Exhibit 10.105


 


BLUE CROSS
SENIOR SECURE


 


MEDICARE+CHOICE

MEDICAL SERVICES AGREEMENT


 


 


Professional
Care IPA Medical Group, Inc.


 


 


 












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


 

















 


BLUE CROSS SENIOR SECURE

MEDICAL SERVICES AGREEMENT


 


TABLE OF CONTENTS


 


	
  I.

  	
  RECITALS

  	
   

  
	
  II.

  	
  DEFINITIONS

  	
   

  
	
  III.

  	
  RELATIONSHIP
  BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
  IV.

  	
  PARTICIPATING
  MEDICAL GROUP SERVICES AND RESPONSIBILITIES

  	
   

  
	
  V.

  	
  BLUE CROSS
  SERVICES AND RESPONSIBILITIES

  	
   

  
	
  VI.

  	
  ELIGIBILITY
  LISTINGS

  	
   

  
	
  VII.

  	
  COMPENSATION
  TO PARTICIPATING MEDICAL GROUP

  	
   

  
	
  VIII.

  	
  ENROLLMENT PROTECTION

  	
   

  
	
  IX.

  	
  NON-CAPITATED SERVICES

  	
   

  
	
  X.

  	
  BILLING
  FOR MEDICARE BLUE USA AWAY FROM HOME CARE SERVICES

  	
   

  
	
  XI.

  	
  TERM
  OF AGREEMENT, TERMINATION

  	
   

  
	
  XII.

  	
  MUTUAL
  AGREEMENT - AMENDMENT PROCEDURES

  	
   

  
	
  XIII.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
  XIV.

  	
  MEMBER
  RECONSIDERATION AND GRIEVANCE PROCESS

  	
   

  
	
  XV.

  	
  MISCELLANEOUS PROVISIONS

  	
   

  



 


EXHIBITS


 


	
  Exhibit A

  	
  Covered Medical
  Services

  	
   

  
	
  Exhibit A(1)

  	
  Division of
  Financial Responsibilities

  	
   

  
	
  Exhibit
  B

  	
  PARTICIPATING
  MEDICAL GROUP Facilities

  	
   

  
	
  Exhibit C

  	
  BLUE
  CROSS SENIOR SECURE Hospitals

  	
   

  
	
  Exhibit
  D

  	
  Administrative
  Responsibilities of PARTICIPATING MEDICAL GROUP

  	
   

  
	
  Exhibit E

  	
  Capitation

  	
   

  
	
  Exhibit
  F

  	
  Non-Capitated
  Performance Settlement Schedule

  	
   

  
	
  Exhibit
  G

  	
  Medicare
  Blue USA – Away From Home Care

  	
   

  
	
  Exhibit
  H

  	
  PARTICIPATING
  MEDICAL GROUP’s Delegated Activities

  	
   

  



 

















 


BLUE CROSS SENIOR SECURE


 


MEDICARE+CHOICE

MEDICAL SERVICES AGREEMENT


 


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


 


I.              RECITALS


 


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


 


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


 


1.03    BLUE CROSS has a contract with the Health Care
Financing Administration (“HCFA”) of the United States Government to provide
Medicare benefits to eligible persons through its BLUE CROSS SENIOR SECURE
program.


 


1.04    PARTICIPATING MEDICAL GROUP and its
PARTICIPATING MEDICAL GROUP Physicians desire to participate in BLUE CROSS
SENIOR SECURE by arranging for or providing Covered Medical Services in
coordination with BLUE CROSS, its Members and participating BLUE CROSS SENIOR
SECURE Hospitals on a prepaid basis.


 


II.            DEFINITIONS


 


2.01    “Adjusted Percent Non-Capitated Expense” means PARTICIPATING MEDICAL GROUP’s Percent
Non-Capitated Expense after adjustments in accordance with PARTICIPATING
MEDICAL GROUP’s Plan Factor and Region Factor, as mutually agreed upon by
PARTICIPATING MEDICAL GROUP and BLUE CROSS, for use in identifying the
PARTICIPATING MEDICAL GROUP’s Non-Capitated Performance Settlement.


 


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


 


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


 


1

















 


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


 


2.05    “Away from Home Care” means Urgent Blue Care, Follow-Up Care, and
Guest Program services as defined in the MEDICARE BLUE USA member’s plan
certificate or benefit agreement.


 


2.06    “Base Plan” means the benefits that are covered under the Benefit Agreements
approved by HCFA for BLUE CROSS SENIOR SECURE.


 


2.07    “Benefit Agreement(s)” means the written agreement(s) entered into
between BLUE CROSS and groups or individuals under which BLUE CROSS provides,
indemnifies, or administers health benefits to persons enrolled in the BLUE
CROSS SENIOR SECURE program.  “Benefit
Agreement(s)” also mean arrangements established by BLUE CROSS and/or one or
more of its Affiliates, or by persons or entities utilizing the Managed Care
Network pursuant to a contract with BLUE CROSS and/or one or more of its
Affiliates.  Subject to the terms
hereof, BLUE CROSS and/or one or more of its Affiliates may contract, on
PARTICIPATING MEDICAL GROUP’s behalf, with Other Payors wishing to utilize the
services of the Managed Care Network, incorporating the terms and conditions of
this Agreement.


 


2.08    “BLUE CROSS SENIOR SECURE” means the health services plan offered by
BLUE CROSS as described in the BLUE CROSS SENIOR SECURE Benefit Agreement.


 


2.09    “BLUE CROSS SENIOR SECURE Case Manager” means a BLUE CROSS employee charged with
assisting PARTICIPATING MEDICAL GROUPs in case management.


 


2.10    “BLUE CROSS SENIOR SECURE Coordinator” means an employee of PARTICIPATING MEDICAL
GROUP as set forth in Section 4.08(B).


 


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


 


2.12    “BLUE CROSS SENIOR SECURE Quality Management
Representative” means an
employee of BLUE CROSS responsible for the BLUE CROSS SENIOR SECURE Quality
Management Program.


 


2.13    “Capitation” means a uniform prepayment fee per Member per month for Capitation
Services, based on a percent of the Monthly HCFA Payment for each Member, or a
percent of the sum of the monthly Member Part A Premium plus the Monthly HCFA
Payment applicable to Medicare Part B only Members, and the applicable Benefit
Agreement.


 


2.14    “Capitation Services” means all BLUE CROSS SENIOR SECURE Covered
Medical Services which are not otherwise defined in this Agreement or in the
Division of Financial Responsibilities (Exhibit A(1) hereto) as Non-Capitated
Services, or MEDICARE BLUE USA Away From Home Care Services.


 


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


 


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


 


2.17    “Covered Medical Services” means the services and benefits covered under
the Benefit Agreements.  A list of those
services and benefits is set forth in Exhibit A.


 


2

















 


2.18    “Covered Persons” means Members who are covered by an
Affiliate’s Benefit Agreement or by an Other Payor.


 


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


 


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


 


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


 


C&R charges are
determined by BLUE CROSS


 


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


 


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


 


B.   Serious impairment to bodily functions,


 


C.   Other serious medical consequences, or


 


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


 


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


 


2.22    “HCFA” means the Health Care Financing Administration, an administrative
agency of the United States Government.


 


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


 


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


 


2.25    “Home HMO” means the Participating Plan in which a MEDICARE BLUE USA Participating
Plan member is enrolled.


 


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


 


2.27    “Hospital Services” means Medically Necessary acute care
inpatient and hospital outpatient services and supplies which are both (a)
covered by a Benefit Agreement, and (b) ordered or


 


3

















 


authorized by a PARTICIPATING MEDICAL GROUP Physician.  Hospital Services do not include long-term
non-acute care.


 


2.28    “Host HMO” means any Participating Plan in whose Service Area a MEDICARE BLUE USA
Participating Plan member temporarily stays, excluding the member’s Home HMO.


 


2.29    “Independent Practice Association” (IPA) means an incorporated association of
independent physicians which has entered into an agreement with BLUE CROSS to
provide and arrange for health services to persons who are enrolled in BLUE
CROSS SENIOR SECURE.


 


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


 


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


 


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


 


A.  Appropriate for the symptoms, diagnosis or
treatment of the medical condition, and


 


B.   Provided for the diagnosis or direct care and
treatment of the medical condition, and


 


C.   Within standards of good medical practice
within the organized medical community, and


 


D.  Not primarily for the convenience of the
Member’s physician, or another provider, and


 


E.   The most appropriate procedures, supplies,
equipment or service which can safely be provided.  The most appropriate procedures, supplies, equipment or service
must satisfy the following criteria: (i) there must be valid scientific evidence
demonstrating that the expected health benefits from the procedure, supplies
equipment or service are clinically significant and produce a greater
likelihood of benefit, without a disproportionately greater risk of harm or
complications, for the Member with the particular medical condition being
treated than other alternatives; and (ii) generally accepted forms of treatment
that are less invasive have been tried and found to be ineffective or are
otherwise unsuitable; and (iii) for hospital stays, acute care as an inpatient
is necessary due to the kind of services the Member is receiving or the
severity of the medical condition, and safe and adequate care cannot be
received as an outpatient or in a less intensified medical setting.


 


2.33    “Medicare Allowed Amount” is a charge limit determined by HCFA and
administered in accordance with the Medicare Guidelines.


 


2.34    “MEDICARE BLUE USA Away From Home Care” means a nationwide network of Blue Cross and
Blue Shield Plan HMOs (Participating Plans) sponsored by the Blue Cross and
Blue Shield Association (BCBSA).  BCBSA
Participating Plan HMOs have entered into agreements to provide each other’s
members with Urgent Blue Care. 
Follow-Up Care, and Guest Program services as preapproved and authorized
by the Home BLUE USA Plan when the member is traveling away from his or her
Home MEDICARE BLUE USA Participating Plan.


 


2.35    “Member” means a Subscriber who is a Medicare beneficiary covered by a BLUE
CROSS SENIOR SECURE Benefit Agreement and assigned to PARTICIPATING MEDICAL
GROUP.


 


2.36    “Member Months” means a count that records one Member month
for each month the Member is enrolled on the BLUE CROSS SENIOR SEC JRE program.


 


4

















 


2.37    “Member Part A Premium” means monthly payment required by BLUE CROSS
of those Members who have Part B of Medicare only and purchase Part A from BLUE
CROSS.


 


2.38    “Monthly HCFA Payment” means the revenue received by BLUE CROSS each
month from HCFA for each Member as determined by HCFA.  The Monthly HCFA Payment is comprised, in
whole or in part, from Federal Funds.


 


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


 


2.40    “Non-Capitated Performance Settlement” means the amount due to or from PARTICIPATING
MEDICAL GROUP for managing Non-Capitated Services.


 


2.41    “Non-Capitated Performance Settlement
Schedule” means a
schedule of Non-Capitated Performance Settlement amounts associated with
varying Non-Capitated Expenses expressed as a percentage of Monthly HCFA
Payment.  Exhibit F sets forth the
Non-Capitated Performance Schedule.


