Exhibit 10.191


 


 












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


 

















 


PacifiCare®


of California


 


	
   

  	
  5757
  Plaza Drive, Suite 150

  
	
   

  	
  Mail
  Stop CY 44-116

  
	
   

  	
  Cypress,
  California 90630

  



 


November 15,
2002


 


Raj
Takhar


Chief
Executive Officer


Gateway
Physicians Medical Associates, Inc.


710
N. Euclid St


Anaheim,
CA 92801


 


Re: Amendment to Agreement for Financial Terms for 2003


 


Dear
Raj:


 


This
letter constitutes an amendment to the current PacifiCare Medical Group/IPA
Services Agreement, dated January 1, 2001 (the “Agreement”) between
PacifiCare of California (“PacifiCare”) and Gateway Physicians Medical
Associates (“Medical Group”) setting forth the financial terms for their
arrangements for calendar year 2003.  Attached
are the material financial terms.  The
attached financial terms and the parties’ other agreements will be memorialized
in a formal Amendment to the PacifiCare Medical Group/IPA Services Agreement.  The formal Amendment will need to executed
by December 15, 2002 or the terms attached hereto may be rescinded by
PacifiCare.


 


NOW,
THEREFORE, in consideration of the foregoing, the parties hereto agree that the
Agreement is hereby modified as specified below:


 


1.                                       A new Section 1.35 National Preferred
Transplant Network (“NPTN”) under ARTICLE 1 DEFINTIONS is added to the
Agreement as follows:


 


1.34                           National Preferred Transplant Network (“NPTN”) is the national preferred referral network of hospitals,
professionals, ancillary, and other Participating Providers that have been
selected by PacifiCare (based on various criteria including quality,
performance levels, and outcomes) to provide to PacifiCare Members Covered
Services consisting of specific Transplant Services as set forth in the
applicable NPTN Agreement between PacifiCare and the NPTN Participating
Providers.


 


2.                                       New Sections 3.8  Transplant Services, 3.8.1 Transplant Services -
Definitions, 3.8.2 Financial Responsibility for Transplant Services,
and 3.8.3 Medical Management of Transplant Services under ARTICLE 3
ADMINISTRATIVE DUTIES OF PACIFICARE are added to the Agreement as follows:


 


3.8                                 Transplant Services.


 


3.8.1                        Transplant Services - Definitions.


 


K and R Letter Agreement


Gateway Physicians Medical Associates


Version 1.1


Effective: January 1, 2003


 


2

















 


(a)                                  “Transplant Services” are Covered Services
for solid organ transplants, autologous hemopoetic stem cell transplantation
and allogeneic hemopoetic stem cell transplantation as described in the applicable
Subscriber Agreement and Evidence of Coverage.


 


(b)                              “NPTN” Transplant Services are Transplant
Services provided pursuant to and in accordance with PacifiCare’s NPTN program
to NPTN Members.


 


(c)                                    “NPTN Members” are:


 


(i) Members who have been approved for Transplant Services on or before
December 31, 2002 who consent to receive services pursuant to PacifiCare’s
NPTN Program and whose anticipated transplant outcomes should not be adversely
affected by a transfer into the NPTN Program;


 


(ii) Members who have been approved for Transplant Services on or after
January 1, 2003.


 


(d)                                 “Non-NPTN” Transplant Services are all
Transplant Services, which are not NPTN Transplant Services.  Without limiting the foregoing, Non-NPTN
Transplant Services include all Transplant Services provided to Members who are
not NPTN Members.


 


3.8.2                        Financial Responsibility for Transplant
Services.  The parties’ respective financial
responsibility for the various components of Transplant Services are described
in this Section 3.8, Section 5.14 (Compensation for Transplant
Services), and the Division of Financial Responsibility Matrix including
Attachment A to the DFR.


 


3.8.3                        Medical Management of Transplant Services.


 


(a)                                  All Transplant Services shall be provided in
accordance with the provisions of PacifiCare’s MM Program including without
limitation, the provisions of PacifiCare’s Provider Manual.  Specifically, but without limitation,
authorization of the evaluation of the recipient prior to listing for
transplantation, the actual transplant itself, and post transplant care up to
365 days post discharge, must be obtained from PacifiCare’s NPTN Medical
Director, or his or her designee, prior to the provision of Transplant
Services.


 


(b)                                 PacifiCare shall be responsible for providing,
coordinating and arranging for the Medical Management of NPTN Transplant
Services for which it is financially responsible.  Medical Group shall be responsible for providing, coordinating
and arranging Transplant Services for which it is financially responsible,
subject to coordination with PacifiCare pursuant to the terms of PacifiCare’s
MM Program.


 


(c)                                  Transplant Services provided by Medical Group
or pursuant to a Medical Group referral that are not authorized by PacifiCare
prior to the provision of the Transplant Services shall constitute Non-NPTN
Transplant Services and be the sole financial responsibility of the Medical
Group regardless of whether such


 


3

















 


Transplant Services would have otherwise constituted NPTN Transplant
Services.


 


3.                                       Exhibit 1 MEDICAL GROUP FACILITIES AND
HOSPITAL(S) is deleted in its entirety. 
A new Exhibit 1 MEDICAL GROUP FACILITIES AND HOSPITAL(S) is
attached hereto and incorporated into the Agreement.


 


4.                                       Product Attachment A PACIFICARE COMMERCIAL
HEALTH PLAN is deleted in its entirety. 
A new Product Attachment A PACIFICARE COMMERCIAL HEALTH PLAN is
attached hereto and incorporated into the Agreement.


 


5.                                       Product Attachment B PACIFICARE COMMERCIAL
POINT OF SERVICE PLAN is deleted in its entirety.  A new Product Attachment B PACIFICARE COMMERCIAL POINT OF
SERVICE PLAN is attached hereto and incorporated into the Agreement.


 


6.                                       Product Attachment C SECURE HORIZONS
HEALTH PLAN is deleted in its entirety. 
A new Product Attachment C SECURE HORIZONS HEALTH PLAN is
attached hereto and incorporated into the Agreement.


 


7.                                       DIVISION OF FINANCIAL RESPONSIBILITY is deleted in its entirety.  A new Exhibit 4 DIVISION OF FINANCIAL
RESPONSIBILITY is attached hereto and incorporated into the Agreement.


 


8.                                       A new Attachment A NATIONAL PROVIDER
TRANSPLANT NETWORK under Exhibit 4 DIVISION OF FINANCIAL RESPONSIBILITY
is added to the Agreement and is attached hereto and incorporated into the
Agreement.


 


9.                                       A new Exhibit 5  QUALITY INCENTIVE PROGRAM is added to the Agreement
and is attached hereto and incorporated into the Agreement.


 


This
letter agreement, when counter-signed by Medical Group will constitute a
binding amendment to the Agreement and shall be terminable only in connection
with a termination of the Agreement.


 


If
you agree, please sign the enclosed duplicate copy of this letter.  In the interim, if you have any questions or
require additional information, please call Brian Jeffrey at 714-226-6570 or
myself at 714-226-8687.


 


	
  Sincerely,

  
	
   

  
	
   

  
	
  /s/ Aimee Ward

  	
   

  
	
  Aimee Ward

  
	
  Contract Manager I

  



 


4

















 


ACKNOWLEDGED
AND AGREED:


 


	
  For
  Medical Group

  	
  For PacifiCare of California

  
	
   

  	
   

  
	
   

  	
   

  
	
  By:

  	
  /s/ Michael
  Olson

  	
   

  	
  By:

  	
  /s/ Brian
  Jeffrey

  	
   

  
	
   

  	
  Name:

  	
  Michael
  Olson

  	
   

  	
   

  	
  Name:

  	
  Brian
  Jeffrey

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  	
   

  	
   

  	
  Title:

  	
  VP,
  Network Management 

  
	
   

  	
  Date:

  	
  11/18/02

  	
   

  	
   

  	
  Date:

  	
   

  	
  11/21/02

  	
   

  
												



 


5

















 


PRODUCT ATTACHMENT A


 


PACIFICARE COMMERCIAL HEALTH PLAN


 


This
Product Attachment A, along with the Base Agreement, sets forth the specific
terms and conditions which are applicable to the PacifiCare Commercial Health
Plan, as  defined below.


 


ARTICLE 1


DEFINITIONS


 


The
following terms shall have the meaning attributed below for purposes of the
PacifiCare Commercial Health Plan, as described in this Product Attachment
A.  Capitalized terms not otherwise
defined herein shall have the meaning assigned to them in the Base Agreement.


 


1.1                                 Commercial Plan Members are Medical Group Members enrolled in the
PacifiCare Commercial Plan.


 


1.2                                 Commercial Plan Premium is the premium received by PacifiCare each
month for PacifiCare Commercial Plan Members, excluding amounts to pay broker
and agent commissions/compensation, administrative fees paid to affiliates in
connection with joint marketing arrangements, Premium taxes and premiums for
Supplemental Benefits.


 


1.3                                 OPM Agreement is the agreement between PacifiCare and the
Federal Office of Personnel Management for the provision of Covered Services to
persons enrolled in the PacifiCare Commercial Plan through their participation
in the health benefits programs for federal employees and their dependents.


