Document:

Exhibit
10.108

 

AIM

 

MEDICAL
SERVICES AGREEMENT

 

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

 

 

AIM

MEDICAL SERVICES AGREEMENT

 

TABLE OF CONTENTS

 

	
  I.

  	
  RECITALS

  	
   

  
	
   

  	
   

  	
   

  
	
  II.

  	
  DEFINITIONS

  	
   

  
	
   

  	
   

  	
   

  
	
  III.

  	
  RELATIONSHIP
  BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  IV.

  	
  PARTICIPATING
  MEDICAL GROUP SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  V.

  	
  BLUE CROSS
  SERVICES AND RESPONSIBILITIES

  	
   

  
	
   

  	
   

  	
   

  
	
  VI.

  	
  ELIGIBILITY
  LISTINGS

  	
   

  
	
   

  	
   

  	
   

  
	
  VII.

  	
  COMPENSATION
  TO PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  VIII.

  	
  ENROLLMENT PROTECTION

  	
   

  
	
   

  	
   

  	
   

  
	
  IX.

  	
  BLUE
  CROSS SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  X.

  	
  TERM OF AGREEMENT,
  TERMINATION

  	
   

  
	
   

  	
   

  	
   

  
	
  XI.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  XII.

  	
  AIM MEMBER GRIEVANCE
  SYSTEM

  	
   

  
	
   

  	
   

  	
   

  
	
  XIII.

  	
  MISCELLANEOUS PROVISIONS

  	
   

  
	
   

  	
   

  
	
  EXHIBITS

  	
   

  
	
   

  	
   

  
	
  Exhibit A

  	
  Covered Medical Services

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  A(1)

  	
  Division
  of Financial Responsibilities

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit B

  	
  AIM
  Hospitals

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  C

  	
  Administrative
  Responsibilities of PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit D

  	
  Capitation

  	
   

  
	
   

  	
   

  	
   

  
	
  Exhibit
  E

  	
  PARTICIPATING
  MEDICAL GROUP Facilities

  	
   

  
				

 

 

AIM

MEDICAL SERVICES AGREEMENT

 

This AGREEMENT is effective on May 1, 2001, between BLUE CROSS OF CALIFORNIA and Affiliates
(jointly and severally “BLUE CROSS”)
and Professional Care IPA Medical Group,
(“PARTICIPATING MEDICAL GROUP”).

 

I.                                         RECITALS

 

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

 

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

 

II.                                     DEFINITIONS

 

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

 

2.02                 “AIM Case Manager” means a BLUE CROSS employee charged with
assisting PARTICIPATING MEDICAL GROUPs in case management.

 

2.03                 “AIM Coordinator” means an employee of PARTICIPATING MEDICAL
GROUP as set forth in Section 4.08B.

 

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

 

2.05                 “AIM Program” means the program for increased access to
maternity, delivery, and infant care services for low income women, offered by
BLUE CROSS as a California Care program under contract with the State of
California pursuant to California Insurance Code Section 12695 et seq. Although the AIM Program is a
California Care program, it is in some ways unique and will, therefore, be
separately identified in this Agreement.

 

2.06                 “AIM Quality Management Representative” means an employee of BLUE CROSS responsible
for the AIM Quality Management Program.

 

1

 

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

 

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

 

2.09                 “Benefit Agreement(s)” means the written agreement(s) entered into
between BLUE CROSS and the State of California, under which BLUE CROSS
provides, indemnifies, or administers health benefits to persons enrolled in
the AIM Program.

 

2.10                 “BLUE CROSS Managed Care Network” means the network of health care providers
that have entered into contracts with BLUE CROSS and/or one or more of its
Affiliates pursuant to which those providers have agreed to participate in the
AIM Program.

 

2.11                 “BLUE CROSS Services” means the designated services set forth in
Article IX and Exhibit A (1).

 

2.12                 “California Care” means direct care prepayment plan(s) offered
by BLUE CROSS.

 

2.13                 “Capitation” means a uniform prepayment fee per Member per month, adjusted by age.

 

2.13                 “Capitation Services” means all AIM Covered Medical Services which
are not otherwise designated as Insured Services or the responsibility of BLUE
CROSS, in the Division of Financial Responsibilities under Exhibit A(1).

 

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

 

2.16                 “Covered Medical Services” means the services and benefits covered under
the Benefit Agreements.  A matrix of
those services and benefits is set forth in Exhibit A (incorporated by
reference herein).  A matrix of financial
responsibility for those services and benefits is set forth in Exhibit A(1).

 

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

 

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

 

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

 

C & R charges are
determined by BLUE CROSS.

 

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

 

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

 

2

 

B.             Serious
impairment to bodily functions,

 

C.             Other
serious medical consequences, or

 

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

 

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

 

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

 

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

 

2.22                 “Hospital Services” means Medically Necessary acute and sub-acute
care inpatient and hospital outpatient services and supplies which are both (a)
covered by a Benefit Agreement, and (b) ordered or authorized by a
PARTICIPATING MEDICAL GROUP Physician. 
Hospital Services do not include long-term non-acute care.

 

2.23                 “Independent Practice Association” means an incorporated association of
independent physicians which has entered into an agreement with BLUE CROSS to
provide and arrange for health services to Members.

 

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

 

2.25                 “Insured Services”   means
the benefits and services as set forth in Article VII, COMPENSATION TO
PARTICIPATING MEDICAL GROUP, including:

 

A.           The
benefits and services referenced in Section 7.08 (expenses which are paid
directly by PARTICIPATING MEDICAL GROUP, to be reimbursed by BLUE CROSS).

 

B.             The
benefits and services referenced in Section 7.09 (expenses which are paid
directly by BLUE CROSS).

 

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

 

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

 

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

 

3

 

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

 

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

 

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

 

2.27                 “Member”
means a Subscriber or enrolled dependent covered by a Benefit Agreement.

 

2.28                 “Member
Months” means a count that records one Member month for each month the
Member is enrolled in the AIM Program.

 

2.29                 ‘Operations Manual” means the AIM PMG Operations Manual.

 

2.30                 “Out-of-Area Emergency Services” means Emergency services which are rendered
to a Member at a distance of more than twenty (20) mile radius from the medical
offices of PARTICIPATING MEDICAL GROUP or the Satellite Facility to which the
Member is assigned.  When PARTICIPATING
MEDICAL GROUP is organized as an Independent Practice Association, Out-of-Area
Emergency Services are those Emergency services which are rendered to a Member
at a distance of more than twenty (20) mile radius from each hospital
designated in Exhibit B as a Service Area hospital.  Out-of-Area Emergency Services shall also
include Out of Area urgently needed services to prevent serious deterioration
of a Member’s health resulting from unforeseen illness or injury for which treatment
cannot be delayed until the Member returns to the Service Area.

 

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

 

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

 

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

 

2.34                 “Quality Management Committee” means a committee of physicians and other
licensed health care providers, at least fifty percent (50%) of whom
participate in CaliforniaCare, which meets regularly to review the Quality
Management Program.

 

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

 

4

 

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

 

2.37                 “Referral Services” means Capitation Services which are rendered
to Members through a process established by PARTICIPATING MEDICAL GROUP.

 

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

 

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

 

2.40                 “Subscriber” means an individual who has qualified for and is covered under a
Benefit Agreement.

 

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

 

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

 

III.                                 RELATIONSHIP BETWEEN BLUE CROSS AND
PARTICIPATING MEDICAL GROUP

 

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

 

3.02                 BLUE CROSS and PARTICIPATING MEDICAL GROUP
agree that PARTICIPATING MEDICAL GROUP Physicians shall maintain a
physician-patient relationship with each Member assigned to PARTICIPATING
MEDICAL GROUP.  PARTICIPATING MEDICAL GROUP
shall be solely responsible to the Member for treatment and medical care with
respect to the provision of Capitation Services and arrangements for Insured
Services and BLUE CROSS Services. 
PARTICIPATING MEDICAL GROUP may freely communicate with Members
regarding the treatment options available to them, including mediation
treatment options, regardless of benefit coverage limitations.

 

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

 

5

 

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

 

IV.                                 PARTICIPATING MEDICAL GROUP SERVICES AND
RESPONSIBILITIES

 

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

 

4.01                 Provision of Services.

 

A.           To
promptly provide, arrange through referral, or authorize all Capitation
Services and Insured Services, and to authorize or arrange for the provision of
BLUE CROSS Services, and further, to accept full financial responsibility for
all Capitation Services provided, authorized or arranged through referral, by
PARTICIPATING MEDICAL GROUP in accordance with the provisions of this
Agreement.

 

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

 

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

 

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

 

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

 

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

 

6

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

4.02                           Accessibility and Continuity of Care.

 

A.           To
promptly provide or arrange for available and accessible Covered Medical
Services for each Member assigned to PARTICIPATING MEDICAL GROUP, in accordance
with that Member’s Benefit Agreement and this Agreement, and to provide those
services in and through facilities designated in Exhibit F (incorporated by
reference herein).

 

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

 

C.             To
promptly provide, arrange or authorize all Emergency services for each Member
assigned to PARTICIPATING MEDICAL GROUP. 
Authorization of any Emergency services, as set forth in
Section 2.18 herein, shall not be withheld by PARTICIPATING MEDICAL GROUP
regardless of whether PARTICIPATING MEDICAL GROUP is notified within
forty-eight (48) hours from the time such Emergency services were
rendered.  PARTICIPATING MEDICAL GROUP
shall comply with all requirements set forth in California Health and Safety
Code Section 1371.4(a) - (d).

 

D.            That
PARTICIPATING MEDICAL GROUP shall manage and facilitate access to Emergency
services within a twenty (20) mile radius of each Satellite Facility and
PARTICIPATING MEDICAL GROUP’s main facility at all times, twenty-four (24)
hours a day, seven (7) days a week.  In
the event that PARTICIPATING MEDICAL GROUP is an Independent Practice
Association, PARTICIPATING MEDICAL GROUP shall manage and facilitate access to
Emergency services within a twenty (20) mile radius of the Hospital(s)
designated in Exhibit B (incorporated by reference herein) as the AIM
Hospital(s) within PARTICIPATING MEDICAL GROUP’s Service Area.

 

7

 

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

 

F.              Notwithstanding
Section 4.02E, for those Members that require transplant services (solid
organ and bone marrow/stem cell) that are Covered Medical Services,
PARTICIPATING MEDICAL GROUP agrees to admit, or authorize the inpatient
admission or outpatient treatment of Members, solely at those AIM Hospitals
whose transplant programs have been approved by BLUE CROSS and identified as
such in the Operations Manual.

 

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

 

G.             That
in circumstances where a Member requires specialized tertiary care or because
of bed unavailability in an AIM Hospital, the Member must be admitted to a
non-AIM in-area or out-of-area facility for Hospital Services, then until the
Member is transferred to an AIM Hospital, the PARTICIPATING MEDICAL GROUP will
be financially responsible for care the same as if care had been provided in an
AIM Hospital.

 

H.            To
use a referral request process by which Capitation Services are to be rendered
by Health Professionals other than the Member’s Primary Care Physician,
including PARTICIPATING MEDICAL GROUP Physicians or other Health Professionals
who do not belong to PARTICIPATING MEDICAL GROUP.  This process shall assure that:

 

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

 

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

 

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

 

(4)          Members may directly access PARTICIPATING MEDICAL GROUP Physicians in
the following specialties without the prior authorization of PARTICIPATING
MEDICAL GROUP’s Utilization Management Program:

 

(a)          Dermatology

(b)         Allergy

(c)          Obstetrics/Gynecology

(d)         Ear, Nose and Throat

 

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

 

8

 

J.                To
assure that Members shall not be subject to discrimination in access to Covered
Medical Services.  PARTICIPATING MEDICAL
GROUP shall comply with State of California non-discrimination requirements.

 

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

 

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

 

M.         To
provide a patient education program on smoking for Members within the
guidelines indicated in the Operations Manual.

 

4.03                 Utilization/Quality Management and Grievance
Procedures.

 

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

 

4.04                 Quality Management Program.

 

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

 

A.           The
Quality Management Program shall:

 

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

 

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

 

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

 

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

 

(1)          Credentialing, recredentialing and peer review of all PARTICIPATING
MEDICAL GROUP Physicians and allied Health Professional providers.

 

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

 

(3)          Incident identification and risk management.

 

(4)          Member grievance resolution.

 

9

 

(5)          General and focused health care audits.

 

(6)          Development and implementation of appropriate recommendations.

 

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

 

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

 

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

 

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

 

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

 

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

 

D.            PARTICIPATING
MEDICAL GROUP shall:

 

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

 

(2)          Provide BLUE CROSS with access to all PARTICIPATING MEDICAL GROUP
Quality Management data directly or indirectly relating to Members.

 

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

 

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

 

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

 

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

 

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

 

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

 

4.05                 Utilization Management Program.

 

To adopt and maintain a Utilization Management Program consistent with
BLUE CROSS standards and approved by BLUE CROSS.  This program will cover all Covered Medical
Services provided or arranged by PARTICIPATING MEDICAL GROUP for Members.  PARTICIPATING

 

10

 

MEDICAL GROUP agrees to allow on-site review(s) of Utilization
Management Program by BLUE CROSS.

 

11

 

A.           The
Utilization Management Program shall:

 

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

 

(2)          Include documentation as described in the Operations Manual of remedial
procedures for instances of inappropriate or substandard services(s) and or
failure to provide Medically Necessary Covered Medical Services.

 

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

 

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

 

(5)          Work closely with AIM Hospitals.

 

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

 

(7)          Utilize prospective, concurrent, and retrospective review.

 

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

 

(9)          Permit BLUE CROSS to have access to all PARTICIPATING MEDICAL GROUP
Utilization Management data directly or indirectly relating to Members.

 

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

 

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

 

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

 

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

 

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

 

C.             PARTICIPATING
MEDICAL GROUP shall:

 

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

 

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

 

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

 

4.06                 Records and Reserves.

 

A.           BLUE
CROSS shall have access at reasonable times upon demand to the books, records
and papers of PARTICIPATING MEDICAL GROUP relating to the services
PARTICIPATING MEDICAL GROUP provides to Members, to the cost thereof, and to
payments PARTICIPATING MEDICAL GROUP receives from Members or others on their
behalf.  PARTICIPATING MEDICAL GROUP
shall maintain such records and provide such

 

12

 

information
to BLUE CROSS and the Commissioner of Corporations as may be necessary for BLUE
CROSS’ compliance with the requirements of the Knox-Keene Act.  PARTICIPATING MEDICAL GROUP shall maintain
such records for at least five (5) years, and such obligations shall not be
terminated upon a termination of this Agreement, whether by rescission or
otherwise.

 

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

 

(1)          Balance sheets

 

(2)          Statements of revenues and expenses

 

(3)          Statements of cash flow

 

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

 

C.             To
maintain financial reserves adequate to cover all risks assumed by
PARTICIPATING MEDICAL GROUP hereunder, including, but not limited to,
unanticipated claims for Referral Services that are the potential
responsibility of PARTICIPATING MEDICAL GROUP.

 

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

 

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

 

4.07                 Insurance Programs or Policies.

 

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

 

A.           Professional
Liability Insurance

 

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

 

13

 

in minimum amounts of ONE MILLION DOLLARS ($1,000,000.00) for any one
incident, ONE MILLION DOLLARS ($1,000,000.00) annual aggregate.

 

B.             Other
Insurance

 

(1)          General Liability Insurance.  In
addition to Subsection A., above, PARTICIPATING MEDICAL GROUP shall also
maintain a policy or program of comprehensive general liability insurance (or
other risk protection) with minimum coverage including no less than ONE HUNDRED
THOUSAND DOLLARS ($100,000.00) for PARTICIPATING MEDICAL GROUP’s property,
together with combined single limit bodily injury and property damage insurance
of not less that SIX HUNDRED THOUSAND DOLLARS ($600,000.00).

 

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

 

4.08                           Administrative Responsibilities.

 

A.           To
comply with all BLUE CROSS administrative policies and procedures in the areas
listed in Exhibit C (incorporated by reference herein) and as set forth in the
Operations Manual (incorporated by reference herein) and to comply with all
applicable state and federal laws and regulations relating to the delivery of
Covered Medical Services.

 

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

 

C.             To
notify BLUE CROSS within Fifteen (15) days concerning:

 

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

 

(2)          Any legal or governmental action initiated against a PARTICIPATING
MEDICAL GROUP Physician or against PARTICIPATING MEDICAL GROUP which might
affect BLUE CROSS or this Agreement including, but not limited to, any change
in PARTICIPATING MEDICAL GROUP Physician(s) licensure, insurance,
certification, malpractice, disciplinary experience or physical or mental
health status.

 

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

 

D.            To
obtain BLUE CROSS’ prior written approval for any literature related to AIM and
intended for Members.

 

E.              To
continually meet all criteria for PARTICIPATING MEDICAL GROUP’s, set forth in
the Operations Manual, and to continually meet all criteria for Satellite
Facilities (if applicable) set forth in the Operations Manual.

 

F.              To
provide BLUE CROSS, on a monthly basis, all ambulatory encounter data
electronically as described in the Operations Manual.

 

14

 

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

 

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

 

I.                 To
provide at least ninety (90) days advance written notice to BLUE CROSS whenever
(a) a PARTICIPATING MEDICAL GROUP Physician who is a Primary Care Physician is
no longer a PARTICIPATING MEDICAL GROUP Physician; or (b) a Satellite Facility
closes, relocates or is unable to serve Members.

 

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

 

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

 

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

 

4.09                           Payments and Member Billing.

 

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

 

If PARTICIPATING MEDICAL GROUP should receive any surcharge or payment
from a Member, in addition to those permissible charges set forth above,
PARTICIPATING MEDICAL GROUP shall promptly refund the full amount thereof to
the Member.

 

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

 

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

 

D.            That
PARTICIPATING MEDICAL GROUP shall promptly notify, in writing, the AIM Case
Management Department of all cases that reach the Enrollment Protection level
specified herein.

 

15

 

E.              To
pay all Health Professionals who have rendered authorized Referral Services to
Members, within forty-five (45) working days following receipt of a clean,
undisputed claim, consistent with the regulations of the Commissioner of
Corporations governing BLUE CROSS.

 

F.              That
BLUE CROSS may change Exhibit E.  In the
event of such change, BLUE CROSS shall notify PARTICIPATING MEDICAL GROUP of
the change at least ninety (90) days in advance of the effective date of the
change.

 

4.10                 Membership.

 

A.           To
accept any and all Members who select PARTICIPATING MEDICAL GROUP until such
time as PARTICIPATING MEDICAL GROUP shall have provided ninety (90) days prior
written notice to BLUE CROSS that it has reached its maximum capacity as set
forth in Section 13.08 herein, or that it anticipates reaching such
maximum within ninety (90) days from the date of the notice to BLUE CROSS.  The maximum capacity of PARTICIPATING MEDICAL
GROUP designated in Section 13.08 shall be reduced only upon ninety (90)
days written notice to BLUE CROSS.  The
parties acknowledge their understanding that enrollment from individual
accounts, or changes in selection of PARTICIPATING MEDICAL GROUP by Members,
are not entirely within the control of BLUE CROSS.

 

B.             That
PARTICIPATING MEDICAL GROUP will not request, demand, require or otherwise seek
the transfer or removal of any Member from the care of PARTICIPATING MEDICAL
GROUP, based on that Member’s need of, or utilization of, Medically Necessary
services.

 

C.             PARTICIPATING
MEDICAL GROUP agrees that, in the event a Member who is covered for workers’
compensation benefits by a workers’ compensation carrier affiliated with BLUE
CROSS, seeks services for a work-related illness or injury, PARTICIPATING
MEDICAL GROUP shall have the option to (a) provide such Medically Necessary
medical services or (b) refer such Member to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.  In the event
that PARTICIPATING MEDICAL GROUP elects to treat such Member, PARTICIPATING
MEDICAL GROUP shall complete a Doctor’s First Report of Injury as defined in
the California Labor Code.  As payment
for such medical services rendered, PARTICIPATING MEDICAL GROUP agrees to
accept, as payment in full, compensation in accordance with the then current
Blue Cross of California Prudent Buyer Plan Participating Physician Agreement
fee schedule for the applicable region. 
PARTICIPATING MEDICAL GROUP further agrees that, in the event such
Member requires medical services in connection with such work-related illness
or injury beyond the treatment provided at the initial visit, PARTICIPATING
MEDICAL GROUP shall refer such Member only to a provider that participates in
the Prudent Buyer Comp provider network or the CalCare Comp provider network,
whichever is applicable.

 

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

 

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

 

16

 

V.                                     BLUE CROSS SERVICES AND RESPONSIBILITIES

 

BLUE CROSS agrees:

 

5.01                 To perform, or arrange for the performance of,
all necessary accounting and enrollment functions with respect to marketing and
administering the AIM Program, and to issue an identification card to each
Subscriber as described in the Operations Manual.  AIM Program enrollment shall be determined by
the State of California and shall be reported to PARTICIPATING MEDICAL GROUP by
BLUE CROSS as directed by the State of California.

 

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

 

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

 

5.04                 To provide PARTICIPATING MEDICAL GROUP with
claims paid and BLUE CROSS Services data as described in the Operations Manual.

 

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

 

5.06                 To undertake reasonable efforts, in accordance
with a standard of good faith, to assure that Members assigned to PARTICIPATING
MEDICAL GROUP will live or work within the Service Area defined in this
Agreement.  However, BLUE CROSS reserves
the right to assign any Members to PARTICIPATING MEDICAL GROUP when the Member
changes residence, or when BLUE CROSS determines such transfer to be in the
Member’s best interest due to special circumstances under the terms of the Member’s
Benefit Agreement.

 

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

 

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

 

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

 

5.10                 To collect, or arrange to have collected, all
premiums, Member payments and other items of income to which BLUE CROSS is
entitled under its contracts or otherwise, except for (a) co-payments,

 

17

 

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

 

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

 

VI.                                 ELIGIBILITY LISTINGS

 

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

 

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

 

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

 

(1)          duplicate copies of paper reports,

 

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

 

(3)          duplicate reports for prior months.

 

C.             BLUE
CROSS will discourage retroactive cancellation of more than ninety (90) days
from BLUE CROSS’ applicable monthly billing process date.  However, when no services have been rendered,
BLUE CROSS may make occasional exceptions due to legitimate administrative processing
requirements.  Notwithstanding any
retroactive cancellation of a Member of more than ninety (90) days, BLUE CROSS
shall not be entitled to any refund of Capitation payments made for such Member
beyond the ninety (90) day period.  BLUE
CROSS will attempt to discourage retroactively adding any Member after the
applicable billing is reconciled.  In the
event BLUE CROSS finds it necessary to assign, up to ninety (90) days
retroactively, a new Member to PARTICIPATING MEDICAL GROUP, Capitation payment
for that Member shall be made, and PARTICIPATING MEDICAL GROUP agrees to be
responsible for all Covered Medical Services due that Member under the terms of
the Member’s Benefit Agreement which were provided or arranged by PARTICIPATING
MEDICAL GROUP, from the date the Member was assigned.

 

18

 

D.            In
the event care is provided to an ineligible person, based on an erroneous or
delayed Eligibility Report, BLUE CROSS shall be financially responsible for all
care provided by PARTICIPATING MEDICAL GROUP prior to the time PARTICIPATING
MEDICAL GROUP received notice of that person’s ineligibility and, on the
condition that PARTICIPATING MEDICAL GROUP shall supply BLUE CROSS with
evidence that PARTICIPATING MEDICAL GROUP has unsuccessfully sought payment for
all or a portion of the charges from the ineligible person, or the person
having legal responsibility for the ineligible person, through two billing
cycles, or through a period of sixty (60) days, whichever is greater.  In that event, BLUE CROSS’ responsibility for
physician compensation shall be measured as set forth in the then current Blue
Cross of California Prudent Buyer Plan Participating Physician fee
schedule for the applicable region or the actual billed amount, whichever
is less.  The obligations of BLUE CROSS
under this Subsection D shall be conditioned upon the (1) exercise of
prudent judgment by PARTICIPATING MEDICAL GROUP, evidenced by reasonable
efforts to contact BLUE CROSS for verification of the eligibility of each
Member prior to providing or arranging Covered Medical Services, and (2)
submission to BLUE CROSS of both the claim and evidence of its unsuccessful
collection efforts within twelve (12) months of the date of service.

 

VII.                             COMPENSATION TO PARTICIPATING MEDICAL GROUP 

 

7.01                           CAPITATION

 

A.           Exhibit
D (incorporated by reference herein), sets forth the Capitation payments.  The applicable Capitation payment for each
Member assigned to PARTICIPATING MEDICAL GROUP, shall be paid monthly, prorated
in accordance with Member eligibility.

 

B.             The
Capitation payment to PARTICIPATING MEDICAL GROUP for each mother will begin on
the date the mother is assigned to PARTICIPATING MEDICAL GROUP and will
continue up to sixty (60) days after delivery.

 

C.             In
the event BLUE CROSS assigns a mother to PARTICIPATING MEDICAL GROUP
retroactively, the Capitation payment will be made from the date the mother is
assigned to PARTICIPATING MEDICAL GROUP. 
BLUE CROSS will discourage retroactive additions beyond a ninety (90)
day period.

 

D.            The
Capitation payment to PARTICIPATING MEDICAL GROUP will be made for each infant
for professional services related to normal pregnancy and cesarean
section delivery including the administration of pediatric immunizations,
periodic checkups, other covered professional services and covered outpatient
services.  The Capitation payment made
under this Section 7.01.D will begin from the date of birth and continue
for a period of up to twenty-four (24) months after birth.

 

E.              The
provision of professional services for treatment of complications for an infant
on an inpatient basis will be paid at the rates set forth at in the then
current Blue Cross of California Prudent Buyer Plan Participating Physician
Agreement fee schedule for the applicable region.  “Complications” means it is Medically
Necessary to admit the infant to a Level II or Level III intensive care newborn
nursery (hereafter referred to as “Complications”).  PARTICIPATING MEDICAL GROUP shall bill BLUE
CROSS for services rendered in conjunction with the treatment of Complications
within twelve (12) months of date of service.

 

19

 

F.              All
covered professional services and supplies for infants treated for
Complications will be paid in accordance to the coverage limits of the Benefit
Agreement, not to exceed total expense incurred for those services and
supplies.

 

G.             The
Capitation payment for infants treated for Complications will be suspended and
resume when further confinement in a Level II or Level III intensive care
newborn nursery is not Medically Necessary. 
BLUE CROSS will reconcile the Capitation payment for infants on a
retroactive basis pursuant to the date an infant begins treatment for
Complications and therefore the PARTICIPATING MEDICAL GROUP commences receiving
payment under Paragraphs E and F above.

 

H.            PARTICIPATING
MEDICAL GROUP will not be at risk for the provision of Institutional services
to Members.  For Members, hospitals and
other institutions will be paid based on BLUE CROSS contracted rates and/or
fee-for-service.

 

7.02                 Capitation shall be paid in consideration for
providing Capitation Services and Insured Services and arranging BLUE CROSS
Services for each Member assigned to PARTICIPATING MEDICAL GROUP and in
consideration for all Capitation Services and Insured Services arranged through
referral for Members by PARTICIPATING MEDICAL GROUP.  The Capitation payment shall be made by the
tenth of each month and shall be computed on the basis of the most current
information available.  In the event that
an error is made in the computation of the Capitation payment, resulting in an
overpayment or underpayment to PARTICIPATING MEDICAL GROUP, BLUE CROSS reserves
the right to adjust subsequent Capitation payments to PARTICIPATING MEDICAL
GROUP to offset such overpayment or underpayment.

 

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

 

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

 

7.04                 PARTICIPATING MEDICAL GROUP agrees to be
responsible for professional and facility charges, as described in Exhibit A(1)
(incorporated by reference herein).

 

7.05                 In the event a referral provider has not been
reimbursed for authorized Referral Services or that any other provider has not
been reimbursed by PARTICIPATING MEDICAL GROUP as required under their
agreement for services provided to Members within forty-five (45) working days
following receipt of a clean, undisputed claim, then after notice BLUE CROSS
shall have the option to pay a clean and uncontested claim and deduct such
payment (including any interest payable under Health & Safety Code
Section 1371), plus an administrative charge equal to ten percent (10%) of
the claim amount, from any money due from BLUE CROSS to PARTICIPATING MEDICAL
GROUP.  If a total of five (5) or more
instances occur where any provider associated with PARTICIPATING MEDICAL GROUP
bills a Member in violation of this Agreement during any calendar year, BLUE
CROSS may, in its sole discretion, suspend the assignment of new Members to
PARTICIPATING MEDICAL GROUP until such time as PARTICIPATING MEDICAL GROUP has
rectified the problem to BLUE CROSS’ satisfaction.

 

20

 

7.06                 Transplant Services.

 

For those transplant (bone marrow/stem cell and solid organ) services
for which PARTICIPATING MEDICAL GROUP is financially responsible (i.e.,
professional component), PARTICIPATING MEDICAL GROUP shall pay for services at
the applicable rate negotiated by BLUE CROSS for professional transplant
services or at the rate negotiated by PARTICIPATING MEDICAL GROUP.  If such payment has been made directly by
BLUE CROSS to the provider, PARTICIPATING MEDICAL GROUP shall remit payment to
BLUE CROSS within forty-five (45) days of BLUE CROSS’ written request or BLUE
CROSS may adjust subsequent Capitation payments to offset such payment amount.

 

7.07                 With respect to BLUE CROSS’ AIM Program,
pregnancy and maternity services (as set forth in the Benefit Agreement)
rendered by PARTICIPATING MEDICAL GROUP to a Member shall, at the date of
delivery, be compensated at *** per applicable Member (hereafter referred to as
the “Global Fee”).  For the purposes of
this Section, “delivery” shall mean a live birth, either by vaginal or cesarean
delivery with both a minimum fetal weight of 500 grams and a minimum length of
20 centimeters or with a minimum of 20 weeks gestation.  Alternately, “delivery” shall mean the
vaginal delivery of a stillbirth of a minimum of 20 weeks gestation, labor
induced by pitosin or prostoglandin, with a licensed obstetrician in
attendance.  The Global Fee payment is
compensation for pregnancy and maternity care services, professional services
provided to the mother for delivery including prenatal and postnatal physician’s
office visits, other covered professional services and covered outpatient
services.  PARTICIPATING MEDICAL GROUP
shall bill BLUE CROSS for a Global Fee within twelve (12) months of “delivery”.

 

7.08                 INSURED SERVICES, as defined in this
Agreement, shall include each of the services and benefits set forth in this
Section 7.08, which shall be provided according to the Benefit Agreement
and paid directly by PARTICIPATING MEDICAL GROUP.  Except as stated below, reimbursement to
PARTICIPATING MEDICAL GROUP for the following Insured Services shall be made by
BLUE CROSS in accordance with the lesser of (i) actual billed charges; (ii) the
Blue Cross of California Prudent Buyer Plan Physician Agreement fee
schedule for the applicable region; (iii) the rate negotiated between BLUE
CROSS and the provider of service; or (iv) the amount actually paid by
PARTICIPATING MEDICAL GROUP, within forty-five (45) working days following
receipt of a clean, undisputed claim as follows, on the condition that such
claim shall be submitted to BLUE CROSS no later than twelve (12) months after
the date of service:

 

A.           Chemotherapy
drugs, intravenously administered, exclusive of professional charges.

 

B.             Durable
medical equipment and prosthetic devices.

 

C.             Mammography.
Reimbursement for routine mammograms shall be limited to *** per Member per
calendar year.

 

D.            Pregnancy
and maternity services.  Reimbursement
shall equal the Global Fee *** as
set forth in Section 7.07 above.

 

E.              Professional
hemodialysis services.

 

F.              Hepatitis
B vaccine and gamma globulin.

 

G.             Pediatric
immunization serums.

 

7.09                 The provider of Insured Services may bill BLUE
CROSS directly, in which case, BLUE CROSS shall reimburse said provider within
forty-five (45) working days following receipt of a clean, undisputed claim
accompanied by an Authorization from PARTICIPATING MEDICAL GROUP.  This section shall only apply for the
following Insured Services: Chemotherapy drugs, durable medical equipment and
prosthetics devices, and professional hemodialysis services.

 

21

 

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

 

VIII.                         ENROLLMENT
PROTECTION

 

8.01                 Enrollment Protection is a program designed to
limit PARTICIPATING MEDICAL GROUP’s liability for Capitation Services expense.

 

8.02                 The liability of PARTICIPATING MEDICAL GROUP
for expenses for Capitation Services rendered to any single Member enrolled in
BLUE CROSS’ AIM Program shall be limited to the first *** of such expenses
during the mother’s enrollment and each calendar year of the infant’s
enrollment if PARTICIPATING MEDICAL GROUP elects Enrollment Protection as set
forth in Exhibit D herein.

 

8.03                 The total expenses of PARTICIPATING MEDICAL
GROUP for Capitation Services rendered to any single Member during the mother’s
enrollment and each calendar year of the infant’s enrollment shall be
calculated according to the then current Blue Cross of California Prudent Buyer
Plan Participating Physician Agreement fee schedule for the applicable
region.  In the event the foregoing
calculation for any given procedure results in a figure greater than the actual
cost of the procedure as billed by a third party, then the actual cost for that
procedure shall be deemed to be the amount actually paid by PARTICIPATING
MEDICAL GROUP.

 

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

 

A.           Pregnancy
and maternity services covered by the Global Fee under Section 7.07
herein.

 

B.             Services
rendered to infants for treatment of Complications pursuant to Sections 7.01E
and F.

 

C.             Services
rendered in connection with Workers’ Compensation cases.

 

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

 

E.              Services
for which payment is obtained from BLUE CROSS through any coverage other than
the AIM Program.

 

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

 

8.05                 PARTICIPATING MEDICAL GROUP shall maintain
records necessary to evidence having reached the Enrollment Protection
level.  After reaching the Enrollment
Protection level with regard to any Member, during the remainder of the
mother’s enrollment or the remainder of the calendar year of the infant’s
enrollment PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for one hundred
percent (100%) of services rendered, or provided, to that Member by
PARTICIPATING MEDICAL GROUP, calculated in accordance with Sections 8.02, 8.03,
and 8.04.  Reimbursement to PARTICIPATING
MEDICAL GROUP for Enrollment Protection shall be made by BLUE CROSS in
accordance with the lesser of (i) actual billed charges; (ii) the then

 

22

 

current Blue Cross of California Prudent Buyer Plan Participating
Physician Agreement fee schedule for the applicable region; (iii) the rate
negotiated between BLUE CROSS and the provider of service; or (iv) the amount
actually paid by PARTICIPATING MEDICAL GROUP. 
Such reimbursement shall be made on a monthly basis, within forty-five
(45) working days of submission of complete and accurate documentation by
PARTICIPATING MEDICAL GROUP, Services which are not set forth in the then
current Blue Cross of California Prudent Buyer Plan Participating Physician
Agreement fee schedule for the applicable region shall be reimbursed by
BLUE CROSS at the actual charges paid by PARTICIPATING MEDICAL GROUP.

 

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

 

IX.                                BLUE CROSS SERVICES

 

9.01                 BLUE CROSS Services, as defined in this
Article, shall include Covered Medical Services, as set forth in the applicable
Benefit Agreement and as authorized or referred by PARTICIPATING MEDICAL GROUP.

 

The Covered Medical Services encompassed in BLUE CROSS Services are
delineated in Exhibit A(1) and include, but are not limited to:

 

A.           Inpatient
Hospital Services (exclusive of professional charges).

 

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

 

C.             Hemodialysis
Services (exclusive of professional charges).

 

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

 

E.              Related
Hospital Services.

 

F.              Ambulance
Services.

 

G.             Home
Health Services.

 

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

 

I.                 Out-of-Area
Emergency Services (Facility and Professional Expenses).

 

9.02                 The provider of BLUE CROSS Services shall bill
BLUE CROSS directly.  BLUE CROSS shall
reimburse said provider within forty-five (45) working days following receipt
of a clean, undisputed claim accompanied by an authorization from PARTICIPATING
MEDICAL GROUP.

 

23

 

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

 

X.                                    TERM OF AGREEMENT, TERMINATION

 

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

 

10.02           Should this Agreement be terminated pursuant to Section 10.01
above, PARTICIPATING MEDICAL GROUP agrees to continue to provide or arrange
Capitation Services, Insured Services and BLUE CROSS Services for all Members
assigned to PARTICIPATING MEDICAL GROUP, including any Members who become
eligible during the notice period set forth in Section 10.01 above; and to
provide these services consistent with the terms and conditions of the
applicable Benefit Agreements.  In such
case, Capitation Services rendered to Members shall be compensated at the
applicable rates set forth in the then current Blue Cross of California Prudent
Buyer Plan Participating Physician Agreement fee schedule for the
appropriate region until the services being rendered to that Member are
completed or reasonable and medically appropriate provision is made for the
assumption of such services by another contracting provider, but in no event
later the annual anniversary dates of the Benefit Agreements of Members
assigned to PARTICIPATING MEDICAL GROUP. 
The foregoing anniversary date limitation shall not apply with respect
to the continuation of services, as required under Section 1373.95 of the
California Health and Safety Code.

 

In the event this Agreement is terminated, any and all outstanding
deficits owed to BLUE CROSS under this Agreement shall be immediately due and
payable, and BLUE CROSS may offset the entire such deficit against any and all
amounts then due or thereafter due to PARTICIPATING MEDICAL GROUP under this
Agreement or any other agreement with PARTICIPATING MEDICAL GROUP.

 

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

 

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

 

Without limiting the foregoing, if this Agreement is terminated, at BLUE
CROSS’ sole discretion, PARTICIPATING MEDICAL GROUP shall continue to provide
and be compensated under the terms of this Agreement for Covered Medical
Services provided to Members who at the time of termination are undergoing a
course of treatment from a PARTICIPATING MEDICAL GROUP Physician for an acute
condition, serious chronic condition, high-risk pregnancy, or a pregnancy that
has reached the second or third trimester. 
For cases involving an acute condition or a serious chronic condition,
such services may continue for up to ninety (90) days or a longer period if
necessary for a safe transfer to another participating medical group physician
as determined by BLUE CROSS in consultation with the PARTICIPATING MEDICAL
GROUP Physician, consistent with good professional practice.  For pregnancy cases as specified above, such
services will

 

24

 

continue until postpartum services related to the delivery are completed
or for a longer period if necessary for a safe transfer to another
participating medical group physician, consistent with good professional
practice.

 

10.04           In the event of a material breach of this Agreement the party claiming
the breach shall give written notice to the other, with registered or certified
mail.  The notice shall specify the
breach with as much detail as possible. 
The party receiving the notice shall then have thirty (30) days to
commence curing the breach.  If the
breach is not cured to the satisfaction of the complaining party within sixty (60)
days after the notice is received by the other party, this Agreement shall
terminate at the end of the sixtieth (60th) day or, if the breach is by
PARTICIPATING MEDICAL GROUP, BLUE CROSS may in the alternative freeze
enrollment of PARTICIPATING MEDICAL GROUP and/or withhold fifteen percent (15%)
of the Capitation until such breach is cured to BLUE CROSS’ satisfaction.

 

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

 

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

 

11.02           Any problem or dispute arising under this Agreement and/or concerning
the terms of this Agreement that is not satisfactorily resolved under Section 11.01
shall be arbitrated.  The arbitration
shall be initiated by either party making a written demand for arbitration on
the other party.  Arbitration shall be
conducted by the American Arbitration Association (AAA) under the Commercial
Rules of the AAA.  The arbitration shall
also be subject to California Code of Civil Procedure, Title Nine,
Section 1280, et. seq., unless
otherwise mutually agreed.  The parties
agree that the decision of the arbitrator shall be final and binding as to each
of them, except to the extent that California or Federal law provide for the
review of arbitration proceedings.  BLUE
CROSS waives any right to pursue, on a class basis, any such problem or dispute
against PARTICIPATING MEDICAL GROUP, and PARTICIPATING MEDICAL GROUP waives any
right to pursue, on a class basis, any such problem or dispute against BLUE
CROSS.  Issues as to whether malpractice
was committed by a physician shall not be subject to Arbitration by the AAA
unless otherwise agreed in writing by the parties and the AAA.

 

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

 

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

 

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

 

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

 

25

 

BLUE CROSS or PARTICIPATING MEDICAL GROUP, respectively, shall be
considered the initiating party for the purposes of Section 11.03 hereof.

 

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

 

XII.                            AIM MEMBER GRIEVANCE SYSTEM

 

12.01           In the event a Member perceives a problem which the AIM Coordinator is
unable to satisfactorily resolve, the Member shall be advised to complete a
Grievance Form and submit it to the AIM Coordinator.  The grievance shall be reviewed and resolved
if possible, by the PARTICIPATING MEDICAL GROUP’s Quality Management Committee.

 

12.02           PARTICIPATING   MEDICAL GROUP
shall maintain a log of all grievances heard by PARTICIPATING MEDICAL GROUP’s Quality
Management Committee filed by Members who are assigned to PARTICIPATING MEDICAL
GROUP and shall, on a quarterly basis, forward a copy of each grievance to the
AIM Quality Management Representative.

 

12.03           PARTICIPATING MEDICAL GROUP shall provide a written response to Member
within fifteen (15) working days of receipt of grievance.  In the event a grievance cannot be resolved
by the PARTICIPATING MEDICAL GROUP’s Quality Management Committee to the
complaining Member’s satisfaction within fifteen (15) working days of receipt,
the Member may appeal to BLUE CROSS using the procedures in the Member’s
Benefit Agreement and in the Operations Manual. 
In the event that the Member appeals to BLUE CROSS, PARTICIPATING MEDICAL
GROUP agrees to provide BLUE CROSS with a response to the grievance and the
pertinent medical records within ten (10) days from the date of such request by
BLUE CROSS.

 

12.04           The Member shall be notified of the disposition of the complaint by BLUE
CROSS within fifteen (15) working days of making the appeal.

 

XIII.                        MISCELLANEOUS
PROVISIONS

 

13.01           Amendment.  This Agreement or any part or
section of it may be amended at any time during the term of the Agreement
by mutual written consent of duly authorized representatives of BLUE CROSS and
PARTICIPATING MEDICAL GROUP.

 

13.02           Assignment.  BLUE CROSS and PARTICIPATING
MEDICAL GROUP, pursuant to mutual written agreement, may assign rights and
duties established under this Agreement, provided that no such assignment shall
adversely affect the rights or duties of Members or be in conflict with the
requirements of state or federal laws or regulations under which BLUE CROSS is
licensed or regulated.

 

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

 

Except as provided above, BLUE CROSS and PARTICIPATING MEDICAL GROUP
each reserve the right to control the use of their respective names and all
symbols, trademarks or service marks presently existing, or later
established.  In addition, except as
provided above, neither BLUE CROSS nor PARTICIPATING MEDICAL GROUP shall use
the other party’s name,

 

26

 

symbols, trademarks or service marks in advertising or promotional
materials, or otherwise, without the prior written consent of that party, and
shall cease any such usage immediately upon written notice of the party, or on
termination of this Agreement, whichever first occurs.  Any prohibition, restriction or limitation on
advertising hereunder shall comply with the requirements of the Knox-Keene Act,
including Health and Safety Code Section 1395.5.

 

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

 

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

 

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

 

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

 

	
  To
  Blue Cross:

  	
   

  	
  21555
  Oxnard Street -12D

  
	
   

  	
   

  	
  Woodland
  Hills, CA 91367

  
	
   

  	
   

  	
  ­

  
	
  To
  PARTICIPATING MEDICAL GROUP:

  	
   

  	
   

  

 

 

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

 

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

 

13.10           Solicitation of Members.  The
business relationship between BLUE CROSS and its Members shall be deemed the
property of BLUE CROSS.  Similarly, all
lists of Members accepted by PARTICIPATING MEDICAL GROUP under the provisions
of this Agreement shall be deemed the property of BLUE CROSS.  During the term of this Agreement or any
renewal thereof, and for a period of one (1) year from the date of termination,
PARTICIPATING MEDICAL GROUP agrees and will require its PARTICIPATING MEDICAL
GROUP Physicians and all other contracted Health Professionals to agree, that
they will not, within the service area of BLUE CROSS: (1) interfere with BLUE
CROSS’ contract and/or property rights; (2) advise or counsel any Member to
disenroll from BLUE CROSS; (3) solicit such Member to become enrolled with any
other health maintenance organization, preferred provider organization or any
other similar hospitalization or medical payment plan or insurance company; or
(4) disclose proprietary BLUE CROSS information.  This section shall not apply to general
mailings unless the mailings specifically target BLUE CROSS Members and as long
as the mailings do not violate the intent of this section.