 


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


 


2.43    “Operations Manual” means the BLUE CROSS SENIOR SECURE
PARTICIPATING MEDICAL GROUP Operations Manual, which is hereby incorporated by
reference herein.


 


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


 


2.45    “Out-of-Area Services” means Emergency and Urgently Needed Services
which are rendered to a Member at a distance of more than thirty (30) miles
from the medical offices of PARTICIPATING MEDICAL GROUP or the Satellite
Facility to which the Member is assigned. 
When PARTICIPATING MEDICAL GROUP is organized as an Independent Practice
Association, Out-of-Area Services are those Emergency and Urgently Needed
Services which are rendered to a Member at a distance of more than thirty (30)
miles from a hospital designated in Exhibit C as a Service Area hospital.


 


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


 


2.47    “Outpatient Prescription Drug Expenses” means benefit amount paid by BLUE CROSS to
pharmacies or pharmacists for a Member’s covered outpatient prescription drug
expenses.


 


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


 


2.49    “PARTICIPATING MEDICAL GROUP Provider” means any of the following who have entered
into an agreement with PARTICIPATING MEDICAL GROUP to provide health care
services: A doctor of medicine or osteopathy, licensed to practice medicine or
osteopathy where the care is received, or a dentist, an optometrist, a
podiatrist or chiropodist, a clinical psychologist, a chiropractor, an
acupuncturist, a clinical social worker, a marriage family and child counselor,
a physical therapist, a speech pathologist, an audiologist, an occupational
therapist, a physician assistant, a registered nurse, a nurse practitioner
and/or nurse midwife providing services within the scope of practice as defined
by the appropriate clinical license and/or regulatory board.


 


5

















 


2.50    “Percent Non-Capitated Expense” means the sum of the medical portion of
Non-Capitated Expense and the Outpatient Prescription Drug Expense, expressed
as a percentage of the Monthly HCFA Payment, adjusted for cost variations
across counties.


 


2.51    “Plan Factors” means factors used to adjust the
PARTICIPATING MEDICAL GROUP’s Capitation to account for cost variations
attributable to the mix of Member Benefit Agreements.


 


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


 


2.53    “PRO Program” or Peer Review Organization means the
provider utilization review program developed by HCFA for providers of Covered
Medical Services.


 


2.54    “Quality Management Committee” means a committee of physicians and other
licensed health care providers, at least 50% of whom participate in BLUE CROSS
SENIOR SECURE, which meets regularly to review the Quality Management Program.


 


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


 


2.56    “Referral Services” means Capitation Services which are rendered
to Members through referral as authorized by PARTICIPATING MEDICAL GROUP
Physicians.


 


2.57    “Region Factor” means a factor which adjusts the medical
portion of Non-Capitated Expenses to account for cost variations across
counties, as mutually agreed upon by PARTICIPATING MEDICAL GROUP and BLUE
CROSS.


 


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


 


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


 


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


 


2.61    “Skilled Nursing Facility Services” means inpatient and related services provided
by a licensed Skilled Nursing Facility. 
Skilled Nursing Facility Services exclude custodial care services.


 


2.62    “Subscriber” means an individual who has qualified for and is covered under a BLUE
CROSS SENIOR SECURE Benefit Agreement.


 


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


 


6

















 


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


 


2.65    “Urgently Needed Services” means Covered Medical Services which are
required without delay, in order to prevent serious deterioration of Member’s
health as the result of an unforeseen illness or injury while the Member is
temporarily absent from the PARTICIPATING MEDICAL GROUP Service Area and
receipt of such Covered Medical Services cannot be delayed until Member returns
to PARTICIPATING MEDICAL GROUP’s Service Area.


 


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


 


III.           RELATIONSHIP BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP


 


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


 


3.02    BLUE CROSS and PARTICIPATING MEDICAL GROUP
agree that PARTICIPATING MEDICAL GROUP Physicians shall maintain a
physician-patient relationship with each Member assigned to PARTICIPATING
MEDICAL GROUP.  PARTICIPATING MEDICAL
GROUP shall be solely responsible to the Member for treatment and medical care
with respect to the provision of Capitation Services and arrangements for
Non-Capitated Services.


 


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


 


3.04    Nothing contained in this Article shall
limit the right of BLUE CROSS to perform monitoring functions as required by
applicable state and federal law, as amended.


 


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


 


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


 


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


 


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3.08    Nothing contained in this Article shall
limit the right of BLUE CROSS to perform monitoring functions as required by
BLUE CROSS’ contract with HCFA and applicable state and Federal law.


 


IV.           PARTICIPATING MEDICAL GROUP SERVICES AND
RESPONSIBILITIES


 


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


 


4.01    Provision of Services.


 


A.  To promptly provide, arrange through referral,
or authorize all Capitation Services; to authorize or arrange all Non-Capitated
Services, and further, to accept full financial responsibility for all
Capitation Services provided, authorized or arranged through referral by
PARTICIPATING MEDICAL GROUP. 
PARTICIPATING MEDICAL GROUP shall assure that all Health Professionals
contracted with PARTICIPATING MEDICAL GROUP to provide Referral Services follow
appropriate billing procedures.


 


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


 


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


 


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


 


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


 


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


 


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


 


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


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


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


 


8

















 


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


(5)  the ability of the PARTICIPATING MEDICAL GROUP
Physician(s) to perform the services covered by this Agreement is otherwise
impaired; then


 


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


 


H.  To provide BLUE CROSS with a current list of
participating Primary Care Physicians upon BLUE CROSS’ request.


 


I.    To comply with Title VI of the Civil Rights
Act of 1964, Section 504 of the Rehabilitation Act of 1973 and the Age
Discrimination Act of 1975.


 


J.    To comply with the requirements of the Privacy
Act, as implemented by 45 C.F R.  Part
5B and Subpart B of Part 401, Chapter IV, as specified at 42 C.F.R.  Section 417.486 (C).


 


K.  To comply with the confidentiality
requirements of 42 C.F.R. 
Section 482.24 of Chapter IV for medical records and for all other
information on Medicare enrollee Members, not covered by 42 C.F.R.
Section 417.486 (C), that is contained in its records or obtained from
HCFA or others.


 


L.   To comply with all applicable HCFA regulations
as set forth in the Code of Federal Regulations (C.F.R.).


 


M. To accept as final all decisions by HCFA
regarding disputes over Covered Medical Services.


 


N.  To comply with the requirements for PRO
Program review of services furnished to Medicare enrollees, as set forth at 42
C.F.R. Part 462, Subchapter D.


 


O.  To provide Members direct access to women’s
health specialists within the PARTICIPATING MEDICAL GROUP’s network of
contracted specialists.


 


4.02    Accessibility and Continuity of Care.


 


A.  To promptly provide or arrange for available
and accessible BLUE CROSS SENIOR SECURE Covered Medical Services for each
Member assigned to PARTICIPATING MEDICAL GROUP, in accordance with that
Member’s Benefit Agreement and this Agreement, and to provide those services in
and through the facilities designated in Exhibit B.


 


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


 


C.   To promptly provide, arrange or authorize all
Emergency services and/or Urgently Needed Services for each Member assigned to
PARTICIPATING MEDICAL GROUP. 
Authorization of any Emergency services and/or Urgently Needed Services,
as set forth in Sections 2.20


 


9

















 


and 2.65 herein, shall not be withheld by PARTICIPATING MEDICAL GROUP
regardless of whether PARTICIPATING MEDICAL GROUP is notified within
forty-eight (48) hours from the time such Emergency services were
rendered.  PARTICIPATING MEDICAL GROUP
shall comply with all requirements set forth in California Health and Safety
Code Section 1371.4(a) -(d).


 


D.  That PARTICIPATING MEDICAL GROUP shall manage
and facilitate access to Emergency services and/or Urgently Needed Services,
within PARTICIPATING MEDICAL GROUP’s Service Area at all times, twenty-four
(24) hours a day, seven (7) days a week. 
In the event that PARTICIPATING MEDICAL GROUP is an Independent Practice
Association, PARTICIPATING MEDICAL GROUP shall manage and facilitate access to
Emergency services and/or Urgently Needed Services within a thirty (30) mile
radius of the Hospital(s) designated in Exhibit C as the BLUE CROSS SENIOR
SECURE Hospital(s) within PARTICIPATING MEDICAL GROUP’s Service Area.


 


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


 


F.   Notwithstanding Section 4.02(E) for those
Members that require organ transplant services (solid organ and bone
marrow/stem cell) that are Covered Medical Services, PARTICIPATING MEDICAL
GROUP agrees to admit, or authorize the inpatient admission or outpatient
treatment of Members, solely to those BLUE CROSS SENIOR SECURE Hospitals whose
transplant programs have been approved by BLUE CROSS and identified as such in
the Operations Manual.  Upon execution
of this Agreement PARTICIPATING MEDICAL GROUP shall provide BLUE CROSS with a
list of the transplant facilities used by PARTICIPATING MEDICAL GROUP for each
of the following types of transplants: heart, lung, heart-lung, liver,
pancreas-kidney, autologous bone marrow/stem cell and allogenic bone
marrow/stem cell.  BLUE CROSS will
evaluate those facilities/programs to determine if they meet the BLUE CROSS
transplant program requirements.  Upon
approval of the programs by BLUE CROSS, PARTICIPATING MEDICAL GROUP can
authorize admission of Members to such facilities/programs.  PARTICIPATING MEDICAL GROUP will pay
transplant facilities for transplant services that are Covered Medical Services
at the lesser of the BLUE CROSS transplant rates with such facility or
PARTICIPATING MEDICAL GROUP’s negotiated rate with such facility.


 


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


 


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


 


H.  To use a referral request process by which
Capitation Services and Non-Capitated Services are to be rendered or arranged
to be rendered by Health Professionals other than the


 


10

















 


Member’s Primary Care Physician, including PARTICIPATING MEDICAL GROUP
Physicians or other Health Professionals who do not belong to PARTICIPATING
MEDICAL GROUP.  This process shall
assure that:


 


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


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


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


 


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


 


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


 


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


 


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


 


M. To develop a program to identify Members with
complex or serious medical conditions to ensure ongoing care and the
establishment and implementation of a treatment plan appropriate to the
Member’s condition.  In addition, the
treatment plan will be time-specific, updated periodically, and include an
adequate number of direct access visits to specialists to accommodate the
treatment plan.


 


4.03    Utilization/Quality Management Procedures.


 


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


 


4.04    Quality Management Program.


 


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


 


11

















 


of its Quality Management Program by BLUE CROSS staff.  Any failure to allow or to so cooperate in
such review(s) shall constitute a material breach of this Agreement.


 


A.  The Quality Management Program shall:


 


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


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


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


 


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


 


(1)  Credentialing, recredentialing and peer review
of all PARTICIPATING MEDICAL GROUP Physicians and allied Health Professionals
and other providers in accordance with HCFA guidelines.


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


(3)  Incident identification and risk management.


(4)  Cooperation with BLUE CROSS’ Member grievance
resolution process.


(5)  General and focused health care audits.


(6)  Development and implementation of appropriate
recommendations.


