Exhibit 10.95


 




	
   

  	
  FULLY EXECUTED

  
	
   

  	
  ORIGINAL

  






 


AMENDMENT

to the


PARTICIPATING PROVIDER SERVICES AGREEMENT

between

HEALTH NET INC., AFFILIATES

and

Professional Care Medical Group IPA


 


The Provider Services Agreement
dated March 1, 1999 and all subsequent Amendments between Professional Care
Medical Group IPA (“PPG”) and Health Net Inc. Affiliates (“HNI”), formerly
known as Foundation Health Systems Affiliates (“FHS”) is hereby amended
effective October 1, 2002.


 


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


 


1                  All references
to Foundation Health Systems, Affiliates (“FHS”) are hereby changed to read.
Health Net. Inc., Affiliates (“HNI”).


 


2                  Section 6.1 of
the Agreement is hereby deleted in its entirety and replaced with the
following:


 


This Agreement
shall be in effect for an initial period of twenty-four (24) months from
October 1, 2002 through September 30, 2004 and shall be continued for
consecutive annual periods each year thereafter, unless terminated as provided
herein.  The term of this Agreement
shall remain the same for all Benefit Programs covered hereunder


 


3                  Effective October 1, 2002, Addendum
B, Section B. 1. STANDARD HMO,
subsection 1.1, Capitation Rates, will be amended as follows


 




	
  Effective Date

  	
   

  	
  Standard

  HMO Capitation

  
	
  October 1, 2002 - September 30, 2003

  	
   

  	
  $ *** PMPM

  
	
  October 1, 2003

  	
   

  	
  $ *** PMPM

  






 


4                  Effective
October 1, 2002, Addendum B, Section B.3. STANDARD
HMO,  subsection 3.1, Shared Risk Budget will be amended as
follows


 




	
  Effective Date

  	
   

  	
  Standard

  HMO Shared Risk Budget

  
	
  October 1, 2002 - September 30, 2003

  	
   

  	
  $ *** PMPM

  
	
  October 1, 2003

  	
   

  	
  $ *** PMPM

  






 


5                  Effective
October 1, 2002, Addendum B, Section B, subsection 4.4. AIDS Transplant and
Transfer Reinsurance Premium, shall be deleted in its entirety and replaced
with the following:


 


4.4                               AIDS and Transfer Reinsurance Premium.   The Reinsurance Program rates, as set forth
below shall be deducted from PPG's Capitation.


 


	
  •

  	
   

  	
  AIDS
  Reinsurance

  	
   

  	
  $ *** PMPM
  Effective October 1, 2002 - December 31, 2003

  
	
  •

  	
   

  	
  Transfer
  Reinsurance

  	
   

  	
  $ *** PMPM
  Effective October 1, 2002 - December 31, 2003

  



 


6                                          Effective
October 1, 2002, Addendum B, Section C.1. 
SMALL GROUP HMO,
subsection 1.1. Capitation Rates will be amended as follows


 












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


 


1

















 




	
  Effective Date

  	
   

  	
  Small
  Group

  HMO Capitation

  
	
  October 1, 2002 - September 30, 2003

  	
   

  	
  $ *** PMPM

  
	
  October 1, 2003

  	
   

  	
  $ *** PMPM

  






 


7.               Effective
October 1, 2002, Addendum B, Section C. SMALL
GROUP HMO, subsection 3, Shared Risk Budget, will be amended as
follows


 




	
  Effective Date

  	
   

  	
  Small
  Group

  HMO Shared Risk Budget

  
	
  October 1, 2002 - September 30, 2003

  	
   

  	
  $ *** PMPM

  
	
  October 1, 2003

  	
   

  	
  $ *** PMPM

  






 


8                  Effective
October 1, 2002, Addendum B, Section C, Subsection 4. AIDS Transplant and
Transfer Reinsurance Premium, shall be deleted in its entirety and replaced
with the following:


 


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


 


	
  •

  	
   

  	
  AIDS
  Reinsurance

  	
   

  	
  $ *** PMPM
  Effective October 1, 2002 - December 31, 2003

  
	
  •

  	
   

  	
  Transfer
  Reinsurance

  	
   

  	
  $ *** PMPM
  Effective October 1, 2002 - December 31, 2003

  



 


9                  Effective
October 1, 2002, Addendum B, Section G. COMMERCIAL
POS, subsection 4, Professional Capitation Rate, shall be
deleted in its entirety and replaced with the following:


 


4.              Professional
Capitation Rate.  PPG shall be compensated for rendering
professional In-Network Services to Commercial POS Members at the PMPM amounts
set forth for Commercial HMO Members, less a forty percent (40%) withhold
(Professional Capitation).  This
Withhold shall partially fund the Professional Out-of-Network Budget


 


10.         Effective
October 1, 2002, Addendum B, Section G. COMMERCIAL
POS,  Subsection 6.1, POS Shared Risk Budgets, shall be deleted
in its entirety and replaced with the following:


 


6.1                               POS Shared Risk Budgets. The budgets
shall be determined for each Commercial POS population.  Standard POS and Small Group POS Members
Each Budget shall cover In-Network. 
Out-of-Network and Out-of-Area Shared Risk Services. Each of the
normalized Shared Risk Budgets shall be equal to the normalized HMO Shared Risk
Budget, or institutional capitation PMPM, if applicable, and multiplied by one
hundred ten percent (100%).  Actual
Shared Risk Budget shall fluctuate from month to month to the extent that PPG’s
age, sex and benefit plan mix fluctuates


 


	
  Effective Date

  	
   

  	
  Standard
  HMO

  Shared Risk

  + 10%

  	
   

  	
  Small
  Group HMO

  Shared Risk

  + 10%

  
	
  October 1,
  2002 - September 30, 2003

  	
   

  	
  $ ***

  	
   

  	
  $ ***

  
	
  October 1,
  2003

  	
   

  	
  $ ***

  	
   

  	
  $ ***

  



 


11            Effective
October 1, 2002, Addendum B, Section G, Subsection 8. AIDS Transplant
Reinsurance, shall be deleted in its entirety and replaced with the following:


 


8.              AIDS
Reinsurance.  As farther defined in Section B.4 of this Addendum,
the AIDS Reinsurance rate shall be $0.56


 


2

















 


PMPM which
shall be deducted from PPG’s Capitation and $0.38 PMPM shall be deducted from
PPG’s Professional Out-of-Network Risk Sharing Budget. For the subsequent
years, these deductions shall fluctuate to correspond with the Professional
Out-of-Network Withhold percentage change


 


12.         Effective
October 1, 2002, Addendum B, Section 1. Pharmacy
Shared Risk Program, Subsection 1.  Pharmacy Budget, shall be amended as follows


 


Pharmacy Budget.  Each month HMO shall fund the Pharmacy
Budget at $ 18.00 per eligible Member per month (“PEMPM”) subject to the age,
sex and benefit plan factors set forth in Addendum B.  The Pharmacy Budget shall be adjusted according to the aggregate
PEMPM dollar change experienced by those participating physician groups
comprising the top third of lowest PEMPM normalized pharmacy costs, based on
current calendar year experience.  Such
adjustment shall occur prior to calculating the final settlement for the
Pharmacy Reconciliation, as set forth in this Addendum.  Any calculation of the normalized pharmacy
costs shall be based upon actual claims. 
The top third calculation shall be weighed by eligible Member month.


 


13            Effective
October 1, 2002, Addendum B, Section 1. Pharmacy
Shared Risk Program.  Subsection 2. Pharmacy Reconciliation For
Commercial HMG Members, shall be deleted and replaced with the following:


 


2.                                       Pharmacy Reconciliation For Commercial HMO Members. For
each Reconciliation period, HMO shall calculate pharmacy claims subject to this
Program as outlined in the Operations Manual. 
HMO shall compare such claims to the corresponding Pharmacy Budget.  In the event pharmacy claims are less than
the Pharmacy Budget, PPG’s share of the Pharmacy Budget surplus shall be ***.
In the event pharmacy claims exceed the Pharmacy Budget, PPG’s share of the
Pharmacy Budget deficit shall be *** not to exceed ***, MPM.