 

27

 

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

 

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

 

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

 

 

	
  BLUE CROSS OF CALIFORNIA

  	
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
   

  
	
   

  	
   

  
	
  Signature:

  	
   

  	
  /s/ Lorraine Salvatore

  	
   

  	
  Signature:

  	
   

  	
  /s/
  Edward Rotan

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
   

  	
  Lorraine Salvatore

  	
   

  	
  Name:

  	
   

  	
  Edward
  Rotan

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Vice President

  	
   

  	
   

  	
   

  	
   

  
	
  Title

  	
   

  	
  Network
  Development &

  Management

  	
   

  	
  Title

  	
   

  	
  President

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
   

  	
  5/4/01

  	
   

  	
  Date:

  	
   

  	
  4/26/01

  	
   

  

 

28

 

EXHIBIT A

 

COVERED MEDICAL SERVICES

 

I.                                         Medical and Surgical Services

 

A.           Physician’s
services at the:

 

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

 

(2)          Hospital

 

B.             Professional
services of an anesthetist or anesthesiologist

 

C.             Diagnostic
X-ray examinations

 

D.            Laboratory
tests

 

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

 

F.              Professional
services of other participating Health Professionals

 

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

 

II.                                   Psychiatric Care Benefits

 

A.           Inpatient
Visits

 

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

 

B.             Outpatient
Visits or Sessions

 

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

 

III.                             Covered Preventive Care Benefits

 

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

 

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

 

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

 

C.             Pediatric
and adult immunizations.

 

D.            Eye
examinations

 

E.              Ear
examinations.

 

F.              Health
education services as follows:

 

 

 

A-1

 

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

 

(2)          Instruction in personal health care measures.

 

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

 

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

 

H.            Allergy
testing and administration of injections.

 

A-2

 

EXHIBIT A (1)

AIM

DIVISION OF FINANCIAL RESPONSIBILITY

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ALLERGY
  TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Serums

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMBULANCE:
  Air or Ground

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  AMNIOCENTESIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ANESTHETICS,
  Administration of

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  EYE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ARTIFICIAL
  LIMBS (Prosthetic Device)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  BLOOD
  AND BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous
  Blood Donation

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMICAL
  DEPENDENCY REHABILITATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHEMOTHERAPY
  DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chemotherapy
  Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-1

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CHIROPRACTIC
  (Referred Service only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In
  Conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DENTAL
  SERVICES

  (accidental
  injury to sound natural teeth and dental work

  necessary for the construction of non-dental structures)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DETOXIFICATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT (DME)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ADMISSIONS: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMERGENCY
  ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMPLOYMENT
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-2

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ENDOSCOPIC STUDIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EXPERIMENTAL PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FAMILY PLANNING SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  FETAL MONITORING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENETIC TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEALTH EVALUATIONS / PHYSICALS (1) 

  (required by third party or outside
  agency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPICE (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(1)
Routine physical examinations or tests which do not directly treat an actual
illness, injury or condition unless authorized by a Primary Care Physician,
except in no event will any physical examination or test required by employment
or government authority, or at the request of a third party such as a school,
camp or sport affiliated organization be covered

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

 

A(1)-3

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurosurgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedic Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  HOSPITALIZATION / INPATIENT SERVICES,

  SUPPLIES & TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Out-of-Area (Emergency)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMEDIATE CARE - Out Of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-4

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT
  APNEA MONITOR (DME)

  (in conjunction with or concurrent with
  authorized inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFERTILITY(Diagnosis
  / Treatment)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFUSION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Infused
  Substances

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INJECTABLE MEDICATIONS:
  Outpatient
    (excluding
  take-home insulin)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LABORATORY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MAMMOGRAPHY
  (2)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MENTAL
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  NUTRITIONIST
  / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(2)
Limited to $75.00 per member per year

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

 

 

A(1)-5

 

	
  List of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OBSTETRICAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Professional Component (3)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  (non-hospital facility) Diagnostic Services (4)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OFFICE
  VISIT SUPPLIES, SPLINTS, CASTS,

  BANDAGES, DRESSINGS etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ORGAN
  TRANSPLANTS (non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Primary
  Care Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Physicians

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  CLINIC OR NON-HOSPITAL FACILITY

  COMPONENT FOR DIAGNOSTIC SERVICES &

  TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Angiograms

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CAT
  Scan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2-D
  Echo

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EEG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EKG
  (aka: ECG)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  EMG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Holter
  Monitor

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  MRI

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Treadmill

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Ultrasound

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT
  DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(3)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.

(4)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.

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

 

A(1)-6

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  General Surgery

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Obstetrics / Gynecology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  OUTPATIENT SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component for:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Cardiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Emergency Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neonatology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Neurology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Nephrology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Orthopedics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pathology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-7

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services 

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PEDIATRIC
  SERVICES (newborn)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICAL
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Skilled Nursing Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  To
  Patient Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PHYSICIAN
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Consultations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Specialty
  Visits

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PODIATRY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREADMISSION
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic or Non-Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  / Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PREGNANCY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component (5)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PROSTHETIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIATION
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient
  Clinic Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(5)
Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after
delivery.

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

 

A(1)-8

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RADIOLOGY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Hospital Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RECONSTRUCTIVE SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REFRACTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REHABILITATION SERVICES

  (Physical Therapy, Occupational Therapy, Speech

  Therapy, Cardiac Therapy)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Clinic or Non-Hospital Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ROUTINE PHYSICAL EXAMINATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SKILLED NURSING FACILITY (SNF)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SPECIALIST CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  SURGICAL SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Dental Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  (for the diagnosis and medically
  necessary correction)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  From Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous Blood Donations

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-9

 

	
  List
  of Benefits/Services

  	
   

  	
  Capitation

  	
   

  	
  Blue Cross

  Services

  	
   

  	
  Insured

  Services

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE: In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  URGENT CARE: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Refraction

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Lenses / Frames (covered by optional rider)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Contact lenses (fitting only)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

A(1)-10

 

EXHIBIT B

 

AIM HOSPITALS

 

B-1

 

EXHIBIT C

 

ADMINISTRATIVE RESPONSIBILITIES OF PARTICIPATING MEDICAL
GROUP

 

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

 

A.           PROFESSIONAL
SERVICES ADMINISTRATION

 

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

 

Outside Referrals - Control, process and report encounter information

 

Ancillary - Control, process and report encounter information

 

B.             INSTITUTIONAL SERVICES ADMINISTRATION

 

Preadmission certification process

 

Medical Review of claims

 

Length-of-stay (monitoring and control)

 

C.             UTILIZATION
REVIEW

 

D.            PEER
REVIEW, EDUCATION AND CREDENTIALING

 

E.              QUALITY
MANAGEMENT

 

F.              GRIEVANCE
PROCEDURE COMPLIANCE

 

G.             MONITOR
AND REVISE SPECIALIST/OTHER REFERRAL CONTRACTS

 

H.            PATIENT
EDUCATION

 

I.                 CASE
MANAGEMENT

 

C-1

 

EXHIBIT D

 

CAPITATION

 

I.                                        Mother With Enrollment Protection Provided by
BLUE CROSS

 

	
  1.

  	
   

  	
  Non-Pregnancy
  and

  Non-Maternity

  	
   

  	
  $***
  per month from enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Pregnancy
  and

  Maternity

  	
   

  	
  Global
  Fee applies per Section 7.07 

  

 

Child With Enrollment Protection Provided by BLUE CROSS

 

	
  1.

  	
   

  	
  Age
  0 - 1 year

  	
   

  	
  $***
  per month from birth through first birthday

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Age
  1 - 2 years

  	
   

  	
  $*** per month from 13 through 24 months

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
   

  	
  Complications
  for

  infants

  	
   

  	
  Then
  current Blue Cross of California Prudent Buyer Plan Participating Physician
  Agreement fee schedule for the applicable region applies per Sections
  7.01.1E and F

  

 

II.                                   Mother Without Enrollment Protection Provided
by BLUE CROSS

 

	
  1.

  	
   

  	
  Non-Pregnancy
  and

  Non-Maternity

  	
   

  	
  $***
  per month from enrollment through 60 days after termination of pregnancy

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Pregnancy
  and

  Maternity

  	
   

  	
  Global
  Fee applies per Section 7.07

  

 

Child Without Enrollment Protection Provided by BLUE CROSS

 

	
  1.

  	
   

  	
   Age 0 - 1 year

  	
   

  	
  $***
  per month from birth through first birthday

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  2.

  	
   

  	
  Age
  1 - 2 years

  	
   

  	
  $***
  per month from 13 through 24 months

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  3.

  	
   

  	
  Complications
  for

  infants

  	
   

  	
  Then
  current Blue Cross of California Prudent Buyer Plan Participating Physician
  Agreement fee schedule for the applicable region applies per Sections
  7.01.1E and F

  

 

 

 

D-1

 

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

 

A.                                   PARTICIPATING MEDICAL GROUP agrees to participate
in Article VIII, Enrollment Protection as set forth in Sections 8.02,
8.03, 8.04, 8.05, 8.06 of this Agreement; or

 

B.                                     PARTICIPATING MEDICAL GROUP, at it sole
expense, agrees to obtain and maintain stop loss insurance for all expenses
incurred under this Agreement in amounts acceptable to BLUE CROSS.  Upon request, PARTICIPATING MEDICAL GROUP
shall provide BLUE CROSS with copies of its stop loss insurance policy
referenced in this Subsection B.

 

PARTICIPATING MEDICAL
GROUP hereby elects to accept risk pursuant to

 

	
  Subsection

  	
   

  	
  o   A.

  	
   

  	
  or

  	
   

  	
  ý   B.

  	
   

  	
  (check one)

  

 

D-2

 

EXHIBIT E

 

PARTICIPATING
MEDICAL GROUP FACILITIES

 

E-1Exhibit
10.117

 

1998

 

FHS

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

PROSPECT MEDICAL GROUP

 

PRODUCTS

INCORPORATED

WITHIN:

A) STANDARD HMO

B) SMALL GROUP HMO

C) INDIVIDUAL HMO

D) A.I.M.

E) MEDICARE SUPPLEMENT

F) COMMERCIAL P.O.S.

G) MEDICARE

H) MEDICARE P.O.S.

I) P.P.O.

J) E.O.P.

K) CHAMPUS

L) WORKMENS COMP

 

 

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

 

 

TABLE OF CONTENTS:

 

	
  RECITALS

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DEFINITIONS

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  REPRESENTATIONS AND
  DUTIES OF PPG

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DUTIES OF FHS

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  COMPENSATION

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  DELEGATION

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TERM
  AND TERMINATION

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  RECORDS,
  AUDITS AND REGULATORY REQUIREMENTS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  GENERAL
  PROVISIONS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM A

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Benefit
  Programs

  Affiliates

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM B COMMERCIAL HMO
  AND POS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  A.

  	
  General Reimbursement
  Provisions

  	
   

  	
   

  
	
   

  	
  B.

  	
  Standard HMO

  	
   

  	
   

  
	
   

  	
  C.

  	
  Small GroupHMO

  	
   

  	
   

  
	
   

  	
  D.

  	
  Individual HMO

  	
   

  	
   

  
	
   

  	
  E.

  	
  Access for
  Infants and Mothers

  	
   

  	
   

  
	
   

  	
  F.

  	
  Medicare
  Supplement

  	
   

  	
   

  
	
   

  	
  G.

  	
  Commercial POS

  	
   

  	
   

  
	
   

  	
  H.

  	
  Partnership
  Bonus

  	
   

  	
   

  
	
   

  	
  I.

  	
  QCIP

  	
   

  	
   

  
	
   

  	
  J.

  	
  Pharmacy Shared Risk
  Program

  	
   

  	
   

  
	
   

  	
  K.

  	
  Pharmacy
  Rebate Program

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM B.1

  	
  AGE, SEX AND BENEFIT
  PLAN FACTORS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM B.2

  	
  COMMERCIAL HMO and POS
  DIVISION OF FINANCIAL

  RESPONSIBILITY MATRIX

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM C

  	
  MEDICARE HMO AND POS

  	
   

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  	
   

  
	
   

  	
  B.

  	
  Medicare HMO Benefit
  Program

  	
   

  	
   

  
	
   

  	
  C.

  	
  Medicare POS Benefit
  Program

  	
   

  	
   

  
	
   

  	
  D.

  	
  Administration
  Of Shared Risk Budgets For HMO and POS

  	
   

  	
   

  
	
   

  	
  E.

  	
  Other Services

  	
   

  	
   

  
						

 

ii

 

	
  ADDENDUM C.1

  	
  SUPPLEMENTAL BENEFITS
  COSTS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM C.2

  	
  PHARMACY SHARED RISK
  BUDGETS

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM C.3

  	
  MEDICARE DIVISION OF
  FINANCIAL RESPONSIBILITY MATRIX

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM D

  	
  PPO, EPO AND POS

  	
   

  	
   

  
	
   

  	
  A.

  	
  Benefit Program
  Requirements

  	
   

  	
   

  
	
   

  	
  B.

  	
  PPO And EPO Benefit
  Programs

  	
   

  	
   

  
	
   

  	
  C.

  	
  POS Benefit Programs

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM E

  	
  FEE FOR SERVICE
  COMPENSATION

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F

  	
  MEDI-CAL BENEFIT PROGRAM

  	
   

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  	
   

  
	
   

  	
  B.

  	
  Compensation
  Provisions

  	
   

  	
   

  
	
   

  	
  C.

  	
  General
  Provisions

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F.1

  	
  FEE-FOR-SERVICE
  COMPENSATION SCHEDULE

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F.2

  	
  CAPITATION
  COMPENSATION SCHEDULE

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F.3

  	
  SHARED RISK PROGRAM
  DISTRIBUTION MATRIX

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F.4

  	
  DIVISION OF FINANCIAL
  RESPONSIBILITY

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM F.5

  	
  DISCLOSURE FORM

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM G

  	
  CHAMPUS/TRICARE

  	
   

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  	
   

  
	
   

  	
  B.

  	
  Programs And
  Regulations

  	
   

  	
   

  
	
   

  	
  C.

  	
  Other Governmental Programs

  	
   

  	
   

  
	
   

  	
  D.

  	
  Provider
  Obligations

  	
   

  	
   

  
	
   

  	
  E.

  	
  CHAMPUS
  PRIME and EXTRA Benefit Programs

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM H

  	
  WORKERS COMPENSATION

  	
   

  	
   

  
	
   

  	
  A.

  	
  Compensation

  	
   

  	
   

  
	
   

  	
  B.

  	
  Other Duties

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM H.1

  	
  WORKERS’ COMPENSATION
  RATE SCHEDULE

  	
   

  	
   

  

 

iii

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

This
Participating Physician Group Provider Services Agreement (“Agreement”) is made
and entered into by and between the Foundation Health Systems Affiliate(s)
(“FHS”) identified in Addendum A to this Agreement and Prospect Medical
Group. Inc., a Participating Physician Group (“PPG”), to be effective January
1, 1998.

 

RECITALS

 

A.            PPG is a medical group or individual
practice association that provides or arranges for the provision of
professional health care services, supplies, products or related services.

 

B.            FHS is one or more corporations that
have the legal authority to enter into this Agreement, and to perform the
obligations of FHS hereunder with respect to the Benefit Programs identified on
Addendum A.

 

C.            FHS desires to enter into this
Agreement to arrange for PPG to render Contracted Services to Members of the
various Benefit Programs identified on Addendum A.

 

D.            PPG desires to enter into this
Agreement to render Contracted Services to Members of the various Benefit
Programs identified on Addendum A.

 

AGREEMENT

 

NOW,
THEREFORE, in consideration of the above recitals and the covenants contained
herein, the parties hereby agree as follows:

 

I.             DEFINITIONS

 

Many
words and terms are capitalized throughout this Agreement to indicate that they
are defined as set forth in this Article I.

 

1.1            Affiliate.  An
entity in which Foundation Health Systems, Inc., a Delaware corporation, owns
51% or more of the voting stock, or which is managed by FHS or a FHS
subsidiary.  The Affiliates provide,
arrange for, or administer one or more Benefit Programs covered under this
Agreement.

 

1.2            Benefit
Program.  FHS’ obligation to pay for, provide, arrange
or administer Covered Services, provider networks, administrative or other
related services pursuant to a written agreement between an employer or other
entity or an individual and FHS.  The
Benefit Programs covered under this Agreement are listed on Addendum A.

 

1.3            Capitation.  The
compensation paid per Member per month (“PMPM”) for each HMO Member who has
selected or been assigned to PPG.

 

1.4            Commercial
HMO Member.  An HMO Member whose premium is fully paid and
enrolled in a commercial Benefit Program, including 1) a Benefit Program
offered to an employer other than a small group employer (“Standard HMO
Member”), 2) a Benefit Program offered to a small group employer as defined in
Section 1357(1) of the California Health and Safety Code (“Small Group HMO
Member”), 3) a Benefit Program offered to individuals (“Individual HMO
Member”), 4) a Benefit Program offered to an individual participating in

 

1

 

the Access for Infants and
Mothers Program (“AIM Member”), 5) a Benefit Program which is fully or
partially self-funded (“Flexible Funded HMO Member”), or 6) a Benefit Program
offered to Members with primary coverage through Medicare and health care
coverage under an HMO or POS Plan (“Medicare Supplement Member”).

 

1.5            Contracted
Services.  Those Medically Necessary Covered Services to
be rendered by PPG to a Member in accordance with this Agreement.

 

1.6             Coordination
of Benefits.  The allocation of financial responsibility
between two or more payors of health care services, each with a legal duty to
pay for or provide Covered Services to a Member at the same lime.

 

1.7             Copayment.
 That portion of the cost of Covered Services
that a Member is obligated to pay under a particular Benefit Program, including
deductibles and coinsurance.

 

1.8             Coverage
Certificate or Certificate.  The document which describes the
benefits available to a Member in connection with a Benefit Program.

 

1.9             Covered
Services.  The health care services, products, supplies
or related services that are covered under an applicable Benefit Program.

 

1.10          Emergency.  A medical condition manifesting itself by acute symptoms of sufficient
severity such that a prudent layperson who possesses average knowledge of
health and medicine, could reasonably expect the absence of immediate medical
attention to result in:  (i) placing the
individual in serious jeopardy (and in the case of a pregnant woman, her health
or that of her unborn child); (ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part.  FHS shall have the final authority in
decisions regarding emergencies and emergency services.

 

1.11          HMO
Member.  A person who is eligible to receive Covered
Services under those Benefit Programs offered by an Affiliate which is a health
care service plan licensed under the Knox Keene Act, and whose premium has been
fully paid. An HMO Member shall be a person enrolled in a Medicare Benefit
Program as set forth in Addendum C (“Medicare HMO Member”), a person enrolled
in a Medicaid Benefit Program as set forth in Addendum F (“Medi-Cal HMO
Member”) or a person enrolled in a commercial Benefit Program as set forth in
Addendum B (“Commercial HMO Member”).

 

1.12          Insured
Services.  Contracted Services that are arranged or
provided and paid for by PPG but which are reimbursable by HMO in addition to
the Capitation paid.  Such Insured
Services are set forth in the applicable Addendum.

 

1.13          Interim
Period.  The six-month period, January 1st
through June 30th, used for the purpose of calculating an interim
settlement.

 

1.14          Medically
Necessary.  Those Covered Services which, under the
provision of this Agreement, are determined to be:

 

(a)           Appropriate and necessary for the
symptoms, diagnosis or treatment of a condition, illness or injury; and

 

(b)           Provided for the diagnosis or the
direct care and treatment of a medical condition, illness or injury; and

 

2

 

(c)           Within the standards of good medical
practice within the organized medical community; and

 

(d)           Not primarily for the convenience of
the Member, or the Member’s physician or other Provider; and

 

(e)           The most appropriate supply or level
of service, including levels of acute care such as intensive care unit services
or regular acute medical and surgical services as determined by the clinical
status of the Member, which can safely be provided to the Member. For
hospitalization, this means that the Member requires acute care as an inpatient
due to the nature of the services the Member is receiving, or the severity of
the Member’s condition, and that safe and adequate care cannot be received as
an outpatient or at a less intensified medical setting such as a sub-acute unit
or skilled nursing facility.

 

Notwithstanding the above, Medically Necessary services for HMO Members
shall not differ from that defined in the Evidence of Coverage document
approved by the Department of Corporation.

 

1.15          Member. 
(Beneficiary) A person who is eligible to receive Covered Services under
a Benefit Program included in this Agreement by virtue of completing the
required enrollment process and whose premium has been fully paid. Member shall
include HMO Member.

 

1.16          Member
Physician.  A physician who practices medicine in the
capacity of a shareholder, partner, employee, subcontractor, locum tenens or
associate of PPG.

 

1.17          Operations
Manual.  All Operations Manuals, including medical
policy manuals, issued by FHS, as updated from time to time, which are
incorporated in this Agreement by this reference.  In the event that any provision in an
Operations Manual or any updates thereto are clearly inconsistent with the
terms of this Agreement as amended, the terms of this Agreement shall prevail.

 

1.18          Participating
Provider.  A hospital, physician, physician
organization, Participating Physician Group, Member Physician, other health
care practitioner or other organization which has a direct or indirect
contractual relationship with FHS or another Participating Provider to provide
Covered Services to Members.  In the
event PPG contracts with a health care provider to render Covered Services
under this Agreement, such provider is a Participating Provider.

 

1.19          Payor.  A
public or private entity contracted with FHS which funds, insures or is
responsible for paying Participating Providers for Covered Services rendered to
Members pursuant to the terms of this Agreement and as  stipulated on the Member’s identification
card.

 

1.20          Pharmacy
Budget.  The amount allocated per eligible Member per
month (“PEMPM”) for the cost of contracted pharmaceutical benefits established
by FHS as set forth in the applicable Addendum.

 

1.21          PPG
Capitated Services.  Contracted Services as described in an
Addendum to this Agreement for which PPG has accepted Capitation under the
applicable Benefit Programs to which the Addendum applies.

 

1.22          Preventive
Care.  Preventive Care is care which attempts to
remove or reduce disease risk factors and promotes early detection of disease
or precursor states.

 

1.23          Primary
Care Physician (PCP).  A Member Physician who is
responsible for providing and/or coordinating the delivery of Covered Services
to an HMO Member pursuant to the applicable Benefit Program. Primary Care
Physicians include general practitioners, family practitioners, internists,
pediatricians,

 

3

 

obstetrician/gynecologists
and other specialists, if approved by FHS.

 

1.24          Prior
Authorization.  The written approval by FHS, Payor, PPG, or
other permitted entity, prior to admitting a Member to a hospital or a skilled
nursing facility, or to providing certain other Covered Services to a Member,
which approval is required under the Utilization Management Program of the applicable
Benefit Program as  described in
the Operations Manual.

 

1.25          Quality
Improvement Program.  A program to meet FHS standards, approved by
FHS, and designed to assure the provision of quality medical services, as
described more fully in the Operations Manual.

 

1.26          Reconciliation
Period.  The 12-month period, January 1st
through December 31st, used for the purpose of calculating Shared
Risk and Pharmacy Budget surpluses or deficits. 
The first Reconciliation Period shall be the period beginning on the date
that HMO  Members are first
assigned to PPG under this Agreement through December 31st of that
calendar year.

 

1.27          Service
Area.  The geographic area in the continental United
States within a 30-air mile radius of an HMO Member’s PCP’s office location for
the purpose of determining in-area versus out-of-area services for such Member
as set forth in the Operations Manual.

 

1.28          Shared
Risk Budget.  The amount allocated per Member per month
(“PMPM”) for the cost of Shared Risk Services established by FHS as set forth
in the applicable Addendum.

 

1.29          Shared
Risk Reinsurance.  The program through which the PPG’s risk for
Shared Risk Claims shall be limited per assigned HMO Member in a Reconciliation
Period.

 

1.30          Shared
Risk Claims.  Shared Risk Claims shall include all claims
for Shared Risk Services including amounts for out of area services as set
forth in the applicable Addendum minus those amounts in excess of the Shared
Risk Reinsurance threshold which are payable under such program as set forth in
the applicable Addendum and minus any amounts received from third parties,
including but not limited to, Coordination of Benefits, workers’ compensation
and Copayments.

 

1.31          Shared
Risk Services.  The Covered Services set forth in the
attached matrix under the heading “Shared Risk Services”.

 

1.32          State.  The
State of California.

 

1.33          Surcharge.  An
additional fee which is charged to a Member for a Covered Service, but which is
not approved by the applicable State and federal regulatory authority, and is
neither disclosed nor provided for in a Coverage Certificate.

 

1.34          Urgently
Needed Services.  Covered Services required in order to prevent
a serious deterioration of an HMO Member’s health that results from an
unforeseen illness or injury if (i) such Member is temporarily absent from the
Service Area and (ii) receipt of the health care service cannot be delayed
until the Member’s return to the Service Area.

 

1.35          Utilization/Care
Management Program.  A program that meets FHS’ standards and is
approved by FHS and designed to review and manage the utilization of Covered
Services, as described more fully in the Operations Manual.

 

4

 

II.            REPRESENTATIONS AND DUTIES OF PPG

 

2.1          Representation
of PPG.

 

(a)           PPG warrants that it has the
authority to contract on behalf of its Member Physicians and to bind them to
all of the terms and provisions of this Agreement.  PPG will notify Member Physicians of their
rights and duties under this Agreement, and of all amendments and modifications
thereto.

 

(b)           PPG shall provide FHS, upon request,
with its written applicable policies and procedures and its bylaws and articles
of incorporation and any modifications thereto.

 

(c)           PPG represents that the terms of this
Agreement do not conflict with the terms of its agreements with Participating
Providers. PPG further represents that the terms of this Agreement shall apply
in any situation where there is an inconsistency or conflict with the terms of
any agreement between the Participating Provider and PPG or with respect to any
matter which is not addressed in any such agreement between the Participating
Provider and PPG. PPG shall be responsible to FHS for any such inconsistency or
conflict in terms. This provision shall supersede any similar provision in any
agreement between PPG and a Participating Provider.

 

2.2          PPG
Network.  PPG shall
provide FHS with a list of the names, practice locations, federal tax
identification numbers, professional practice name, the business hours and any
additional information as required in the Operations Manual for all Member
Physicians and Participating Providers that contract with PPG in a format
acceptable to FHS. If more than one such provider uses the same federal tax
identification number, PPG shall include the professional practice name
registered with such number.  FHS shall
notify PPG of all such Member Physicians and Participating Providers approved
by FHS. PPG shall provide FHS with at least a monthly list of additions,
deletions and address changes to such list and a complete listing annually.

 

PPG
shall take all reasonable and prudent steps to ensure that all Participating
Providers provide adequate personnel and facilities in order to perform the
duties and responsibilities associated with the proper administration of this
Agreement, including but not limited to, ensuring that all facilities utilized
by Participating Providers shall satisfy the standards for licensure and
certification, if applicable, by the appropriate governmental licensing agency
as well as applicable State and federal law. The Participating Provider assumes
the responsibility for supervision of all personnel associated with the
Participating Provider.

 

2.3          PPG
Contracts.  PPG shall not contract for the performance of
services under this Agreement without the consent of FHS.  Upon entering into any arrangements with a
Participating Provider as may be necessary to fulfill PPG’s obligations to
provide or arrange for the provision of Contracted Services and Covered
Services under this Agreement, PPG shall obtain written contracts with such
providers which include the following requirements:

 

(a)           Secure adherence by Participating
Providers to all the obligations of this Agreement which affect Participating
Providers, including but not limited to:

 

(1)           Accepting Members upon referral from
Member Physicians.

 

(2)           Collecting any Copayments due from
Member and accepting payment from PPG as payment-in-full for Contracted
Services rendered to Members referred to them, except for authorized Copayments,
and agree not to bill FHS or Members and shall hold them harmless for such
services regardless of whether or not payment is received from PPG or FHS.

 

(3)           Hospitalizing Members in accordance
with the applicable Benefit Program and the Operations Manual.

 

5

 

(4)           Conforming to the drug dispensing
guidelines set forth in the Operations Manual or FHS’ drug formulary.

 

(5)           Maintaining in force adequate
professional liability insurance as set forth in this Agreement and in the
Operations Manual.

 

(6)           Conforming to all State, federal and
other government requirements regarding retention of and access to records, and
submission of reports.

 

(7)           Maintaining offices in a condition
which conforms to FHS’ standards for safety, appearance and accessibility of
services.

 

(8)           Accepting all HMO Members when
selected, assigned or transferred to PPG, provided PPG and its Participating
Providers have capacity to provide Contracted Services under this Agreement and
PPG and Member Physicians continue to accept new patients from any other health
care service plan.

 

(9)           Conforming to FHS’ processing of
retroactive eligibility changes as set forth in this Agreement.

 

(10)         Conforming with FHS’ guidelines for
rapid medical records review, response and resolution of Member complaints.

 

(b)           No agreement between PPG and a
Participating Provider shall contain any incentive plan that includes a
specific payment made, in any type or form, as an inducement to deny, reduce,
or limit Covered Services to a Member. PPG shall comply and shall cause its
Participating Providers to comply with State and federal law regarding
physician incentives and stop loss insurance requirements, where applicable.
PPG shall furnish FHS with all PPG’s contracting templates for FHS’ review and
approval upon request and at such time templates are changed.  Every PPG contract shall provide that it is
terminable with respect to Members by PPG upon FHS’ request.  PPG shall furnish FHS with copies of any
amendments to a contract with a Participating Provider within ten (10) days of
execution. In addition, any agreement or amendment between PPG and a Member
Physician shall not restrict the rights and obligations of Member Physician to
communicate freely with Members regarding their medical condition and treatment
alternatives.  In the event PPG enters
into a contract with a Participating Provider, PPG will provide FHS with
documentation thereof as set forth in the Operations Manual.

 

(c)           PPG shall assure through written
communication that all Member Physicians are aware of the appeals process
regarding any decision, policy, or practice of FHS or PPG which Member
Physician believes is not consistent with the provision of quality medical care
to Members.

 

(d)           As requested or required by FHS, PPG
shall maintain and make available to FHS, the California Department of Health
Services (“DHS”), the California Department of Corporations (“DOC”), the U.S.
Department of Justice (“DOJ”), the U.S. Department of Defense (“DOD”), the U.S.
Department of Health and Human Services (“DHHS”) and any other regulatory
agency having jurisdiction over FHS, copies of PPG’s policies and procedures
and all Participating Provider subcontracts and any amendments thereto.

 

2.4          Member
Physician Selection.  PPG shall be responsible for the selection of
Member Physicians, or other providers who provide Covered Services to Members.
Selection of Member Physicians shall be made by PPG with reference to
reasonable requirements and PPG procedures. PPG shall assist each HMO Member in
selecting a PCP when necessary.

 

6

 

PPG
agrees to select Member Physician(s) to function in a liaison capacity with FHS
and serve, if requested, on Quality Committees or any specified committee
established by FHS.

 

In
the event PPG adds new or satellite facilities, except by acquisition or
merger, or a new Member Physician(s), PPG shall notify FHS in writing as
soon as possible but at least ninety (90) days before such addition is effective
with FHS.  PPG acknowledges and agrees
that FHS shall have the right to determine whether the new or satellite
facilities or the new Member Physician(s) are acceptable to FHS. PPG agrees
that no new satellite facility shall be added, or new Member Physician shall be
allowed to render Covered Services under this Agreement, until FHS has approved
such facility or Member Physician.  PPG
understands and agrees that FHS shall be free to deny participation under this Agreement
to any new or satellite facilities without any obligation to:

 

(a)           state a cause or provide an
explanation for denying such addition, or

 

(b)           provide the PPG with any right to
appeal or any other due process.  PPG
agrees that FHS’ decision regarding the foregoing shall be final and binding.

 

PPG
further understands and agrees that FHS may deny participation under this
Agreement to any new Member Physician(s). FHS shall afford Member Physician
such rights to appeal and due process, if any, as required by State and federal
law. In the event PPG acquires or merges with another participating physician
group, PPG shall offer and FHS has the right to accept any rates which are the
most favorable to FHS. Such rates shall be retroactive to the date of any
merger or acquisition.

 

2.5          Member
Physician Termination.  Whenever possible, PPG shall
notify FHS in writing at least ninety (90) days prior to any action by PPG to
terminate a Member Physician’s agreement with PPG, or if Member Physician
decides to close his or her medical practice or refuse to accept any additional
Members.  When ninety (90) days prior
written notice is not possible, PPG shall provide as much advance notice as
possible.  PPG shall immediately notify FHS
whenever a Member Physician fails to renew his or her agreement with PPG, whenever
PPG has reason to believe a Member Physician will fail to renew his or her
agreement with PPG, and whenever PPG knows of an occurrence giving rise to an
immediate termination of a Member Physician by PPG. In the event of a Member
Physician termination, PPG shall ensure that there is sufficient capacity in
the network to meet the access standards as set forth in the Operations Manual.

 

FHS
may request and PPG shall terminate any Member Physician from participation
under this Agreement, at any time, upon at least thirty (30) days prior written
notice from FHS to PPG; provided, however, that no such termination shall be
because a Member Physician is advocating on behalf of a Member for health care
services. Notwithstanding the foregoing, if a Member Physician is found guilty
of a criminal offense, is barred or sanctioned from participation under the
Medicare program, or if FHS makes a determination, at its sole discretion, that
treatment by a Member Physician may jeopardize the health and safety of any Member,
PPG, upon FHS’ request, shall immediately terminate such Member Physician from
participation under this Agreement.

 

2.6          Eligibility.  Except
in an Emergency, PPG shall verify the eligibility of Members before providing
Contracted Services.  FHS shall make a
good faith effort to confirm the eligibility of any Member. When PPG has not
made reasonable efforts to verify eligibility, PPG shall not hold FHS
financially responsible for Covered Services rendered to any person who was not
eligible for FHS benefits as determined by FHS.

 

2.7          Performance
Standards.  PPG shall comply with the performance
standards and indicators set forth in the Operations Manual. These standards
and indicators shall be monitored by PPG on an ongoing basis using mutually
agreeable measurements, and shall be reported to FHS on a regular basis as set
forth in the Operations Manual.  FHS
shall have the right, upon advance written notice, to audit PPG’s reported
performance.

 

7

 

2.8          Provision
of Services.  PPG agrees to render, and to ensure that
Participating Providers render, Covered Services to Members in accordance with:

 

(a)           The terms and conditions of this
Agreement, and all laws, rules and regulations applicable to PPG, FHS, and Payors;

 

(b)           The Utilization/Care Management
Program, the Quality Improvement Program, the applicable Benefit Programs, the
Member’s Coverage Certificate and the Operations Manual;

 

(c)           The performance standards and
indicators that are established by FHS including, but not limited to, waiting
periods for appointments, waiting periods in a Member Physician’s office and
processing of prior authorizations;

 

(d)           The drug dispensing guidelines set
forth in FHS’ drug formulary and the Operations Manual;

 

(e)           The termination procedures outlined
in the Operations Manual when requesting termination of a Member. PPG shall not
request, demand, or require or otherwise seek, directly or indirectly, the
removal of any Member based on that Member’s need for, or utilization of,
Covered Services;

 

(f)            The Member selection or assignment
provisions of this Agreement.  PPG agrees
to accept any and all Members who select or are assigned to PPG.  PPG and Member Physicians shall maintain a
professional relationship with each Member to whom PPG or Member Physician
renders Contracted Services, and shall be solely responsible to such Member for
such services; and

 

(g)           The eligibility verification and
notification procedures as set forth in the Operations Manual.

 

2.9          Offices
and Hours.  Member Physician shall maintain offices,
equipment, and personnel as may be necessary to provide Contacted Services
under this Agreement, in accordance with State law and as reasonably requested
by FHS.  Member Physician shall provide
Contracted Services under this Agreement during normal business hours, and
shall be available to Members by telephone twenty-four (24) hours a day, seven
(7) days a week on an Emergency basis and for consultation.

 

2.10          Coverage.  In the
event of a Member Physician’s illness, vacation or other absence from his or
her practice, PPG shall arrange for coverage and shall ensure that such
coverage shall be by a Participating Provider.

 

2.11          Non-Discrimination.  PPG
and Member Physicians shall not discriminate against any Member in the
provision of Covered Services hereunder, on any basis including age, sex,
marital status, sexual orientation, race, color, religion, ancestry, national
origin, disability, handicap, health status, source of payment, utilization of
medical or mental health services or supplies, or other unlawful basis
including without limitation, the filing by such Member of any complaint,
grievance, appeal, or legal action against PPG. PPG and Member Physicians shall
provide Covered Services in the same manner, and with the same availability, as
services are rendered to its other patients.

 

2.12          Utilization/Care Management
Program.  PPG and Member Physicians agree to
participate in and cooperate fully with the provisions and all decisions
rendered in connection with FHS’ Utilization/Care Management Program.  PPG and Member Physician agrees to render
Covered Services at the most appropriate level of service (including levels of
acute care such as intensive care unit services or regular acute medical and
surgical services as determined by the clinical status of the Member) which can
safely be provided to the Member.

 

8

 

For
hospitalization, this means that the Member requires acute care as an inpatient
due to the nature of the services the Member is receiving, or the severity of
the Member’s condition, and that safe and adequate care cannot be received as
an outpatient or at a less intensified medical setting. PPG and Member
Physicians also agree to provide such records and other information as may be required or requested under such
Utilization/Care Management Program as set forth in the Operations Manual. FHS
may, at its sole discretion, delegate certain Utilization/Care Management
Program activities. If so determined qualified and delegated by FHS, the
obligations of PPG for delegation shall be as set forth herein.

 

2.13        Prior
Authorization and Referrals.  PPG and Member Physicians agree
to comply with prior authorization and referral processes as required by the
particular Benefit Program or Utilization/Care Management Program as set forth
in the Operations Manual. In the event PPG agrees to participate in a program
offered by another health plan, preferred provider organization, managed care
organization, or insurer which includes an expedited process for referrals or
authorizations, PPG agrees to participate in and offer the same access for FHS
Members for any such program offered by FHS.

 

Prior
authorizations or referrals may be issued by FHS, PPG, a Participating Provider,
or Member Physician in accordance with the applicable Benefit Program. For
non-emergent services, PPG or Participating Provider agrees to obtain prior
authorization or a referral before providing or ordering Covered Services if
required by the applicable Benefit Program. In an Emergency, PPG agrees to
attempt to obtain prior authorization or a referral, by telephone if necessary,
before providing or ordering Covered Services. If prior authorization or a
referral cannot be obtained, PPG agrees to notify FHS and the appropriate
Participating Provider, as soon as possible, but no later than twenty-four (24)
hours after admission. In the even PPG fails to obtain an authorization or a
referral, PPG agrees not to seek payment from FHS or a Payor for Contracted Services
rendered to a Member unless prior authorization or a referral was obtained. FHS
shall retain the right to authorize Emergency services in accordance with the
Operations Manual.

 

2.14        Notification
of Institutional Services.  PPG shall notify FHS prior to or
at the time of each admission of a Member to a hospital or skilled nursing
facility whose admission is the financial responsibility of FHS. In the event
of an Emergency admission, PPG shall notify FHS regarding such Member within
twenty-four (24) hours.

 

2.15        Participating
Providers.  Except in an Emergency or as otherwise
required by law, PPG shall refer Members only to Participating Providers for
Covered Services unless such services are not reasonably available from
Participating Provider.  In the event PPG
or a Member Physician refers a Member to a non-Participating Provider, PPG
agrees to be responsible for payment of claims incurred for the Covered
Services rendered by such non-Participating Provider, and PPG agrees to hold
harmless the Member for such claims.

 

If
FHS is obligated to pay for services which FHS determines are the financial
responsibility of PPG or which it would not otherwise be obligated to pay, FHS
shall have the right to deduct the cost of such services from any amounts due to
PPG. FHS agrees not to deduct any amount as set forth in this Section without
first giving PPG ten (10) days prior written notice during which time PPG shall
have the opportunity to show cause why such amount should not be deducted by
FHS.

 

2.16        Catastrophic
Cases.  PPG shall actively participate with FHS in
managing Members with potentially catastrophic medical conditions including,
but not limited to, Acquired Immune Deficiency Syndrome (AIDS) cases, organ
transplantation, infants requiring intensive care, and burn cases. Such
participation includes, but is not limited to, prompt notification to FHS of
all known or suspected catastrophic cases, obtaining prior authorization from
FHS for organ transplantation evaluations and organ transplantations, and utilizing
regional centers designated by FHS for the purpose of delivering specialized
care.  PPG shall abide by the policies
and procedures for catastrophic case management as set forth in the Operations
Manual.

 

9

 

2.17        Quality
Improvement Program.  PPG agrees to participate in and cooperate
fully with the applicable Quality Improvement Program and to comply with
decisions rendered by FHS in connection with a Quality Improvement Program. The
quality of Contracted Services rendered to Members shall be monitored under the
Quality Improvement Program applicable to the particular Benefit Program.  PPG also agrees to provide medical and other
records within five (5) calendar days of receipt of written notice, and review
data and other information as may be required or requested under a Quality
Improvement Program, including reporting in accordance with, but not limited
to, the current Health Plan Employer Data and Information Set (HEDIS), or its
successor. In the event that PPG’s performance, including but not limited to,
its structures, processes or outcomes, is found to be unacceptable under any
Quality Improvement Program, FHS shall give written notice to PPG to correct
the specified deficiencies within the time period specified in the notice.  PPG shall correct such deficiencies within
that time period.

 

2.18        Preventive
Care and Health Education.  PPG shall provide quality health
promotion and disease prevention programs to Members in a manner which meets
specified criteria outlined in the Operations Manual.  Such program shall (a) stress healthy
lifestyles to minimize health risk factors and maximize health potential; (b)
focus on patient education as a part of the medical treatment plan directed by
physicians; (c) utilize an integrated and systematic approach to planning,
implementing, and evaluating programs including a physician advisory committee
and data collection of program usage and results; and, (d) delegate
responsibility for the program to an interested and qualified health care
professional who will coordinate the program for the PPG and act as liaison to
FHS.

 

2.19        Member
Grievance and Appeal Procedure.  PPG shall participate in and be
bound by the applicable Benefit Program, Member’s Certificate and the
applicable Member grievance and appeal procedure, as set forth in the
Operations Manual.

 

2.20        Credentialing
of PPG and/or Participating Providers.  PPG
shall submit to FHS the Credentials Application, as set forth in the Operations
Manual.  Such application shall be
completed on behalf of PPG, and/or on behalf of each Participating Provider
rendering Covered Services under this Agreement.  The submitted Credentials Application is
construed to be a part of this Agreement. If so permitted by State law, and
required and delegated by FHS, the obligations of PPG in Article V also shall
apply.  PPG represents and warrants that
each Member Physician meets the credentialing and recredentialing standards
adopted by FHS set forth in the Operations Manual and that PPG shall perform
credentialing and recredentialing functions in accordance with the Operations
Manual.

 

2.21        Notice of
Adverse Action.  PPG shall notify FHS in writing, within five
days of receiving any notice of any complaint, grievance, appeal, or adverse
action, including, without limitation, (i) any action against any license,
certification under Title XVIII or Title XIX or other applicable statute of the
Social Security Act or other State law, or DEA narcotic registration
certificate; (ii) any action which results in the filing of a report on a
Member Physician under California Business & Professions Code Section 805;
(iii) any action by an insurance carrier indicating that such carrier will
cancel or not renew the insurance coverage required to be carried by a Member
Physician as specified in this Agreement; (iv) any malpractice litigation or
settlement involving a Member Physician; and (v) any other event, occurrence or
situation which might materially interfere with, modify or alter performance of
any of PPG’s duties or obligations under this Agreement. PPG shall maintain a
written record of any Member complaint and provide such record to FHS promptly
upon request.

