality
review and improvement organization’s activities pertaining to provision of
services for Members.


 


8.2.         To comply with Health Net’s medical policy,
quality assurance program, and medical management program.


 


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IX. COMPLIANCE


 


Provider agrees:


 


9.1.         That Provider must notify any contracting
healthcare provider being terminated, in writing, of the reason(s) for denial,
suspension or termination determinations.


 


9.2.         To provide Health Net with at least sixty
(60) days written notice before terminating an agreement without cause.


 


9.3.         To meet the requirements of all other laws
and regulation, including Title VI of the Civil Rights Act of 1964, the Age
Discrimination Act of 1975, the Americans with Disabilities Act, and all other
laws applicable to recipients of Federal funds.


 


9.4.         To comply with all applicable Health Net
procedures and Health Net Seniority Plus Participating Provider Group
Operations Manual including, but not limited to, the accountability provisions.


 


9.5.         To comply with and require that all
Downstream Providers comply with applicable state and Federal laws and
regulations, including Medicare laws and regulations and HCFA instructions.


 


9.6.         To not employ or contract with individuals excluded
from participation in Medicare under Section 1128 or 1128A of the Social
Security Act.


 


9.7.         To adhere to Medicare’s appeals, expedited
appeals and expedited review procedures for Health Net Members, including
gathering and forwarding information on appeals to Health Net, as necessary.


 


X. PRIVATE FEE FOR SERVICE


 


Provider agrees:


 


10.1.       That contracts with private Fee-for-Service
providers must specify uniform Fee-for-Service payment rates.


 


10.2.       That Provider cannot charge more than cost
sharing and balanced billing amounts permitted under the applicable Health Net
plan.  Health Net must specify cost
sharing amounts, and balance billing may not exceed fifteen percent (15%) of
uniform payment rate.


 


XI. ADOPTION OF MEDICARE RISK
PROGRAM CONTRACT REQUIREMENTS


 


Provider agrees:


 


11.1.        That all contracts
must be signed and dated.


 


11.2.        To serve Members
during the term of this Addendum.


 


11.3.       To comply with the regulatory requirements
and Health Net’s guidelines promulgated by HCFA, which are more fully
documented in Health Net’s policies, procedures, and manuals.


 


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Except as provided
in this Addendum, all other provisions of the Agreement between Health Net and
Provider not inconsistent herewith shall remain in full force and effect.  This Addendum shall remain in force as a
separate but integral addition to such Agreement to ensure compliance with
required HCFA provisions, and shall terminate upon the termination of such
Agreement.


 


IN WITNESS WHEREOF,
the parties hereto have executed this Addendum the date set forth below each
signature.


 


	
  StarCare Medical Group dba Gateway

  Medical Group

  	
  Health Net

  
	
   

  	
   

  
	
  By:

  	
  /s/ Marlean Free

  	
   

  	
  By:

  	
  /s/ Christopher Ciano

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Marlean Free

  	
   

  	
  Name

  	
  Christopher
  Ciano

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Director

  	
   

  	
  Title:

  	
  Senior
  Vice President and

  General Manager

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  8/30/99

  	
   

  	
  Date:

  	
  11/8/00

  	
   

  



 


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