 


HMO shall perform an interim and final settlement for the Pharmacy Risk
Sharing Program.  The timing of these
settlements shall correspond to the interim and final settlements of other risk
sharing programs.  Subject to Section
4.? of this Agreement, any Pharmacy Budget deficit shall be offset against any
amounts payable by HMO or any amounts remaining in the Withhold Fund, or shall
be offset against Capitation


 


14            Effective
October 1, 2002, Addendum C, Section B. 2.
Capitation: PPG Capitated Services. 
Subsection 2.1 Compensation for PPG Capitated Services, shall be
deleted and replaced with the following:


 


2.                                      Capitation: PPG Capitated Services.


 


2.1                               Compensation for PPG Capitated Services.  As compensation for rendering PPG Capitated
Services as defined herein. HMO shall pay PPG Capitation at *** of CMS Premium
as set forth below for each Medicate HMO Member eligible to receive such
services from PPG during any particular month. 
Capitation shall be computed on the basis of the most current
information available and shall be paid by HMO by wire transfer on or before
the fifteenth (15th) day of each month or the first business day following the
fifteenth.  If the fifteenth is a
holiday or on a weekend or within two (2) days of CMS’s payment to HMO,
whichever is later.  Each Capitation
payment shall be accompanied by a remittance summary.  The remittance summary identifies the total Capitation payable
and those Medicare HMO Members for whom Capitation is being paid. In the event
of a Capitation error, resulting in an overpayment or underpayment to PPG. HMO
shall adjust subsequent Capitation to offset such error


 


15            Effective
October 1, 2002, Addendum C, Section B. 2.1 Compensation for Employer Group
Retirees, shall be deleted in its entirety


 


16            Effective
October 1, 2002, Addendum C, Section B. 3.
Shared Risk Program,
Subsection 3.1 Shared Risk Budget, shall be deleted and replaced with the
following:


 


3

















 


3                                         Shared Risk Program.


 


3.1                               Shared
Risk Budget   As a contingency for any PPG liability under
the Shared Risk Program.  HMO shall
deduct five percent (5%) of PPG’s Capitation and place such amount in the
Withhold Fund as described in this Agreement. 
In the event the interim settlement results in a deficit, HMO may, at
its sole discretion, withhold from PPG’s Capitation up to *** of PPG’s
Capitation and may continue such withhold until the deficit amount is
recovered.  Each month, HMO shall fund
the Shared Risk Budget for each eligible Medicare HMO Member at *** of CMS
Premium


 


17            Effective
October 1, 2002, Addendum C, Section C.3.
Capitation: PPG Capitated Services. Subsection 3.1 Capitation
Rate shall be deleted and replaced with the following;


 


3.                                      Capitation: PPG Capitated Services.


 


3.1                               Capitation
Rate.   PPG shall be compensated for rendering
professional in-Network Services to Medicare POS Members at the percent of
Monthly Revenue for Medicare HMO Members as set forth in this Addendum C, less
a ten percent (10%) withhold (Professional Out-of-Network Withhold), for each
Medicare POS Member eligible to receive such services from PPC during any
particular month.


 


In the event PPG’s enrollment exceeds five hundred (500) Medicare POS
Members, the Professional Out-of-Network Withhold percentage shall be equal to
(i) PPG’s prior year’s professional Out-of-Network costs, divided by the total
of PPG’s Capitation for Medicare POS Members (prior to the Professional
Out-of-Network Withhold) rounded to the nearest multiple of five, plus *** or
(ii) *** if there is no prior year experience or if PPG has 500 or less Medicare
POS Members.  On or before December 15th
of each year, HMO shall notify PPG of PPG’s Out-of-Network experience incurred
between July 1 of the previous year and June 30 of the current year and the
calculation noted above and such shall be PPG’s Professional Out-of-Network
Withhold percentage for the following year.


 


Capitation shall be calculated on the basis of the most current
information available and shall be paid by HMO by wire transfer on or before
the fifteenth (15th) day of each month, or the first business day following the
fifteenth if the fifteenth is a holiday or on a weekend, or within two (2) days
of CMS’s payment to HMO, whichever is later. 
Each Capitation payment shall be accompanied by a remittance
summary.  The remittance summary identifies
the total Capitation payable and those Medicare POS Members for whom Capitation
is being paid.  In the event of a
Capitation overpayment or underpayment to PPG, HMO shall adjust subsequent
Capitation to offset such error.