 

2.22        Insurance.  PPG
shall maintain appropriate insurance programs or policies as follows and in
accordance with the Operations Manual:

 

(a)           PPG agrees to maintain professional
liability insurance and managed care errors and

 

10

 

omissions insurance, or other
risk protection program, in the amounts required by law but no less than One
Million Dollars ($1,000,000.00) per claim and Three Million Dollars
($3,000,000.00) annual aggregate and, where possible, shall name FHS as an
additional insured. Notification to FHS by PPG of cancellation or material
modification of the risk protection program shall be made to FHS at least
thirty (30) days prior to any cancellation. Certificates of Coverage or
documents evidencing professional liability insurance or other risk protection
required under this subsection shall be provided to FHS upon request.

 

(b)           PPG shall maintain a policy or
program of comprehensive general liability insurance (or other risk protection)
with minimum coverage including a Combined Single Limit Body Injury and
Property Damage Insurance of not less than One Million Dollars ($1,000,000.00)
per claim.

 

(c)           PPG’s employees shall be covered by
Workers’ Compensation Insurance in an amount and form meeting all requirements
of applicable provisions of the California Labor Code.

 

2.23        Conflict of
Interest.  PPG shall not, during the term of this
Agreement, acquire, or make any commitment to acquire a proprietary interest in
any organization which is licensed as a health care service plan or which has
submitted an application for such licensure except as to a health care service
plan with waivers.  This restriction
shall include any affiliated, subsidiary or parent organizations to which PPG
may belong in which thirty percent (30%) or more is under common ownership.
“Proprietary Interest”, as used herein, shall not be deemed to include:

 

(a)           participation as a provider of
services for any other health care service plan or system of prepaid health
care delivery; or

 

(b)           ownership of shares having a current
value of less than two hundred fifty thousand dollars ($250,000.00) in a
corporation whose shares are regularly traded in a public market.

 

2.24        Non-Solicitation.  PPG
and Member Physicians shall not, either during or after the term of this
Agreement, solicit any Member to enroll in any other health care service plan
or insurance program for the primary purpose of securing financial gain. FHS
shall have the right to review all correspondence or communications to Members
prior to dissemination or mailing.

 

2.25        Encounter
Reporting.  For HMO Members for which PPG receives
Capitation under this Agreement, PPG shall provide FHS encounter data in
accordance with the Operations Manual, via magnetic media for all Contracted
Services provided to HMO Members during a calendar month within thirty (30)
days of the end of the month in which such services are rendered.  PPG shall also promptly provide FHS with all
corrections to and revisions of such encounter data.  FHS and PPG shall work in good faith to
eliminate hard copy reports and transition to Electronic Data Interface (EDI)
exchange of information.

 

2.26        Regulatory
and Accreditation Surveys.  PPG shall participate in and
assist FHS with any review conducted by a regulatory agency or any
accreditation survey or study.

 

2.27        New or
Additional Benefit Plan Designs.  PPG agrees to accept any new or
additional benefit plan designs developed by FHS and shall provide Covered
Services pursuant hereto. FHS shall determine appropriate actuarial values,
consistent with existing actuarial assumptions, in order to compensate PPG.

 

III.           DUTIES OF FHS

 

3.1          Enrollment
List.  FHS shall periodically provide PPG with a
list of HMO Members assigned to

 

11

 

PPG via electronic
transmission or magnetic media.  FHS
shall maintain a system to allow PPG and Member Physicians to make telephonic
or electronic inquiries regarding Member eligibility.

 

3.2          Administration.  FHS
shall perform, or have performed, all necessary administrative, accounting,
enrollment, and other functions appropriate for marketing and administration of
the Benefit Programs contained in this Agreement.

 

3.3          Member-Physician
Relationship.  FHS shall not interfere with the professional
relationship between any Member and his or her Member Physician(s). In no event
shall FHS interfere with the responsibilities or legal right of Member
Physicians or other licensed health care providers to discuss with Members
information relevant to such Members’ health care. Member Physicians shall have
the right to act as an advocate for and to communicate freely with Members
regarding their health care, including, but not limited to, communications
regarding diagnostic and treatment options.

 

3.4          Insurance.  FHS
shall maintain appropriate insurance programs or policies including a policy of
bodily injury and personal injury coverage which includes persons serving on
FHS committees as insured by definition. In the event that a policy or program
is terminated or the coverage of committee persons is materially changed, FHS
shall so notify PPG.

 

3.5          Timely
Assignment of Members.  FHS shall require Members to
select a PCP and/or a participating physician group at the time of enrollment
when required under a Benefit Program. 
FHS may assist Members in such selection by providing information, as
determined by FHS, regarding PCPs and physician groups. Nothing in this
Agreement shall be construed to require FHS to assign a minimum or maximum
number of Members to PPG or to utilize PPG for any Members in the Service Area.

 

3.6          Reporting
to Regulators.  FHS shall accept sole responsibility for
filing reports, obtaining approvals, and complying with the applicable laws and
regulations of State, federal, and other regulatory agencies having
jurisdiction over FHS; provided, however, that PPG agrees to cooperate in
providing FHS with any information and assistance reasonably required in
connection therewith.

 

3.7          Premiums. FHS shall collect all premiums, dues, Member
payments, and other items of revenue to which FHS is entitled, except for
Copayments and payments for non-Covered Services.

 

3.8          Out-of-Area
Services.  FHS shall manage and coordinate out-of-area
services.  PPG shall cooperate fully with
FHS and shall provide any information necessary to transfer Members back into
the Service Area, including but not limited to, notification to FHS of known or
suspected out-of-area services.  PPG
shall accept the prompt transfer of Member to the care of PPG and its
Participating Providers following the receipt of out-of-area services when
medically appropriate.

 

3.9          Operations
Manual.  FHS shall provide PPG with various Operations
Manuals which identify the methods of administration of this Agreement,
including grievance and appeal procedures, Utilization/Care Management
Programs, Quality Improvement Programs, encounter reporting procedures, and
billing and accounting of Covered Services rendered hereunder. Updates to the
Operations Manual will be made by FHS and, whenever possible, shall be sent to
PPG for review thirty (30) days prior to implementation. Such updates shall not
materially affect the compensation rates or financial responsibility of PPG
under this Agreement.

 

3.10        Marketing
Activities.  FHS shall make reasonable efforts to market
the Benefit Programs. Nothing in this Agreement shall require FHS to conduct
any specific marketing activities on behalf of PPG or to identify PPG in any
specific FHS marketing or informational materials.

 

12

 

IV.           COMPENSATION

 

4.1          Compensation
Rates.  PPG and Member Physician shall accept as
payment in full for Contracted Services and all other services rendered to
Members under this Agreement the amounts payable by FHS or a Payor as set forth
in the applicable Addendum to this Agreement. Except when PPG is paid
Capitation, PPG may require Member Physicians to bill and accept compensation
as payment in full. PPG shall bill and accept payment for Contracted Services
rendered by Member Physicians, and be responsible for administering such funds
and compensating Member Physicians therefrom. When PPG is paid Capitation, FHS
reserves the right to create new benefit plans and to establish capitation
rates for new benefit plans based on actuarial assumptions that are consistent
with existing actuarial assumptions. FHS shall adjust the actuarial assumptions
which support the rates in the applicable Addenda on a periodic basis, and
shall advise PPG of any such adjustments in methodology. Capitation may also be
adjusted in the event benefits are added or deleted from PPG Capitated Services.

 

4.2             Performance
Incentives.  In consideration of PPG offering an approved
wellness program and their participation in the Quality of Care Improvement
Program, or its successor, as defined in the Operations Manual, FHS shall
reimburse PPG pursuant to the program set forth in the Operations Manual.

 

4.3             Billing
and Payment.

 

(a)           Billing.  PPG shall submit to FHS via FHS electronic
claims submission program or by hard copy, clean, complete and accurate claims
for Contracted Services in accordance with the Operations Manual and the
applicable Benefit Program, unless PPG is paid Capitation for such
services.  PPG shall submit claims within
sixty (60) days of rendering Contracted Services. Where FHS is the secondary
payor under Coordination of Benefits, such sixty (60) day period shall commence
immediately after the primary payor has paid or denied the claim. In the event
PPG is capitated and elects to purchase reinsurance from FHS, PPG shall submit
reinsurance claims within sixty (60) calendar days of the end of the annual
reinsurance period.

 

FHS
shall not be under any obligation to pay PPG for any claim not timely submitted
as set forth above. PPG shall not seek payment from any Member in the event FHS
does not pay PPG for a claim not timely submitted.

 

(b)           Payment.  Unless a claim is disputed, FHS or a Payor
shall pay PPG’s clean, complete, accurate and timely submitted claims for
Contracted Services rendered to a Member, in accordance with applicable State
and federal law.

 

(c)           Adjustments
and Appeals.  PPG or
Member Physicians shall submit requests for adjustments and/or appeals
regarding claim payments to FHS within sixty (60) calendar days after the date
of the payment of such claim to PPG or Member Physician.  In the event PPG or Member Physician fails to
appeal a claim within such time period, PPG or Member Physician shall not have
the right to appeal such claim.

 

(d)           Offsetting.  FHS shall have the right to offset any
amounts owed to FHS by PPG, including but not limited to, amounts owed by PPG
under loans guaranteed by FHS, errors, or FHS interim payment for Contracted
Services, including Capitation payments. Effective July 1, 1998 and
notwithstanding any other provision of this Agreement or any other contract to
the contrary, only deficits in the shared risk programs which provide financial
incentives for the control or management of Shared Risk Services’ expenses or
utilization will neither be collected from PPG by FHS nor offset against PPG
Capitation; provided however, that FHS shall not be restricted from (i)
offsetting such deficits against payments to PPG including, but not limited to,
surpluses from other shared risk programs, stop loss payments, bonus or other
incentive program payments; (ii) establishing reasonable withholds from
Capitation approved by DOC as set forth in the applicable Addendum to offset
PPG

 

13

 

liability when the cost of
Shared Risk Services exceed the Shared Risk Budget (Withhold Fund); or (iii)
carrying forward such shared risk program deficits to be applied against future
year’s program surpluses and Withhold Fund. Each PPG numbered site shall be
calculated as a separate entity and any payments to or from PPG with multiple
sites shall be net amount due/owed from all sites.

 

(e)           Reciprocity.  PPG shall cooperate and develop arrangements
with FHS and Participating Providers to assure reciprocity of the rates for
Covered Services for Members who are not assigned to PPG. FHS shall, where
contractually available, provide reciprocity to FHS rates for Covered Services
provided to PPG’s assigned Members. FHS shall adjudicate and pay such referred
claims on behalf of PPG (at available reciprocity rates or, if reciprocity
rates are unavailable, at rates negotiated in consultation with PPG), shall
deduct the costs of such claims from PPG’s monthly Capitation, and shall
provide PPG an accounting thereof.

 

PPG
agrees that FHS may allow the compensation rates set forth in this Agreement to
be used by other Participating Providers who may from time to time be
responsible for compensating PPG for Covered Services rendered by PPG to a
Member.

 

4.4          Reconciliation
of Eligibility.  In the event of a retroactive cancellation or
addition of an HMO Member, FHS shall adjust Capitation accordingly. In the event
Contracted Services are provided to an individual who is not a Member, based on
an erroneous or delayed enrollment list or confirmation of enrollment of said
individual by FHS, FHS shall be financially responsible for all such services
provided by PPG prior to the time PPG received notice of that person’s
ineligibility, except when the individual is enrolled in another health care
service plan or insurance program from whom PPG or Participating Provider has
or may receive capitation or other payment for the individual.  In the event FHS is financially responsible,
FHS shall pay PPG at the fee-for-service rates in Addendum E when PPG supplies
FHS with evidence that it has unsuccessfully sought payment through two billing
cycles for all or a portion of such charges from the patient, or the person
having legal responsibility for the patient or the entity having financial
responsibility for such payment. In the event FHS pays PPG pursuant to this
Section, PPG shall have no further right and shall not attempt to collect any
additional payment from the patient for said services and PPG shall be deemed
to have transferred all legal rights of collection and Coordination of Benefits
for services to FHS.

 

4.5          Extension
of Benefit Members.  When PPG is capitated, PPG’s Capitation for a
Member who is or becomes eligible for coverage under the extension of benefits
provisions of the Member’s Coverage Certificate shall be equal to the current
amount for the plan type under which the Member is or was enrolled.  PPG shall provide services to any Member who
is totally disabled on the original date of the Member’s FHS coverage. In the
event payment for such Contracted Services is obtained by FHS from a prior
carrier as an extension of benefits, FHS shall reimburse PPG to the extent
payment is received from the prior carrier.

 

4.6          Collection
from Member.  PPG shall collect all Copayments due from
Members, and shall not waive or fail to pursue collection of Copayments from
Members.  PPG shall not charge a Member
any fees or Surcharges for Covered Services rendered pursuant to this
Agreement, except for authorized Copayments. 
In addition, PPG shall not collect a sales, use or other applicable tax
from Members for the sale or delivery of Covered Services.  If FHS receives notice of any additional
charge, FHS shall take appropriate action. 
PPG may bill a Member for non-Covered Services rendered by PPG to such
Member only if the Member is notified in advance that the services to be
provided are not covered under the Member’s Benefit Program, and the Member
requests in writing that PPG render the non-Covered Services, prior to PPG’s
rendition of such services.

 

4.7          Member
Held Harmless.  PPG agrees that in no event, including, but
not limited to, non-payment by FHS, insolvency of FHS, or breach of this
Agreement, shall PPG bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against Members, the
State, or persons other than FHS for Covered Services provided pursuant to this
Agreement.  This provision shall not

 

14

 

prohibit
collection of Copayments or any amounts due for services which are determined
not to be Covered Services in accordance with the terms of the applicable Benefit
Program.

 

PPG
further agrees that: (a) this provision shall survive the termination of this
Agreement regardless of the cause giving rise to termination and shall be
construed to be for the benefit of Members; and (b) this provision supersedes
any oral or written contrary agreement existing or hereafter entered into
between PPG and Members or persons acting on their behalf. Any modification,
addition, or deletion of or to the provisions of this clause shall be effective
on a date no earlier than fifteen (15) days after the State regulatory agency
has received written notice of such proposed change and has approved such
change.

 

4.8          Coordination
of Benefits.  PPG agrees to conduct Coordination of
Benefits in accordance with the policies and procedures in the Operations
Manual, including but not limited to, the prompt notification to FHS of any
third party entity who may be responsible for payment and collection of
Copayments. PPG shall not bill Members for any portion of Contracted Services
not paid by the primary carrier when FHS is the secondary carrier, but shall
seek payment from FHS. When FHS is secondary under the Coordination of Benefit
rules, FHS shall pay PPG only those amounts which, when added to the amount
paid to PPG from other sources, equals the amount due to PPG under this
Agreement in the absence of other sources of payment.  Any legal right to collection of overpayments
from FHS which may occur under this Section shall be deemed to be transferred
from PPG to FHS if PPG has been paid in full according to the primary carrier’s
contracted rate. PPG shall report on a monthly basis, the nature and extent of
all Coordination of Benefits recoveries for services rendered by PPG under this
Agreement. Such recoveries shall be performed in accordance with the applicable
Evidence of Coverage and FHS’ policies set forth in the Operations Manual.

 

4.9          Third
Party Recoveries, Worker’s Compensation.  In the
event PPG provides services to FHS Members for injuries resulting from the acts
of third parties, or resulting from work related injuries, PPG shall have the
right to recover from any settlement, award, or recovery from any responsible
third-party the value of Covered Services rendered pursuant to the applicable
provisions of the Coverage Certificate except as specifically stated otherwise
in the Operations Manual. PPG shall notify FHS of any third party payor and
shall, upon request from FHS, provide FHS with an accounting of all such sums
recovered.

 

4.10        Audit of
Claims.  FHS shall have the right to review and audit
any claims and to reconcile any amounts accordingly.

 

4.11        Reinsurance.  For
selected Benefit Programs, FHS shall provide certain stop loss and reinsurance
programs designed to protect the PPG from excessive financial risk.  Such programs are specified in the applicable
Addendum.  FHS shall charge PPG a premium
in consideration for these programs. Notwithstanding any other provision in
this Agreement, FHS may adjust the premium and thresholds for such programs by
providing sixty (60) days prior written notice to PPG.

 

PPG
may elect not to participate in certain stop loss and reinsurance programs
effective the first day of any calendar year provided that PPG provides written
notice to FHS at least sixty (60) calendar days prior to the beginning of the
calendar year that PPG shall not participate in the stop loss program and
specifies the name of the third party insurance carrier and proposed effective
date, coverage levels and charges. In such event, PPG shall be required to
obtain stop loss coverage in the amounts required by FHS and State and federal
law from a third party insurance carrier acceptable to FHS. If FHS does not
object to such coverage in writing within fifteen (15) days of the date of the
notice, PPG shall be required to purchase such coverage as of the effective
date specified in the notice. If such notice is not received when due or if
coverage levels are not acceptable, FHS shall automatically enroll PPG in its
programs to afford protection effective on the first day of the calendar year.

 

PPG
shall submit claims under the applicable stop loss and reinsurance programs in
accordance

 

15

 

with the procedures set forth
in the Operations Manual but no later than sixty (60) calendar days following
the end of the calendar year. For purposes of calculating stop loss and
reinsurance thresholds, the following shall apply: (i) for PPG and Member
Physicians, the compensation schedule set forth in Addendum E shall be
utilized; (ii) for any other Provider who is subcontracted to PPG, such
subcontract rates shall be utilized; (iii) for a Participating Provider who is
not subcontracted with PPG but is contracted with FHS.  FHS’ contract rate shall be utilized; or (iv)
the actual charges paid by PPG when none of the above applies. FHS shall
compensate PPG for claims in excess of the stop loss threshold at *** of the
fee-for-service rates in Addendum E unless otherwise provided for in an
applicable Addendum, less applicable Copayments, coinsurance, deductibles and
payments from third parties or Coordination of Benefits.

 

V.            DELEGATION

 

5.1          Delegation
of Certain Functions.  If qualified, as determined by
FHS, PPG shall accept delegation of and perform such utilization management,
quality improvement, credentialing and recredentialing, Member grievance and
appeal, medical record review, and capitation and claims adjudication
functions, in accordance with the performance standards and criteria of FHS as
set forth in the Operations Manual. PPG shall ensure the timely payment of
Covered Services rendered by referral health professionals and shall perform
such claims processing in accordance with applicable Benefit Program and
Operations Manual.

 

5.2          Termination
of Delegation.  FHS shall have the right to audit PPG’s
performance of utilization management, quality improvement, credentialing and
recredentialing, Member grievance and appeal, medical record review, and
capitation and claims adjudication functions from time to time. If FHS
determines that deficiencies exist in PPG’s performance, PPG shall accept
consulting assistance from FHS. Failure to cure any identified deficiencies
within a reasonable period of time as defined by FHS policies, or if FHS
determines PPG does not have the ability to perform delegated functions, or is
not effectively performing delegated functions, FHS may revoke delegation of
all or any of these functions in accordance with procedures set forth in the
Operations Manual and re-assume the performance of such functions itself.
Should it become necessary for FHS to reassume delegated functions, FHS shall
charge the following administrative fees: utilization management *** of PPG
Capitation; quality improvement *** of PPG Capitation; claims processing *** of
PPG Capitation.

 

VI.           TERM AND TERMINATION

 

6.1          Term.  The
term of this Agreement shall commence on the date set forth on the first page
of this Agreement and shall continue for a period of thirty six (36) months.
This Agreement shall automatically renew for successive one year periods on the
annual renewal date, unless terminated as set forth herein.  The term of this Agreement shall remain the
same for all Benefit Programs covered hereunder.

 

6.2          Without
Cause Termination.  Either party may terminate this Agreement at
the scheduled renewal date upon one hundred twenty (120) days prior written
notice to the other party.  In the event
FHS provides PPG with such notice, FHS may, at its option, begin to transition
Members immediately under this Agreement to another Participating Provider after
such notice.

 

6.3          Immediate
Termination.  FHS may terminate this Agreement immediately
upon notice to PPG, in the event of: (a) PPG’s violation of any applicable law,
rule or regulation; (b) PPG’s failure to maintain the professional liability
insurance coverage specified hereunder; (c) PPG’s failure to comply with the
terms, conditions

 

16

 

or determinations of any
Utilization/Care Improvement Program or Quality Improvement Program, or Benefit
Program; or, (d) FHS’ determination that the health, safety or welfare of any
Member may be in jeopardy if this Agreement is not terminated.

 

6.4          Termination
for Failure to Pay.  In the event FHS fails to make payments to
PPG under the terms and conditions of this Agreement within the times set forth
herein, PPG may terminate this Agreement, but only if FHS has failed to make
such payments following ten (10) business days prior written notice from PPG.
PPG may not terminate this Agreement after giving such notice unless, PPG has
first made itself available to meet with FHS to attempt in good faith to
resolve the matter.

 

6.5          Termination
Due to Material Breach Other Than Non-Payment.  Except
as set forth in above, in the event that either PPG or FHS fails to cure a
material breach of this Agreement within thirty (30) days of receipt of written
notice of such breach from the other party, the non-defaulting party may
terminate this Agreement.  If the breach
is cured within such thirty (30) day period, or if the breach is one which
cannot reasonably be corrected within thirty (30) days, and the non-defaulting
party determines that the defaulting party is making substantial and diligent
progress toward correction during such thirty (30) day period, this Agreement
shall remain in full force and effect.

 

6.6          Termination
of an Affiliate.  In the event FHS ceases to own fifty-one
percent (51%) or more of the voting stock, or to manage or have a FHS
subsidiary manage, an entity, such entity shall cease being a FHS Affiliate
hereunder.  Effective on the date FHS
ceases to own fifty-one percent (51%) or manage, or an FHS subsidiary ceases to
manage, the entity, such entity shall no longer be a party to this Agreement
and the terms and conditions hereunder shall not apply to such entity.

 

6.7          Effect
of Termination.  In the event that a Member is receiving
Contracted Services at the time this Agreement terminates, PPG shall continue
to provide Contracted Services to the Member until the later of: (a) treatment
is completed; (b) the Member is discharged from an inpatient facility; (c) the
Member is assigned to another Participating Provider; or (d) the anniversary
date of the Member’s Coverage Certificate, if requested by FHS.  Compensation for such Contracted Services
shall be at the rates contained in the applicable Addendum. Termination of this
Agreement shall not affect any right or obligations hereunder which shall have
previously accrued, or shall thereafter arise with respect to any occurrence
prior to termination, and such rights and obligations shall continue to be
governed by the terms of this Agreement.

 

6.8          Termination
Withhold from Capitation.  In the event either party gives
the other party notice of termination as set forth in this Article, FHS may, at
its sole discretion, withhold up to one-third of each of the final three months
of Capitation due PPG. If FHS exercises its option to transition HMO Members
prior to the end of the termination notice period, FHS may withhold the entire
last month’s Capitation. FHS may use such funds to offset any PPG liability to
FHS or for payment of PPG Capitated Services on behalf of PPG.  FHS shall pay PPG simple interest on all
funds withheld as set forth in this Section at the interest rate per annum which
shall be the lower of five percent (5%) or the prime interest rate, e.g. the
base rate on corporate loans posted by at least seventy five percent (75%) of
the nation’s thirty largest banks, as of the last business day in December of
the prior contract year. PPG understands and agrees that a decision by FHS to
withhold any Capitation shall not relieve PPG of its obligations to perform
under this Agreement  All amounts
withheld by FHS and all interest accrued on such amounts as set forth in this
Section shall be included in any calculations regarding a final settlement
between the parties.

 

Notwithstanding
any other provision of this Agreement, in the event FHS decides to withhold
Capitation from PPG as set forth in this Section, FHS may, upon three days
prior written notice to PPG, administer or oversee all or part of PPG Capitated
Services oh behalf of PPG. PPG agrees to fully cooperate with FHS in the
administration of such claims, including providing all necessary information,
and to take no action which may

 

17

 

jeopardize the payment of
such claims.

 

6.9          Financial
Settlement Upon Termination.  Within one hundred eighty (180)
calendar days of the effective date of termination of this Agreement, an
accounting shall be made by FHS of the monies due and owing either party and
payment shall be forthcoming by the appropriate party to settle such balance
within thirty (30) calendar days of such accounting. PPG may request an
independent audit of such FHS accounting. Such audit may be performed by a mutually
acceptable independent certified public accountant and shall be paid for solely
by PPG. In the event such independent audit results in findings different from
FHS’s findings, the parties shall meet and confer to resolve such differences.

 

VII.         RECORDS, AUDITS AND REGULATORY
REQUIREMENTS

 

7.1          Medical
and Other Records.  PPG shall prepare and maintain all medical
and other books and records required by law in accordance with the general
standards applicable. PPG shall maintain such records for at least seven (7)
years after the rendering of Contracted Services and records of a minor child
shall be kept for at least one (1) year after the minor has reached the age of
eighteen (18), but in no event less than seven (7) years. Additionally, PPG
shall maintain such financial, administrative and other records as may be
necessary for compliance by FHS with all applicable local, State, and federal
laws, rules and regulations. PPG agrees to submit upon request such reports and
financial information as is necessary for FHS to comply with regulatory
requirements to monitor the financial viability of PPG.

 

7.2          Access
to Records; Audits.  The records referred to above shall not be
removed or transferred from PPG except in accordance with applicable local,
State, and federal laws, rules and regulations. 
Subject to applicable State and federal confidentiality or privacy laws,
FHS or its designated representatives, and designated representatives of local,
State, and federal regulatory agencies having jurisdiction over FHS shall have
access to PPG’s records, at PPG’s place of business on request during normal
business hours, to inspect and review and make copies of such records.  Such governmental agencies shall include, but
not be limited to, when applicable to the Benefit Programs identified on
Addendum A, the DHS, the DHHS, the DOC, the DOD and the DOJ.  When requested by FHS, PPG shall produce
copies of any such records at no cost. Additionally, PPG agrees to permit FHS,
and its designated representatives, accreditation organizations, and designated
representatives of local, State, and federal regulatory agencies having
jurisdiction over FHS or any Payor, to conduct site evaluations and inspections
of PPG’s offices and service locations.

 

7.3            Continuing
Obligation.  The obligations of PPG under this Article
shall not be terminated upon termination of this Agreement, whether by
rescission or otherwise. After termination of this Agreement, FHS and Payors
shall continue to have access to the other party’s records as necessary to
fulfill the requirements of this Agreement and to comply with all applicable
taws, rules and regulations.

 

VIII.        GENERAL PROVISIONS

 

8.1          Amendments.  Except
as provided herein, FHS and PPG may only amend this Agreement by written mutual
consent. Amendments required because of legislative, regulatory or legal
requirements do not require the consent of PPG or FHS and will be effective
immediately on the effective date thereof. Any amendment to this Agreement
requiring prior approval of or notice to any federal or State regulatory agency
shall not become effective until all necessary approvals have been granted or
all required notice periods have expired.

 

8.2            Separate
Obligations.  The rights and obligations of under this
Agreement shall apply to each Affiliate listed on Addendum A to this Agreement
only with respect to the Benefit Programs of such Affiliate. No

 

18

 

such Affiliate shall be
responsible for the obligations of any other Affiliate under this Agreement
with respect to the other Affiliate’s Benefit Programs. The person executing
this Agreement has been duly authorized by each Affiliate to execute this
Agreement on such Affiliates behalf. In no event shall FHS or any FHS Affiliate
be responsible for any payment which is the financial responsibility of a Payor
and PPG shall seek compensation for such services only from Payor.

 

8.3          Assignment. 
Neither party shall assign its rights nor delegate its duties and
obligations hereunder without the prior written consent of the other party;
provided, however FHS shall have the right to automatically assign this
Agreement to any entity which controls, is controlled by, or is under common
control with FHS. PPG agrees to provide prior written notice to FHS of its
intent to either sell, transfer or convey its business assets to another entity
or enter into a management contract with a physician practice management entity
which does not manage PPG as of the effective date of this Agreement.

 

In
the event PPG (1) files a petition in bankruptcy, makes a general assignment
for the benefit of creditors or has a petition in bankruptcy filed against it,
a receiver or trustee appointed over its assets, or an attachment, seizure,
lien or levy made against a substantial portion of its assets; or (2) becomes
otherwise incapable, as determined by FHS of performing basic functions
associated with operating a medical group or performing its duties and
responsibilities under this Agreement, including but not limited to, claims payment,
medical management, and quality assurance then, PPG agrees to make full
assignment (not including any delegation of prior obligations) of its provider
contracts to FHS.  Nothing in this
paragraph shall be construed to mean that PPG cannot or shall not contract or
re-contract with the same physicians, medical groups and ancillary providers
for other lines of business and/or for the same lines of business with other
health plans-which rights are hereby expressly retained by PPG.

 

8.4          Confidentiality.  FHS
and PPG agree to hold all confidential or proprietary information or trade
secrets of each other in trust and confidence and agree that such information
shall be used only for the purposes contemplated herein, and not for any other
purpose.  Specifically, PPG acknowledges
that the names, addresses and other identifying information concerning Members
and employers and other groups contracting with FHS constitute confidential
information which derives independent economic value from not being generally known
or readily accessible to others who can obtain economic value from its
disclosure or use. FHS acknowledges that the names, contracts, addresses, and
other information concerning Member Physicians, employees and other providers
and other groups contracting with PPG constitute proprietary information of
PPG. FHS shall use such information only as necessary and appropriate for the
performance of its obligations under this Agreement. In the event FHS could
obtain such information from a source other than PPG, such information shall
not be proprietary to PPG. Neither PPG, a Member Physician, nor FHS shall
disclose the terms of this Agreement except as may be required by law;
provided, however, nothing herein shall prohibit PPG or a Member Physician from
disclosing to a Member any information the PPG or Member Physician determines
is relevant to the Member’s care including the basic method of reimbursement
and whether financial bonuses or incentives are used.

 

8.5          Provider
Dispute Resolution Procedure.  FHS has established a Provider
Dispute Resolution Procedure under which PPG may submit disputes to FHS.  The Provider Dispute Resolution Procedure
which contains the procedures for processing and resolving such disputes including
the location and telephone number where information regarding disputes may be
submitted, is set forth in the Operations Manual.  Any provider dispute which is not resolved
informally through the Provider Dispute Resolution Procedure may be submitted for
arbitration as provided in Section 8.6 below.

 

8.6          Binding
Arbitration.  PPG and FHS agree to meet and confer in good
faith to resolve any problems or disputes that may arise under this Agreement.
Such good faith meet and confer shall be a condition precedent to the filing of
any arbitration demand by either party. In addition, should the parties, prior
to submitting a dispute to arbitration, desire to utilize other impartial
dispute settlement techniques such as mediation

 

19

 

or fact-finding, a joint
request for such services may be made to the American Arbitration Association
(“AAA”), Judicial Arbitration and Mediation Services (“JAMS”), or the parties
may initiate such other procedures as they may mutually agree upon at such
time. Notwithstanding the foregoing, nothing contained herein is intended to
require arbitration of disputes for medical malpractice between a Member and
the PPG.

 

The
parties further agree that any controversy or claim arising out of or relating
to this Agreement, or the breach thereof, whether involving a claim in tort,
contract, or otherwise, shall be settled by final and binding arbitration, upon
the motion of either party, to arbitration under the appropriate rules of the
AAA or JAMS, as agreed by the parties. The arbitration shall be conducted in
Sacramento, Los Angeles, or San Francisco, California by a single, neutral
arbitrator who is licensed to practice law. The written demand shall contain a
detailed statement of the matter and facts and include copies of all related
documents supporting the demand. Arbitration must be initiated within six (6)
months after the alleged controversy or claim occurred by submitting a written
demand to the other party. The failure to initiate arbitration within that
period shall mean the complaining party shall be barred forever from initiating
such proceedings.

 

All
such arbitration proceedings shall be administered by the AAA or JAMS, as
agreed by the parties; however, the arbitrator shall be bound by applicable
state and federal law, and shall issue a written opinion setting forth findings
of fact and conclusions of law. The parties agree that the decision of the
arbitrator shall be final and binding as to each of them. Judgment upon the
award rendered by the arbitrator may be entered in any court having
jurisdiction. The arbitrator shall have no authority to make material errors of
law or to award punitive damages or to add to, modify, or refuse to enforce any
agreements between the parties. The arbitrator shall make findings of fact and
conclusions of law and shall have no authority to make any award which could
not have been made by a court of law. The party against whom the award is
rendered shall pay any monetary award and/or comply with any other order of the
arbitrator within sixty (60) days of the entry of judgment on the award, or
take an appeal pursuant to the provisions of the California Civil Code. The
parties waive their right to a jury or court trial.

 

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

 

8.7          Indemnification
of Parties.

 

(a)           PPG agrees to indemnify, defend, and
hold harmless FHS, its agents, officers, and employees from and against any and
all liability expense including defense costs and legal fees incurred in
connection with claims for damages of any nature whatsoever, including but not
limited to, bodily injury, death, personal injury, or property damage arising
from PPG’s performance or failure to perform its obligations hereunder.

 

(b)           FHS agrees to indemnify, defend, and
hold harmless PPG, its agents, officers, and employees from and against any and
all liability expense, including defense costs and legal fees incurred in
connection with claims for damages of any nature whatsoever, including but not
limited to, bodily injury, death, personal injury, or property damage arising
from FHS’ performance or failure to perform its obligations hereunder.

 

8.8          Status
as Independent Entities.  None of the provisions of this
Agreement is intended to create or shall be deemed or construed to create any
relationship between PPG and FHS other than that of independent entities
contracting with each other solely for the purpose of effecting the provisions
of this Agreement.  Neither PPG nor FHS,
nor any of their respective agents, employees, or representatives shall be
construed to be the agent, employee or representative of the other.

 

8.9          Cooperation
of Parties.  The parties shall cooperate in administering
and determining Member

 

20

 

benefits under the applicable
Coverage Certificate in accordance with the Operations Manual and as agreed to
by the parties. PPG understands and agrees that PPG is not authorized to make
nor shall it make any variances, alterations, or exceptions to the provisions,
terms, and conditions of a Member’s Coverage Certificate. FHS shall have the
final decision-making authority between the parties for payment of claims for
Covered Services rendered to Members, determination of Covered Services,
including Medically Necessary Services, determination of eligibility and
determination of Members’ benefits under the applicable Benefit Program.
Notwithstanding the foregoing, PPG and Member Physicians shall be solely
responsible for providing Contracted Services to Members. The parties shall
refrain from unduly criticizing each other, especially in the presence of third
parties and shall attempt to resolve all issues in a cooperative and
professional manner.

 

8.10        Use of
Name.  Each party agrees that the other party may
not list the name, address, telephone number and other factual information of
the other party in its marketing and informational materials without such
party’s prior written consent, provided FHS shall be entitled to list PPG’s
information in any FHS provider directory.

 

8.11        Non-Exclusive
Contract.  This Agreement is non-exclusive and shall not
prohibit PPG or FHS from entering into agreements with other health care
providers or purchasers of health care services.

 

8.12        No Third
Party Beneficiary.  Nothing in this Agreement is intended to, nor
shall be deemed or construed to create, any rights or remedies in any third
party, including a Member. Nothing contained herein shall operate (or be
construed to operate) in any manner whatsoever to increase the rights of any
such Member or the duties or responsibilities of PPG or FHS with respect to
such Members.

 

8.13        Notice.  Any
notice required or desired to be given under this Agreement shall be in writing
and shall be sent by certified mail, return receipt requested, postage prepaid,
or overnight courier, or facsimile, addressed as follows:

 

FHS

C/O
Health Net

21600
Oxnard Street

Woodland Hills,
California 91367

Attention:
Senior Vice President, Provider Network Management

 

PPG:

Prospect
Medical Gorup

18200
Yorba Linda Blvd., Suite 409

Yorba
Linda, CA 92686

Attn:
Administrator / CEO

 

The addresses to which
notices are to be sent may be changed by written notice given in accordance
with this Section.

 

8.14        Severability.  If any
provision of this Agreement is rendered invalid or unenforceable by any local,
State, or federal law, rule or regulation, or declared null and void by any
court of competent jurisdiction, the remainder of this Agreement shall remain
in full force and effect.

 

8.15        Addenda.  Each
Addendum to this Agreement is made a part of this Agreement as though set forth
fully herein. Any provision of an Addendum that is in conflict with any
provision of this Agreement shall

 

21

 

take precedence and supersede
the conflicting provision of this Agreement.

 

8.16        Regulatory
Approval.  If FHS has not been licensed to provide, or
provides services in connection with, a particular Benefit Program in a
particular State, or has not received all required regulatory approvals for use
of this Agreement with respect to the Benefit Program in the State prior to the
execution of this Agreement, this Agreement shall be deemed to be a binding
letter of intent with respect to such Benefit Program in the State. In such
event, this Agreement shall become effective with respect to any such Benefit
Program in the State on the date that the required licensure and regulatory
approvals are obtained. If FHS is unable to obtain such licensure or regulatory
approvals after due diligence, FHS shall notify PPG and both parties shall be
released from any liability under this Agreement with respect to the Benefit
Program in question in the applicable State; provided however, that if such
licensure or regulatory approval is conditioned upon amendment of this
Agreement, then this Agreement shall be amended automatically pursuant to this
Article.

 

8.17        Headings.  The
headings of articles and paragraphs contained in this Agreement are for
reference purposes only and shall not affect in any way the meaning or
interpretation of this Agreement.

 

8.18        Entire
Agreement.  Except as expressly provided in the
applicable Addendum, this Agreement including its Addendum supersedes any and
all other agreements, either oral or written, between the parties with respect
to the subject matter hereof, and no other agreement, statement or promise
relating to the subject matter of this Agreement shall be valid or binding.

 

8.19        Governing
Law.  This Agreement shall be governed by and
construed and enforced in accordance with the laws of the State, except to the
extent such laws conflict with or are preempted by any federal law, in which
case such federal law shall govern. 
Federal law shall also govern with respect to federal Benefit Programs.
In addition, FHS is subject to the requirements of Chapter 2.2 of Division 2 of
the California Health and Safety Code and of Subchapter 5.5 of Chapter 3 of
Title 10 of the California code of Regulations. 
Any provision required to be in this Agreement by either of the above
shall bind the parties whether or not provided in this Agreement.

 

22

 

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

 

 

 

	
  Participating Physician Group

  	
   

  	
  Foundation
  Health Systems Affiliates

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  /s/ James Wilcox

  	
   

  	
  /s/ Linda S. Pollnow

  	
   

  
	
  Signature

  	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  JAMES WILCOX

  	
   

  	
  Linda S. Pollnow

  	
   

  
	
  Print Name

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Senior Vice President

  	
   

  
	
  VICE PRESIDENT, CONTRACTING

  	
   

  	
  Provider Network Management

  	
   

  
	
  Title

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  5/14/98

  	
   

  	
  5-20-98

  	
   

  
	
  Date

  	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  33-021 9957

  	
   

  	
   

  	
   

  
	
  Federal Tax Identification Number

  	
   

  	
   

  	
   

  

 

PPG
acknowledges that it is contractually bound to the Operations Manual and any
updates or revisions to such to be issued to PPG by having a duly authorized
representative sign in the space provided below.

 

	
  Participating
  Physician Group

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ James Wilcox

  	
   

  
	
  Signature

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  JAMES WILCOX

  	
   

  
	
  Print Name

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  VICE PRESIDENT, CONTRACTING

  	
   

  
	
  Title

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  5/14/98

  	
   

  
	
  Date

  	
   

  

 

23

 

ADDENDUM A

 

BENEFIT PROGRAMS AND AFFILIATES

 

I.              BENEFIT PROGRAMS

 

Benefit Program participation included under
this Agreement is as follows:

 

	
  BENEFIT PROGRAM

  	
   

  	
  ADDENDUM

  	
   

  	
  PPG

  PARTICIPATION

  	
   

  
	
  Standard HMO

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Flex Funded HMO

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Small Group HMO

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Individual HMO

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  AIM

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Medicare Supplement

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Commercial POS

  	
   

  	
  B

  	
   

  	
  YES

  	
   

  
	
  Medicare HMO

  	
   

  	
  C

  	
   

  	
  YES

  	
   

  
	
  Medicare POS

  	
   

  	
  C

  	
   

  	
  YES

  	
   

  
	
  PPO/EPO/POS (out-of-network)

  	
   

  	
  D

  	
   

  	
  YES

  	
   

  
	
  Medi-Cal

  	
   

  	
  F

  	
   

  	
  NO

  	
   

  
	
  CHAMPUS

  	
   

  	
  G

  	
   

  	
  YES

  	
   

  
	
  Occupational Medicine

  	
   

  	
  H

  	
   

  	
  YES

  	
   

  

 

II.            AFFILIATES

 

Upon
execution of this Agreement, the Affiliates primarily using this Agreement
include, but are not limited to, the following: Health Net; Foundation Health,
a California Health Plan; Health Net Life Insurance Company; Qualmed Life and
Health Insurance Company; Foundation Health National Life Insurance Company;
Business Insurance Group. Inc.; Business Insurance Company; California
Compensation Insurance Company; Combined Benefits Insurance Company; Commercial
Compensation Insurance Company; Foundation Health Federal Services; Foundation
Health Medical Resource Management; Preferred Health Network Inc.; and
Foundation Health System Life and Health Insurance Company.  The Affiliates are defined in Section 1.1 of
this Agreement.

 

Notwithstanding
the foregoing. PPG agrees that any other Affiliate of FHS not listed above may
access the rates set forth in this Agreement and Addenda. This would include
Members of non-California based affiliates who may be treated by PPG.

 

24

 

ADDENDUM B

 

COMMERCIAL
HEALTH MAINTENANCE ORGANIZATION (HMO) AND COMMERCIAL POINT OF SERVICE (POS)
BENEFIT PROGRAMS

 

A.            GENERAL REIMBURSEMENT PROVISIONS.

 

1.             PPG understands and agrees that the
obligations of FHS set forth in this Addendum are only the obligations of
Health Net (hereafter “HMO”) and not the obligations of FHS or any other
Affiliate of FHS.  PPG shall be
compensated according to this Addendum B and this Addendum shall be applicable
to only those Commercial HMO and Commercial POS Members listed on the
applicable Capitation remittance summaries. Pursuant to Section 8.18, Entire
Agreement, PPG understands and agrees that the compensation and provisions
under the agreement between PPG and the entity formerly known as Foundation
Health, a California Health Plan, are applicable to those Commercial HMO and
Commercial POS Members listed on the Foundation Health capitation remittance
summary, and that the Foundation Health agreement shall remain in full force
and effect for those Members until such time those Members are no longer
enrolled in Foundation Health Benefit Programs.

 

2.             Benefit
Programs. This
Addendum B is applicable to the following Benefit Programs:

 

•                  Commercial HMO

•                  Standard HMO

•                  Flex Funded HMO

•                  Small Group HMO

•                  Individual HMO

•                  AIM

•                  Medicare Supplement

•                  Commercial POS

 

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

 

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

 

5.             Contracted
Services.  PPG and Member Physicians shall render
Contracted Services which are not PPG Capitated Services to Members covered
under this Addendum B and shall be compensated on a fee-for- service basis at
the rates set forth in Addendum E. PPG shall submit claims in accordance with
the terms of this Agreement and State and federal law.

 

6.             Division
of Financial Responsibility Changes.  In
July 1998, HMO shall change the Division of Financial Responsibility. As a
result, PPG shall have a change in its Professional Capitation PMPM rates and
its

 

25

 

Shared Risk Budgets; Hospital shall have a change in
its Capitation rates, if applicable.

 

7.             Shared Risk Budget.  In July 1998, PPGs Shared Risk Budgets shall
be converted from a flat PMPM amount to an age, sex and benefit plan adjusted
structure. Such conversion shall be revenue neutral (before Division of
Financial Responsibility change.