 


1.4                                 PacifiCare Commercial Plan is any and all of the various Managed Care
Plans sold by PacifiCare to individuals (excluding individuals eligible for the
PacifiCare Medicaid Plan and the Secure Horizons Health Plan) and employer
groups, associations with employer group participation and unions which
purchase benefits for their employees and their dependents.


 


1.5                                 Supplemental Benefits are benefits offered under the PacifiCare
Commercial Plan which require separate premium, in addition to the Commercial
Plan Premium, as consideration for the additional benefits.


 


ARTICLE 2

DUTIES OF MEDICAL GROUP


 


2.1                                 Provision of Covered Services. 
Medical Group and its Participating Providers shall provide Covered
Services to Commercial Plan Members pursuant to the terms of the Base Agreement
and this Product Attachment A.


 


2.2                                 Compliance with OPM Agreement.  Medical Group shall comply with all requirements in the OPM
Agreement which are applicable to Medical Group as a subcontractor of
PacifiCare as a result of this Agreement. 
Without limiting the foregoing, Medical Group shall ensure that all
provisions of the OPM Agreement which are applicable to Medical Group’s
Participating Providers are included in Medical Group’s subcontracts with its
Participating Providers.


 


6

















 


A copy of the OPM Agreement shall be provided to Medical Group
concurrent with the execution of this Agreement.


 


2.3                                 Compliance with Subscriber Agreements for
PacifiCare Commercial Plan.  Medical Group and its Participating
Providers shall comply with all requirements in Subscriber Agreements for the
PacifiCare Commercial Plan which are applicable to Medical Group.  PacifiCare shall make good faith efforts to
notify Medical Group of any such requirements that are not otherwise reflected
in this Agreement.


 


ARTICLE 3

COMPENSATION


 


3.1                                 Age/Gender/Benefit Adjusted Commercial
Capitation.  Capitation Payments for Commercial Plan
Members shall be made based upon a per Member per month base capitation rate
(“Base Capitation Rate”) adjusted to reflect the Medical Group Members’ age,
gender, and benefit plan participation. 
The Base Capitation Rate for both Gateway Physicians-United Western
Medical Center (DEC 16210) and Gateway Physicians-Placentia Linda (DEC 16206)
shall be *** per Commercial Plan Member per month.  Age/gender adjustment factors are actuarially determined and are
listed below.  Benefit adjustment
factors are actuarially determined by PacifiCare and may take into
consideration variations in benefit plan types, Copayment and coinsurance
levels.  PacifiCare may change its
benefit adjustment factors as needed to support the differing plan types that
it offers.  On an annual basis,
PacifiCare may modify the benefit adjustment factors based on actuarially
determined changes.  The Standard
Service Capitation Amount will vary during subsequent months as a result of
changes in the age, gender, and benefit plan participation of the Medical
Group’s Members for the applicable month. 
The total monthly Capitation Payment shall also be adjusted in the
manner set forth in Article 5 of the Base Agreement.


 


The following are PacifiCare’s age/gender adjustment factors:


 


 




	
  Gender

  	
   

  	
  Age Band

  	
   

  	
  Physician

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  C

  	
   

  	
  00-00

  	
   

  	
  1.8412

  
	
  C

  	
   

  	
  01-01

  	
   

  	
  1.1116

  
	
  C

  	
   

  	
  02-09

  	
   

  	
  0.4434

  
	
  C

  	
   

  	
  10-17

  	
   

  	
  0.4411

  
	
  F

  	
   

  	
  18-19

  	
   

  	
  0.6649

  
	
  F

  	
   

  	
  20-24

  	
   

  	
  0.9544

  
	
  F

  	
   

  	
  25-29

  	
   

  	
  1.3620

  
	
  F

  	
   

  	
  30-34

  	
   

  	
  1.3911

  
	
  F

  	
   

  	
  35-39

  	
   

  	
  1.3147

  
	
  F

  	
   

  	
  40-44

  	
   

  	
  1.3872

  
	
  F

  	
   

  	
  45-49

  	
   

  	
  1.5017

  
	
  F

  	
   

  	
  50-54

  	
   

  	
  1.7097

  






 


7

















 




	
  F

  	
   

  	
  55-59

  	
   

  	
  1.9981

  
	
  F

  	
   

  	
  60-64

  	
   

  	
  2.2818

  
	
  F

  	
   

  	
  65 and Over

  	
   

  	
  1.9375

  
	
  M

  	
   

  	
  18-19

  	
   

  	
  0.3840

  
	
  M

  	
   

  	
  20-24

  	
   

  	
  0.3787

  
	
  M

  	
   

  	
  25-29

  	
   

  	
  0.4805

  
	
  M

  	
   

  	
  30-34

  	
   

  	
  0.6052

  
	
  M

  	
   

  	
  35-39

  	
   

  	
  0.6675

  
	
  M

  	
   

  	
  40-44

  	
   

  	
  0.8186

  
	
  M

  	
   

  	
  45-49

  	
   

  	
  1.0095

  
	
  M

  	
   

  	
  50-54

  	
   

  	
  1.3110

  
	
  M

  	
   

  	
  55-59

  	
   

  	
  1.7451

  
	
  M

  	
   

  	
  60-64

  	
   

  	
  2.1970

  
	
  M

  	
   

  	
  65 and Over

  	
   

  	
  2.0813

  






 


3.1.1                        PacifiCare guarantees that the Medical Group
will receive a Minimum Capitation Guaranty per Commercial Health Plan Member
per month, for the provision of Medical Services.  In exchange for this minimum guaranty, the parties have also
agreed to establish a Maximum Capitation Guaranty.  The program shall only apply to calendar year 2003.  The guaranty (the “Minimum/Maximum
Capitation Guaranty Program”) is described further as follows:


 


For the period January 1, 2003, to December 31, 2003 only,
the Medical Group Minimum Capitation Guaranty shall be *** per Member per month
(“Minimum Capitation Guaranty”) and the maximum payment shall be limited to ***
per Member per month (“Maximum Capitation Guaranty”). The capitation guaranty
shall be based on a flat per Member per Month amount, not adjusted for age/sex
benefit plan factors.


 


If the Average Capitation Amount per Member per month for Medical
Group, calculated as set forth below, is less than the Minimum Capitation
Guaranty, PacifiCare shall pay the Medical Group the difference.  If the average Capitation Amount per Member
per month exceeds the Maximum Capitation Guaranty, the Medical Group shall pay
PacifiCare the difference.  Such
payments shall be made at the times and in the manner described below.  The Minimum/Maximum Capitation Guaranty
Program shall be calculated and applied prior to any other adjustments pursuant
to the Agreement.


 


Calculation of the Minimum/Maximum Capitation Guaranty Program will be
based on the “Standard Service Capitation Amounts” shown on the monthly
capitation report for the applicable calendar quarter(s) inclusive of
adjustments for retroactive changes in Membership, but excluding all other
adjustments to Capitation Payments (the “Average Capitation Amount”).  The Standard Service Capitation amount(s)
shall be divided by the total Member months for the period and compared with
the Minimum Capitation Guaranty and Maximum Capitation Guaranty for the
applicable period.  PacifiCare shall
determine whether any payments are due under the Minimum/Maximum Capitation
Guaranty Program within forty-five (45) calendar days after the end of each
calendar


 


8

















 


quarter for the first three quarters of calendar year 2003, with a
final calculation as provided below.


 


If amounts are due to the Medical Group, PacifiCare will provide
payment thirty (30) days after the calculation is due (i.e. 75 days after the
calendar quarter).  If amounts are due
to PacifiCare, PacifiCare will deduct such amount from the Capitation Payment
of the Medical Group in the month following provision of the calculation (i.e.
if the calculation is provided on November 15th, the deduction will be
taken from the Capitation Payment due on December 10th). If amounts are
due to Medical Group, PacifiCare will make the payment on the fifteenth (15th)
calendar day of the month following the provision of the calculation.


 


A final, aggregated, year-end settlement will be determined by
PacifiCare on September 15, 2004, based on a calculation for the entire
calendar year 2003.  If amounts are due
to the Medical Group, PacifiCare will provide payment by October 15,
2004.  If amounts are due to PacifiCare,
PacifiCare will deduct such amount from the October 10, 2004, Medical
Group Capitation Payment.  If the
Agreement is terminated prior to the final year-end settlement timeframes as
specified in this Section, then the final settlement will be settled in the
manner described at 6.6, Repayment Upon Termination.


