Document:

Exhibit 10.149

 

2001

 

HNI

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

NORTHWEST ORANGE COUNTY

MEDICAL GROUP

 

1 Year Agreement

 

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

 

 

TABLE OF CONTENTS:

 

	
  RECITALS

  	
   

  
	
   

  	
   

  
	
  DEFINITIONS

  	
   

  
	
   

  	
   

  
	
  REPRESENTATIONS AND
  DUTIES OF PPG

  	
   

  
	
   

  	
   

  
	
  DUTIES OF HNI

  	
   

  
	
   

  	
   

  
	
  COMPENSATION

  	
   

  
	
   

  	
   

  
	
  DELEGATION

  	
   

  
	
   

  	
   

  
	
  TERM
  AND TERMINATION

  	
   

  
	
   

  	
   

  
	
  RECORDS,
  AUDITS AND REGULATORY REQUIREMENTS

  	
   

  
	
   

  	
   

  
	
  GENERAL PROVISIONS

  	
   

  
	
   

  	
   

  
	
  ADDENDUM A

  	
   

  
	
   

  	
  Benefit Programs

  	
   

  
	
   

  	
  Affiliates

  	
   

  
	
   

  	
  Main/Satellite
  Offices

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM B

  	
  COMMERCIAL HMO AND POS

  	
   

  
	
   

  	
  A.

  	
  General Reimbursement
  Provisions

  	
   

  
	
   

  	
  B.

  	
  Standard HMO

  	
   

  
	
   

  	
  C.

  	
  Small Group HMO

  	
   

  
	
   

  	
  D.

  	
  Individual HMO

  	
   

  
	
   

  	
  E.

  	
  Access for Infants and
  Mothers

  	
   

  
	
   

  	
  F.

  	
  Medicare
  Supplement

  	
   

  
	
   

  	
  G.

  	
  Commercial POS

  	
   

  
	
   

  	
  H.

  	
  QCIP

  	
   

  
	
   

  	
  I.

  	
  Pharmacy Shared Risk
  Program

  	
   

  
	
   

  	
   

  
	
   

  	
  ADDENDUM B.1

  	
  AGE, SEX AND BENEFIT PLAN FACTORS

  	
   

  
	
   

  	
   

  
	
   

  	
  ADDENDUM B.2

  	
  COMMERCIAL HMO and POS DIVISION OF
  FINANCIAL

  FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  
	
  ADDENDUM C

  	
  MEDICARE HMO AND POS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM D

  	
  PPO, EPO AND POS

  	
   

  
	
   

  	
   

  
	
   

  	
  A.

  	
  Benefit Program
  Requirements

  	
   

  
	
   

  	
  B.

  	
  POS Benefit Programs

  	
   

  
	
   

  	
  C.

  	
  Medicare Select
  Benefit Program

  	
   

  
							

 

1

 

	
  ADDENDUM E

  	
  FEE FOR SERVICE COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F

  	
  MEDI-CAL BENEFIT PROGRAM

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM G

  	
  CHAMPUS/TRICARE

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  
	
   

  	
  B.

  	
  Programs and
  Regulations

  	
   

  
	
   

  	
  C.

  	
  Other Governmental Programs

  	
   

  
	
   

  	
  D.

  	
  Provider
  Obligations

  	
   

  
	
   

  	
  E.

  	
  CHAMPUS PRIME
  and EXTRA Benefit Programs and Compensation

  	
   

  
	
   

  	
   

  
	
  ADDENDUM H

  	
  WORKERS COMPENSATION BENEFIT PROGRAM

  	
   

  
						

 

2

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

This
Participating Physician Group Provider Services Agreement (“Agreement”) is made
and entered into by and between the Health Net, Inc. Affiliate(s) (“HNI”)
identified in Addendum A to this Agreement and Northwest Orange County Medical
Group, a Participating Physician Group (“PPG”), to be effective June 1, 2001.

 

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

 

C.                                     HNI 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:

 

1.                                      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 Health Net, Inc., a Delaware corporation, owns 51% or more of
the voting stock, or which is managed by HNI or a HNI subsidiary.  The Affiliates provide, arrange for, or
administer one or more Benefit Programs covered under this Agreement.

 

1.2                               Benefit Program.  HNI’
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
HNI.  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. A 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

 

3

 

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 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 time.

 

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.  HNI 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 HNI 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 1” 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,

 

4

 

illness or injury; and

 

(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 Coverage Certificate 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 HNI, as updated
from time to time, which are incorporated in this Agreement by this
reference.  PPG agrees to be
contractually bound to comply with the Operations Manual, including the medical
policy manuals, and any updates or revisions to such, to be issued to PPG.  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 HNI 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 HNI 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 HNI 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.

 

5

 

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

 

1.24                        Prior Authorization.  The
written approval by HNI, 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 HNI standards, approved by HNI, 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 HNI as set forth in the applicable Addendum.

 

1.29                        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.

 

1.30                        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.

 

1.31                        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 HNI’ standards and is

 

6

 

approved by HNI and designed to
review and manage the utilization of Covered Services, as described more fully
in the Operations Manual.

 

II.                                     REPRESENTATIONS AND DUTIES OF PPG

 

2.1                               Representations 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 HNI, 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 HNI 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 HNI 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 HNI.  If more than one
such provider uses the same federal tax identification number, PPG shall
include the professional practice name registered with such number.  HNI shall notify PPG of all such Member
Physicians and Participating Providers approved by HNI.  PPG shall provide HNI 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 HNI.  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.

 

7

 

(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 HNI or Members and shall hold them harmless for such services regardless
of whether or not payment is received from PPG or HNI.

 

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

 

(4)                                  Conforming to the drug dispensing guidelines
set forth in the Operations Manual or HNI’ 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 HNI’ 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 HNI’ processing of retroactive
eligibility changes as set forth in this Agreement.

 

(10)                            Conforming with HNI’ 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 HNI with
all PPG’s contracting templates for HNI’ review 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 HNI’ request.  PPG shall furnish
HNI 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 including medication treatment options, regardless of benefit
coverage limitations.  In the event PPG
enters into a contract with a Participating Provider, PPG will provide HNI 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 HNI or PPG which Member Physician believes is
not consistent with the provision of quality medical care to Members.

 

(d)                                 As requested or required by HNI, PPG shall
maintain and make available to HNI, 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

 

8

 

and Human Services (“DHHS”) and
any other regulatory agency having jurisdiction over HNI, copies of PPG’s
policies and procedures and all Participating Provider subcontracts and any
amendments thereto.

 

(e)                                  To the extent that a PPG maintains economic
profiles, as defined in Health and Safety Code Section 1367.02 (d), of its
contracting Member Physicians, it shall, upon request, provide a copy of the
individual economic profiling information to the Member Physicians who are
profiled.  Such profiling information
shall be provided to a Member Physician upon request until sixty days after the
date the contract between the PPG and such Member Physician terminates.

 

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.

 

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

 

In
the event PPG adds new or satellite facilities, except by acquisition or
merger, or a new Member Physician(s), PPG shall notify HNI in writing as soon
as possible but at least sixty (60) days before such addition is effective with
HNI.  PPG acknowledges and agrees that
HNI shall have the right to determine whether the new or satellite facilities
or the new Member Physician(s) are acceptable to HNI.  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 HNI has approved such facility or Member Physician.  PPG understands and agrees that if satellite
does not meet HNI’s standards, HNI may deny participation.  HNI shall not unreasonably deny the approval
of new Member Physicians when credentialing standards are met.  HNI 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
HNI’ decision regarding the foregoing shall be final and binding.

 

PPG
further understands and agrees that HNI may deny participation under this
Agreement to any new Member Physician(s). 
HNI shall afford Member Physician such rights to appeal and due process,
if any, as required by State and federal law.

 

2.5                               Member Physician Termination. 
Whenever possible, PPG shall notify HNI in writing at least sixty (60)
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 sixty (60) days prior written notice is not possible, PPG shall
provide as much advance notice as possible. 
PPG shall immediately notify HNI 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.

 

HNI
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 HNI with an explanation of HNIs decision 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

 

9

 

foregoing, if a Member
Physician is found guilty of a criminal offense, is barred or sanctioned from
participation under the Medicare program, or if HNI makes a determination, at
its sole discretion, that treatment by a Member Physician may jeopardize the
health and safety of any Member, PPG, upon HNI’ 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. 
HNI 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 HNI financially
responsible for Covered Services rendered to any person who was not eligible
for HNI benefits as determined by HNI, except as set forth in Section 4.4 of
this Agreement.  Reasonable efforts to
verify eligibility shall be considered to include reviewing the most current
eligibility list and comparing it to the member’s ID card.

 

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 HNI on a regular basis as set
forth in the Operations Manual.  HNI
shall have the right, upon advance written notice, to audit PPG’s reported
performance.

 

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, HNI, 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 HNI 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
HNI’ 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 Contracted Services under this Agreement, in accordance
with State law and as reasonably requested by HNI.  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,

 

10

 

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 make best efforts to
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.

 

During
the term of this Agreement, Provider and its subcontractors shall not
unlawfully discriminate against any employee or applicant for employment
because of race, religious creed, color, national origin, ancestry, physical
disability, mental disability, medical condition, marital status, age (over 40)
or sex.  Provider and its subcontractors
also shall ensure that the evaluation and treatment of their employees and
applicants for employment are free of such discrimination.  Provider and its subcontractors shall comply
with the provisions of the Fair Employment & Housing Act (California
Government Code, Section 12990 et seq.) and the applicable regulations
promulgated thereunder (California Code of Regulations, Title 2, Section 7285.0
et seq.).  The applicable regulations
of the Fair Employment &  Housing
Commission implementing Government Code, Section 12990, set forth in Chapter 5
of Division 4 of Title 2 of the California Code of Regulations are incorporated
into this Agreement by reference and made a part hereof as if set forth in
full.  Provider and its subcontractors
shall meet the requirements of all other laws and regulation, including Title
VI of the Civil Rights Act of 1964, the Age Discrimination Act of 1975, the
Americans with Disabilities Act, and all other laws applicable to recipients of
Federal funds.  Provider and its
subcontractors shall give written notice of their obligations under this clause
to labor organizations with which they have a collective bargaining or other
agreements.