 

8.             Plan Wide Change of Age, Sex and
Benefit Plan Factors. 
In September 1998, HMO shall implement new age, sex and benefit plan
factors. Such implementation shall produce a change in the Professional and
Institutional Capitation rates and in Shared Risk Budgets. HMO shall commit to
make such conversion revenue neutral to PPG. 
After this September conversion, Capitation and Shared Risk Budgets
shall be based on the new normalized PMPM and new factors as set forth in
Addendum B.

 

B.            STANDARD HMO.

 

1.             Professional
Capitation Rates.

 

1.1          Capitation Rates.  PPG Capitation for Standard HMO Members shall
be determined on a monthly basis by multiplying the following normalized PMPM
rates by the age, sex and benefit plan factors set forth in Addendum B for each
assigned Member. Normalized rates represent the PMPM prior to the adjustment
for PPG’s assigned Members’ age, sex and benefit plan. Actual PPG gross
Capitation shall fluctuate from month to month to the extent that PPG’s age,
sex and benefit plan mix fluctuates.

 

	
  Period

  	
   

  	
  Standard

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $ PMPM (See section

  A8 above)

  	
   

  

 

1.2          1999 and
2000 Capitation Rates.  PPG Capitation shall be
increased according to the normalized amounts set forth below for calendar
years 1999 and for 2000. Capitation increases for these years for Standard HMO
Members shall be based on the PPG’s Member satisfaction survey results.

 

HMO
shall conduct annual Member satisfaction surveys.  Survey results for the year shall be reported
on or before December 15th of each year and results arrayed for all
participating physician groups. PPG’s Capitation PMPM increase for Standard HMO
Members shall be determined by PPG’s performance relative to other physician
groups. Three performance tiers shall be established; each tier shall represent
approximately one-third of the HMO’s total Standard HMO Member population,
provided, however, that any physician group with assigned Standard HMO Members
exceeding 600,000 annual Member months shall be excluded from tier
determination, PPG’s Capitation increase for 1999 and 2000 shall be based upon
PPG’s tier ranking for Member satisfaction as follows:

 

	
  Calendar

  Year

  	
   

  	
  Top 33%

  	
   

  	
  Middle 33%

  	
   

  	
  Lowest 33%

  	
   

  
	
  1999

  	
   

  	
  $

  	
   *** PMPM

  	
   

  	
  $

  	
   *** PMPM

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  2000

  	
   

  	
  $

  	
   *** PMPM

  	
   

  	
  $

  	
   *** PMPM

  	
   

  	
  $

  	
  *** PMPM

  	
   

  

 

Should
results for PPG be unavailable or should results not be statistically meaningful,
PPG shall receive the increase amount for the lowest tier. PPG shall have the
right to examine HMO’s calculation of the Member satisfaction survey results,
subject to the blinding of other participating physician groups’ names.

 

26

 

PPG
shall request any such examination within sixty (60) calendar days following
notification of survey results, tier ranking and PMPM increase.

 

2.             Professional
Stop Loss Program.

 

PPG
elects not to participate in the Professional Stop Loss Program. PPG shall
provide HMO with proof of Professional Stop Loss coverage.

 

3.             Shared
Risk Program.  PPG shall participate in an incentive program
for Shared Risk Services which shall reward PPG for effectively coordinating
such care. Under this Program, a budget shall be established for Shared Risk
Services, and the actual cost of such services shall be compared to the budget.
In 1998 HMO shall transition from flat Shared Risk Budgets to budgets adjusted
by age, sex and benefit plan.

 

3.1          Shared
Risk Budget.  Each month from January to June 1998, HMO
shall fund the Shared Risk Budget for Standard HMO Members, at the flat PMPM
rate as set forth below. Starting in July 1998, HMO shall fund the Shared Risk
Budget for Members, with normalized rates. These normalized rates shall be
adjusted for PPG’s assigned Members by the age, sex and benefit plan factors as
set forth in Addendum B. Actual Shared Risk Budget shall fluctuate from month
to month to the extent that PPG’s age, sex and benefit plan mix fluctuates.

 

	
  Period

  	
   

  	
  Standard HMO

  	
   

  
	
  January 1, 1998
  to June 30, 1998

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  July 1, 1998 to
  August 31, 1998

  	
   

  	
  $ PMPM

  (See Section A7 above)

  	
   

  
	
  September 1,
  1998

  	
   

  	
  $ PMPM

  (See Section A8 above)

  	
   

  
					

 

3.2          Shared
Risk Administration.  As a contingency for any PPG liability under
this Shared Risk Program, HMO shall deduct *** of PPG’s Capitation for Standard
HMO Members and place such amount in the Withhold Fund as described in the
Agreement.

 

In
the event the claims for Shared Risk Services exceed Shared Risk Revenue at the
interim settlement date., HMO may, at its sole discretion, deduct up to five
percent (5%) of PPG’s Capitation for Standard HMO Members and place such amount
in the Withhold Fund as described in this Agreement, and may continue such
withhold until the final Shared Risk settlement. The Withhold fund shall accrue
interest which shall be the lower of five percent (5%) or the prime interest
rate as stated in the Wall Street Journal, on the last business day in December
of the contract year.

 

If,
upon final Shared Risk settlement, (i) a Shared Risk gain exists, HMO shall
refund the Withhold Fund, plus accrued interest, to PPG together with the PPG’s
share of the gain , or (ii) a Shared Risk deficit exists, subject to Section
4.3, of the Agreement. HMO shall offset the Withhold Fund against PPG’s
outstanding liability or any other amounts payable to HMO. Any amount in the
Withhold Fund not offset against such PPG liability shall be refunded to PPG at
the final Risk Sharing settlement. However, as a contingency for any PPG
liability under this Shared Risk Program, HMO shall continue, at its sole
discretion, to deduct up to *** PPG’s Capitation for Standard HMO Members and
place such amount in the Withhold Fund as described in this Agreement.

 

Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget.  HMO shall perform

 

27

 

both an interim and final
settlement. In the event that such claims are less than the Shared Risk Budget
for the Interim Period, PPG’s share of the settlement shall be seventy-five
percent (75%), subject to Section 4.3 of this Agreement.

 

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

 

3.3          Shared
Risk Budget Surplus.  In the event of a Shared Risk Budget surplus,
PPG’s share of the surplus shall be limited to the lesser of (a) fifty percent
(50%) of the Shared Risk Budget surplus, or (b) an amount not to exceed *** of
the annual gross PPG Capitation. Subject to Section 4.3 of the Agreement, the
Shared Risk Budget surplus shall be offset against any amounts payable by
PPG.  Any surplus remaining shall be paid
to PPG by April 30 of the following year.

 

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

 

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

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: 3.75% of Shared Risk Budget.

 

Out-of-Area
Emergency and Urgently Needed Services are reimbursed at eighty percent (80%)
of allowed amount, and the remaining twenty percent (20%) shall be charged
against the Shared Risk Budget.

 

(b)           In-Area Shared Risk Services: *** of
Shared Risk Budget.

 

The
cost of in-area Shared Risk services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as  follows: *** of any amount over *** up to
*** and *** of any amount over ***.

 

4.             AIDS,
and Transplant Reinsurance Programs.  On a
network wide basis, reinsurance programs shall be established by HMO to cover
the cost of organ transplants for Members, the payment of expenses incurred in
the treatment of Members who have been diagnosed with Acquired Immune
Deficiency Syndrome (“AIDS Members”).

 

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

 

28

 

eligible for payment under
this Program.

 

4.2          Transplant
Reinsurance.  Professional and institutional costs related
to organ transplantation shall be the financial responsibility of HMO, as set
forth in the Operations Manual. PPG shall refer Members to HMO’s designated
regional transplant centers to qualify for payment of the organ transplant
costs under this Program. In the event PPG refers a transplant case to a
facility that is not an HMO-designated regional transplant center, those claims
shall not be eligible for payment under this Program.

 

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

 

	
  •

  	
   

  	
  AIDS Reinsurance

  	
   

  	
  $*** PMPM

  
	
  •

  	
   

  	
  Transplant Reinsurance

  	
   

  	
  $*** PMPM

  

 

5.             Insured
Service(s).  In the event that a Member new to HMO is
assigned to PPG and gives birth within six (6) months of such assignment, HMO
shall pay PPG a flat fee of eight-hundred dollars ($800.00) for such Member’s
delivery.  This fee shall be in addition
to the Capitation for such Member, provided that the delivery services were
rendered by a contracted physician of PPG.

 

6.             Flex
Funded HMO.  Flex Funded HMO Members, (those enrolled in a
benefit program which is fully or partially self-funded) shall not be subject
to a Dual Risk Program nor to a Shared Risk Program.  PPG Capitation, Professional Stop Loss,
Reinsurance Programs and Insured Services shall be as set forth above.

 

C.            SMALL GROUP HMO.

 

1.             Professional
Capitation Rates.

 

1.1          Capitation
Rates.  PPG Capitation for Small Group HMO Members
shall be determined on a monthly basis by multiplying the following normalized
PMPM rates by the age, sex and benefit plan factors set forth in Addendum B for
each assigned Member. Normalized PMPM rates represent the PMPM prior to the
adjustment for PPG’s assigned Members’ age, sex and benefit plan. Actual PPG
gross Capitation shall fluctuate from month to month to the extent that PPG’s
age, sex and benefit plan mix fluctuates.

 

	
  Period

  	
   

  	
  Small Group

  HMO

  	
   

  
	
  January 1, 1998
  to June 30, 1998

  	
   

  	
  $

  	
   *** PMPM

  	
   

  
	
  July 1, 1998 to
  August 31, 1998

  	
   

  	
  $

  	
   *** PMPM

  	
   

  
	
  September 1,
  1998

  	
   

  	
  $

  	
   PMPM
 (See Section A8 above)

  	
   

  

 

2.             Professional
Stop Loss Program.

 

PPG
elects not to participate in the Professional Stop Loss Program. PPG shall provide
HMO with proof of Professional Stop Loss coverage.

 

3.             Shared
Risk Budget.  Each month from January to June 1998, HMO
shall fund the Shared Risk Budget for Small Group HMO Members, at the flat PMPM
rate as set forth below. Starting in July 1998, HMO shall fund the Shared Risk
Budget for Members, with normalized rates. These normalized rates shall be
adjusted for PPG’s assigned Members by the age, sex and benefit plan factors as
set forth in Addendum B. Actual Shared Risk Budget shall fluctuate from month
to month to the extent that PPG’s age, sex and benefit plan mix fluctuates.

 

29

 

	
  Period

  	
   

  	
  Small Group

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $  *** PMPM

  	
   

  
	
  July 1,1998 to August 31, 1998

  	
   

  	
  $  PMPM

  (See Section A7 above)

  	
   

  
	
  September 1,1998

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  

 

3.2          Shared
Risk Administration.  As a contingency for any PPG liability under
this Shared Risk Program, HMO shall deduct *** of PPG’s Capitation for Small
Group Members and place such amount in the Withhold Fund as described in the
Agreement.

 

In
the event the claims for Shared Risk Services exceed Shared Risk Revenue at the
interim settlement date., HMO may, at its sole discretion, deduct up to five
percent (5%) of PPG’s Capitation for Small Group HMO Members and place such
amount in the Withhold Fund as described in this Agreement, and may continue
such withhold until the final Shared Risk settlement. The Withhold fund shall
accrue interest which shall be the lower of five percent (5%) or the prime
interest rate as stated in the Wall Street Journal, on the last business day in
December of the contract year.

 

If,
upon final Shared Risk settlement, (i) a Shared Risk gain exists, HMO shall
refund the Withhold Fund, plus accrued interest, to PPG together with the PPG’s
share of the gain, or (ii) a Shared Risk deficit exists, subject to Section
4.3, of the Agreement, HMO shall offset the Withhold Fund against PPG’s
outstanding liability or any other amounts payable to HMO. Any amount in the Withhold
Fund not offset against such PPG liability shall be refunded to PPG at the
final Risk Sharing settlement. However, as a contingency for any PPG liability
under this Shared Risk Program, HMO shall continue, at its sole discretion, to
deduct up to five percent (5%) of PPG’s Capitation for Small Group HMO Members
and place such amount in the Withhold Fund as described in this Agreement.

 

Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget. HMO shall perform both an interim and final settlement. In
the event that such claims are less than the Shared Risk Budget for the Interim
Period, PPG’s share of the settlement shall be seventy-five percent (75%),
subject to Section 4.3 of this Agreement.

 

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

 

3.3          Shared Risk Budget Surplus.  In the
event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a) fifty percent (50%) of the Shared Risk Budget
surplus, or (b) an amount not to exceed *** of the annual gross PPG Capitation.
Subject to Section 4.3 of the Agreement, the Shared Risk Budget surplus shall
be offset against any amounts payable by PPG. Any surplus remaining shall be
paid to PPG by April 30 of the following year.

 

3.4          Shared
Risk Budget Deficit.  In the event of a Shared Risk Budget deficit,
PPG’s share of the deficit shall be limited to the lesser of (a) *** of the
Shared Risk Budget deficit, or (b) an

 

30

 

amount
not to exceed *** of the annual gross PPG Capitation. Subject to Section 4.3,
of the Agreement, any amounts payable by PPG shall be offset against the
Withhold Fund and any other amounts payable by HMO.

 

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

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: *** of Shared Risk Budget.

 

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

 

(b)           In-Area Shared Risk Services: *** %
of Shared Risk Budget.

 

The
cost of in-area Shared Risk services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as follows: *** of any
amount over *** up to *** and *** of any amount over ***.

 

4.             AIDS,
and Transplant Reinsurance Premium.  As
further defined in Section B.4 of this Addendum B, the Reinsurance Program rates, as set forth below, shall be
deducted from PPG’s Capitation:

 

	
  •

  	
   

  	
  AIDS Reinsurance

  	
   

  	
  $ *** PMPM

  
	
  •

  	
   

  	
  Transplant Reinsurance

  	
   

  	
  $ *** PMPM

  

 

5.             Insured
Service(s).  In the event that a Member new to HMO is
assigned to PPG and gives birth within six (6) months of such assignment, HMO
shall pay PPG a flat fee of eight hundred dollars ($800.00) for such Member’s
delivery. This fee shall be in addition to the Capitation for such Member,
provided that the delivery services were rendered by a contracted physician of
the PPG.

 

D.                          INDIVIDUAL HMO.

 

1.             Professional
Capitation Rates.

 

1.1          Capitation
Rates.  PPG Capitation for Individual HMO Members
shall be determined on a monthly basis by multiplying the following normalized
PMPM rates by the age, sex and benefit plan factors set forth in Addendum B for
each assigned Member.  Normalized PMPM
rates represent the PMPM prior to the adjustment for PPG’s assigned Members’
age, sex and benefit plan. Actual PPG gross Capitation shall fluctuate from
month to month to the extent that PPG’s age, sex and benefit plan mix
fluctuates.

 

	
  Period

  	
   

  	
  Individual

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $

  	
   *** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $

  	
   *** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  

 

31

 

2.             Professional
Stop Loss Program.

 

PPG
elects not to participate in the Professional Stop Loss Program. PPG shall
provide HMO with proof of Professional Stop Loss coverage.

 

3.             Shared
Risk Program.  PPG shall participate in an incentive program
for Shared Risk Services which shall reward PPG for effectively coordinating
such care. Under this Program, a budget shall be established for Shared Risk
Services, and the actual cost of such services shall be compared to the budget.
In 1998 HMO shall transition from flat Shared Risk Budgets to budgets adjusted
by age, sex and benefit plan.

 

3.1          Shared
Risk Budget. Each
month from January to June 1998, HMO shall fund the Shared Risk Budget for
Individual HMO Members, at the flat PMPM rate as set forth below. Starting in
July 1998, HMO shall fund the Shared Risk Budget for Members, with normalized
rates. These normalized rates shall be adjusted for PPG’s assigned Members by
the age, sex and benefit plan factors as set forth in Addendum B. Actual Shared
Risk Budget shall fluctuate from month to month to the extent that PPG’s age,
sex and benefit plan mix fluctuates.

 

	
  Period

  	
   

  	
  Individual

  HMO

  	
   

  
	
  January 1, 1998
  to June 30, 1998

  	
   

  	
  $ *** PMPM

  	
   

  
	
  July 1, 1998 to
  August 31,1998

  	
   

  	
  $ PMPM

  (See Section A7 above)

  	
   

  
	
  September 1,
  1998

  	
   

  	
  $ PMPM

  (See Section A8 above)

  	
   

  

 

3.2          Shared
Risk Administration.  As a contingency for any PPG liability under
this Shared Risk Program, HMO shall deduct zero percent (0 %) of PPG’s
Capitation for Individual Members and place such amount in the Withhold Fund as
described in the Agreement.

 

In
the event the claims for Shared Risk Services exceed Shared Risk Revenue at the
interim settlement date., HMO may, at its sole discretion, deduct up to *** of
PPG’s Capitation for Individual HMO Members and place such amount in the
Withhold Fund as described in this Agreement, and may continue such withhold
until the final Shared Risk settlement. The Withhold fund shall accrue interest
which shall be the lower of *** the prime interest rate as stated in the Wall
Street Journal, on the last business day in December of the contract year.

 

If,
upon final Shared Risk settlement, (i) a Shared Risk gain exists, HMO shall
refund the Withhold Fund, plus accrued interest, to PPG together with the PPG’s
share of the gain, or (ii) a Shared Risk deficit exists, subject to Section
4.3, of the Agreement, HMO shall offset the Withhold Fund against PPG’s
outstanding liability or any other amounts payable to HMO. Any amount in the
Withhold Fund not offset against such PPG liability shall be refunded to PPG at
the final Risk Sharing settlement. However, as a contingency for any PPG
liability under this Shared Risk Program, HMO shall continue, at its sole
discretion, to deduct up to *** of PPG’s Capitation for Individual HMO Members
and place such amount in the Withhold Fund as described in this Agreement.

 

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

 

Shared
Risk Claims with dates of service within the Reconciliation Period and paid by
March 31

 

32

 

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

 

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

 

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

 

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

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: *** Shared Risk Budget.

 

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

 

(b)           In-Area Shared Risk Services: ***
Shared Risk Budget.

 

The
cost of in-area Shared Risk services utilized by a Member in a Reconciliation
Period shall be charged against the Shared Risk Budget as follows:   *** of any amount over *** up to ***; and
*** any amount over ***

 

4.             AIDS,
and Transplant Reinsurance Premium.  As
further defined in Section B.4 of this Addendum B, the Reinsurance Program
rates, as set forth below, shall be deducted from PPG’s Capitation:

 

	
  •

  	
   

  	
  AIDS Reinsurance

  	
   

  	
  $ *** 
  PMPM

  
	
  •

  	
   

  	
  Transplant Reinsurance

  	
   

  	
  $ *** 
  PMPM

  

 

5.             Insured
Service(s).  In the event that a Member new to HMO is
assigned to PPG and gives birth within six (6) months of assignment, HMO shall
pay PPG a flat fee of eight-hundred dollars ($800.00) for such Member’s
delivery. This fee shall be payable in addition to the Capitation for such
Member provided the delivery services were rendered by a contracted physician
of the PPG.

 

E.             ACCESS FOR INFANTS AND MOTHERS.  The
Access for Infants and Mothers (“AIM”) Program provides health care coverage to
low-income women, pursuant to state law, who are pregnant but without insurance
for  such pregnancy. The AIM
Program is funded by the State through Proposition 99 Cigarette and Tobacco Tax
Revenue. At such time PPG is certified by the State for participation in the
AIM Program, PPG shall provide Covered Services for AIM Members as set forth in
the Operations Manual.

 

1.             Compensation.  HMO
shall pay PPG a flat fee of ***

 

33

 

(***) for each adult AIM
Member to cover the professional services related to the birth of an infant. In
addition to this flat fee, HMO shall pay PPG *** PMPM for each adult AIM Member
enrolled in the AIM Program. HMO shall pay PPG *** PMPM during the first year
of life for each infant AIM Member and *** PMPM during the second year of life.

 

2.             Reinsurance
Programs.  PPG’s professional stop loss level shall be
*** per AIM Member. The professional stop loss level shall be provided to the
PPG for AIM Members at no cost. All other terms and conditions of the Agreement
regarding Professional Stop Loss shall apply to AIM Members.

 

AIM
Members shall not be included in the AIDS Reinsurance Program, the Transplant
Reinsurance Program, or the Transfer Reinsurance Program.

 

3.             Shared
Risk Programs.  HMO shall be solely responsible for all
Shared Risk services and for pharmacy benefit costs of AIM Members.

 

F.             MEDICARE SUPPLEMENT. The Medicare Supplement Benefits Programs are
provided to Members who have primary coverage through Medicare. Capitation for
Members enrolled in such Benefit Programs compensates PPG for Copayments that
would be normally a Member’s responsibility under Medicare.

 

1.             Capitation
Rates.  PPG Capitation rates for Medicare Supplement
Members shall be at the following PMPM levels, subject to age, sex and benefit
plan factors set forth in Addendum B:

 

	
  Period

  	
   

  	
  Medicare Supplement

  HMO

  	
   

  	
  Medicare Supplement

  POS

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $  *** PMPM

  	
   

  	
  $  *** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $  *** PMPM

  	
   

  	
  $  *** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  

 

2.             Reinsurance
Programs.  Medicare Supplement Members shall not be
included in the Professional Stop Loss Program, the AIDS Reinsurance Program,
and the Transplant Reinsurance Program.

 

3.             Shared
Risk Program.  HMO shall be solely responsible for all
Shared Risk services and for pharmacy benefit costs of Medicare Supplement
Members.

 

G.            COMMERCIAL POS.

 

1.             Commercial
POS Benefit Program.  Under a POS Benefit Program, Members may elect, at the time of obtaining each Covered
Service, to utilize: (i) HMO coverage through PPG; (ii) coverage by
self-referring to any PPO Provider; or (iii) indemnity coverage for
self-referring to non-Participating Providers in accordance with Benefit
Program requirements. Standard HMO Members, Small Group HMO Members, Individual
HMO Members, and Flex Funded HMO Members may be eligible for Commercial POS Benefit
Programs.

 

2.             Definitions.

 

2.1          In-Network
Services.  PPG Capitated Services and Shared Risk
Services provided or

 

34

 

arranged through PPG.

 

2.2          Out-of-Network
Services.  In accordance with Benefit Program
requirements, Covered Services provided as a result of a Member’s self-referral
to a PPG or HMO Provider or to a non-Participating Provider. Out-of-Network
Services may be provided in area or out of area.

 

3.             Compensation. 
Compensation to PPG for Commercial POS Members shall include: a) PPG
professional Capitation for In-Network professional services, b) any surplus
resulting from the Professional Out-of-Network Shared Risk Program, and c) any
surplus resulting from the Institutional In-Network and Out-of-Network Shared
Risk Program.

 

4.             Professional
Capitation Rate.  In 1998, PPG shall be compensated for
rendering professional In-Network Services to Commercial POS Members at the
PMPM amounts set forth for Commercial HMO Members, less a *** withhold (Professional
Capitation). This Withhold shall partially fund the Professional Out-of-Network
Budget.

 

5.             Professional
Out-of-Network Risk Sharing Program.  The
budget for this Program shall be equal to the sum of the following two
components: 1) The Professional Out-of-Network Withhold as described in Section
4 above, and 2) an amount equal to *** of the Commercial POS Professional
Capitation prior to withhold.

 

Each
year, HMO shall settle the risk sharing program by calculating the difference
between the budget and the actual claims. If a surplus remains, PPG’s share
shall be *** subject to Section 4.3. PPG shall not be subject to any downside.

 

6.             Institutional Shared Risk
Program.

 

6.1          POS
Shared Risk Budgets.
The budgets shall be determined for each Commercial POS population: Standard
POS, Small Group POS and, at a later date, Individual POS Members. Each Budget
shall cover In-Network, Out-of-Network and Out-of-Area Shared Risk Services.
The Shared Risk Budgets effective January 1, 1998 shall be a flat amount. Each
of the Shared Risk Budgets shall be equal to the HMO Shared Risk Budget, or
institutional capitation PMPM, if applicable, and multiplied by ***.

 

	
  Period

  	
   

  	
  Standard HMO Shared

  Risk

  + 10%

  	
   

  	
  Small Group HMO

  Shared Risk

  + 10%

  	
   

  	
  Individual HMO

  Shared Risk

  + 10%

  	
   

  
	
  January 1, 1998
  to June 30, 1998

  	
   

  	
  $ *** PMPM

  	
   

  	
  $ *** PMPM

  	
   

  	
  $ ***PMPM

  	
   

  
	
  July 1, 1998 to
  August 31, 1998

  	
   

  	
  $  PMPM

  (See Section A7 above)

  	
   

  	
  $ PMPM

  (See Section A7 above)

  	
   

  	
  $ PMPM

  (See Section A7 above)

  	
   

  
	
  September 1,
  1998

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  	
  $ PMPM

  (See Section A8 above)

  	
   

  	
  $  PMPM

  (See Section A8 above)

  	
   

  

 

6.2          POS
Shared Risk Administration. Each Reconciliation Period, HMO shall calculate Shared Risk Claims in
accordance with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget. HMO shall perform both an interim and final settlement. In
the event any amounts remain in the Withhold Fund following the reconciliation
of any shared risk program, those excess funds shall be paid to PPG by April 30
of the following year. In the event that such claims are less than the Shared
Risk Budget for the Interim Period, PPG’s share of the settlement shall be ***,
subject to Section 4.3 of this Agreement.

 

Shared
Risk Claims with dates of service within the Reconciliation Period and paid by
March 31

 

35

 

of the following year shall
be used in the calculation.  Shared Risk
Services incurred within the Reconciliation Period but paid after March 31 of
the following year will be included in the next Reconciliation Period
calculation.

 

6.3          POS
Shared Risk Budget Surplus.  In the event of a POS Shared
Risk Budget surplus, PPG’s share of the surplus shall be of *** or an amount
not to exceed *** of the annual gross PPG Capitation.

 

6.4          POS
Shared Risk Budget Deficit.  In the event of a POS Shared
Risk Budget deficit, PPG shall not be liable for the deficit.

 

6.5          POS
Shared Risk Reinsurance.  PPG shall participate in the POS
Shared Risk Reinsurance Program which provides reinsurance for In-Network and
Out-of-Network services. The cost to PPG for the POS Shared Risk Reinsurance
Program shall be calculated as follows:

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: *** of POS Shared Risk Budget.

 

Out-of-Area
Emergency and Urgently Needed Services shall be reimbursed at *** of cost, and
the remaining *** of the cost shall be charged against the POS Shared Risk
Budget.

 

(b)           In-Network and Out-of-Network POS
Shared Risk Services: 1.6 % of POS Shared Risk Budget.

 

The
cost of In-Network and Out-of-Network POS Shared Risk Services during the
Reconciliation Period shall be charged against the POS Shared Risk Budget as
follows:  *** of any amount over *** up
to *** and *** of any amount over ***.

 

7.             Professional
Stop Loss Program.  The Professional Stop Loss Program includes
coverage for In- Network Services, an optional program, as well as for
Out-of-Network Services, a program in which PPG’s participation is required.

 

(a)           In-Network Professional Stop Loss.

 

PPG elects not to participate
in the Professional Stop Loss Program. 
PPG shall provide HMO with proof of Professional Stop Loss coverage.

 

(b)           Out-of-Network Professional Stop
Loss.  PPG’s Out-of-Network Professional
Stop Loss threshold shall be *** per Commercial POS Member during the calendar
year. The cost to PPG for the Out-of-Network Professional Stop Loss program
shall be $ *** PMPM, which, shall be deducted from PPG’s Out-of-Network Risk
Sharing Budget.

 

8.             AIDS
and Transplant Reinsurance.  As further defined in Section
B.4 of this Addendum, the 1998 AIDS Reinsurance rate shall be $ *** PMPM, which
shall be deducted from PPG’s Capitation and $ 0.19 PMPM shall be deducted from
PPG’s Professional Out-of-Network Risk Sharing Budget. For the subsequent
years, these deductions shall fluctuate to correspond with the Professional
Out-of-Network Withhold percentage change. The 1998 Transplant Reinsurance
Program rate shall be $ *** MPM, which, shall be deducted from PPG’s Capitation
and $ *** PMPM shall be deducted from PPG’s Professional Out-of-Network Risk
Sharing Budget. The Transplant Reinsurance Program’s deductions for subsequent
years shall also fluctuate to correspond with the Professional Out-of-Network
Withhold percentage change.

 

36

 

H.            Partnership Bonus.  PPG
shall receive a Partnership Bonus in the calendar years 1999 and 2000 if HMO
achieves profitability levels defined below. Such Partnership Bonus shall be in
the form of a lump sum payment, payable no later than May 31,1999 and May 31,
2000.

 

HMO
shall report to the Department of Corporations (“DOC”) HMO’s calendar year-end
financial results no later than April 30th of each year for the prior calendar
year.  HMO’s Net After Tax Income PMPM
from the most recent year-end shall be compared with that from the preceding
year. Calculation of the Partnership Bonus shall be determined as follows:

 

(a)           “Net Income” for the most recent
year-end and the preceding year-end as reported on Line 31 of DOC Report #2,
Statement of Revenue, Expenses and Net Worth (“Report 2”) shall be used.

 

(b)           Net Income for each year shall be
divided by the applicable annual Member months as reported on Report 2 to
derive Net After Tax Income PMPM.

 

(c)           When HMO’s Net After Tax Income PMPM
of the most recent year is more than five percent (5%) greater than HMO’s Net
After Tax Income PMPM of the preceding year (as calculated to the fourth
decimal point), HMO shall fund the Partnership Bonus equal to twenty-five
percent (25%) of the incremental Net After Tax Income PMPM of the most recent
year.

 

(d)           This bonus PMPM multiplied by PPG’s
annual Member months for all Commercial HMO and Commercial POS Members shall
equal PPG’s lump sum payment.

 

In
the event year-end data is inconsistent or incomparable due to, but not limited
to, changes in reporting requirements, extraordinary items, or future margin
activity, HMO reserves the right to adjust the methodology to ensure
comparability. Such adjustments, when necessary, shall be reviewed and approved
by an external financial auditor selected by HMO (“Independent Opinion”). HMO
shall provide PPG information supporting the above calculation and, when
applicable, an Independent Opinion by May 31, 1999 and May 31, 2000.

 

I.              Quality of Care Improvement Program
(QCIP).  QCIP, as further described in the Operations
Manual, rewards PPG for meeting and exceeding quality standards and Member
satisfaction levels. PPG shall be eligible for a lump sum award, if performance
is achieved in all categories. The PMPM award set forth below shall be
multiplied by PPG’s Member months for Standard HMO, Small Group HMO, Individual
HMO and Flex Funded Benefit Programs. The lump sum award shall be payable in
September following the calendar year in which the measurements were taken.

 

	
  Calendar Year

  	
   

  	
  Award

  	
   

  
	
  1998

  	
   

  	
  Up to $*** PMPM

  	
   

  
	
  1999

  	
   

  	
  Up to $*** PMPM

  	
   

  
	
  2000

  	
   

  	
  Up to $***PMPM

  	
   

  

 

The
Aim for Wellness Program, shall be a component of QCIP. The above PMPM award
includes funding for the Aim for Wellness Program. In 1998, Compensation for
the Aim for Wellness Program shall be payable at $*** PMPM and shall be
distributed to PPG monthly with Capitation. HMO reserves the right to alter
components and measurements of QCIP annually.

 

J.             Pharmacy Shared Risk Program.  The
Pharmacy Shared Risk Program shall be applicable to the following Members:
Standard HMO, Flex Funded HMO, Small Group HMO, and Individual HMO.

 

37

 

1.             Pharmacy
Budget.  In accordance with the formula outlined in
Section 2 below, PPG’s Pharmacy Budget shall be the percent as set forth below
of the difference between PPG’s actual normalized pharmacy costs and the actual
pharmacy costs experienced by those participating physician group.  Physician groups comprising the top third of
lowest PEMPM normalized costs.  For
eligible Commercial HMO Members, each month, HMO shall fund the 1998 Pharmacy
Budget at $ 13.36 per eligible Member per month (“PEMPM”) subject to the age,
sex and benefit plan factors set forth in Addendum B.

 

2.               1999
and 2000 Pharmacy Budget.  Each year the Pharmacy Budget
shall be adjusted according to the aggregate PEMPM dollar change experience by
those participating physician groups comprising the top third of the lowest
PEMPM normalized pharmacy costs and the percentage set forth below. Such
adjustment shall occur prior to calculating the final settlement for the
Pharmacy Reconciliation, as set forth in this Addendum. Any Calculation of the
normalized pharmacy costs shall be based upon actual claims. The top third
calculation shall be weighed by eligible Member months.

 

	
  Pharmacy Budget

  Year

  	
   

  	
  Percent Difference

  	
   

  
	
  1998

  	
   

  	
  ***

  	
   

  
	
  1999

  	
   

  	
  ***

  	
   

  
	
  2000

  	
   

  	
  ***

  	
   

  

 

3.             Pharmacy
Reconciliation For Commercial HMO Members.  For
each Reconciliation Period, HMO shall calculate pharmacy claims subject this
Program as outlined in the Operations Manual. HMO shall compare such claims to
the corresponding Pharmacy Budget.  In
the event pharmacy claims are less than the Pharmacy Budget, PPG’s share of the
Pharmacy Budget surplus shall be fifty percent (50%). In the event pharmacy
claims exceed the Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit
shall be fifty percent (50%).

 

HMO
shall perform an interim and final settlement for the Pharmacy Risk Sharing
Program. The timing of these settlements shall correspond to the interim and
final settlements of other risk sharing programs. Subject to Section 4.3 of
this Agreement, any Pharmacy Budget deficit shall be offset against any amounts
payable by HMO, or any amounts remaining in the Withhold Fund, or shall be
offset against Capitation.

 

K.            Pharmacy Rebate Program.  The
Pharmacy Rebate Program, as set forth in the Operations Manual, permits the
sharing of calendar year pharmaceutical rebates (“Annual Rebates”).

 

HMO
shall multiply the Annual Rebates by an annually-determined percentage (“Rebate
Percentage”) to establish the Rebate Fund. HMO shall divide the Rebate Fund by
the total number of Commercial HMO Members eligible for a pharmacy benefit to
determine the Rebate PEMPM. On or before December 15th of each year,
HMO shall notify PPG of the Rebate Percentage.

 

PPG
is eligible for a lump sum award as determined and identified below. Such sum
is payable in April following the calendar year of the Rebate Fund, beginning
April 1999.  PPG’s PEMPM award shall be
determined by PPG’s cost performance relative to other participating physician
groups. Cost performance shall be determined by the normalized pharmacy cost
for each calendar year for each participating physician groups. Three
performance tiers shall be established; each tier shall represent approximately
one-third of the total Commercial HMO Members, provided, however, that any
participating physician group with assigned Commercial HMO Members less than
*** or exceeding  *** annual Member
months shall be excluded from the tier determination. PPG’s PEMPM award for
eligible Commercial HMO Members shall be as follows based upon PPG’s tier
ranking:

 

	
  Tier

  	
   

  	
  Award

  	
   

  
	
  Lowest
  Normalized Pharmacy Costs

  	
   

  	
  ***
  of Rebate PEMPM  

  	
   

  
	
  Middle
  Normalized Pharmacy Costs  

  	
   

  	
  ***
  of Rebate PEMPM  

  	
   

  
	
  Highest
  Normalized Pharmacy Costs  

  	
   

  	
  ***
  of Rebate PEMPM  

  	
   

  

 

38

 

 

ADDENDUM B.1

 

AGE, SEX AND BENEFIT PLAN FACTORS

 

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

 

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

A.1
Age, Sex Factors for PPG Capitation and Hospital Capitation Shared Risk Budgets
Effective January 1, 1998 through

 

39

 

August 31,1998

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Female

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  	
   

  
	
   

  	
   

  	
  2 - 4

  	
   

  	
  0.493

  	
   

  	
  0.370

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.436

  	
   

  	
  0.382

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.399

  	
   

  	
  0.390

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.421

  	
   

  	
  0.418

  	
   

  
	
   

  	
   

  	
  20 - 24

  	
   

  	
  0.902

  	
   

  	
  0.999

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  1.525

  	
   

  	
  1.664

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  1.543

  	
   

  	
  1.478

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  1.547

  	
   

  	
  1.281

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  1.567

  	
   

  	
  1.272

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  1.630

  	
   

  	
  1.293

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.712

  	
   

  	
  1.448

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.982

  	
   

  	
  1.927

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.161

  	
   

  	
  2.260

  	
   

  
	
   

  	
   

  	
  65 +

  	
   

  	
  2.251

  	
   

  	
  2.025

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  
	
  Male

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  	
   

  
	
   

  	
   

  	
  2 - 4

  	
   

  	
  0.493

  	
   

  	
  0.370

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.436

  	
   

  	
  0.382

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.399

  	
   

  	
  0.390

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.421

  	
   

  	
  0.418

  	
   

  
	
   

  	
   

  	
  20 - 24

  	
   

  	
  0.432

  	
   

  	
  0.447

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  0.492

  	
   

  	
  0.486

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  0.569

  	
   

  	
  0.536

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  0.667

  	
   

  	
  0.673

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  0.780

  	
   

  	
  0.800

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  0.933

  	
   

  	
  0.975

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.251

  	
   

  	
  1.415

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.625

  	
   

  	
  1.998

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.177

  	
   

  	
  2.928

  	
   

  
	
   

  	
   

  	
  65 +

  	
   

  	
  2.276

  	
   

  	
  2.658

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  

 

40

 

A.2 Age,
Sex Factors for PPG Capitation and Hospital Capitation/Shared Risk Budgets

Effective
September 1, 1998

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Child

  	
   

  	
  0

  	
   

  	
  2.008

  	
   

  	
  5.228

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  1.075

  	
   

  	
  0.644

  	
   

  
	
   

  	
   

  	
  2 - 4

  	
   

  	
  0.598

  	
   

  	
  0.406

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.439

  	
   

  	
  0.296

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.418

  	
   

  	
  0.338

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.590

  	
   

  	
  0.607

  	
   

  
	
  Female

  	
   

  	
  20 - 24

  	
   

  	
  1.195

  	
   

  	
  1.066

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  1.653

  	
   

  	
  1.431

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  1.509

  	
   

  	
  1.315

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  1.378

  	
   

  	
  1.143

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  1.322

  	
   

  	
  1.031

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  1.386

  	
   

  	
  1.102

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.551

  	
   

  	
  1.338

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.794

  	
   

  	
  1.741

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.090

  	
   

  	
  2.313

  	
   

  
	
   

  	
   

  	
  65 +

  	
   

  	
  2.414

  	
   

  	
  2.907

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  
	
  Male

  	
   

  	
  20 - 24

  	
   

  	
  0.398

  	
   

  	
  0.477

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  0.477

  	
   

  	
  0.486

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  0.546

  	
   

  	
  0.506

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  0.626

  	
   

  	
  0.589

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  0.734

  	
   

  	
  0.768

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  0.890

  	
   

  	
  1.087

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.139

  	
   

  	
  1.580

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.516

  	
   

  	
  2.203

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.009

  	
   

  	
  2.880

  	
   

  
	
   

  	
   

  	
  65 +

  	
   

  	
  2.561

  	
   

  	
  3.586

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  

 

41

 

A.3
Benefit Plan Factors for PPG Capitation and Hospital Capitation Effective
January 1,1998

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0740

  	
   

  	
  0.9697

  	
   

  
	
  A1

  	
   

  	
  1.0857

  	
   

  	
  0.9751

  	
   

  
	
  A2

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  	
   

  
	
  A3

  	
   

  	
  1.0831

  	
   

  	
  0.9846

  	
   

  
	
  A4

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  	
   

  
	
  A5

  	
   

  	
  1.0857

  	
   

  	
  0.9782

  	
   

  
	
  A6

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  	
   

  
	
  A7

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  	
   

  
	
  A8

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  	
   

  
	
  A9

  	
   

  	
  1.0411

  	
   

  	
  1.0408

  	
   

  
	
  HB

  	
   

  	
  1.0039

  	
   

  	
  0.8702

  	
   

  
	
  BB

  	
   

  	
  1.0039

  	
   

  	
  0.8709

  	
   

  
	
  B1

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  	
   

  
	
  B2

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  	
   

  
	
  B3

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  	
   

  
	
  B4

  	
   

  	
  0.9027

  	
   

  	
  0.8252

  	
   

  
	
  B5

  	
   

  	
  0.9007

  	
   

  	
  0.8371

  	
   

  
	
  B6

  	
   

  	
  1.0039

  	
   

  	
  0.8812

  	
   

  
	
  B7

  	
   

  	
  0.9732

  	
   

  	
  1.0271

  	
   

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0165

  	
   

  
	
  B9

  	
   

  	
  0.9646

  	
   

  	
  1.0408

  	
   

  
	
  HC

  	
   

  	
  1.0840

  	
   

  	
  1.0122

  	
   

  
	
  C1

  	
   

  	
  1.0769

  	
   

  	
  1.0122

  	
   

  
	
  C2

  	
   

  	
  1.0954

  	
   

  	
  1.0238

  	
   

  
	
  C3

  	
   

  	
  1.0067

  	
   

  	
  1.0122

  	
   

  
	
  C6

  	
   

  	
  1.0095

  	
   

  	
  1.0408

  	
   

  
	
  C7

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  	
   

  
	
  C8

  	
   

  	
  0.9459

  	
   

  	
  0.9755

  	
   

  
	
  C9

  	
   

  	
  0.9047

  	
   

  	
  1.0408

  	
   

  
	
  HD

  	
   

  	
  1.1158

  	
   

  	
  1.0232

  	
   

  
	
  D1

  	
   

  	
  1.0769

  	
   

  	
  1.0232

  	
   

  
	
  D2

  	
   

  	
  1.0249

  	
   

  	
  1.0290

  	
   

  
	
  D3

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  	
   

  
	
  D4

  	
   

  	
  0.9493

  	
   

  	
  0.8696

  	
   

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9806

  	
   

  
	
  D6

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  	
   

  
	
  D7

  	
   

  	
  0.9655

  	
   

  	
  1.0326

  	
   

  
	
  D8

  	
   

  	
  1.0274

  	
   

  	
  1.0220

  	
   

  
	
  D9

  	
   

  	
  1.0456

  	
   

  	
  1.0442

  	
   

  
	
  HE

  	
   

  	
  1.0320

  	
   

  	
  1.0417

  	
   

  
	
  E1

  	
   

  	
  1.0166

  	
   

  	
  0.9761

  	
   

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0408

  	
   

  
	
  E3

  	
   

  	
  1.0067

  	
   

  	
  0.9806

  	
   

  
	
  E4

  	
   

  	
  0.9487

  	
   

  	
  0.9934

  	
   

  
	
  E5

  	
   

  	
  1.0522

  	
   

  	
  1.0439

  	
   

  
	
  E6

  	
   

  	
  0.9587

  	
   

  	
  0.9761

  	
   

  
	
  E7

  	
   

  	
  0.9942

  	
   

  	
  1.0439

  	
   

  
	
  E8

  	
   

  	
  1.0178

  	
   

  	
  1.0238

  	
   

  
	
  E9

  	
   

  	
  0.9735

  	
   

  	
  0.9806

  	
   

  
	
  EA

  	
   

  	
  0.9715

  	
   

  	
  1.0372

  	
   

  
	
  EB

  	
   

  	
  0.9036

  	
   

  	
  0.8192

  	
   

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0408

  	
   

  
	
  ED

  	
   

  	
  1.0053

  	
   

  	
  0.9940

  	
   

  
	
  EE

  	
   

  	
  1.0078

  	
   

  	
  0.9831

  	
   

  
	
  EF

  	
   

  	
  1.0479

  	
   

  	
  1.0442

  	
   

  
	
  EG

  	
   

  	
  0.9999

  	
   

  	
  1.0442

  	
   

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0226

  	
   

  
	
  EI

  	
   

  	
  0.9914

  	
   

  	
  0.9794

  	
   

  
	
  EJ

  	
   

  	
  1.0578

  	
   

  	
  1.0499

  	
   

  
	
  EK

  	
   

  	
  0.9180

  	
   

  	
  1.0408

  	
   

  
	
  EL

  	
   

  	
  1.0522

  	
   

  	
  0.9779

  	
   

