Exhibit
10.153


 


AMENDMENT


TO

CALIFORNIACARE MEDICAL SERVICES AGREEMENT


BETWEEN

BLUE CROSS OF CALIFORNIA


AND

NORTHWEST ORANGE COUNTY MEDICAL GROUP, INC.


 


This Amendment to the CaliforniaCare Medical Services Agreement is
entered into at Woodland Hills, Los Angeles County, California, and will be
effective as of January 1, 2003 between Blue Cross of California and its
Affiliates (“BLUE CROSS”) and Northwest Orange County Medical Group, Inc.
(“PARTICIPATING MEDICAL GROUP”).


 


RECITALS


 


A.                                   BLUE CROSS and PARTICIPATING MEDICAL GROUP
have previously entered into a CaliforniaCare Medical Services Agreement,
effective January 1, 1997 (as may have been amended, the “Agreement”).


 


B.                                     The parties now desire to amend the Agreement.


 


NOW,
THEREFORE, IT IS AGREED:


 


1.                                       All references in the Agreement to the
Department of Corporations and the Commissioner of Corporations shall hereafter
mean the California Department of Managed Health Care and the Director of the
California Department of Managed Health Care, respectively.


 


2.                                       Article II of the Agreement is hereby
amended as follows:


 


A.                                   The following Sections are hereby deleted from
Article II: 2.01 (Adjusted Per Member Per Month Non-Capitated Expense),
2.03 (Age/Sex Factors), 2.06 (Attachment Point), 2.20 (Case Management Stop-Loss
Threshold), 2.40 (Non-Capitated Expenses), 2.41 (Non-Capitated Performance
Settlement), 2.42 (Non-Capitated Performance Settlement Schedule), 2.48
(Outpatient Prescription Drug Expense), 2.49 (Outpatient Prescription Drug
Settlement), 2.50 (Outpatient Prescription Drug Settlement Schedule), 2.52 (Per
Member Per Month Non-Capitated Expense), 2.53 (Per Member Per Month (PMPM)
Outpatient Prescription Drug Expense), 2.54 (Plan Factors), 2.60 (Region
Factor) and 2.64 (Stop-Loss Factor).


 


B.                                     Section 2.23 of the Agreement is hereby
deleted in its entirety and replaced with the following:


 


“Emergency” means a sudden onset of a medical condition manifesting
itself by acute symptoms of sufficient severity (including, without limitation,
severe pain) such that the patient may reasonably believe that the absence of
immediate medical or psychiatric 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 or psychiatric
consequences, or


 


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


 












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


 


1

















 


C.                                     Section 2.42 of the Agreement is hereby
deleted and replaced with the following:


 


“Operations Manual” means the CaliforniaCare PMG Operations Manual, as
found on BLUE CROSS’ Internet web site at www.bluecrossca.com.


 


D.                                    The following sections are hereby added to
Article II:


 


2.09.1                  “BLUE CROSS Services” means all CALIFORNIACARE Covered Medical
Services which are designated in this Agreement or in the Division of Financial
Responsibility as BLUE CROSS Services.


 


2.37.1                  “Mental Health Parity Services” means those mental health services related
to the diagnosis and Medically Necessary treatment of “severe mental illnesses”
and “serious emotional disturbances of a child,” as such terms are defined in
Section 1374.72 of the California Health and Safety Code.


 


2.69.1                  “Generic Outpatient Prescription Drug(s)” means an outpatient prescription drug
identified as a generic by BLUE CROSS or First Data Bank and refers to an
outpatient prescription drug product having the same active ingredients as a
brand or trade name product.


 


2.70.1                  Generic Outpatient Prescription Drug
Utilization Incentive” means
an amount paid to PARTICIPATING MEDICAL GROUP based on the prescription of
Generic Outpatient Prescription Drugs to Members assigned to PARTICIPATING MEDICAL
GROUP who have an outpatient prescription drug benefit included in their
Benefit Agreement.


 


2.71.1                  “Generic Outpatient Prescription Drug
Utilization Incentive Schedule”
means a schedule of incentive amounts associated with varied levels of
prescription of Generic Outpatient Prescription Drugs to Members assigned to
PARTICIPATING MEDICAL GROUP who have an outpatient prescription drug benefit
included in their Benefit Agreement. 
This Schedule is set forth in Exhibit H attached and incorporated
herein.


 


2.72.1                  “GOPDU Attachment Point” is the point at which no Generic Outpatient
Prescription Drug Utilization Incentive shall be paid if PARTICIPATING MEDICAL
GROUP’s GOPDU (as defined in Section 10.01 of this Agreement) is less than
or equal to that amount.  The GOPDU
Attachment Point is shown on the Generic Outpatient Prescription Drug
Utilization Incentive Schedule, as set forth on Exhibit H attached and
incorporated herein.


 


2.73.1                  “Scorecard Percentile Attachment Point” is the point at which no Quality/Best
Practices Scorecard Incentive shall be paid if PARTICIPATING MEDICAL GROUP’s
percentile ranking (rounded to the nearest whole number) of its results on the
Quality/Best Practices Scorecard is less than or equal to such point.  The Scorecard Percentile Attachment Point is
shown on the Quality/Best Practices Scorecard Incentive Schedule, as set forth
on Exhibit I attached and incorporated herein.


 


3.                                       Section 4.05C of the Agreement is hereby
amended and replaced in its entirety with the following:


 


PARTICIPATING MEDICAL GROUP shall:


 


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


 


2

















 


(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 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 Medical Director
shall notify PARTICIPATING MEDICAL GROUP in advance of his or her attendance
and shall not be excluded from any deliberation on activities related to
Members.


 


(4)                                  Comply with all applicable laws and
regulations concerning utilization management criteria and processes, including,
without limitation, California Health and Safety Code Sections 1363.5 and
1367.01.


 


4.                                       Section 4.06 of the Agreement is hereby
amended to add the following sentence to the beginning of such Section:


 


PARTICIPATING MEDICAL GROUP agrees to provide financial information to
BLUE CROSS or its designated agent and to meet any other financial requirements
that assist BLUE CROSS in maintaining the financial viability of its
arrangements for the provision of health care services in the manner described
in Section 1375.4 of the California Health and Safety Code and applicable
regulations.


 


5.                                       Section 4.10A of the Agreement is hereby
deleted in its entirety and replaced with the following:


 


To accept any and all Members who select
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 16.08
herein.  PARTICIPATING MEDICAL GROUP
shall be responsible for maintaining sufficient professional and other
resources to maintain its maximum capacity at or above the specified
level.  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.  Except as required by
applicable law or regulation, nothing in this Section shall require that
BLUE CROSS reassign any Members assigned to PARTICIPATING MEDICAL GROUP as of
the effective date of the ninety (90) day notice referenced herein.


 


6.                                       Section 4.10E of the Agreement is hereby
amended to add the following paragraph to the beginning of such

Section:


 


BLUE CROSS will comply with all requirements of California Health and
Safety Code Section 1395.6.  The
BLUE CROSS Managed Care Network may be sold, leased, transferred or conveyed to
Other Payors, which may include workers’ compensation insurers or automobile
insurers.  BLUE CROSS will disclose upon
initial signing of this Agreement and within 30 days of receipt of a written
request from PARTICIPATING MEDICAL GROUP a summary of all Other Payors
currently eligible to pay the negotiated rates under this Agreement as a result
of their arrangement with BLUE CROSS. 
BLUE CROSS requires such Other Payors to actively encourage Covered
Persons to use network participating providers when obtaining medical care
through the use of one or more of the following: reduced copayments, reduced
deductibles, premium discounts directly attributable to the use of a
participating provider, financial penalties directly attributable to the
non-use of a participating provider, providing Covered Persons with the names,
addresses and phone numbers of participating providers in advance of their
selection of a health care provider through the use of provider directories,
toll-free telephone numbers and internet web site addresses.  In the event BLUE CROSS enters into an
arrangement with an Other Payor that does not require such active encouragement
of the use of the BLUE CROSS Managed Care Network, PARTICIPATING MEDICAL GROUP
shall be allowed to decline to provide services to such Other Payor.


 


3

















 


7.                                       The following Section 4.13.1 is hereby
added to Article IV of the Agreement:


 


4.13.1                  The parties agree that the financial risk
provisions of this Agreement have been negotiated and agreed to by BLUE CROSS
and PARTICIPATING MEDICAL GROUP.


 


8.                                       Section 5.13 of the Agreement is hereby
replaced in its entirety to read as follows:


 


5.13                           Notwithstanding any provision herein to the
contrary, BLUE CROSS agrees to give PARTICIPATING MEDICAL GROUP at least ninety
(90) days prior notice of any change by BLUE CROSS to a material term of this
Agreement (except for any change necessary to comply with state or federal law
or regulations or any accreditation requirements of a private sector
accreditation organization and a shorter timeframe is required for
compliance).  If PARTICIPATING MEDICAL
GROUP desires to negotiate the change (except for any change necessary to
comply with state or federal law or regulations or any accreditation
requirements of a private sector accreditation organization), PARTICIPATING
MEDICAL GROUP shall notify BLUE CROSS no later than thirty (30) days after
receipt of BLUE CROSS’s notice.  If the
parties are unable to agree to such change by the forty-fifth (45th)
day prior to the effective date of the change, PARTICIPATING MEDICAL GROUP may
terminate this Agreement as of the effective date of the change upon prior
written notice given to BLUE CROSS no later than the forty-second (42nd) day
prior to the effective date of the change, notwithstanding the provisions of
Section 13.01 of this Agreement.


 


9.                                       The following Sections 5.14.1 and 5.15.1 are
hereby added to Article V of the Agreement:


 


5.14.1                  To disclose information to PARTICIPATING
MEDICAL GROUP that enables PARTICIPATING MEDICAL GROUP to be informed regarding
the financial risk assumed under this Agreement, as required in California
Health and Safety Code Section 1375.4 and applicable regulations.


 


5.15.1                  To authorize and arrange for the provision of
BLUE CROSS Services to Members for all new and renewing business.


 


10.                                 Article IX of the Agreement is hereby
deleted and replaced in its entirety with the following: 


 


IX.                                NON-CAPITATED SERVICES


 


9.01                           The Covered Medical Services encompassed in
Non-Capitated Services are delineated in Exhibit A(1)


 


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 forty-five  (45) working
days 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 forty-five
(45) working days following BLUE CROSS’s 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


 


4

















 


Services: mammography services, DME, prosthetics and injectable
medications (including chemotherapy drugs and infused substances).


 


In either case described above, BLUE CROSS shall pay contracting
providers at the rate negotiated between BLUE CROSS and said provider.  In the case of non-contracting providers,
BLUE CROSS shall pay the lesser of: the actual billed charges, or the maximum
allowable rate according to the BLUE CROSS Customary and Reasonable charges, or
the rate arranged for by a CALIFORNIACARE Case Manager.


 


11.                                 Article X of the Agreement is hereby
deleted and replaced in its entirety with the following:


 


X.                                    GENERIC OUTPATIENT PRESCRIPTION DRUG
UTILIZATION INCENTIVE


 


10.01                     Calculating PARTICIPATING MEDICAL GROUP’s
Generic Outpatient Prescription Drug Utilization (“GOPDU”).