 


Example:


 


Calendar Yr 2003 Quarter Average PMPM Calculation Due Date
Paid/Recovered


	
  Ql

  	
   

  	
  Avg
  for Ql

  	
   

  	
  May
  15, 2003

  	
   

  	
  June 15
  (pd) June 10 (recovered)

  
	
  Q2

  	
   

  	
  Avg.
  for Ql-Q2

  	
   

  	
  Aug.
  15, 2003

  	
   

  	
  Sept.
  15 (pd) Sept. 10 (recovered)

  
	
  Q3

  	
   

  	
  Avg.
  for Ql-Q3

  	
   

  	
  Nov.
  15, 2003

  	
   

  	
  Dec.
  15 (pd) Dec. 10 (recovered)

  
	
  Q4

  	
   

  	
  Avg.
  for Q1-Q4

  	
   

  	
  Feb.
  15, 2004

  	
   

  	
  March 15
  (pd) March 10 (recovered)

  



2003 Year-end Settlement Avg. for Q1-Q4, adjusted for retroactivity


Sept. 15, 2004 Oct. 15, 2004 (pd) Oct. 10, 2004 (recovered)


 


3.1.2                        Adjustment for ISL Premium.  In
calculating Capitation Payments due to Medical Group, PacifiCare shall deduct
the ISL Premium amount set forth herein from the amounts otherwise due to Medical
Group, unless PacifiCare has approved of Medical Group’s opting out of
PacifiCare’s ISL Program.


 


3.2                                 ISL Program.  The ISL Deductible, ISL
Premium and ISL Coinsurance for the Commercial Plan shall initially be:


 


(i)                                     ISL Deductible shall be zero dollars and no
cents ($0.00) per Commercial Plan Member per calendar year.


 


(ii)                                  ISL Premium shall be zero dollars and zero
cents ($0.00) per Commercial Plan Member per month.


 


(iii)                               ISL Coinsurance shall be zero percent (0%) of
Cost of Care in excess of the ISL Deductible.


 


9

















 


If PacifiCare has approved of Medical Group’s opt out of the ISL
Program, the above amounts and percentages will reflect “zero.” In such event,
Medical Group shall be required to obtain ISL coverage from a third-party
insurance carrier in accordance with Section 5.6.5 of the Base Agreement.


 


3.3                                 Commercial Hospital Incentive Program. 
PacifiCare shall establish and administer an annual Commercial Hospital
Incentive Program for the PacifiCare Commercial Plan (the “CHIP”).  The CHIP is designed to provide an incentive
for the efficient and effective use of Hospital Services, and shall be
calculated utilizing the terms defined below. 
All calculations for the CHIP shall be based upon Commercial Plan
Members, excluding Commercial POS Plan Members.


 


3.3.1                        Reinsurance Program. 
Claims under the Reinsurance Program shall be valued at the Cost of Care
as defined in this Agreement.  The
Reinsurance Deductible, Reinsurance Premium and Reinsurance Coinsurance for the
Commercial Plan shall initially be:


 


(i)                                     Reinsurance Deductible shall be fifty
thousand dollars ($50,000) per Commercial Plan Member per calendar year.


 


(ii)                                  Reinsurance Premium shall be six and
ninety-six tenths percent (6.96%) of Commercial Plan Premium.


 


(iii)                               Reinsurance Coinsurance shall be fifty
percent (50%) of the Cost of Care for amounts in excess of the Reinsurance
Deductible but less than two hundred fifty thousand dollars ($250,000) and
twenty percent (20%) of the Cost of Care for amounts in excess of two hundred
fifty thousand dollars ($250,000).


 


3.3.2                        CHIP Budget.  The CHIP Budget for
Commercial Plan Members shall be established based upon a per Member per month
rate (“Base Rate”) adjusted to reflect the Assigned Medical Group Members’ age,
gender, and benefit plan participation. 
The Base Rate for both Gateway Physicians-United Western Medical Center
(DEC 16210) and Gateway Physicians-Placentia Linda (DEC 16206) shall be ***
(***) per Commercial Plan Member per month. 
Age/gender adjustment factors are actuarially determined by PacifiCare
and are listed below.  Benefit
adjustment factors are actuarially determined by PacifiCare and take into
consideration variations in benefit plan types, Copayment and coinsurance
levels.  PacifiCare may change its
benefit adjustment factors as needed to support the differing plan types that
it offers.  On an annual basis,
PacifiCare may modify the benefit adjustment factors based on actuarially
determined changes.  The CHIP Budget
will vary during subsequent months as a result of changes in the age, gender,
and benefit plan participation of the Assigned Medical Group Members for the
applicable month.


 


The following are PacifiCare’s CHIP Budget age/gender adjustment
factors:


 


10

















 




	
  Gender

  	
   

  	
  Age Band

  	
   

  	
  Hospital

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  C

  	
   

  	
  00-00

  	
   

  	
  4.0488

  
	
  C

  	
   

  	
  01-01

  	
   

  	
  0.7234

  
	
  C

  	
   

  	
  02-09

  	
   

  	
  0.3228

  
	
  C

  	
   

  	
  10-17

  	
   

  	
  0.3706

  
	
  F

  	
   

  	
  18-19

  	
   

  	
  0.5841

  
	
  F

  	
   

  	
  20-24

  	
   

  	
  0.9398

  
	
  F

  	
   

  	
  25-29

  	
   

  	
  1.4088

  
	
  F

  	
   

  	
  30-34

  	
   

  	
  1.3551

  
	
  F

  	
   

  	
  35-39

  	
   

  	
  1.1025

  
	
  F

  	
   

  	
  40-44

  	
   

  	
  1.0464

  
	
  F

  	
   

  	
  45-49

  	
   

  	
  1.1741

  
	
  F

  	
   

  	
  50-54

  	
   

  	
  1.4581

  
	
  F

  	
   

  	
  55-59

  	
   

  	
  2.0324

  
	
  F

  	
   

  	
  60-64

  	
   

  	
  2.4463

  
	
  F

  	
   

  	
  65 and Over

  	
   

  	
  2.2225

  
	
  M

  	
   

  	
  18-19

  	
   

  	
  0.4431

  
	
  M

  	
   

  	
  20-24

  	
   

  	
  0.4520

  
	
  M

  	
   

  	
  25-29

  	
   

  	
  0.5000

  
	
  M

  	
   

  	
  30-34

  	
   

  	
  0.5081

  
	
  M

  	
   

  	
  35-39

  	
   

  	
  0.6558

  
	
  M

  	
   

  	
  40-44

  	
   

  	
  0.8823

  
	
  M

  	
   

  	
  45-49

  	
   

  	
  1.1058

  
	
  M

  	
   

  	
  50-54

  	
   

  	
  1.5844

  
	
  M

  	
   

  	
  55-59

  	
   

  	
  2.2785

  
	
  M

  	
   

  	
  60-64

  	
   

  	
  3.0045

  
	
  M

  	
   

  	
  65 and Over

  	
   

  	
  2.9368

  






 


3.3.3                        CHIP
Expense.  CHIP Expense shall be
equal to the sum of the following:


 


(i)                                     Inpatient
costs for Hospital Services rendered to Commercial Plan Members, excluding
Commercial POS Plan Members, by Participating Providers, valued at the actual
costs incurred by PacifiCare; plus,


 


(ii)                                  Other
Hospital Services rendered to Commercial Plan Members, excluding Commercial POS
Plan Members, by Participating Providers other than inpatient services, valued
at actual costs incurred by PacifiCare; plus,


 


(iii)                               The
actual amount paid for Hospital Services which are rendered by
non-Participating Providers; minus,


 


(iv)                              Amounts
paid by PacifiCare under the Reinsurance Program, if any; minus


 


11

















 


v)                                     Any and all amounts received from third
parties for Hospital Services provided to Commercial Plan Members, excluding
Commercial POS Plan Members, through coordination of benefits, work-related
accidents or injuries, stop-loss and reinsurance payments and Member
Copayments.


 


3.3.4                        CHIP Surplus.  In
the event the CHIP Expense is less than the CHIP Budget, the surplus shall be
allocated as follows:


 


*** to Medical Group


*** to PacifiCare


 


3.3.5                        CHIP Deficit.  In
the event the CHIP Expense is greater than the CHIP Budget, the deficit shall
be allocated as follows:


 


*** to Medical Group, not to exceed ***


*** per Commercial Plan Member per month.


*** to PacifiCare


 


3.3.6                        Settlements and Reconciliation. 
Interim settlements and the final settlement and reconciliation of the
CHIP shall be performed by PacifiCare as provided in Article 5 of the Base
Agreement.


 


3.4                                 Commercial Plan Pharmacy Incentive Program. 
PacifiCare shall establish and administer an annual Pharmacy Incentive
Program for the PacifiCare Commercial Plan (the “PIP”).  The PIP is designed to provide an incentive
for the efficient and effective use of Outpatient Pharmacy Supplemental
Benefits for Commercial Plan Members. 
The PIP shall be calculated as follows:


 


3.4.1                        Outpatient Pharmacy Supplemental Benefits shall be the benefits made available by
PacifiCare under the PacifiCare Supplemental Pharmacy Benefit, as defined in
the applicable Subscriber Agreement.


 


3.4.2                        PIP Budget shall equal *** of the premium received by PacifiCare for Outpatient Pharmacy
Supplemental Benefits for Commercial Plan Members plus *** per Commercial Plan
Member per month, which amount is established as a credit for rebates received
from pharmaceutical manufacturers.  This
credit may or may not reflect the total pharmaceutical manufacturer rebate
revenues received by PacifiCare.  The
PIP Budget shall be retained by PacifiCare for purposes of administering the
PIP.