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0475

  	
   

  
	
  EN

  	
   

  	
  0.9797

  	
   

  	
  0.9767

  	
   

  
	
  EO

  	
   

  	
  0.9749

  	
   

  	
  0.9961

  	
   

  
	
  EP

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  	
   

  
	
  EQ

  	
   

  	
  0.9769

  	
   

  	
  1.0274

  	
   

  
	
  ES

  	
   

  	
  0.9729

  	
   

  	
  1.0436

  	
   

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0071

  	
   

  
	
  F1

  	
   

  	
  1.0161

  	
   

  	
  1.0095

  	
   

  
	
  F2

  	
   

  	
  1.0166

  	
   

  	
  0.9779

  	
   

  
	
  F3

  	
   

  	
  1.0070

  	
   

  	
  0.9806

  	
   

  
	
  F4

  	
   

  	
  0.9808

  	
   

  	
  1.0332

  	
   

  
	
  F5

  	
   

  	
  1.0218

  	
   

  	
  0.9812

  	
   

  
	
  F6

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  	
   

  
	
  F7

  	
   

  	
  1.1087

  	
   

  	
  0.9925

  	
   

  
	
  F8

  	
   

  	
  0.9050

  	
   

  	
  0.9697

  	
   

  
	
  F9

  	
   

  	
  1.0522

  	
   

  	
  1.0445

  	
   

  
	
  FA

  	
   

  	
  1.0269

  	
   

  	
  1.0341

  	
   

  
	
  FB

  	
   

  	
  1.0277

  	
   

  	
  1.0487

  	
   

  
	
  FC

  	
   

  	
  1.0164

  	
   

  	
  1.0372

  	
   

  
	
  FD

  	
   

  	
  1.0309

  	
   

  	
  1.0366

  	
   

  
	
  FE

  	
   

  	
  0.9635

  	
   

  	
  1.0341

  	
   

  
	
  FF

  	
   

  	
  0.9703

  	
   

  	
  1.0396

  	
   

  
	
  FG

  	
   

  	
  0.9635

  	
   

  	
  1.0016

  	
   

  
	
  FH

  	
   

  	
  0.9712

  	
   

  	
  1.0341

  	
   

  
	
  FI

  	
   

  	
  0.9749

  	
   

  	
  1.0341

  	
   

  
	
  FJ

  	
   

  	
  0.9203

  	
   

  	
  1.0341

  	
   

  
	
  FK

  	
   

  	
  0.9749

  	
   

  	
  0.9885

  	
   

  
	
  FL

  	
   

  	
  0.9203

  	
   

  	
  0.9572

  	
   

  
	
  HG

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  	
   

  
	
  G1

  	
   

  	
  0.9459

  	
   

  	
  0.9697

  	
   

  
	
  G2

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  	
   

  
	
  G3

  	
   

  	
  1.0155

  	
   

  	
  0.9806

  	
   

  
	
  G4

  	
   

  	
  0.9459

  	
   

  	
  0.9806

  	
   

  
	
  G5

  	
   

  	
  0.8965

  	
   

  	
  0.9694

  	
   

  
	
  G6

  	
   

  	
  1.0164

  	
   

  	
  1.0211

  	
   

  
	
  G9

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  	
   

  
	
  I3

  	
   

  	
  0.9644

  	
   

  	
  1.0442

  	
   

  
	
  I4

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  	
   

  
	
  I5

  	
   

  	
  0.9553

  	
   

  	
  1.0113

  	
   

  
	
  I6

  	
   

  	
  1.0448

  	
   

  	
  0.9551

  	
   

  
	
  I7

  	
   

  	
  1.0513

  	
   

  	
  1.0411

  	
   

  
	
  I8

  	
   

  	
  0.9573

  	
   

  	
  1.0268

  	
   

  
	
  I9

  	
   

  	
  0.9891

  	
   

  	
  1.0408

  	
   

  
	
  J3

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  	
   

  
	
  J4

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  	
   

  
	
  J5

  	
   

  	
  1.0130

  	
   

  	
  0.9809

  	
   

  
	
  J6

  	
   

  	
  0.9766

  	
   

  	
  0.9800

  	
   

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0305

  	
   

  
	
  J8

  	
   

  	
  0.9729

  	
   

  	
  0.9852

  	
   

  
	
  J9

  	
   

  	
  1.1604

  	
   

  	
  1.0667

  	
   

  
	
  HK

  	
   

  	
  1.0840

  	
   

  	
  1.0411

  	
   

  
	
  K1

  	
   

  	
  1.0138

  	
   

  	
  1.0411

  	
   

  
	
  K2

  	
   

  	
  0.9720

  	
   

  	
  0.9806

  	
   

  
	
  K3

  	
   

  	
  1.0237

  	
   

  	
  1.0414

  	
   

  
	
  K4

  	
   

  	
  1.0956

  	
   

  	
  1.0411

  	
   

  
	
  K6

  	
   

  	
  0.9698

  	
   

  	
  1.0420

  	
   

  
	
  K7

  	
   

  	
  0.9905

  	
   

  	
  1.0180

  	
   

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0223

  	
   

  
	
  K9

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  	
   

  
	
  KI

  	
   

  	
  0.9635

  	
   

  	
  1.0347

  	
   

  
	
  KJ

  	
   

  	
  1.0269

  	
   

  	
  1.0347

  	
   

  
	
  KK

  	
   

  	
  0.9749

  	
   

  	
  0.9894

  	
   

  
	
  KL

  	
   

  	
  0.9632

  	
   

  	
  1.0098

  	
   

  
	
  KM

  	
   

  	
  0.9317

  	
   

  	
  1.0347

  	
   

  
	
  L1

  	
   

  	
  0.9939

  	
   

  	
  1.0442

  	
   

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9806

  	
   

  
	
  L3

  	
   

  	
  0.9601

  	
   

  	
  0.9806

  	
   

  
	
  L4

  	
   

  	
  0.9081

  	
   

  	
  0.9803

  	
   

  
	
  L5

  	
   

  	
  0.9459

  	
   

  	
  0.9818

  	
   

  
	
  L6

  	
   

  	
  1.0039

  	
   

  	
  0.9818

  	
   

  
	
  L7

  	
   

  	
  1.0334

  	
   

  	
  0.9809

  	
   

  
	
  L8

  	
   

  	
  1.0192

  	
   

  	
  0.9697

  	
   

  
	
  L9

  	
   

  	
  0.9558

  	
   

  	
  1.0411

  	
   

  
	
  HM

  	
   

  	
  1.1684

  	
   

  	
  1.0609

  	
   

  
	
  M1

  	
   

  	
  0.9791

  	
   

  	
  1.0417

  	
   

  
	
  M2

  	
   

  	
  1.1834

  	
   

  	
  1.0609

  	
   

  
	
  M3

  	
   

  	
  1.0070

  	
   

  	
  1.0414

  	
   

  
	
  M4

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  	
   

  
	
  M5

  	
   

  	
  1.0246

  	
   

  	
  1.0268

  	
   

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9666

  	
   

  
	
  M7

  	
   

  	
  0.9493

  	
   

  	
  0.8754

  	
   

  
	
  M8

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  	
   

  
	
  M9

  	
   

  	
  1.0769

  	
   

  	
  1.0411

  	
   

  
	
  HN

  	
   

  	
  1.0067

  	
   

  	
  1.0408

  	
   

  
	
  N1

  	
   

  	
  1.0218

  	
   

  	
  1.0427

  	
   

  
	
  N2

  	
   

  	
  1.0124

  	
   

  	
  1.0408

  	
   

  
	
  N3

  	
   

  	
  1.0161

  	
   

  	
  1.0420

  	
   

  
	
  N4

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  	
   

  
	
  N5

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  	
   

  
	
  N6

  	
   

  	
  1.0184

  	
   

  	
  1.0232

  	
   

  
	
  N7

  	
   

  	
  1.0184

  	
   

  	
  1.0408

  	
   

  
	
  N8

  	
   

  	
  1.0357

  	
   

  	
  1.0387

  	
   

  
	
  N9

  	
   

  	
  1.0124

  	
   

  	
  1.0259

  	
   

  
	
  HO

  	
   

  	
  0.9487

  	
   

  	
  1.0408

  	
   

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0408

  	
   

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0031

  	
   

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0420

  	
   

  
	
  O4

  	
   

  	
  1.0184

  	
   

  	
  1.0031

  	
   

  
	
  O5

  	
   

  	
  0.9487

  	
   

  	
  1.0080

  	
   

  
	
  O6

  	
   

  	
  1.0380

  	
   

  	
  1.0539

  	
   

  
	
  O7

  	
   

  	
  1.0402

  	
   

  	
  1.0393

  	
   

  
	
  O8

  	
   

  	
  1.0053

  	
   

  	
  0.9761

  	
   

  
	
  O9

  	
   

  	
  0.9752

  	
   

  	
  1.0420

  	
   

  
	
  HP

  	
   

  	
  1.0064

  	
   

  	
  1.0122

  	
   

  
	
  P1

  	
   

  	
  1.0161

  	
   

  	
  1.0156

  	
   

  
	
  P2

  	
   

  	
  0.9081

  	
   

  	
  0.9426

  	
   

  
	
  P3

  	
   

  	
  0.9516

  	
   

  	
  0.9806

  	
   

  
	
  P4

  	
   

  	
  1.0070

  	
   

  	
  1.0518

  	
   

  
	
  P5

  	
   

  	
  0.8965

  	
   

  	
  0.9755

  	
   

  
	
  P6

  	
   

  	
  1.1008

  	
   

  	
  0.9867

  	
   

  
	
  P7

  	
   

  	
  1.0243

  	
   

  	
  1.0408

  	
   

  
	
  P8

  	
   

  	
  0.9789

  	
   

  	
  0.9882

  	
   

  
	
  P9

  	
   

  	
  1.0155

  	
   

  	
  0.9855

  	
   

  
	
  HR

  	
   

  	
  1.1684

  	
   

  	
  1.0624

  	
   

  
	
  R1

  	
   

  	
  1.0252

  	
   

  	
  1.0265

  	
   

  
	
  R2

  	
   

  	
  0.9502

  	
   

  	
  1.0439

  	
   

  
	
  R3

  	
   

  	
  0.9644

  	
   

  	
  1.0408

  	
   

  
	
  R4

  	
   

  	
  0.8976

  	
   

  	
  0.8985

  	
   

  
	
  R5

  	
   

  	
  1.0053

  	
   

  	
  0.9806

  	
   

  
	
  R6

  	
   

  	
  1.0053

  	
   

  	
  0.9429

  	
   

  
	
  R7

  	
   

  	
  0.8965

  	
   

  	
  0.9043

  	
   

  
	
  R8

  	
   

  	
  0.9672

  	
   

  	
  1.0265

  	
   

  
	
  R9

  	
   

  	
  0.9019

  	
   

  	
  0.8262

  	
   

  
	
  HS

  	
   

  	
  1.0956

  	
   

  	
  1.0238

  	
   

  
	
  S1

  	
   

  	
  1.1428

  	
   

  	
  1.0685

  	
   

  
	
  S2

  	
   

  	
  1.0303

  	
   

  	
  1.0296

  	
   

  
	
  S3

  	
   

  	
  1.0559

  	
   

  	
  1.0530

  	
   

  
	
  S4

  	
   

  	
  0.9459

  	
   

  	
  0.9332

  	
   

  
	
  S5

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  	
   

  
	
  S6

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  	
   

  
	
  S7

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  	
   

  
	
  S8

  	
   

  	
  1.0169

  	
   

  	
  0.9806

  	
   

  
	
  S9

  	
   

  	
  1.0169

  	
   

  	
  0.9429

  	
   

  
	
  HT

  	
   

  	
  1.0769

  	
   

  	
  1.0408

  	
   

  
	
  T1

  	
   

  	
  1.0826

  	
   

  	
  1.0408

  	
   

  
	
  T2

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  	
   

  
	
  T3

  	
   

  	
  1.0192

  	
   

  	
  1.0235

  	
   

  
	
  T4

  	
   

  	
  1.0147

  	
   

  	
  1.0214

  	
   

  
	
  T5

  	
   

  	
  1.0115

  	
   

  	
  1.0417

  	
   

  
	
  T7

  	
   

  	
  0.9257

  	
   

  	
  0.9867

  	
   

  
	
  T8

  	
   

  	
  1.0144

  	
   

  	
  0.9855

  	
   

  
	
  T9

  	
   

  	
  1.0388

  	
   

  	
  1.0278

  	
   

  
	
  TA

  	
   

  	
  0.9797

  	
   

  	
  0.9879

  	
   

  
	
  TB

  	
   

  	
  0.9914

  	
   

  	
  0.9767

  	
   

  
	
  TC

  	
   

  	
  1.0076

  	
   

  	
  0.9770

  	
   

  
	
  HU

  	
   

  	
  1.0365

  	
   

  	
  1.0503

  	
   

  
	
  U1

  	
   

  	
  1.0243

  	
   

  	
  0.9937

  	
   

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9429

  	
   

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.9697

  	
   

  
	
  U4

  	
   

  	
  1.0863

  	
   

  	
  1.0256

  	
   

  
	
  U5

  	
   

  	
  0.9490

  	
   

  	
  1.0442

  	
   

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0326

  	
   

  
	
  U7

  	
   

  	
  0.9772

  	
   

  	
  1.0299

  	
   

  
	
  U8

  	
   

  	
  1.0277

  	
   

  	
  1.0442

  	
   

  
	
  U9

  	
   

  	
  1.0320

  	
   

  	
  1.0524

  	
   

  
	
  HV

  	
   

  	
  1.0925

  	
   

  	
  1.0454

  	
   

  
	
  HW

  	
   

  	
  1.0536

  	
   

  	
  0.9697

  	
   

  
	
  W1

  	
   

  	
  1.0442

  	
   

  	
  0.9697

  	
   

  
	
  W2

  	
   

  	
  1.0232

  	
   

  	
  1.0214

  	
   

  
									

 

42

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W3

  	
   

  	
  0.9493

  	
   

  	
  1.0487

  	
   

  
	
  W4

  	
   

  	
  0.9328

  	
   

  	
  0.9910

  	
   

  
	
  W5

  	
   

  	
  1.0371

  	
   

  	
  1.0329

  	
   

  
	
  W6

  	
   

  	
  0.9516

  	
   

  	
  0.9840

  	
   

  
	
  W7

  	
   

  	
  0.9760

  	
   

  	
  1.0156

  	
   

  
	
  W8

  	
   

  	
  1.0002

  	
   

  	
  1.0408

  	
   

  
	
  W9

  	
   

  	
  0.9021

  	
   

  	
  1.0408

  	
   

  
	
  HX

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  	
   

  
	
  X1

  	
   

  	
  0.9493

  	
   

  	
  0.8699

  	
   

  
	
  X2

  	
   

  	
  0.9575

  	
   

  	
  0.9320

  	
   

  
	
  X3

  	
   

  	
  0.9459

  	
   

  	
  0.9429

  	
   

  
	
  X4

  	
   

  	
  0.9581

  	
   

  	
  0.9426

  	
   

  
	
  X5

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  	
   

  
	
  X6

  	
   

  	
  1.0127

  	
   

  	
  1.0408

  	
   

  
	
  X7

  	
   

  	
  0.8965

  	
   

  	
  0.9803

  	
   

  
	
  X8

  	
   

  	
  1.0155

  	
   

  	
  0.9809

  	
   

  
	
  X9

  	
   

  	
  0.8965

  	
   

  	
  0.9645

  	
   

  
	
  HY

  	
   

  	
  0.8965

  	
   

  	
  0.8934

  	
   

  
	
  Y1

  	
   

  	
  0.8993

  	
   

  	
  0.9627

  	
   

  
	
  Y2

  	
   

  	
  0.8965

  	
   

  	
  0.9317

  	
   

  
	
  Y3

  	
   

  	
  0.8965

  	
   

  	
  1.0028

  	
   

  
	
  Y4

  	
   

  	
  0.9081

  	
   

  	
  1.0028

  	
   

  
	
  Y5

  	
   

  	
  0.9487

  	
   

  	
  0.9630

  	
   

  
	
  Y6

  	
   

  	
  0.8965

  	
   

  	
  0.9426

  	
   

  
	
  Y7

  	
   

  	
  1.0107

  	
   

  	
  0.9806

  	
   

  
	
  Y8

  	
   

  	
  1.0252

  	
   

  	
  1.0408

  	
   

  
	
  Y9

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  	
   

  
	
  ZA

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  	
   

  
	
  ZB

  	
   

  	
  0.9797

  	
   

  	
  0.8660

  	
   

  
	
  ZC

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  	
   

  
	
  ZG

  	
   

  	
  0.9797

  	
   

  	
  0.9654

  	
   

  
	
  ZK

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  	
   

  
	
  ZM

  	
   

  	
  1.1005

  	
   

  	
  0.9882

  	
   

  
	
  ZN

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  ZO

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  ZS

  	
   

  	
  1.0615

  	
   

  	
  0.9770

  	
   

  
	
  ZZ

  	
   

  	
  0.9922

  	
   

  	
  0.9770

  	
   

  
	
  1A

  	
   

  	
  0.9987

  	
   

  	
  1.0198

  	
   

  
	
  1B

  	
   

  	
  1.0343

  	
   

  	
  1.0232

  	
   

  
	
  1C

  	
   

  	
  1.0385

  	
   

  	
  1.0256

  	
   

  
	
  1D

  	
   

  	
  0.9709

  	
   

  	
  1.0423

  	
   

  
	
  1E

  	
   

  	
  1.0348

  	
   

  	
  1.0271

  	
   

  
	
  1F

  	
   

  	
  1.0348

  	
   

  	
  1.0232

  	
   

  
	
  1G

  	
   

  	
  1.0348

  	
   

  	
  1.0220

  	
   

  
	
  1H

  	
   

  	
  1.0348

  	
   

  	
  0.9469

  	
   

  
	
  1J

  	
   

  	
  1.0348

  	
   

  	
  1.0393

  	
   

  
	
  1K

  	
   

  	
  1.0198

  	
   

  	
  1.0271

  	
   

  
	
  1L

  	
   

  	
  1.0368

  	
   

  	
  0.9803

  	
   

  
	
  1M

  	
   

  	
  1.0274

  	
   

  	
  1.0083

  	
   

  
	
  1N

  	
   

  	
  1.0274

  	
   

  	
  1.0423

  	
   

  
	
  1P

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  	
   

  
	
  1Q

  	
   

  	
  1.0274

  	
   

  	
  0.9469

  	
   

  
	
  1R

  	
   

  	
  1.0996

  	
   

  	
  1.0423

  	
   

  
	
  1S

  	
   

  	
  0.9709

  	
   

  	
  1.0049

  	
   

  
	
  1T

  	
   

  	
  0.9627

  	
   

  	
  1.0049

  	
   

  
	
  U

  	
   

  	
  0.9271

  	
   

  	
  1.0031

  	
   

  
	
  1V

  	
   

  	
  1.0232

  	
   

  	
  1.0214

  	
   

  
	
  1W

  	
   

  	
  0.9678

  	
   

  	
  0.9803

  	
   

  
	
  1X

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  	
   

  
	
  1Y

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  	
   

  
	
  1Z

  	
   

  	
  1.0192

  	
   

  	
  1.0049

  	
   

  
	
  2A

  	
   

  	
  0.9709

  	
   

  	
  0.9469

  	
   

  
	
  2B

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  	
   

  
	
  2C

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  	
   

  
	
  2D

  	
   

  	
  0.9405

  	
   

  	
  1.0056

  	
   

  
	
  2E

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  	
   

  
	
  2F

  	
   

  	
  1.0235

  	
   

  	
  1.0214

  	
   

  
	
  6A

  	
   

  	
  1.0615

  	
   

  	
  0.9709

  	
   

  
	
  6G

  	
   

  	
  0.9217

  	
   

  	
  0.9654

  	
   

  
	
  6H

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  6R

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  	
   

  
	
  6S

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  	
   

  
	
  6T

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  6V

  	
   

  	
  0.9217

  	
   

  	
  0.9615

  	
   

  
	
  6W

  	
   

  	
  0.9700

  	
   

  	
  0.9797

  	
   

  
	
  6Z

  	
   

  	
  0.9252

  	
   

  	
  0.8657

  	
   

  
	
  7C

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  	
   

  
	
  7E

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  	
   

  
	
  7F

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  	
   

  
	
  7G

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  	
   

  
	
  7H

  	
   

  	
  0.9217

  	
   

  	
  0.9079

  	
   

  
	
  7I

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  	
   

  
	
  7J

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  	
   

  
	
  7K

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  	
   

  
	
  7L

  	
   

  	
  1.0053

  	
   

  	
  0.9882

  	
   

  
	
  7M

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  7N

  	
   

  	
  0.9794

  	
   

  	
  0.9764

  	
   

  
	
  7O

  	
   

  	
  0.8723

  	
   

  	
  0.9761

  	
   

  
	
  7Q

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  7R

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  7S

  	
   

  	
  0.8723

  	
   

  	
  0.9384

  	
   

  
	
  7T

  	
   

  	
  0.9217

  	
   

  	
  0.9466

  	
   

  
	
  7U

  	
   

  	
  0.9618

  	
   

  	
  0.9764

  	
   

  
	
  7V

  	
   

  	
  0.9811

  	
   

  	
  0.9387

  	
   

  
	
  7W

  	
   

  	
  0.9232

  	
   

  	
  0.9387

  	
   

  
	
  7X

  	
   

  	
  1.1155

  	
   

  	
  0.9882

  	
   

  
	
  7Y

  	
   

  	
  1.0363

  	
   

  	
  0.9882

  	
   

  
	
  7Z

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  9A

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  9B

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9C

  	
   

  	
  0.9735

  	
   

  	
  0.9764

  	
   

  
	
  9E

  	
   

  	
  0.9968

  	
   

  	
  0.9770

  	
   

  
	
  9F

  	
   

  	
  1.0615

  	
   

  	
  0.9764

  	
   

  
	
  9G

  	
   

  	
  0.9945

  	
   

  	
  0.9764

  	
   

  
	
  9H

  	
   

  	
  0.9530

  	
   

  	
  0.9764

  	
   

  
	
  9I

  	
   

  	
  0.9820

  	
   

  	
  0.9764

  	
   

  
	
  9J

  	
   

  	
  0.8766

  	
   

  	
  0.8313

  	
   

  
	
  9M

  	
   

  	
  0.9928

  	
   

  	
  0.9764

  	
   

  
	
  9N

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  	
   

  
	
  9O

  	
   

  	
  0.9368

  	
   

  	
  0.9764

  	
   

  
	
  9P

  	
   

  	
  1.0007

  	
   

  	
  0.9785

  	
   

  
	
  9Q

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9R

  	
   

  	
  0.9959

  	
   

  	
  0.9837

  	
   

  
	
  9S

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9T

  	
   

  	
  0.9797

  	
   

  	
  0.9767

  	
   

  
	
  9U

  	
   

  	
  0.9789

  	
   

  	
  0.9803

  	
   

  
	
  9W

  	
   

  	
  0.9217

  	
   

  	
  0.9566

  	
   

  
	
  9X

  	
   

  	
  0.8840

  	
   

  	
  0.9764

  	
   

  

 

43

 

A.3
Benefit Plan Fators for PPG Capitation and Hospital Capitation Effective
January 1, 1998

 

	
  Small Group HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.7692

  	
   

  	
  0.7857

  	
   

  
	
  C5

  	
   

  	
  0.6886

  	
   

  	
  0.7740

  	
   

  
	
  Q1

  	
   

  	
  0.9857

  	
   

  	
  0.9697

  	
   

  
	
  Q2

  	
   

  	
  0.9285

  	
   

  	
  0.9315

  	
   

  
	
  Q3

  	
   

  	
  0.8792

  	
   

  	
  0.8692

  	
   

  
	
  Q4

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  	
   

  
	
  Q5

  	
   

  	
  1.0160

  	
   

  	
  1.0230

  	
   

  
	
  Q6

  	
   

  	
  0.9095

  	
   

  	
  1.0076

  	
   

  
	
  Q7

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  	
   

  
	
  Q8

  	
   

  	
  0.9285

  	
   

  	
  0.9697

  	
   

  
	
  QT

  	
   

  	
  0.7737

  	
   

  	
  0.7841

  	
   

  
	
  QU

  	
   

  	
  0.6971

  	
   

  	
  0.7709

  	
   

  
	
  QV

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  	
   

  
	
  QW

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  	
   

  
	
  QX

  	
   

  	
  0.7237

  	
   

  	
  0.7808

  	
   

  
	
  QY

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  	
   

  
	
  QZ

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  	
   

  
	
  V1

  	
   

  	
  1.0104

  	
   

  	
  0.9940

  	
   

  
	
  V2

  	
   

  	
  0.9409

  	
   

  	
  0.9853

  	
   

  
	
  V3

  	
   

  	
  0.8406

  	
   

  	
  0.9783

  	
   

  

 

	
  Individual HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9886

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9639

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.9124

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8616

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.8054

  	
   

  

 

	
  Medicare Supplement HMO

  
	
  Plan

  	
   

  	
  Prof

  Factor

  
	
  Medicare Conversion Plan J

  	
   

  	
  1.2467

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1604

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6676

  

 

	
  Medicare Supplement POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB
  $0 Copay

  	
   

  	
  1.1604

  	
   

  
	
  POS Medicare COB
  $5 and up Copay

  	
   

  	
  0.6676

  	
   

  

 

44

 

A.4
Benefit Plan Factors for PPG Capitation and Hospital Capitation/Shared Risk
Budgets

Effective
July 1, 1998

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0754

  	
   

  	
  0.9716

  	
   

  
	
  A1

  	
   

  	
  1.0869

  	
   

  	
  0.9752

  	
   

  
	
  A2

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  	
   

  
	
  A3

  	
   

  	
  1.0843

  	
   

  	
  0.9830

  	
   

  
	
  A4

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  	
   

  
	
  A5

  	
   

  	
  1.0869

  	
   

  	
  0.9782

  	
   

  
	
  A6

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  	
   

  
	
  A7

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  	
   

  
	
  A8

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  	
   

  
	
  A9

  	
   

  	
  1.0420

  	
   

  	
  1.0387

  	
   

  
	
  HB

  	
   

  	
  1.0042

  	
   

  	
  0.8737

  	
   

  
	
  BB

  	
   

  	
  1.0042

  	
   

  	
  0.8746

  	
   

  
	
  B1

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  	
   

  
	
  B2

  	
   

  	
  0.8999

  	
   

  	
  0.8300

  	
   

  
	
  B3

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  	
   

  
	
  B4

  	
   

  	
  0.9019

  	
   

  	
  0.8291

  	
   

  
	
  B5

  	
   

  	
  0.8999

  	
   

  	
  0.8377

  	
   

  
	
  B6

  	
   

  	
  1.0042

  	
   

  	
  0.8812

  	
   

  
	
  B7

  	
   

  	
  0.9745

  	
   

  	
  1.0285

  	
   

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0163

  	
   

  
	
  B9

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  	
   

  
	
  HC

  	
   

  	
  1.0855

  	
   

  	
  1.0139

  	
   

  
	
  C1

  	
   

  	
  1.0783

  	
   

  	
  1.0139

  	
   

  
	
  C2

  	
   

  	
  1.0967

  	
   

  	
  1.0252

  	
   

  
	
  C3

  	
   

  	
  1.0071

  	
   

  	
  1.0139

  	
   

  
	
  C6

  	
   

  	
  1.0103

  	
   

  	
  1.0387

  	
   

  
	
  C7

  	
   

  	
  1.0855

  	
   

  	
  1.0211

  	
   

  
	
  C8

  	
   

  	
  0.9457

  	
   

  	
  0.9758

  	
   

  
	
  C9

  	
   

  	
  0.9042

  	
   

  	
  1.0387

  	
   

  
	
  HD

  	
   

  	
  1.1174

  	
   

  	
  1.0211

  	
   

  
	
  D1

  	
   

  	
  1.0783

  	
   

  	
  1.0211

  	
   

  
	
  D2

  	
   

  	
  1.0255

  	
   

  	
  1.0303

  	
   

  
	
  D3

  	
   

  	
  0.9002

  	
   

  	
  0.8300

  	
   

  
	
  D4

  	
   

  	
  0.9492

  	
   

  	
  0.8731

  	
   

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9791

  	
   

  
	
  D6

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  	
   

  
	
  D7

  	
   

  	
  0.9659

  	
   

  	
  1.0306

  	
   

  
	
  D8

  	
   

  	
  1.0316

  	
   

  	
  1.0199

  	
   

  
	
  D9

  	
   

  	
  1.0466

  	
   

  	
  1.0456

  	
   

  
	
  HE

  	
   

  	
  1.0325

  	
   

  	
  1.0431

  	
   

  
	
  E1

  	
   

  	
  1.0226

  	
   

  	
  0.9746

  	
   

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0387

  	
   

  
	
  E3

  	
   

  	
  1.0071

  	
   

  	
  0.9791

  	
   

  
	
  E4

  	
   

  	
  0.9486

  	
   

  	
  0.9920

  	
   

  
	
  E5

  	
   

  	
  1.0587

  	
   

  	
  1.0417

  	
   

  
	
  E6

  	
   

  	
  0.9639

  	
   

  	
  0.9746

  	
   

  
	
  E7

  	
   

  	
  0.9999

  	
   

  	
  1.0417

  	
   

  
	
  E8

  	
   

  	
  1.0183

  	
   

  	
  1.0235

  	
   

  
	
  E9

  	
   

  	
  0.9734

  	
   

  	
  0.9791

  	
   

  
	
  EA

  	
   

  	
  0.9716

  	
   

  	
  1.0350

  	
   

  
	
  EB

  	
   

  	
  0.9033

  	
   

  	
  0.8215

  	
   

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0386

  	
   

  
	
  ED

  	
   

  	
  1.0056

  	
   

  	
  0.9926

  	
   

  
	
  EE

  	
   

  	
  1.0079

  	
   

  	
  0.9811

  	
   

  
	
  EF

  	
   

  	
  1.0482

  	
   

  	
  1.0419

  	
   

  
	
  EG

  	
   

  	
  1.0002

  	
   

  	
  1.0419

  	
   

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0204

  	
   

  
	
  EI

  	
   

  	
  0.9916

  	
   

  	
  0.9775

  	
   

  
	
  EJ

  	
   

  	
  1.0582

  	
   

  	
  1.0477

  	
   

  
	
  EK

  	
   

  	
  0.9179

  	
   

  	
  1.0386

  	
   

  
	
  EL

  	
   

  	
  1.0528

  	
   

  	
  0.9760

  	
   

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0489

  	
   

  
	
  EN

  	
   

  	
  0.9799

  	
   

  	
  0.9748

  	
   

  
	
  EO

  	
   

  	
  0.9762

  	
   

  	
  0.9978

  	
   

  
	
  EP

  	
   

  	
  0.9333

  	
   

  	
  0.9745

  	
   

  
	
  EQ

  	
   

  	
  0.9782

  	
   

  	
  1.0253

  	
   

  
	
  ES

  	
   

  	
  0.9730

  	
   

  	
  1.0413

  	
   

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0088

  	
   

  
	
  F1

  	
   

  	
  1.0169

  	
   

  	
  1.0112

  	
   

  
	
  F2

  	
   

  	
  1.0172

  	
   

  	
  0.9764

  	
   

  
	
  F3

  	
   

  	
  1.0074

  	
   

  	
  0.9791

  	
   

  
	
  F4

  	
   

  	
  0.9820

  	
   

  	
  1.0345

  	
   

  
	
  F5

  	
   

  	
  1.0284

  	
   

  	
  0.9788

  	
   

  
	
  F6

  	
   

  	
  1.0077

  	
   

  	
  1.0387

  	
   

  
	
  F7

  	
   

  	
  1.1102

  	
   

  	
  0.9908

  	
   

  
	
  F8

  	
   

  	
  0.9041

  	
   

  	
  0.9727

  	
   

  
	
  F9

  	
   

  	
  1.0532

  	
   

  	
  1.0423

  	
   

  
	
  FA

  	
   

  	
  1.0285

  	
   

  	
  1.0356

  	
   

  
	
  FB

  	
   

  	
  1.0313

  	
   

  	
  1.0501

  	
   

  
	
  FC

  	
   

  	
  1.0199

  	
   

  	
  1.0386

  	
   

  
	
  FD

  	
   

  	
  1.0345

  	
   

  	
  1.0380

  	
   

  
	
  FE

  	
   

  	
  0.9647

  	
   

  	
  1.0356

  	
   

  
	
  FF

  	
   

  	
  0.9716

  	
   

  	
  1.0410

  	
   

  
	
  FG

  	
   

  	
  0.9647

  	
   

  	
  1.0032

  	
   

  
	
  FH

  	
   

  	
  0.9725

  	
   

  	
  1.0356

  	
   

  
	
  FI

  	
   

  	
  0.9762

  	
   

  	
  1.0356

  	
   

  
	
  FJ

  	
   

  	
  0.9213

  	
   

  	
  1.0356

  	
   

  
	
  FK

  	
   

  	
  0.9762

  	
   

  	
  0.9902

  	
   

  
	
  FL

  	
   

  	
  0.9213

  	
   

  	
  0.9588

  	
   

  
	
  HG

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  	
   

  
	
  G1

  	
   

  	
  0.9457

  	
   

  	
  0.9716

  	
   

  
	
  G2

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  	
   

  
	
  G3

  	
   

  	
  1.0160

  	
   

  	
  0.9791

  	
   

  
	
  G4

  	
   

  	
  0.9457

  	
   

  	
  0.9791

  	
   

  
	
  G5

  	
   

  	
  0.8956

  	
   

  	
  0.9713

  	
   

  
	
  G6

  	
   

  	
  1.0172

  	
   

  	
  1.0226

  	
   

  
	
  G9

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  	
   

  
	
  I3

  	
   

  	
  0.9645

  	
   

  	
  1.0455

  	
   

  
	
  I4

  	
   

  	
  0.9004

  	
   

  	
  0.8366

  	
   

  
	
  I5

  	
   

  	
  0.9553

  	
   

  	
  1.0108

  	
   

  
	
  I6

  	
   

  	
  1.0451

  	
   

  	
  0.9548

  	
   

  
	
  I7

  	
   

  	
  1.0516

  	
   

  	
  1.0425

  	
   

  
	
  I8

  	
   

  	
  0.9573

  	
   

  	
  1.0247

  	
   

  
	
  I9

  	
   

  	
  0.9893

  	
   

  	
  1.0386

  	
   

  
	
  J3

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  	
   

  
	
  J4

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  	
   

  
	
  J5

  	
   

  	
  1.0134

  	
   

  	
  0.9794

  	
   

  
	
  J6

  	
   

  	
  0.9765

  	
   

  	
  0.9818

  	
   

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0318

  	
   

  
	
  J8

  	
   

  	
  0.9783

  	
   

  	
  0.9869

  	
   

  
	
  J9

  	
   

  	
  1.1627

  	
   

  	
  1.0642

  	
   

  
	
  HK

  	
   

  	
  1.0855

  	
   

  	
  1.0390

  	
   

  
	
  K1

  	
   

  	
  1.0146

  	
   

  	
  1.0390

  	
   

  
	
  K2

  	
   

  	
  0.9719

  	
   

  	
  0.9791

  	
   

  
	
  K3

  	
   

  	
  1.0247

  	
   

  	
  1.0393

  	
   

  
	
  K4

  	
   

  	
  1.0973

  	
   

  	
  1.0390

  	
   

  
	
  K6

  	
   

  	
  0.9699

  	
   

  	
  1.0399

  	
   

  
	
  K7

  	
   

  	
  0.9941

  	
   

  	
  1.0196

  	
   

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0205

  	
   

  
	
  K9

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  	
   

  
	
  KI

  	
   

  	
  0.9647

  	
   

  	
  1.0362

  	
   

  
	
  KJ

  	
   

  	
  1.0285

  	
   

  	
  1.0362

  	
   

  
	
  KK

  	
   

  	
  0.9762

  	
   

  	
  0.9911

  	
   

  
	
  KL

  	
   

  	
  0.9633

  	
   

  	
  1.0114

  	
   

  
	
  KM

  	
   

  	
  0.9327

  	
   

  	
  1.0362

  	
   

  
	
  L1

  	
   

  	
  0.9941

  	
   

  	
  1.0420

  	
   

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9791

  	
   

  
	
  L3

  	
   

  	
  0.9598

  	
   

  	
  0.9791

  	
   

  
	
  L4

  	
   

  	
  0.9074

  	
   

  	
  0.9788

  	
   

  
	
  L5

  	
   

  	
  0.9460

  	
   

  	
  0.9803

  	
   

  
	
  L6

  	
   

  	
  1.0045

  	
   

  	
  0.9803

  	
   

  
	
  L7

  	
   

  	
  1.0345

  	
   

  	
  0.9800

  	
   

  
	
  L8

  	
   

  	
  1.0201

  	
   

  	
  0.9716

  	
   

  
	
  L9

  	
   

  	
  0.9558

  	
   

  	
  1.0390

  	
   

  
	
  HM

  	
   

  	
  1.1708

  	
   

  	
  1.0585

  	
   

  
	
  M1

  	
   

  	
  0.9794

  	
   

  	
  1.0396

  	
   

  
	
  M2

  	
   

  	
  1.1857

  	
   

  	
  1.0585

  	
   

  
	
  M3

  	
   

  	
  1.0077

  	
   

  	
  1.0393

  	
   

  
	
  M4

  	
   

  	
  1.0077

  	
   

  	
  1.0423

  	
   

  
	
  M5

  	
   

  	
  1.0252

  	
   

  	
  1.0246

  	
   

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9659

  	
   

  
	
  M7

  	
   

  	
  0.9492

  	
   

  	
  0.8755

  	
   

  
	
  M8

  	
   

  	
  1.0172

  	
   

  	
  1.0300

  	
   

  
	
  M9

  	
   

  	
  1.0783

  	
   

  	
  1.0390

  	
   

  
	
  HN

  	
   

  	
  1.0074

  	
   

  	
  1.0387

  	
   

  
	
  N1

  	
   

  	
  1.0226

  	
   

  	
  1.0405

  	
   

  
	
  N2

  	
   

  	
  1.0131

  	
   

  	
  1.0387

  	
   

  
	
  N3

  	
   

  	
  1.0169

  	
   

  	
  1.0399

  	
   

  
	
  N4

  	
   

  	
  1.0071

  	
   

  	
  1.0211

  	
   

  
	
  N5

  	
   

  	
  1.0074

  	
   

  	
  1.0211

  	
   

  
	
  N6

  	
   

  	
  1.0189

  	
   

  	
  1.0211

  	
   

  
	
  N7

  	
   

  	
  1.0192

  	
   

  	
  1.0387

  	
   

  
	
  N8

  	
   

  	
  1.0365

  	
   

  	
  1.0366

  	
   

  
	
  N9

  	
   

  	
  1.0131

  	
   

  	
  1.0240

  	
   

  
	
  HO

  	
   

  	
  0.9489

  	
   

  	
  1.0387

  	
   

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0387

  	
   

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0016

  	
   

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0399

  	
   

  
	
  O4

  	
   

  	
  1.0189

  	
   

  	
  1.0016

  	
   

  
	
  O5

  	
   

  	
  0.9486

  	
   

  	
  1.0064

  	
   

  
	
  O6

  	
   

  	
  1.0388

  	
   

  	
  1.0516

  	
   

  
	
  O7

  	
   

  	
  1.0411

  	
   

  	
  1.0372

  	
   

  
	
  O8

  	
   

  	
  1.0056

  	
   

  	
  0.9746

  	
   

  
	
  O9

  	
   

  	
  0.9754

  	
   

  	
  1.0399

  	
   

  
	
  HP

  	
   

  	
  1.0068

  	
   

  	
  1.0139

  	
   

  
	
  P1

  	
   

  	
  1.0166

  	
   

  	
  1.0172

  	
   

  
	
  P2

  	
   

  	
  0.9071

  	
   

  	
  0.9417

  	
   

  
	
  P3

  	
   

  	
  0.9515

  	
   

  	
  0.9791

  	
   

  
	
  P4

  	
   

  	
  1.0077

  	
   

  	
  1.0495

  	
   

  
	
  P5

  	
   

  	
  0.8956

  	
   

  	
  0.9740

  	
   

  
	
  P6

  	
   

  	
  1.1025

  	
   

  	
  0.9866

  	
   

  
	
  P7

  	
   

  	
  1.0252

  	
   

  	
  1.0387

  	
   

  
	
  P8

  	
   

  	
  0.9800

  	
   

  	
  0.9899

  	
   

  
	
  P9

  	
   

  	
  1.0175

  	
   

  	
  0.9872

  	
   

  
	
  HR

  	
   

  	
  1.1708

  	
   

  	
  1.0600

  	
   

  
	
  R1

  	
   

  	
  1.0258

  	
   

  	
  1.0243

  	
   

  
	
  R2

  	
   

  	
  0.9503

  	
   

  	
  1.0417

  	
   

  
	
  R3

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  	
   

  
	
  R4

  	
   

  	
  0.8967

  	
   

  	
  0.8980

  	
   

  
	
  R5

  	
   

  	
  1.0056

  	
   

  	
  0.9791

  	
   

  
	
  R6

  	
   

  	
  1.0056

  	
   

  	
  0.9420

  	
   

  
	
  R7

  	
   

  	
  0.8956

  	
   

  	
  0.9039

  	
   

  
	
  R8

  	
   

  	
  0.9670

  	
   

  	
  1.0243

  	
   

  
	
  R9

  	
   

  	
  0.9010

  	
   

  	
  0.8300

  	
   

  
	
  HS

  	
   

  	
  1.0973

  	
   

  	
  1.0220

  	
   

  
	
  S1

  	
   

  	
  1.1445

  	
   

  	
  1.0660

  	
   

  
	
  S2

  	
   

  	
  1.0324

  	
   

  	
  1.0309

  	
   

  
	
  S3

  	
   

  	
  1.0569

  	
   

  	
  1.0507

  	
   

  
	
  S4

  	
   

  	
  0.9457

  	
   

  	
  0.9357

  	
   

  
	
  S5

  	
   

  	
  0.8999

  	
   

  	
  0.8380

  	
   

  
	
  S6

  	
   

  	
  1.0872

  	
   

  	
  1.0211

  	
   

  
	
  S7

  	
   

  	
  1.0267

  	
   

  	
  1.0208

  	
   

  
	
  S8

  	
   

  	
  1.0175

  	
   

  	
  0.9791

  	
   

  
	
  S9

  	
   

  	
  1.0175

  	
   

  	
  0.9420

  	
   

  
	
  HT

  	
   

  	
  1.0783

  	
   

  	
  1.0387

  	
   

  
	
  T1

  	
   

  	
  1.0840

  	
   

  	
  1.0387

  	
   

  
	
  T2

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  	
   

  
	
  T3

  	
   

  	
  1.0198

  	
   

  	
  1.0232

  	
   

  
	
  T4

  	
   

  	
  1.0152

  	
   

  	
  1.0211

  	
   

  
	
  T5

  	
   

  	
  1.0123

  	
   

  	
  1.0396

  	
   

  
	
  T7

  	
   

  	
  0.9264

  	
   

  	
  0.9887

  	
   

  
	
  T8

  	
   

  	
  1.0160

  	
   

  	
  0.9872

  	
   

  
	
  T9

  	
   

  	
  1.0408

  	
   

  	
  1.0291

  	
   

  
	
  TA

  	
   

  	
  0.9799

  	
   

  	
  0.9860

  	
   

  
	
  TB

  	
   

  	
  0.9916

  	
   

  	
  0.9748

  	
   

  
	
  TC

  	
   

  	
  1.0079

  	
   

  	
  0.9784

  	
   

  
	
  HU

  	
   

  	
  1.0376

  	
   

  	
  1.0486

  	
   

  
	
  U1

  	
   

  	
  1.0252

  	
   

  	
  0.9926

  	
   

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9420

  	
   

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.9716

  	
   

  
	
  U4

  	
   

  	
  1.0878

  	
   

  	
  1.0238

  	
   

  
	
  U5

  	
   