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


 


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


 


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


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


(3)  PARTICIPATING MEDICAL GROUP shall take corrective
action to eliminate any deficiencies in areas needing improvement within a
reasonable period of time.  Any failure
to take such corrective action to the satisfaction of BLUE CROSS shall
constitute a material breach of this Agreement.


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


 


D.  PARTICIPATING MEDICAL GROUP shall:


 


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


(2)  Provide BLUE CROSS with access to all
PARTICIPATING MEDICAL GROUP quality management data directly or indirectly
relating to BLUE CROSS SENIOR SECURE Members.


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


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


 


12

















 


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


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


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


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


(9)  Provide copies of annual reports and other
public information on its Quality Management Program activities to BLUE CROSS
upon request.  PARTICIPATING MEDICAL
GROUP further agrees that BLUE CROSS shall have the right to access statistical
information and other such summary data as PARTICIPATING MEDICAL GROUP may
prepare from time to time related to its internal quality management
activities.  The provision of information
provided by PARTICIPATING MEDICAL GROUP to BLUE CROSS shall not impair
PARTICIPATING MEDICAL GROUP’s rights and protections under Section 1157 of
the Evidence Code.


 


4.05    Utilization Management Program.


 


To adopt and maintain a Utilization Management Program consistent with
BLUE CROSS standards and approved by BLUE CROSS.  This program will cover all Covered Medical Services provided or
arranged by PARTICIPATING MEDICAL GROUP for Members.  PARTICIPATING MEDICAL GROUP agrees to allow and shall cooperate
in the scheduling and conduct of on-site review(s) of Utilization Management
Program by BLUE CROSS.  Any failure to
allow or to so cooperate in such review(s) shall constitute a material breach
of this Agreement.


 


A.  The Utilization Management Program shall:


 


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


(2)  Include documentation of remedial procedures
for instances of inappropriate or substandard services(s) and/or failure to
provide Medically Necessary Covered Medical Services.


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


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


(5)  Work closely with BLUE CROSS SENIOR SECURE
Hospitals.


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


(7)  Utilize prospective, concurrent, and
retrospective review.  Utilization
Management for Inpatient Hospital Services shall include:


(a)   “Pre-Admission Review” to determine whether a
scheduled inpatient admission is Medically Necessary.


(b)   “Admission Review” to determine whether an
unscheduled inpatient admission, or admission not subject to Pre-Admission
Review, is Medically Necessary.


(c)   “Concurrent Review” to determine whether a
continued inpatient hospital stay is Medically Necessary.


(8)  Encompass an expedited initial determination
review process as required by HCFA regulations and in conjunction with BLUE
CROSS policy.


 


13

















 


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


 


(10) Permit BLUE CROSS to have access to all
PARTICIPATING MEDICAL GROUP utilization management data directly or indirectly
relating to Members.


 


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


 


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


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


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


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


 


C.   PARTICIPATING MEDICAL GROUP shall:


 


(1)  Make available to BLUE CROSS summaries of all
minutes and notes from any and all utilization management committees and/or
activities which relate to Members.


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


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


 


4.06    Records and Reserves.


 


A.  BLUE CROSS shall have access upon advance
notice at reasonable times upon demand to the books, records, claims and papers
of PARTICIPATING MEDICAL GROUP relating to the services PARTICIPATING MEDICAL
GROUP provides to Members, to the cost thereof, and to payments PARTICIPATING
MEDICAL GROUP receives from Members or others on their behalf.  PARTICIPATING MEDICAL GROUP shall maintain
such records and provide such information to BLUE CROSS, the Commissioner of
Corporations and HCFA as may be necessary for BLUE CROSS’ compliance with the
requirements of the Knox-Keene Act and Federal law.  PARTICIPATING MEDICAL GROUP shall maintain such records for at
least six (6) years, and such obligations shall not be terminated upon a
termination of this Agreement, whether by rescission or otherwise.


 


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


 


14

















 


 


(1)  Balance sheets


(2)  Statements of revenues and expenses


(3)  Statements of cash flow


 


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


 


C.   To maintain financial reserves adequate to
cover all risks assumed by PARTICIPATING MEDICAL GROUP hereunder, including,
but not limited to, unanticipated claims for Referral Services that are the
potential responsibility of PARTICIPATING MEDICAL GROUP.  The failure to maintain such reserves shall
constitute a material breach of this Agreement.


 


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


 


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


 


F.   PARTICIPATING MEDICAL GROUP shall ensure
Members have timely access to their records and information that pertain to
them in accordance with State and Federal regulations.


 


4.07    Insurance Programs or Policies.


 


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


 


A.  Professional Liability Insurance


 


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


 


B.   Other Insurance


 


(1)  General Liability Insurance  In
addition to Subsection A., above, PARTICIPATING MEDICAL GROUP shall also
maintain a policy or program of comprehensive general liability insurance (or
other risk protection) with minimum coverage including no less than ONE HUNDRED
THOUSAND DOLLARS ($100,000.00) for PARTICIPATING MEDICAL


 


15

















 


GROUP’s property, together with combined single limit bodily injury and
property damage insurance of not less that SIX HUNDRED THOUSAND DOLLARS
($600,000.00).


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


 


4.08    Administrative Responsibilities.


 


A.  To comply with all BLUE CROSS SENIOR SECURE
administrative policies and procedures in the areas listed in Exhibit D and as
set forth in the BLUE CROSS SENIOR SECURE Operations Manual and to comply with
all applicable state and federal laws and regulations relating to the delivery
of Covered Medical Services.


 


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


 


C.   To provide at least ninety (90) days prior
written notification to BLUE CROSS of any of the following:


 


(1)  A Primary Care Physician’s termination of
his/her affiliation with PARTICPATING MEDICAL GROUP or a PARTICPATING MEDICAL
GROUP Provider.


(2)  The termination of a Primary Care Physician by
PARTICPATING MEDICAL GROUP or a PARTICPATING MEDICAL GROUP Provider.


(3)  Any Satellite Facility closure, relocation or
inability to serve Members.


(4)  Any change in business address of
PARTICIPATING MEDICAL GROUP or any PARTICIPATING MEDICAL GROUP Provider.


(5)  A Primary Care Physician’s non-acceptance of
additional Members.


 


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


 


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


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


 


E.   To notify BLUE CROSS in writing within fifteen
(15) days concerning any of the following:


 


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


(2)  Any change in ownership.  For the purpose of this Agreement, a change
of ownership shall be defined as the merger of the corporation into another
corporation or the consolidation of the corporation with one or more
corporations, resulting in a new corporate body.


(3)  Any legal or governmental action initiated
against PARTICIPATING MEDICAL GROUP, a PARTICIPATING MEDICAL GROUP Physician or
a PARTICIPATING MEDICAL GROUP Provider, including, but not limited to, a
disciplinary or other action: (a) for professional negligence; (b) for a
violation of law; or (c) against any license, insurance or certification;
which, if successful, would materially impair the ability of PARTICIPATING
MEDICAL GROUP, any PARTICIPATING MEDICAL GROUP Physician or any PARTICIPATING
MEDICAL GROUP Provider to carry out the duties and obligations of this
Agreement.


(4)  Any other situation that may interfere with
PARTICIPATING MEDICAL GROUP, any PARTICIPATING MEDICAL GROUP Physician or any
PARTICIPATING MEDICAL GROUP Provider’s duties and obligations under this
Agreement.


 


16

















 


F.   To obtain BLUE CROSS’ and HCFA’s prior written
approval for any literature related to BLUE CROSS SENIOR SECURE and intended
for Members.


 


G.   To continually meet all criteria for
PARTICIPATING MEDICAL GROUPs, set forth in the Operations Manual and to
continually meet all criteria for Satellite Facilities (if applicable) set
forth in the Operations Manual.  Any
failure to continually meet such criteria shall constitute a material breach of
this Agreement.


 


H.  To electronically provide BLUE CROSS, on a
monthly basis by the fifteenth (15th) day of the succeeding month, complete and
accurate ambulatory encounter data either directly or through PARTICIPATING
MEDICAL GROUP’s billing agent in accordance with standards established by BLUE
CROSS.  PARTICIPATING MEDICAL GROUP
shall certify, to the best of its knowledge, as to the completeness and
truthfulness of all submitted encounter data. 
Any failure to so provide such data shall constitute a material breach
of this Agreement.


 


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


 


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


 


K.  To disclose to BLUE CROSS information related
to physician incentives necessary to comply with HCFA regulations.


 


4.09    Payments and Member Billing.


 


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


 


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


 


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


 


D.  That PARTICIPATING MEDICAL GROUP shall promptly
notify, in writing, the BLUE CROSS SENIOR SECURE Case Management Department of
all cases that reach the Enrollment Protection level specified in
Article VIII.


 


17

















 


E.   To pay ninety-five percent (95%) of all
non-contracted Health Professionals or providers who have rendered Referral
Services to Members, within thirty (30) calendar days following receipt of a
clean, undisputed claim, and to pay or deny all other claims within sixty (60)
calendar days from the date first received by PARTICIPATING MEDICAL GROUP, BLUE
CROSS or BLUE CROSS contracted provider, consistent with the regulations of
HCFA.  If payment is not made on a clean
claim (from non-contracted providers) within thirty (30) days, PARTICIPATING
MEDICAL GROUP shall pay interest on such claim at the rate used for purposes of
Section 3902 (a) of Title 31, United States Code.


 


PARTICIPATING MEDICAL GROUP agrees to include the above referenced
prompt payment provision, the terms of which are developed and agreed to by
both BLUE CROSS and the relevant provider, in all of the PARTICIPATING MEDICAL
GROUP’s contractual agreements.


 


Payment of provider claims is a delegation of BLUE CROSS authority, all
or part of which may be revoked at any time. 
Any failure to comply with the provisions of this Section 4.09(E)
shall constitute a material breach of this Agreement, and BLUE CROSS shall be
entitled to take action in accordance with Section 11.04, or in the
alternative, BLUE CROSS may require that PARTICIPATING MEDICAL GROUP execute
and maintain a contract with BLUE CROSS or a third party designated by BLUE
CROSS to perform on-site oversight of PARTICIPATING MEDICAL GROUP’s claims
payment processes in accordance with applicable HCFA regulations, the cost of
which shall be borne by PARTICIPATING MEDICAL GROUP.


 


F.   To issue notices of non-coverage in accordance
with HCFA regulations within sixty (60) days for all adverse claims
determinations.


 


G.   That when a Member has reached the maximum
out-of-pocket payment, as defined by the applicable Benefit Agreement,
PARTICIPATING MEDICAL GROUP will forego collection of co-payments, co-insurance
or deductibles.  PARTICIPATING MEDICAL
GROUP will not look to BLUE CROSS for such payments.


 


H.  That when a Member has exceeded the maximum
out-of-pocket payment, whether the copayments, co-insurance or deductibles
accruing towards the maximum out-of-pocket payment were paid to PARTICIPATING
MEDICAL GROUP or other provider, PARTICIPATING MEDICAL GROUP will promptly
refund the Member’s excess payment.