 

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 HNI’ 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.  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.  HNI may, at its sole
discretion, delegate certain Utilization/Care Management Program
activities.  If so determined qualified
and delegated by HNI, 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 HNI Members for any such program offered by HNI.

 

Prior
authorizations or referrals may be issued by HNI, PPG, a Participating
Provider, or Member Physician in accordance with the applicable Benefit
Program.  For non-emergent services, PPG
or Participating

 

11

 

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 in an Emergency, PPG agrees to notify HNI and the
appropriate Participating Provider, as soon as possible, but no later than
twenty-four (24) hours after admission. 
In the event PPG fails to obtain an authorization or a referral, PPG
agrees not to seek payment from HNI or a Payor for Contracted Services rendered
to a Member unless prior authorization or a referral was obtained.

 

2.14                        Notification of Institutional
Services.  PPG shall notify HNI 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 HNI.  In the event of an Emergency admission, PPG shall notify HNI
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
HNI is obligated to pay for services which HNI determines are the financial
responsibility of PPG or which it would not otherwise be obligated to pay, HNI
shall have the right to deduct the cost of such services from any amounts due
to PPG.  HNI agrees not to deduct any
amount as set forth in this Section without first giving PPG fifteen (15) days
prior written notice during which time PPG shall have the opportunity to show
cause why such amount should not be deducted by HNI.

 

2.16                        Catastrophic Cases.  PPG
shall actively participate with HNI 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 HNI of
all known or suspected catastrophic cases, obtaining prior authorization from
HNI for organ transplantation evaluations and organ transplantations, and
utilizing regional centers designated by HNI 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.

 

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 HNI 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,
HNI 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)

 

12

 

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 HNI.

 

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 HNI 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 HNI, 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 HNI
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 HNI in writing, within five (5) 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 HNI 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 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 HNI as an additional insured.  Notification to HNI by PPG of cancellation or
material modification of the risk protection program shall be made to HNI 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 HNI 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.

 

13

 

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 the term of this Agreement or
after the term of this Agreement for a period of twelve (12) months, solicit
any Member to enroll in any other health care service plan or insurance program
for the primary purpose of securing financial gain.  HNI 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 HNI 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 HNI with all corrections to and revisions of such encounter
data.  HNI 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 HNI 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 HNI and shall provide Covered Services
pursuant hereto.  HNI shall determine
appropriate actuarial values, consistent with existing actuarial assumptions,
in order to compensate PPG.  If the
parties are not able to resolve the issue, both parties agree to use the
dispute mechanisms outlined in section 8.5 to resolve issues.

 

III.                                 DUTIES
OF HNI

 

3.1                               Enrollment List.  HNI
shall provide PPG with a list of HMO Members assigned to PPG via electronic
transmission or magnetic media by the 12th of each month.  HNI shall maintain a system to allow PPG and
Member Physicians to make telephonic or electronic inquiries regarding Member
eligibility.

 

3.2                               Administration.  HNI
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.  HNI shall not interfere with the
professional relationship between any Member and his or her Member
Physician(s).  In no event shall HNI
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.

 

14

 

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

 

3.5                               Timely Assignment of Members.  HNI
shall require Members to select a PCP and/or a participating physician group at
the time of enrollment when required under a Benefit Program.  HNI may assist Members in such selection by
providing information, as determined by HNI, regarding PCPs and physician
groups.  Nothing in this Agreement shall
be construed to require HNI 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.  HNI
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 HNI; provided, however, that PPG
agrees to cooperate in providing HNI with any information and assistance
reasonably required in connection therewith.

 

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

 

3.8                               Out-of-Area Services.  HNI
shall manage and coordinate out-of-area services.  PPG shall cooperate fully with HNI and shall provide any information
necessary to transfer Members back into the Service Area, including but not
limited to, notification to HNI 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.  HNI
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 HNI 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.  HNI
shall make reasonable efforts to market the Benefit Programs.  Nothing in this Agreement shall require HNI
to conduct any specific marketing activities on behalf of PPG or to identify
PPG in any specific HNI marketing or informational materials.

 

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 HNI 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,
HNI 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. 
HNI 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 governed under the provisions of Section 2.27.  If actuarial assumptions

 

15

 

materially affect PPG’s
compensation under this agreement, both parties agree to enter into good faith
negotiations regarding compensation to PPG. 
PPG and HNI shall meet and confer to resolve any disputes regarding
actuarial values and reimbursement levels to PPG for new or added benefit plan
designs.

 

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, HNI shall reimburse PPG pursuant to the
program set forth in the Operations Manual.

 

4.3                               Billing and Payment.

 

(a)                                  Billing.  PPG
shall submit to HNI via HNI 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 ninety (90) days of rendering Contracted
Services.  Where HNI is the secondary
payor under Coordination of Benefits, such ninety (90) 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 HNI, PPG shall submit reinsurance claims within sixty
(60) calendar days of the end of the annual reinsurance period.

 

HNI
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 HNI does not pay PPG for a claim not
timely submitted.

 

(b)                                 Payment. 
Unless a claim is disputed, HNI 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 HNI 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.  HNI shall have
the right to offset any amounts owed to HNI by PPG, including but not limited
to, amounts owed by PPG under loans guaranteed by HNI, errors, or HNI interim
payment for Contracted Services, including Capitation payments.  HNI agrees to provide PPG the opportunity to
review and dispute said offset. 
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 HNI nor offset against PPG Capitation; provided however, that HNI 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 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.  In no event shall PPG be required
to make any cash payment to HNI for any deficit in a shared risk program for
institutional services.

 

(e)                                  Reciprocity.  PPG
shall cooperate and develop arrangements with HNI and Participating Providers
to assure reciprocity of the rates for Covered Services for Members who are not

 

16

 

assigned to PPG.  HNI shall, where contractually available,
provide reciprocity to HNI rates for Covered Services provided to PPG’s
assigned Members.  HNI 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 HNI 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, HNI shall adjust Capitation accordingly, not to
exceed one-hundred and twenty (120) days. 
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 HNI, HNI 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 HNI is financially responsible,
HNI shall pay PPG at the fee-for-service rates in Addendum E when PPG supplies
HNI 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 HNI 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 HNI.

 

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 HNI coverage.  In the event
payment for such Contracted Services is obtained by HNI from a prior carrier as
an extension of benefits, HNI 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 HNI
receives notice of any additional charge, HNI 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 HNI,
insolvency of HNI, 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 HNI for Covered
Services provided pursuant to this Agreement. 
This provision shall not 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.

 

17

 

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 HNI of any third parry 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 HNI is the secondary carrier, but shall seek
payment from HNI.  When HNI is secondary
under the Coordination of Benefit rules, HNI 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 HNI which may occur under this Section shall be deemed to
be transferred from PPG to HNI 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 HNI’ policies set forth
in the Operations Manual.

 

4.9                               Third Party Recoveries,
Worker’s Compensation.  In the event PPG provides services to HNI
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 full value
of Covered Services rendered pursuant to the applicable provisions of the
Coverage Certificate and as set forth in the Operations Manual.  PPG shall notify HNI of any third party
payor and shall, upon request from HNI, provide HNI with an accounting of all
such sums recovered.  In the event HNI
has compensated PPG for such Covered Services, PPG agrees to immediately refund
such amounts paid to HNI.

 

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

 

4.11                        Reinsurance.  For
selected Benefit Programs, HNI 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.  HNI shall charge
PPG a premium in consideration for these programs.  Notwithstanding any other provision in this Agreement, HNI 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 HNI 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 HNI and State and federal law from a third party insurance carrier
acceptable to HNI.  If HNI 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, HNI
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 with the procedures set forth in the Operations Manual but no later
than sixty (60) calendar days

 

18

 

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 HNI, HNI’
contract rate shall be utilized; or (iv) the actual charges paid by PPG when
none of the above applies.  HNI shall
compensate PPG for claims in excess of the stop loss threshold at eighty
percent (80%) 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 HNI, PPG
shall accept delegation of and perform such utilization management,
credentialing and recredentialing, medical record review, and capitation and
claims adjudication functions, in accordance with the performance standards and
criteria of HNI 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.  HNI
shall have the right to audit PPG’s performance of utilization management,
credentialing and recredentialing, medical record review, and capitation and
claims adjudication functions from time to time.  If HNI determines that deficiencies exist in PPG’s performance,
PPG shall accept consulting assistance from HNI.  Failure to cure any identified deficiencies within a reasonable
period of time as defined by HNI policies, or if HNI determines PPG does not
have the ability to perform delegated functions, or is not effectively
performing delegated functions, HNI 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 HNI to
reassume delegated functions, HNI shall charge the following administrative
fees: utilization management 2.5% of PPG Capitation; credentialing 2.5% of PPG
Capitation; and claims processing 2.5% 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 twelve (12) 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.  After
the initial twelve (12) months, Provider may terminate this Agreement upon one
hundred and twenty (120) days prior written notice.  HNI may terminate this Agreement at the scheduled renewal date
upon one hundred twenty (120) days prior written notice.  In the event HNI provides PPG with such
notice, HNI may, at its option, begin to transition Members immediately under
this Agreement to another Participating Provider after such notice.