  	
  0.9492

  	
   

  	
  1.0456

  	
   

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0306

  	
   

  
	
  U7

  	
   

  	
  0.9771

  	
   

  	
  1.0312

  	
   

  
	
  U8

  	
   

  	
  1.0284

  	
   

  	
  1.0420

  	
   

  
	
  U9

  	
   

  	
  1.0327

  	
   

  	
  1.0501

  	
   

  
	
  HV

  	
   

  	
  1.0941

  	
   

  	
  1.0432

  	
   

  
	
  HW

  	
   

  	
  1.0546

  	
   

  	
  0.9716

  	
   

  
	
  W1

  	
   

  	
  1.0454

  	
   

  	
  0.9716

  	
   

  
	
  W2

  	
   

  	
  1.0238

  	
   

  	
  1.0211

  	
   

  
	
  W3

  	
   

  	
  0.9495

  	
   

  	
  1.0465

  	
   

  
	
  W4

  	
   

  	
  0.9322

  	
   

  	
  0.9929

  	
   

  
	
  W5

  	
   

  	
  1.0379

  	
   

  	
  1.0342

  	
   

  
	
  W6

  	
   

  	
  0.9515

  	
   

  	
  0.9824

  	
   

  
	
  W7

  	
   

  	
  0.9763

  	
   

  	
  1.0154

  	
   

  

 

45

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W8

  	
   

  	
  1.0007

  	
   

  	
  1.0390

  	
   

  
	
  W9

  	
   

  	
  0.9013

  	
   

  	
  1.0390

  	
   

  
	
  HX

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  	
   

  
	
  X1

  	
   

  	
  0.9492

  	
   

  	
  0.8734

  	
   

  
	
  X2

  	
   

  	
  0.9572

  	
   

  	
  0.9345

  	
   

  
	
  X3

  	
   

  	
  0.9457

  	
   

  	
  0.9420

  	
   

  
	
  X4

  	
   

  	
  0.9584

  	
   

  	
  0.9420

  	
   

  
	
  X5

  	
   

  	
  1.0172

  	
   

  	
  1.0300

  	
   

  
	
  X6

  	
   

  	
  1.0134

  	
   

  	
  1.0387

  	
   

  
	
  X7

  	
   

  	
  0.8956

  	
   

  	
  0.9788

  	
   

  
	
  X8

  	
   

  	
  1.0160

  	
   

  	
  0.9794

  	
   

  
	
  X9

  	
   

  	
  0.8956

  	
   

  	
  0.9665

  	
   

  
	
  HY

  	
   

  	
  0.8956

  	
   

  	
  0.8965

  	
   

  
	
  Y1

  	
   

  	
  0.8985

  	
   

  	
  0.9618

  	
   

  
	
  Y2

  	
   

  	
  0.8956

  	
   

  	
  0.9342

  	
   

  
	
  Y3

  	
   

  	
  0.8956

  	
   

  	
  1.0013

  	
   

  
	
  Y4

  	
   

  	
  0.9074

  	
   

  	
  1.0013

  	
   

  
	
  Y5

  	
   

  	
  0.9489

  	
   

  	
  0.9620

  	
   

  
	
  Y6

  	
   

  	
  0.8956

  	
   

  	
  0.9417

  	
   

  
	
  Y7

  	
   

  	
  1.0111

  	
   

  	
  0.9791

  	
   

  
	
  Y8

  	
   

  	
  1.0258

  	
   

  	
  1.0387

  	
   

  
	
  Y9

  	
   

  	
  1.0264

  	
   

  	
  1.0208

  	
   

  
	
  ZA

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  	
   

  
	
  ZB

  	
   

  	
  0.9800

  	
   

  	
  0.8695

  	
   

  
	
  ZC

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  	
   

  
	
  ZG

  	
   

  	
  0.9800

  	
   

  	
  0.9674

  	
   

  
	
  ZK

  	
   

  	
  1.0509

  	
   

  	
  0.9749

  	
   

  
	
  ZM

  	
   

  	
  1.1022

  	
   

  	
  0.9863

  	
   

  
	
  ZN

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  ZO

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  ZS

  	
   

  	
  1.0627

  	
   

  	
  0.9755

  	
   

  
	
  ZZ

  	
   

  	
  0.9924

  	
   

  	
  0.9788

  	
   

  
	
  1A

  	
   

  	
  1.0022

  	
   

  	
  1.0214

  	
   

  
	
  1B

  	
   

  	
  1.0382

  	
   

  	
  1.0246

  	
   

  
	
  1C

  	
   

  	
  1.0428

  	
   

  	
  1.0270

  	
   

  
	
  1D

  	
   

  	
  0.9742

  	
   

  	
  1.0438

  	
   

  
	
  1E

  	
   

  	
  1.0388

  	
   

  	
  1.0285

  	
   

  
	
  1F

  	
   

  	
  1.0388

  	
   

  	
  1.0246

  	
   

  
	
  1G

  	
   

  	
  1.0388

  	
   

  	
  1.0235

  	
   

  
	
  1H

  	
   

  	
  1.0388

  	
   

  	
  0.9498

  	
   

  
	
  1J

  	
   

  	
  1.0391

  	
   

  	
  1.0408

  	
   

  
	
  1K

  	
   

  	
  1.0258

  	
   

  	
  1.0285

  	
   

  
	
  1L

  	
   

  	
  1.0445

  	
   

  	
  0.9818

  	
   

  
	
  1M

  	
   

  	
  1.0316

  	
   

  	
  1.0100

  	
   

  
	
  1N

  	
   

  	
  1.0316

  	
   

  	
  1.0438

  	
   

  
	
  1Q

  	
   

  	
  1.0316

  	
   

  	
  0.9498

  	
   

  
	
  1R

  	
   

  	
  1.1048

  	
   

  	
  1.0438

  	
   

  
	
  1S

  	
   

  	
  0.9742

  	
   

  	
  1.0067

  	
   

  
	
  1T

  	
   

  	
  0.9659

  	
   

  	
  1.0067

  	
   

  
	
  1U

  	
   

  	
  0.9299

  	
   

  	
  1.0052

  	
   

  
	
  1V

  	
   

  	
  1.0273

  	
   

  	
  1.0235

  	
   

  
	
  1W

  	
   

  	
  0.9711

  	
   

  	
  0.9818

  	
   

  
	
  1X

  	
   

  	
  1.0284

  	
   

  	
  0.9818

  	
   

  
	
  1Y

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  	
   

  
	
  1Z

  	
   

  	
  1.0232

  	
   

  	
  1.0073

  	
   

  
	
  2A

  	
   

  	
  0.9742

  	
   

  	
  0.9498

  	
   

  
	
  2B

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  	
   

  
	
  2C

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  	
   

  
	
  2D

  	
   

  	
  0.9431

  	
   

  	
  1.0085

  	
   

  
	
  2E

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  	
   

  
	
  2F

  	
   

  	
  1.0275

  	
   

  	
  1.0229

  	
   

  
	
  6A

  	
   

  	
  1.0627

  	
   

  	
  0.9710

  	
   

  
	
  6G

  	
   

  	
  0.9215

  	
   

  	
  0.9674

  	
   

  
	
  6H

  	
   

  	
  0.9803

  	
   

  	
  0.9749

  	
   

  
	
  6R

  	
   

  	
  0.9330

  	
   

  	
  0.9749

  	
   

  
	
  6S

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  	
   

  
	
  6T

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  6V

  	
   

  	
  0.9215

  	
   

  	
  0.9603

  	
   

  
	
  6W

  	
   

  	
  0.9702

  	
   

  	
  0.9779

  	
   

  
	
  6Z

  	
   

  	
  0.9250

  	
   

  	
  0.8692

  	
   

  
	
  7C

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  	
   

  
	
  7E

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  	
   

  
	
  7F

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  	
   

  
	
  7G

  	
   

  	
  1.0509

  	
   

  	
  0.9749

  	
   

  
	
  7H

  	
   

  	
  0.9215

  	
   

  	
  0.9069

  	
   

  
	
  7I

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  	
   

  
	
  7J

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  	
   

  
	
  7K

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  	
   

  
	
  7L

  	
   

  	
  1.0062

  	
   

  	
  0.9863

  	
   

  
	
  7M

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  7N

  	
   

  	
  0.9797

  	
   

  	
  0.9749

  	
   

  
	
  7O

  	
   

  	
  0.8714

  	
   

  	
  0.9746

  	
   

  
	
  7Q

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  7R

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  7S

  	
   

  	
  0.8711

  	
   

  	
  0.9375

  	
   

  
	
  7T

  	
   

  	
  0.9215

  	
   

  	
  0.9456

  	
   

  
	
  7U

  	
   

  	
  0.9621

  	
   

  	
  0.9749

  	
   

  
	
  7V

  	
   

  	
  0.9814

  	
   

  	
  0.9378

  	
   

  
	
  7W

  	
   

  	
  0.9229

  	
   

  	
  0.9378

  	
   

  
	
  7X

  	
   

  	
  1.1172

  	
   

  	
  0.9863

  	
   

  
	
  7Z

  	
   

  	
  0.9215

  	
   

  	
  0.9782

  	
   

  
	
  9A

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  9B

  	
   

  	
  0.9918

  	
   

  	
  0.9749

  	
   

  
	
  9C

  	
   

  	
  0.9739

  	
   

  	
  0.9749

  	
   

  
	
  9E

  	
   

  	
  0.9970

  	
   

  	
  0.9788

  	
   

  
	
  9F

  	
   

  	
  1.0627

  	
   

  	
  0.9749

  	
   

  
	
  9G

  	
   

  	
  0.9950

  	
   

  	
  0.9749

  	
   

  
	
  9H

  	
   

  	
  0.9535

  	
   

  	
  0.9746

  	
   

  
	
  9I

  	
   

  	
  0.9823

  	
   

  	
  0.9749

  	
   

  
	
  9J

  	
   

  	
  0.8757

  	
   

  	
  0.8318

  	
   

  
	
  9M

  	
   

  	
  0.9933

  	
   

  	
  0.9749

  	
   

  
	
  9N

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  	
   

  
	
  9O

  	
   

  	
  0.9365

  	
   

  	
  0.9749

  	
   

  
	
  9P

  	
   

  	
  1.0010

  	
   

  	
  0.9803

  	
   

  
	
  9Q

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  	
   

  
	
  9R

  	
   

  	
  0.9961

  	
   

  	
  0.9854

  	
   

  
	
  9S

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  	
   

  
	
  9T

  	
   

  	
  0.9800

  	
   

  	
  0.9752

  	
   

  
	
  9U

  	
   

  	
  0.9791

  	
   

  	
  0.9788

  	
   

  
	
  9W

  	
   

  	
  0.9215

  	
   

  	
  0.9552

  	
   

  
	
  9X

  	
   

  	
  0.8836

  	
   

  	
  0.9745

  	
   

  
	
  9Y

  	
   

  	
  1.0449

  	
   

  	
  0.9597

  	
   

  

 

46

 

	
  IP

  	
   

  	
  1.0284

  	
   

  	
  0.9818

  	
   

  
	
  7Y

  	
   

  	
  1.0371

  	
   

  	
  0.9863

  	
   

  

 

A.4 Benefit Plan Factors for PPG Capitation and Hospital
Capitation/Shared Risk Budgets Effective July 1, 1998

 

	
  Small Group HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.7696

  	
   

  	
  0.7841

  	
   

  
	
  C5

  	
   

  	
  0.6881

  	
   

  	
  0.7728

  	
   

  
	
  Q1

  	
   

  	
  0.9862

  	
   

  	
  0.9700

  	
   

  
	
  Q2

  	
   

  	
  0.9282

  	
   

  	
  0.9324

  	
   

  
	
  Q3

  	
   

  	
  0.8783

  	
   

  	
  0.8711

  	
   

  
	
  Q4

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q5

  	
   

  	
  1.0165

  	
   

  	
  1.0212

  	
   

  
	
  Q6

  	
   

  	
  0.9088

  	
   

  	
  1.0059

  	
   

  
	
  Q7

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q8

  	
   

  	
  0.9282

  	
   

  	
  0.9700

  	
   

  
	
  QT

  	
   

  	
  0.7766

  	
   

  	
  0.7825

  	
   

  
	
  QU

  	
   

  	
  0.6991

  	
   

  	
  0.7696

  	
   

  
	
  QV

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QW

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QX

  	
   

  	
  0.7261

  	
   

  	
  0.7823

  	
   

  
	
  QY

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  QZ

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  V1

  	
   

  	
  1.0111

  	
   

  	
  0.9926

  	
   

  
	
  V2

  	
   

  	
  0.9421

  	
   

  	
  0.9829

  	
   

  
	
  V3

  	
   

  	
  0.8417

  	
   

  	
  0.9762

  	
   

  

 

	
  Individual BMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

	
  Medicare Supplement HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare
  Conversion Plan J

  	
   

  	
  1.2513

  	
   

  
	
  Medicare COB $0
  Copay

  	
   

  	
  1.1627

  	
   

  
	
  Medicare COB $5
  and up Copay

  	
   

  	
  0.6580

  	
   

  

 

	
  Medicare Supplement POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1627

  	
   

  
	
  POS Medicare COB $5 and up

  Copay

  	
   

  	
  0.6580

  	
   

  

 

47

 

 

A.5 Benefit Plan Factors for PPG
Capitation and Hospital Capitation/Shared Risk Budgets Effective

September
1, 1998

 

	
  Standard HMO

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0595

  	
   

  	
  0.9673

  	
   

  
	
  A1

  	
   

  	
  1.0628

  	
   

  	
  0.9725

  	
   

  
	
  A2

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A3

  	
   

  	
  1.0619

  	
   

  	
  0.9810

  	
   

  
	
  A4

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A5

  	
   

  	
  1.0628

  	
   

  	
  0.9752

  	
   

  
	
  A6

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  A7

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  A8

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  A9

  	
   

  	
  1.0257

  	
   

  	
  1.0076

  	
   

  
	
  HB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  BB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  B1

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B2

  	
   

  	
  0.9198

  	
   

  	
  0.8252

  	
   

  
	
  B3

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B4

  	
   

  	
  0.9198

  	
   

  	
  0.8460

  	
   

  
	
  B5

  	
   

  	
  0.9198

  	
   

  	
  0.8357

  	
   

  
	
  B6

  	
   

  	
  1.0047

  	
   

  	
  0.8758

  	
   

  
	
  B7

  	
   

  	
  0.9743

  	
   

  	
  1.0085

  	
   

  
	
  B8

  	
   

  	
  0.9644

  	
   

  	
  0.9941

  	
   

  
	
  B9

  	
   

  	
  0.9690

  	
   

  	
  1.0076

  	
   

  
	
  HC

  	
   

  	
  1.0639

  	
   

  	
  0.9919

  	
   

  
	
  C1

  	
   

  	
  1.0613

  	
   

  	
  0.9919

  	
   

  
	
  C2

  	
   

  	
  1.0668

  	
   

  	
  1.0032

  	
   

  
	
  C3

  	
   

  	
  1.0066

  	
   

  	
  0.9919

  	
   

  
	
  C6

  	
   

  	
  1.0162

  	
   

  	
  1.0076

  	
   

  
	
  C7

  	
   

  	
  1.0639

  	
   

  	
  1.0022

  	
   

  
	
  C8

  	
   

  	
  0.9463

  	
   

  	
  0.9695

  	
   

  
	
  C9

  	
   

  	
  0.9243

  	
   

  	
  1.0076

  	
   

  
	
  HD

  	
   

  	
  1.0807

  	
   

  	
  1.0031

  	
   

  
	
  D1

  	
   

  	
  1.0613

  	
   

  	
  1.0022

  	
   

  
	
  D2

  	
   

  	
  1.0182

  	
   

  	
  1.0041

  	
   

  
	
  D3

  	
   

  	
  0.9327

  	
   

  	
  0.8259

  	
   

  
	
  D4

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  D5

  	
   

  	
  0.9599

  	
   

  	
  0.9776

  	
   

  
	
  D6

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  D7

  	
   

  	
  0.9897

  	
   

  	
  1.0074

  	
   

  
	
  D8

  	
   

  	
  1.0189

  	
   

  	
  1.0056

  	
   

  
	
  D9

  	
   

  	
  1.0319

  	
   

  	
  1.0076

  	
   

  
	
  HE

  	
   

  	
  1.0286

  	
   

  	
  1.0105

  	
   

  
	
  E1

  	
   

  	
  1.0137

  	
   

  	
  0.9737

  	
   

  
	
  E2

  	
   

  	
  0.9836

  	
   

  	
  1.0050

  	
   

  
	
  E3

  	
   

  	
  1.0064

  	
   

  	
  0.9776

  	
   

  
	
  E4

  	
   

  	
  0.9584

  	
   

  	
  0.9706

  	
   

  
	
  E5

  	
   

  	
  1.0403

  	
   

  	
  1.0037

  	
   

  
	
  E6

  	
   

  	
  0.9656

  	
   

  	
  0.9737

  	
   

  
	
  E7

  	
   

  	
  0.9905

  	
   

  	
  1.0037

  	
   

  
	
  E8

  	
   

  	
  1.0180

  	
   

  	
  0.9985

  	
   

  
	
  E9

  	
   

  	
  0.9690

  	
   

  	
  0.9801

  	
   

  
	
  EA

  	
   

  	
  0.9755

  	
   

  	
  1.0033

  	
   

  
	
  EB

  	
   

  	
  0.9023

  	
   

  	
  0.8278

  	
   

  
	
  EC

  	
   

  	
  0.9604

  	
   

  	
  1.0076

  	
   

  
	
  ED

  	
   

  	
  1.0061

  	
   

  	
  0.9805

  	
   

  
	
  EE

  	
   

  	
  0.9951

  	
   

  	
  0.9793

  	
   

  
	
  EF

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EG

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EH

  	
   

  	
  0.9585

  	
   

  	
  1.0018

  	
   

  
	
  EI

  	
   

  	
  0.9966

  	
   

  	
  0.9805

  	
   

  
	
  EJ

  	
   

  	
  1.0329

  	
   

  	
  1.0118

  	
   

  
	
  EK

  	
   

  	
  0.9310

  	
   

  	
  1.0050

  	
   

  
	
  EL

  	
   

  	
  1.0481

  	
   

  	
  0.9786

  	
   

  
	
  EM

  	
   

  	
  0.9714

  	
   

  	
  1.0135

  	
   

  
	
  EN

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  
	
  EO

  	
   

  	
  0.9727

  	
   

  	
  0.9633

  	
   

  
	
  EP

  	
   

  	
  0.9486

  	
   

  	
  0.9777

  	
   

  
	
  EQ

  	
   

  	
  0.9740

  	
   

  	
  1.0035

  	
   

  
	
  ES

  	
   

  	
  0.9796

  	
   

  	
  1.0076

  	
   

  
	
  HF

  	
   

  	
  0.9682

  	
   

  	
  0.9875

  	
   

  
	
  F1

  	
   

  	
  1.0230

  	
   

  	
  0.9893

  	
   

  
	
  F2

  	
   

  	
  1.0084

  	
   

  	
  0.9737

  	
   

  
	
  F3

  	
   

  	
  1.0071

  	
   

  	
  0.9776

  	
   

  
	
  F4

  	
   

  	
  0.9731

  	
   

  	
  1.0074

  	
   

  
	
  F5

  	
   

  	
  1.0087

  	
   

  	
  0.9780

  	
   

  
	
  F6

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  F7

  	
   

  	
  1.0804

  	
   

  	
  0.9903

  	
   

  
	
  F8

  	
   

  	
  0.8346

  	
   

  	
  0.8083

  	
   

  
	
  F9

  	
   

  	
  1.0350

  	
   

  	
  1.0037

  	
   

  
	
  FA

  	
   

  	
  1.0203

  	
   

  	
  1.0008

  	
   

  
	
  FB

  	
   

  	
  1.0213

  	
   

  	
  1.0145

  	
   

  
	
  FC

  	
   

  	
  1.0234

  	
   

  	
  1.0039

  	
   

  
	
  FD

  	
   

  	
  1.0241

  	
   

  	
  1.0023

  	
   

  
	
  FE

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FF

  	
   

  	
  0.9709

  	
   

  	
  1.0062

  	
   

  
	
  FG

  	
   

  	
  0.9694

  	
   

  	
  0.9858

  	
   

  
	
  FH

  	
   

  	
  0.9708

  	
   

  	
  1.0008

  	
   

  
	
  FI

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FJ

  	
   

  	
  0.9260

  	
   

  	
  1.0008

  	
   

  
	
  FK

  	
   

  	
  0.9727

  	
   

  	
  0.9581

  	
   

  
	
  FL

  	
   

  	
  0.9260

  	
   

  	
  0.9633

  	
   

  
	
  HG

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  G1

  	
   

  	
  0.9566

  	
   

  	
  0.9673

  	
   

  
	
  G2

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  G3

  	
   

  	
  1.0080

  	
   

  	
  0.9776

  	
   

  
	
  G4

  	
   

  	
  0.9566

  	
   

  	
  0.9776

  	
   

  
	
  G5

  	
   

  	
  0.9095

  	
   

  	
  0.9671

  	
   

  
	
  G6

  	
   

  	
  1.0231

  	
   

  	
  0.9967

  	
   

  
	
  G9

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  I3

  	
   

  	
  0.9909

  	
   

  	
  1.0106

  	
   

  
	
  I4

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  I5

  	
   

  	
  0.9677

  	
   

  	
  1.0044

  	
   

  
	
  I6

  	
   

  	
  1.0338

  	
   

  	
  0.9745

  	
   

  
	
  I7

  	
   

  	
  1.0022

  	
   

  	
  1.0076

  	
   

  
	
  I8

  	
   

  	
  0.9746

  	
   

  	
  0.9916

  	
   

  
	
  I9

  	
   

  	
  0.9851

  	
   

  	
  1.0037

  	
   

  
	
  J3

  	
   

  	
  1.0165

  	
   

  	
  0.9849

  	
   

  
	
  J4

  	
   

  	
  1.0108

  	
   

  	
  0.9849

  	
   

  
	
  J5

  	
   

  	
  1.0071

  	
   

  	
  0.9778

  	
   

  
	
  J6

  	
   

  	
  0.9714

  	
   

  	
  0.9783

  	
   

  
	
  J7

  	
   

  	
  0.9756

  	
   

  	
  1.0085

  	
   

  
	
  J8

  	
   

  	
  0.9666

  	
   

  	
  0.9839

  	
   

  
	
  J9

  	
   

  	
  1.1169

  	
   

  	
  1.0283

  	
   

  
	
  HK

  	
   

  	
  1.0784

  	
   

  	
  1.0076

  	
   

  
	
  K1

  	
   

  	
  1.0236

  	
   

  	
  1.0076

  	
   

  
	
  K2

  	
   

  	
  0.9663

  	
   

  	
  0.9801

  	
   

  
	
  K3

  	
   

  	
  1.0255

  	
   

  	
  1.0080

  	
   

  
	
  K4

  	
   

  	
  1.0817

  	
   

  	
  1.0076

  	
   

  
	
  K6

  	
   

  	
  0.9782

  	
   

  	
  1.0054

  	
   

  
	
  K7

  	
   

  	
  0.9845

  	
   

  	
  0.9966

  	
   

  
	
  K8

  	
   

  	
  0.9749

  	
   

  	
  0.9844

  	
   

  
	
  K9

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  KI

  	
   

  	
  0.9727

  	
   

  	
  1.0010

  	
   

  
	
  KJ

  	
   

  	
  1.0203

  	
   

  	
  1.0010

  	
   

  
	
  KK

  	
   

  	
  0.9727

  	
   

  	
  0.9583

  	
   

  
	
  KL

  	
   

  	
  0.9763

  	
   

  	
  0.9864

  	
   

  
	
  KM

  	
   

  	
  0.9260

  	
   

  	
  1.0010

  	
   

  
	
  L1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  L2

  	
   

  	
  0.9599

  	
   

  	
  0.9777

  	
   

  
	
  L3

  	
   

  	
  0.9566

  	
   

  	
  0.9777

  	
   

  
	
  L4

  	
   

  	
  0.9128

  	
   

  	
  0.9774

  	
   

  
	
  L5

  	
   

  	
  0.9695

  	
   

  	
  0.9776

  	
   

  
	
  L6

  	
   

  	
  1.0177

  	
   

  	
  0.9776

  	
   

  
	
  L7

  	
   

  	
  1.0424

  	
   

  	
  0.9756

  	
   

  
	
  L8

  	
   

  	
  1.0243

  	
   

  	
  0.9673

  	
   

  
	
  L9

  	
   

  	
  0.9755

  	
   

  	
  1.0076

  	
   

  
	
  HM

  	
   

  	
  1.1360

  	
   

  	
  1.0225

  	
   

  
	
  M1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  M2

  	
   

  	
  1.1361

  	
   

  	
  1.0225

  	
   

  
	
  M3

  	
   

  	
  1.0195

  	
   

  	
  1.0108

  	
   

  
	
  M4

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  M5

  	
   

  	
  1.0124

  	
   

  	
  1.0054

  	
   

  
	
  M6

  	
   

  	
  0.9749

  	
   

  	
  0.9175

  	
   

  
	
  M7

  	
   

  	
  0.9671

  	
   

  	
  0.8754

  	
   

  
	
  M8

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  M9

  	
   

  	
  1.0743

  	
   

  	
  1.0078

  	
   

  
	
  HN

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  N1

  	
   

  	
  1.0246

  	
   

  	
  1.0076

  	
   

  
	
  N2

  	
   

  	
  1.0211

  	
   

  	
  1.0076

  	
   

  
	
  N3

  	
   

  	
  1.0230

  	
   

  	
  1.0076

  	
   

  
	
  N4

  	
   

  	
  1.0066

  	
   

  	
  1.0022

  	
   

  
	
  N5

  	
   

  	
  1.0082

  	
   

  	
  1.0022

  	
   

  
	
  N6

  	
   

  	
  1.0099

  	
   

  	
  1.0022

  	
   

  
	
  N7

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  N8

  	
   

  	
  1.0294

  	
   

  	
  1.0033

  	
   

  
	
  N9

  	
   

  	
  1.0207

  	
   

  	
  0.9916

  	
   

  
	
  HO

  	
   

  	
  0.9714

  	
   

  	
  1.0076

  	
   

  
	
  O1

  	
   

  	
  0.9747

  	
   

  	
  1.0076

  	
   

  
	
  O2

  	
   

  	
  0.9714

  	
   

  	
  0.9676

  	
   

  
	
  O3

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  O4

  	
   

  	
  1.0195

  	
   

  	
  0.9676

  	
   

  
	
  O5

  	
   

  	
  0.9584

  	
   

  	
  0.9864

  	
   

  
	
  O6

  	
   

  	
  1.0327

  	
   

  	
  1.0149

  	
   

  
	
  O7

  	
   

  	
  1.0317

  	
   

  	
  1.0033

  	
   

  
	
  O8

  	
   

  	
  1.0050

  	
   

  	
  0.9733

  	
   

  
	
  O9

  	
   

  	
  0.9822

  	
   

  	
  1.0076

  	
   

  
	
  HP

  	
   

  	
  1.0049

  	
   

  	
  0.9919

  	
   

  
	
  P1

  	
   

  	
  1.0121

  	
   

  	
  0.9949

  	
   

  
	
  P2

  	
   

  	
  0.9030

  	
   

  	
  0.9396

  	
   

  
	
  P3

  	
   

  	
  0.9649

  	
   

  	
  0.9776

  	
   

  
	
  P4

  	
   

  	
  1.0195

  	
   

  	
  1.0186

  	
   

  
	
  P5

  	
   

  	
  0.9095

  	
   

  	
  0.9731

  	
   

  
	
  P6

  	
   

  	
  1.0823

  	
   

  	
  0.9838

  	
   

  
	
  P7

  	
   

  	
  1.0273

  	
   

  	
  1.0076

  	
   

  
	
  P8

  	
   

  	
  0.9614

  	
   

  	
  0.9828

  	
   

  
	
  P9

  	
   

  	
  1.0165

  	
   

  	
  0.9833

  	
   

  
	
  HR

  	
   

  	
  1.1304

  	
   

  	
  1.0233

  	
   

  
	
  R1

  	
   

  	
  1.0121

  	
   

  	
  1.0052

  	
   

  
	
  R2

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  R3

  	
   

  	
  0.9909

  	
   

  	
  1.0076

  	
   

  
	
  R4

  	
   

  	
  0.9003

  	
   

  	
  0.9029

  	
   

  
	
  R5

  	
   

  	
  1.0047

  	
   

  	
  0.9777

  	
   

  
	
  R6

  	
   

  	
  1.0047

  	
   

  	
  0.9399

  	
   

  
	
  R7

  	
   

  	
  0.8997

  	
   

  	
  0.9025

  	
   

  
	
  R8

  	
   

  	
  0.9640

  	
   

  	
  1.0052

  	
   

  
	
  R9

  	
   

  	
  0.9198

  	
   

  	
  0.8412

  	
   

  
	
  HS

  	
   

  	
  1.0817

  	
   

  	
  1.0022

  	
   

  
	
  S1

  	
   

  	
  1.0973

  	
   

  	
  1.0283

  	
   

  
	
  S2

  	
   

  	
  1.0259

  	
   

  	
  1.0091

  	
   

  
	
  S3

  	
   

  	
  1.0485

  	
   

  	
  1.0156

  	
   

  
	
  S4

  	
   

  	
  0.9629

  	
   

  	
  0.9295

  	
   

  
	
  S5

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  S6

  	
   

  	
  1.0658

  	
   

  	
  1.0022

  	
   

  
	
  S7

  	
   

  	
  1.0085

  	
   

  	
  1.0000

  	
   

  
	
  S8

  	
   

  	
  1.0080

  	
   

  	
  0.9777

  	
   

  
	
  S9

  	
   

  	
  1.0080

  	
   

  	
  0.9399

  	
   

  
	
  HT

  	
   

  	
  1.0743

  	
   

  	
  1.0076

  	
   

  
	
  T1

  	
   

  	
  1.0759

  	
   

  	
  1.0076

  	
   

  
	
  T2

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  T3

  	
   

  	
  1.0187

  	
   

  	
  0.9985

  	
   

  
	
  T4

  	
   

  	
  1.0156

  	
   

  	
  0.9985

  	
   

  
	
  T5

  	
   

  	
  1.0212

  	
   

  	
  1.0078

  	
   

  
	
  T7

  	
   

  	
  0.9229

  	
   

  	
  0.9673

  	
   

  
	
  T8

  	
   

  	
  1.0086

  	
   

  	
  0.9833

  	
   

  
	
  T9

  	
   

  	
  1.0245

  	
   

  	
  1.0079

  	
   

  
	
  TA

  	
   

  	
  0.9966

  	
   

  	
  0.9894

  	
   

  
	
  TB

  	
   

  	
  0.9929

  	
   

  	
  0.9778

  	
   

  
	
  TC

  	
   

  	
  1.0104

  	
   

  	
  0.9780

  	
   

  
	
  HU

  	
   

  	
  1.0443

  	
   

  	
  1.0165

  	
   

  
	
  U1

  	
   

  	
  1.0260

  	
   

  	
  0.9805

  	
   

  
	
  U2

  	
   

  	
  0.9599

  	
   

  	
  0.9399

  	
   

  
	
  U3

  	
   

  	
  0.9599

  	
   

  	
  0.9673

  	
   

  
	
  U4

  	
   

  	
  1.0778

  	
   

  	
  1.0022

  	
   

  
	
  U5

  	
   

  	
  0.9714

  	
   

  	
  1.0106

  	
   

  
	
  U6

  	
   

  	
  0.9750

  	
   

  	
  1.0074

  	
   

  
	
  U7

  	
   

  	
  0.9731

  	
   

  	
  1.0085

  	
   

  
	
  U8

  	
   

  	
  1.0263

  	
   

  	
  1.0080

  	
   

  
	
  U9

  	
   

  	
  1.0210

  	
   

  	
  1.0141

  	
   

  
	
  HV

  	
   

  	
  1.0907

  	
   

  	
  1.0107

  	
   

  
	
  HW

  	
   

  	
  1.0524

  	
   

  	
  0.9681

  	
   

  
	
  W1

  	
   

  	
  1.0542

  	
   

  	
  0.9681

  	
   

  
	
  W2

  	
   

  	
  1.0067

  	
   

  	
  1.0000

  	
   

  

 

48

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W3

  	
   

  	
  0.9715

  	
   

  	
  1.0128

  	
   

  
	
  W4

  	
   

  	
  0.9287

  	
   

  	
  0.9680

  	
   

  
	
  W5

  	
   

  	
  1.0266

  	
   

  	
  1.0095

  	
   

  
	
  W6

  	
   

  	
  0.9649

  	
   

  	
  0.9806

  	
   

  
	
  W7

  	
   

  	
  0.9839

  	
   

  	
  0.9941

  	
   

  
	
  W8

  	
   

  	
  1.0162

  	
   

  	
  0.9776

  	
   

  
	
  W9

  	
   

  	
  0.9112

  	
   

  	
  0.9774

  	
   

  
	
  HX

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  X1

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  X2

  	
   

  	
  0.9533

  	
   

  	
  0.9295

  	
   

  
	
  X3

  	
   

  	
  0.9500

  	
   

  	
  0.9398

  	
   

  
	
  X4

  	
   

  	
  0.9821

  	
   

  	
  0.9058

  	
   

  
	
  X5

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  X6

  	
   

  	
  1.0240

  	
   

  	
  1.0076

  	
   

  
	
  X7

  	
   

  	
  0.9095

  	
   

  	
  0.9774

  	
   

  
	
  X8

  	
   

  	
  1.0043

  	
   

  	
  0.9779

  	
   

  
	
  X9

  	
   

  	
  0.9095

  	
   

  	
  0.9627

  	
   

  
	
  HY

  	
   

  	
  0.8997

  	
   

  	
  0.8921

  	
   

  
	
  Y1

  	
   

  	
  0.9145

  	
   

  	
  0.9280

  	
   

  
	
  Y2

  	
   

  	
  0.8997

  	
   

  	
  0.9293

  	
   

  
	
  Y3

  	
   

  	
  0.9145

  	
   

  	
  0.9674

  	
   

  
	
  Y4

  	
   

  	
  0.9178

  	
   

  	
  0.9674

  	
   

  
	
  Y5

  	
   

  	
  0.9714

  	
   

  	
  0.9282

  	
   

  
	
  Y6

  	
   

  	
  0.8997

  	
   

  	
  0.9396

  	
   

  
	
  Y7

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  Y8

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  Y9

  	
   

  	
  0.9985

  	
   

  	
  1.0000

  	
   

  
	
  ZA

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZB

  	
   

  	
  0.9934

  	
   

  	
  0.8655

  	
   

  
	
  ZC

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZG

  	
   

  	
  0.9934

  	
   

  	
  0.9673

  	
   

  
	
  ZK

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  
	
  ZM

  	
   

  	
  1.0941

  	
   

  	
  0.9903

  	
   

  
	
  ZN

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  ZO

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  ZS

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  
	
  ZZ

  	
   

  	
  0.9870

  	
   

  	
  0.9780

  	
   

  
	
  1A

  	
   

  	
  0.9803

  	
   

  	
  0.9966

  	
   

  
	
  1B

  	
   

  	
  1.0012

  	
   

  	
  1.0012

  	
   

  
	
  1C

  	
   

  	
  1.0311

  	
   

  	
  1.0012

  	
   

  
	
  1D

  	
   

  	
  0.9805

  	
   

  	
  1.0064

  	
   

  
	
  1E

  	
   

  	
  1.0186

  	
   

  	
  1.0056

  	
   

  
	
  1F

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  
	
  1G

  	
   

  	
  1.0149

  	
   

  	
  1.0004

  	
   

  
	
  1H

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  
	
  1J

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  
	
  1K

  	
   

  	
  1.0138

  	
   

  	
  1.0056

  	
   

  
	
  1L

  	
   

  	
  1.0292

  	
   

  	
  1.0021

  	
   

  
	
  1M

  	
   

  	
  1.0152

  	
   

  	
  0.9854

  	
   

  
	
  1N

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  
	
  1P

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  
	
  1Q

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  
	
  1R

  	
   

  	
  1.0863

  	
   

  	
  1.0064

  	
   

  
	
  1S

  	
   

  	
  0.9661

  	
   

  	
  0.9820

  	
   

  
	
  1T

  	
   

  	
  0.9629

  	
   

  	
  0.9820

  	
   

  
	
  1U

  	
   

  	
  0.9208

  	
   

  	
  0.9617

  	
   

  
	
  1V

  	
   

  	
  1.0337

  	
   

  	
  0.9678

  	
   

  
	
  1W

  	
   

  	
  0.9661

  	
   

  	
  1.0012

  	
   

  
	
  1X

  	
   

  	
  1.0187

  	
   

  	
  1.0012

  	
   

  
	
  1Y

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  
	
  1Z

  	
   

  	
  1.0119

  	
   

  	
  0.9582

  	
   

  
	
  2A

  	
   

  	
  0.9661

  	
   

  	
  0.9228

  	
   

  
	
  2B

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  
	
  2C

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  
	
  2D

  	
   

  	
  0.9181

  	
   

  	
  0.9228

  	
   

  
	
  2E

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  
	
  2F

  	
   

  	
  1.0091

  	
   

  	
  1.0000

  	
   

  
	
  6A

  	
   

  	
  1.0514

  	
   

  	
  0.9725

  	
   

  
	
  6G

  	
   

  	
  0.9452

  	
   

  	
  0.9673

  	
   

  
	
  6H

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  6R

  	
   

  	
  0.9485

  	
   

  	
  0.9776

  	
   

  
	
  6S

  	
   

  	
  0.9452

  	
   

  	
  0.9398

  	
   

  
	
  6T

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  6V

  	
   

  	
  0.9452

  	
   

  	
  0.9625

  	
   

  
	
  6W

  	
   

  	
  0.9851

  	
   

  	
  0.9819

  	
   

  
	
  6Z

  	
   

  	
  0.9524

  	
   

  	
  0.8651

  	
   

  
	
  7C

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  7E

  	
   

  	
  0.9987

  	
   

  	
  0.9776

  	
   

  
	
  7F

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  
	
  7G

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  
	
  7H

  	
   

  	
  0.9452

  	
   

  	
  0.9319

  	
   

  
	
  7I

  	
   

  	
  0.9988

  	
   

  	
  0.9776

  	
   

  
	
  7J

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  
	
  7K

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7L

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  
	
  7M

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7N

  	
   

  	
  0.9836

  	
   

  	
  0.9779

  	
   

  
	
  7O

  	
   

  	
  0.8981

  	
   

  	
  0.9774

  	
   

  
	
  7Q

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  7R

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7S

  	
   

  	
  0.8884

  	
   

  	
  0.9396

  	
   

  
	
  7T

  	
   

  	
  0.9452

  	
   

  	
  0.9474

  	
   

  
	
  7U

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  7V

  	
   

  	
  0.9934

  	
   

  	
  0.9399

  	
   

  
	
  7W

  	
   

  	
  0.9452

  	
   

  	
  0.9399

  	
   

  
	
  7X

  	
   

  	
  1.0942

  	
   

  	
  0.9903

  	
   

  
	
  7Y

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  
	
  7Z

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  9A

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  9B

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9C

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9E

  	
   

  	
  0.9908

  	
   

  	
  0.9780

  	
   

  
	
  9F

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  
	
  9G

  	
   

  	
  1.0012

  	
   

  	
  0.9776

  	
   

  
	
  9H

  	
   

  	
  0.9967

  	
   

  	
  0.9805

  	
   

  
	
  9I

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  9J

  	
   

  	
  0.9084

  	
   

  	
  0.8363

  	
   

  
	
  9M

  	
   

  	
  0.9967

  	
   

  	
  0.9777

  	
   

  
	
  9N

  	
   

  	
  0.9485

  	
   

  	
  0.9398

  	
   

  
	
  9O

  	
   

  	
  0.9560

  	
   

  	
  0.9776

  	
   

  
	
  9P

  	
   

  	
  0.9876

  	
   

  	
  0.9795

  	
   

  
	
  9Q

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9R

  	
   

  	
  0.9970

  	
   

  	
  0.9849

  	
   

  
	
  9S

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9T

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  
	
  9U

  	
   

  	
  0.9866

  	
   

  	
  0.9811

  	
   

  
	
  9W

  	
   

  	
  0.9460

  	
   

  	
  0.9592

  	
   

  
	
  9X

  	
   

  	
  0.9014

  	
   

  	
  0.9776

  	
   

  
	
  9Y

  	
   

  	
  1.0327

  	
   

  	
  0.9334

  	
   

  

 

49

 

A.5
Benefit Plan Factors for PPG Capitation and Hospital Capitation/Shared Risk
Budgets Effective

September
1, 1998

 

	
  Small Group HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.9958

  	
   

  	
  1.0075

  	
   

  
	
  C5

  	
   

  	
  0.9016

  	
   

  	
  0.9893

  	
   

  
	
  Q1

  	
   

  	
  0.9877

  	
   

  	
  0.9749

  	
   

  
	
  Q2

  	
   

  	
  0.9350

  	
   

  	
  0.9367

  	
   

  
	
  Q3

  	
   

  	
  0.8834

  	
   

  	
  0.8703

  	
   

  
	
  Q4

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q5

  	
   

  	
  0.9958

  	
   

  	
  1.0103

  	
   

  
	
  Q6

  	
   

  	
  0.9016

  	
   

  	
  0.9921

  	
   

  
	
  Q7

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q8

  	
   

  	
  0.9350

  	
   

  	
  0.9747

  	
   

  
	
  QT

  	
   

  	
  0.9867

  	
   

  	
  1.0057

  	
   

  
	
  QU

  	
   

  	
  0.8977

  	
   

  	
  0.9898

  	
   

  
	
  QV

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QW

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QX

  	
   

  	
  0.9476

  	
   

  	
  0.9927

  	
   

  
	
  QY

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  QZ

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  V1

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  

 

	
  Individual HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

	
  Medicare Supplement HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare
  Conversion Plan J

  	
   

  	
  1.2018

  	
   

  
	
  Medicare COB $0
  Copay

  	
   

  	
  1.1169

  	
   

  
	
  Medicare COB $5
  and up

  Copay

  	
   

  	
  0.6326

  	
   

  

 

	
  Medicare Supplement POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB
  $0 Copay

  	
   

  	
  1.1169

  	
   

  
	
  POS Medicare COB
  $5 and up

  Copay

  	
   

  	
  0.6326

  	
   

  

 

50

 

A.6
Benefit Plan Factors for PPG Standard POS Capitation Effective January 1, 1998

 

	
  Standard POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9217

  	
   

  
	
  AD

  	
   

  	
  0.9217

  	
   

  
	
  AG

  	
   

  	
  0.8723

  	
   

  
	
  AH

  	
   

  	
  0.9217

  	
   

  
	
  AJ

  	
   

  	
  0.8723

  	
   

  
	
  AW

  	
   

  	
  0.9217

  	
   

  
	
  BA

  	
   

  	
  0.9357

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  
	
  BD

  	
   

  	
  0.9334

  	
   

  
	
  BE

  	
   

  	
  0.9459

  	
   

  
	
  BF

  	
   

  	
  0.8723

  	
   

  
	
  BG

  	
   

  	
  0.8965

  	
   

  
	
  BH

  	
   

  	
  0.9334

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  
	
  BK

  	
   

  	
  1.0184

  	
   

  
	
  BL

  	
   

  	
  0.9942

  	
   

  
	
  BM

  	
   

  	
  1.0036

  	
   

  
	
  BN

  	
   

  	
  0.8965

  	
   

  
	
  BO

  	
   

  	
  0.9629

  	
   

  
	
  BP

  	
   

  	
  0.8965

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  
	
  BR

  	
   

  	
  0.9820

  	
   

  
	
  BS

  	
   

  	
  0.9348

  	
   

  
	
  BT

  	
   

  	
  0.8854

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  
	
  BV

  	
   

  	
  0.9030

  	
   

  
	
  BW

  	
   

  	
  0.9655

  	
   

  
	
  BX

  	
   