 


3.4.3                        PIP Expense shall equal the expense incurred for the provision of Outpatient
Pharmacy Supplemental Benefits during the applicable period.


 


3.4.4                        PIP Threshold shall be calculated using several factors,
included trended 2002 calendar year and ongoing actual performance for Medical
Group, inflationary trends and benefit adjustments.  Effective January 1, 2003, the PIP Threshold shall be ***
per Commercial Plan Member per month. 
The PIP Threshold shall be re-calculated yearly and PacifiCare shall
notify Medical Group of the new PIP


 


12

















 


Threshold by sixty (60) calendar days prior to the anniversary date.


 


3.4.5                        PIP Surplus.  Medical Group shall
participate in the Pharmacy Upside Sharing Program.  In the event the PIP Expense is less than the PIP Threshhold
during the 2003 calendar year, the amount of this difference will be referred
to as the PIP Surplus.  In  this event, fifty percent (50%) of the
surplus shall be allocated to Medical Group. 
This PIP shall be settled on a quarterly basis beginning with the second
quarter of the 2003 calendar year and ongoing within ninety (90) days of the
end of the quarter.  Quarterly payouts
will be subject to an IBNR adjustment. 
There will be a final, cummulative settlement produced within one hundred
eight (180) days of the 2003 calendar year.


 


3.4.6                        PIP Deficit.  In the event that the PIP
Expense is greater than the PIP Budget, zero percent (0%) of the deficit shall
be allocated to Medical Group.


 


3.4.7                        Pharmacy Management Programs. 
Medical Group shall continue its Pharmacy Management Programs.  PacifiCare’s Clinical Pharmacist will
continue to work with Medical Group to identify performance improvement
opportunities.  Medical Group shall work
cooperatively with PacifiCare’s Clinical Pharmacist and participate in
PacifiCare’s Pharmacy Management Initiatives, as applicable.


 


3.4.8                        Annual Review.  The
PIP shall be adjusted annually to reflect changes, including Pharmacy expenses,
inflation, benefit plans and drug management programs.


 


IN
WITNESS WHEREOF, the parties hereto have executed this Product Attachment A.


 


 


	
   

  	
  PACIFICARE
  OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  11/21/02

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL
  GROUP

  GATEWAY PHYSICIANS MEDICAL

  ASSOCIATES

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Michael Olson

  
	
   

  	
   

  	
  Michael Olson

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  11/18/02

  



 


13

















 


PRODUCT ATTACHMENT B




PACIFICARE COMMERCIAL POINT-OF-SERVICE PLAN


 


In
addition to the terms and conditions set forth in the Base Agreement and
Product Attachment A, the following terms and conditions, as defined below, are
also applicable to the PacifiCare Commercial Point-of-Service Plan.


 


ARTICLE 1


DEFINITIONS


 


The
following terms shall have the meaning attributed below for purposes of the
PacifiCare Commercial Point-of-Service Plan, as described in this Product
Attachment B.  Capitalized terms not
otherwise defined herein shall have the meaning assigned to them in the Base
Agreement.


 


1.1                                 Commercial POS Plan Members are Medical Group Members enrolled in the
PacifiCare Commercial POS Plan.


 


1.2                                 In-Network Services are Covered Services received by Commercial
POS Plan Members which are (a) provided or arranged by Medical Group pursuant
to the PacifiCare Commercial Plan; (b) received from a non-contracting Provider
following an authorization from Medical Group; (c) Emergency Services; and (d)
Urgently Needed Services.


 


1.3                                 In-Network Hospital Services are Hospital Services received by Commercial
POS Plan Members which are (a) provided or arranged by Medical Group pursuant
to the PacifiCare Commercial Plan; (b) received from a non-contracting Provider
following an authorization from Medical Group; (c) Emergency Services; and (d)
Urgently Needed Services.


 


1.4                                 Out-of-Network Services are Covered Services, excluding Emergency
Services and Urgently Needed Services, which are received by Commercial POS
Plan Members without the prior authorization of Medical Group.


 


1.5                                 PacifiCare Commercial Point-of-Service
(“POS”) Plan is any
PacifiCare Commercial Plan, as defined in Product Attachment A, under which
Members are entitled to coverage for both In-Network Services and
Out-of-Network Services.


 


ARTICLE 2


DUTIES OF MEDICAL GROUP


 


2.1                                 Covered Services. 
Medical Group and its Participating Providers shall provide or arrange
Covered Services to Commercial POS Plan Members under same terms and conditions
as Commercial Plan Members.


 


2.1                                 Reciprocity: Reimbursement for Out-of-Network
Services.  If any of Medical Group’s Participating
Providers provides Out-of-Network Services to a Commercial POS Plan Member,
such Medical Group Participating Provider shall bill PacifiCare or the payor
responsible for


 


14

















 


payment for Out-of-Network Services for such services and agrees to
accept full payment at the Cost of Care. 
Neither Medical Group nor its Participating Providers shall encourage
Members to receive Covered Services from non-Participating Providers.  Medical Group shall include the requirements
of this Section in all subcontracts with its Participating Providers.


 


ARTICLE 3

COMPENSATION


 


3.1                                 Capitation Payments for Commercial POS Plan
Members.  For Commercial POS Plan Members, PacifiCare
will pay Medical Group eighty five percent (85%) of the monthly Standard
Service Capitation Amount for Commercial Plan Members, subject to the
adjustments set forth in Article 5 of the Base Agreement and the
adjustments set forth below in this Section. 
The payment described in this Section is payment in full for
In-Network Services, except for Copayments, coordination of benefits and third
party recoveries.


 


3.1.1                        Premium Adjustments.  The
Commercial Plan Premium and benefits may be amended for each Subscriber
Agreement upon the annual renewal date of each Subscriber Agreement at the sole
discretion of PacifiCare.


 


3.2                                 Commercial POS Control Program. 
Effective January 1, 2003, the Commercial POS Control Program is
discontinued.  Therefore, this
Section 3.2 [Commercial POS Control Program] is hereby deleted and the
numbering reserved for future use.


 


3.3                                 Adjustment of Rates. 
Capitation Payments for Commercial POS Plan Members and the POS Plan
Budget may be prospectively adjusted on an annual basis to reflect actual
experience under the Commercial POS Plan; provided, however, that in no event
shall the amount of any increase or decrease to such Capitation Payments be
greater than ten (10) percentage points in any given year.


 


IN
WITNESS WHEREOF, the parties hereto have executed this Product Attachment B.


 


 


	
   

  	
  PACIFICARE
  OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  11/21/02

  



 


15

















 


	
   

  	
  MEDICAL
  GROUP

  GATEWAY PHYSICIANS MEDICAL

  ASSOCIATES

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Michael Olson

  
	
   

  	
   

  	
  Michael Olson

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  11/18/02

  



 


16

















 


PRODUCT ATTACHMENT C


 


SECURE HORIZONS HEALTH PLAN


 


This
Product Attachment C, along with the Base Agreement, sets forth the terms and
conditions which are applicable to the Secure Horizons Health Plan, as defined
below.


 


ARTICLE 1

DEFINITIONS


 


The
following terms shall have the meaning attributed below for purposes of the
Secure Horizons Health Plan, as described in this Product Attachment C.  Capitalized terms not otherwise defined
herein shall have the meaning assigned to them in the Base Agreement.


 


1.1                                 CMS Agreement is the Medicare + Choice contract between
PacifiCare and CMS.


 


1.2                                 Medicare is the Hospital Insurance Plan (Part A) and the Supplementary Medical
Insurance Plan (Part B) provided under Title XVIII of the Social Security Act,
as amended.


 


1.3                                 Monthly CMS Payment is the revenue received by PacifiCare each
month from CMS, as determined by CMS, for providing Covered Services to Secure
Horizons Members.


 


1.4                                 Secure Horizons Health Plan is the prepaid health plan operated by
PacifiCare pursuant to the CMS Agreement which provides Covered Services to
individuals (including retirees) eligible to receive Medicare benefits.


 


1.5                                 Secure Horizons Members are Medical Group Members enrolled in the
Secure Horizons Health Plan.


 


1.6                                 Secure Horizons Revenue is the Monthly CMS Payment for Medical Group
Members enrolled in the Secure Horizons Health Plan, less payments for
broker and agent commissions/compensation (when applicable), amounts paid for
certain third parties for services provided in connection with the
identification and enrollment of individuals who can be designated as Specified
Low-Income Beneficiaries eligible for the Qualified Medicare Beneficiary
Program, and premium taxes.


 


ARTICLE 2

DUTIES OF MEDICAL GROUP


 


2.1                                 Compliance with CMS Agreement and Federal
Medicare Law.  Medical Group shall comply with all
requirements in the CMS Agreement which are applicable to Medical Group as a
subcontractor of PacifiCare as a result of this Agreement.  Without limiting the foregoing, Medical
Group shall ensure that all provisions of the CMS Agreement which are
applicable to Medical Group’s Participating Providers as a subcontractor of
PacifiCare are included in Medical Group’s subcontracts with its Participating
Providers.  A copy of the CMS Agreement
shall be made available to Medical Group concurrent with the execution of this
Agreement.