 


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


 


J.    That with respect to obstetrical admissions of
Members, there shall be no charge for routine care to the newborn during any
period when the mother is an obstetrical inpatient.  Routine care shall not include the services of an Intensive Care
Newborn Nursery.


 


K.  To take all necessary measures to assure that
neither PARTICIPATING MEDICAL GROUP nor any of its PARTICIPATING MEDICAL GROUP
Physicians or contracted or non-contracted Health Professionals will ever bill
Medicare for any BLUE CROSS SENIOR SECURE Covered Medical Services, (except
when Medicare is the primary payor). 
PARTICIPATING MEDICAL GROUP agrees to immediately repay Medicare when it
becomes aware of a Medicare overpayment.


 


4.10    Member and Medical Records.


 


A.  That all information shall be provided to each
party to this Agreement pursuant to procedures designed to protect the
confidentiality of patient medical records in accordance with


 


18

















 


applicable legal requirements, recognized standards of professional
practice and generally accepted procedures followed by health maintenance
organizations (HMOs).


 


B.   To prepare
and maintain all appropriate records with respect to Members who receive
Capitation Services at PARTICIPATING MEDICAL GROUP.  The records shall be maintained in accordance with prudent record
keeping procedures and as required by law.


 


C.   That BLUE
CROSS or its authorized representatives and any governmental agency having
jurisdiction over BLUE CROSS may review, audit and duplicate data and other
records maintained on Members, including but not limited to medical records or
other records relating to billing, payment and assignment, to the extent
permitted by law.


 


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


 


E.   Subject to
all applicable laws relating to privacy and confidentiality requirements,
medical records of Members shall be made available, upon reasonable request, to
each health professional treating a Member and to BLUE CROSS.


 


F.   Ownership and
access to records of Members shall be controlled by applicable laws.


 


G.   PARTICIPATING
MEDICAL GROUP shall ensure the Member has timely access to Member’s records and
information that pertain to them in accordance with applicable state and
Federal regulations.


 


4.11    Membership.


 


A.  To accept any
and all Members who select or who have been assigned to the PARTICIPATING
MEDICAL GROUP until such time as PARTICIPATING MEDICAL GROUP shall have
provided ninety (90) days prior written notice to BLUE CROSS that it has
reached its maximum capacity as set forth in Section 15.07 herein, or that
it anticipates reaching such maximum within ninety (90) days from the date of
the notice to BLUE CROSS.  The maximum
capacity of PARTICIPATING MEDICAL GROUP designated in Section15.07 shall be
reduced only upon ninety (90) days written notice to BLUE CROSS.  The parties acknowledge their understanding
that enrollment from individual accounts, or changes in selection of
PARTICIPATING MEDICAL GROUP by Members, are not entirely within the control of
BLUE CROSS.


 


B.   That
PARTICIPATING MEDICAL GROUP will not request, demand, require or otherwise seek
the transfer or removal of any Member from the care of PARTICIPATING MEDICAL
GROUP based on that Member’s need of, or utilization of, Medically Necessary
services.  PARTICIPATING MEDICAL GROUP agrees
BLUE CROSS shall have sole and ultimate authority to terminate any Member’s
coverage and shall do so in accordance with the disenrollment policies and
procedures promulgated by HCFA for Members as set forth in the Benefit
Agreements and the Operations Manual.


 


C.   PARTICIPATING
MEDICAL GROUP agrees that, in the event a Member who is covered for workers’
compensation benefits by a workers’ compensation carrier affiliated with BLUE
CROSS, seeks services for a work-related illness or injury, PARTICIPATING
MEDICAL GROUP shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that participates in
the Prudent Buyer Comp provider network or the CaliforniaCare Comp provider
network, whichever is applicable.  In
the event that PARTICIPATING MEDICAL GROUP elects to treat such Member,
PARTICIPATING MEDICAL GROUP shall complete a Doctor’s First Report of Injury as
defined in the California Labor Code. 
As payment for such medical services rendered, PARTICIPATING MEDICAL


 


19

















 


GROUP agrees to accept, as payment in full, compensation in accordance
with the then current Blue Cross of California Prudent Buyer Plan Participating
Physician fee schedule for the applicable region.  PARTICIPATING MEDICAL GROUP further agrees
that, in the event such Member requires medical services in connection with
such work-related illness or injury beyond the treatment provided at the initial
visit, PARTICIPATING MEDICAL GROUP shall refer such Member only to a provider
that participates in the Prudent Buyer Comp provider network or the
CaliforniaCare Comp provider network, whichever is applicable.  If PARTICIPATING MEDICAL GROUP elects not to
treat such Member with a work-related illness or injury, PARTICIPATING MEDICAL
GROUP agrees to refer such Member only to a provider that participates in the
Prudent Buyer Comp provider network or the CaliforniaCare Comp provider
network.  The foregoing shall not apply
if PARTICIPATING MEDICAL GROUP is a participating provider for the Prudent
Buyer Comp provider network or the CaliforniaCare Comp provider network.


 


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


 


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


 


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


 


F.   To designate dedicated customer service staff
to service Members.


 


G.   To participate in all existing and new
Medicare products developed by BLUE CROSS, upon BLUE CROSS’ request.


 


4.12    PARTICIPATING MEDICAL GROUP agrees to adhere
to the following provisions and, PARTICIPATING MEDICAL GROUP agrees to
incorporate these provisions, as appropriate, into all of the PARTICIPATING
MEDICAL GROUP’s contracted and subcontracted agreements with providers of
health care to Members.


 


A.  BLUE CROSS has the ultimate responsibility and
accountability for ensuring compliance with HCFA guidelines through its
contracted and subcontracted entities.


 


B.   The U.S. 
Department of Health and Human Services, the Comptroller General, or
other designated entities, shall have access to all related documents
pertaining to the BLUE CROSS contract for a period up to six (6) years.


 


C.   Providers are prohibited from holding a Member
liable for the payment of fees that are the obligation of BLUE CROSS.


 


D.  Providers shall comply with BLUE CROSS
Medicare+Choice contractual obligations.


 


20

















 


E.   Providers shall safeguard the privacy of any
information that identifies a particular Member and shall maintain records in
an accurate and timely manner.


 


F.   Providers shall submit to PARTICIPATING
MEDICAL GROUP all data necessary to characterize content and purpose of each
encounter with a Member.


 


G.   Providers are prohibited from discriminating
against Members based on health status.


 


H.  Providers shall provide access to benefits in
a manner described by HCFA.


 


I.    Providers shall conduct a health assessment on
all new enrollees within ninety (90) days of effective enrollment.


 


J.    Providers shall provide all covered benefits
in a manner consistent with professionally recognized standards of health care.


 


K.  Providers shall hold enrollees harmless from
financial liabilities that are the legal obligation of PARTICIPATING MEDICAL
GROUP.


 


L.   All payment and incentive arrangements,
including requirements pertaining to the receipt of Federal Funds shall be
specified.


 


M. Providers shall be subject to all laws
applicable to individuals/entities receiving Federal funds and shall comply
with all other laws and regulations including Title VI of the Civil Rights Act
of 1964, the Age Discrimination Act of 1975 and the Americans with Disabilities
Act.


 


N.  Providers shall agree to the prompt payment
language as described in Section 4.09(E).


 


O.  Providers shall certify the completeness and
truthfulness of their encounter data.


 


P.   Providers shall cooperate with an independent
quality review and improvement organization’s activities pertaining to
provision of services for Members as well as comply with BLUE CROSS’ medical
policy, QA program and medical management program.


 


Q.  Providers shall provide written reasons for
denial, suspension and/or termination determinations which affect health care
professionals.


 


R.   Providers shall provide at least sixty (60)
days notice to contracting providers before terminating their contracts without
cause.


 


S.   Providers shall continue to provide services
to Members who are hospitalized on the date BLUE CROSS’ Medicare+Choice
contract terminates through the date of discharge or through the period the
HCFA premium is paid.


 


T.   Providers shall not contract with providers
excluded from participation in Medicare under Sections 1128 or 1128A of the
Social Security Act.


 


U.  Providers shall comply with Medicare
appeals/expedited appeals procedures for Members, including
gathering/forwarding information on appeals to BLUE CROSS as necessary.


 


V.   BLUE CROSS has the right to approve, suspend
or terminate arrangements pertaining to the selection of providers, contractors
or subcontractors.


 


W. For delegated activities, all BLUE CROSS
contracted and subcontracted entities will receive the following:


 


(1)  A list of delegated activities and reporting
responsibilities,


(2)  Arrangements for the revocation of delegated
activities,


 


21

















 


(3)  Notification that the performance of the contracted
and subcontracted entities will be monitored by BLUE CROSS,


(4)  Notification that the credentialing process
must be approved and monitored by BLUE CROSS, and


(5)  Notification that all contracted or
subcontracted entities must comply with all applicable Medicare laws,
regulations and HCFA instructions.


 


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


 


4.14    PARTICIPATING MEDICAL GROUP shall not take or
threaten punitive action, prohibit or otherwise restrict a health care provider
from advising or advocating on behalf of the Member in the area of medical care
as it relates to expedited determinations, expedited reconsiderations or
treatment options, including risks, benefits and consequences of treatment or
non-treatment, or the Members right to refuse treatment and express preferences
about future treatment decisions, in accordance with HCFA regulations.  Failure to adhere to these regulations will
constitute a material breach of this Agreement.


 


4.15    PARTICIPATING MEDICAL GROUP or PARTICIPATING
MEDICAL GROUP’s contracted or subcontracted entities are not required to
provide, or pay for, Covered Medical Services that PARTICIPATING MEDICAL GROUP
has:


 


A.  Identified in advance as being objectionable
on moral or religious grounds,


 


B.   Identified in its original contractual
arrangement with BLUE CROSS as a service it will not provide, or


 


C.   With respect to existing Members, provide
ninety (90) days written notice of intent to not provide such service.


 


4.16    PARTICIPATING MEDICAL GROUP agrees to perform
the delegated activities, as set forth on Exhibit H, attached and incorporated
herein.


 


V.            BLUE CROSS SERVICES AND RESPONSIBILITIES


 


BLUE CROSS AGREES:


 


5.01    To perform, or arrange for the performance of,
all necessary accounting and enrollment functions with respect to marketing and
administering the BLUE CROSS SENIOR SECURE program, and to issue a BLUE CROSS
SENIOR SECURE identification card to each Member as described in the Operations
Manual.


 


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


 


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


 


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


 


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


 


22

















 


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


 


5.07    To undertake reasonable efforts, in accordance
with a standard of good faith, to assure that Members assigned to PARTICIPATING
MEDICAL GROUP will live within the Service Area defined in this Agreement.  Pursuant to HCFA requirements, BLUE CROSS
may recommend, but not require, that Members select a PARTICIPATING MEDICAL
GROUP within thirty (30) miles of their home. 
However, BLUE CROSS reserves the right to assign any Members to
PARTICIPATING MEDICAL GROUP at the Member’s open enrollment, or when the Member
changes residence, or when BLUE CROSS determines such transfer to be in the
Member’s best interest due to special circumstances under the terms of the
Member’s Benefit Agreement.