 

6.3                               Immediate Termination.  HNI
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 correct
within the notice period and comply with the terms, conditions or
determinations of any Utilization/Care Improvement Program or Quality
Improvement Program, or Benefit Program; or, (d) HNI’ determination that the
health, safety or welfare of any Member may be in jeopardy if this Agreement is
not terminated.

 

19

 

6.4                               Termination for Failure to
Pay.  In the event HNI 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 immediately upon notice to HNI, but
only if HNI 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 HNI 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 HNI 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 HNI ceases to own fifty-one percent (51%) or more of the voting
stock, or to manage or have a HNI subsidiary manage, an entity, such entity
shall cease being a HNI Affiliate hereunder. 
Effective on the date HNI ceases to own fifty-one percent (51%) or
manage, or an HNI 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.

 

In
the event the terminated Affiliate under this Section 6.6 is a licensed health
care service plan, such Affiliate and PPG understand and agree that Sections
6.7, 6.8 and 6.9 of the Agreement shall apply to such Affiliate and the Members
of such Affiliate.

 

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 HNI.  Compensation for such
Contracted Services shall be at the rates contained in Addendum E.  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 sec forth in this Article, HNI may, if it
reasonably believes that Provider will not fulfill its obligations under this
Agreement to pay other Participating Providers for providing Covered Services,
withhold up to twenty percent (20%) of each of the final three months of
Capitation due PPG.  If HNI exercises
its option to transition HMO Members prior to the end of the termination notice
period, HNI may withhold the entire last month’s Capitation.  HNI may use such funds to offset any PPG
liability to HNI or for payment of PPG Capitated Services on behalf of
PPG.  HNI 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 HNI to withhold any Capitation shall
not relieve PPG of its obligations to perform under this Agreement.  All amounts withheld by HNI 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 HNI
decides to

 

20

 

withhold Capitation from PPG as
set forth in this Section, HNI may, upon three days prior written notice to
PPG, administer or oversee all or part of PPG Capitated Services on behalf of
PPG.  PPG agrees to fully cooperate with
HNI in the administration of such claims, including providing all necessary
information, and to take no action which may 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 HNI 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 HNI 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 HNI’s findings, the parties shall meet
and confer to resolve such differences.

 

6.10                        Survivability of Terms. 
Notwithstanding any other terms or provisions of this Agreement, the
parties understand and agree that certain Sections herein shall survive the
termination of this Agreement.  These
Sections include, but are not limited to, the following: 2.12, Utilization/Care
Management Program; 2.19, Member Grievance and Appeal Procedure; 2.24,
Non-Solicitation; 2.25, Encounter Reporting; 4.1, Compensation Rates; 4.3(a),
Billing; 4.3(c), Adjustments and Appeals; 4.3(d), Offsetting; 4.6, Collection
from Members; 4.7, Member Held Harmless; 4.8, Coordination of Benefits; 4.9,
Third Party Recoveries; Worker’s Compensation; 4.10, Audit of Claims; 6.7,
Effect of Termination; 6.9, Financial Settlement Upon Termination; 8.2,
Separate Obligations; 8.4, Confidentiality; 8.6, Binding Arbitration; 8.7,
Indemnification of Parties; 8.8, Status as Independent Entities; 8.10, Use of
Name.

 

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 HNI with all applicable local, State, and federal laws, rules and
regulations accreditation agencies.  PPG
agrees to the policies established by HNI that describe personal health
information, including medical records, claims benefits and other
administrative data that are personally identifiable.  The HNI policies include: provisions for inclusions in routine
consent, care and treatment of Members who are unable to give consent, member
access to their medical records, protection of privacy in all setting, use of
measurement data, information for employers and the sharing of personal health
information with employers.  The HNI
policies are further defined in the PPG Operations Manual.  PPG agrees to submit upon request such
reports and financial information as is necessary for HNI to comply with
regulatory requirements to monitor the financial viability of PPG.  PPG shall comply with all confidentiality
and Member record accuracy requirements.

 

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, HNI or its designated
representatives, and designated representatives of local, State, and federal
regulatory agencies having jurisdiction over HNI 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 HNI, to comply with local State and federal laws,
rules, regulation and agencies, PPG shall produce copies of any such records at
no cost.  Any additional requests by HNI
for records shall be compensated to PPG at three cents ($0.03) per page not to
exceed fifteen dollars ($15.00) per records.

 

21

 

In no event shall PPG charge for copying records requested for the
payment of claims.  Additionally, PPG
agrees to permit HNI, and its designated representatives, accreditation
organizations, and designated representatives of local, State, and federal
regulatory agencies having jurisdiction over HNI or any Payor, to conduct site
evaluations and inspections of PPG’s offices and service locations.  HNI shall use best efforts to provide
seventy-two (72) hours advance notice to PPG of such visit.

 

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, HNI and
Payors shall continue to have access to the other parry’s records as necessary
to fulfill the requirements of this Agreement and to comply with all applicable
laws, rules and regulations.

 

VIII.                        GENERAL PROVISIONS

 

8.1                               Amendments. 
Except as provided herein, HNI 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 HNI 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 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 HNI or any
HNI 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 HNI shall have the right to automatically assign this
Agreement to any entity which controls, is controlled by, or is under common
control with HNI.  PPG agrees to provide
prior written notice to HNI 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 HNI 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 shall use its best
efforts to assist HNI in obtaining agreements with its Participating
Providers.  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.  HNI
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

 

22

 

names, addresses and other
identifying information concerning Members and employers and other groups
contracting with HNI 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.  HNI 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.  HNI shall use such
information only as necessary and appropriate for the performance of its
obligations under this Agreement.  In
the event HNI could obtain such information from a source other than PPG, such
information shall not be proprietary to PPG. 
Neither PPG, a Member Physician, nor HNI 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.  HNI has established a Provider Dispute
Resolution Procedure under which PPG may submit disputes to HNI, 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 HNI 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 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.

 

23

 

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 HN1, 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)                                 HNI 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 HNI’ 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 HNI other than that of independent entities contracting with
each other solely for the purpose of effecting the provisions of this
Agreement.  Neither PPG nor HNI, 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 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.  HNI
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
HNI shall be entitled to list PPG’s information in any HNI provider directory.

 

8.11                        Non-Exclusive Contract.  This
Agreement is non-exclusive and shall not prohibit PPG or HNI 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 of responsibilities of PPG or HNI 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,

 

24

 

addressed as follows:

 

HNI

C/O
Health Net

21600
Oxnard Street

Woodland
Hills, California 91367

Attention:
Vice President, Provider Network Management

 

PPG:                       Northwest Orange County Medical Group

2600 Redondo Avenue

Long Beach, CA 90806

 

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 take
precedence and supersede the conflicting provision of this Agreement.

 

8.16                        Regulatory Approval.  If
HNI 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 HNI is
unable to obtain such licensure or regulatory approvals after due diligence,
HNI 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, HNI 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.

 

25

 

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.

 

	
  Northwest Orange County
  Medical Group

  	
  Health Net, Inc.  Affiliates

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  /s/ Pratihba
  Patel

  	
   

  	
  /s/
  Christopher Ciano

  	
   

  
	
  Signature

  	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  PRATIHBA
  PATEL, MD

  	
   

  	
  Christopher Ciano

  	
   

  
	
  Print Name

  	
   

  	
  Print Name

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  PRESIDENT

  	
   

  	
  Senior Vice President &
  General Manager - South

  Title

  
	
  Title

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  6/5/01

  	
   

  	
  06/21/01

  	
   

  
	
  Date

  	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Federal Tax Identification
  Number

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  PREMIER PHYSICIAN SERVICES

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  /s/ James P. Agronick CEO

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  6/5/01

  	
   

  	
   

  	
   

  

 

26

 

ADDENDUM
A

 

BENEFIT PROGRAMS AND AFFILIATES

 

I.                                         BENEFIT PROGRAMS

 

Benefit Program participation included under
this Agreement is as follows:

 

	
  BENEFIT PROGRAM

  	
   

  	
  ADDENDUM

  	
   

  	
  PPG

  PARTICIPATION

  Yes/No

  
	
  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

  	
   

  	
  No

  
	
  Medicare POS

  	
   

  	
  C

  	
   

  	
  No

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

  	
   

  	
  D
  (POS only)

  	
   

  	
  Yes

  
	
  Medicare Select

  	
   

  	
  D

  	
   

  	
  Yes

  
	
  Medi-Cal

  	
   

  	
  F

  	
   

  	
  No

  
	
  CHAMPUS

  	
   

  	
  G

  	
   

  	
  Yes

  
	
  Occupational Medicine

  	
   

  	
  H

  	
   

  	
  No

  

 

II.                            AFFILIATES

 

Upon
execution of this Agreement, the Affiliates primarily using this Agreement
include, but are not limited to, the following: Health Net; Health Net, a
California Health Plan; Health Net Life Insurance Company; Foundation Health
Federal Services Inc.; Foundation Health Medical Resource Management;
Foundation Integrated Risk Management Solution, Inc.; and Foundation Health
Systems 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 HNI 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.

 

27

 

III.                                 MAIN/SATELLITE OFFICES

 

	
  PPG#

  	
   

  	
  Main and Satellite Offices

  	
   

  	
  Addresses

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  689

  	
   

  	
  Main site

  	
   

  	
  2600 Redondo
  Ave., Long Beach, 90806

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  

 

28

 

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 HNI set forth in this Addendum are only the obligations of
Health Net (hereafter “HMO”) and not the obligations of HNI or any other
Affiliate of HNI. 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.

 

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.                                      Withhold Fund and
Determination of Maximum Downside of Shared Risk Deficits.  Notwithstanding
any provision in this Agreement or in any Addendum hereto to the contrary,
PPG’s total downside liability for all Shared Risk Budget deficits shall not
exceed ten percent (10%) of PPG’s gross annual Capitation.  Any and all Withhold Fund amounts as set
forth herein shall be applied to offset such total downside liability.