 


PARTICIPATING MEDICAL GROUP’s Generic Outpatient Prescription Drug
Utilization (“GOPDU”) is the quotient (rounded to the nearest whole number) of
(i) the number of Generic Outpatient Prescription Drugs prescribed during each
calendar year for Members assigned to PARTICIPATING MEDICAL GROUP who have an
outpatient prescription drug benefit included in their Benefit Agreement and
paid for by BLUE CROSS as specified below, divided by (ii) the total number of
outpatient prescription drugs (generic, brand and trade name) prescribed during
each calendar year for Members assigned to PARTICIPATING MEDICAL GROUP who have
an outpatient prescription drug benefit included in their Benefit Agreement and
paid for by BLUE CROSS as specified below.


 


After the end of each calendar year BLUE CROSS shall calculate the GOPDU
for PARTICIPATING MEDICAL GROUP based on the prescriptions written for Members
assigned to PARTICIPATING MEDICAL GROUP who have an outpatient prescription
drug benefit included in their Benefit Agreement and the pharmacy claims paid
for such prescriptions during such prior calendar year through March 31st
after year-end.  Beginning in year two
(2) of this Agreement, all outpatient drug prescriptions on pharmacy claims
received after calculation of the final Generic Outpatient Prescription Drug
Utilization Incentive will be included in the following year’s GOPDU
calculation.


 


10.02                     Generic Outpatient Prescription Drug
Utilization Incentive Schedule


 


To be eligible for a Generic Outpatient Prescription Drug Utilization
Incentive, PARTICIPATING MEDICAL GROUP must have participated in BLUE CROSS’S
CaliforniaCare network for a minimum of nine (9) months during the applicable
calendar year.


 


The Generic Outpatient Prescription Drug Utilization Incentive
Schedule set forth in Exhibit H will be the basis for determining any
Generic Outpatient Prescription Drug Utilization Incentive to PARTICIPATING
MEDICAL GROUP.


 


10.03                     Calculating the Generic Outpatient
Prescription Drug Utilization Incentive


 


If PARTICIPATING MEDICAL GROUP’s GOPDU is greater than the GOPDU
Attachment Point, as described in Exhibit H, PARTICIPATING MEDICAL GROUP will
be entitled to receive a Generic Outpatient Prescription Drug Utilization
Incentive, as determined in accordance with Exhibit H; provided that
PARTICIPATING MEDICAL GROUP meets the eligibility requirement set forth in
Section 10.02 above.


 


5

















 


The amount of the Generic Outpatient Prescription Drug Utilization
Incentive will be based on the applicable PMPM incentive calculation under
Exhibit H multiplied by PARTICIPATING MEDICAL GROUP’s Member Months for the
calendar year for Members with outpatient prescription drug benefits in their
Benefit Agreement. Within one hundred eighty (180) days after the end of the
“contract year,” BLUE CROSS will pay any Generic Outpatient Prescription Drug
Utilization Incentive that is due PARTICIPATING MEDICAL GROUP for the previous
calendar year.  Notwithstanding the
foregoing, in the event this Agreement is terminated, BLUE CROSS shall
calculate the Generic Outpatient Prescription Drug Utilization Incentive in
accordance with this Article X and shall pay PARTICIPATING MEDICAL GROUP
the applicable Generic Outpatient Prescription Drug Utilization Incentive
within 180 days after the date of termination. For purposes of calculating the
Generic Outpatient Prescription Drug Utilization Incentive, “contract year”
shall mean calendar year.


 


PARTICIPATING MEDICAL GROUP shall review such incentive payment and/or
any statement showing the calculation of such incentive payment prepared by
BLUE CROSS and shall within forty-five (45) days of receipt, notify BLUE CROSS
in writing of any problem or discrepancy; otherwise the right to challenge the
amount and/or the calculation of the incentive shall be deemed waived by
PARTICIPATING MEDICAL GROUP.


 


12.                                 Article XI of the Agreement is hereby
deleted and replaced in its entirety with the following:


 


XI.                                QUALITY/BEST PRACTICES SCORECARD INCENTIVE


 


After the end of each calendar year BLUE CROSS will evaluate
PARTICIPATING MEDICAL GROUP’s performance during such prior calendar year in
certain areas related to quality of care, compliance with administrative
requirements and service delivery to Members using a scorecard. PARTICIPATING
MEDICAL GROUP will be notified of the scorecard parameters and scoring
methodology prior to the start of each year.


 


BLUE CROSS will rank PARTICIPATING MEDICAL GROUP’s scorecard result with
all other participating medical groups’ scorecard results. If PARTICIPATING
MEDICAL GROUP’s percentile ranking (rounded to the nearest whole number)
exceeds the Scorecard Percentile Attachment Point set forth on attached Exhibit
I, PARTICIPATING MEDICAL GROUP will be entitled to receive a Quality/Best
Practices Scorecard Incentive calculated in accordance with Exhibit I, provided
that PARTICIPATING MEDICAL GROUP participated in BLUE CROSS’s CaliforniaCare
network for a minimum of nine (9) months during the applicable calendar year.


 


If PARTICIPATING MEDICAL GROUP’s member satisfaction survey results are
not available (but PARTICIPATING MEDICAL GROUP participated in such survey) or
if PARTICIPATING MEDICAL GROUP was ineligible to participate in such survey due
to a minimum membership requirement or if another component(s) of the scorecard
were not evaluated, BLUE CROSS will extrapolate PARTICIPATING MEDICAL GROUP’s
available scorecard result and then will rank such result with all other
participating medical groups’ scorecard results and use Exhibit I to determine
the amount of any Quality/Best Practices Scorecard Incentive, as set forth in
the above paragraph. If PARTICIPATING MEDICAL GROUP was eligible to participate
in the member satisfaction survey designated by BLUE CROSS, but did not
participate for any reason, PARTICIPATING MEDICAL GROUP will not receive any
points in those scorecard categories (or portions thereof) that are based on
such survey results. BLUE CROSS will notify PARTICIPATING MEDICAL GROUP of its
scorecard result and its ranking after the end of the applicable calendar year.


 


Any Quality/Best Practices Scorecard Incentive payable to PARTICIPATING
MEDICAL GROUP in accordance with the PMPM Quality/Best Practices Scorecard
Incentive Schedule shown in Exhibit I will be made within 180 days after
the end of the “contract year” for which it is based. Notwithstanding the
foregoing, in the event this Agreement is terminated, BLUE CROSS


 


6

















 


shall calculate PARTICIPATING MEDICAL GROUP’s Quality/Best Practices
Scorecard Incentive payment in accordance with this Article XI and shall
pay any such incentive payment within 180 days after the date of
termination.  For purposes of
calculating the Quality/Best Practices Scorecard Incentive, “contract year”
shall mean calendar year.


 


PARTICIPATING MEDICAL GROUP shall review such incentive payment and/or
any statement showing the calculation of such incentive payment prepared by
BLUE CROSS and shall within forty-five (45) days of receipt, notify BLUE CROSS
in writing of any problem or discrepancy; otherwise the right to challenge the
amount and/or the calculation of the incentive shall be deemed waived by
PARTICIPATING MEDICAL GROUP.


 


13.                                 Exhibit A(l) of the Agreement is hereby
amended to delete in its entirety the categories of “Chemical Dependency
Rehabilitation,” “Detoxification” and “Mental Health Services” and all
provisions thereunder concerning financial responsibility for the professional
and facility components thereof and to replace them with the following,
respectively:


 


	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	
   

  	
  BLUE

  CROSS

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *
  CHEMICAL DEPENDENCY REHABILITATION(1)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION(1)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  *
  MENTAL HEALTH SERVICES (PARITY & NON-PARITY)(1)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












(1)                                  Services must have been provided in a mental
health facility, if inpatient, and by a mental health provider, in all cases.


 


14.                                 Exhibit F of the Agreement is hereby deleted
in its entirety.


 


15.                                 Exhibits H and I of the Agreement are hereby
deleted and replaced in their entirety with Exhibits H and I attached and
incorporated herein.


 


7

















 


Upon acceptance of the parties, this Amendment, as of the date specified
on page one hereof, shall become a part of the Agreement, and all provisions of
the Agreement not specifically inconsistent herewith shall remain in full force
and effect.


 


	
  BLUE CROSS OF CALIFORNIA

  	
  PARTICIPATING MEDICAL GROUP

  Northwest Orange County Medical Group, Inc.

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ Barry Ford

  	
   

  	
  /s/ Pratibha Patel

  	
   

  
	
  Signature

  	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  BARRY FORD

  	
   

  	
  PRATIBHA PATEL, MD

  	
   

  
	
  Print
  Name

  	
   

  	
  Print
  Name

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  5/5/03

  	
   

  	
  PRESIDENT

  	
  4/25/03

  	
   

  
	
  Title

  	
  Date

  	
   

  	
  Title

  	
    Date

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Tax
  ID #:

  	
   

  
						



 


	
   

  	
  /s/ James P. Agronick

  	
   

  
	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  James P. Agronick

  	
   

  
	
   

  	
  Print
  Name

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  CEO

  	
  4/25/03

  	
   

  
	
   

  	
  Title

  	
    Date

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
  Tax
  ID #:

  	
   

  



 


8

















 


EXHIBIT
H


 


Generic
Outpatient Prescription Drug Utilization Incentive Schedule


 


Calculation
of Generic Outpatient Prescription Drug Utilization Incentive:


 


1)              Identify
the payment band that contains the PARTICIPATING MEDICAL GROUP’s Generic
Outpatient Prescription Drug Utilization (“GOPDU”).


2)              Calculate
the difference between PARTICIPATING MEDICAL GROUP’s GOPDU and the low value of
the payment band. 


3)              Multiply
the result from Step 2 by the payment multiplier for the payment band.


4)              Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM GOPDU Incentive.


5)              Multiply
the PMPM GOPDU Incentive from Step 4 by the PARTICIPATING MEDICAL GROUP’s
Member Months for the calendar year (for Members with outpatient prescription
drug benefits in their Benefit Agreement) to calculate the GOPDU Incentive.


 


	
  Band

  	
   

  	
  GOPDU

  	
   

  	
  Payment

  Multiplier

  	
   

  	
  Minimum
  Payment

  PMPM

  	
   

  	
  Maximum
  Payment

  PMPM

  
	
  Low

  	
   

  	
  High

  
	
  1

  	
   

  	
  0%

  	
   

  	
  47%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  2

  	
   

  	
  48%

  	
  (*)

  	
  51%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  3

  	
   

  	
  52%

  	
   

  	
  55%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  4

  	
   

  	
  56%

  	
   

  	
  59%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  5

  	
   

  	
  60%

  	
   

  	
  63%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  6

  	
   

  	
  64%

  	
   

  	
  >64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 


PARTICIPATING
MEDICAL GROUPs that have a GOPDU over 64% will get a maximum payment of $2.50
PMPM based on the number of Members with outpatient prescription drug benefits
in their Benefit Agreement.


 


Example of Generic Outpatient Prescription Drug Utilization
Incentive Calculation:


 


Assume: PARTICIPATING MEDICAL GROUP has GOPDU of 62%; and
there are 100,000 member months


 


(1)               Identify the payment band that contains the
PARTICIPATING MEDICAL GROUP’S GOPDU.  PARTICIPATING MEDICAL GROUP’s GOPDU of 62% falls
between the low and high values of payment band 5


(2)               Calculate the difference between PARTICIPATING
MEDICAL GROUP’s GOPDU and the low value for the payment band 62% - 60% = 2%


(3)               Multiply the result from Step 2 by the payment
multiplier for the payment band.

2% x $12.50 = $0.25


(4)               Add the result from Step 3 to (he minimum
payment amount for the payment band to get the PMPM GOPDU Incentive.

$2.00 + $0.25 = $2.25 PMPM GOPDU Incentive


(5)               Multiply the PMPM GOPDU Incentive from Step 4
by the PARTICIPATING MEDICAL GROUP’s Member Months for the calendar year to
calculate the GOPDU Incentive.