 


18.         Effective
October 1, 2002, Addendum C, Section D, Subsection 2 Pharmacy Reconciliation
For Medicare HMO Members shall be deleted and replaced with the following:


 


3.                                      Pharmacy Reconciliation For Medicare HMO Members  [This section does not apply to all group
members including POS Members.]  For
each Reconciliation Period HMO shall calculate pharmacy claims subject to the
Program as outlined in the Operations Manual HMO shall compare such claims to
the corresponding Pharmacy Budget.  In
the event pharmacy claims are less than the Pharmacy Budget, PPG’s share of the
Pharmacy Budget surplus shall be *** In the event pharmacy claims exceed the
Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit shall be *** not to
exceed ***.  HMO shall perform an
interim and final settlement for the Pharmacy Risk Sharing Program.  The timing of these settlements shall
correspond to the interim and final settlements of other shared risk
programs.  Subject to Section 4.3 of
this Agreement any Pharmacy Budget deficit shall be offset against any amounts
payable by HMO or any amounts remaining in the Withhold Fund, or shall be
offset against Capitation.  In the event
the Withhold Fund eliminates the Pharmacy Budget deficit, any amounts remaining
in the Withhold Fund shall be paid to PPG within one hundred twenty (120)
calendar days after the end of the Reconciliation Period.


 


19    Effective October 1, 2002 A
New Addendum 1, Healthy Families Program is attached hereto and incorporated by
reference


 


Except as amended all other
provisions of the Agreement shall remain unchanged and in effect.


 


4

















 


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


 


	
  Professional Care Medical Group IPA

  	
  Health Net Inc., Affiliates

  
	
   

  	
   

  
	
  /s/ Rick
  Shinto

  	
   

  	
  /s/ Jenni
  Vargas

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  Rick Shinto, MD

  	
   

  	
  Jenni Vargas

  
	
  Print Name

  	
   

  
	
   

  	
   

  
	
  Medical Director

  	
   

  	
  Network
  Management and Development Officer

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  September 13, 2002

  	
   

  	
  [ILLEGIBLE]

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
    95-4378353

  	
   

  	
   

  
	
  Federal Tax
  Identification Number

  	
   

  
						



 


5

















 


ADDENDUM 1


 


HEALTHY FAMILIES PROGRAM


 


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


 


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


 


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


 


A.            GENERAL
PROVISIONS


 


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


 


1.1                                 The terms and
conditions of this Addendum and the Agreement


 


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


 


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


 


1.4                                 Healthy Families
Program regulations and statutes.


 


1.5                                 All laws applicable to
PPG or HEALTH NET.


 


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


 


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


 


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


 


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


 


6

















 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


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


 


B.            REIMBURSEMENT
PROVISIONS


 


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


 


7

















 


2.              Compensation for PPG
Capitated Services.    As
compensation for rendering PPG Capitated Services.   HEALTH NET shall pay PPG Capitation as set forth in this
Addendum 1 for each Healthy Families Member to receive services from PPG during
any particular month.   Capitation shall
be payable on a per Member per month (PMPM) basis.  Capitation shall be computed on the basis of the most current
information available and shall be paid by HEALTH NET by wire transfer on or
before the fifteenth (15th) day of each month or the first business day
following the fifteenth if the fifteenth is a holiday or on a weekend.   Each Capitation payment shall be
accompanied by a remittance summary.  
The remittance summary identifies the total Capitation payable and those
Healthy Families Members for whom Capitation is being paid.   In the event of a Capitation error,
resulting in an overpayment or underpayment to PPG, HEALTH NET shall adjust
subsequent Capitation to offset such error.


 


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


 


4.              Contracted Services.   PPG and Member Physicians shall render
Contracted Services which are not PPG Capitated Services to Members covered
under this Addendum 1 and shall be compensated on a fee-for-service basis at
one hundred percent of the Medi-Cal Fee Schedule.   PPG shall submit claims in accordance with the terms of this
Agreement and State and federal law.


 


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


 


6.              Professional
Capitation Rates.


 


6.1                               Capitation
Rates.   PPG Capitation for Healthy
Families Members shall be determined on a monthly basis by multiplying the
number of members by the flat Capitation amount set forth in Addendum 1.


 




	
  Healthy Families Capitation

  
	
  $*** PMPM

  






 


7.              Professional Stop
Loss.


 


PPG’s Professional Stop Loss
threshold shall be $ *** per Healthy Families Member during the calendar
year.   The cost to PPG for the
Professional Stop Loss Program shall be $ *** PMPM, which shall be deducted
from PPG’s Capitation.   PPG shall
report potential stop loss claims and receive payment for such claims in
accordance with procedures set forth in the Operations Manual.


 


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


 


8.1                               Shared
Risk Budget.   HEALTH NET shall fund
the Shared Risk Budget for Members, with normalized rates.  These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum 1.1.   Actual Shared Risk
Budget shall fluctuate from month to month to the extent that PPG’s age, sex
and benefit plan and fluctuates.