  	
  0.9220

  	
   

  
	
  BY

  	
   

  	
  0.9612

  	
   

  
	
  BZ

  	
   

  	
  0.9553

  	
   

  
	
  CA

  	
   

  	
  1.0004

  	
   

  
	
  CB

  	
   

  	
  1.0121

  	
   

  
	
  CC

  	
   

  	
  0.9763

  	
   

  
	
  CD

  	
   

  	
  0.9879

  	
   

  
	
  CE

  	
   

  	
  0.9425

  	
   

  
	
  CF

  	
   

  	
  0.9541

  	
   

  
	
  CG

  	
   

  	
  0.9183

  	
   

  
	
  CH

  	
   

  	
  0.9300

  	
   

  
	
  CI

  	
   

  	
  0.8916

  	
   

  
	
  CJ

  	
   

  	
  0.9033

  	
   

  
	
  CK

  	
   

  	
  0.8675

  	
   

  
	
  CL

  	
   

  	
  0.8791

  	
   

  
	
  CM

  	
   

  	
  0.8499

  	
   

  
	
  CN

  	
   

  	
  0.8615

  	
   

  
	
  CO

  	
   

  	
  0.8257

  	
   

  
	
  CP

  	
   

  	
  0.8374

  	
   

  
	
  DA

  	
   

  	
  0.9459

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  
	
  DC

  	
   

  	
  0.9459

  	
   

  
	
  DD

  	
   

  	
  0.8965

  	
   

  
	
  DE

  	
   

  	
  0.9490

  	
   

  
	
  DF

  	
   

  	
  0.9490

  	
   

  
	
  DG

  	
   

  	
  0.8996

  	
   

  
	
  DH

  	
   

  	
  0.9459

  	
   

  
	
  DI

  	
   

  	
  0.9459

  	
   

  
	
  DJ

  	
   

  	
  0.8965

  	
   

  
	
  DK

  	
   

  	
  0.8965

  	
   

  
	
  DL

  	
   

  	
  0.9490

  	
   

  
	
  DM

  	
   

  	
  0.8965

  	
   

  
	
  DN

  	
   

  	
  0.8541

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  
	
  DP

  	
   

  	
  0.9897

  	
   

  
	
  DQ

  	
   

  	
  0.9729

  	
   

  
	
  DR

  	
   

  	
  0.9334

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  
	
  DT

  	
   

  	
  0.9081

  	
   

  
	
  DU

  	
   

  	
  0.8840

  	
   

  
	
  DV

  	
   

  	
  0.9851

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  
	
  DX

  	
   

  	
  0.9220

  	
   

  
	
  DY

  	
   

  	
  0.9459

  	
   

  
	
  DZ

  	
   

  	
  1.0024

  	
   

  
	
  FN

  	
   

  	
  0.9928

  	
   

  
	
  FO

  	
   

  	
  0.9928

  	
   

  
	
  FP

  	
   

  	
  0.9436

  	
   

  
	
  FQ

  	
   

  	
  0.9436

  	
   

  
	
  FR

  	
   

  	
  0.9902

  	
   

  
	
  FS

  	
   

  	
  0.9851

  	
   

  
	
  FT

  	
   

  	
  0.9843

  	
   

  
	
  FU

  	
   

  	
  0.9939

  	
   

  
	
  FV

  	
   

  	
  0.9825

  	
   

  
	
  FW

  	
   

  	
  0.9885

  	
   

  
	
  FX

  	
   

  	
  0.9806

  	
   

  
	
  FY

  	
   

  	
  0.9516

  	
   

  
	
  FZ

  	
   

  	
  0.9567

  	
   

  
	
  GA

  	
   

  	
  0.9334

  	
   

  
	
  GB

  	
   

  	
  0.8965

  	
   

  
	
  GK

  	
   

  	
  0.9459

  	
   

  
	
  KA

  	
   

  	
  0.9939

  	
   

  
	
  KB

  	
   

  	
  0.9610

  	
   

  
	
  KC

  	
   

  	
  1.0027

  	
   

  
	
  LA

  	
   

  	
  0.9487

  	
   

  
	
  LB

  	
   

  	
  0.9459

  	
   

  
	
  LC

  	
   

  	
  0.9459

  	
   

  
	
  LD

  	
   

  	
  0.9487

  	
   

  
	
  LE

  	
   

  	
  0.9487

  	
   

  
	
  LF

  	
   

  	
  0.9487

  	
   

  
	
  LG

  	
   

  	
  0.8993

  	
   

  
	
  LH

  	
   

  	
  0.9459

  	
   

  
	
  LI

  	
   

  	
  0.9487

  	
   

  
	
  LJ

  	
   

  	
  0.8993

  	
   

  
	
  LK

  	
   

  	
  0.8723

  	
   

  
	
  LL

  	
   

  	
  0.9459

  	
   

  
	
  LM

  	
   

  	
  0.9217

  	
   

  
	
  LN

  	
   

  	
  0.9487

  	
   

  
	
  LP

  	
   

  	
  0.9459

  	
   

  
	
  LQ

  	
   

  	
  0.8993

  	
   

  
	
  LR

  	
   

  	
  0.9487

  	
   

  
	
  LS

  	
   

  	
  0.8965

  	
   

  
	
  LT

  	
   

  	
  0.8572

  	
   

  
	
  LU

  	
   

  	
  0.8965

  	
   

  
	
  LV

  	
   

  	
  0.9487

  	
   

  
	
  LW

  	
   

  	
  0.9487

  	
   

  
	
  LX

  	
   

  	
  0.8965

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  
	
  LZ

  	
   

  	
  0.8541

  	
   

  
	
  NP

  	
   

  	
  0.9897

  	
   

  
	
  OA

  	
   

  	
  0.9234

  	
   

  
	
  OB

  	
   

  	
  0.9217

  	
   

  
	
  OC

  	
   

  	
  0.9217

  	
   

  
	
  OD

  	
   

  	
  0.9092

  	
   

  
	
  OE

  	
   

  	
  0.9036

  	
   

  
	
  OF

  	
   

  	
  0.9490

  	
   

  
	
  OG

  	
   

  	
  0.9655

  	
   

  
	
  OK

  	
   

  	
  0.8723

  	
   

  
	
  OL

  	
   

  	
  0.9217

  	
   

  
	
  OM

  	
   

  	
  0.9217

  	
   

  
	
  ON

  	
   

  	
  0.9217

  	
   

  
	
  OO

  	
   

  	
  0.9217

  	
   

  
	
  OP

  	
   

  	
  0.9217

  	
   

  
	
  OQ

  	
   

  	
  0.9217

  	
   

  
	
  OR

  	
   

  	
  0.9578

  	
   

  
	
  OS

  	
   

  	
  0.9217

  	
   

  
	
  OT

  	
   

  	
  1.0178

  	
   

  
	
  OU

  	
   

  	
  0.9575

  	
   

  
	
  OV

  	
   

  	
  0.9107

  	
   

  
	
  OW

  	
   

  	
  0.9217

  	
   

  
	
  OX

  	
   

  	
  0.9217

  	
   

  
	
  OY

  	
   

  	
  0.9217

  	
   

  
	
  OZ

  	
   

  	
  0.9217

  	
   

  
	
  PA

  	
   

  	
  0.9217

  	
   

  
	
  PB

  	
   

  	
  0.9067

  	
   

  
	
  PC

  	
   

  	
  0.9232

  	
   

  
	
  PD

  	
   

  	
  0.8737

  	
   

  
	
  PE

  	
   

  	
  0.9217

  	
   

  
	
  PF

  	
   

  	
  0.9914

  	
   

  
	
  PG

  	
   

  	
  1.0522

  	
   

  
	
  PH

  	
   

  	
  0.9612

  	
   

  
	
  PI

  	
   

  	
  0.9655

  	
   

  
	
  PJ

  	
   

  	
  0.9487

  	
   

  
	
  PK

  	
   

  	
  0.9459

  	
   

  
	
  PL

  	
   

  	
  0.9183

  	
   

  
	
  PM

  	
   

  	
  0.9334

  	
   

  
	
  PN

  	
   

  	
  0.9217

  	
   

  
	
  PO

  	
   

  	
  0.9334

  	
   

  
	
  PP

  	
   

  	
  1.0701

  	
   

  
	
  PQ

  	
   

  	
  0.9217

  	
   

  
	
  PR

  	
   

  	
  0.9334

  	
   

  
	
  PS

  	
   

  	
  1.0013

  	
   

  
	
  PT

  	
   

  	
  0.9183

  	
   

  
	
  PU

  	
   

  	
  0.9797

  	
   

  
	
  PV

  	
   

  	
  0.8979

  	
   

  
	
  PW

  	
   

  	
  1.0269

  	
   

  
	
  PX

  	
   

  	
  0.9490

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  
	
  PZ

  	
   

  	
  0.9095

  	
   

  
	
  XA

  	
   

  	
  0.9217

  	
   

  
	
  XB

  	
   

  	
  0.8371

  	
   

  
	
  XC

  	
   

  	
  0.9402

  	
   

  
	
  XD

  	
   

  	
  0.9459

  	
   

  
	
  XE

  	
   

  	
  0.9573

  	
   

  
	
  XF

  	
   

  	
  0.9246

  	
   

  
	
  XG

  	
   

  	
  1.1008

  	
   

  
	
  XI

  	
   

  	
  1.1008

  	
   

  
	
  XJ

  	
   

  	
  0.8743

  	
   

  
	
  XK

  	
   

  	
  0.9698

  	
   

  
	
  XL

  	
   

  	
  0.9962

  	
   

  
	
  XM

  	
   

  	
  0.9575

  	
   

  
	
  XN

  	
   

  	
  0.9220

  	
   

  
	
  XO

  	
   

  	
  0.8683

  	
   

  
	
  XP

  	
   

  	
  0.9740

  	
   

  
	
  XQ

  	
   

  	
  0.8746

  	
   

  
	
  XR

  	
   

  	
  0.8464

  	
   

  
	
  XS

  	
   

  	
  0.9408

  	
   

  
	
  XT

  	
   

  	
  0.9220

  	
   

  
	
  XU

  	
   

  	
  0.9220

  	
   

  
	
  XV

  	
   

  	
  0.9220

  	
   

  
	
  XW

  	
   

  	
  0.9220

  	
   

  
	
  XY

  	
   

  	
  0.9743

  	
   

  

 

51

 

A.6 Benefit Plan Factors for PPG
Small Group POS Capitation Effective January 1, 1998

 

	
  Small Group

  POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9857

  	
   

  
	
  QB

  	
   

  	
  0.9285

  	
   

  
	
  QC

  	
   

  	
  0.8447

  	
   

  

 

52

 

A.7 Benefit Plan Factors for PPG
Standard POS Capitation and Standard POS Shared Risk Budgets Effective July 1,
1998

 

	
  Standard POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9215

  	
   

  	
  0.9300

  	
   

  
	
  AD

  	
   

  	
  0.9215

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8714

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8714

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9355

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9330

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9457

  	
   

  	
  0.9489

  	
   

  
	
  BF

  	
   

  	
  0.8714

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.8956

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9330

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0192

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9947

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  1.0039

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.8956

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9662

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.8956

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9821

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9345

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.8843

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9025

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9653

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9218

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9552

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  1.0007

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  1.0126

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9765

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9881

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0.9423

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9538

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9178

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9296

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8907

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.9022

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8662

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8780

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8480

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8598

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8238

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8353

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9458

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.8961

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.8992

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9458

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.8961

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.8961

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9489

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.8961

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8535

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9730

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9332

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9078

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.8835

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9850

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9218

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  1.0038

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9961

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9961

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9447

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9447

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9915

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9864

  	
   

  	
  0.9254

  	
   

  
	
  FT

  	
   

  	
  0.9855

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9952

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9858

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9898

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9784

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9527

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9578

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9332

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.8961

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9457

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9952

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9609

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  1.0041

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9457

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9489

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9489

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.8987

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9489

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.8987

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8714

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9215

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9483

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9457

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.8987

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9489

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.8956

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8558

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.8956

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9486

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9489

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.8956

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8526

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  OA

  	
   

  	
  0.9232

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9215

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9085

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9028

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9492

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9653

  	
   

  	
  0.9138

  	
   

  
	
  OK

  	
   

  	
  0.8714

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9215

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9215

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OO

  	
   

  	
  0.9215

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OQ

  	
   

  	
  0.9215

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9575

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9215

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0238

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9572

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9100

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9215

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9215

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9215

  	
   

  	
  0.9313

  	
   

  
	
  PA

  	
   

  	
  0.9215

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9062

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9229

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8728

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9215

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9918

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0584

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9653

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9489

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9330

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9215

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9330

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0711

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9215

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9330

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  1.0016

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9800

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.8970

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0275

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9492

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9088

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9215

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8405

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9399

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9457

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9569

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9244

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.1022

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.1022

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8734

  	
   

  	
  0.8275

  	
   

  
	
  XK

  	
   

  	
  0.9699

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  1.0039

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9572

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9218

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8722

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9742

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8741

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8509

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9407

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9218

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9218

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9218

  	
   

  	
  0.9113

  	
   

  
	
  XW

  	
   

  	
  0.9218

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9744

  	
   

  	
  0.8502

  	
   

  

 

53

 

 

A.7
Benefit Plan Factors for PPG Small Group POS Capitation and Small Group POS
Shared Risk Budgets

Effective
July 1, 1998

 

	
  Small Group POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9862

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9282

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8430

  	
   

  	
  0.7381

  	
   

  

 

54

 

 

A.8
Benefit Plan Factors for PPG Standard POS Capitation and Standard POS Shared
Risk Budgets

Effective
September 1, 1998

 

	
  Standard POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  AD

  	
   

  	
  0.9452

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8981

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8981

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9480

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9485

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  BF

  	
   

  	
  0.8981

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9485

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9747

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9966

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  0.9934

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.9095

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9792

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9485

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.9014

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9747

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9271

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9452

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9590

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  0.9950

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  0.9983

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9837

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9870

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0.9432

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9465

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9318

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9351

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8924

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.8957

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8811

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8844

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8440

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8473

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8326

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8359

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.9095

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9714

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9795

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9892

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9485

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9747

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9128

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.9014

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9788

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  0.9886

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9832

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9832

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9347

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9347

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9808

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9621

  	
   

  	
  0.9454

  	
   

  
	
  FT

  	
   

  	
  0.9619

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9743

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9813

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9667

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9565

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9394

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9421

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9485

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9567

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9823

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9730

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  0.9850

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9566

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9714

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9714

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9714

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.9243

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8981

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9452

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9452

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9566

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.9243

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9714

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8658

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.9095

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9584

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9714

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9599

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  
	
  OA

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9128

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9112

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9714

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  
	
  OK

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9452

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9452

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OO

  	
   

  	
  0.9452

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OQ

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9460

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9452

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0098

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9526

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9124

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9452

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9452

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9452

  	
   

  	
  0.9313

  	
   

  
	
  PA

  	
   

  	
  0.9452

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9307

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9453

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9960

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0367

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9492

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9714

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9485

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9452

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9485

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0313

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9452

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9485

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  0.9934

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9933

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.9095

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0270

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9714

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9599

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9128

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8298

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9566

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9422

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.0793

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.0793

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8981

  	
   

  	
  0.8275

  	
   

  
	
  XK

  	
   

  	
  0.9782

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9452

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8564

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9819

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8981

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8493

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9681

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9452

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9452

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9452

  	
   

  	
  0.9113

  	
   

  
	
  XW

  	
   

  	
  0.9452

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9782

  	
   

  	
  0.8502

  	
   

  

 

55

 

A.8
Benefit Plan Factors for PPG Small Group POS Capitation and Small Group POS
Shared Risk Budgets

Effective
September 1, 1998

 

	
  Small Group POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9877

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9350

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8346

  	
   

  	
  0.7381

  	
   

  

 

56

 

B.            Age/Sex
and Benefit Plan Factors for Pharmacy Budgets:

 

B.1 Age/Sex Factors for Pharmacy Budgets Effective
January 1, 1998

 

	
  Age

  	
   

  	
  Male

  	
   

  	
  Female

  	
   

  
	
  0

  	
   

  	
  0.231

  	
   

  	
  0.231

  	
   

  
	
  1

  	
   

  	
  0.366

  	
   

  	
  0.366

  	
   

  
	
  2 - 4

  	
   

  	
  0.323

  	
   

  	
  0.323

  	
   

  
	
  5 - 9

  	
   

  	
  0.289

  	
   

  	
  0.289

  	
   

  
	
  10 - 14

  	
   

  	
  0.276

  	
   

  	
  0.276

  	
   

  
	
  15 - 19

  	
   

  	
  0.408

  	
   

  	
  0.408

  	
   

  
	
  20 - 24

  	
   

  	
  0.280

  	
   

  	
  0.714

  	
   

  
	
  25 - 29

  	
   

  	
  0.382

  	
   

  	
  0.868

  	
   

  
	
  30 - 34

  	
   

  	
  0.547

  	
   

  	
  0.919

  	
   

  
	
  35 - 39

  	
   

  	
  0.756

  	
   

  	
  1.067

  	
   

  
	
  40 - 44

  	
   

  	
  0.974

  	
   

  	
  1.265

  	
   

  
	
  45 - 49

  	
   

  	
  1.295

  	
   

  	
  1.654

  	
   

  
	
  50 - 54

  	
   

  	
  1.746

  	
   

  	
  2.198

  	
   

  
	
  55 - 59

  	
   

  	
  2.133

  	
   

  	
  2.573

  	
   

  
	
  60 - 64

  	
   

  	
  2.610

  	
   

  	
  3.000

  	
   

  
	
  65 +

  	
   

  	
  3.175

  	
   

  	
  3.467

  	
   

  

 

57

 

B.2 Benefit Plan Factors for Pharmacy Budgets
Effective January 1, 1998

 

	
  Plan

  	
   

  	
  Factor

  	
   

  
	
  01

  	
   

  	
  1.3376

  	
   

  
	
  02

  	
   

  	
  1.1000

  	
   

  
	
  03

  	
   

  	
  0.6448

  	
   

  
	
  04

  	
   

  	
  1.1000

  	
   

  
	
  05

  	
   

  	
  0.7255

  	
   

  
	
  06

  	
   

  	
  1.1102

  	
   

  
	
  07

  	
   

  	
  0.6448

  	
   

  
	
  08

  	
   

  	
  1.1000

  	
   

  
	
  09

  	
   

  	
  1.1000

  	
   

  
	
  0A

  	
   

  	
  1.7495

  	
   

  
	
  0B

  	
   

  	
  1.6378

  	
   

  
	
  0C

  	
   

  	
  1.7578

  	
   

  
	
  0D

  	
   

  	
  1.6457

  	
   

  
	
  0E

  	
   

  	
  1.7827

  	
   

  
	
  0F

  	
   

  	
  0.5134

  	
   

  
	
  0G

  	
   

  	
  0.9368

  	
   

  
	
  0H

  	
   

  	
  0.7255

  	
   

  
	
  0I

  	
   

  	
  0.8948

  	
   

  
	
  0J

  	
   

  	
  1.7578

  	
   

  
	
  0P

  	
   

  	
  1.1577

  	
   

  
	
  0R

  	
   

  	
  1.1577

  	
   

  
	
  0S

  	
   

  	
  1.0470

  	
   

  
	
  0T

  	
   

  	
  0.6771

  	
   

  
	
  0U

  	
   

  	
  1.1577

  	
   

  
	
  0V

  	
   

  	
  1.1577

  	
   

  
	
  0W

  	
   

  	
  0.7232

  	
   

  
	
  0X

  	
   

  	
  0.9409

  	
   

  
	
  0Y

  	
   

  	
  0.6411

  	
   

  
	
  0Z

  	
   

  	
  1.0945

  	
   

  
	
  10

  	
   

  	
  0.7564

  	
   

  
	
  11

  	
   

  	
  0.5166

  	
   

  
	
  12

  	
   

  	
  0.4105

  	
   

  
	
  13

  	
   

  	
  0.4806

  	
   

  
	
  14

  	
   

  	
  0.5590

  	
   

  
	
  16

  	
   

  	
  1.0821

  	
   

  
	
  17

  	
   

  	
  0.6411

  	
   

  
	
  18

  	
   

  	
  0.7292

  	
   

  
	
  19

  	
   

  	
  1.1000

  	
   

  
	
  1A

  	
   

  	
  1.6037

  	
   

  
	
  1B

  	
   

  	
  1.5013

  	
   

  
	
  1C

  	
   

  	
  1.6115

  	
   

  
	
  1D

  	
   

  	
  1.5087

  	
   

  
	
  1E

  	
   

  	
  1.1102

  	
   

  
	
  1F

  	
   

  	
  1.1102

  	
   

  
	
  1G

  	
   

  	
  0.7412

  	
   

  
	
  1H

  	
   

  	
  0.7412

  	
   

  
	
  1I

  	
   

  	
  1.1102

  	
   

  
	
  1J

  	
   

  	
  0.7564

  	
   

  
	
  1K

  	
   

  	
  1.1102

  	
   

  
	
  1L

  	
   

  	
  0.8989

  	
   

  
	
  1M

  	
   

  	
  0.7564

  	
   

  
	
  1N

  	
   

  	
  0.8625

  	
   

  
	
  1O

  	
   

  	
  0.6845

  	
   

  
	
  1P

  	
   

  	
  0.5991

  	
   

  
	
  1Q

  	
   

  	
  1.1000

  	
   

  
	
  1R

  	
   

  	
  0.9368

  	
   

  
	
  1S

  	
   

  	
  1.0945

  	
   

  
	
  1T

  	
   

  	
  1.1157

  	
   

  
	
  1U

  	
   

  	
  0.9119

  	
   

  
	
  1V

  	
   

  	
  1.1000

  	
   

  
	
  1W

  	
   

  	
  1.1102

  	
   

  
	
  1X

  	
   

  	
  0.8989

  	
   

  
	
  1Y

  	
   

  	
  1.2135

  	
   

  
	
  1Z

  	
   

  	
  1.1000

  	
   

  
	
  20

  	
   

  	
  0.7292

  	
   

  
	
  23

  	
   

  	
  0.9368

  	
   

  
	
  24

  	
   

  	
  1.1157

  	
   

  
	
  26

  	
   

  	
  1.1000

  	
   

  
	
  2A

  	
   

  	
  1.4635

  	
   

  
	
  2B

  	
   

  	
  1.3699

  	
   

  
	
  2C

  	
   

  	
  1.4704

  	
   

  
	
  2D

  	
   

  	
  1.3768

  	
   

  
	
  2E

  	
   

  	
  1.4912

  	
   

  
	
  2F

  	
   

  	
  0.9409

  	
   

  
	
  2G

  	
   

  	
  0.6448

  	
   

  
	
  2H

  	
   

  	
  1.1000

  	
   

  
	
  2I

  	
   

  	
  0.6448

  	
   

  
	
  2J

  	
   

  	
  0.6882

  	
   

  
	
  2L

  	
   

  	
  1.1761

  	
   

  
	
  2M

  	
   

  	
  1.1157

  	
   

  
	
  2N

  	
   

  	
  1.1157

  	
   

  
	
  2O

  	
   

  	
  0.7412

  	
   

  
	
  2P

  	
   

  	
  1.1577

  	
   

  
	
  2Q

  	
   

  	
  1.1102

  	
   

  
	
  2R

  	
   

  	
  1.1102

  	
   

  
	
  2S

  	
   

  	
  0.8989

  	
   

  
	
  2T

  	
   

  	
  0.7292

  	
   

  
	
  2U

  	
   

  	
  0.8989

  	
   

  
	
  2V

  	
   

  	
  0.7269

  	
   

  
	
  2W

  	
   

  	
  0.8989

  	
   

  
	
  2X

  	
   

  	
  0.6448

  	
   

  
	
  2Y

  	
   

  	
  0.7269

  	
   

  
	
  2Z

  	
   

  	
  1.2135

  	
   

  
	
  30

  	
   

  	
  1.1102

  	
   

  
	
  31

  	
   

  	
  1.1102

  	
   

  
	
  32

  	
   

  	
  0.7255

  	
   

  
	
  33

  	
   

  	
  0.7269

  	
   

  
	
  34

  	
   

  	
  1.1102

  	
   

  
	
  35

  	
   

  	
  1.1102

  	
   

  
	
  36

  	
   

  	
  1.1102

  	
   

  
	
  37

  	
   

  	
  1.1102

  	
   

  
	
  38

  	
   

  	
  1.2135

  	
   

  
	
  39

  	
   

  	
  0.8791

  	
   

  
	
  3A

  	
   

  	
  1.3311

  	
   

  
	
  3B

  	
   

  	
  1.2458

  	
   

  
	
  3C

  	
   

  	
  1.3376

  	
   

  
	
  3D

  	
   

  	
  1.2518

  	
   

  
	
  3E

  	
   

  	
  1.3311

  	
   

  
	
  3F

  	
   

  	
  1.3376

  	
   

  
	
  3G

  	
   

  	
  1.3311

  	
   

  
	
  3I

  	
   

  	
  0.8989

  	
   

  
	
  3J

  	
   

  	
  0.8989

  	
   

  
	
  3K

  	
   

  	
  1.1157

  	
   

  
	
  3L

  	
   

  	
  0.6448

  	
   

  
	
  3M

  	
   

  	
  0.8671

  	
   

  
	
  3N

  	
   

  	
  1.2135

  	
   

  
	
  3O

  	
   

  	
  1.4704

  	
   

  
	
  3P

  	
   

  	
  0.8989

  	
   

  
	
  3Q

  	
   

  	
  1.4912

  	
   

  
	
  3R

  	
   

  	
  0.6882

  	
   

  
	
  3S

  	
   

  	
  0.5166

  	
   

  
	
  3T

  	
   

  	
  0.7292

  	
   

  
	
  3U

  	
   

  	
  1.6378

  	
   

  
	
  3V

  	
   

  	
  0.7255

  	
   

  
	
  3X

  	
   

  	
  0.7398

  	
   

  
	
  3Y

  	
   

  	
  0.9967

  	
   

  
	
  3Z

  	
   

  	
  0.5590

  	
   

  
	
  40

  	
   

  	
  0.7292

  	
   

  
	
  41

  	
   

  	
  0.9119

  	
   

  
	
  42

  	
   

  	
  1.1637

  	
   

  
	
  46

  	
   

  	
  1.1637

  	
   

  
	
  47

  	
   

  	
  1.3588

  	
   

  
	
  48

  	
   

  	
  0.9368

  	
   

  
	
  49

  	
   

  	
  1.2310

  	
   

  
	
  4A

  	
   

  	
  1.2080

  	
   

  
	
  4B

  	
   

  	
  1.1305

  	
   

  
	
  4E

  	
   

  	
  1.2015

  	
   

  
	
  4F

  	
   

  	
  1.2836

  	
   

  
	
  4G

  	
   

  	
  1.1000

  	
   

  
	
  4H

  	
   

  	
  1.1000

  	
   

  
	
  4I

  	
   

  	
  1.1102

  	
   

  
	
  4K

  	
   

  	
  1.0032

  	
   

  
	
  4L

  	
   

  	
  1.0945

  	
   

  
	
  4M

  	
   

  	
  0.9917

  	
   

  
	
  4N

  	
   

  	
  0.9331

  	
   

  
	
  4P

  	
   

  	
  0.9548

  	
   

  
	
  4Q

  	
   

  	
  0.9548

  	
   

  
	
  4R

  	
   

  	
  1.1000

  	
   

  
	
  4S

  	
   

  	
  1.1102

  	
   

  
	
  4T

  	
   

  	
  1.1000

  	
   

  
	
  4U

  	
   

  	
  0.7398

  	
   

  
	
  4V

  	
   

  	
  1.0945

  	
   

  
	
  4W

  	
   

  	
  1.2135

  	
   

  
	
  4X

  	
   

  	
  1.1000

  	
   

  
	
  4Y

  	
   

  	
  0.7269

  	
   

  
	
  51

  	
   

  	
  0.7255

  	
   

  
	
  52

  	
   

  	
  0.7292

  	
   

  
	
  53

  	
   

  	
  0.6448

  	
   

  
	
  54

  	
   

  	
  0.5166

  	
   

  
	
  55

  	
   

  	
  0.7292

  	
   

  
	
  56

  	
   

  	
  0.6448

  	
   

  
	
  57

  	
   

  	
  0.5166

  	
   

  
	
  58

  	
   

  	
  0.7255

  	
   

  
	
  59

  	
   

  	
  0.6448

  	
   

  
	
  5A

  	
   

  	
  1.0945

  	
   

  
	
  5B

  	
   

  	
  1.1157

  	
   

  
	
  5C

  	
   

  	
  1.1000

  	
   

  
	
  5D

  	
   

  	
  1.0299

  	
   

  
	
  5E

  	
   

  	
  1.0834

  	
   

  
	
  5F

  	
   

  	
  1.1577

  	
   

  
	
  5G

  	
   

  	
  1.1637

  	
   

  
	
  5H

  	
   

  	
  1.1798

  	
   

  
	
  5I

  	
   

  	
  1.1180

  	
   

  
	
  5J

  	
   

  	
  0.6005

  	
   

  
	
  5K

  	
   

  	
  1.1821

  	
   

  
	
  5L

  	
   

  	
  1.1577

  	
   

  
	
  5M

  	
   

  	
  1.1000

  	
   

  
	
  5N

  	
   

  	
  1.0834

  	
   

  
	
  5O

  	
   

  	
  0.7292

  	
   

  
	
  5P

  	
   

  	
  1.1577

  	
   

  
	
  5Q

  	
   

  	
  0.5973

  	
   

  
	
  5R

  	
   

  	
  0.7292

  	
   

  
	
  5S

  	
   

  	
  0.7255

  	
   

  
	
  5T

  	
   

  	
  1.1000

  	
   

  
	
  5U

  	
   

  	
  1.1157

  	
   

  
	
  5V

  	
   

  	
  1.1000

  	
   

  
	
  5W

  	
   

  	
  1.1157

  	
   

  
	
  5X

  	
   

  	
  0.7412

  	
   

  
	
  5Y

  	
   

  	
  0.7412

  	
   

  
	
  5Z

  	
   

  	
  1.7495

  	
   

  
	
  61

  	
   

  	
  1.1102

  	
   

  
	
  62

  	
   

  	
  1.1102

  	
   

  
	
  63

  	
   

  	
  1.7578

  	
   

  
	
  64

  	
   

  	
  0.9409

  	
   

  
	
  65

  	
   

  	
  0.7292

  	
   

  
	
  66

  	
   

  	
  1.1637

  	
   

  
	
  67

  	
   

  	
  1.1637

  	
   

  
	
  68

  	
   

  	
  1.1000

  	
   

  
	
  69

  	
   

  	
  0.8989

  	
   

  
	
  6A

  	
   

  	
  0.9917

  	
   

  
	
  6B

  	
   

  	
  1.1157

  	
   

  
	
  6C

  	
   

  	
  0.9967

  	
   

  
	
  6D

  	
   

  	
  1.0945

  	
   

  
	
  6E

  	
   

  	
  0.9750

  	
   

  
	
  6F

  	
   

  	
  1.0424

  	
   

  
	
  6G

  	
   

  	
  0.6005

  	
   

  
	
  6H

  	
   

  	
  1.1577

  	
   

  
	
  6I

  	
   

  	
  1.1102

  	
   

  
	
  6J

  	
   

  	
  1.1102

  	
   

  
	
  6K

  	
   

  	
  0.8989

  	
   

  
	
  6L

  	
   

  	
  0.8989

  	
   

  
	
  6M

  	
   

  	
  1.1180

  	
   

  
	
  6N

  	
   

  	
  1.1180

  	
   

  
	
  6O

  	
   

  	
  1.1102

  	
   

  
	
  6P

  	
   

  	
  1.0424

  	
   

  
	
  6Q

  	
   

  	
  0.9280

  	
   

  
	
  6R

  	
   

  	
  1.1637

  	
   

  
	
  6S

  	
   

  	
  0.8805

  	
   

  
	
  6T

  	
   

  	
  1.1102

  	
   

  
	
  6U

  	
   

  	
  1.1102

  	
   

  
	
  6V

  	
   

  	
  1.1102

  	
   

  
	
  6W

  	
   

  	
  1.1102

  	
   

  
	
  6X

  	
   

  	
  1.1102

  	
   

  
	
  6Y

  	
   

  	
  1.7578

  	
   

  
	
  6Z

  	
   

  	
  1.2241

  	
   

  
	
  71

  	
   

  	
  1.1102

  	
   

  
	
  72

  	
   

  	
  1.1102

  	
   

  
	
  73

  	
   

  	
  0.8948

  	
   

  
	
  74

  	
   

  	
  1.1102

  	
   

  
	
  75

  	
   

  	
  0.9368

  	
   

  
	
  76

  	
   

  	
  0.8989

  	
   

  
	
  77

  	
   

  	
  0.9368

  	
   

  
	
  78

  	
   

  	
  0.9409

  	
   

  
	
  79

  	
   

  	
  0.8948

  	
   

  
	
  7A

  	
   

  	
  0.8948

  	
   

  
	
  7B

  	
   

  	
  0.8371

  	
   

  
	
  7C

  	
   

  	
  0.8989

  	
   

  
	
  7D

  	
   

  	
  0.8768

  	
   

  
	
  7E

  	
   

  	
  0.8768

  	
   

  
	
  7F

  	
   

  	
  0.9368

  	
   

  
	
  7G

  	
   

  	
  0.9409

  	
   

  
	
  7H

  	
   

  	
  1.1102

  	
   

  
	
  7I

  	
   

  	
  1.1102

  	
   

  
	
  7J

  	
   

  	
  0.9409

  	
   

  
	
  7K

  	
   

  	
  0.9368

  	
   

  
	
  7L

  	
   

  	
  0.8989

  	
   

  
	
  7M

  	
   

  	
  0.8371

  	
   

  
	
  7N

  	
   

  	
  0.9368

  	
   

  
	
  7O

  	
   

  	
  0.8989

  	
   

  
	
  7P

  	
   

  	
  0.8948

  	
   

  
	
  7Q

  	
   

  	
  0.7527

  	
   

  
	
  7R

  	
   

  	
  1.7578

  	
   

  
	
  7S

  	
   

  	
  1.7578

  	
   

  
	
  7T

  	
   

  	
  1.1102

  	
   

  
	
  7U

  	
   

  	
  1.1102

  	
   

  
	
  7V

  	
   

  	
  1.1102

  	
   

  
	
  7W

  	
   

  	
  1.1102

  	
   

  
	
  7X

  	
   

  	
  1.1102

  	
   

  
	
  7Y

  	
   

  	
  1.1102

  	
   

  
	
  7Z

  	
   

  	
  1.7495

  	
   

  
	
  82

  	
   

  	
  1.1000

  	
   

  
	
  8A

  	
   

  	
  1.1102

  	
   

  
	
  8B

  	
   

  	
  0.8989

  	
   

  
	
  8C

  	
   

  	
  0.8948

  	
   

  
	
  8E

  	
   

  	
  0.7869

  	
   

  
	
  8F

  	
   

  	
  0.8404

  	
   

  
	
  8G

  	
   

  	
  1.1102

  	
   

  
	
  8H

  	
   

  	
  1.0032

  	
   

  
	
  8I

  	
   

  	
  0.8989

  	
   

  
	
  8J

  	
   

  	
  0.8989

  	
   

  
	
  8K

  	
   

  	
  0.8989

  	
   

  
	
  8L

  	
   

  	
  1.6115

  	
   

  
	
  8M

  	
   

  	
  0.9986

  	
   

  
	
  8N

  	
   

  	
  0.9548

  	
   

  
	
  8P

  	
   

  	
  1.1000

  	
   

  
	
  8R

  	
   

  	
  1.7864

  	
   

  
	
  8S

  	
   

  	
  1.0618

  	
   

  
	
  8T

  	
   

  	
  0.5590

  	
   

  
	
  8U

  	
   

  	
  1.6346

  	
   

  
	
  8V

  	
   

  	
  1.1637

  	
   

  
	
  8X

  	
   

  	
  0.6448

  	
   

  
	
  8Y

  	
   

  	
  0.7255

  	
   

  
	
  8Z

  	
   

  	
  0.7527

  	
   

  
	
  91

  	
   

  	
  1.2135

  	
   

  
	
  92

  	
   

  	
  1.1577

  	
   

  
	
  93

  	
   

  	
  0.7292

  	
   

  
	
  96

  	
   

  	
  0.9368

  	
   

  
	
  9A

  	
   

  	
  0.7232

  	
   

  
	
  9B

  	
   

  	
  0.6771

  	
   

  
	
  9C

  	
   

  	
  0.7269

  	
   

  
	
  9D

  	
   

  	
  0.7232

  	
   

  
	
  9E

  	
   

  	
  0.7048

  	
   

  
	
  9F

  	
   

  	
  0.7527

  	
   

  
	
  9G

  	
   

  	
  0.7564

  	
   

  
	
  9H

  	
   

  	
  0.7675

  	
   

  
	
  9I

  	
   

  	
  0.7269

  	
   

  
	
  9J

  	
   

  	
  0.7232

  	
   

  
	
  9L

  	
   

  	
  1.7495

  	
   

  
	
  9M

  	
   

  	
  0.6411

  	
   

  
	
  9N

  	
   

  	
  0.7048

  	
   

  
	
  9O

  	
   

  	
  0.6448

  	
   

  
	
  9P

  	
   

  	
  0.6411

  	
   

  
	
  9Q

  	
   

  	
  0.6411

  	
   

  
	
  9R

  	
   

  	
  0.7527

  	
   

  
	
  9S

  	
   

  	
  0.6411

  	
   

  
	
  9T

  	
   

  	
  0.9409

  	
   

  
	
  9U

  	
   

  	
  1.2135

  	
   

  
	
  9W

  	
   

  	
  0.6448

  	
   

  
	
  9X

  	
   

  	
  1.1102

  	
   

  
	
  9Y

  	
   

  	
  1.1000

  	
   

  
	
  9Z

  	
   

  	
  1.0424

  	
   

  
	
  AI

  	
   

  	
  1.7578

  	
   

  
	
  B1

  	
   

  	
  0.7292

  	
   

  
	
  B2

  	
   

  	
  0.7564

  	
   

  
	
  B3

  	
   

  	
  0.7564

  	
   

  
	
  B4

  	
   

  	
  0.7292

  	
   

  
	
  B5

  	
   

  	
  0.8989

  	
   

  
	
  B6

  	
   

  	
  1.1798

  	
   

  
	
  B7

  	
   

  	
  1.1637

  	
   

  
	
  B8

  	
   

  	
  0.7255

  	
   

  
	
  B9

  	
   

  	
  0.7255

  	
   

  
	
  C2

  	
   

  	
  0.6536

  	
   

  
	
  C3

  	
   

  	
  0.6536

  	
   

  
	
  C5

  	
   

  	
  0.9091

  	
   

  
	
  C7

  	
   

  	
  0.7292

  	
   

  
	
  C8

  	
   

  	
  0.7292

  	
   

  
	
  C9

  	
   

  	
  0.7412

  	
   

  
	
  D1

  	
   

  	
  0.7412

  	
   

  
	
  D2

  	
   

  	
  0.7292

  	
   

  
	
  D3

  	
   

  	
  0.7689

  	
   

  
	
  D4

  	
   

  	
  0.7689

  	
   

  
	
  D5

  	
   

  	
  0.7689

  	
   

  
	
  D6

  	
   

  	
  0.7195

  	
   

  
	
  E2

  	
   

  	
  0.7721

  	
   

  
	
  E3

  	
   

  	
  0.8989

  	
   

  
	
  E5

  	
   

  	
  0.7412

  	
   

  
	
  E7

  	
   

  	
  1.1157

  	
   

  
	
  F1

  	
   

  	
  0.7292

  	
   

  
	
  F3

  	
   

  	
  0.7412

  	
   

  
	
  F4

  	
   

  	
  0.7292

  	
   

  
	
  F7

  	
   

  	
  0.7398

  	
   

  
	
  I2

  	
   

  	
  1.0106

  	
   

  
	
  I3

  	
   

  	
  0.6171

  	
   

  
	
  I8

  	
   

  	
  1.1798

  	
   

  
	
  I9

  	
   

  	
  0.6448

  	
   

  
	
  OH

  	
   

  	
  1.7578

  	
   

  
	
  P3

  	
   

  	
  0.5134

  	
   

  
	
  P4

  	
   

  	
  0.6517

  	
   

  
	
  P9

  	
   

  	
  1.1157

  	
   

  
	
  Q4

  	
   

  	
  0.7255

  	
   

  
	
  S1

  	
   

  	
  1.1277

  	
   

  
	
  S2

  	
   

  	
  1.8025

  	
   

  
	
  S3

  	
   

  	
  0.8768

  	
   

  
	
  S4

  	
   

  	
  1.6378

  	
   

  
	
  S5

  	
   

  	
  1.1102

  	
   

  
	
  S6

  	
   

  	
  1.1102

  	
   

  
	
  S7

  	
   

  	
  1.7578

  	
   

  
	
  S8

  	
   

  	
  0.8768

  	
   

  
	
  S9

  	
   

  	
  1.7495

  	
   

  

 

58

 

ADDENDUM B.2

 

DIVISION
OF RESPONSIBILITY

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

 

COMMERCIAL
HMO AND POINT OF SERVICE BENEFIT PROGRAMS

 

The following matrix outlines the division of financial responsibility
between FHS, PPG and Hospital.  The
matrix is intended only as a summary guide. 
The applicable Subscriber’s Certificate should be consulted for an
accurate and complete description of Covered Services and the Provider
Operations Manual for clarification.

 

MATRIX EFFECTIVE 1/1/98 THROUGH
6/30/98

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS - Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS -
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Drugs, including
  Epogen, Nupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by PPG from FHS.  Claims shall be submitted to and processed by
FHS’ Claims Dept.

 

59

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  COSMETIC
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DIAGNOSTIC TESTING - Outpatient

  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY ROOM VISITS – Out-of-

  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R:
Reinsurance purchased by PPG from FHS. Claims shall be submitted to and
processed by FHS’ Claims Dept.

 

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

 

60

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPITAL
  BASED PHYSICIANS -

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTIBLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF &
  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY – Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY
  – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R:
Reinsurance purchased by PPG from FHS. Claims shall be submitted to and
processed by FHS’ Claims Dept.

 

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

 

61

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  PATHOLOGY
  – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE
  ADMISSION -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •
  Related to an Outpatient Office Visit:

  Splints, Casts, Bandages, etc....

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Related to a Hospital
  Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Surgical
  Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Chem. Strips, Lancet,
  Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY- Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY:
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by PPG from FHS.
Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

62

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Exams and Medically
  Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Implanted Lenses
  (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Lenses and Frames
  (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R:
Reinsurance purchased by  PPG from
FHS. Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

63

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD
  PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Storage and Collection of
  Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Drugs, including Epogen, Nupogen and adjunctivc therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COSMETIC
  SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DIAGNOSTIC
  TESTING - Outpatient

  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by
PPG from FHS. Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

64

MATRIX EFFECTIVE 7/1/98

 

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – Out of
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS – In
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPITAL
  BASED PHYSICIANS -

  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R:
Reinsurance purchased by PPG from FHS. Claims shall be submitted to and
processed by FHS’ Claims Dept.

 

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

 

65

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  INJECTIBLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF &
  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY –  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE
  ADMISSION -
  Outpatient

  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (within 72 hrs. or related
  admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by PPG from FHS.
Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

66

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  RADIOLOGY - Inpatient, Ambulatory Surgery or
  Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY
  – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Related to an Outpatient
  Office Visit:

  Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Related to a Hospital
  Stay:

  Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Chem, Strips, Lancet,
  Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY: Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by PPG from FHS.
Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

67

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Exams and Medically
  Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Implanted Lenses
  (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Lenses and Frames
  (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

R: Reinsurance purchased by
PPG from FHS. Claims shall be submitted to and processed by FHS’ Claims Dept.