$2.25 PMPM x 100,000 member months = $225,000


 












*GOPDU
Attachment Point


 


H-1

















 


EXHIBIT 1


 


Quality/Best
Practices Scorecard Incentive Schedule


 


PARTICIPATING MEDICAL GROUP can receive a maximum payment of $4.50 PMPM.


 


Calculation of the Quality/Best Practices Scorecard Incentive
Payment:


 


1)              Identify
the payment band that contains PARTICIPATING MEDICAL GROUP’s percentile ranking
(rounded to the nearest whole number) based its result from the Quality/Best
Practices Scorecard.


2)              Calculate
the difference between PARTICIPATING MEDICAL GROUP’s Quality/Best Practices
Scorecard percentile ranking (rounded to the nearest whole number) and the low
percentile ranking of the payment band.


3)              Multiply
the result from Step 2 by the payment multiplier for the payment band.


4)              Add
the result from Step 3 to the minimum payment amount for the payment band to
get the PMPM Quality/Best Practices Scorecard Incentive.


5)              Multiply
the PMPM Quality/Best Practices Scorecard Incentive from Step 4 by
PARTICIPATING MEDICAL GROUP’S Member Months for the calendar year to calculate
the Quality/Best Practices Scorecard Incentive payment.


 


	
   

  	
   

  	
  Scorecard
  Percentile Ranking

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Band

  	
   

  	
  Low

  	
   

  	
  High

  	
   

  	
  Payment

  Multiplier

  	
   

  	
  Minimum
  Payment

  PMPM

  	
   

  	
  Maximum
  Payment

  PMPM

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1

  	
   

  	
  0%

  	
   

  	
  19%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  2

  	
   

  	
  20%

  	
  (*)

  	
  39%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  3

  	
   

  	
  40%

  	
   

  	
  59%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  4

  	
   

  	
  60%

  	
   

  	
  79%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  5

  	
   

  	
  80%

  	
   

  	
  100%

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  



 


Example of Quality/Best Practices Scorecard Incentive Payment
Calculation:


 


Assume: PARTICIPATING MEDICAL GROUP’S performance on the
scorecard places it in the 90% percentile rank, and 


there are 100,000 member months


(1)               Identify the payment band that contains
PARTICIPATING MEDICAL GROUP’s percentile ranking (rounded to the nearest whole
number) based on its result from me Quality/Best Practices Scorecard


PARTICIPATING MEDICAL GROUP’s ranking of 90% falls
between the low and high percentile rankings of payment band 5


(2)               Calculate the difference between PARTICIPATING
MEDICAL GROUP’s Quality/Best Practices Scorecard percentile ranking (rounded to
the nearest whole number) and the low percentile ranking for the payment band.


90% - 80% = 10%


(3)               Multiply the result from Step 2 by the payment
multiplier for the payment band.

10% x $5.00 = $0.50


(4)               Add the result from Step 3 to the minimum
payment amount for the payment band to get the PMPM Quality/Best Practices
Scorecard Incentive.

$0.50 + $3.50 = S4.00 PMPM Quality/Best
Practices Scorecard Incentive


(5)               Multiply the PMPM Quality/Best Practices
Scorecard Incentive from Step 4 by PARTICIPATING MEDICAL GROUP’s Member Months
for the calendar year to calculate the Quality/Best Practices Scorecard
Incentive payment.


$4.00 PMPM x 100,000 member months = $400,000
Quality/Best Practices Scorecard Incentive Payment


 












*Scorecard
Percentile Attachment Point


 


I-1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule G-1


Blue Cross Plus Plans


 


Effective Date:
01/01/2005 To 12/31/2005


Professional Blue
Cross Plus Plan Code Adjusted Capitation Rates

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate (100%)

  	
   

  	
  $1.08

  
	
  EP Rate (50%)

  	
   

  	
  $0.54

  
	
  Capitation Advance/Guarantee%

  	
   

  	
  10%

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 




	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ.
  RATE @ 50%

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  






 












(1)                                  Plan adjusted
Capitation Rate includes 50% Guaranteed Base Rate plus the respective
Capitation Advance/Capitation Guarantee:                                                10%


(2)                                  Plan adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
as shown above by the appropriate age/sex factor. Then add EP rate and Direct
Access rate.  Please refer to age/sex
factors on Schedule G-1 A


 


4

















 


Supplemental Capitation Payment


To compute the Supplemental Capitation Payment, see
Exhibit G, II in the CaliforniaCare Medical Services Agreement.


 


Supplemental Capitation Payment is expressed
as a percent of the Total Capitation Payment and includes any advance
supplemental capitation payment already paid.


 


Below
is the In-Network Utilization Factor table and respective supplemental
capitation payment percentage:


 




	
  In-Network Utilization Factor
  (INUF)

  	
   

  	
  Supplemental

  Capitation Payment%

  
	
  0.0000 thru 0.4199

  	
   

  	
  0.0%

  
	
  0.4200 thru 0.4799

  	
   

  	
  10.0%

  
	
  0.4800 thru 0.5499

  	
   

  	
  20.0%

  
	
  0.5500 thru 0.6499

  	
   

  	
  30.0%

  
	
  0.6500 thru 0.7999

  	
   

  	
  40.0%

  
	
  0.8000 and above

  	
   

  	
  50.0%

  






 


5

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule G-1A

Age/Sex Factors - Blue Cross Plus Plans


 


Effective Date:
01/01/2005 To 12/31/2005

Professional Capitation Age/Sex Relativity Table

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN

Age/Sex Factors (includes HMO Commercial, Durational and Blue Cross Plus plans)


 


	
  AGE RANGE

  	
   

  	
  Factor

  Male

  	
   

  	
  Factor

  Female

  
	
  From

  	
   

  	
  To

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0

  	
   

  	
  0

  	
   

  	
  1.8000

  	
   

  	
  1.8000

  
	
  1

  	
   

  	
  4

  	
   

  	
  0.5000

  	
   

  	
  0.5000

  
	
  5

  	
   

  	
  14

  	
   

  	
  0.4600

  	
   

  	
  0.4700

  
	
  15

  	
   

  	
  19

  	
   

  	
  0.5500

  	
   

  	
  0.7700

  
	
  20

  	
   

  	
  24

  	
   

  	
  0.5000

  	
   

  	
  1.0100

  
	
  25

  	
   

  	
  29

  	
   

  	
  0.5900

  	
   

  	
  1.2800

  
	
  30

  	
   

  	
  34

  	
   

  	
  0.6800

  	
   

  	
  1.4500

  
	
  35

  	
   

  	
  39

  	
   

  	
  0.7800

  	
   

  	
  1.4600

  
	
  40

  	
   

  	
  44

  	
   

  	
  0.9000

  	
   

  	
  1.4900

  
	
  45

  	
   

  	
  49

  	
   

  	
  1.0500

  	
   

  	
  1.5800

  
	
  50

  	
   

  	
  54

  	
   

  	
  1.2500

  	
   

  	
  1.6900

  
	
  55

  	
   

  	
  59

  	
   

  	
  1.6100

  	
   

  	
  1.8400

  
	
  60

  	
   

  	
  64

  	
   

  	
  2.0500

  	
   

  	
  2.0700

  
	
  65

  	
   

  	
  120

  	
   

  	
  2.2800

  	
   

  	
  2.2200

  
	
  65+

  	
   

  	
  MP *

  	
   

  	
  0.6840

  	
   

  	
  0.6661

  



 












* Employer insurance is
secondary payer to Medicare.


 


1

















 


CALIFORNIACARE
HEALTH PLANS


Schedule D

HMO Commercial Plans (excludes Durational and Blue Cross Plus)


 


Effective Date:
01/01/2004 To 12/31/2004

Professional  HMO Plan Code
Adjusted Capitation Rates

For Book of Business Employer Groups


 


NORTHWEST
ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  GH

  	
   

  	
   

  	
  ***

  
	
  GH3

  	
   

  	
   

  	
  ***

  
	
  GL

  	
   

  	
   

  	
  ***

  
	
  H1

  	
   

  	
   

  	
  ***

  
	
  H10

  	
   

  	
   

  	
  ***

  
	
  H2

  	
   

  	
   

  	
  ***

  
	
  H3

  	
   

  	
   

  	
  ***

  
	
  H4

  	
   

  	
   

  	
  ***

  
	
  H5

  	
   

  	
   

  	
  ***

  
	
  H6

  	
   

  	
   

  	
  ***

  
	
  H7

  	
   

  	
   

  	
  ***

  
	
  H8

  	
   

  	
   

  	
  ***

  
	
  H9

  	
   

  	
   

  	
  ***

  
	
  HAA

  	
   

  	
   

  	
  ***

  
	
  HAB

  	
   

  	
   

  	
  ***

  
	
  HAC

  	
   

  	
   

  	
  ***

  
	
  HAD

  	
   

  	
   

  	
  ***

  
	
  HAE

  	
   

  	
   

  	
  ***

  
	
  HAF

  	
   

  	
   

  	
  ***

  
	
  HAG

  	
   

  	
   

  	
  ***

  
	
  HAH

  	
   

  	
   

  	
  ***

  
	
  HAI

  	
   

  	
   

  	
  ***

  
	
  HAJ

  	
   

  	
   

  	
  ***

  
	
  HAK

  	
   

  	
   

  	
  ***

  
	
  HAL

  	
   

  	
   

  	
  ***

  
	
  HAM

  	
   

  	
   

  	
  ***

  
	
  HAN

  	
   

  	
   

  	
  ***

  
	
  HAO

  	
   

  	
   

  	
  ***

  
	
  HAP

  	
   

  	
   

  	
  ***

  
	
  HAQ

  	
   

  	
   

  	
  ***

  
	
  HAR

  	
   

  	
   

  	
  ***

  
	
  HAS

  	
   

  	
   

  	
  ***

  
	
  HAT

  	
   

  	
   

  	
  ***

  
	
  HAU

  	
   

  	
   

  	
  ***

  
	
  HAV

  	
   

  	
   

  	
  ***

  
	
  HAW

  	
   

  	
   

  	
  ***

  
	
  HAX

  	
   

  	
   

  	
  ***

  



 


2

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HAY

  	
   

  	
   

  	
  ***

  
	
  HAZ

  	
   

  	
   

  	
  ***

  
	
  HBA

  	
   

  	
   

  	
  ***

  
	
  HBB

  	
   

  	
   

  	
  ***

  
	
  HBC

  	
   

  	
   

  	
  ***

  
	
  HBD

  	
   

  	
   

  	
  ***

  
	
  HBF

  	
   

  	
   

  	
  ***

  
	
  HBG

  	
   

  	
   

  	
  ***

  
	
  HBH

  	
   

  	
   

  	
  ***

  
	
  HBI

  	
   

  	
   

  	
  ***

  
	
  HBJ

  	
   

  	
   

  	
  ***

  
	
  HBK

  	
   

  	
   

  	
  ***

  
	
  HBL

  	
   

  	
   

  	
  ***

  
	
  HBM

  	
   

  	
   

  	
  ***

  
	
  HBN

  	
   

  	
   

  	
  ***

  
	
  HBO

  	
   

  	
   

  	
  ***

  
	
  HBP

  	
   

  	
   

  	
  ***

  
	
  HBQ

  	
   

  	
   

  	
  ***

  
	
  HBR

  	
   

  	
   

  	
  ***

  
	
  HBS

  	
   

  	
   

  	
  ***

  
	