 

29

 

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 Capitation

  
	
   

  	
   

  	
   

  
	
  June 1, 2001

  	
   

  	
  *** PMPM

  
	
  January 1, 2002

  	
   

  	
  *** PMPM

  

 

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.

 

3.1                               Shared Risk Budget.  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.

 

	
  Standard

  HMO Shared Risk

  Budget

  	 

	
  *** PMPM

  

 

3.2                               Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct one percent (1 %) 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 Shared Risk claims exceed
the Shared Risk Budget at the interim settlement date, HMO may, withhold from
PPG’s gross monthly capitation up to *** of PPG’s monthly capitation and may
continue such withhold until the deficit amount is recovered.

 

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 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

 

30

 

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 twenty
percent (20%) 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 ten percent (10%) 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.

 

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

 

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 ***.

 

(c)                                  Transfer Reinsurance: *** PMPM, shall be
deducted from the Shared Risk Budget. *** eligible charges shall be charged
against the Shared Risk Budget.

 

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

 

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 eligible for
payment under this Program.

 

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

 

31

 

This Program shall cover eligible Members who
accumulate more than four thousand six hundred dollars ($4,600) in PPG
Capitated Services or thirty five thousand dollars ($35,000) in Shared Risk
Services.  Such threshold shall be
calculated using the most current Medicare allowable charges for PPG Capitated
Services or actual amount paid for Shared Risk Services and shall be
accumulated within one hundred eighty (180) days of the Member’s transfer to
PPG.  On a first dollar basis, this
Program shall cover *** of the allowed Program charges.  PPG shall be responsible for the remaining
*** Capitated Services.  Ten percent
(10%) of Shared Risk Claims shall be charged against the Shared Risk
Budget.  PPG shall submit claims to HMO
within ninety (90) calendar days of meeting the threshold.

 

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

 

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

 

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

 

	
  •   AIDS Reinsurance

  	
   

  	
   

  	
  *** PMPM

  
	
  •   Transfer Reinsurance

  	
   

  	
   

  	
  *** PMPM

  

 

5.                                      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 and Reinsurance Programs 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 Capitation

  
	
  June 1, 2001

  	
   

  	
  *** PMPM

  
	
  January 1, 2002

  	
   

  	
  *** PMPM

  

 

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.

 

32

 

3.                                      Shared Risk Budget.  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.

 

	
  Small
  Group

  HMO Shared Risk 

  Budget

  	 

	
  *** PMPM

  

 

 

3.2                               Shared Risk Administration.  As a contingency
for any PPG liability under this Shared Risk Program, HMO shall deduct one
percent (1%) 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 Shared Risk claims exceed the Shared Risk Budget
at the interim settlement date, HMO may, withhold from PPG’s gross monthly
capitation up to three percent (3%) of the PPG’s monthly capitation and may
continue such withhold until the deficit amount is recovered.

 

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) *** 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.

 

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

 

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 eighty percent (80%)
of allowed amount, and the remaining *** shall be charged against the Shared
Risk Budget.

 

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

 

33

 

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

 

(c)                                  Transfer Reinsurance:  *** PMPM, shall be deducted from the Shared
Risk Budget.  *** of eligible charges
shall be charged against the Shared Risk Budget.

 

4.                                      AIDS and Transfer 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

  
	
  •   Transfer Reinsurance

  	
   

  	
   

  	
  *** PMPM

  

 

 

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 Capitation

  
	
  June 1, 2001

  	
   

  	
  *** PMPM

  
	
  January 1, 2002

  	
   

  	
  ***
  PMPM

  

 

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.

 

3.1                               Shared Risk Budget.  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.

 

	
  Individual

  HMO Shared Risk 

  Budget

  	 

	
  *** PMPM

  	
   

  
			

 

34

 

3.2                               Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct one percent (1%) of PPG’s Capitation for Individual Members and place
such amount in the Withhold Fund as described in the Agreement.  In the event the Shared Risk claims exceed
the Shared Risk Budget at the interim settlement date, HMO may, withhold from
PPG’s gross monthly capitation up to three percent (3%) of the PPG’s monthly
capitation and may continue such withhold until the deficit amount is
recovered.

 

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 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) 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.

 

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

 

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: 5.45% of Shared
Risk Budget.

 

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

 

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

 

4.                                      AIDS and Transfer 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

  
	
  •   Transfer Reinsurance

  	
   

  	
   

  	
  *** PMPM

  

 

35

 

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 *** 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 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 Benefit
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:

 

	
  Medicare 

  Supplement HMO

  	
   

  	
  Medicare
  Supplement 

  POS

  	
   

  
	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
					

 

2.                                      Reinsurance Programs. 
Medicare Supplement Members shall not be included in the Professional
Stop Loss Program, the AIDS Reinsurance Program or the Transfer 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,
Medicare Supplemental HMO Members and Flex Funded HMO Members may be eligible
for Commercial POS Benefit Programs.

 

36

 

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

 

4.1                               Professional Out-of-Network
Withhold.  The Professional Out-of-Network Withhold
percentage for subsequent years shall be determined using PPG’s actual cost for
professional Out-of-Network services in the prior year.  The following formula shall apply:

 

a.                                       Actual Out-of-Network Professional PMPM Cost 
Commercial POS PMPM
Capitation (before withhold)

 

b.                                      Above result shall be rounded to the nearest
multiple of five, and

 

c.                                       10% shall be added to produce the Professional
Out-of-Network Withhold for the subsequent year.

 

On or before December I5th of each
year, HMO shall notify PPG of it’s Out-of-Network cost experience incurred
during the twelve month period ending June 30. 
HMO shall perform above calculation and shall notify PPG of the
Professional Out-of-Network Withhold percentage for the following year.

 

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 10% 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
fifty percent not to exceed twenty per cent (20%) of PPG’s annual gross
capitation, 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.  Each of the normalized Shared Risk Budgets shall be equal to the
normalized HMO Shared Risk Budget, or institutional capitation PMPM, if
applicable,

 

37

 

and multiplied by one hundred ten percent (110%).  Actual Shared Risk Budget shall fluctuate
from month to month to the extent that PPG’s age, sex and benefit plan mix
fluctuates.

 

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 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.

 

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 limited to the lesser of (a) fifty
percent (50%), or (b) an amount not to exceed twenty percent (20%) 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: 5.37 %  of POS Shared
Risk Budget.

 

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

 

(b)                                  In-Network and Out-of-Network POS Shared Risk
Services: 6.59% 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: twenty percent (20%) of any amount over
$250,000.

 

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 $ 25,000 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.

 

38

 

8.                                      AIDS Reinsurance.  As further
defined in Section B.4 of this Addendum, the AIDS Reinsurance rate shall be
$0.49 PMPM, which shall be deducted from PPG’s Capitation and $0.33 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.

 

H.                                    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 HMO
Benefit Programs.  The lump sum award
shall be payable in September following the calendar year in which the
measurements were taken provided that PPG is under contract with HMO for the
duration of the calendar year and at the time of the disbursement.  HMO reserves the right to alter components
and measurements of the QCIP Program annually.

 

	
  QCIP Award

  
	
  Up to ***
  PMPM

  

 

I.                                         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.

 

1.                                      Pharmacy Budget.  Each month HMO
shall fund the Pharmacy Budget at $ 15.00 per eligible Member per month
(“PEMPM”) subject to the age, sex and benefit plan factors set forth in
Addendum B.  The Pharmacy Budget shall
be adjusted according to the aggregate PEMPM dollar change experienced by those
participating physician groups comprising the top third of lowest PEMPM
normalized pharmacy costs, based on current calendar year experience.  Such adjustment shall occur prior to
calculating the final settlement for the Pharmacy Reconciliation, as set forth
in this Addendum.  Any calculation of
the normalized pharmacy costs shall be based upon actual claims.  The top third calculation shall be weighed
by eligible Member months.

 

2.                                      Pharmacy Reconciliation For
Commercial HMO Members.  For each Reconciliation Period, HMO shall
calculate pharmacy claims subject to this Program as outlined in the Operations
Manual.  HMO shall compare such claims
to the corresponding Pharmacy Budget. 
In the event pharmacy claims are less than the Pharmacy Budget, PPG’s
share of the Pharmacy Budget surplus shall be fifty percent (50%).  In the event pharmacy claims exceed the
Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit shall be
twenty-five percent (25%), not to exceed 10% of PPG annual pharmacy budget.

 

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.