 


17

















 


Medical Group and its Participating Providers
shall comply with title XVIII of the Social Security Act and the regulations
adopted thereunder by CMS for the Medicare program.


 


2.2                                 Medicare
Participation Standards.  Medical
Group shall require that all of its Participating Providers who provide
services to Secure Horizons Members meet the standards for participation and
all applicable requirements for providers of health care services under the
Medicare program.  In addition, Medical
Group shall require that all facilities and offices utilized by Medical Group
and its Participating Providers to provide or arrange Covered Services to
Secure Horizons Members shall comply with facility standards established by
CMS.


 


2.3                                 Specific
Provisions Pertaining to Benefits, Coverage and Beneficiary Protections.  Without limiting any of Medical Group’s
other obligations under this Agreement, Medical Group specifically agrees to
comply with the following policies and procedures:


 


(i)                                     PacifiCare’s
policies pertaining to the collection of Copayments which prohibit the
collection of Copayments for routine injections, routine immunizations, flu
immunizations, and the administration of pneumococcal/pneumonia vaccine.


 


(ii)                                  PacifiCare’s
policies pertaining to pre-certification which provide that Secure Horizons
Members may directly access a provider for mammography and influenza
vaccinations and women’s health specialists for routine and preventative health
care.


 


(iii)                               PacifiCare’s
policies pertaining to complex and serious conditions which provide for
procedures to identify, assess and establish treatment plans for persons with
complex or serious medical conditions.


 


(iv)                              PacifiCare’s
policies pertaining to enrollment and assessment of new Secure Horizons Members
including requirements to conduct a health assessment of all new Secure
Horizons Members within ninety (90) days of the effective date of their
enrollment.


 


2.4                                 Confidentiality
of Medical Records.  Medical Group
shall establish and maintain procedures and controls so that no information
contained in its records or obtained from CMS or from others in carrying out
the terms of this Agreement shall be used by or disclosed by it, its agents,
officers, or employees except as provided in Section 1106 of the Social
Security Act, as amended, and regulations prescribed thereunder.


 


2.5                                 Submission
of Data.  Medical Group shall
cooperate with PacifiCare in submitting to the Secretary of Health and Human
Services statistical data pertaining to Covered Services provided by Medical
Group, enrollment and disenrollment data and any other reports the Secretary
may reasonably require to carry out its functions under the Medicare + Choice
program.


 


2.6                                 Advance
Directives.  Medical Group shall
document all Secure Horizons Member patient records with respect to the
existence of an Advance Directive in compliance with the Patient
Self-Determination Act (Section 4751 of the Omnibus Reconciliation Act of
1990), as amended, and other appropriate laws. 
For purposes of this Agreement, an Advance Directive is a Member’s
written instructions, recognized under State law, relating to the provision of
health care when the Member is not competent to make health care decisions as
determined under State law.  Examples of
Advance Directives are living wills and durable powers of attorney for health
care.


 


18

















 


to Secure Horizons Members through coordination of benefits,
work-related accidents or injuries, stop-loss and reinsurance payments and
Medical Group Member Copayments.


 


3.3.4                        SHIP Surplus.  In the event the SHIP Expense is less than the SHIP Budget, the
surplus shall be allocated as follows:


 


*** Medical Group


*** to PacifiCare


 


3.3.5                        SHIP Deficit.  In the event the SHIP Expense is greater than the SHIP Budget,
the deficit shall be allocated as follows:


 


*** to Medical Group, not to exceed ***


*** per Secure Horizons Plan Member per month.


*** to PacifiCare


 


3.3.6                        Settlements and Reconciliation. 
Interim settlements and the final settlement and reconciliation of the
SHIP shall be performed by PacifiCare as provided in Article 5 of the Base
Agreement.


 


3.3.7                        One Time Adjustment for 2003 Increases in
Secure Horizons Revenue.  The Capitation Percentage set forth above
assumes a prospective Secure Horizons Revenue increase effective as of
January 1, 2003, of no greater than *** over the average Secure Horizons
Revenue for Assigned Medical Group Members for calendar year 2002 (the “Annual
Increase”).  In the event that the
actual Annual Increase is more than two percent (2%), as determined by law or
legislative or regulatory action or federal administrative agency
interpretation no later than December 31, 2002 (as calculated by
PacifiCare for Assigned Medical Group Members) the increase shall be used to
enhance market competitiveness and/or improve Secure Horizons Plan benefits.  PacifiCare shall reduce the Capitation
Percentage to an amount that will adjust Medical Group’s Standard Service
Capitation Payments to reflect the *** agreedlimit on the Annual Increase in Secure Horizons Revenue under this
Agreement.  The  resulting adjustment, if any, in the
Capitation Percentage shall begin with the January 2003 Standard Service
Capitation Payment.


 


3.4                                 Collection of Charges From Third Parties When
Medicare Is Not the Primary Payor.  Medical Group shall accept
Capitation Payments from PacifiCare as payment in full for Covered Services
provided to Secure Horizons Members; provided, however, when Medicare is not
the primary payor for Covered Services, such as when the Secure Horizons Member
is entitled to payment from another third party or for payment for a workers’
compensation claim, or from other primary insurance coverage maintained by
Secure Horizons Member, Medical Group shall make no demand upon PacifiCare for
reimbursement under the Individual Stop-Loss Program until all primary sources
of payment have been pursued and it is determined that full payment cannot be
obtained within ten (10) months from the date of the provision of Covered
Services.


 


21

















 


IN
WITNESS WHEREOF, the parties hereto have executed this Product Attachment C.


 


	
   

  	
  PACIFICARE
  OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  
	
   

  	
   

  
	
   

  	
  Date:

  	
  11/21/02

  
	
   

  	
   

  
	
   

  	
  MEDICAL
  GROUP

  GATEWAY PHYSICIANS MEDICAL

  ASSOCIATES

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Michael Olson

  
	
   

  	
   

  	
  Michael
  Olson

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  
	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  11/18/02

  



 


22

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT


(PROFESSIONAL CAPITATION)


 


EXHIBIT 1


MEDICAL GROUP FACILITIES AND HOSPITAL(S)


(This Exhibit 1 is an integral part of this
Agreement)


 


Medical
Group Facilities:


 


Gateway
Physicians Medical Associates—United Western Medical Center


Commercial and Secure Horizons Health Plan


 


Gateway
Physicians Medical Associates—Placentia Linda


Commercial Health Plan Only


 


Facilities
shall also include each facility at which a Medical Group Participating
Provider routinely provides services pursuant to this Agreement.


 


All
Medical Group Facilities shall, in accordance with PacifiCare’s policies and
procedures, be subject to PacifiCare’s prior written approval.


 


Hospital(s):


Western
Medical Center


Placentia
Linda Hospital


 


Medical
Group Service Area:


 


The
Medical Group Service Area is the geographic area served by the Medical Group’s
Participating Providers, including referral providers.  The Medical Group Service Area is defined as
being within a thirty (30) mile radius of each of the Medical Group Facilities,
and includes the facilities and physician offices beyond the thirty mile radius
where Referral Services are arranged for by Medical Group.  The Medical Group Service Area shall be
determined by PacifiCare, based upon the shortest route using public streets
and highways.


 


23

















 


PACIFICARE
OF CALIFORNIA


 


MEDICAL GROUP IPA SERVICES AGREEMENT


(PROFESSIONAL CAPITATION)


 


EXHIBIT 4


ATTACHMENT A


 


NATIONAL
PROVIDER TRANSPLANT NETWORK


(This
Exhibit 4, Attachment A is an integral part of this Agreement)


 


Division
of Financial Responsibility.  The Division of Financial
Responsibility (DFR), attached to this Agreement as Exhibit 4, shall serve as
the specific designation of financial risk for the Medical Group, Hospital
Incentive Programs and PacifiCare for Transplant Services (other than skin or
ophthalmic transplants, which are addressed separately in the DFR):


 


I.                                         Designated NPTN Components
(Phases) of Care—General


 


Transplant Services are generally described in the following components
of care:


 


•                                          Transplant Evaluation


•                                          Transplant Candidacy and Maintenance


•                                          Transplant Procedure and Procurement


•                                          Post-Transplant Follow-up (Year 1)


•                                          Post-Transplant Follow-up (Years 2-5)


 


II.                                     Transplant Services Phases
of Care Definitions and Service Components.


 


1.                                       SOLID ORGAN
TRANSPLANTATION.  The solid organ Transplant Services are segregated
into the following components:


 


a)                                      TRANSPLANT EVALUATION PHASE.  Pre-transplant medically necessary services
required to assess and evaluate the Member to determine acceptance to
transplant program.  This phase ends
upon acceptance or denial into the transplant program.  This Phase shall include:


 


•                  Consultation
with surgeon(s), psychiatrist(s), specialist(s), transplant coordinator(s),
social services.


 


•                  Hematology,
blood banking, serology, chemistry, histocompatibility.


 


•                X-rays,
pulmonary function tests, skin tests, leukopheresis consultation, CT scan,
tissue typing, MRI.