 


8

















 




	
  Effective Date

  	
   

  	
  HEALTH NET
  Shared Risk Budget

  
	
  October 1, 2002 - September 30, 2003

  	
   

  	
  $*** PMPM

  
	
  October 1, 2003

  	
   

  	
  $*** PMPM

  






 


8.2                               Shared
Risk Administration.


 


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


 


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


 


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


 


8.4                               Shared
Risk Budget Deficit.   In the event
of a Shared Risk Budget deficit, PPG’s share of the deficit shall be limited to
the lesser of (a) fifty percent (50%) of the Shared Risk Budget deficit, or (b)
an amount not to *** of the annual gross PPG Capitation.   Subject to Section 4.3, of the Agreement,
any amounts payable by PPG shall be offset against the Withhold Fund and any
other amounts payable by HEALTH NET.


 


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


 


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


 


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


 


(b)                                 In-Area
Shared Risk Services: 4.59% of Shared Risk Budget.   The cost of In-Area Shared Risk Services utilized by a Member in
a Reconciliation Period shall be charged against the Shared Risk Budget as
follows *** of any amount over ***.


 


(c)                                  Transfer
Reinsurance: $ *** PMPM shall be deducted from the Shared Risk Budget.   Ten percent (10%) of eligible charges shall
be charged against the Shared Risk Budget.


 


9.                                      AIDS
and Transfer Reinsurance Programs.  
On a network wide basis, reinsurance programs shall be established by
HEALTH NET to cover the payment of expenses incurred in the treatment of
Members who have been diagnosed with Acquired Immune Deficiency Syndrome C
("AIDS Members") and to cover the costs for Members who transfer from
one participating physician group to another while undergoing acute treatment.


 


9.1       AIDS Reinsurance.   AIDS Reinsurance shall only be applicable
for Healthy Families Adults age


 


9

















 


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


 


9.2                               Transfer
Reinsurance.  Professional and
institutional costs incurred by Members undergoing medical treatment who have
transferred from another participating physician group to PPG, shall be the
shared financial responsibility of HEALTH NET and PPG, as set forth in the
Operations Manual.  The Transfer
Reinsurance Program is not applicable to Members who have: 1) selected PPG
through the open enrollment process: 2) changed a home or work address, or 3)
been assigned to PPG due to a physician termination or physician affiliation
change.  This Program shall be effective
when the other participating physician group is located within PPG’s Service
Area.


 


This Program shall cover eligible Members who
accumulate more than *** in PPG Capitated Services or *** in Shared Risk
Services. Such threshold shall be calculated using the most current Medicare
allowable charges for PPG Capitated Services or actual amount paid for Shared
Risk Services and shall be accumulated within one hundred eighty (180) days of
the Member’s transfer to PPG.  On a
first collar basis, this Program shall cover *** of the allowed Program
charges.  PPG shall be responsible for
the remaining *** of PPG Capitated Services. 
*** of Shared Risk Claims shall be charged against the Shared Risk
Budget PPG shall submit claims to HEALTH NET within ninety (90) calendar days
of meeting the threshold.


 


This Program shall cover eligible Member
changes until such Member’s next open enrollment date.  Members covered under the AIDS Reinsurance
Program shall not qualify for coverage under this Program.  In the event a Member qualifies per coverage
under both this Program and any another reinsurance program, the other
reinsurance program shall be primary. 
The transfer Reinsurance Program shall cover charges only up to the
beginning of those other reinsurance programs.


 


Notwithstanding
any other provision in this Agreement. 
HEALTH NET reserves the right to discontinue this Program after any
calendar year.  In the event HEALTH NET
continues this Program HEALTH NET shall communicate the reinsurance premiums
for any calendar year by December 15th of the prior year.


 


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


 


	
  •

  	
   

  	
  AIDS
  Reinsurance*

  	
   

  	
  $*** PMPM
  Effective October 1, 2002   December
  31, 2003

  
	
  •

  	
   

  	
  Transfer
  Reinsurance

  	
   

  	
  $ *** PMPM
  Effective October 1, 2002   December
  31, 2003

  



 












*  AIDS Reinsurance shall only
be applicable for Healthy Families Adults, age 21 and over


 


10.                               Immunizations:


10.1                        Immunizations.            PPG assumes financial
responsibility for immunization under the capitation rate set forth in this
Addendum.  New authorizations approved
by American Academy of Pediatries and the Advisory Committee on Immunizations
Practices (ACIP) of the US Public Health Service, after the effective date of
the Agreement shall be reimbursed at rates that are negotiated based on
experimental data which shall be mutually agreed upon on Health Net and PPG.