 

39

 

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, 2000

 

	
  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

  	
   

  

 

40

 

A. 2 Benefit Plan Factors for PPG Capitation and
Hospital Capitation/Shared Risk Budgets Effective January 1, 2000

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  9Y

  	
   

  	
  1.0327

  	
   

  	
  0.9334

  	
   

  
	
  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

  	
   

  
	
  1I

  	
   

  	
  1.0059

  	
   

  	
  0.9903

  	
   

  
	
  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

  	
   

  
	
  1O

  	
   

  	
  1.0524

  	
   

  	
  1.0156

  	
   

  
	
  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

  	
   

  
	
  3K

  	
   

  	
  0.8532

  	
   

  	
  0.9728

  	
   

  
	
  3L

  	
   

  	
  0.9985

  	
   

  	
  0.9733

  	
   

  
	
  3M

  	
   

  	
  0.9313

  	
   

  	
  0.9202

  	
   

  
	
  3S

  	
   

  	
  0.9332

  	
   

  	
  1.0049

  	
   

  
	
  3T

  	
   

  	
  0.9856

  	
   

  	
  1.0049

  	
   

  
	
  3W

  	
   

  	
  0.9681

  	
   

  	
  0.9768

  	
   

  
	
  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

  	
   

  
	
  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

  	
   

  
	
  9D

  	
   

  	
  0.9287

  	
   

  	
  1.0026

  	
   

  
	
  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

  	
   

  
	
  9K

  	
   

  	
  0.9146

  	
   

  	
  0.9863

  	
   

  
	
  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

  	
   

  
	
  9Z  

  	
   

  	
  1.0859
  

  	
   

  	
  1.0222
  

  	
   

  
	
  Al

  	
   

  	
  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

  	
   

  
	
  Bl

  	
   

  	
  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

  	
   

  
	
  BB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  Cl

  	
   

  	
  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

  	
   

  
	
  Dl

  	
   

  	
  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

  	
   

  
	
  El

  	
   

  	
  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

  	
   

  
	
  ER

  	
   

  	
  1.0858

  	
   

  	
  1.0032

  	
   

  
	
  ES

  	
   

  	
  0.9796

  	
   

  	
  1.0076

  	
   

  
	
  ET

  	
   

  	
  0.9163

  	
   

  	
  0.9774

  	
   

  
	
  EU

  	
   

  	
  0.9617

  	
   

  	
  0.9863

  	
   

  
	
  EV

  	
   

  	
  1.0046

  	
   

  	
  0.9628

  	
   

  
	
  EW

  	
   

  	
  1.0104

  	
   

  	
  1.0108

  	
   

  
	
  EX

  	
   

  	
  0.9277

  	
   

  	
  0.8955

  	
   

  
	
  EY 

  	
   

  	
  0.9746

  	
   

  	
  0.9281

  	
   

  
	
  EZ

  	
   

  	
  0.9230

  	
   

  	
  0.8441

  	
   

  
	
  Fl

  	
   

  	
  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
  

  	
   

  
	
  FM

  	
   

  	
  0.9755

  	
   

  	
  1.0058

  	
   

  
	
  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

  	
   

  
	
  HA

  	
   

  	
  1.0595

  	
   

  	
  0.9673

  	
   

  
	
  HB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  HC

  	
   

  	
  1.0639

  	
   

  	
  0.9919

  	
   

  
	
  HD

  	
   

  	
  1.0807

  	
   

  	
  1.0031

  	
   

  
	
  HE

  	
   

  	
  1.0286

  	
   

  	
  1.0105

  	
   

  
	
  HF

  	
   

  	
  0.9682

  	
   

  	
  0.9875

  	
   

  
	
  HG

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  HK

  	
   

  	
  1.0784

  	
   

  	
  1.0076

  	
   

  
	
  HM

  	
   

  	
  1.1360

  	
   

  	
  1.0225

  	
   

  
	
  HN

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  HO

  	
   

  	
  0.9714

  	
   

  	
  1.0076

  	
   

  
	
  HP

  	
   

  	
  1.0049

  	
   

  	
  0.9919

  	
   

  
	
  HR

  	
   

  	
  1.1304

  	
   

  	
  1.0233

  	
   

  
	
  HS

  	
   

  	
  1.0817

  	
   

  	
  1.0022

  	
   

  
	
  HT

  	
   

  	
  1.0743

  	
   

  	
  1.0076

  	
   

  
	
  HU

  	
   

  	
  1.0443

  	
   

  	
  1.0165

  	
   

  
	
  HV

  	
   

  	
  1.0907

  	
   

  	
  1.0107

  	
   

  
	
  HW

  	
   

  	
  1.0524

  	
   

  	
  0.9681

  	
   

  
	
  HX

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  HY

  	
   

  	
  0.8997

  	
   

  	
  0.8921

  	
   

  
	
  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

  	
   

  
	
  Kl

  	
   

  	
  1.0236

  	
   

  	
  1.0076

  	
   

  
	
  K2

  	
   

  	
  0.9663

  	
   

  	
  0.9801

  	
   

  
	
  K3

  	
   

  	
  1.0255

  	
   

  	
  1.0080

  	
   

  
	
  K4

  	
   

  	
  1.0817

  	
   

  	
  1.0076

  	
   

  
	
  K6

  	
   

  	
  0.9782
  

  	
   

  	
  1.0054

  	
   

  

 

41

 

	
  Standard
  HMO

  	
   

  
	
  K7

  	
   

  	
  0.9845

  	
   

  	
  0.9966

  	
   

  
	
  K8

  	
   

  	
  0.9749

  	
   

  	
  0.9844

  	
   

  
	
  K9

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  KE

  	
   

  	
  0.9275

  	
   

  	
  1.0075

  	
   

  
	
  KF

  	
   

  	
  1.0209

  	
   

  	
  0.9776

  	
   

  
	
  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

  	
   

  
	
  KN

  	
   

  	
  1.0961

  	
   

  	
  1.0239

  	
   

  
	
  KO

  	
   

  	
  1.0349

  	
   

  	
  1.0079

  	
   

  
	
  KP

  	
   

  	
  0.9039

  	
   

  	
  0.9383

  	
   

  
	
  KQ

  	
   

  	
  0.9695

  	
   

  	
  0.9978

  	
   

  
	
  KR

  	
   

  	
  1.0227

  	
   

  	
  1.0075

  	
   

  
	
  KS

  	
   

  	
  0.8981

  	
   

  	
  0.9317

  	
   

  
	
  KT

  	
   

  	
  1.0099

  	
   

  	
  1.0021

  	
   

  
	
  KU

  	
   

  	
  1.0336

  	
   

  	
  1.0170

  	
   

  
	
  KV

  	
   

  	
  1.0367

  	
   

  	
  1.0101

  	
   

  
	
  KW

  	
   

  	
  0.9177

  	
   

  	
  0.9693

  	
   

  
	
  KX

  	
   

  	
  1.0243

  	
   

  	
  0.9776

  	
   

  
	
  KY

  	
   

  	
  0.9836

  	
   

  	
  1.0009

  	
   

  
	
  KZ

  	
   

  	
  1.0231

  	
   

  	
  1.0092

  	
   

  
	
  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

  	
   

  
	
  Ml

  	
   

  	
  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

  	
   

  
	
  Nl

  	
   

  	
  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

  	
   

  
	
  NE

  	
   

  	
  0.9242

  	
   

  	
  0.9673

  	
   

  
	
  NJ

  	
   

  	
  1.0185

  	
   

  	
  0.9722

  	
   

  
	
  NM

  	
   

  	
  0.9750

  	
   

  	
  0.9966

  	
   

  
	
  NN

  	
   

  	
  0.9230

  	
   

  	
  0.9035

  	
   

  
	
  NO

  	
   

  	
  1.0276

  	
   

  	
  1.0118

  	
   

  
	
  NQ

  	
   

  	
  0.9380

  	
   

  	
  0.9802

  	
   

  
	
  NR

  	
   

  	
  0.9495

  	
   

  	
  0.9693

  	
   

  
	
  NX

  	
   

  	
  0.9650

  	
   

  	
  0.9708

  	
   

  
	
  NY

  	
   

  	
  1.1012

  	
   

  	
  1.0075

  	
   

  
	
  NZ

  	
   

  	
  1.0563

  	
   

  	
  1.0222

  	
   

  
	
  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

  	
   

  
	
  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

  	
   

  
	
  Q0

  	
   

  	
  0.9461

  	
   

  	
  1.0018

  	
   

  
	
  QP

  	
   

  	
  1.0176

  	
   

  	
  0.9848

  	
   

  
	
  Rl

  	
   

  	
  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

  	
   

  
	
  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

  	
   

  
	
  SI

  	
   

  	
  0.9452

  	
   

  	
  0.9590

  	
   

  
	
  SN

  	
   

  	
  1.0111

  	
   

  	
  1.0041

  	
   

  
	
  SO

  	
   

  	
  0.9755

  	
   

  	
  1.0061

  	
   

  
	
  SQ

  	
   

  	
  0.9404

  	
   

  	
  0.9955

  	
   

  
	
  SR

  	
   

  	
  0.9872

  	
   

  	
  1.0058

  	
   

  
	
  SS

  	
   

  	
  0.9815

  	
   

  	
  1.0046

  	
   

  
	
  Tl

  	
   

  	
  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

  	
   

  
	
  TD

  	
   

  	
  1.0164

  	
   

  	
  1.0000

  	
   

  
	
  TE

  	
   

  	
  1.1100

  	
   

  	
  1.0239

  	
   

  
	
  TF

  	
   

  	
  0.9965

  	
   

  	
  0.9805

  	
   

  
	
  TQ

  	
   

  	
  0.9856

  	
   

  	
  1.0075

  	
   

  
	
  TR

  	
   

  	
  1.0823

  	
   

  	
  0.9888

  	
   

  
	
  TT

  	
   

  	
  0.8910

  	
   

  	
  0.8277

  	
   

  
	
  TU

  	
   

  	
  0.9676

  	
   

  	
  1.0000

  	
   

  
	
  TV

  	
   

  	
  1.0211

  	
   

  	
  1.0075

  	
   

  
	
  TW

  	
   

  	
  0.9707

  	
   

  	
  0.9742

  	
   

  
	
  TX

  	
   

  	
  1.0811

  	
   

  	
  1.0156

  	
   

  
	
  TY

  	
   

  	
  0.9328

  	
   

  	
  1.0067

  	
   

  
	
  TZ

  	
   

  	
  0.9777

  	
   

  	
  1.0084

  	
   

  
	
  Ul

  	
   

  	
  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

  	
   

  
	
  UA

  	
   

  	
  1.0790

  	
   

  	
  0.9776

  	
   

  
	
  UB

  	
   

  	
  0.9459

  	
   

  	
  0.9733

  	
   

  
	
  UD

  	
   

  	
  0.9707

  	
   

  	
  1.0064

  	
   

  
	
  UE

  	
   

  	
  1.0297

  	
   