  HBT

  	
   

  	
   

  	
  ***

  
	
  HBU

  	
   

  	
   

  	
  ***

  
	
  HBV

  	
   

  	
   

  	
  ***

  
	
  HBW

  	
   

  	
   

  	
  ***

  
	
  HBX

  	
   

  	
   

  	
  ***

  
	
  HBY

  	
   

  	
   

  	
  ***

  
	
  HBZ

  	
   

  	
   

  	
  ***

  
	
  HC

  	
   

  	
   

  	
  ***

  
	
  HCA

  	
   

  	
   

  	
  ***

  
	
  HCB

  	
   

  	
   

  	
  ***

  
	
  HCC

  	
   

  	
   

  	
  ***

  
	
  HCD

  	
   

  	
   

  	
  ***

  
	
  HCE

  	
   

  	
   

  	
  ***

  
	
  HCF

  	
   

  	
   

  	
  ***

  
	
  HCG

  	
   

  	
   

  	
  ***

  
	
  HCH

  	
   

  	
   

  	
  ***

  
	
  HCI

  	
   

  	
   

  	
  ***

  



 


3

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HCJ

  	
   

  	
   

  	
  ***

  
	
  HCK

  	
   

  	
   

  	
  ***

  
	
  HCL

  	
   

  	
   

  	
  ***

  
	
  HCM

  	
   

  	
   

  	
  ***

  
	
  HCN

  	
   

  	
   

  	
  ***

  
	
  HCO

  	
   

  	
   

  	
  ***

  
	
  HCP

  	
   

  	
   

  	
  ***

  
	
  HCQ

  	
   

  	
   

  	
  ***

  
	
  HCR

  	
   

  	
   

  	
  ***

  
	
  HCS

  	
   

  	
   

  	
  ***

  
	
  HCT

  	
   

  	
   

  	
  ***

  
	
  HCU

  	
   

  	
   

  	
  ***

  
	
  HCV

  	
   

  	
   

  	
  ***

  
	
  HCW

  	
   

  	
   

  	
  ***

  
	
  HCX

  	
   

  	
   

  	
  ***

  
	
  HCY

  	
   

  	
   

  	
  ***

  
	
  HCZ

  	
   

  	
   

  	
  ***

  
	
  HDA

  	
   

  	
   

  	
  ***

  
	
  HDB

  	
   

  	
   

  	
  ***

  
	
  HDC

  	
   

  	
   

  	
  ***

  
	
  HDD

  	
   

  	
   

  	
  ***

  
	
  HDE

  	
   

  	
   

  	
  ***

  
	
  HDF

  	
   

  	
   

  	
  ***

  
	
  HDG

  	
   

  	
   

  	
  ***

  
	
  HDH

  	
   

  	
   

  	
  ***

  
	
  HDI

  	
   

  	
   

  	
  ***

  
	
  HDJ

  	
   

  	
   

  	
  ***

  
	
  HDK

  	
   

  	
   

  	
  ***

  
	
  HDL

  	
   

  	
   

  	
  ***

  
	
  HDM

  	
   

  	
   

  	
  ***

  
	
  HDN

  	
   

  	
   

  	
  ***

  
	
  HDO

  	
   

  	
   

  	
  ***

  
	
  HDP

  	
   

  	
   

  	
  ***

  
	
  HDQ

  	
   

  	
   

  	
  ***

  
	
  HDR

  	
   

  	
   

  	
  ***

  
	
  HDS

  	
   

  	
   

  	
  ***

  
	
  HDT

  	
   

  	
   

  	
  ***

  



 


4

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
   

  	
   

  	
   

  	
   

  
	
  HDU

  	
   

  	
   

  	
  ***

  
	
  HDV

  	
   

  	
   

  	
  ***

  
	
  HDW

  	
   

  	
   

  	
  ***

  
	
  HDX

  	
   

  	
   

  	
  ***

  
	
  HDY

  	
   

  	
   

  	
  ***

  
	
  HDZ

  	
   

  	
   

  	
  ***

  
	
  HEA

  	
   

  	
   

  	
  ***

  
	
  HEB

  	
   

  	
   

  	
  ***

  
	
  HEC

  	
   

  	
   

  	
  ***

  
	
  HED

  	
   

  	
   

  	
  ***

  
	
  HEE

  	
   

  	
   

  	
  ***

  
	
  HEF

  	
   

  	
   

  	
  ***

  
	
  HEG

  	
   

  	
   

  	
  ***

  
	
  HEH

  	
   

  	
   

  	
  ***

  
	
  HEI

  	
   

  	
   

  	
  ***

  
	
  HEJ

  	
   

  	
   

  	
  ***

  
	
  HEK

  	
   

  	
   

  	
  ***

  
	
  HEL

  	
   

  	
   

  	
  ***

  
	
  HEM

  	
   

  	
   

  	
  ***

  
	
  HEN

  	
   

  	
   

  	
  ***

  
	
  HEO

  	
   

  	
   

  	
  ***

  
	
  HEP

  	
   

  	
   

  	
  ***

  
	
  HEQ

  	
   

  	
   

  	
  ***

  
	
  HER

  	
   

  	
   

  	
  ***

  
	
  HES

  	
   

  	
   

  	
  ***

  
	
  HET

  	
   

  	
   

  	
  ***

  
	
  HEU

  	
   

  	
   

  	
  ***

  
	
  HEV

  	
   

  	
   

  	
  ***

  
	
  HEW

  	
   

  	
   

  	
  ***

  
	
  HEX

  	
   

  	
   

  	
  ***

  
	
  HEY

  	
   

  	
   

  	
  ***

  
	
  HEZ

  	
   

  	
   

  	
  ***

  
	
  HFA

  	
   

  	
   

  	
  ***

  
	
  HFB

  	
   

  	
   

  	
  ***

  
	
  HFC

  	
   

  	
   

  	
  ***

  
	
  HFD

  	
   

  	
   

  	
  ***

  
	
  HFE

  	
   

  	
   

  	
  ***

  



 


5

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
   

  	
   

  	
   

  	
   

  
	
  HFF

  	
   

  	
   

  	
  ***

  
	
  HFG

  	
   

  	
   

  	
  ***

  
	
  HFH

  	
   

  	
   

  	
  ***

  
	
  HFI

  	
   

  	
   

  	
  ***

  
	
  HFJ

  	
   

  	
   

  	
  ***

  
	
  HFK

  	
   

  	
   

  	
  ***

  
	
  HFL

  	
   

  	
   

  	
  ***

  
	
  HFM

  	
   

  	
   

  	
  ***

  
	
  HFN

  	
   

  	
   

  	
  ***

  
	
  HFO

  	
   

  	
   

  	
  ***

  
	
  HFP

  	
   

  	
   

  	
  ***

  
	
  HFQ

  	
   

  	
   

  	
  ***

  
	
  HFR

  	
   

  	
   

  	
  ***

  
	
  HFS

  	
   

  	
   

  	
  ***

  
	
  HFT

  	
   

  	
   

  	
  ***

  
	
  HFU

  	
   

  	
   

  	
  ***

  
	
  HFV

  	
   

  	
   

  	
  ***

  
	
  HFW

  	
   

  	
   

  	
  ***

  
	
  HFX

  	
   

  	
   

  	
  ***

  
	
  HFY

  	
   

  	
   

  	
  ***

  
	
  HFZ

  	
   

  	
   

  	
  ***

  
	
  HGA

  	
   

  	
   

  	
  ***

  
	
  HGB

  	
   

  	
   

  	
  ***

  
	
  HGC

  	
   

  	
   

  	
  ***

  
	
  HGD

  	
   

  	
   

  	
  ***

  
	
  HGE

  	
   

  	
   

  	
  ***

  
	
  HGF

  	
   

  	
   

  	
  ***

  
	
  HGG

  	
   

  	
   

  	
  ***

  
	
  HGH

  	
   

  	
   

  	
  ***

  
	
  HGI

  	
   

  	
   

  	
  ***

  
	
  HGJ

  	
   

  	
   

  	
  ***

  
	
  HGK

  	
   

  	
   

  	
  ***

  
	
  HGL

  	
   

  	
   

  	
  ***

  
	
  HGM

  	
   

  	
   

  	
  ***

  
	
  HGN

  	
   

  	
   

  	
  ***

  
	
  HGO

  	
   

  	
   

  	
  ***

  
	
  HGP

  	
   

  	
   

  	
  ***

  



 


6

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HGQ

  	
   

  	
   

  	
  ***

  
	
  HGR

  	
   

  	
   

  	
  ***

  
	
  HGS

  	
   

  	
   

  	
  ***

  
	
  HGT

  	
   

  	
   

  	
  ***

  
	
  HGU

  	
   

  	
   

  	
  ***

  
	
  HGV

  	
   

  	
   

  	
  ***

  
	
  HGW

  	
   

  	
   

  	
  ***

  
	
  HGX

  	
   

  	
   

  	
  ***

  
	
  HGY

  	
   

  	
   

  	
  ***

  
	
  HGZ

  	
   

  	
   

  	
  ***

  
	
  HHA

  	
   

  	
   

  	
  ***

  
	
  HHB

  	
   

  	
   

  	
  ***

  
	
  HHC

  	
   

  	
   

  	
  ***

  
	
  HHD

  	
   

  	
   

  	
  ***

  
	
  HHE

  	
   

  	
   

  	
  ***

  
	
  HHF

  	
   

  	
   

  	
  ***

  
	
  HHG

  	
   

  	
   

  	
  ***

  
	
  HHH

  	
   

  	
   

  	
  ***

  
	
  HHI

  	
   

  	
   

  	
  ***

  
	
  HHJ

  	
   

  	
   

  	
  ***

  
	
  HHK

  	
   

  	
   

  	
  ***

  
	
  HHL

  	
   

  	
   

  	
  ***

  
	
  HHM

  	
   

  	
   

  	
  ***

  
	
  HHN

  	
   

  	
   

  	
  ***

  
	
  HHO

  	
   

  	
   

  	
  ***

  
	
  HHP

  	
   

  	
   

  	
  ***

  
	
  HHQ

  	
   

  	
   

  	
  ***

  
	
  HHR

  	
   

  	
   

  	
  ***

  
	
  HHS

  	
   

  	
   

  	
  ***

  
	
  HHT

  	
   

  	
   

  	
  ***

  
	
  HHU

  	
   

  	
   

  	
  ***

  
	
  HHV

  	
   

  	
   

  	
  ***

  
	
  HHW

  	
   

  	
   

  	
  ***

  
	
  HHX

  	
   

  	
   

  	
  ***

  
	
  HHY

  	
   

  	
   

  	
  ***

  
	
  HHZ

  	
   

  	
   

  	
  ***

  
	
  HIA

  	
   

  	
   

  	
  ***

  



 


7

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HIB

  	
   

  	
   

  	
  ***

  
	
  HIC

  	
   

  	
   

  	
  ***

  
	
  HID

  	
   

  	
   

  	
  ***

  
	
  HIE

  	
   

  	
   

  	
  ***

  
	
  HIF

  	
   

  	
   

  	
  ***

  
	
  HIG

  	
   

  	
   

  	
  ***

  
	
  HIH

  	
   

  	
   

  	
  ***

  
	
  HII

  	
   

  	
   

  	
  ***

  
	
  HIJ

  	
   

  	
   

  	
  ***

  
	
  HIK

  	
   

  	
   

  	
  ***

  
	
  HIL

  	
   

  	
   

  	
  ***

  
	
  HIM

  	
   

  	
   

  	
  ***

  
	
  HIN

  	
   

  	
   