 

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

 

68

 

ADDENDUM C

 

MEDICARE HEALTH MAINTENANCE ORGANIZATION (HMO) AND
MEDICARE POINT OF SERVICE (POS) BENEFIT PROGRAMS

 

PPG
understands and agrees that the obligations of FHS set forth in this Addendum
are only the obligations of Health Net (hereafter “HMO”) and not the
obligations of FHS or any other Affiliate of FHS.  PPG shall be compensated according to this
Addendum B and this Addendum shall be applicable to only those Medicare HMO and
Medicare POS Members listed on the applicable Capitation remittance summaries.
Pursuant to Section 8.18, Entire Agreement, PPG understands and agrees
that the compensation and provisions under the agreement between PPG and the
entity formerly known as Foundation Health, a California Health Plan, are
applicable to those Medicare HMO and Medicare POS Member listed on the
Foundation Health capitation remittance summary, and that the Foundation Health
agreement shall remain in full force and effect for those Members until such
time those Members are no longer enrolled in Foundation Health Benefit
Programs.

 

A.            DEFINITIONS.  For
purposes of this Addendum C, the definitions included herein shall have the
meaning required by law to applicable Medicare Risk Programs.

 

1.   HCFA.  The
Health Care Financing Administration which is the agency of the federal
government responsible for administration of the Medicare Benefit program.

 

2.   Medicare Enrollment Area.  The
area approved by HCFA and the State regulatory agency as the area in which HMO
may market and enroll Medicare HMO and Medicare POS Members.  At any given time during the term of this
Agreement, the Medicare Enrollment Area consists of the list of zip codes
currently approved by HCFA and/or the State regulatory agency as the Medicare
Enrollment Area. (This is not the area for which PPG shall be responsible for
“in-area” services.)

 

3.   Monthly Revenue.  The
amount equal to the sum of the applicable HCFA payment, the county premium, if
any, less specific amounts withheld to cover the actual cost of supplemental
benefits that are not PPG Capitated Services, including but not limited to,
pharmacy, vision, and dental benefits, commissions, or taxes, if any, as set
forth in Addendum C, plus POS premium, if any. The withhold amounts shall be
revised annually and Capitation adjustments made accordingly.

 

B.            MEDICARE HMO BENEFIT PROGRAMS.

 

1.             HMO
Benefit Program.  The Medicare HMO Benefit Program shall apply
to Medicare HMO Members; any per Member per month (‘‘PMPM”) or any percent of
Monthly Revenue calculation under Addendum C shall be based on Medicare HMO
Members.

 

2.             Capitation;
PPG Capitated Services.

 

2.1          Compensation
for PPG Capitated Services.  As compensation for rendering
PPG Capitated Services as defined herein, HMO shall pay PPG Capitation at forty
two and twenty four one hundredths percent (42.24%) of Monthly Revenue as set
forth below for each Medicare HMO Member eligible to receive such services from
PPG during any particular month. Capitation shall be computed on the basis of
the most current information available and shall be paid by HMO by wire
transfer on or before the fifteenth (15th) day of each month or the first
business day following the fifteenth if the fifteenth is a holiday or on a
weekend or within two (2) days of HCFA’s payment to HMO, whichever is later.
Each Capitation payment shall be accompanied by a remittance summary. The
remittance summary identifies the total Capitation payable and those Medicare
HMO

 

69

 

Members
for whom Capitation is being paid. In the event of a Capitation error,
resulting in an overpayment or underpayment to PPG, HMO shall adjust subsequent
Capitation to offset such error.

 

2.2          Professional Stop Loss Program.

 

PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage.

 

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

 

2.4          Compensation
for Employer Group Retirees.  As compensation for supplemental benefits
sold to employer group retirees for Medicare HMO Members, HMO shall pay PPG the
applicable PMPM rates as illustrated below.

 

 

	
  Supplemental Benefit

  	
   

  	
  PMPM

  
	
  $5 office visit &
  specialist consultation copay waived

  	
   

  	
  ***

  
	
  $5 vision and hearing exam
  copay waived

  	
   

  	
  ***

  
	
  $20 outpatient mental
  health copay waived

  	
   

  	
  ***

  
	
  $20 outpatient substance
  abuse copay waived

  	
   

  	
  ***

  

 

HMO
shall develop and adjust supplemental benefits PMPM rates on a calendar year basis
and forward such rates to PPG on or before December 15th of the
prior year.

 

3.             Shared Risk Program.

 

3.1          Shared
Risk Budget.  As a contingency for any PPG liability under
the Shared Risk Program, HMO shall deduct *** of PPG’s Capitation and place
such amount in the Withhold Fund as described in this Agreement. Each month,
HMO shall fund the Shared Risk Budget for each eligible Medicare HMO Member at
*** of Monthly Revenue.

 

In
the event the claims for Shared Risk Services exceed Shared Risk Revenue at the
interim settlement date., HMO may, at its sole discretion, deduct up to *** of
PPG’s Capitation for Medicare HMO Members and place such amount in the Withhold
Fund as described in this Agreement, and may continue such withhold until the
final Shared Risk settlement. The Withhold fund shall accrue interest which
shall be the lower of *** the prime interest rate as stated in the Wall Street
Journal, on the last business day in December of the contract year.

 

If, upon final Shared Risk settlement, (i) a Shared
Risk gain exists, HMO shall refund the Withhold Fund, plus accrued interest, to
PPG together with the PPG’s share of the gain or (ii) a Shared Risk deficit
exists, subject to Section 4.3, of the Agreement, HMO shall offset the Withhold
Fund against PPG’s outstanding liability or any other amounts payable to
HMO.  Any amount in the Withhold Fund not
offset against

 

70

 

such PPG liability shall be
refunded to PPG at the final Risk Sharing settlement.  However, as a contingency for any PPG
liability under this Shared Risk Program, HMO shall continue, at its sole
discretion, to deduct up to *** of PPG’s Capitation for Medicare HMO Members
and place such amount in the Withhold Fund as described in this Agreement

 

3.2          Shared
Risk Budget Surplus.  In the event of a Shared Risk Budget surplus,
PPG’s share of the surplus shall be limited to the lesser of (a) *** of the
Shared Risk Budget surplus, or (b) an amount not to exceed *** of the annual
gross PPG Capitation.

 

3.3          Shared
Risk Budget Deficit.  In the event of a Shared Risk Budget deficit,
PPG’s share of the deficit shall be limited to the lesser of (a) *** of the
Shared Risk Budget deficit, or (b) an amount not to exceed *** of the annual
gross PPG Capitation.

 

3.4          Shared
Risk Reinsurance.  PPG shall participate in the Shared Risk
Reinsurance program. The cost to the PPG for the Shared Risk Reinsurance
program shall be calculated as follows:

 

(a)           Out-of-Area Emergency and Urgently
Needed services: *** of the applicable Medicare HMO Member’s HCFA payment and
county premium, if any.

 

Out-of-Area
Emergency and Urgently Needed services are reimbursed at *** of cost, and the
remaining *** of the cost shall be charged against the Shared Risk Budget.

 

(b)           In-Area Shared Risk services: 0.06 %
of the applicable Medicare HMO Member’s HCFA payment and county premium, if
any.

 

The
cost of in-area Shared Risk services utilized by a Medicare HMO Member in a
Reconciliation Period shall be charged against the Shared Risk Budget as
follows: *** any amount over ***.

 

4.             Pharmacy
Budget.  For applicable Medicare HMO Members, each
month HMO shall fund the Pharmacy Budget as set forth in this Addendum C.

 

5.             Quality
of Care Improvement Program (QCIP).  QCIP,
as in the Operations Manual, rewards PPG for meeting and exceeding quality
standards and Member satisfaction levels. PPG is eligible for a lump sum award
up to *** PMPM, if performance is achieved in all categories. The lump sum
shall be payable in September following the calendar year in which the
measurement was taken. Wellness programs, as set forth in the Operations
Manual, are a component of QCIP.  The
above PMPM award includes funding for wellness programs. Compensation for
wellness programs for eligible PPG’s contracted with HMO for a full twelve
months shall be payable at *** per class up to *** total until *** Medicare HMO
members. Thereafter, for Medicare HMO Members, *** PMPM shall be distributed to
PPG monthly with the Capitation. HMO reserves the right to alter components and
measurements of QCIP annually. Wellness programs and wellness compensation
shall be subject to annual change by HMO.

 

71

 

C.            MEDICARE POS BENEFIT PROGRAM.

 

1.             POS Benefit Program.  Under a POS Benefit Program, Members may
elect, at the time of obtaining each Covered Service, to utilize: (i) HMO
coverage through PPG; (ii) coverage by self-referring to any PPO Provider; or
(iii) coverage for self-referring to non-Participating Providers in accordance
with Benefit Program requirements. Medicare HMO Members may be eligible for
Medicare POS Benefit Programs.

 

2.             Definitions.

 

2.1          In-Network
Services.  PPG Capitated Services and Shared Risk
Services provided or arranged through PPG.

 

2.2          Out-of-Network
Services.  In accordance with Benefit Program
requirements, Covered Services provided as a result of a Members self referral
to a PPO Provider, or to a non-Participating Provider. Out-of-Network Services
may be provided in-area or out-of-area.

 

3.             Capitation: PPG Capitated
Services.

 

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

 

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

 

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

 

3.2          Professional
Stop Loss Program.

 

(a)           In-Network Professional Stop Loss.

 

PPG
elects not to participate in the Professional Stop Loss Program.  PPG shall provide HMO with proof of
Professional Stop Loss coverage.

 

(b)           Out-of-Network
Professional Stop Loss, PPG’s Out-of-Network Professional Stop Loss threshold
shall be *** per Medicare POS Member during the

 

72

 

calendar
year.  The cost to PPG for the
Out-of-Network Professional Stop Loss program shall be *** of applicable
Medicare POS Member’s MCFA payment and county premium, if any, which shall be
deducted from PPG’s Out-of-Network Risk Sharing Fund.

 

3.3          Professional
Out-of-Network Withhold Fund.  The Professional Out-of-Network
Withhold Fund shall be equal to the amount withheld from POS Capitation as
described above. Each year, HMO shall calculate the difference between the
amount in the Professional Out-of-Network Withhold Fund and the actual claims.
PPG’s share of the difference shall be ***. 
PPG shall not be subject to any downside.

 

4.             POS Shared Risk.

 

4.1          POS
Shared Risk Budget.  Each month, HMO shall fund the POS Shared
Risk Budget for POS Shared Risk Services, at the percent of Monthly Revenue for
Medicare HMO Members as set forth in this Addendum C. HMO shall calculate and
pay POS Shared Risk Claims.

 

4.2          POS
Shared Risk Budget Surplus.  In the event of a POS Shared
Risk Budget surplus, PPG’s share of the surplus shall be the lesser of ***, or
an amount not to exceed *** of the annual gross PPG Capitation.

 

4.3          POS
Shared Risk Deficit.  In the event of a POS Shared Risk Budget
deficit, PPG shall not be liable for the deficit.

 

4.4          Shared Risk Reinsurance.  PPG
shall participate in the POS Shared Risk Reinsurance Program. The cost to the
PPG for the POS Shared Risk Reinsurance Program shall be calculated as follows:

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: 0.75% % of applicable Medicare POS Member’s HCFA payment and
county premium, if any.

 

Out-of-Area
Emergency and Urgently Needed Services are reimbursed at *** cent *** of cost,
and the remaining *** of the cost shall be charged against the POS Shared Risk
Budget.

 

(b)           In-Network and Out-of-Network POS
Shared Risk Services: 0.04 % of applicable Medicare POS Member’s HCFA payment
and county premium, if any.

 

The cost of In-Network and Out-of-Network POS
Shared Risk Services during the Reconciliation Period shall be charged against
the POS Shared Risk Budget as follows: 
*** of any amount over ***.

 

D.            ADMINISTRATION OF SHARED RISK
BUDGET FOR MEDICARE HMO AND POS.

 

1.             Shared Risk Administration.  Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claims to the corresponding Shared
Risk Budget.

 

HMO shall perform both an interim and final
settlement.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall be paid to PPG by

 

73

 

April 30 of the following
year. In the event that such claims are less than the Shared Risk Budget for
the Interim Period, PPG’s share of the settlement shall be seventy-five percent
(75%), subject to Section 4.3 of this Agreement. Shared Risk Claims with dates
of service within the Reconciliation Period and paid by March 31 of the
following year shall be used in the calculation. Shared Risk Services incurred
within the Reconciliation Period but paid after March 31 of the following year
will be included in the next Reconciliation Period calculation.

 

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

 

E.             OTHER SERVICES.

 

1.             Contracted Services.  PPG
and Member Physicians shall render Contracted Services which are not PPG
Capitated Services to Members covered under this Addendum C and shall be
compensated on a fee-for-service basis at the rates set forth in Addendum E.
PPG shall submit claims in accordance with the terms of this Agreement.

 

74

 

ADDENDUM C.1

 

SUPPLEMENTAL
BENEFITS COSTS

 

For
purposes of calculating PPG’s Capitation, the specific amounts set forth below
as a percent of the applicable HCFA payment and the county premium, if any,
shall be withheld to cover the actual cost of supplemental benefits that are
not PPG Capitated Services, and commissions and taxes, if any. Such supplemental
benefits may include, but are not limited to, pharmacy, vision, and dental
benefits. On an annual basis, these withheld amounts shall be revised,
forwarded to PPG, and incorporated into this Agreement by reference.

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  5.71

  	
  %

  
	
  Butte

  	
   

  	
  0.55

  	
  %

  
	
  Colusa

  	
   

  	
  0.52

  	
  %

  
	
  Contra Costa

  	
   

  	
  5.68

  	
  %

  
	
  El Dorado

  	
   

  	
  5.22

  	
  %

  
	
  Fresno

  	
   

  	
  5.11

  	
  %

  
	
  Glenn

  	
   

  	
  0.57

  	
  %

  
	
  Kern

  	
   

  	
  11.80

  	
  %

  
	
  Los Angeles

  	
   

  	
  9.27

  	
  %

  
	
  Madera

  	
   

  	
  4.90

  	
  %

  
	
  Marin

  	
   

  	
  4.09

  	
  %

  
	
  Mariposa

  	
   

  	
  5.42

  	
  %

  
	
  Napa

  	
   

  	
  0.48

  	
  %

  
	
  Orange

  	
   

  	
  10.03

  	
  %

  
	
  Placer

  	
   

  	
  6.71

  	
  %

  
	
  Plumas

  	
   

  	
  0.55

  	
  %

  
	
  Riverside

  	
   

  	
  12.08

  	
  %

  
	
  Sacramento

  	
   

  	
  6.01

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.57

  	
  %

  
	
  San Diego

  	
   

  	
  11.27

  	
  %

  
	
  San Francisco

  	
   

  	
  5.90

  	
  %

  
	
  San Joaquin

  	
   

  	
  7.03

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  11.37

  	
  %

  
	
  San Matco

  	
   

  	
  7.16

  	
  %

  
	
  Santa Barbara

  	
   

  	
  11.28

  	
  %

  
	
  Santa Clara

  	
   

  	
  6.68

  	
  %

  
	
  Sierra

  	
   

  	
  0.58

  	
  %

  
	
  Solano

  	
   

  	
  0.59

  	
  %

  
	
  Sonoma

  	
   

  	
  5.28

  	
  %

  
	
  Stanislaus

  	
   

  	
  7.09

  	
  %

  
	
  Sutter

  	
   

  	
  0.57

  	
  %

  
	
  Tulare

  	
   

  	
  4.91

  	
  %

  
	
  Ventura

  	
   

  	
  11.81

  	
  %

  
	
  Yolo

  	
   

  	
  5.35

  	
  %

  
	
  Yuba

  	
   

  	
  0.55

  	
  %

  

 

75

 

ADDENDUM C.2

 

PHARMACY
SHARED RISK BUDGETS

 

For purposes of calculating
PPG’s Pharmacy Budget, the specific amounts set forth below as a percent of the
applicable HCFA payment and the county premium, if any, are applicable. On an
annual basis, these amounts shall be revised, forwarded to PPG, and
incorporated into this Agreement by reference.

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  4.48

  	
  %

  
	
  Butte

  	
   

  	
  0.00

  	
  %

  
	
  Colusa

  	
   

  	
  0.00

  	
  %

  
	
  Contra Costa

  	
   

  	
  4.45

  	
  %

  
	
  El Dorado

  	
   

  	
  4.60

  	
  %

  
	
  Fresno

  	
   

  	
  4.42

  	
  %

  
	
  Glenn

  	
   

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  10.35

  	
  %

  
	
  Los Angeles

  	
   

  	
  8.14

  	
  %

  
	
  Madera

  	
   

  	
  4.25

  	
  %

  
	
  Marin

  	
   

  	
  3.58

  	
  %

  
	
  Mariposa

  	
   

  	
  4.69

  	
  %

  
	
  Napa

  	
   

  	
  0.00

  	
  %

  
	
  Orange

  	
   

  	
  8.80

  	
  %

  
	
  Placer

  	
   

  	
  5.26

  	
  %

  
	
  Plumas

  	
   

  	
  0.00

  	
  %

  
	
  Riverside

  	
   

  	
  11.51

  	
  %

  
	
  Sacramento

  	
   

  	
  4.67

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.02

  	
  %

  
	
  San Diego

  	
   

  	
  9.89

  	
  %

  
	
  San Francisco

  	
   

  	
  4.62

  	
  %

  
	
  San Joaquin

  	
   

  	
  5.51

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  10.66

  	
  %

  
	
  San Mateo

  	
   

  	
  5.61

  	
  %

  
	
  Santa Barbara

  	
   

  	
  10.58

  	
  %

  
	
  Santa Clara

  	
   

  	
  5.24

  	
  %

  
	
  Sierra

  	
   

  	
  0.00

  	
  %

  
	
  Solano

  	
   

  	
  0.00

  	
  %

  
	
  Sonoma

  	
   

  	
  4.70

  	
  %

  
	
  Stanislaus

  	
   

  	
  5.55

  	
  %

  
	
  Sutter

  	
   

  	
  0.00

  	
  %

  
	
  Tulare

  	
   

  	
  4.25

  	
  %

  
	
  Ventura

  	
   

  	
  11.25

  	
  %

  
	
  Yolo

  	
   

  	
  4.71

  	
  %

  
	
  Yuba

  	
   

  	
  0.00

  	
  %

  

 

76

 

ADDENDUM C.3

DIVISION
OF FINANCIAL RESPONSIBILITY

MATRIX
OF HMO AND PPG CAPITATED SERVICES

MEDICARE
BENEFIT PROGRAM

 

The following matrix outlines the division of financial responsibility
between FHS, PPG and Hospital. The matrix is intended only as a summary guide.
The applicable Subscriber’s Certificate should be consulted for an accurate and
complete description of Covered Services and the Provider Operations Manual for
clarification.

 

MATRIX
EFFECTIVE 1/1/98

	
   

  
	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED RISK/HOSPITAL

  CAPITATED SERVICES

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Drugs, including Epogen, Napugen and
  adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COSMETIC SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

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

 

77

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  DIAGNOSTIC TESTING - Outpatient

  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS -
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS -
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED
  CARE/SKILLED

  NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPITAL
  BASED PHYSICIANS –

  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTIBLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

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

 

78

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF & GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Inpatient, Ambulatory

  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PRE
  ADMISSION -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  (within 72 hrs. or related
  admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Inpatient, Ambulatory

  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

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

 

79

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Related to an Outpatient
  Office Visit:

    Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Related to a Hospital
  Stay:

    Surgical Supplies, Equipment, etc..

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES, DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chem.
  Strips, Lancet, Needles, Syringes

  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY- Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY: Physical,
  Occupational,

  Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Exams and Medically
  Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Implanted Lenses
  (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • Lenses and Frames
  (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

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

 

80

 

ADDENDUM D

 

PREFERRED
PROVIDER ORGANIZATION (PPO)

EXCLUSIVE
PROVIDER ORGANIZATION (EPO)

POINT OF
SERVICE (POS)

 

BENEFIT
PROGRAMS

 

PPG understands that Affiliates or Payors contracted with FHS who are
qualified may provide PPO, EPO and POS Benefit Programs. FHS shall provide PPG
with a listing of all such Payors, as updated from time to time by FHS.
Notwithstanding any provision in this Agreement, PPG and Member Physicians
understand and agree that each Payor is solely responsible for paying PPG
and/or Member Physicians for those individuals to whom Payor provides health
care coverage. In no event shall FHS or any FHS Affiliate be responsible for
any payment which is the financial responsibility of a Payor and PPG shall seek
compensation for such services only from Pursuant to Section 8.18, Entire
Agreement, PPG understands and agrees that the compensation and provisions
under the agreement between PPG and the entity formerly known as Foundation
Health, a California Health Plan, is applicable to those PPO, EPO and POS
Members with Foundation Health Identification Cards and such agreement shall
remain in full force and effect for those PPO, EPO and POS Members. PPG shall
be compensated according to this Addendum D and this Addendum shall be
applicable to those PPO, EPO and POS Members with Health Net or other FHS
Affiliate Identification Cards.

 

A.            BENEFIT PROGRAM REQUIREMENTS

 

PPG agrees:

 

1.             That
all Member Physicians will comply with the terms and conditions of this
Addendum, the terms of the applicable Benefit Programs, and of the Operations
Manual.

 

2.             To
comply with FHS efforts to provide Case Management. PPG agrees to provide PPG’s
written treatment plan within five (5) working days of receipt of request from
FHS. A treatment plan includes a statement of diagnosis, current patient
condition, current or proposed treatment, and anticipated outcomes.

 

3.             That
if PPG admits or arranges for an inpatient admission to a non-Participating
Provider or facility for an elective procedure, PPG shall document that PPG has
given such Member prior notice of the following:

 

a)             Provider or facility is
non-participating;

 

b)            The non-Participating Provider or
facility will not be restricted to seeking payment only from FHS; and

 

c)             The non-Participating provider or
facility may bill the Member for amounts other than deductibles, Copayments,
and medical services not covered under the Member’s Coverage Certificate.

 

4.             That
PPG may appeal a Utilization/Care Management decision as set forth in the
Operations Manual.

 

5.             FHS
agrees that any determination under the Utilization/Care Management Program
that a Member’s services rendered by PPG were not Medically Necessary shall not
retroactively affect PPG’s right to payment hereunder if such services were
authorized by FHS prior to admission and the information provided by PPG to FHS
regarding the Member’s medical condition was substantially true and accurate.

 

81

 

B.            PPO AND EPO BENEFIT PROGRAMS

 

1.             Compensation Method.  As
compensation for rendering Contracted Services under this Addendum D, PPG shall
be paid in accordance with the rates set forth in Addendum E. Such compensation
shall be paid within the time and subject to the billing requirements set forth
in this Agreement. The above notwithstanding, for self-insured and other such
Payors, FHS shall not be obligated to pay all or any portion of any PPG claim
on a Payor’s behalf unless and until FHS has received sufficient funds from the
applicable Payor to cover such claim. In the event such Payor fails to provide
funds to FHS, PPG may seek payment from Member up to the rates specified in
Addendum E, unless prohibited by applicable law.

 

In the event that a PPG Participating
Physician enters into an independent contract arrangement with FHS for PPO
services, the rates established in such independent Physician Service Agreement
shall prevail, and claims will be adjudicated according to the fee schedule
established in said independent Agreement.

 

C.            POINT OF SERVICE BENEFIT PROGRAMS

 

1.             Benefit Program Design.  Under
a Point of Service Benefit Program, Members may elect, at the time of obtaining
each Covered Service, to utilize either: 
(1) HMO coverage through their selected or assigned PCP; (2) optional
Preferred Provider Organization (“PPO”) coverage available through PPO
Participating Providers; or (3) other indemnity coverage through either
non-Participating Providers, or Participating Providers where other Benefit
Program Requirements are not met.

 

2.             Compensation Method.  PPG
shall render Contracted Services on a fee-for-service basis to Members of FHS’
Point of Service Benefit Programs covered under the PPO option of such Benefit
Programs. As compensation for rendering such Contracted Services, PPG shall be
paid the fee-for-service compensation rates set forth in Addendum E. Such
compensation shall be paid within the time and subject to the billing
requirements set forth in this Agreement.

 

82

 

ADDENDUM E

 

FEE
-FOR-SERVICE COMPENSATION SCHEDULE

 

PPG or Member Physician shall
be compensated for non-capitated Contracted Services, less applicable
Copayments, in an amount equal to the lesser of: (a) ninety percent (90%)  of the Medicare allowable charges based
on the Medicare Resource Based Relative Value Scale (RBRVS) unit values and
HCFA Geographical Practice Cost Indices as published in the most current
published edition of the Federal Register; (b) *** of PPG’s allowable billed
charges; or (c) such other fee schedules as may be established or adopted from
time to time by FHS.

 

For
“by report” procedures, procedures not listed, or procedures with relativities
not established in RBRVS, PPG shall be compensated at *** of PPG or the
Participating Provider’s billed charges, less any applicable Copayment.

 

Anesthesiology
Services:

PPG or Participating Provider shall be
compensated for Contracted Services at (a) *** per unit value in the American
Society of Anesthesiology Relative Value study or (b) *** of the Participating
Provider’s billed charges, whichever is less.

 

Assistant
Surgeons:

PG
or Participating Provider shall be compensated for Contracted Services at ***
of the surgeon’s reimbursement as determined above.

 

Total
Obstetrical Care:   (for
HMO Benefit Programs)

 

	
  Total OB care, vaginal
  delivery

  	
   

  	
  $*** global rate

  
	
  Total OB care, Cesarean
  delivery

  	
   

  	
  $*** global rate

  

 

Services included in global
reimbursement (professional and technical component) for total OB care:

 

	
  Total
  OB care, vaginal delivery

  	
   

  	
  ***
  global rate

  
	
  Total OB care, Cesarean delivery

  	
   

  	
  $*** global rate

  

 

Services included in global
reimbursement for total OB care:

office
visits (sick care as well as routine)

consultations
including initial OB consultation

emergency
department visits

therapeutic
injections

amniocentesis

fetal
contraction stress test

fetal
non-stress test

fetal
monitoring, including initiation or supervision

version

delivery
of placenta

ultrasound

laboratory
tests

venipuncture

specimen
collection and laboratory supplies

educational
materials/nutritional counseling

OB
standby

other
services which do not warrant extra charge: delivery of twins/multiple births,
physician’s

supervision
of home care, hospitalization during pregnancy for conditions such as
pre-clempsia,

HTN

 

83

 

Antepartum
care only:

 

	
  First trimester only

  	
  $ ***

  
	
  Second trimester only

  	
  $ ***

  
	
  First and second trimester
  only

  	
  $ ***

  
	
  Third trimester excluding
  delivery

  	
  $ ***

  
	
  Third trimester including
  delivery

  	
  $ ***

  

 

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

84

 

ADDENDUM F

 

MEDI-CAL
BENEFIT PROGRAM

 

 

(NOT APPLICABLE)

 

85

 

ADDENDUM F.1

 

FEE-FOR-SERVICE
COMPENSATION SCHEDULE

 

ASSIGNED
AND UNASSIGNED MEDI-CAL HMO MEMBERS

 

 

(NOT APPLICABLE)

 

86

 

ADDENDUM F.2

 

CAPITATION
COMPENSATION SCHEDULE

 

 

(NOT
APPLICABLE)

 

87

 

ADDENDUM F.3

 

SHARED
RISK PROGRAM DISTRIBUTION MATRIX

 

 

(NOT APPLICABLE)

 

88

 

ADDENDUM F.4

DIVISION
OF FINANCIAL RESPONSIBILITY

MATRIX
OF FHS AND PPG RISK SERVICES

MEDI-CAL
BENEFIT PROGRAM

 

 

(NOT
APPLICABLE)

 

89

 

ADDENDUM F.5

 

DISCLOSURE
FORM

 

 

(NOT APPLICABLE)

 

90

 

ADDENDUM G

 

CHAMPUS/TRICARE
AND OTHER GOVERNMENT BENEFIT PROGRAMS

 

PPG understands and agrees
that the obligations of FHS set forth in this Addendum are the obligations of
Foundation Health Federal Service Inc., an Affiliate of FHS (“FHFS”), and not
obligations of FHS, or any other Affiliate of FHS. FHFS may contract with the
United States Department of Defense (“DoD”) to arrange for the provision of
health and administrative services to certain Members of the Civilian Health
and Medical Program of the Uniformed Services (“CHAMPUS), and may contract with
other local, Stale or federal agencies to arrange for the provision of health,
administrative and certain other services to the Beneficiaries of other local,
State and/or federal programs.

 

A.            CHAMPUS/TRICARE DEFINITIONS.
PROGRAMS AND REGULATIONS

 

1.             Member (Beneficiary).  A
person who is eligible to receive Covered Services under the FHFS Benefit
Program included in this Addendum, including a newborn baby who is a dependent
of Member during the first 120 days following the baby’s birth and/or 120 days
following legal adoption,

 

2.             Copayment and Cost Shares.  That
portion of the cost of Covered Services that a Member is obligated to pay under
a particular Benefit Program, including a deductible and co-insurance. A
Copayment is a fixed dollar amount. A Cost Share is a percentage of the
applicable Participating Provider contract rate. FHFS will advise Participating
Providers of the amounts or methods by which Copayments and/or Cost Shares may
be determined and/or as outlined in the TRICARE Network Provider Manual.

 

3.             Primary Care Manager (PCM), is a TRICARE Prime military/civilian network
PPG or network clinic site, or clinic site at a Military Treatment Facility
(MTF) whose primary responsibility is to coordinate and manage the delivery of
Covered Services to Members selected or assigned to such PPG.

 

4.             Supplemental Care.  FHFS
will work with MTF (Military Treatment Facility) Commanders to define
Supplemental Care needs and to extend CHAMPUS/TRICARE contract rates to the
MTF’s for those services.

 

B.            CHAMPUS/TRICARE PROGRAMS AND
REGULATIONS

 

1.             CHAMPUS/TRICARE Programs. 
CHAMPUS/TRICARE Programs are those services and benefits which require
the use of the services of a contracted medical provider network and are
purchased by the United States Government through the authorized agency
pursuant to Chapter 55 of Title 10 of the United States Code and the
regulations promulgated thereunder.

 

2.             CHAMPUS/TRICARE Regulations.  FHFS
is obligated to comply with all applicable CHAMPUS/TRICARE regulations,
operations manuals, Automated Data Processing manuals, policy manuals and the
prime contract technical proposals, and with the American Disabilities
Act.  These document provide a
comprehensive description of the applicable CHAMPUS/TRICARE program benefits
and operational requirements.  The
parties to this Addendum acknowledge that all services rendered by PPG
hereunder are governed by such requirements. 
FHFS shall provide PPG with all information regarding such requirements
as necessary for proper compliance.

 

3.             CHAMPUS/TRICARE Term.  Term
of this Agreement will remain in effect as defined in Section 6.1, unless the
term of Foundation Health Federal Services’ prime contract expires or is
pursuant to termination by the Government of Foundation Health Federal
Services’ prime contract to provide health services.

 

91

 

C.            OTHER GOVERNMENTAL PROGRAMS.  FHFS may contract with local,
State or federal entities to provide medical delivery programs such as
universal health care programs, or other Benefit Programs for which FHFS has
contracted with a Payor to provide Participating Provider networks, or certain
Covered Services.  PPG shall render
Contracted Services covered under such other governmental benefit programs, and
shall bill and accept payment from FHFS or a Payor as payment in full for such
services, except for applicable Copayments as set forth in this Addendum.

 

D.            PROVIDER OBLIGATIONS

 

1.             Contracted Services.  PPG
shall provide Covered Services to Members of CHAMPUS/TRICARE, CHAMPUS/TRICARE
Supplemental Care in accordance with the terms and conditions of those
programs. PPG shall be solely responsible for the quality of Covered Services
rendered by PPG to Members. PPG must be contracted and accept assignment for
both CHAMPUS/TRICARE and Medicare as Participating Providers in order to render
services to CHAMPUS/TRICARE Members. FHFS shall provide PPG with the Benefit
Program Requirements of the CHAMPUS/TRICARE, and CHAMPUS/TRICARE Supplement.
Such Benefit Program Requirements may include Utilization Care Management
Program and Quality Improvement Program requirements with which PPG shall
comply in rendering Covered Services under this Agreement. PPG and/or office
staff is obligated to attend a PPG seminar and/or agree to have read the
TRICARE Network Provider Manual prior to rendering Covered Services under this
Agreement. Participating Providers shall monitor the accessibility of care to
Enrollees, and adhere to the following standards: a) office wait times for
non-emergencies shall not exceed 30 minutes; b) wait times for appointments
shall not exceed 4 weeks for well visits, 1 week for routine visits, nor 1 day
for acute illness.  Participating
Providers shall comply with the FHFS’ reasonable efforts to monitor and
evaluate same.

 

2.             Specialty Providers.  FHFS
requires all specialty providers to request a CHAMPUS/TRICARE Prime Member to
sign a release of medical information at each visit, to include ancillary
services associated with each visit whereby the PCM and/or the MTF Commanders
are designated as the recipients of the medical records. Specialty providers
are required to submit the medical records to the PCM and/or MTF Commander
within 14 days for all routine referrals.

 

3.             Eligibility. 
Except in an Emergency, PPG shall verify the eligibility of Members
before providing Covered Services. FHFS shall make a good faith effort to
confirm the eligibility of any Member when such is in question.  Eligibility of all CHAMPUS/TRICARE and other
governmental program Members may be verified by the designated agent of such program
(e.g., Defense Enrollment Eligibility Reporting System). However, if the
designated agent initially indicates that a patient is a Member under the
applicable CHAMPUS/TRICARE or other governmental program, and that patient is
later determined to be ineligible at the time of service, then FHFS shall deny
any claims for payment due to non-eligibility, and PPG may seek compensation
from the patient or the patient’s other health insurance coverage.

 

4.             Access Requirements.  When
required by a particular CHAMPUS/TRICARE program, PPG understands that the
Military Treatment Facility (MTF) is the first resource for health care for
CHAMPUS/TRICARE Members, and that Members gain access to the civilian
CHAMPUS/TRICARE provider network only through referral of the Health Care
Finder Program, or a Member’s Primary Care Manager (“PCM”), in coordination
with the Health Care Finder (HCF) Program. 
PPG agrees to provide services to CHAMPUS/TRICARE Members for
non-emergency services only after obtaining appropriate Referral by Member’s
PCM, and/or prior authorization through the HCF Program.

 

5.             Benefit Program Phase-Out.  PPG
agrees to use its best efforts to submit all CHAMPUS/TRICARE claims within 30
days from date of service or discharge during the Phase-out period of a DoD
prime contract.

 

92

 

6.             Active Duty Personnel.  When
required under a DoD prime Contract, PPG shall render Covered Services to
United States military active duty personnel and seek compensation from the
appropriate service organization at the same rates as provided in this
Addendum.  If the Active Duty Service
Member is enrolled in TRICARE Prime under the Geographic Separate Unit (GSU)
Program Provider shall seek compensation from FHFS

 

7.             CHAMPUS/TRICARE Quality and
Utilization Review Programs.  PPG agrees to comply with all
provisions of the CHAMPUS/TRICARE Quality and Utilization Review programs,
including the provision of medical records and other documentation for cases
being reviewed by FHFS or another CHAMPUS/TRICARE contractor in compliance with
these programs.  PPG further authorizes
such CHAMPUS/TRICARE National Quality Monitoring Contractors to release all
review data obtained through medical record and other document audit to FHFS.
(Per TRICARE Network Provider Manual, approved by DoD.)

 

8.             Prior Authorization and
Referrals.  Unless a particular Benefit Program or
Utilization/Care Management Program contains no such requirement, and except in
an Emergency, PPG agrees not to seek payment from FHFS or a Payor for Covered
Services rendered to a Member unless Prior Authorization or a Referral was
obtained for the rendering of such services. Such Prior Authorization or
Referral may be issued by FHFS, or the applicable Payor. If Prior Authorization
or a Referral cannot be obtained, PPG agrees to notify FHFS or the applicable
Payor and the appropriate Participating Provider, as applicable, as soon as
possible, but no later than twenty-four (24) hours after providing the Covered
Services, or ordering the other Covered Services, or on the next working day.
(See TRICARE Network Provider Manual.)

 

9.             Conditions for Reimbursement for
Non-Covered Services.  Neither a Member nor FHFS, nor any Payor
shall be liable to pay PPG for any Contracted Services rendered by PPG to a
Member which is determined under a Utilization/Care Management Program not to
be Medically Necessary.  Provided,
however, PPG may bill a Member for non-Covered Services rendered by PPG to such
Member only if the Member is notified in advance that the services to be
provided are not Covered Services under the Member’s Benefit Program and the
Member requests in writing that PPG render the non-Covered Services prior to
the rendition of such services.

 

10.          Coordination of Benefit. 
Notwithstanding any other provision of this Agreement, PPG agrees to
conduct Coordination of Benefits in accordance with the policies and procedures
established by FHFS or a Payor for the applicable Benefit Program, PPG shall
not bill Member for any portion of Covered Services not paid by the primary
carrier when FHFS or a Payor is the secondary carrier, but shall instead seek
compensation from FHFS or Payor for such service. When a Member has coverage
which is primary through another carrier, then FHFS’ or a Payer’s compensation
to PPG shall be limited to the difference between the amount paid by the
primary carrier and the contract rates, including Copayments and cost shares.

 

11.          Name or Logo.  In no
event shall PPG market or advertise the CHAMPUS/TRICARE Program or other
governmental programs without the prior written consent of FHFS.

 

E.            CHAMPUS PRIME AND EXTRA BENEFIT
PROGRAMS AND COMPENSATION

 

1.             Fee-for-Service Contracted
Services.  PPG shall render Contracted Services to
Members of CHAMPUS/TRICARE Programs, including the TRICARE Prime and TRICARE
Extra Programs and shall accept as payment in full, the lesser of: a negotiated
percentage of CMAC (CHAMPUS Maximum Allowable Charges, not to exceed 100% of
such charges), or the rates set forth in this Addendum G for Covered Services
and all other services (including payment for any and all sales, use or other
applicable taxes on the sale or delivery of medical services) rendered under
this Agreement to Members, less Copayment or Cost Share amounts payable by
Members in accordance with the Benefit Program. Such compensation shall be paid
within 30 working days of receipt by FHFS of a complete and accurate claim for
Contracted Services rendered to a Member in accordance with the provisions of
this Agreement. In the case where preauthorization is required, but not
obtained prior to services

 

93

 

being rendered, the claim
will be denied.

 

2              Compensation.  Compensation to PPG for the delivery of
Medically Necessary Covered Contracted Services will be the lesser of *** of
the CHAMPUS Maximum Allowable Charges or *** of billed charges for those
services which have a defined Allowable. 
If there is no CMAC reimbursement defined for a procedure code,
reimbursement will be at the lesser of *** of billed charges or *** of the
CHAMPUS area prevailing rates.  Services
for which a procedure code has not been assigned, or are unvalued by
CHAMPUS/TRICARE, compensation will be the lesser of Average Wholesale Price
minus *** or *** of billed charges.

 

3.             Recoupment.  In accordance with Section 4.3 (d) of this
Agreement, FHFS shall have the right to conduct recoupments from PPG for
amounts owed to FHFS per the CHAMPUS Operations Manual.

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

94

 

ADDENDUM H

 

OCCUPATIONALLY
ILL/INJURED OR WORKERS’ COMPENSATION BENEFIT

PROGRAMS

 

 

FHS shall contract with
Payors, which may include Affiliates of FHS, to provide Occupationally
Ill/Injured or Workers’ Compensation Benefit Programs for Members for work
related injuries and diseases compensable under State Occupationally
Ill/Injured or Workers’ Compensation law. PPG shall render Contracted Services
to Members for occupational illnesses and injuries covered such Benefit Programs.
FHS shall provide PPG with a listing of all such Payors, as updated from time
to time by FHS, including those Payors for whom FHS serves only in an
administrative capacity. The listing shall include the Payors’ utilization
management administrator and claims administrator when such is not FHS.

 

A.            COMPENSATION.

 

1.             Billing and Payment.  As
compensation for the delivery of Contracted Services, limited as described
above, PPG shall be paid in accordance with the rates set forth below. Such
compensation shall be paid within the time and subject to the billing
requirements set forth in Section 3.2 of the Agreement.  The above notwithstanding, for self-insured
and other such Payors, FHS shall not be obligated to pay all or any portion of
any PPG claim, as allowed by applicable law, unless and until FHS has received
sufficient funds from the applicable Payor to cover such claim.  Physician claims shall be coded and submitted
according to the Official California Workers’ Compensation Medical Fee Schedule
(Fee Schedule).

 

2.             Rates. 
Reimbursements under the Agreement shall be the lessor of:   (a) the physician’s usual and customary
charges (“UCR”); (b) *** of the Fee Schedule adopted by the State of California
department of Industrial Relations, Division of Workers’ Compensation; or  (c) 
the allowable charge based on the Medicare Resource Based Relative Value
Scale (RBRVS) unit values and HCFA Geographical Practice Cost Indices.

 

“By
report” procedures, unlisted procedures and relativities not established in RBRVS
shall be subject to FHS’ review and based upon relative complexity shall be
assigned a unit value and subsequently reimbursed in accordance with the HCFA
Cost Indices. If a unit value cannot be reasonably determined, reimbursement
shall be at 60% of billed charges.

 

B.           OTHER DUTIES

 

1.             Requirement for Eligibility
Verification and Service Authorization.  The
applicable Occupationally Ill/Injured or Workers’ Compensation Utilization/Care
Improvement Programs may require PPG to: (a) verify Member eligibility to
receive Contracted Services; (b) verify that the Member’s injury or disease has
been determined to “arise out of and in the course of employment”; (c)
determine the requested treatment is Medically Necessary to cure and relieve
the work-related condition; and (d) obtain a referral or prior authorization to
provide Contracted Services prior to rendering such services.  PPG agrees to comply with all
requirements.  FHS shall advise PPG of
all applicable Utilization/Care Improvement Program requirements.

 

2.             Reports.  PPG
agrees to furnish, upon request, all information reasonably required by FHS or
a Payor to verify and provide written substantiation of the provision of
Contracted Services, and the charges for such services.

 

3.             Return to Work.  In
addition to Contracted Services, and without further compensation from FHS or a
Payor, PPG shall work with FHS and each Payor to develop a return-to work
program for each Member.

 

95

 

ADDENDUM H.1

 

OCCUPATIONALLY
ILL/INJURED OR WORKERS’ COMPENSATION RATE SCHEDULE

 

Physician
claims shall be coded and submitted according to the Official California
Workers’ Compensation Medical Fee Schedule (Fee Schedule). Reimbursements under
the Agreement shall be the lesser of: (a) the physician’s usual and customary
charges (“UCR”); (b) *** Schedule adopted by the State of California Department
of Industrial Relations, Division of Workers’ Compensation; or (c) the
allowable charges based on the Medicare Resource Based Relative Value Scale
(RBRVS) unit values and HCFA Geographical Practice Cost Indices as published in
the most current published edition of the Federal Register.

 

HCFA Has not developed a geographically adjusted fee schedule for
anesthesiology. Anesthesiology is reimbursed based upon CPT-4 codes. FHS is
following HCFA guidelines for Anesthesiology (American Society of
Anesthesiologists (ASA) guidelines). The HCFA conversion factor will be
multiplied by an adjustment factor to equate reimbursement to *** per unit.

 

For
“by report” procedures, procedures not listed, or procedures with relativities
established in RBRVS, PPG will be compensated at sixty percent (60%) of PPG’s
billed charges not to exceed usual, reasonable, and customary charges, less any
applicable Copayment. Usual, reasonable, and customary means the usual charge
made by a physician or supplier of services, medicines, or supplies and will
not exceed the general level of charges made by others rendering or furnishing
such services, medicines, or supplies within an area in which the charge is
incurred for sickness or injuries comparable in severity and nature to the
sickness or injury being treated. The term “area” as it would apply to any
particular service, medicine or supply means a county or such greater areas as
is necessary to obtain a representative cross section of level of charges.

 

Unlisted
procedures shall be subject to FHS' review and, based upon relative complexity,
shall be assigned a unit value and subsequently reimbursed in accordance with
the above conversion factors.  RBRVS is
updated and modified from time to time.

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

96

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