 


•                Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services.


 


b)                                     TRANSPLANT CANDIDACY AND MAINTENANCE PHASE:
Services necessary to assess referral for formal evaluation for Transplant
Services and Medically Necessary inpatient and/or


 


28

















 


outpatient
services, in order to maintain the Member’s health prior to a transplant.


 


c)                                      TRANSPLANT PROCEDURE AND PROCUREMENT
PHASE.  Transplant related services from
the day before a transplant is performed through discharge.  Includes all hospital, physician, ancillary,
transportation, acquisition costs and other services necessary to acquire a
cadaver or living transplantable human organ for transplantation into
designated Member.  This Phase includes
retransplantation.  This Phase includes:


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and all
other ancillary services for recipient and living donor


 


•                  Surgical
transplant and other surgical procedures during admission


 


•                  Organ
and tissue procurement and transportation costs related to procurement


 


•                  Donor
testing and identification and preparation or organ and tissue


 


d)                                     POST-TRANSPLANT FOLLOW-UP (YEAR 1).  Transplant- related Medically Necessary
services rendered to recipient for follow-up for up to 365 days post discharge
for recipient and 90 days post discharge for living donor.  This Phase includes:


 


•                   Inpatient or outpatient, including professional, room and board,
nursing, pharmacy and all other ancillary services for recipient and donor.


 


•                   Readmissions related to transplant complications


 


•                   Transplant rejection diagnosis and treatment


 


•                   Transplant related complications (medical care necessary related
directly to transplant or re-transplantation)


 


e)                                                                                      POST-TRANSPLANT FOLLOW-UP (YEARS 2-5).  Transplant-related Medically Necessary
services provided after the post-transplant follow-up period described above.


 


2.                                       AUTOLOGOUS HEMOPOETIC STEM
CELL TRANSPLANTATION.  The autologous hemopoetic stem cell
Transplant Services are segregated into the following components:


 


a)                                      TRANSPLANT EVALUATION PHASE.  Begins with initial consult with transplant
physician through day prior to myeoloblative or immunoablative therapy
beginning.  This phase ends upon
acceptance or denial into the transplant program.  The Evaluation Phase shall include:


 


•                  Consultation
with transplant physician(s), psychiatrist(s), specialist(s), transplant
coordinator(s), social services.


 


•                  Hematology,
blood banking, serology, chemistry, histocompatibility.


 


29

















 


•                  X-rays,
pulmonary function tests, skin tests, leukopheresis consultation, CT scan,
tissue typing, MRI.


 


•                  Restaging
of disease


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services.


 


•                  IV
or oral medications for mobilization


 


•                  Bone
marrow harvest/stem cell collection


 


•                  Stem
cell cryopreservation and storage


 


b)                                     TRANSPLANT CANDIDACY AND MAINTENANCE
PHASE.  Services necessary to assess
referral for formal evaluation for Transplant Services and Medically Necessary
inpatient and/or outpatient services, in order to maintain the Member’s health
prior to transplant.


 


c)                                      TRANSPLANT PROCEDURE PHASE.  From day myeoloblative or immunoablative
therapy begins through discharge.


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services for recipient.


 


•                  Marrow
ablative or immunoablative therapy (total body irradiation and/or chemotherapy)


 


•                  Marrow
or cord acquisition


 


•                  Transplant


 


d)                                     POST-TRANSPLANT FOLLOW-UP (YEAR 1).  Transplant related Medically Necessary
services rendered to recipient for follow-up for up to 365 days post discharge.


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services for recipient.


 


•                  Transplant
physician visits


 


•                  Laboratory
testing


 


•                  Radiology
exams


 


•                  Retransplantation


 


•                  Readmissions
related to transplant complications


 


30

















 


•                  Treatment
for delayed stem cell engraftment (GCSF)


 


•                  Transplant
related complications (medical care necessary related directed to transplant or
re-transplantation)


 


3.                                       ALLOGENEIC HEMOPOETIC STEM
CELL TRANSPLANTATION (Related or Unrelated).  The allogenic hemopoetic stem
cell Transplant Services are segregated into the following components:


 


a)                                      TRANSPLANT EVALUATION PHASE.  Pre-transplant Medically Necessary Services
required to assess and evaluate the Member to determine acceptance to the
transplant program.  This phase ends
upon acceptance or denial into the transplant program.  This Phase shall include:


 


•                  Consultation
with transplant physician(s), psychiatrist(s), specialist(s), transplant
coordinator(s), social services.


 


•                  Hematology,
blood banking, serology, chemistry, histocompatibility


 


•                  X-rays,
pulmonary function tests, skin tests, leukopheresis consultation, CT scan,
tissue typing, MRI.


 


•                  Restaging
of disease


 


•                  HLA
typing


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services.


 


•                  IV
or oral medications for mobilization


 


•                  Bone
marrow harvest/stem cell collection


 


•                  Stem
cell cryopreservation and storage


 


•                  NMDP
or cord bank search


 


•                  NMDP
or cord bank testing of donors


 


b)                                     TRANSPLANT CANDIDACY AND MAINTENANCE
PHASE.  Services necessary to assess
referral for formal evaluation for Transplant Services.  Medically necessary inpatient and/or
outpatient services, in order to maintain the Member’s health prior to
transplant.


 


c)                                      TRANSPLANT PROCEDURE AND PROCUREMENT
PHASE.  From day myeoloblative or
immunoablative therapy begins through discharge.


 


31

















 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services for recipient.


 


•                  Marrow
ablative or immunoablative therapy (total body irradiation and/or chemotherapy)


 


•                  Transplant


 


d)                                     POST-TRANSPLANT CARE.  Transplanted related medically necessary
services rendered to recipient for follow-up for up to 365 days post discharge.


 


•                  Inpatient
or outpatient, including professional, room and board, nursing, pharmacy and
all other ancillary services for recipient.


 


•                  Transplant
physician visits


 


•                  Laboratory
testing


 


•                  Radiology
exams


 


•                  Retransplantation


 


•                  Readmissions
related to transplant complications


 


•                  Transplant
related complications (medical care necessary related directly to transplant or
re-transplantation)


 


•                  Treatment
for GVHD (liver biopsy, hepatic panel, medications)


 


•                  CMV,
PCP, VZV prophylaxis


 


•                  Treatment
for delayed stem cell engraftment


 


4.                                       TRANSPORTATION AND
HOUSING.  Transportation and local housing may be a
Covered Service for NPTN Members.  All
such services must be pre-authorized by PacifiCare’s Case Management
Department.


 


Use
of Defined Terms.  Terms utilized in this Amendment shall have
the same meaning set forth in the definitions to the Agreement.


 


Agreement
Remains in Full Force and Effect.  Except as specifically
amended by this Amendment, the Agreement shall continue in full force and
effect.


 


32

















 


IN WITNESS
WHEREOF, the undersigned parties hereby agree to this Amendment as of the date
first set forth above.


 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  11/21/02

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  GATEWAY PHYSICIANS MEDICAL ASSOCIATES

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Michael Olson

  	
   

  
	
   

  	
   

  	
  Michael Olson

  	
   

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  11/18/02

  	
   

  
					



 


33

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT


(SPLIT CAPITATION)


 


EXHIBIT 5


 


QUALITY INCENTIVE PROGRAM


(This Exhibit 5 is an integral part of this
Agreement)


 


1.                                       Introduction.


 


This Exhibit sets forth the terms of a quality incentive program being
implemented by PacifiCare.  The program
is designed to compensate Medical Group for efforts it takes to improve the
quality of services provided to PacifiCare Members as reflected by data
measured by PacifiCare, all as described below (the “Quality Incentive Program”
or the “QIP”).


 


The Quality Incentive Program provides additional compensation to
Medical Groups which are successful in improving and maintaining certain levels
of patient safety, patient satisfaction and quality of care.  The Quality Incentive Program tracks
specific performance measures and calculates payments to the Medical Group
based on aggregating and paying specific amounts for separate performance
measures, as described in this Exhibit.


 


2.                                       Definitions.


 


In addition to other terms defined in this Exhibit or in the Agreement,
the following terms shall have the meanings set forth below:


 


2.1                                 Eligible Membership shall be the monthly Secure Horizons Members
reflected on the PacifiCare Eligibility List for the month preceding the month
in which the applicable QIP Payment will be made.  The determination of Eligible Membership shall not be changed at
any later time to reflect retroactive membership adjustments otherwise made by
PacifiCare in connection with its Managed Care Plans.  Additionally, Eligible Membership shall exclude Members who had
been transferred to Medical Group in a group transfer from another PacifiCare
Participating Provider within six (6) months prior to the date of the
applicable QIP Payment.


 


2.2                                 Leapfrog as used in the Table shall refer to data reported to PacifiCare on the
website maintained by The Leapfrog Group and supplemental data reviewed by
PacifiCare as reported by the California Office of Statewide Health Planning
and Development.


 


2.3                                 Measurement Component shall mean the Measures described in the QIP
Table.


 


2.4                                 Measurement Period is the period for which PacifiCare shall
measure data in order to calculate the applicable QIP Payment.  For the initial and subsequent QIP Payment,
the Measurement Period shall vary as defined in Section 3, QIP Table.