  	
  ***

  
	
  HIO

  	
   

  	
   

  	
  ***

  
	
  HIP

  	
   

  	
   

  	
  ***

  
	
  HIQ

  	
   

  	
   

  	
  ***

  
	
  HIR

  	
   

  	
   

  	
  ***

  
	
  HIS

  	
   

  	
   

  	
  ***

  
	
  HIT

  	
   

  	
   

  	
  ***

  
	
  HIU

  	
   

  	
   

  	
  ***

  
	
  HIW

  	
   

  	
   

  	
  ***

  
	
  HIX

  	
   

  	
   

  	
  ***

  
	
  HIY

  	
   

  	
   

  	
  ***

  
	
  HIZ

  	
   

  	
   

  	
  ***

  
	
  HJA

  	
   

  	
   

  	
  ***

  
	
  HJB

  	
   

  	
   

  	
  ***

  
	
  HJC

  	
   

  	
   

  	
  ***

  
	
  HJD

  	
   

  	
   

  	
  ***

  
	
  HJE

  	
   

  	
   

  	
  ***

  
	
  HJF

  	
   

  	
   

  	
  ***

  
	
  HJG

  	
   

  	
   

  	
  ***

  
	
  HJH

  	
   

  	
   

  	
  ***

  
	
  HJI

  	
   

  	
   

  	
  ***

  
	
  HJK

  	
   

  	
   

  	
  ***

  
	
  HJL

  	
   

  	
   

  	
  ***

  
	
  HJM

  	
   

  	
   

  	
  ***

  
	
  HJN

  	
   

  	
   

  	
  ***

  



 


8

















 


	
  PLAN CODE

  	
   

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HJO

  	
   

  	
   

  	
  ***

  
	
  HJP

  	
   

  	
   

  	
  ***

  
	
  HJQ

  	
   

  	
   

  	
  ***

  
	
  HJR

  	
   

  	
   

  	
  ***

  
	
  HJS

  	
   

  	
   

  	
  ***

  
	
  HJT

  	
   

  	
   

  	
  ***

  
	
  HJU

  	
   

  	
   

  	
  ***

  
	
  HJV

  	
   

  	
   

  	
  ***

  
	
  HJW

  	
   

  	
   

  	
  ***

  
	
  HJX

  	
   

  	
   

  	
  ***

  
	
  HJY

  	
   

  	
   

  	
  ***

  
	
  HJZ

  	
   

  	
   

  	
  ***

  
	
  HKA

  	
   

  	
   

  	
  ***

  
	
  HKB

  	
   

  	
   

  	
  ***

  
	
  HKC

  	
   

  	
   

  	
  ***

  
	
  HKD

  	
   

  	
   

  	
  ***

  
	
  HKE

  	
   

  	
   

  	
  ***

  
	
  HKF

  	
   

  	
   

  	
  ***

  
	
  HKG

  	
   

  	
   

  	
  ***

  
	
  HM2

  	
   

  	
   

  	
  ***

  
	
  HM3

  	
   

  	
   

  	
  ***

  
	
  HM4

  	
   

  	
   

  	
  ***

  
	
  HM6

  	
   

  	
   

  	
  ***

  
	
  HM7

  	
   

  	
   

  	
  ***

  
	
  HM8

  	
   

  	
   

  	
  ***

  
	
  HM9

  	
   

  	
   

  	
  ***

  
	
  HS

  	
   

  	
   

  	
  ***

  
	
  I

  	
   

  	
   

  	
  ***

  
	
  IN

  	
   

  	
   

  	
  ***

  
	
  KC

  	
   

  	
   

  	
  ***

  
	
  L

  	
   

  	
   

  	
  ***

  
	
  L3

  	
   

  	
   

  	
  ***

  
	
  LA

  	
   

  	
   

  	
  ***

  
	
  LS

  	
   

  	
   

  	
  ***

  
	
  LX

  	
   

  	
   

  	
  ***

  
	
  M2

  	
   

  	
   

  	
  ***

  
	
  M4

  	
   

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
  ***

  



 


9

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  M8

  	
   

  	
   

  	
  ***

  
	
  NG

  	
   

  	
   

  	
  ***

  
	
  NK

  	
   

  	
   

  	
  ***

  
	
  S6

  	
   

  	
   

  	
  ***

  
	
  SI

  	
   

  	
   

  	
  ***

  
	
  X4

  	
   

  	
   

  	
  ***

  
	
  X4M

  	
   

  	
   

  	
  ***

  
	
  X5

  	
   

  	
   

  	
  ***

  
	
  X5M

  	
   

  	
   

  	
  ***

  
	
  X6 

  	
   

  	
   

  	
  ***

  
	
  X7

  	
   

  	
   

  	
  ***

  



 












(1)                                  Plan Adjusted
Capitation rate = Base Capitation Rate X Plan Relativity Factor.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual Capitation payment, multiply the Plan Adjusted Capitation rate as
defined in Item (1) above, by the appropriate age/sex factor. Then add EP rate
plus the Direct Access rate.  Please
refer to the age/sex factors on  
Schedule D-1A


 


10

















 


CALIFORNIACARE
HEALTH PLANS


 


Schedule D

Individual Duration Plans


 


Effective Date: 01/01/2004
To 12/31/2004


Professional
HMO Plan Code Adjusted Capitation Rates by Durational Year

For Book of Business Employer Groups


 


NORTHWEST
ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  Base Capitation Rate

  
	
   

  	
  Year 1

  	
   

  	
  ***

  
	
   

  	
  Year 2

  
	
   

  	
  Year 3

  
	
   

  	
  Year 4

  
	
   

  	
  Year 5

  
	
   

  	
  Year 6

  
	
   

  	
  Year 7

  
	
   

  	
  Year8

  



 


 


	
  PLAN CODE

  	
   

  	
  DURATIONAL
  YEAR

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IC, IL

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  ICM

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  



 












(1)                                  Base Capitation
rate X Plan Relativity Factor X Durational Year Relativity Factor = Plan
Adjusted Capitation rate.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
for the Durational year as shown above by the appropriate age/sex factor. Then
add the Enrollment Protection rate plus the Direct Access rate. Please refer to
age/sex factors on Schedule D-1A


 


1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule D

Small Group Durational Plans


 


Effective Date:
01/01/2004 To 12/31/2004


Professional HMO
Plan Code Adjusted Capitation Rates by Durational Year

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
   

  



 


	
  Base Capitation Rate

  
	
   

  	
  Year 1

  	
   

  	
  ***

  
	
   

  	
  Year 2

  	
   

  	
  ***

  
	
   

  	
  Year 3

  	
   

  	
  ***

  
	
   

  	
  Year 4

  	
   

  	
  ***

  
	
   

  	
  Year 5

  	
   

  	
  ***

  
	
   

  	
  Year 6

  	
   

  	
  ***

  
	
   

  	
  Year 7

  	
   

  	
  ***

  
	
   

  	
  Year 8

  	
   

  	
  ***

  



 


	
  PLAN CODE

  	
   

  	
  DURATIONAL
  YEAR

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L4, L5, L6, D4, D5, D6,

  	
   

  	
  1

  	
   

  	
  ***

  
	
  D8, D9, D10

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  DM4, DM5, L4M

  	
   

  	
  1

  	
   

  	
  ***

  
	
  D11, D12

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  L7, D7

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  



 












(1)                                  Base Capitation
rate X Plan Relativity Factor X Durational Year Relativity Factor = Plan Adjusted
Capitation rate.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
for the Durational year as shown above by the appropriate age/sex factor Then
add the Enrollment Protection rate plus the Direct Access rate. Please refer to
age/sex factors on Schedule D-1A


 


1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule D-1A


 


Age/Sex Factors
(Includes HMO Commercial and Durational plans)


 


Effective
Date:  01/01/2004 To 12/31/2004

Professional Capitation Age/Sex Relativity Table

For New & Renewing Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 




	
  AGE RANGE

  	
   

  	
  Factor

  Male

  	
   

  	
  Factor

  Female

  
	
  From

  	
   

  	
  To

  
	
  0

  	
   

  	
  0

  	
   

  	
  1.8000

  	
   

  	
  1.8000

  
	
  1

  	
   

  	
  4

  	
   

  	
  0.5000

  	
   

  	
  0.5000

  
	
  5

  	
   

  	
  14

  	
   

  	
  0.4600

  	
   

  	
  0.4700

  
	
  15

  	
   

  	
  19

  	
   

  	
  0.5500

  	
   

  	
  0.7700

  
	
  20

  	
   

  	
  24

  	
   

  	
  0.5000

  	
   

  	
  1.0100

  
	
  25

  	
   

  	
  29

  	
   

  	
  0.5900

  	
   

  	
  1.2800

  
	
  30

  	
   

  	
  34

  	
   

  	
  0.6800

  	
   

  	
  1.4500

  
	
  35

  	
   

  	
  39

  	
   

  	
  0.7800

  	
   

  	
  1.4600

  
	
  40

  	
   

  	
  44

  	
   

  	
  0.9000

  	
   

  	
  1.4900

  
	
  45

  	
   

  	
  49

  	
   

  	
  1.0500

  	
   

  	
  1.5800

  
	
  50

  	
   

  	
  54

  	
   

  	
  1.2500

  	
   

  	
  1.6900

  
	
  55

  	
   

  	
  59

  	
   

  	
  1.6100

  	
   

  	
  1.8400

  
	
  60

  	
   

  	
  64

  	
   

  	
  2.0500

  	
   

  	
  2.0700

  
	
  65

  	
   

  	
  120

  	
   

  	
  2.2800

  	
   

  	
  2.2200

  
	
  65+

  	
   

  	
  MP*

  	
   

  	
  0.6840

  	
   

  	
  0.6661

  






 












*Employer insurance is secondary payer to Medicare.


 


1

















 


CALIFORNIACARE HEALTH PLANS


Schedule G-1

Blue Cross Plus Plans


 


Effective Date:
01/01/2004 To 12/31/2004


Professional Blue
Cross Plus Plan Code Adjusted Capitation Rates

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate (100%)

  	
   

  	
  $1.08

  
	
  EP Rate (50%)

  	
   

  	
  $0.54

  
	
  Capitation Advance/Guarantee%

  	
   

  	
  10%

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ.
  RATE @ 50%

  	 

	
  PAB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 

	
  PAC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBT

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


1

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ.
  RATE @ 50%

  	 

	
  PCA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 

	
  PCB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCW

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCY

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


2

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ.
  RATE @ 50%

  	 

	
  PDO

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 

	
  PDP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDT

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Z4

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZAB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZAC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZAN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZFI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZPS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZTA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZTB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZVH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZW

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZW2

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZWM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZXB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZXL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZXS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ZZ2

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


3

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED RATE (1). (2)

  	
   

  	
  PLAN ADJ.
  RATE @ 50%

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  



 












(1)                                  Plan adjusted
Capitation Rate includes 50% Guaranteed Base Rate plus the respective
Capitation Advance/Capitation Guarantee:                                                10%


 


(2)                                  Plan adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
as shown above by the appropriate age/sex factor. Then add EP rate and Direct
Access rate. Please refer to age/sex factors on   Schedule G-1 A


 


4

















 


Supplemental Capitation Payment


 


To compute the Supplemental Capitation
Payment, see Exhibit G, II in the CaliforniaCare Medical Services Agreement.


 


Supplemental Capitation Payment is expressed
as a percent of the Total Capitation Payment and includes any advance
supplemental capitation payment already paid.