 


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


 


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


 


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


 


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


 


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


 


5.13    To conduct an initial health risk assessment
within ninety (90) days of a new Member’s effective enrollment.


 


23

















 


VI.           ELIGIBILITY LISTINGS


 


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


 


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


 


B.   PARTICIPATING MEDICAL GROUP shall receive a
copy of the Eligibility Reports at PARTICIPATING MEDICAL GROUP’s main
site.  Should PARTICIPATING MEDICAL
GROUP request reports in an electronic format, paper reports will continue to
be provided for an additional ninety (90) days only.  As described in the Operations Manual, BLUE CROSS will charge a
fee of between Fifty Dollars ($50.00) and Five Hundred Dollars ($500.00) per
report, for each of the following:


 


(1)  duplicate copies of paper reports,


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


(3)  duplicate reports for prior months.


 


C.   BLUE CROSS will discourage retroactive
cancellation of any Member.  However,
when no services have been rendered, BLUE CROSS may make occasional exceptions
due to legitimate administrative processing requirements or to comply with HCFA
requirements.  BLUE CROSS shall be
entitled to a refund of Capitation payments made for any Member who retroactively
cancels or who is retroactively cancelled. 
BLUE CROSS will attempt to discourage retroactively adding any Member
after the applicable billing is reconciled. 
In the event BLUE CROSS finds it necessary to assign a new Member to
PARTICIPATING MEDICAL GROUP, Capitation payment for that Member shall be made,
and PARTICIPATING MEDICAL GROUP agrees to be responsible for all Covered
Medical Services due that Member under the terms of the Member’s Benefit
Agreement which were provided or arranged by PARTICIPATING MEDICAL GROUP, from
the date the Member was assigned.


 


D.  In the event care is provided to an ineligible
person, based on an erroneous or delayed Eligibility Report, PARTICIPATING
MEDICAL GROUP shall bill Medicare directly for services rendered.  If a Member presents a BLUE CROSS SENIOR
SECURE identification card, receives covered services and is then determined
not to be eligible for Medicare, BLUE CROSS will guarantee payment according to
the then current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region or the actual
billed amount or the Medicare Allowed Amount, whichever is less, on the
condition that PARTICIPATING MEDICAL GROUP shall supply BLUE CROSS with
evidence that PARTICIPATING MEDICAL GROUP has unsuccessfully sought payment for
all or a portion of the charges from the ineligible person, or the person
having legal responsibility for the ineligible person, through two billing
cycles, or through a period of sixty (60) days, whichever is greater.  The obligations of BLUE CROSS under this
Subsection D shall be subject to the (1) exercise of prudent judgment by
PARTICIPATING MEDICAL GROUP, evidenced by reasonable efforts to contact BLUE
CROSS for verification of eligibility of each Member prior to providing or
arranging Covered Medical Services, (2) submission to BLUE CROSS of both the
claim and evidence of its unsuccessful collection efforts within twelve (12)
months of the date of service.  In the
event payment is made to PARTICIPATING MEDICAL GROUP by BLUE CROSS, pursuant to
this Section, PARTICIPATING MEDICAL GROUP shall have no further right to and
shall not attempt to collect any additional payment from the Member for said
services.


 


24

















 


VII.          COMPENSATION TO PARTICIPATING MEDICAL GROUP


 


7.01    Exhibit E sets forth Capitation payments for
new and renewing business.  The
applicable Capitation payment for each Member assigned to PARTICIPATING MEDICAL
GROUP shall be paid monthly, prorated in accordance with Member eligibility.


 


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


 


7.02    Capitation shall be paid in consideration for
providing Capitation Services and arranging Non-Capitated Services for each
Member assigned to PARTICIPATING MEDICAL GROUP, and in consideration for all
Capitation Services arranged through referral of Members by PARTICIPATING
MEDICAL GROUP.  The Capitation payment
shall be made by the tenth (10) of each month or within two (2) days following
receipt of payment from HCFA, whichever occurs later, and shall be computed on
the basis of the most current information available from HCFA.  In the event that an error is made in the
computation of the Capitation payment, or HCFA determinations result in an
overpayment or underpayment to PARTICIPATING MEDICAL GROUP, BLUE CROSS reserves
the right to adjust subsequent Capitation payments to PARTICIPATING MEDICAL
GROUP to offset such overpayment or underpayment.


 


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


 


7.03    PARTICIPATING MEDICAL GROUP agrees to look
solely to BLUE CROSS for payment for Capitation Services subject only to


 


A.  The order of benefit determination provisions
set forth in Title 10 of the California Code of Regulations, Section 1300.67.13
for Coordination of Benefits, and


 


B.   The relevant copayment provisions of the
Member’s Benefit Agreement, and as described in relevant provisions in
Subsection 4.09(A),


 


7.04    PARTICIPATING MEDICAL GROUP agrees that the
only charges for which a Member may be liable and be billed by PARTICIPATING
MEDICAL GROUP shall be:


 


A.  Services not covered under the Member’s
Benefit Agreement, and


 


B.   Co-payments, deductibles or co-insurance
payable directly to PARTICIPATING MEDICAL GROUP under the terms of the Member’s
Benefit Agreement.


 


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


 


7.06    Except as otherwise provided herein,
PARTICIPATING MEDICAL GROUP shall accept the payments specified in this
Agreement as payment in full for all Covered Medical Services provided or
arranged for Members during each month for which such payments are to be
received by PARTICIPATING MEDICAL GROUP from BLUE CROSS.  In the event BLUE CROSS fails to make any
payments to PARTICIPATING MEDICAL GROUP as provided herein, whether from BLUE
CROSS’ insolvency or otherwise, BLUE CROSS SENIOR SECURE Members shall not be
liable to PARTICIPATING MEDICAL GROUP or its PARTICIPATING MEDICAL GROUP
Physicians under any circumstances for Covered Medical Services.


 


25

















 


Surcharges for Covered Medical Services provided or arranged by
PARTICIPATING MEDICAL GROUP Physicians are prohibited, upon notice of the
existence of any such surcharge, BLUE CROSS will take appropriate action
consistent with the terms of this Agreement to eliminate surcharges.


 


7.07    In the event a referral provider has not been
reimbursed for authorized Referral Services or that any other provider has not
been reimbursed by PARTICIPATING MEDICAL GROUP as required under their
agreement for services provided to Members, as set forth in
Section 4.09(E), then, after notice, BLUE CROSS shall have the option to
pay a clean and uncontested claim and deduct such payment (including any
interest payable at the applicable rate set forth in Title 31 of the United
States Code Section 3902(a)), plus an administrative charge equal to ten
percent (10%) of the claim amount, from any money due from BLUE CROSS to
PARTICIPATING MEDICAL GROUP.  If a total
of five (5) or more instances occur where any provider associated with
PARTICIPATING MEDICAL GROUP bills a Member in violation of this Agreement
during any calendar year, BLUE CROSS may, in its sole discretion, suspend the
assignment of new Members to PARTICIPATING MEDICAL GROUP until such time as
PARTICIPATING MEDICAL GROUP has rectified the problem to BLUE CROSS’
satisfaction.


 


7.08    PARTICIPATING MEDICAL GROUP agrees to continue
to provide or arrange for all Covered Medical Services and benefits to any
Member, or former Member, who is eligible for coverage under the Extension of
Benefits provision of the Benefit Agreements, in exchange for the then current
Capitation payment amount per Member per month of the Benefit Agreement type
under which the Member is, or was, enrolled.


 


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


 


7.10    Any amount paid by BLUE CROSS to PARTICIPATING
MEDICAL GROUP under this Agreement or any other agreement between BLUE CROSS
and PARTICIPATING MEDICAL GROUP determined subsequently by BLUE CROSS to have
been an overpayment will be considered indebtedness of PARTICIPATING MEDICAL
GROUP to BLUE CROSS.  BLUE CROSS shall have
a first lien in the amount of such indebtedness and may, at its sole option,
recover such indebtedness by: (i) deducting from and setting off any amount or
amounts due and payable from BLUE CROSS to PARTICIPATING MEDICAL GROUP at any
time under this Agreement or any other agreement between BLUE CROSS and
PARTICIPATING MEDICAL GROUP, or for any reason, an amount or amounts equal to
such indebtedness of PARTICIPATING MEDICAL GROUP; and/or (ii) requesting a
refund from PARTICIPATING MEDICAL GROUP.


 


VIII.        ENROLLMENT PROTECTION


 


8.01    Enrollment Protection is a program designed to
limit PARTICIPATING MEDICAL GROUP’s liability for Capitation Services
expense.  If elected by PARTICIPATING
MEDICAL GROUP as set forth below, PARTICIPATING MEDICAL GROUP’s cost for Enrollment
Protection shall be that percentage of the monthly HCFA payment designated in
Exhibit E.


 


8.02    If PARTICIPATING MEDICAL GROUP has more than
one thousand (1,000) but less than or equal to ten thousand (10,000) Members
and other patients for whom PARTICIPATING MEDICAL GROUP has accepted a
financial risk arrangement comparable to the one in this Agreement, as set
forth in 42 C.F.R Part 417, at the beginning of the calendar year, the
liability of PARTICIPATING MEDICAL GROUP for expenses for Capitation Services
rendered to any single Member during the calendar year, shall be limited to the
first ten thousand dollars ($10,000) of


 


26

















 


Capitation Services expenses which have been incurred by PARTICIPATING MEDICAL
GROUP for that Member.


 


If PARTICIPATING MEDICAL GROUP has more than ten thousand (10,000)
Members and other patients for whom PARTICIPATING MEDICAL GROUP has accepted a
financial risk arrangement comparable to the one in this Agreement, as set forth
in 42 C.F.R. Part 417, at the beginning of the calendar year, the liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first
twenty-five thousand dollars ($25,000) of Capitation Services expenses which
have been incurred by PARTICIPATING MEDICAL GROUP for that Member.


 


PARTICIPATING MEDICAL GROUP may elect not to participate in the
Enrollment Protection program described in this Article VIII.  In such event, PARTICIPATING MEDICAL GROUP
shall be solely responsible for all expenses related to Capitation Services and
shall maintain, at its sole expense, adequate stop loss insurance coverage for
all expense related to Capitation Services which are incurred under this
Agreement.  Upon request, PARTICIPATING
MEDICAL GROUP shall provide BLUE CROSS with evidence of its stop loss insurance
policy with a carrier acceptable to BLUE CROSS or its self insurance program
acceptable to BLUE CROSS.


 


PARTICIPATING MEDICAL GROUP agrees to accept risk under either
Subsection A or Subsection B as indicated below:


 


A.  PARTICIPATING MEDICAL GROUP agrees to
participate in the Enrollment Protection program as set forth in this
Article VIII.


 


B.   PARTICIPATING MEDICAL GROUP, at its sole
expense, agrees to obtain and maintain stop loss insurance for all expenses
incurred under this Agreement in amounts acceptable to BLUE CROSS.