 


34

















 


2.5                                 PMPM
Component Payment shall be the amount attributable to each Measurement
Component as specified in the Table and shall be earned by Medical Group only
if Medical Group meets or exceeds the Performance Target for the applicable
Measurement Component.


 


2.6                                 PMPM
Payment Rate shall be the total of the PMPM Component Payments earned by
Medical Group for the applicable Measurement Period.


 


2.7                                 QIP
Payments are the quarterly payments made pursuant to the Quality Incentive
Program.


 


2.8                                 Table
means the table or tables set forth below specifying the Measurement
Components, Performance Targets, Measurement Period, Data Source, Members Measured and PMPM Component Payment.


 


2.9                                 Performance
Target is the performance target for each Measurement Component as defined
in Section 3, QIP Table. 
Performance Targets are determined by the sole discretion of PacifiCare.


 


Members Measured is defined as described in Section 3.  For Measurement Components in which Members
Measured is a combination of Commercial and Secure Horizons membership,
PacifiCare shall perform calculations utilizing a weighted average of the
Commercial and Secure Horizons membership.


 


3.               OIP Table.


 


 


	
  Measure

  	
   

  	
  Performance
  Target

  	
   

  	
  Measurement

  Period

  	
   

  	
  Data
  Source

  	
   

  	
  PMPM
  Component

  Payment

  	
   

  	
  Members Measured

  
	
  Leapfrog Initiative Participation

  	
   

  	
  85% of elective admissions at hospital
  self-reported on Leapfrog website

  	
   

  	
  12 month period ending six months prior to month
  of payout

  	
   

  	
  Leapfrog website

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and Secure Horizons assigned to
  PMG

  
	
  CABG volume threshold (per PHS TAG threshold),
  combined with CCMRP risk-adjusted CABG outcomes

  	
   

  	
  85% of CABG admissions at qualifying hospitals
  with >100 CABGs in latest reported year (or per latest OSHPD data
  available) AND NOT CCMRP “Worse Than Expected” outcome status.

  	
   

  	
  12 month period ending six months prior to month
  of payout

  	
   

  	
  Leapfrog website, supplemented by OSHPD data

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and Secure Horizons assigned to
  PMG

  
	
  PTCA volume threshold (per PHS TAG threshold)

  	
   

  	
  85% of PTCA admissions at hospitals with >200
  PTCAs in latest reported year (or per latest OSHPD data available)

  	
   

  	
  12 month period ending slix months prior to month
  of payout

  	
   

  	
  Leapfrog website, supplemented by OSHPD data

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and Secure Horizons assigned to
  PMG

  



 


	
  Measure

  	
   

  	
  Performance
  Target

  	
   

  	
  Measurement

  Period

  	
   

  	
  Data
  Source

  	
   

  	
  PMPM
  Component

  Payment

  	
   

  	
  Members
  Measured

  
	
  Computerized patient entry

  	
   

  	
  85% of elective admissions at hospitals with
  self-reported compliance on Leapfrog website

  	
   

  	
  12 month period ending six months prior to month
  of payout

  	
   

  	
  Leapfrog website, supplemented by OSHPD data

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and Secure Horizons assigned to
  PMG

  
	
  Intensive ICU staffing

  	
   

  	
  85% of elective admissions at hospitals with
  self-reported compliance on Leapfrog website

  	
   

  	
  12 month period ending six months prior to month
  of payout

  	
   

  	
  Leapfrog website, supplemented by OSHPD data

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and Secure Horizons assigned to
  PMG

  
	
  PEP-C Project Participation

  	
   

  	
  85% of elective admissions at

  	
   

  	
  2002 Survey

  	
   

  	
  California Health

  	
   

  	
  $

  	
  .1258

  	
   

  	
  All Commercial and

  



 


35

















 


	
   

  	
   

  	
  hospitals participating in PEP-C Project

  	
   

  	
   

  	
   

  	
  and Foundation

  	
   

  	
   

  	
   

  	
  Secure Horizons assigned to PMG

  
	
  Breast Cancer screening

  	
   

  	
  70.6% screening performed on members measured

  	
   

  	
  24 month period ending six months prior to
  payment period

  	
   

  	
  PacifiCare Quality Index and Provider Profile

  	
   

  	
  $

  	
  .2265

  	
   

  	
  Females age 52-69

  
	
  Cervical Cancer Screening

  	
   

  	
  51.0% screening performed on members measured

  	
   

  	
  36 month period ending six months prior to
  payment period

  	
   

  	
  PacifiCare Quality Index and Provider Profile

  	
   

  	
  $

  	
  2265

  	
   

  	
  Females age 21 -64

  
	
  Childhood Immunizations

  	
   

  	
  45.0% of recommended Immunizations performed on
  members measured

  	
   

  	
  12 month period ending six months prior to
  payment period

  	
   

  	
  PacifiCare Quality Index and Provider Profile

  	
   

  	
  $

  	
  .2265

  	
   

  	
  Children age 2

  
	
  HgbA Ic Testing- Diabetes

  	
   

  	
  72.0% Testing performed on members measured

  	
   

  	
  12 month period ending six months prior to
  payment period

  	
   

  	
  PacifiCare Quality Index and Provider Profile

  	
   

  	
  $

  	
  .2265

  	
   

  	
  Diabetic members age 31 or older

  
	
  LDL Cholesterol Testing -CAD

  	
   

  	
  71.4% Testing performed on members measured

  	
   

  	
  12 month period ending six months prior to
  payment period

  	
   

  	
  PacifiCare Quality Index and Provider Profile

  	
   

  	
  $

  	
  .2265

  	
   

  	
  Diabetic members age 31 or older

  
	
  Satisfaction with PMG

  	
   

  	
  69.0% overall satisfaction level

  	
   

  	
  2002 Member Satisfaction Survey

  	
   

  	
  PacifiCare Member Satisfaction Survey

  	
   

  	
  $

  	
  .2265

  	
   

  	
  All Commercial and Secure Horizons members
  assigned to PMG

  
	
  Satisfaction with PCP

  	
   

  	
  77.2% overall satisfaction level

  	
   

  	
  2002 Member Satisfaction Survey

  	
   

  	
  PacifiCare Member Satisfaction Survey

  	
   

  	
  $

  	
  .2265

  	
   

  	
  All Commercial and Secure Horizons members
  assigned to PMG

  
	
  Satisfaction with Specialist

  	
   

  	
  73.4% overall satisfaction level

  	
   

  	
  2002 Member Satisfaction Survey

  	
   

  	
  PacifiCare Member Satisfaction Survey

  	
   

  	
  $

  	
  .2265

  	
   

  	
  All Commercial and Secure Horizons members
  assigned to PMG

  
	
  Satisfaction with Referral Process

  	
   

  	
  68.9% overall satisfaction level

  	
   

  	
  2002 Member Satisfaction Survey

  	
   

  	
  PacifiCare Member Satisfaction Survey

  	
   

  	
  $

  	
  .2265

  	
   

  	
  All Commercial and Secure Horizons members
  assigned to PMG

  
	
  PCP Communicates Effectively

  	
   

  	
  63.1% overall satisfaction level

  	
   

  	
  2002 Member Satisfaction Survey

  	
   

  	
  PacifiCare Member Satisfaction Survey

  	
   

  	
  $

  	
  .2265

  	
   

  	
  All Commercial and Secure Horizons members
  assigned to PMG

  



 


4.               Calculation and Payment of OIP Payments.  The
following calculations and payment mechanisms shall apply:


 


(a)                                  Payment Frequency.  QIP
Payments shall be paid to Medical Group quarterly.  The QIP Payments shall be made together with Medical Group’s
Capitation Payment for the months of July 2003, October 2003,
January 2004, and April 2004.


 


(b)                                 Payment Calculation. 
Each quarterly QIP Payment shall equal: the Eligible Membership
multiplied by three (3), the product of which shall be multiplied by the PMPM
Payment Rate.


 


(c)                                  Criteria for Determining OIP Payment
Eligibility.  In order to comprehensively assess Medical
Group’s improvements in the Measurement Components, data on services


 


36

















 


provided to both Commercial Health Plan Members and Secure Horizons
Health Plan Members will be measured in connection with the Quality Incentive
Program.  Payments shall be based solely
on Eligible Membership, which only includes Secure Horizons Members.  However, payments for certain Measurement
Components, if earned, shall be made from commercial capitation funds.


 


5.                                       QIP Payments Final. 
PacifiCare’s calculation of the QIP Payment shall be final.  Medical Group recognizes that the
measurement of the QIP data is subject to variation and reasonable statistical
and operational error.  Medical Group
acknowledges that PacifiCare would not be willing to offer the Quality
Incentive Program if PacifiCare’s calculation of the QIP Payments would expose
PacifiCare to increased risk of disputes and litigation arising out of
PacifiCare’s calculation of the QIP Payment. 
Accordingly, in consideration of PacifiCare’s agreement to offer the
Quality Incentive Program to Medical Group, Medical Group agrees that Medical
Group will have no right to dispute PacifiCare’s determination of the QIP
Payment, including determination of any data or the number of Eligible Members.