  	
  1.0026

  	
   

  
	
  UF

  	
   

  	
  0.9540

  	
   

  	
  0.9805

  	
   

  
	
  UH

  	
   

  	
  1.0262

  	
   

  	
  1.0110

  	
   

  
	
  UI

  	
   

  	
  1.0080
  

  	
   

  	
  0.8467

  	
   

  
	
  UJ

  	
   

  	
  1.0080

  	
   

  	
  0.7479

  	
   

  
	
  UK

  	
   

  	
  0.9598

  	
   

  	
  0.8467

  	
   

  
	
  UL

  	
   

  	
  0.9598

  	
   

  	
  0.7479

  	
   

  
	
  UM

  	
   

  	
  0.9485

  	
   

  	
  0.9805

  	
   

  
	
  UN

  	
   

  	
  1.0228

  	
   

  	
  0.7688

  	
   

  
	
  UO

  	
   

  	
  1.0228

  	
   

  	
  0.8722

  	
   

  
	
  UP

  	
   

  	
  1.0075

  	
   

  	
  0.9776

  	
   

  
	
  UQ

  	
   

  	
  0.9746

  	
   

  	
  0.8722

  	
   

  
	
  UR

  	
   

  	
  0.9746

  	
   

  	
  0.7688

  	
   

  
	
  US

  	
   

  	
  1.0080

  	
   

  	
  0.9122

  	
   

  
	
  UT

  	
   

  	
  1.0080

  	
   

  	
  0.7838

  	
   

  
	
  UU

  	
   

  	
  0.9598

  	
   

  	
  0.9122

  	
   

  
	
  UV

  	
   

  	
  0.9598

  	
   

  	
  0.7838

  	
   

  
	
  UW

  	
   

  	
  1.0209

  	
   

  	
  0.9400

  	
   

  
	
  UX

  	
   

  	
  1.0209

  	
   

  	
  0.8070

  	
   

  
	
  UY

  	
   

  	
  0.9729

  	
   

  	
  0.9400

  	
   

  
	
  UZ

  	
   

  	
  0.9729

  	
   

  	
  0.8070

  	
   

  
	
  Wl

  	
   

  	
  1.0542

  	
   

  	
  0.9681

  	
   

  
	
  W2

  	
   

  	
  1.0067

  	
   

  	
  1.0000

  	
   

  
	
  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

  	
   

  
	
  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

  	
   

  
	
  Yl

  	
   

  	
  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

  	
   

  
	
  YY

  	
   

  	
  0.9722

  	
   

  	
  0.9837

  	
   

  
	
  YZ

  	
   

  	
  0.9915

  	
   

  	
  1.0098

  	
   

  
	
  Z9

  	
   

  	
  1.0422

  	
   

  	
  1.0075

  	
   

  
	
  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

  	
   

  

 

42

 

A.3 Benefit Plan Factors for PPG Capitation and Hospital
Capitation/Shared Risk Budgets Effective January 1, 2000

 

Small Group HMO

 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Plan

  	
   

  	
  Prof Factor

  	
   

  	
  Inst Factor

  	
   

  
	
  C4

  	
   

  	
  0.9958

  	
   

  	
  1.0075

  	
   

  
	
  C5

  	
   

  	
  0.9016

  	
   

  	
  0.9893

  	
   

  
	
  Ql

  	
   

  	
  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

  	
   

  
	
  QH

  	
   

  	
  1.0092

  	
   

  	
  0.9940

  	
   

  
	
  QI

  	
   

  	
  0.9199

  	
   

  	
  0.9700

  	
   

  
	
  QJ

  	
   

  	
  0.9609

  	
   

  	
  0.9934

  	
   

  
	
  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

  	
   

  
	
  VI

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  
	
  V4

  	
   

  	
  0.7969

  	
   

  	
  0.7147

  	
   

  
	
  V5

  	
   

  	
  0.9971

  	
   

  	
  0.9726

  	
   

  
	
  V6

  	
   

  	
  0.9608

  	
   

  	
  1.0101

  	
   

  
	
  V7

  	
   

  	
  0.8944

  	
   

  	
  0.8767

  	
   

  
	
  V8

  	
   

  	
  0.9455

  	
   

  	
  0.9726

  	
   

  

 

43

 

	
  Individual HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof Factor

  	
   

  	
  Inst
  Factor

  	
   

  
	
  3N (Health Net 10)

  	
   

  	
  0.9034

  	
   

  	
  0.9014

  	
   

  
	
  3N (Health Net 10 Plus)

  	
   

  	
  0.9034

  	
   

  	
  0.9014

  	
   

  
	
  3P (Health Net 20)

  	
   

  	
  0.8063

  	
   

  	
  0.7079

  	
   

  
	
  3R (Health Net 35)

  	
   

  	
  0.6831

  	
   

  	
  0.6278

  	
   

  
	
  NS (Shasta 5)

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  NT (Shasta 15)

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  NU (HMO Advantage 10)

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  NV (Shasta Classic)

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  
	
  NW (Shasta 7)

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  

 

	
  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

  	
   

  

 

44

 

A.4 Benefit
Plan Factors for PPG Standard POS Capitation and Standard POS Shared Risk
Budgets

 

Effective January 1, 2000

 

	
  Standard POS

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  AB

  	
   

  	
  1.0431

  	
   

  	
  0.8885

  	
   

  
	
  AC

  	
   

  	
  0.9660

  	
   

  	
  0.9325

  	
   

  
	
  AD

  	
   

  	
  0.9452

  	
   

  	
  0.8996

  	
   

  
	
  AE

  	
   

  	
  0.9313

  	
   

  	
  0.9309

  	
   

  
	
  AF

  	
   

  	
  0.9784

  	
   

  	
  0.9315

  	
   

  
	
  AG

  	
   

  	
  0.8981

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  AI

  	
   

  	
  1.0238

  	
   

  	
  0.9496

  	
   

  
	
  AJ

  	
   

  	
  0.8981

  	
   

  	
  0.9242

  	
   

  
	
  AN

  	
   

  	
  0.9242

  	
   

  	
  0.8420

  	
   

  
	
  AO

  	
   

  	
  1.0269

  	
   

  	
  0.9515

  	
   

  
	
  AR

  	
   

  	
  1.0047

  	
   

  	
  0.9014

  	
   

  
	
  AS

  	
   

  	
  1.0811

  	
   

  	
  0.8924

  	
   

  
	
  AT

  	
   

  	
  1.0341

  	
   

  	
  0.9489

  	
   

  
	
  AV

  	
   

  	
  0.9789

  	
   

  	
  0.8941

  	
   

  
	
  AW

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  AX

  	
   

  	
  0.9275

  	
   

  	
  0.9266

  	
   

  
	
  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

  	
   

  
	
  CZ

  	
   

  	
  1.0341

  	
   

  	
  0.9496

  	
   

  
	
  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

  	
   

  	
  0.9254

  	
   

  
	
  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

  	
   

  
	
  GC

  	
   

  	
  0.9791

  	
   

  	
  0.9478

  	
   

  
	
  GD

  	
   

  	
  0.9300

  	
   

  	
  0.9485

  	
   

  
	
  GE

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  
	
  GF

  	
   

  	
  0.9858

  	
   

  	
  0.9489

  	
   

  
	
  GG

  	
   

  	
  1.0245

  	
   

  	
  0.9064

  	
   

  
	
  GH

  	
   

  	
  0.9786

  	
   

  	
  0.9489

  	
   

  
	
  GI

  	
   

  	
  0.9242

  	
   

  	
  0.9292

  	
   

  
	
  GJ

  	
   

  	
  1.0269

  	
   

  	
  0.9511

  	
   

  
	
  GK

  	
   

  	
  0.9567

  	
   

  	
  0.9483

  	
   

  
	
  GL

  	
   

  	
  0.9746

  	
   

  	
  0.9483

  	
   

  
	
  GM

  	
   

  	
  0.9712

  	
   

  	
  0.9065

  	
   

  
	
  GN

  	
   

  	
  0.9251

  	
   

  	
  0.9405

  	
   

  
	
  GQ

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  
	
  GR

  	
   

  	
  0.9493

  	
   

  	
  0.9060

  	
   

  
	
  GS

  	
   

  	
  0.9094

  	
   

  	
  0.9489

  	
   

  
	
  GT

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  
	
  GU

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  
	
  GV

  	
   

  	
  0.9130

  	
   

  	
  0.9309

  	
   

  
	
  GW

  	
   

  	
  0.9624

  	
   

  	
  0.9483

  	
   

  
	
  GX

  	
   

  	
  1.0238

  	
   

  	
  0.9489

  	
   

  
	
  GY

  	
   

  	
  0.9688

  	
   

  	
  0.9222

  	
   

  
	
  GZ

  	
   

  	
  0.9884

  	
   

  	
  0.9489

  	
   

  
	
  KA

  	
   

  	
  0.9823

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9730

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  0.9850

  	
   

  	
  0.8643

  	
   

  
	
  KD

  	
   

  	
  0.9789

  	
   

  	
  0.9279

  	
   

  
	
  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

  	
   

  
	
  LO

  	
   

  	
  0.8948

  	
   

  	
  0.9176

  	
   

  
	
  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

  	
   

  
	
  NF

  	
   

  	
  0.8623

  	
   

  	
  0.8885

  	
   

  
	
  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

  	
   

  
	
  OH

  	
   

  	
  0.9751

  	
   

  	
  0.9356

  	
   

  
	
  OI

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  
	
  OJ

  	
   

  	
  0.9610

  	
   

  	
  0.9325

  	
   

  
	
  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

  	
   

  
	
  XH

  	
   

  	
  0.9746

  	
   

  	
  0.8962

  	
   

  
	
  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

  	
   

  

 

45

 