 


PARTICIPATING MEDICAL GROUP hereby elects to accept risk pursuant to
Section 8.02:


 


(check one) A.  o B.  ý


 


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


 


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


 


A.  Services rendered in connection with workers’
compensation cases.


 


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


 


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


 


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


 


27

















 


8.05    PARTICIPATING MEDICAL GROUP shall maintain
records necessary to evidence having reached the Enrollment Protection
level.  After reaching the Enrollment
Protection level with regard to any BLUE CROSS SENIOR SECURE Member, during the
remainder of the calendar year PARTICIPATING MEDICAL GROUP shall bill BLUE
CROSS for one hundred percent (100%) of services rendered, or provided, to that
Member by PARTICIPATING MEDICAL GROUP, calculated in accordance with
Subsections 8.02, 8.03 and 8 04. 
Reimbursement to PARTICIPATING MEDICAL GROUP for Enrollment Protection
shall be made by BLUE CROSS in accordance with the then current Blue Cross of
California Prudent Buyer Plan Participating Physician Agreement fee
schedule for the applicable region, or the Medicare Allowed Amount, or the
billed amount, whichever is less, on a monthly basis, within sixty (60) days of
submission of complete and accurate documentation by PARTICIPATING MEDICAL
GROUP.  Services not set forth in the
then current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region shall be
reimbursed by BLUE CROSS at the charges paid by PARTICIPATING MEDICAL GROUP or
the Medicare Allowed Amount, whichever is less.


 


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


 


IX.           NON-CAPITATED SERVICES


 


9.01    Non-Capitated Services, as defined in this
Article, shall include Covered Medical Services, as set forth in the applicable
Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL
GROUP.  The Covered Services encompassed
in Non-Capitated Services are delineated in Exhibit A(1) and include, but are
not limited to:


 


A   Inpatient Hospital Services (exclusive of
professional charges).


 


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


 


C    Hemodialysis Services (exclusive of
professional charges).


 


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


 


E.   Skilled Nursing Facility Services.


 


F.   Home Health Services.


 


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


 


H.  Outpatient Prescription Drug Expenses.


 


I.    Ten percent (10%) of expenses related to
Out-of-Area Services (Facility and Professional Expenses).


 


J.    Durable Medical Equipment and prosthetic
devices.


 


28

















 


K.  *** of the average wholesale price (AWP)
related to Chemotherapy Drugs (intravenously administered) and Injectable
Medications administered during visit at the physician’s office (exclusive of
take-home insulin).


 


L.   *** of expenses related to Urgently Needed
Services (see Section 2.65; the Member must be temporarily absent from
PARTICIPATING MEDICAL GROUP’s Service Area).


 


M. *** of the average wholesale price (AWP)
related to Immunosuppressive Drugs.


 


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


 


A.  The provider of Non-Capitated Services may
bill BLUE CROSS directly, in which case, BLUE CROSS shall reimburse said
provider within sixty (60) days, for contracted providers, or within thirty
(30) days for non-contracted providers, following receipt of a clean, undisputed
claim accompanied by an authorization from PARTICIPATING MEDICAL GROUP; or,


 


B.   The provider of Non-Capitated Services may
bill PARTICIPATING MEDICAL GROUP, in which case, PARTICIPATING MEDICAL GROUP
shall bill BLUE CROSS for reimbursement. 
BLUE CROSS shall reimburse PARTICIPATING MEDICAL GROUP within sixty (60)
days, for contracted providers, or within thirty (30) days for non-contracted
providers, following BLUE CROSS’ receipt of a clean undisputed claim from
PARTICIPATING MEDICAL GROUP, on the condition that such claim shall be
submitted to BLUE CROSS no later than twelve (12) months after the date of
service.  This section shall only
apply for the following Non-Capitated Services: DME, prosthetics, injectable
medications (including chemotherapy drugs and infused substances) and
immunosuppressive drugs.


 


In either case described above, BLUE CROSS shall pay contracting
providers at the lesser of the then current Blue Cross of California Prudent
Buyer Plan Participating Physician Agreement Fee Schedule for the
appropriate region, the Medicare Allowed Amount, or the rate negotiated between
BLUE CROSS and said provider.  In the
case of non-contracting providers, BLUE CROSS shall pay at the lesser of: the
Medicare Allowed Amount, actual billed charges, or the maximum allowable rate
according to the BLUE CROSS Customary and Reasonable charges, or the rate
arranged for by a BLUE CROSS SENIOR SECURE Case Manager.


 


9.03    Case Management Stop-Loss Threshold


 


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


 


B.   The Case Management Stop-Loss Threshold for an
individual Member shall be *** of Non-Capitated Expenses, exclusive of
Outpatient Prescription Drug Expenses.


 


C.   Authorized expenses for Member’s Non-Capitated
Services, up to the Case Management Stop-Loss Threshold specified above will be
accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.  Additionally, *** of expenses between the
applicable Case Management Stop-loss Threshold and *** incurred by an
individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses.  Non-Capitated


 


29

















 


expenses greater than *** for any individual Member will not be included
in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.


 


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


 


9.04    Calculating PARTICIPATING MEDICAL GROUP
Non-Capitated Expenses


 


Non-Capitated Expenses shall include expenses incurred by BLUE CROSS to
provide Non-Capitated Services to Members, as authorized or referred by the
PARTICIPATING MEDICAL GROUP.  Expenses
above the Case Management Stop-Loss Threshold, as set forth in
Section 9.03, and expenses incurred under benefit riders to BLUE CROSS
SENIOR SECURE are excluded from Non-Capitated Expenses credited to
PARTICIPATING MEDICAL GROUP for purposes of determining the Non-Capitated
Performance Settlement.  BLUE CROSS
shall calculate Non-Capitated Expenses based on the actual expense incurred by
BLUE CROSS in providing Non-Capitated Services to eligible Members.


 


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


 


PARTICIPATING MEDICAL GROUP’s Percent Non-Capitated Expense for medical
services is adjusted to account for PARTICIPATING MEDICAL GROUP’s Plan Factor
and Region Factor, which adjustment Factors shall be mutually agreed to by the
parties, to make PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses
comparable to the Non-Capitated Performance Settlement Schedule, as set forth
in Exhibit F.  The Outpatient
Prescription Drug Expense shall include only those amounts paid by BLUE CROSS
to pharmacies or pharmacists to provide covered outpatient prescription drugs
to Members assigned to PARTICIPATING MEDICAL GROUP.  Any rebates or other similar arrangements between BLUE CROSS and
manufacturers/vendors shall not be considered in determining the Outpatient
Prescription Drug Expense.  The
PARTICIPATING MEDICAL GROUP’s Outpatient Prescription Drug Expense shall not be
adjusted to account for the PARTICIPATING MEDICAL GROUP’s Plan Factor.


 


Within forty-five (45) working days after April 30, BLUE CROSS will
develop Plan Factors to reflect the PARTICIPATING MEDICAL GROUP’s plan mix for
the calendar year.


 


BLUE CROSS shall provide PARTICIPATING MEDICAL GROUP with quarterly
reports advising it of its Non-Capitated Expenses.


 


30

















 


9.05    Non-Capitated Performance Settlement Schedule


 


Non-Capitated Performance Settlement Schedule shall mean a
schedule that will be the basis for determining the Non-Capitated
Performance Settlement.  This
schedule presents BLUE CROSS’ expected Non-Capitated Expenses.  Exhibit F sets forth the Non-Capitated
Performance Settlement Schedule


 


9.06    Calculating the Non-Capitated Performance
Settlement


 


The Non-Capitated Performance Settlement shall be calculated in
accordance with Exhibit F.


 


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


 


X.            BILLING FOR MEDICARE BLUE USA AWAY FROM HOME
CARE SERVICES


 


10.01  PARTICIPATING MEDICAL GROUP agrees to provide
Urgent Blue Care.  Follow-Up Care and
Guest Program services as listed in Exhibit G of this Agreement, as Host HMO to
out-of-state members of MEDICARE BLUE USA Participating Plans, when such care
is prearranged by BLUE CROSS.


 


All Urgent Blue Care, Follow-Up Care and Guest Program services provided
or arranged by PARTICIPATING MEDICAL GROUP or Satellite Facilities, rendered to
members of MEDICARE BLUE USA Participating Plans, shall be paid by BLUE
CROSS.  For such services PARTICIPATING
MEDICAL GROUP provides directly to members of MEDICARE BLUE USA Participating
Plans, BLUE CROSS shall reimburse PARTICIPATING MEDICAL GROUP at PARTICIPATING
MEDICAL GROUP’s invoiced amount, not to exceed reimbursement in accordance with
the then current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region.  For referral services, PARTICIPATING MEDICAL
GROUP shall instruct providers of referral services to bill BLUE CROSS directly
or, such providers may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall be reimbursed by BLUE CROSS.  In all cases, PARTICIPATING MEDICAL GROUP or
provider of referral services shall note on the claim that services were
rendered to a member of a MEDICARE BLUE USA Participating Plan.  Neither PARTICIPATING MEDICAL GROUP nor
provider of referral services shall bill members of MEDICARE BLUE USA
Participating Plans.


 


10.02  BLUE CROSS agrees to pay PARTICIPATING MEDICAL
GROUP within sixty (60) days of receipt of a completed professional services
claim form for covered and appropriately authorized services rendered to
members of MEDICARE BLUE USA Participating Plans under the Away From Home Care
Program.  Any claim under the MEDICARE
BLUE USA Away From Home Care Program which would otherwise be the responsibility
of BLUE CROSS under this Agreement shall be the responsibility of PARTICIPATING
MEDICAL GROUP if such claim is not submitted to BLUE CROSS within twelve (12)
months of the date of service.


 


31

















 


PARTICIPATING MEDICAL GROUP will not receive Capitation for a Member
assigned to PARTICIPATING MEDICAL GROUP while such Member participates in the
MEDICARE BLUE USA Guest Program.


 


Urgent Blue Care services provided by out-of-state Host HMOs to Members
assigned to PARTICIPATING MEDICAL GROUP shall be considered Risk Fund Services,
in accordance with Exhibit A(1) of the Agreement.


 


Payments made by BLUE CROSS on behalf of PARTICIPATING MEDICAL GROUP for
such Professional Services provided to any Member enrolled in the MEDICARE BLUE
USA Follow-Up Care program will be offset against PARTICIPATING MEDICAL GROUP’s
monthly Capitation payment for such Member in an amount not to exceed
seventy-five percent (75%) of the average monthly Capitation payment for such
Member for each month, or portion thereof, that the Member receives Follow-Up
Care services.


 


XI.          TERM
OF AGREEMENT, TERMINATION


 


11.01  This Agreement shall be in effect from the
date noted on page 1 through December 31, 2002 (the “Initial Term”).  Unless written notice of intent not to renew
or of intent to modify this Agreement is provided at least one hundred twenty
(120) days prior to completion of the Initial Term or any subsequent renewal
period, this Agreement shall renew upon the same terms and conditions for
consecutive one year periods each year thereafter.