 


Below is the In-Network Utilization Factor table
and respective supplemental capitation payment percentage:


 




	
  In-Network Utilization Factor
  (INUF)

  	
   

  	
  Supplemental

  Capitation Payment% _

  
	
  0.0000 thru 0.4199

  	
   

  	
  0.0%

  
	
  0.4200 thru 0.4799

  	
   

  	
  10.0%

  
	
  0.4800 thru 0.5499

  	
   

  	
  20.0%

  
	
  0.5500 thru 0.6499

  	
   

  	
  30.0%

  
	
  0.6500 thru 0.7999

  	
   

  	
  40.0%

  
	
  0.8000 and above

  	
   

  	
  50.0%

  






 


5

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule G-1A

Age/Sex Factors - Blue Cross Plus Plans


 


Effective Date:
01/01/2004 To 12/31/2004

Professional Capitation Age/Sex Relativity Table

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN

Age/Sex Factors (includes HMO Commercial, Durational and Blue Cross Plus plans)


 


	
  AGE RANGE

  	
   

  	
  Factor

  Male

  	
   

  	
  Factor

  Female

  
	
  From

  	
   

  	
  To

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0

  	
   

  	
  0

  	
   

  	
  1.8000

  	
   

  	
  1.8000

  
	
  1

  	
   

  	
  4

  	
   

  	
  0.5000

  	
   

  	
  0.5000

  
	
  5

  	
   

  	
  14

  	
   

  	
  0.4600

  	
   

  	
  0.4700

  
	
  15

  	
   

  	
  19

  	
   

  	
  0.5500

  	
   

  	
  0.7700

  
	
  20

  	
   

  	
  24

  	
   

  	
  0.5000

  	
   

  	
  1.0100

  
	
  25

  	
   

  	
  29

  	
   

  	
  0.5900

  	
   

  	
  1.2800

  
	
  30

  	
   

  	
  34

  	
   

  	
  0.6800

  	
   

  	
  1.4500

  
	
  35

  	
   

  	
  39

  	
   

  	
  0.7800

  	
   

  	
  1.4600

  
	
  40

  	
   

  	
  44

  	
   

  	
  0.9000

  	
   

  	
  1.4900

  
	
  45

  	
   

  	
  49

  	
   

  	
  1.0500

  	
   

  	
  1.5800

  
	
  50

  	
   

  	
  54

  	
   

  	
  1.2500

  	
   

  	
  1.6900

  
	
  55

  	
   

  	
  59

  	
   

  	
  1.6100

  	
   

  	
  1.8400

  
	
  60

  	
   

  	
  64

  	
   

  	
  2.0500

  	
   

  	
  2.0700

  
	
  65

  	
   

  	
  120

  	
   

  	
  2.2800

  	
   

  	
  2.2200

  
	
  65+

  	
   

  	
  MP*.

  	
   

  	
  0.6840

  	
   

  	
  0.6661

  



 












* Employer insurance is
secondary payer to Medicare.


 


1

















 


CALIFORNIACARE
HEALTH PLANS


Schedule D

HMO Commercial Plans (excludes Durational and Blue Cross Plus)


 


Effective Date:
01/01/2005 To 12/31/2005

Professional HMO Plan Code Adjusted Capitation Rates

For Book of Business Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP

Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  PLAN CODE

  	
   

  	
  PLAN ADJUSTED
  CAPITATION RATE (1), (2)

  	 

	
  A

  	
   

  	
   

  	
  ***

  	 

	
  C

  	
   

  	
   

  	
  ***

  	
   

  
	
  C1

  	
   

  	
   

  	
  ***

  	
   

  
	
  C10

  	
   

  	
   

  	
  ***

  	
   

  
	
  C11

  	
   

  	
   

  	
  ***

  	
   

  
	
  C14

  	
   

  	
   

  	
  ***

  	
   

  
	
  C17

  	
   

  	
   

  	
  ***

  	
   

  
	
  C2

  	
   

  	
   

  	
  ***

  	
   

  
	
  C2M

  	
   

  	
   

  	
  ***

  	
   

  
	
  C3

  	
   

  	
   

  	
  ***

  	
   

  
	
  C4

  	
   

  	
   

  	
  ***

  	
   

  
	
  C4H

  	
   

  	
   

  	
  ***

  	
   

  
	
  C4S

  	
   

  	
   

  	
  ***

  	
   

  
	
  C5

  	
   

  	
   

  	
  ***

  	
   

  
	
  C5B

  	
   

  	
   

  	
  ***

  	
   

  
	
  C5S

  	
   

  	
   

  	
  ***

  	
   

  
	
  C6

  	
   

  	
   

  	
  ***

  	
   

  
	
  C7

  	
   

  	
   

  	
  ***

  	
   

  
	
  C8

  	
   

  	
   

  	
  ***

  	
   

  
	
  C9

  	
   

  	
   

  	
  ***

  	
   

  
	
  CF

  	
   

  	
   

  	
  ***

  	
   

  
	
  C13

  	
   

  	
   

  	
  ***

  	
   

  
	
  CJ

  	
   

  	
   

  	
  ***

  	
   

  
	
  CK

  	
   

  	
   

  	
  ***

  	
   

  
	
  CK4

  	
   

  	
   

  	
  ***

  	
   

  
	
  CK6

  	
   

  	
   

  	
  ***

  	
   

  
	
  CL

  	
   

  	
   

  	
  ***

  	
   

  
	
  CL3

  	
   

  	
   

  	
  ***

  	
   

  
	
  CS

  	
   

  	
   

  	
  ***

  	
   

  
	
  CT

  	
   

  	
   

  	
  ***

  	
   

  
	
  DG

  	
   

  	
   

  	
  ***

  	
   

  
	
  DS2

  	
   

  	
   

  	
  ***

  	
   

  
	
  F3

  	
   

  	
   

  	
  ***

  	
   

  
	
  F4

  	
   

  	
   

  	
  ***

  	 

	
  FC

  	
   

  	
   

  	
  ***

  	 

	
  FR

  	
   

  	
   

  	
  ***

  	 

	
  G

  	
   

  	
   

  	
  ***

  	 




 


1

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  GH

  	
   

  	
   

  	
  ***

  
	
  GH3

  	
   

  	
   

  	
  ***

  
	
  GL

  	
   

  	
   

  	
  ***

  
	
  H1

  	
   

  	
   

  	
  ***

  
	
  H10

  	
   

  	
   

  	
  ***

  
	
  H2

  	
   

  	
   

  	
  ***

  
	
  H3

  	
   

  	
   

  	
  ***

  
	
  H4

  	
   

  	
   

  	
  ***

  
	
  H5

  	
   

  	
   

  	
  ***

  
	
  H6

  	
   

  	
   

  	
  ***

  
	
  H7

  	
   

  	
   

  	
  ***

  
	
  H8

  	
   

  	
   

  	
  ***

  
	
  H9

  	
   

  	
   

  	
  ***

  
	
  HAA

  	
   

  	
   

  	
  ***

  
	
  HAB

  	
   

  	
   

  	
  ***

  
	
  HAC

  	
   

  	
   

  	
  ***

  
	
  HAD

  	
   

  	
   

  	
  ***

  
	
  HAE

  	
   

  	
   

  	
  ***

  
	
  HAF

  	
   

  	
   

  	
  ***

  
	
  HAG

  	
   

  	
   

  	
  ***

  
	
  HAH

  	
   

  	
   

  	
  ***

  
	
  HAI

  	
   

  	
   

  	
  ***

  
	
  HAJ

  	
   

  	
   

  	
  ***

  
	
  HAK

  	
   

  	
   

  	
  ***

  
	
  HAL

  	
   

  	
   

  	
  ***

  
	
  HAM

  	
   

  	
   

  	
  ***

  
	
  HAN

  	
   

  	
   

  	
  ***

  
	
  HAO

  	
   

  	
   

  	
  ***

  
	
  HAP

  	
   

  	
   

  	
  ***

  
	
  HAQ

  	
   

  	
   

  	
  ***

  
	
  HAR

  	
   

  	
   

  	
  ***

  
	
  HAS

  	
   

  	
   

  	
  ***

  
	
  HAT

  	
   

  	
   

  	
  ***

  
	
  HAU

  	
   

  	
   

  	
  ***

  
	
  HAV

  	
   

  	
   

  	
  ***

  
	
  HAW

  	
   

  	
   

  	
  ***

  
	
  HAX

  	
   

  	
   

  	
  ***

  



 


2

















 


	
  PLAN CODE

  	
   

  	
  PLAN ADJUSTED
  CAPITATION RATE (1), (2)

  
	
  HAY

  	
   

  	
   

  	
  ***

  
	
  HAZ

  	
   

  	
   

  	
  ***

  
	
  HBA

  	
   

  	
   

  	
  ***

  
	
  HBB

  	
   

  	
   

  	
  ***

  
	
  HBC

  	
   

  	
   

  	
  ***

  
	
  HBD

  	
   

  	
   

  	
  ***

  
	
  HBF

  	
   

  	
   

  	
  ***

  
	
  HBG

  	
   

  	
   

  	
  ***

  
	
  HBH

  	
   

  	
   

  	
  ***

  
	
  HBI

  	
   

  	
   

  	
  ***

  
	
  HBJ

  	
   

  	
   

  	
  ***

  
	
  HBK

  	
   

  	
   

  	
  ***

  
	
  HBL

  	
   

  	
   

  	
  ***

  
	
  HBM

  	
   

  	
   

  	
  ***

  
	
  H8N

  	
   

  	
   

  	
  ***

  
	
  HBO

  	
   

  	
   

  	
  ***

  
	
  HBP

  	
   

  	
   

  	
  ***

  
	
  HBQ

  	
   

  	
   

  	
  ***

  
	
  HBR

  	
   

  	
   

  	
  ***

  
	
  HBS

  	
   

  	
   

  	
  ***

  
	
  HBT

  	
   

  	
   

  	
  ***

  
	
  HBU

  	
   

  	
   

  	
  ***

  
	
  HBV

  	
   

  	
   

  	
  ***

  
	
  HBW

  	
   

  	
   

  	
  ***

  
	
  HBX

  	
   

  	
   

  	
  ***

  
	
  HBY

  	
   

  	
   

  	
  ***

  
	
  HBZ

  	
   

  	
   

  	
  ***

  
	
  HC

  	
   

  	
   

  	
  ***

  
	
  HCA

  	
   

  	
   

  	
  ***

  
	
  HCB

  	
   

  	
   

  	
  ***

  
	
  HCC

  	
   

  	
   

  	
  ***

  
	
  HCD

  	
   

  	
   

  	
  ***

  
	
  HCE

  	
   

  	
   

  	
  ***

  
	
  HCF

  	
   

  	
   

  	
  ***

  
	
  HCG

  	
   

  	
   

  	
  ***

  
	
  HCH

  	
   

  	
   

  	
  ***

  
	
  HCI

  	
   

  	
   

  	
  ***

  



 


3

















 


	
  PLAN CODE

  	
   

  	
  PLAN ADJUSTED
  CAPITATION RATE (1), (2)

  
	
  HCJ

  	
   

  	
   

  	
  ***

  
	
  HCK

  	
   

  	
   

  	
  ***

  
	
  HCL

  	
   

  	
   

  	
  ***

  
	
  HCM

  	
   

  	
   

  	
  ***

  
	
  HCN

  	
   

  	
   

  	
  ***

  
	
  HCO

  	
   

  	
   

  	
  ***

  
	
  HCP

  	
   

  	
   

  	
  ***

  
	
  HCQ

  	
   

  	
   

  	
  ***

  
	