	
  Standard POS

  	
   

  
	
  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

  	
   

  
	
  XZ

  	
   

  	
  0.9966

  	
   

  	
  0.9289

  	
   

  

 

46

 

A.4 Benefit
Plan Factors for PPG Small Group POS Capitation and Small Group POS Shared Risk
Budgets

Effective January 1, 2000

 

Small Group POS 

 

	
  Plan

  	
   

  	
  Prof
  Factor

  	
   

  	
  Inst
  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9877

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9350

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8346

  	
   

  	
  0.7381

  	
   

  
	
  QD

  	
   

  	
  0.9442

  	
   

  	
  0.8422

  	
   

  
	
  QE

  	
   

  	
  0.9946

  	
   

  	
  0.9427

  	
   

  
	
  QF

  	
   

  	
  0.9442

  	
   

  	
  0.8368

  	
   

  
	
  QG

  	
   

  	
  0.9946

  	
   

  	
  0.9427

  	
   

  
	
  QK

  	
   

  	
  0.8582

  	
   

  	
  0.8865

  	
   

  
	
  QQ

  	
   

  	
  0.8582

  	
   

  	
  0.7796

  	
   

  
	
  QR

  	
   

  	
  0.9748

  	
   

  	
  0.9067

  	
   

  
	
  QS

  	
   

  	
  0.9278

  	
   

  	
  0.8813

  	
   

  

 

47

 

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

 

B.1 Age/Sex Factors for Pharmacy Budgets Effective January 1, 2000

 

 

	
  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

  	
   

  

 

48

 

B.2 Benefit Plan Factors for Pharmacy Budgets Effective
January 1, 2000

 

	
  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

  	
   

  
	
  OW

  	
   

  	
  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

  	
   

  
	
  IF

  	
   

  	
  1.1102

  	
   

  
	
  1G

  	
   

  	
  0.7412

  	
   

  
	
  1H

  	
   

  	
  0.7412

  	
   

  
	
  1I

  	
   

  	
  1.1102

  	
   

  
	
  1J

  	
   

  	
  0.7564

  	
   

  
	
  IK

  	
   

  	
  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

  	
   

  	
  1.1311

  	
   

  
	
  3F

  	
   

  	
  1.3376

  	
   

  
	
  3G

  	
   

  	
  1.3311

  	
   

  
	
  3I

  	
   

  	
  0.8989

  	
   

  
	
  3J

  	
   

  	
  0.8989

  	
   

  
	
  3K

  	
   

  	
  1.1157

  	
   

  
	
  3L

  	
   

  	
  0.6448

  	
   

  
	
  3M

  	
   

  	
  0.8671

  	
   

  
	
  3N

  	
   

  	
  1.2135

  	
   

  
	
  30

  	
   

  	
  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

  	
   

  
	
  52

  	
   

  	
  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

  	
   

  	
  l.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

  	
   

  
	
  88

  	
   

  	
  1.1000

  	
   

  
	
  9I

  	
   

  	
  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

  	
   

  
	
  AA

  	
   

  	
  1.0116

  	
   

  
	
  AB

  	
   

  	
  0.9183

  	
   

  
	
  AC

  	
   

  	
  0.7772

  	
   

  
	
  AD

  	
   

  	
  0.6638

  	
   

  
	
  AE

  	
   

  	
  0.8309

  	
   

  
	
  AF

  	
   

  	
  0.7141

  	
   

  
	
  AG

  	
   

  	
  0.6903

  	
   

  
	
  AH

  	
   

  	
  0.6059

  	
   

  
	
  AI

  	
   

  	
  1.7578

  	
   

  
	
  AJ

  	
   

  	
  1.1917

  	
   

  
	
  AK

  	
   

  	
  1.2496

  	
   

  
	
  AL

  	
   

  	
  1.1482

  	
   

  
	
  AM

  	
   

  	
  1.0887

  	
   

  
	
  AN

  	
   

  	
  0.9926

  	
   

  
	
  AO

  	
   

  	
  0.9637

  	
   

  
	
  AP

  	
   

  	
  0.8186

  	
   

  
	
  AQ

  	
   

  	
  0.7977

  	
   

  
	
  AS

  	
   

  	
  0.7193

  	
   

  
	
  AT

  	
   

  	
  0.7772

  	
   

  
	
  AU

  	
   

  	
  0.9026

  	
   

  
	
  AV

  	
   

  	
  1.3840

  	
   

  
	
  AW

  	
   

  	
  0.7772

  	
   

  
	
  AX

  	
   

  	
  0.7772

  	
   

  
	
  AY

  	
   

  	
  1.1917

  	
   

  
	
  AZ

  	
   

  	
  1.0534

  	
   

  
	
  Bl

  	
   

  	
  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

  	
   

  
	
  BC

  	
   

  	
  0.7772

  	
   

  
	
  BP

  	
   

  	
  0.7193

  	
   

  
	
  C2

  	
   

  	
  0.6536

  	
   

  
	
  C3

  	
   

  	
  0.6536

  	
   

  
	
  C5

  	
   

  	
  0.9091

  	
   

  
	
  C7

  	
   

  	
  0.7292

  	
   

  
	
  C8

  	
   

  	
  0.7292

  	
   

  
	
  C9

  	
   

  	
  0.7412

  	
   

  
	
  CA

  	
   

  	
  0.7773

  	
   

  
	
  CB

  	
   

  	
  1.3561

  	
   

  
	
  CC

  	
   

  	
  0.7141

  	
   

  
	
  CD

  	
   

  	
  1.1474

  	
   

  
	
  CE

  	
   

  	
  0.8060

  	
   

  
	
  CG

  	
   

  	
  1.1000

  	
   

  
	
  CH

  	
   

  	
  1.2769

  	
   

  
	
  CI

  	
   

  	
  1.1917

  	
   

  
	
  CJ

  	
   

  	
  0.7193

  	
   

  
	
  CK

  	
   

  	
  1.1483

  	
   

  
	
  CL

  	
   

  	
  1.1483

  	
   

  
	
  CM

  	
   

  	
  0.6637

  	
   

  
	
  CN

  	
   

  	
  0.5618

  	
   

  
	
  CO

  	
   

  	
  0.9927

  	
   

  
	
  CP

  	
   

  	
  09707

  	
   

  
	
  CQ

  	
   

  	
  1.1483

  	
   

  
	
  CR

  	
   

  	
  1.2496

  	
   

  
	
  CS

  	
   

  	
  1.3561

  	
   

  
	
  CT

  	
   

  	
  0.9639

  	
   

  
	
  CU

  	
   

  	
  0.5527

  	
   

  
	
  CV

  	
   

  	
  1.1483

  	
   

  
	
  CW

  	
   

  	
  0.6637

  	
   

  
	
  CX

  	
   

  	
  0.6454

  	
   

  
	
  CY

  	
   

  	
  0.9449

  	
   

  
	
  CZ

  	
   

  	
  0.9767

  	
   

  
	
  Dl

  	
   

  	
  0.7412

  	
   

  
	
  D2

  	
   

  	
  0.7292

  	
   

  
	
  D3

  	
   

  	
  0.7689

  	
   

  
	
  D4

  	
   

  	
  0.7689

  	
   

  
	
  D5

  	
   

  	
  0.7689

  	
   

  
	
  D6

  	
   

  	
  0.7195

  	
   

  
	
  DA

  	
   

  	
  0.6638

  	
   

  
	
  DB

  	
   

  	
  0.7772

  	
   

  
	
  DC

  	
   

  	
  0.5528

  	
   

  
	
  DD

  	
   

  	
  0.5295

  	
   

  
	
  DE

  	
   

  	
  0.6854

  	
   

  
	
  DG

  	
   

  	
  0.6638

  	
   

  
	
  DM

  	
   

  	
  1.1000

  	
   

  
	
  DN

  	
   

  	
  0.7397

  	
   

  
	
  DP

  	
   

  	
  0.8060

  	
   

  
	
  DQ

  	
   

  	
  0.5428

  	
   

  
	
  DR

  	
   

  	
  0.5428

  	
   

  
	
  DX

  	
   

  	
  1.1290

  	
   

  
	
  DY

  	
   

  	
  0.7594

  	
   

  
	
  DZ

  	
   

  	
  0.7041

  	
   

  
	
  E2

  	
   

  	
  0.7721

  	
   

  
	
  E3

  	
   

  	
  0.8989

  	
   

  
	
  E5

  	
   

  	
  0.7412

  	
   

  
	
  E7

  	
   

  	
  1.1157

  	
   

  
	
  Fl

  	
   

  	
  0.7292

  	
   

  
	
  F3

  	
   

  	
  0.7412

  	
   

  
	
  F4

  	
   

  	
  0.7292

  	
   

  
	
  F7

  	
   

  	
  0.7398

  	
   

  
	
  HA

  	
   

  	
  1.0084

  	
   

  
	
  HB

  	
   

  	
  0.7896

  	
   

  
	
  HC

  	
   

  	
  0.8060

  	
   

  
	
  HE

  	
   

  	
  0.9767

  	
   

  
	
  HF

  	
   

  	
  1.1000

  	
   

  
	
  HG

  	
   

  	
  0.6353

  	
   

  
	
  HH

  	
   

  	
  1.1917

  	
   

  
	
  HI

  	
   

  	
  0.7194

  	
   

  
	
  HJ

  	
   

  	
  0.9927

  	
   

  
	
  HK

  	
   

  	
  1.1665

  	
   

  
	
  HL

  	
   

  	
  0.5527

  	
   

  
	
  HM

  	
   

  	
  1.7144

  	
   

  
	
  HN

  	
   

  	
  1.1483

  	
   

  
	
  HO

  	
   

  	
  0.7773

  	
   

  
	
  HP

  	
   