 


11.02  In the event this Agreement is terminated,
PARTICIPATING MEDICAL GROUP agrees to continue to provide Capitation Services
and to arrange Non-Capitated Services for all Members assigned to PARTICIPATING
MEDICAL GROUP, including any Members who become eligible during the notice
period set forth in Section 11.01 above; and to provide these services
consistent with the terms and conditions of the applicable Benefit Agreements
until (a) the services being rendered to that Member are completed or reasonable
and medically appropriate provision is made for the assumption of such services
by another contracting provider or (b) in the case of hospital inpatients,
those Members are discharged, but in no event later than the annual anniversary
dates of the Benefit Agreements of Members assigned to PARTICIPATING MEDICAL
GROUP.  The foregoing anniversary date
limitation shall not apply with respect to the continuation of those services
required under Section 1373.96 of the California Health and Safety Code.  In such cases, Capitation Services rendered
to Members shall be compensated at the rate of the then current Blue Cross of
California Prudent Buyer Plan Participating Physician Agreement fee
schedule for the applicable region, the Medicare Allowed Amount or actual
billed charges, whichever is less.


 


In the event this Agreement is terminated, any and all outstanding
deficits owed to BLUE CROSS under this Agreement, including without limitation,
any deficit under Exhibit F, shall be immediately due and payable, and BLUE
CROSS may offset the entire such deficit against any and all amounts then due
or thereafter due to PARTICIPATING MEDICAL GROUP under this Agreement or any
other agreement with PARTICIPATING MEDICAL GROUP.


 


In the event this Agreement is terminated, BLUE CROSS shall have the
right but not the obligation to directly pay any bills for expenses for Covered
Medical Services, including Referral Services, rendered to Members assigned to
PARTICIPATING MEDICAL GROUP which remain outstanding on the date of
termination.  BLUE CROSS shall
immediately be notified in writing of all such outstanding bills for Covered
Medical Services, including Referral Services, and BLUE CROSS shall have the
right to set off the amount of such payments against any amount due PARTICIPATING
MEDICAL GROUP for Capitation and Non-Capitated Services pursuant to
Article IX, or any other payments due PARTICIPATING MEDICAL GROUP.


 


The right to set off such payments against any amounts due under this
Agreement shall be in addition to any other rights BLUE CROSS may have under
this Agreement, or in law or in equity.


 


32

















 


11.03  Termination of this Agreement shall not affect
any rights or obligations hereunder which shall have previously accrued, or
shall thereafter arise, with respect to any occurrence prior to termination,
and such rights and obligations shall continue to be governed by the terms of
this Agreement.


 


11.04  In the event of a material breach of this
Agreement the party claiming the breach shall give written notice to the other,
with registered or certified mail.  The
notice shall specify the breach with as much detail as possible.  The party receiving the notice shall then
have thirty (30) days to cure the breach. 
If the breach is not cured to the satisfaction of the complaining party
within thirty (30) days after the notice is received by the other party, this
Agreement shall terminate at the end of the thirtieth (30) day or, if the
breach is by PARTICIPATING MEDICAL GROUP, or by the hospital named in
Section 4.01 (O) under its BLUE CROSS SENIOR SECURE Medicare+Choice
Hospital Services Agreement, BLUE CROSS may in the alternative freeze
enrollment of PARTICIPATING MEDICAL GROUP and/or withhold fifteen percent (15%)
of the Capitation until such breach is cured to BLUE CROSS’ satisfaction.


 


11.05  This Agreement supersedes and replaces any
prior BLUE CROSS SENIOR SECURE Medical Service Agreement(s) between BLUE CROSS
and PARTICIPATING MEDICAL GROUP in effect on or prior to the date on Page 1 of
this Agreement and shall apply to all Covered Medical Services, including
Capitation Services and Non-Capitated Services, provided to or arranged for
Members during the term of this Agreement, including those Members who are
hospital inpatients at the commencement of the Initial Term.


 


XII.         MUTUAL AGREEMENT - AMENDMENT PROCEDURES


 


12.01  BLUE CROSS and PARTICIPATING MEDICAL GROUP may
amend this Agreement by mutual written agreement, provided that no such
amendment shall affect the rights or duties of Members under the applicable
Benefit Agreement(s) or conflict with state or federal laws or regulations.


 


12.02  In the event that either party to this
Agreement, pursuant to express authority under any Article hereof, wishes
to request that a mutual agreement be arrived at to amend the terms of this
Agreement, that party shall:


 


A.  Notify the other in writing of desired changes
together with a statement of the reason(s) for the changes.


 


B.   Upon notification, the other party shall
within thirty (30) days of receipt of request, respond in writing to the party
that initiated the request for amendment.


 


C.   Upon mutual agreement, an appropriate
amendment will be drafted, executed by both parties, and attached to and
incorporated in this Agreement.


 


XIII.        ARBITRATION OF DISPUTES BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP


 


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


 


13.02  Any problem or dispute arising under this
Agreement and/or concerning the terms of this Agreement that is not
satisfactorily resolved under Section 13.01 shall be arbitrated.  The arbitration shall be initiated by either
party making a written demand for arbitration on the other party.  Arbitration shall be conducted by the
American Arbitration Association (AAA) under the Commercial Rules of the
AAA.  The arbitration shall also be
subject to California Code of Civil Procedure. 
Title Nine, Section 1280, et.seq.,
unless otherwise mutually agreed. 
The parties agree that the decision of the arbitrator shall be final and
binding as to each of them, except to the extent that California and Federal
law provide for the review of arbitration proceedings.  BLUE


 


33

















 


CROSS waives any right to pursue, on a class basis, any such problem or
dispute against PARTICIPATING MEDICAL GROUP, and PARTICIPATING MEDICAL GROUP
waives any right to pursue, on a class basis, any such problem or dispute
against BLUE CROSS.  Issues as to
whether malpractice was committed by a physician shall not be subject to
arbitration by the AAA unless otherwise agreed in writing by the parties and
the AAA.


 


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


 


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


 


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


 


13.06  Limitation.  Nothing contained herein is
intended to create, nor shall it be construed to create, any right of any
Member to independently initiate the arbitration procedure established in this
Article.  This limitation shall not
prevent BLUE CROSS from initiating such procedures as the representative of its
Members, or PARTICIPATING MEDICAL GROUP from initiating such procedures on
behalf of Members for whom they have assumed responsibility for the provision
of Capitation Services and for arranging Non-Capitated Services, provided that
in any such case BLUE CROSS or PARTICIPATING MEDICAL GROUP, respectively, shall
be considered the initiating party for the purposes of Section 13.02
hereof.


 


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


 


XIV.        MEMBER RECONSIDERATION AND GRIEVANCE PROCESS


 


14.01  BLUE CROSS shall have primary responsibility
for establishing and administering the BLUE CROSS Member Grievance Procedures
and the Medicare Reconsideration and Appeals Process both of which are
described in the Operations Manual.


 


14.02  PARTICIPATING MEDICAL GROUP agrees to
cooperate with BLUE CROSS in resolving all Member grievances relating to the
provision of medical services in accordance with the grievance procedures
established by BLUE CROSS in compliance with HCFA requirements, including
without limitation, providing BLUE CROSS with information so BLUE CROSS can
respond to a grievance and/or with copies of the pertinent medical records
within ten (10) days from the date of each such request.


 


14.03  In the event a Member wishes to pursue a
grievance related to the provision of Covered Medical Services, PARTICIPATING
MEDICAL GROUP shall advise the Member to contact BLUE CROSS.  PARTICIPATING MEDICAL GROUP shall forward to
BLUE CROSS any written grievances or complaints it receives from Members within
two (2) working days of receipt.


 


14.04  PARTICIPATING MEDICAL GROUP agrees to
cooperate with BLUE CROSS in processing reconsiderations in accordance with the
Operations Manual and through the standard and expedited process, including and
without limitation providing BLUE CROSS with the required information within
ten (10) days for standard appeals and within twenty-four (24) hours for
expedited review as set forth by the criteria determined by BLUE CROSS.


 


34

















 


 


XV.         MISCELLANEOUS PROVISIONS


 


15.01       Assignment.  No assignment of the rights and duties or
obligations of this Agreement shall be made by PARTICIPATING MEDICAL GROUP,
without the express written agreement approval of a duly authorized
representative of BLUE CROSS.  Any
attempted assignment in violation of this provision shall be void as to BLUE
CROSS.  Subject to the aforementioned,
the provisions of this Agreement and obligations arising hereunder shall extend
to and be binding upon the parties hereto and their respective successors and
assigns and shall insure to the benefit of the parties hereto and their
respective successors and assigns.


 


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


 


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


 


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


 


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


 


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


 


15.06       Notices.  Any notice which is required or permitted to
be given pursuant to this Agreement shall be in writing and shall either be
personally delivered, or sent by registered or certified mail, in the United
States Postal Service, return receipt requested, postage prepaid, addressed to
each party at its principal office or at the address provided in writing to the
other.  Notices shall be effective when
received.


 


15.07       Maximum Capacity.  The Maximum Capacity of PARTICIPATING
MEDICAL GROUP during the term of this Agreement shall be *** Members.


 


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


 


15.09       Solicitation of Members.  The business relationship between BLUE CROSS
and its Members, shall be deemed the property of BLUE CROSS.  Similarly, all lists of Members accepted by
PARTICIPATING MEDICAL GROUP under the provisions of this Agreement shall be
deemed the property of BLUE CROSS.  During the term of this Agreement or any renewal thereof, and for
a period of one (1) year from the date of termination, PARTICIPATING MEDICAL
GROUP agrees


 


35

















 


and will require its PARTICIPATING MEDICAL GROUP Physicians and all
other contracted Health Professionals to agree, that they will not, within the
service area of BLUE CROSS: (1) interfere with BLUE CROSS’ contract and/or
property rights; (2) advise or counsel any Member or employer groups to disenroll
from BLUE CROSS; (3) solicit such Member to become enrolled with any other
health maintenance organization, preferred provider organization or any other
similar hospitalization or medical payment plan or insurance company; or (4)
disclose proprietary BLUE CROSS information. 
This section shall not apply to general mailings unless the
mailings specifically target BLUE CROSS Members and as long as the mailings do
not violate the intent of this section.


 


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


 


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


 


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


 


15.14       Exhibits.  All exhibits attached to this Agreement are
incorporated herein by this reference.


 


	
  BLUE CROSS OF CALIFORNIA

  	
  PARTICIPATING MEDICAL GROUP;

  
	
   

  	
  Professional
  Care IPA Medical Group, Inc.