  HCR

  	
   

  	
   

  	
  ***

  
	
  HCS

  	
   

  	
   

  	
  ***

  
	
  HCT

  	
   

  	
   

  	
  ***

  
	
  HCU

  	
   

  	
   

  	
  ***

  
	
  HCV

  	
   

  	
   

  	
  ***

  
	
  HCW

  	
   

  	
   

  	
  ***

  
	
  HCX

  	
   

  	
   

  	
  ***

  
	
  HCY

  	
   

  	
   

  	
  ***

  
	
  HCZ

  	
   

  	
   

  	
  ***

  
	
  HDA

  	
   

  	
   

  	
  ***

  
	
  HDB

  	
   

  	
   

  	
  ***

  
	
  HDC

  	
   

  	
   

  	
  ***

  
	
  HDD

  	
   

  	
   

  	
  ***

  
	
  HDE

  	
   

  	
   

  	
  ***

  
	
  HDF

  	
   

  	
   

  	
  ***

  
	
  HDG

  	
   

  	
   

  	
  ***

  
	
  HDH

  	
   

  	
   

  	
  ***

  
	
  HDI

  	
   

  	
   

  	
  ***

  
	
  HDJ

  	
   

  	
   

  	
  ***

  
	
  HDK

  	
   

  	
   

  	
  ***

  
	
  HDL

  	
   

  	
   

  	
  ***

  
	
  HDM

  	
   

  	
   

  	
  ***

  
	
  HDN

  	
   

  	
   

  	
  ***

  
	
  HDO

  	
   

  	
   

  	
  ***

  
	
  HDP

  	
   

  	
   

  	
  ***

  
	
  HDQ

  	
   

  	
   

  	
  ***

  
	
  HDR

  	
   

  	
   

  	
  ***

  
	
  HDS

  	
   

  	
   

  	
  ***

  
	
  HDT

  	
   

  	
   

  	
  ***

  



 


4

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HDU

  	
   

  	
   

  	
  ***

  
	
  HDV

  	
   

  	
   

  	
  ***

  
	
  HDW

  	
   

  	
   

  	
  ***

  
	
  HDX

  	
   

  	
   

  	
  ***

  
	
  HDY

  	
   

  	
   

  	
  ***

  
	
  HDZ

  	
   

  	
   

  	
  ***

  
	
  HEA

  	
   

  	
   

  	
  ***

  
	
  HEB

  	
   

  	
   

  	
  ***

  
	
  HEC

  	
   

  	
   

  	
  ***

  
	
  HED

  	
   

  	
   

  	
  ***

  
	
  HEE

  	
   

  	
   

  	
  ***

  
	
  HEF

  	
   

  	
   

  	
  ***

  
	
  HEG

  	
   

  	
   

  	
  ***

  
	
  HEH

  	
   

  	
   

  	
  ***

  
	
  HEI

  	
   

  	
   

  	
  ***

  
	
  HEJ

  	
   

  	
   

  	
  ***

  
	
  HEK

  	
   

  	
   

  	
  ***

  
	
  HEL

  	
   

  	
   

  	
  ***

  
	
  HEM

  	
   

  	
   

  	
  ***

  
	
  HEN

  	
   

  	
   

  	
  ***

  
	
  HEO

  	
   

  	
   

  	
  ***

  
	
  HEP

  	
   

  	
   

  	
  ***

  
	
  HEQ

  	
   

  	
   

  	
  ***

  
	
  HER

  	
   

  	
   

  	
  ***

  
	
  HES

  	
   

  	
   

  	
  ***

  
	
  HET

  	
   

  	
   

  	
  ***

  
	
  HEU

  	
   

  	
   

  	
  ***

  
	
  HEV

  	
   

  	
   

  	
  ***

  
	
  HEW

  	
   

  	
   

  	
  ***

  
	
  HEX

  	
   

  	
   

  	
  ***

  
	
  HEY

  	
   

  	
   

  	
  ***

  
	
  HEZ

  	
   

  	
   

  	
  ***

  
	
  HFA

  	
   

  	
   

  	
  ***

  
	
  HFB

  	
   

  	
   

  	
  ***

  
	
  HFC

  	
   

  	
   

  	
  ***

  
	
  HFD

  	
   

  	
   

  	
  ***

  
	
  HFE

  	
   

  	
   

  	
  ***

  



 


5

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HFF

  	
   

  	
   

  	
  ***

  
	
  HFG

  	
   

  	
   

  	
  ***

  
	
  HFH

  	
   

  	
   

  	
  ***

  
	
  HFI

  	
   

  	
   

  	
  ***

  
	
  HFJ

  	
   

  	
   

  	
  ***

  
	
  HFK

  	
   

  	
   

  	
  ***

  
	
  HFL

  	
   

  	
   

  	
  ***

  
	
  HFM

  	
   

  	
   

  	
  ***

  
	
  HFN

  	
   

  	
   

  	
  ***

  
	
  HFO

  	
   

  	
   

  	
  ***

  
	
  HFP

  	
   

  	
   

  	
  ***

  
	
  HFQ

  	
   

  	
   

  	
  ***

  
	
  HFR

  	
   

  	
   

  	
  ***

  
	
  HFS

  	
   

  	
   

  	
  ***

  
	
  HFT

  	
   

  	
   

  	
  ***

  
	
  HFU

  	
   

  	
   

  	
  ***

  
	
  HFV

  	
   

  	
   

  	
  ***

  
	
  HFW

  	
   

  	
   

  	
  ***

  
	
  HFX

  	
   

  	
   

  	
  ***

  
	
  HFY

  	
   

  	
   

  	
  ***

  
	
  HFZ

  	
   

  	
   

  	
  ***

  
	
  HGA

  	
   

  	
   

  	
  ***

  
	
  HGB

  	
   

  	
   

  	
  ***

  
	
  HGC

  	
   

  	
   

  	
  ***

  
	
  HGD

  	
   

  	
   

  	
  ***

  
	
  HGE

  	
   

  	
   

  	
  ***

  
	
  HGF

  	
   

  	
   

  	
  ***

  
	
  HGG

  	
   

  	
   

  	
  ***

  
	
  HGH

  	
   

  	
   

  	
  ***

  
	
  HGI

  	
   

  	
   

  	
  ***

  
	
  HGJ

  	
   

  	
   

  	
  ***

  
	
  HGK

  	
   

  	
   

  	
  ***

  
	
  HGL

  	
   

  	
   

  	
  ***

  
	
  HGM

  	
   

  	
   

  	
  ***

  
	
  HGN

  	
   

  	
   

  	
  ***

  
	
  HGO

  	
   

  	
   

  	
  ***

  
	
  HGP

  	
   

  	
   

  	
  ***

  



 


6

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HGQ

  	
   

  	
   

  	
  ***

  
	
  HGR

  	
   

  	
   

  	
  ***

  
	
  HGS

  	
   

  	
   

  	
  ***

  
	
  HGT

  	
   

  	
   

  	
  ***

  
	
  HGU

  	
   

  	
   

  	
  ***

  
	
  HGV

  	
   

  	
   

  	
  ***

  
	
  HGW

  	
   

  	
   

  	
  ***

  
	
  HGX

  	
   

  	
   

  	
  ***

  
	
  HGY

  	
   

  	
   

  	
  ***

  
	
  HGZ

  	
   

  	
   

  	
  ***

  
	
  HHA

  	
   

  	
   

  	
  ***

  
	
  HHB

  	
   

  	
   

  	
  ***

  
	
  HHC

  	
   

  	
   

  	
  ***

  
	
  HHD

  	
   

  	
   

  	
  ***

  
	
  HHE

  	
   

  	
   

  	
  ***

  
	
  HHF

  	
   

  	
   

  	
  ***

  
	
  HHG

  	
   

  	
   

  	
  ***

  
	
  HHH

  	
   

  	
   

  	
  ***

  
	
  HHI

  	
   

  	
   

  	
  ***

  
	
  HHJ

  	
   

  	
   

  	
  ***

  
	
  HHK

  	
   

  	
   

  	
  ***

  
	
  HHL

  	
   

  	
   

  	
  ***

  
	
  HHM

  	
   

  	
   

  	
  ***

  
	
  HHN

  	
   

  	
   

  	
  ***

  
	
  HHO

  	
   

  	
   

  	
  ***

  
	
  HHP

  	
   

  	
   

  	
  ***

  
	
  HHQ

  	
   

  	
   

  	
  ***

  
	
  HHR

  	
   

  	
   

  	
  ***

  
	
  HHS

  	
   

  	
   

  	
  ***

  
	
  HHT

  	
   

  	
   

  	
  ***

  
	
  HHU

  	
   

  	
   

  	
  ***

  
	
  HHV

  	
   

  	
   

  	
  ***

  
	
  HHW

  	
   

  	
   

  	
  ***

  
	
  HHX

  	
   

  	
   

  	
  ***

  
	
  HHY

  	
   

  	
   

  	
  ***

  
	
  HHZ

  	
   

  	
   

  	
  ***

  
	
  HIA

  	
   

  	
   

  	
  ***

  



 


7

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HIB

  	
   

  	
   

  	
  ***

  
	
  HIC

  	
   

  	
   

  	
  ***

  
	
  HID

  	
   

  	
   

  	
  ***

  
	
  HIE

  	
   

  	
   

  	
  ***

  
	
  HIF

  	
   

  	
   

  	
  ***

  
	
  HIG

  	
   

  	
   

  	
  ***

  
	
  HIH

  	
   

  	
   

  	
  ***

  
	
  HII

  	
   

  	
   

  	
  ***

  
	
  HIJ

  	
   

  	
   

  	
  ***

  
	
  HIK

  	
   

  	
   

  	
  ***

  
	
  HIL

  	
   

  	
   

  	
  ***

  
	
  HIM

  	
   

  	
   

  	
  ***

  
	
  HIN

  	
   

  	
   

  	
  ***

  
	
  HIO

  	
   

  	
   

  	
  ***

  
	
  HIP

  	
   

  	
   

  	
  ***

  
	
  HIQ

  	
   

  	
   

  	
  ***

  
	
  HIR

  	
   

  	
   

  	
  ***

  
	
  HIS

  	
   

  	
   

  	
  ***

  
	
  HIT

  	
   

  	
   

  	
  ***

  
	
  HIU

  	
   

  	
   

  	
  ***

  
	
  HIW

  	
   

  	
   

  	
  ***

  
	
  HIX

  	
   

  	
   

  	
  ***

  
	
  HIY

  	
   

  	
   

  	
  ***

  
	
  HIZ

  	
   

  	
   

  	
  ***

  
	
  HJA

  	
   

  	
   

  	
  ***

  
	
  HJB

  	
   

  	
   

  	
  ***

  
	
  HJC

  	
   

  	
   

  	
  ***

  
	
  HJD

  	
   

  	
   

  	
  ***

  
	
  HJE

  	
   

  	
   

  	
  ***

  
	
  HJF

  	
   

  	
   

  	
  ***

  
	
  HJG

  	
   

  	
   

  	
  ***

  
	
  HJH

  	
   

  	
   

  	
  ***

  
	
  HJI

  	
   

  	
   

  	
  ***

  
	
  HJK

  	
   

  	
   

  	
  ***

  
	
  HJL

  	
   

  	
   

  	
  ***

  
	
  HJM

  	
   

  	
   

  	
  ***

  
	
  HJN

  	
   

  	
   

  	
  ***

  



 


8

















 


	
  PLAN CODE

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  HJO

  	
   

  	
   

  	
  ***

  
	
  HJP

  	
   

  	
   

