Exhibit 10.93


 


Health Net
Medicare+Choice (M+C)

Addendum to Provider Agreement


 


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


 


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


 


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


 


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


 


NOW, THEREFORE, the parties agree as follows:


 


I.
DEFINITIONS


 


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


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


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


 


II.
ACCESS:  RECORDS AND FACILITIES


 


Provider agrees:


 


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


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


 












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


 


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III.
ACCESS:  BENEFITS & COVERAGE


 


Provider agrees:


 


3.1.                            To not
discriminate based on health status.


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


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


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


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


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


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


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


 


IV.
MEMBER PROTECTIONS


 


Provider agrees:


 


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


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


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


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


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


 


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V.
DELEGATION


 


Provider agrees:


 


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

Manual.


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


 


VI. PAYMENT AND FEDERAL FUNDS


 


Provider agrees:


 


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


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


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


 


VII.
REPORTING AND DISCLOSURE


 


Provider agrees:


 


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


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


 


VIII.
QUALITY ASSURANCE / QUALITY IMPROVEMENT


 


Provider Agrees:


 


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


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


 


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IX.
COMPLIANCE


 


Provider agrees:


 


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


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


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


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


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


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


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


 


X.
PRIVATE FEE FOR SERVICE


 


Provider agrees:


 


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


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


 


XI.
ADOPTION OF MEDICARE RISK PROGRAM CONTRACT REQUIREMENTS


 


Provider agrees:


 


11.1                         That all
contracts must be signed and dated.


11.2                         To serve
Members during the term of this Addendum.


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


 


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


 


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


 


 


	
  Professional Care IPA

  	
  Health Net

  
	
   

  	
   

  
	
   

  	
   

  
	
  By:

  	
  /s/ Ed Rotan

  	
   

  	
  By:

  	
  /s/ Christopher Ciano

  
	
   

  	
   

  
	
  Name:

  	
  Ed Rotan

  	
   

  	
  Name

  	
  Christopher Ciano

  
	
   

  	
   

  
	
  Title:

  	
  President

  	
   

  	
  Title:

  	
  Senior Vice President and

  General Manager

  
	
   

  	
   

  
	
  Date:

  	
  2-7-00

  	
   

  	
  Date:

  	
  3-7-00

  



 


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