  
	
   

  	
   

  
	
   

  	
   

  
	
  Signature:

  	
  /s/
  Barry Ford

  	
   

  	
  Signature:

  	
  /s/
  Rick Shinto

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Barry Ford

  	
   

  	
  Name:

  	
  Rick
  Shinto, MD

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice President

  	
   

  	
  Title:

  	
  MEDICAL
  DIRECTOR

  	
   

  
	
   

  	
  Network
  Development & Management

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  11-1-99

  	
   

  	
  Date:

  	
  10/28/99

  	
   

  



 


36

















 


EXHIBIT A



COVERED MEDICAL SERVICES


 


I.              Medical and Surgical Services


 


A.      Physician’s
services at the:


 


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


 


(2)     Hospital or Skilled Nursing Facility


 


B.        Professional
services of an anesthetist or anesthesiologist


 


C.        Diagnostic
X-ray examinations


 


D.       Laboratory
tests


 


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


 


F.         Professional
services of other participating Health Professionals


 


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


 


II.            Psychiatric Care Benefits


 


A.      Inpatient
Visits


 


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


 


B.        Outpatient
Visits or Sessions


 


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


 


III.           Covered Preventive Care Benefits


 


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


 


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


 


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


 


C.        Pediatric
and adult immunizations.


 


D.       Eye
examinations


 


E.         Infertility
studies for Members aged 18 or over.


 


A-1

















 


F.         Ear
examinations.


 


G.        Health
education services as follows:


 


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


 


(2)     Instruction in personal health care measures.


 


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


 


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


 


I.            Allergy
testing and administration of injections.


 


A-2

















 


EXHIBIT A(1)

BLUE CROSS SENIOR SECURE


 


DIVISION OF FINANCIAL RESPONSIBILITIES


 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE: Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHETICS, Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL EYE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMICAL DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*   
As set forth in the applicable Benefit Agreement


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


 


A(1)-1

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY
  DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  CHIROPRACTIC (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHOICES PLUS (Self-Referral
  Opt-out Benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In Conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DENTAL SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  DIABETIC SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  DURABLE MEDICAL EQUIPMENT
  (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ADMISSIONS: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-2

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMPLOYMENT PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ENDOSCOPIC STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXPERIMENTAL PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FAMILY PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FETAL MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENETIC TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  HEALTH EVALUATIONS / PHYSICALS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-3

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedic Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES
  & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out-of-Area (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-4

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE / URGENT CARE CENTER

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In Area:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out of Area:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urgently Needed Services/Urgent Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNOSUPRESSIVE DRUGS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA MONITOR (DME)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (in conjunction with or
  concurrent with authorized inpatient admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *  INFERTILITY(Diagnosis / Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  *  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFUSION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Infused Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLE MEDICATIONS: Outpatient

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (excluding take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LABORATORY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient
  / Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MAMMOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












*   
As set forth in the applicable Benefit Agreement


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


 


A(1)-5

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  NUTRITIONIST / DIETICIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OBSTETRICAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Diagnostic Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ORGAN TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Primary Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Specialty Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CAT Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  2-D Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EKG (aka: ECG)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Holter Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-6

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-7

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT SURGERY; Professional Component

  continued

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PEDIATRIC SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICAL THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  To Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Specialty Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PODIATRY SERVICES (Including Routine)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREADMISSION TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PRE-EXISTING PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-8

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIATION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RECONSTRUCTIVE SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REHABILITATION SERVICES

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (Short Term: Physical Therapy, Occupational Therapy,
  Speech Therapy, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ROUTINE PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SKILLED NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SPECIALIST CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-9

















 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGICAL SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Dental Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  (for the diagnosis and medically
  necessary correction)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous Blood Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE / IMMEDIATE CARE CENTERS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In Area:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out of Area:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urgently Needed Services / Urgent Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Lenses / Frames (covered by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Contact Lenses (after cataract surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


A(1)-10

















 


EXHIBIT B



PARTICIPATING MEDICAL GROUP FACILITIES


 


B-1

















 


EXHIBIT C



BLUE CROSS SENIOR SECURE HOSPITALS


 


C-1

















 


EXHIBIT D



ADMINISTRATIVE RESPONSIBILITIES OF PARTICIPATING MEDICAL GROUP


 


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


 


A.            PROFESSIONAL SERVICES ADMINISTRATION


 


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


 


Outside Referrals - Control, process and report encounter information


 


Ancillary - Control, process and report encounter information


 


B.            INSTITUTIONAL SERVICES ADMINISTRATION


 


Preadmission certification process


 


Medical Review of claims


 


Length-of-stay (monitoring and control)


 


C.            UTILIZATION REVIEW


 


D.            PEER REVIEW, EDUCATION AND CREDENTIALING


 


E.             QUALITY MANAGEMENT


 


F.             GRIEVANCE PROCEDURE COMPLIANCE


 


G.            MONITOR AND REVISE SPECIALIST/OTHER REFERRAL CONTRACTS


 


H.            PATIENT EDUCATION


 


I.              CASE MANAGEMENT


 


J.             DATA COLLECTION AND REPORTING, as required by HCFA and
described in the Operations Manual.


 


D-1

















 


EXHIBIT E



CAPITATION


 


A.                          For Members with both Medicare Part A and B coverage, BLUE CROSS shall
make monthly Capitation payments to PARTICIPATING MEDICAL GROUP, based on the
number Of BLUE CROSS SENIOR SECURE Members eligible to receive Capitation
Services from PARTICIPATING MEDICAL GROUP as follows:


 


*** of the Monthly HCFA Payment less *** of the Monthly HCFA Payment as
payment for Enrollment Protection, if elected by PARTICIPATING MEDICAL GROUP as
set forth in Section 8.02 herein.


 


B.                            For Members that have Medicare Part B coverage only, and have purchased
Part A coverage from BLUE CROSS, payment shall be made according to the
following:


 


*** of the sum of the Monthly HCFA Payment applicable to Medicare Part B
only Subscribers plus the Member Part A Premium.  In addition, *** of the sum of the Monthly HCFA Payment
applicable to Medicare Part B only Subscribers plus the Member Part A Premium,
shall be deducted for Enrollment Protection, if elected by PARTICIPATING
MEDICAL GROUP as set forth in Section 8.02 herein.


 


C.                            The Capitation payment per Member per month will be increased or
decreased to reflect the increases or decreases made by HCFA in the Monthly
HCFA Payment


 


D.                           If PARTICIPATING MEDICAL GROUP elects to obtain Enrollment Protection
for Capitation Services expense from other than BLUE CROSS, then evidence of
coverage for limited liability for Capitated Services expense must be attached
to this Exhibit E.


 


E-1

















 


EXHIBIT F



NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE


 


A.           If
PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses are less than *** of the
Monthly HCFA Payment, BLUE CROSS shall pay PARTICIPATING MEDICAL GROUP *** of
the difference, as the Non-Capitated Performance Settlement.


 


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


 


B.             If
PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses exceed *** of the Monthly
HCFA Payment, then PARTICIPATING MEDICAL GROUP shall owe BLUE CROSS *** the
difference subject to the following provisions.


 


Notwithstanding the above. PARTICIPATING MEDICAL GROUP’s responsibility
for any deficit under this Section will never exceed twenty percent (20%)
of the capitation revenue received under this Agreement during the calendar
year.  In the event PARTICIPATING
MEDICAL GROUP becomes responsible for any such deficit.  BLUE CROSS will offset the amount of such
deficit against future Capitation payments to PARTICIPATING MEDICAL GROUP.  Said offset shall not exceed twenty percent
(20%) of any monthly Capitation payment paid by BLUE CROSS to PARTICIPATING
MEDICAL GROUP hereunder until the entire deficit is satisfied.  At the time of each Non-Capitated
Performance Settlement, BLUE CROSS shall review the PARTICIPATING MEDICAL
GROUP’s ongoing financial capability to accept the potential *** downside risk
for such Non-Capitated Expense.  In the
event PARTICIPATING MEDICAL GROUP is not in a position to under take such risk,
the parties shall mutually agree on an acceptable amount of such risk of less
than *** for the next contract year.


 












** For the purposes of this Exhibit F, the “Monthly HCFA Payment” means, the
Monthly HCFA Payment for each Subscriber, or a percent of the sum of the
monthly Member Part A Premium plus the Monthly HCFA Payment applicable to
Medicare Part B only Subscribers Payment.


 


F-1

















 


EXHIBIT G



MEDICARE BLUE USA - AWAY FROM HOME CARE

Program Description


 


Urgent Blue Care


 


Urgent
Blue Care is a program that coordinates the provision of Urgently Needed Blue
Care Services (i.e. , services required to prevent a serious deterioration of a
member’s health while traveling resulting from an unforeseen illness or injury
and the services cannot be delayed until the member returns to the Home HMO
service area) while the member is away from home for periods of less than
ninety (90) consecutive days and prearranged by BLUE CROSS.


 


Follow-Up Care


 


Follow-Up Care is medically necessary care that is pre-authorized by the
member’s Home Primary Care Physician (PCP) to be provided out-of-area by a
participating Host HMO provider. 
Examples of appropriate Follow-Up Care are allergy shots, cast removal
and chemotherapy injections.  These
services are provided to the member at no cost at the time of service.  An important difference between Urgent Blue
Care and Follow-Up Care is the origin of the illness or injury.  The Follow-Up Care benefit is intended to
cover an illness or injury that originated in the Home HMO’s service area and
is under the care of the member’s Home HMO PCP.  In contrast, Urgent Blue Care is for an unexpected illness or
injury that originated in the Host service area.  Follow-Up Care services are subject to HCFA’s guidelines
regarding the ninety (90) consecutive day temporary absence provisions.


 


Guest Program


 


The Guest Program is designed for members who intend to spend an
extended period of time away from home (i e., outside of their Home HMO’s
service area).  The Guest Program
provides a temporary registration in a participating HMO from thirty days up to
six months.  This entitles the member to
a comprehensive set of member benefits and services, including the selection of
a primary care physician (PCP).  Without
this benefit, a member who is out-of-area for more than ninety (90) consecutive
days would be disenrolled from the HMO. 
If enrolled in the Guest Program, a beneficiary covered by a Medicare
Blue USA HMO will be able to stay away from home for up to six consecutive
months without being disenrolled and is entitled to comprehensive benefits in
another Medicare Blue USA HMO service area. 
These members will receive the full scope of Guest Program benefits as
set forth in the Schedule of Guest Program Benefits in the Blue Cross
Senior Secure Provider Operations Manual. 
In addition, the member’s Home HMO must provide the member with
information about how to access ancillary benefits (i.e. , benefits that the
member has coverage for at home but that are not included in the Guest Program
benefit package) when registered as a Guest at a participating HMO.


 


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EXHIBIT H



PARTICIPATING MEDICAL GROUP’S

DELEGATED ACTIVITIES


 


The
following table indicates the delegated responsibilities of PARTICIPATING
MEDICAL GROUP


 


	
   

  	
   

  	
  Responsible Entity

  
	
  Compliance Activity

  	
   

  	
  Blue Cross

  	
   

  	
  PMG

  
	
  Processing
  Member Claims

  	
   

  	
   

  	
   

  	
  X

  
	
  Contractual
  Language

  	
   

  	
   

  	
   

  	
  X

  
	
  Utilization
  Management

  	
   

  	
   

  	
   

  	
  X

  
	
  Credentialing

  	
   

  	
   

  	
   

  	
   

  
	
  Medical
  Records

  	
   

  	
   

  	
   

  	
   

  
	
  Member
  Rights and Responsibilities

  	
   

  	
  X

  	
   

  	
  X

  



 


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