 


10

















 


ADDENDUM 1.1


 


AGE, SEX AND
BENEFIT FACTORS


 


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


 


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


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


 




	
  Sex

  	
   

  	
  Age

  	
   

  	
  Inst

  Factor

  
	
  Child

  	
   

  	
  0

  	
   

  	
  5.228

  
	
   

  	
   

  	
  1

  	
   

  	
  0.644

  
	
   

  	
   

  	
  2    4

  	
   

  	
  0.406

  
	
   

  	
   

  	
  5    9

  	
   

  	
  0.296

  
	
   

  	
   

  	
  10    14

  	
   

  	
  0.338

  
	
   

  	
   

  	
  15    19

  	
   

  	
  0.607

  






 


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


 




	
  Healthy Families

  
	
  Plan

  	
   

  	
  Inst

  Factor

  
	
  9Y

  	
   

  	
  0.9331

  
	
  9YA

  	
   

  	
  0.9079

  
	
  MW

  	
   

  	
  0.9076

  
	
  MWA

  	
   

  	
  0.9076

  






 


11

















 


ADDENDUM 1.2


 


DIVISION OF RESPONSIBILITY


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


 


HEALTHY FAMILIES PROGRAM


 


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


 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HEALTH NET

  RISK SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  AIDS - Drugs-Children 0-21 years

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Drugs-Adults 21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Facility Component-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Facility Component-Adults and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component-Adults 21 and
  older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  In Area (30
  Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                   Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                   Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                   Storage and
  Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY Children
  0-21 years 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Drugs
  including Epogen, Neupogen and adjunctive
  therapies 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


12

















 


 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HEALTH NET

  RISK SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  CHEMOTHERAPY Adults 21 years and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Drugs, including Epogen,
  Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC
  SURGERY (Medically
  Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL
  SERVICES
(When
  a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC TESTING Outpatient

  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS  In-Area 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •     Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE/SKILLED NURSING  FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


13

















 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HEALTH NET

  RISK SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTABLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  IVF &
  GIFT -
  Facility and Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY
  -
  Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH   Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH   Inpatient - Serious 

  Emotional Disturbances (SED)-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


14

















 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HEALTH NET

  RISK SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  MENTAL
  HEALTH -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  -
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION - Outpatient Laboratory ,
  X-ray (within 72 hrs or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  -
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH
  AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES - Medical, Surgical,
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Related to a Hospital
  Stay: Surgical Supplies, Equipment, etc... 
  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Related to an Outpatient
  Office Visit:  [ILLEGIBLE] Casts,  Bandages, etc..

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  [ILLEGIBLE] Strips,
  Needles, Syringes 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  [ILLEGIBLE]

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


15

















 


	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HEALTH NET

  RISK SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  SURGERY
  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •       Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  -
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY:
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)-Children
  0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)-Adults
  21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Organ Procurement 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT
  EVALUATIONS-Children 0-21

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT
  EVALUATIONS-Adults 21 and older

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE VISITS   In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE VISITS   Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Exams

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Implanted Lenses (Cataract
  Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •                  Lenses and Frames
  (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


16

















 


ADDENDUM 1.3


 


DISCLOSURE FORM


 


(Required by California Welfare and Institutions Code Section 14452)


 


Professional Care Medical Group, IPA


 


The undersigned hereby
certifies that the following information regarding


 


(the “Organization”) is true
and correct as of the date set forth below:


 


Officers Directors General
Partners


 


 


Co-Owner(s)


 


Stockholders owning more than
ten percent of the stock of the Organization:


 


 


Major creditors holding more
than five percent of Organization’s debt.


 


 


Form of Organization (Corporation,
Partnership, Sole Proprietorship, Individual, etc.)


 


 


If not already disclosed above,
is Organization either directly or indirectly related to or affiliated with the
Contracting Health Plan


Please explain


 


 


	
  Dated: 

  	
  September 13, 2002

  	
   

  	
  Signature:

  	
  /s/ Rick
  Shinto

  
	
   

  	
   

  	
   

  
	
   

  	
  Name: 

  	
  Rick Shinto, MD

  
	
   

  	
   

  	
  (Please type or print)

  
	
   

  	
   

  	
   

  
	
   

  	
  Title

  	
  Medical Director

  
	
   

  	
   

  	
  (Please type or print)

  



 


17