 


6.                                       QIP Programs for Future Periods. 
PacifiCare in its sole and absolute discretion may implement quality
incentive programs for periods from and after January 1, 2004.  Any such programs shall be on terms
determined by PacifiCare.  PacifiCare
currently intends to provide for a quality incentive program for calendar year
2004.  Until PacifiCare and Medical
Group enter into a written agreement with respect to any such new program for
calendar year 2004, or thereafter, no such program shall be binding upon
PacifiCare.


 


7.                                       Cancellation and Termination of QIP.  The
terms of this Exhibit shall be cancelled and of no effect if Medical Group does
not participate in the Secure Horizons Health Plan as of January 1,
2003.  Additionally, the Quality
Incentive Program shall terminate at such time as Medical Group no longer is
assigned eligible Membership of at least both one thousand (1,000) Commercial
Health Plan Members and one hundred (100) Secure Horizons Health Plan
Members.  In the event of such
termination, the QIP Payments shall be prorated by changing the multiple “3” in
Paragraph 4(b) above to be the number of whole months between the last
quarterly QIP Payment and the month of termination. (Example: Last QIP Payment
is July 2003 and the termination date is September, the “3” in Paragraph
4(b) would be changed to “2”.)


 


8.                                       Effect of Termination of Agreements.  In the event of the termination of the
Agreement, for any reason, no QIP Payments shall be earned or made following
termination of the Agreement.  In the
event that the Medical Group’s participation in the Secure Horizons Health Plan
terminates prior to April 10, 2004 but the Agreement continues to be in effect
and apply to Commercial Health Plan Members, QIP Payments shall continue to be
made through the April 2004 quarterly period, with the QIP Payments to be
made based upon the Eligible Members for the month preceding the effective date
of the termination of the Medical Group’s participation in the Secure Horizons
Health Plan under the Agreement.


 


37

















 


	
   

  	
  PACIFICARE OF CALIFORNIA

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/
  Brian Jeffrey

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Vice President

  
	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
  11/21/02

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
  MEDICAL GROUP

  GATEWAY PHYSICIANS MEDICAL ASSOCIATES

  
	
   

  	
   

  
	
   

  	
  By:

  	
  /s/ Michael Olson

  
	
   

  	
   

  	
  Michael Olson

  
	
   

  	
   

  
	
   

  	
  Title:

  	
  Contracting/Network Development Director

  
	
   

  	
   

  	
   

  
	
   

  	
  Date:

  	
   

  



 


38

















 


PACIFICARE OF CALIFORNIA


 


MEDICAL GROUP/IPA SERVICES AGREEMENT


(PROFESSIONAL CAPITATION)


 


EXHIBIT 4


 


DIVISION OF FINANCIAL RESPONSIBILITY

(This Exhibit 4 is an integral part of this Agreement)


 


The following matrix outlines the Division of Financial Responsibility
(DFR) between PacifiCare, Capitated Medical Group and the Hospital, the intent
being to clarity Covered Services categories in order to provide for accurate
administration.  The matrix serves as a
model under which broad Covered Service categories suggest the appropriate
financial responsibility for Covered Services not specifically listed.  The applicable Subscriber Agreement and
Evidence of Coverage should be consulted for an accurate and complete
description of Covered Services and the Provider Manuals for
administrative/operational clarification. 
Member benefit information and eligibility should be verified prior to
the provision of services.


 


Division of Financial Responsibility


 


KEY
M = Opt-out to Medicare benefit for Hospice


 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  	
   

  
	
  Allergy- Serum-OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Allergy - Testing & Tx -  OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Ambulance (Air and Ground) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Amniocentesis - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous Blood Services - OP - Fac &
  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Biofeedback (Medically Necessary) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Detox) - IP & OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Detox) - IP & OP -
  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - IP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - IP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - IP - Prof- CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - IP - Prof -
  SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab)- OP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - OP - Prof- CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemical Dependency (Rehab) - OP - Prof -
  SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemotherapy (Including Chemotherapy Drugs
  - Inject/Oral) - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chemotherapy - IP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chiropractic - Medical - OP- Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chiropractic - Supplemental - OP - Fac &
  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Circumcision - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 












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


 


24

















 


Division of Financial Responsibility


 


KEY
M = Opt-out to Medicare benefit for Hospice


 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  	
   

  
	
  Diagnostic Test - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DME - IP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DME. Ostomy Colostomy Supplies, Prosthetics/Orthotics
  - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Room - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Emergency Room - OP - E.R. Phys.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Endoscopic Studies - IP -

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Endoscopic Studies - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Endoscopic Studies - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Abortions - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Abortions - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Contraceptive Devices -
  Insertion - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Contraceptive Devices -
  Non-Rx (eg. Norplant/IUD) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Contraceptive Devices -
  Prescription - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - GIFT/ZIFT/IVF - OP - Fac
  & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Infertility Procedures -
  OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - infertility Procedures -
  OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Infertility Testing - OP
  - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Sterilization - IP &
  OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Sterilization - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Family Planning - Sterilization - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Fetal Monitoring - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Health Education - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Health Eval/Physical

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hearing Aids/Molds - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hearing Screening (Audiologic Evaluation) -
  OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hemodialysis / Dialysis - IP & OP -
  Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hemodialysis / Dialysis - OP - Fac
  (including all drugs)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Home Health Care / Homebound Infusion
  Therapy - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hosp Based Phys Interpretative Serv Incl
  Radiology & Pathology - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hospice Services (Medicare) - IP - Fac & Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hospice Services - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Hospitalization Services - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Immunizations & Inoculations (Medically
  Necessary) - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Infusion therapy - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Injectables - Not Part of Outpatient
  Pharmacy Benefits - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory/Pathology (Diagnostic Only) - OP
  - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory/Pathology (Diagnostic Only) - OP
  - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory/Pathology - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Lithotripsy - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Lithorripsy - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Med/Surg Supplies (casts, splints,
  bandages) - Office - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Medication - Prescription - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health (Crisis Intervention) - OP -
  Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH: AB88 Benefits (Mental Health
  Parity applies to CO only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP & OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP & OP - Prof - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


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


 


25

















 


Division of Financial Responsibility


 


KEY M = Opt-out to Medicare benefit forHospice


 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  	
   

  
	
  MENTAL HEALTH: Secure Horizons and
  Commercial (nor, AB88 Benefits)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP and OP - Fac - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP and OP - Fac - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP and OP - Prof- CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Mental Health - IP and OP - Prof - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Observation Room - OP -
  Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Oral Surgery / Dental
  Services - Accident & Injury
  Only - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Oral Surgery / Dental Services - Accident
  & Injury Only - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out of Area - IP & OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out of Area - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Surgery - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Outpatient Surgery - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Physician Services (All Professional Services)
  - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Prostheties - Surgical Implants - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Therapy - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiation Therapy - OP - Fac and / or
  freestanding facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology (Diagnostic Only) - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology (Diagnostic
  Only) - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Radiology - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Reconstructive Surgery - IP & OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Reconstructive Surgery - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Rehabilitation - Cardiac. OT/PT/RT/ST - OP
  - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Rehabilitation - Cardiac. OT/PT/RT/ST - OP
  - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Skilled Nursing Facility - IP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Sleep Studies - OP

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TMJ - Evaluation (excludes dental
  exams/treatment) - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transfusions - OP - Fac

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Candidacy and Maintenance; OP
  and IP Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Candidacy and Maintenance; OP
  and IP Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Evaluation (excludes corneal);
  OP and IP Professional. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Evaluation (excludes corneal);
  OP and IP Facility. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Procedure and Procurement
  (excludes corneal); OP and IP Professional Services. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Procedure and Procurement
  (excludes corneal); OP and IP Facility. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Related Transportation and
  Housing - NPTN specific benefit. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Follow-up (excludes corneal); OP
  and IP Professional; Year I. See Note (1).

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Follow-up (excludes corneal); OP
  and IP Facility; Year 1. See Note (1)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Years 2 - 5 Follow-up (excludes
  corneal); OP and IP Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Transplant Years 2 -5; Follow-up (excludes
  corneal); OP and IP Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Urgent Care - OP - Fac & Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Vision - Medical Treatment - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Vision - Refraction for Contact
  Lenses/Frames - OP - Prof

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  



 


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


 


26

















 


Division
of Financial Responsibility


 


KEY: M = Opt-out to Medicare benefit for Hospice


 


	
  Service Description

  	
   

  	
  Medical

  Group

  	
   

  	
  Hospital

  Incentive

  Program

  	
   

  	
  PacifiCare

  	
   

  
	
  Vision Care Materials - Contact
  Lenses/Frames (non-cataract) - OP - CO

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Vision Care Materials - Contact
  Lenses/Frames (non-cataract) - OP - SH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  



 


Notes:


 












(1)                                  PacifiCare responsibility
for transplant services is limited to those services defined in this Agreement,
the DFR and Attachment A, Exhibit 4.


 


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


 


27