  	
  ***

  
	
  HJQ

  	
   

  	
   

  	
  ***

  
	
  HJR

  	
   

  	
   

  	
  ***

  
	
  HJS

  	
   

  	
   

  	
  ***

  
	
  HJT

  	
   

  	
   

  	
  ***

  
	
  HJU

  	
   

  	
   

  	
  ***

  
	
  HJV

  	
   

  	
   

  	
  ***

  
	
  HJW

  	
   

  	
   

  	
  ***

  
	
  HJX

  	
   

  	
   

  	
  ***

  
	
  HJY

  	
   

  	
   

  	
  ***

  
	
  HJZ

  	
   

  	
   

  	
  ***

  
	
  HKA

  	
   

  	
   

  	
  ***

  
	
  HKB

  	
   

  	
   

  	
  ***

  
	
  HKC

  	
   

  	
   

  	
  ***

  
	
  HKD

  	
   

  	
   

  	
  ***

  
	
  HKE

  	
   

  	
   

  	
  ***

  
	
  HKF

  	
   

  	
   

  	
  ***

  
	
  HKG

  	
   

  	
   

  	
  ***

  
	
  HM2

  	
   

  	
   

  	
  ***

  
	
  HM3

  	
   

  	
   

  	
  ***

  
	
  HM4

  	
   

  	
   

  	
  ***

  
	
  HM6

  	
   

  	
   

  	
  ***

  
	
  HM7

  	
   

  	
   

  	
  ***

  
	
  HM8

  	
   

  	
   

  	
  ***

  
	
  HM9

  	
   

  	
   

  	
  ***

  
	
  HS

  	
   

  	
   

  	
  ***

  
	
  I

  	
   

  	
   

  	
  ***

  
	
  IN

  	
   

  	
   

  	
  ***

  
	
  KC

  	
   

  	
   

  	
  ***

  
	
  L

  	
   

  	
   

  	
  ***

  
	
  L3

  	
   

  	
   

  	
  ***

  
	
  LA

  	
   

  	
   

  	
  ***

  
	
  LS

  	
   

  	
   

  	
  ***

  
	
  LX

  	
   

  	
   

  	
  ***

  
	
  M2

  	
   

  	
   

  	
  ***

  
	
  M4

  	
   

  	
   

  	
  ***

  



 


9

















 


 


	
  PLAN CODE

  	
   

  	
  PLAN ADJUSTED
  CAPITATION RATE (1), (2)

  
	
  M8

  	
   

  	
   

  	
  ***

  
	
  NG

  	
   

  	
   

  	
  ***

  
	
  NK

  	
   

  	
   

  	
  ***

  
	
  S6

  	
   

  	
   

  	
  ***

  
	
  SI

  	
   

  	
   

  	
  ***

  
	
  X4

  	
   

  	
   

  	
  ***

  
	
  X4M

  	
   

  	
   

  	
  ***

  
	
  X5

  	
   

  	
   

  	
  ***

  
	
  X5M

  	
   

  	
   

  	
  ***

  
	
  X6

  	
   

  	
   

  	
  ***

  
	
  X7

  	
   

  	
   

  	
  ***

  



 












(1)                                  Plan Adjusted
Capitation rate = Base Capitation Rate X Plan Relativity Factor.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                  To determine the
actual Capitation payment, multiply the Plan Adjusted Capitation rate as
defined in item (1) above, by the appropriate age/sex factor. Then add EP rate
plus the Direct Access rate. Please refer to the age/sex factors on  Schedule D-1A


 


10

















 


CALIFORNIACARE
HEALTH PLANS


 


Schedule D


Individual Durational Plans


 


Effective Date:
01/01/2005 To 12/31/2005


Professional HMO
Plan Code Adjusted Capitation Rates by Durational Year

For Book of Business Employer Groups


 


NORTHWEST
ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  Base Capitation Rate

  
	
   

  	
  Year 1

  	
   

  	
  ***

  
	
   

  	
  Year 2

  	
   

  	
  ***

  
	
   

  	
  Year 3

  	
   

  	
  ***

  
	
   

  	
  Year 4

  	
   

  	
  ***

  
	
   

  	
  Year 5

  	
   

  	
  ***

  
	
   

  	
  Year 6

  	
   

  	
  ***

  
	
   

  	
  Year 7

  	
   

  	
  ***

  
	
   

  	
  Year 8

  	
   

  	
  ***

  



 


	
  PLAN CODE

  	
   

  	
  DURATIONAL
  YEAR

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IC, IL

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  ICM

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  



 












(1)                                  Base Capitation
rate X Plan Relativity Factor X Durational Year Relativity Factor = Plan
Adjusted Capitation rate.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection.


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
for the Durational year as shown above by the appropriate age/sex factor. Then
add the Enrollment Protection rate plus the Direct Access rate. Please refer to
age/sex factors on Schedule D-1A


 


1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule D

Small Group Durational Plans


 


Effective Date:
01/01/2005 To 12/31/2005


Professional HMO
Plan Code Adjusted Capitation Rates by Durational Year

For Book of Business Employer Groups


 


NORTHWEST ORANGE
COUNTY MEDICAL GROUP

Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate:

  	
   

  	
  $1.08

  
	
  Direct Access:

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 


	
  Base Capitation Rate

  
	
   

  	
  Year 1

  	
   

  	
  ***

  
	
   

  	
  Year 2

  	
   

  	
  ***

  
	
   

  	
  Year 3

  	
   

  	
  ***

  
	
   

  	
  Year 4

  	
   

  	
  ***

  
	
   

  	
  Year 5

  	
   

  	
  ***

  
	
   

  	
  Year 6

  	
   

  	
  ***

  
	
   

  	
  Year 7

  	
   

  	
  ***

  
	
   

  	
  Year 8

  	
   

  	
  ***

  



 


	
  PLAN CODE

  	
   

  	
  DURATIONAL
  YEAR

  	
   

  	
  PLAN
  ADJUSTED CAPITATION RATE (1), (2)

  
	
  L4, L5, L6, D4, D5, D6

  	
   

  	
  1

  	
   

  	
  ***

  
	
  D8, D9, D10

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  DM4, DM5, L4M

  	
   

  	
  1

  	
   

  	
  ***

  
	
  D11, D12

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
  ***

  
	
  L7, D7

  	
   

  	
  1

  	
   

  	
  ***

  
	
   

  	
   

  	
  2

  	
   

  	
  ***

  
	
   

  	
   

  	
  3

  	
   

  	
  ***

  
	
   

  	
   

  	
  4

  	
   

  	
  ***

  
	
   

  	
   

  	
  5

  	
   

  	
  ***

  
	
   

  	
   

  	
  6

  	
   

  	
  ***

  
	
   

  	
   

  	
  7

  	
   

  	
  ***

  
	
   

  	
   

  	
  8

  	
   

  	
  ***

  



 












(1)                                  Base Capitation
rate X Plan Relativity Factor X Durational Year Relativity Factor = Plan
Adjusted Capitation rate.


 


(2)                                  Plan Adjusted
Capitation rates exclude Direct Access and Enrollment Protection,


 


Note:                   To determine the
actual monthly Capitation payment, multiply the Plan Adjusted Capitation rate
for the Durational year as shown above by the appropriate age/sex factor. Then
add the Enrollment Protection rate plus the Direct Access rate. Please refer to
age/sex factors on Schedule D-1A


 


1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule D-1 A

Age/Sax Factors (includes HMO Commercial and Durational plans)


 


Effective Date:
01/01/2005 To 12/31/2005

Professional Capitation Age/Sex Relativity Table

For New & Renewing Employer Groups


 


NORTHWEST ORANGE COUNTY MEDICAL GROUP


Prime Code: 0DN


 


	
  AGE RANGE

  	
   

  	
   

  	
   

  	
   

  
	
  From

  	
   

  	
  To

  	
   

  	
  Factor

  Male

  	
   

  	
  Factor

  Female

  
	
  0

  	
   

  	
  0

  	
   

  	
  1.8000

  	
   

  	
  1.8000

  
	
  1

  	
   

  	
  4

  	
   

  	
  0.5000

  	
   

  	
  0.5000

  
	
  5

  	
   

  	
  14

  	
   

  	
  0.4600

  	
   

  	
  0.4700

  
	
  15

  	
   

  	
  19

  	
   

  	
  0.5500

  	
   

  	
  0.7700

  
	
  20

  	
   

  	
  24

  	
   

  	
  0.5000

  	
   

  	
  1.0100

  
	
  25

  	
   

  	
  29

  	
   

  	
  0.5900

  	
   

  	
  1.2800

  
	
  30

  	
   

  	
  34

  	
   

  	
  0.6800

  	
   

  	
  1.4500

  
	
  35

  	
   

  	
  39

  	
   

  	
  0.7800

  	
   

  	
  1.4600

  
	
  40

  	
   

  	
  44

  	
   

  	
  0.9000

  	
   

  	
  1.4900

  
	
  45

  	
   

  	
  49

  	
   

  	
  1.0500

  	
   

  	
  1.5800

  
	
  50

  	
   

  	
  54

  	
   

  	
  1.2500

  	
   

  	
  1.6900

  
	
  55

  	
   

  	
  59

  	
   

  	
  1.6100

  	
   

  	
  1.8400

  
	
  60

  	
   

  	
  64

  	
   

  	
  2.0500

  	
   

  	
  2.0700

  
	
  65

  	
   

  	
  120

  	
   

  	
  2.2800

  	
   

  	
  2.2200

  
	
  65+

  	
   

  	
  MP*

  	
   

  	
  0.6840

  	
   

  	
  0.6661

  



 












*Employer insurance is secondary payer to Medicare.


 


1

















 


CALIFORNIACARE HEALTH PLANS


 


Schedule G-1


Blue Cross Plus Plans


 


Effective Date:
01/01/2005 To 12/31/2005


Professional Blue
Cross Plus Plan Code Adjusted Capitation Rates

For Book of Business Employer Groups


 


NORTHWEST
ORANGE COUNTY MEDICAL GROUP

Prime Code: 0DN


 


	
  Enrollment Protection (EP) Threshold:

  	
   

  	
  PMG assumes full financial
  responsibility

  
	
  EP Rate (100%)

  	
   

  	
  $1.08

  
	
  EP Rate (50%)

  	
   

  	
  $0.54

  
	
  Capitation Advance/Guarantee%

  	
   

  	
  10%

  
	
  Direct Access;

  	
   

  	
  Does Not Participate

  
	
  PQIP:

  	
   

  	
  N/A

  



 




	
  PLAN COD

  	
   

  	
  PLAN ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ. RATE @ 50%

  	 

	
  PAC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 

	
  PAD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBT

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PBZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  






 


1

















 




	
  PLAN COD

  	
   

  	
  PLAN ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ. RATE @ 50%

  	 

	
  PCA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 

	
  PCB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCW

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCY

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PCZ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDD

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDE

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDG

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDI

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDJ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PDN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	 







 


1

















 




	
  PLAN COD

  	
   

  	
  PLAN ADJUSTED RATE (1), (2)

  	
   

  	
  PLAN ADJ. RATE @ 50%

  
	
  PDO

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDQ

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDR

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDT

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PDU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Z4

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZAB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZAC

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZAN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZF

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZF1

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZK

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZN

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZP

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZPS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZTA

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZTB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZU

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZV

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZVH

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZW

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZW2

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZWM

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZX

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZXB

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZXL

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZXS

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ZZ2

  	
   

  	
   

  	
  ***

  	
   

  	
  ***

  






 


3