  	
  1.2051

  	
   

  
	
  HR

  	
   

  	
  1.1917

  	
   

  
	
  HS

  	
   

  	
  0.7773

  	
   

  
	
  HT

  	
   

  	
  0.7124

  	
   

  
	
  HU

  	
   

  	
  0.6669

  	
   

  
	
  HV

  	
   

  	
  0.7489

  	
   

  
	
  HX

  	
   

  	
  1.4705

  	
   

  
	
  HY

  	
   

  	
  0.9928

  	
   

  
	
  I2

  	
   

  	
  1.0106

  	
   

  
	
  13

  	
   

  	
  0.6171

  	
   

  
	
  15

  	
   

  	
  0.6357

  	
   

  

 

49

 

	
  Pharmacy

  	
   

  
	
  I8

  	
   

  	
  1.1798

  	
   

  
	
  I9

  	
   

  	
  0.6448

  	
   

  
	
  JA

  	
   

  	
  1.0888

  	
   

  
	
  JB

  	
   

  	
  0.7194

  	
   

  
	
  JD

  	
   

  	
  0.6637

  	
   

  
	
  JF

  	
   

  	
  0.8060

  	
   

  
	
  JG

  	
   

  	
  0.6537

  	
   

  
	
  JH

  	
   

  	
  0.6854

  	
   

  
	
  JI

  	
   

  	
  0.8585

  	
   

  
	
  JJ

  	
   

  	
  0.8046

  	
   

  
	
  JN

  	
   

  	
  0.6291

  	
   

  
	
  K1

  	
   

  	
  0.7772

  	
   

  
	
  K3

  	
   

  	
  0.7667

  	
   

  
	
  K6

  	
   

  	
  0.9637

  	
   

  
	
  K9

  	
   

  	
  0.7977

  	
   

  
	
  L1

  	
   

  	
  0.6915

  	
   

  
	
  L6

  	
   

  	
  1.1752

  	
   

  
	
  LI

  	
   

  	
  0.6915

  	
   

  
	
  OE

  	
   

  	
  1.5744

  	
   

  
	
  OH

  	
   

  	
  1.7578

  	
   

  
	
  P3

  	
   

  	
  0.5134

  	
   

  
	
  P4

  	
   

  	
  0.6517

  	
   

  
	
  P9

  	
   

  	
  1.1157

  	
   

  
	
  PA

  	
   

  	
  0.7772

  	
   

  
	
  Q0

  	
   

  	
  0.9653

  	
   

  
	
  Q4

  	
   

  	
  0.7255

  	
   

  
	
  Q7

  	
   

  	
  0.8141

  	
   

  
	
  Q8

  	
   

  	
  0.9010

  	
   

  
	
  R2

  	
   

  	
  1.3561

  	
   

  
	
  R5

  	
   

  	
  0.7667

  	
   

  
	
  R6

  	
   

  	
  0.7667

  	
   

  
	
  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

  	
   

  
	
  T2

  	
   

  	
  0.6059

  	
   

  
	
  T7

  	
   

  	
  0.6638

  	
   

  
	
  T8

  	
   

  	
  0.7386

  	
   

  
	
  T9

  	
   

  	
  0.6352

  	
   

  
	
  U8

  	
   

  	
  0.7772

  	
   

  
	
  V0

  	
   

  	
  0.8793

  	
   

  
	
  V2

  	
   

  	
  0.7772

  	
   

  
	
  V3

  	
   

  	
  1.1917

  	
   

  
	
  V4

  	
   

  	
  0.9926

  	
   

  
	
  V5

  	
   

  	
  0.7772

  	
   

  
	
  V6

  	
   

  	
  0.6059

  	
   

  
	
  V7

  	
   

  	
  0.6638

  	
   

  
	
  V8

  	
   

  	
  0.6352

  	
   

  
	
  V9

  	
   

  	
  0.9637

  	
   

  
	
  VA

  	
   

  	
  0.8585

  	
   

  
	
  VB

  	
   

  	
  0.6495

  	
   

  
	
  VC

  	
   

  	
  0.5783

  	
   

  
	
  VD

  	
   

  	
  0.7300

  	
   

  
	
  VE

  	
   

  	
  0.6592

  	
   

  
	
  VS

  	
   

  	
  0.7300

  	
   

  
	
  VT

  	
   

  	
  0.8585

  	
   

  
	
  VU

  	
   

  	
  0.5428

  	
   

  
	
  VV

  	
   

  	
  0.4657

  	
   

  
	
  W7

  	
   

  	
  0.9589

  	
   

  
	
  X0

  	
   

  	
  0.7397

  	
   

  
	
  X2

  	
   

  	
  0.7772

  	
   

  
	
  X5

  	
   

  	
  0.6637

  	
   

  
	
  X6

  	
   

  	
  0.7772

  	
   

  
	
  X8

  	
   

  	
  1.3563

  	
   

  
	
  X9

  	
   

  	
  0.9767

  	
   

  
	
  Y0

  	
   

  	
  0.8060

  	
   

  
	
  Yl

  	
   

  	
  1.1000

  	
   

  
	
  Y3

  	
   

  	
  0.9632

  	
   

  
	
  Y4

  	
   

  	
  0.6537

  	
   

  
	
  Y6

  	
   

  	
  0.7141

  	
   

  
	
  Z0

  	
   

  	
  1.1000

  	
   

  
	
  Z6

  	
   

  	
  0.9927

  	
   

  
	
  Z8

  	
   

  	
  0.5403

  	
   

  

 

50

 

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 HMO, 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 1/1/00

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  AIDS – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS – Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS –
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Autologous/Homologous 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Drugs, including Epogen, Neupogen and
  adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.

 

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

 

51

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  COSMETIC SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CRITICAL CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC TESTING -
  Outpatient Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS –
  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS –
  In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
											

 

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

 

52

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED PHYSICIANS -

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient, Ambulatory Surgery or Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTABLES. SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF &GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH –
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

53

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  PATHOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY –
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES- Medical,
  Surgical, Office 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to a Hospital Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Related to an Outpatient Office Visit:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Splints, Casts, Bandages, 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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

54

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  THERAPY: Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  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 responsibility have been deleted.

 

55

 

ADDENDUM C

 

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

 

NOT APPLICABLE TO THIS AGREEMENT

 

R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.

 

56

 

ADDENDUM D

 

Provider
does not Participate in the PREFERRED PROVIDER ORGANIZATION (PPO) Program

Provider
does not Participate in the EXCLUSIVE PROVIDER ORGANIZATION (EPO) Program

 

POINT OF
SERVICE (POS) 

 

BENEFIT
PROGRAMS

 

PPG understands that
Affiliates or Payors contracted with HNI who are qualified may provide PPO, EPO
and POS Benefit Programs. HNI shall provide PPG with a listing of all such
Payors, as updated from time to time by HNI. 
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 HNI or
any HNI 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.

 

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 HNI efforts to provide Case
Management.  PPG agrees to provide PPG’s
written treatment plan within five (5) working days of receipt of request from
HNI.  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 HNI; 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.                                       HNI 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 HNI prior to admission
and the information provided

 

R: Reinsurance
purchased by PPG from HMO.  Claims shall
be submitted to and processed by Health Net’s Claims Dept.

 

57

 

by
PPG to HNI regarding the Member’s medical condition was substantially true and
accurate.

 

B.                                    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 HNI’
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.

 

C.                                    MEDICARE SELECT BENEFIT PROGRAMS

 

1.                                      Medicare Select Programs.  Under
the Medicare Select Programs PPG shall accept Medicare assignment from Members
for Contracted Services covered under the Medicare Program, and shall bill and
accept payment from Medicare as payment in full for such services, except for
applicable Copayments and deductibles. 
PPG shall bill HMO and not Members for such Copayments and deductibles
or for Contracted Services rendered that are not covered under Medicare, but
which are covered under the applicable Medicare Select Program.  PPG shall submit claims to HMO in accordance
with the terms of the Agreement.

 

2.                                      Compensation for Medicare
Select Members.  PPG shall be paid the fee-for-service
compensation rates as set forth in Addendum E of the Agreement for Contracted
Services rendered under the Medicare Select Program.

 

58

 

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 HNI.

 

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) $29.90 per unit value in the
American Society of Anesthesiology Relative Value study or (b) seventy-five
percent (75%) of the Participating Provider’s billed charges, whichever is
less.

 

Assistant
Surgeons:

PPG
or Participating Provider shall be compensated for Contracted Services at
twenty percent (20%) of the surgeon’s reimbursement as determined above.

 

Total
Obstetrical Care:  (for HMO Benefit Programs)

Services included in global
reimbursement (professional and technical component): 

 

	
  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

 

59

 

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

 

60

 

ADDENDUM F

 

MEDI-CAL BENEFIT PROGRAM 

 

NOT
APPLICABLE TO THIS AGREEMENT

 

61

 

ADDENDUM G

 

CHAMPUS/TRICARE
AND OTHER GOVERNMENT BENEFIT PROGRAMS

 

PPG understands and agrees
that the obligations of HNI set forth in this Addendum are the obligations of
Foundation Health Federal Service Inc., an Affiliate of HNI (“FHFS”), and not
obligations of HNI, or any other Affiliate of HNI.  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, State 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

 

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).  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 documents 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.

 

62

 

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.

 

63

 

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/TR1CARE 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 Payor’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 one hundred percent (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

 

64

 

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
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 90% of the CHAMPUS Maximum Allowable
Charges or 75% 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 75% of billed charges or 90% of the CHAMPUS area prevailing rates.  Services for which a procedure code has not
been assigned, or are unvalued by CHAMPUS/TR1CARE, compensation will be the
lesser of Average Wholesale Price minus fifteen percent (AWP - 15%) or 75% 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.

 

The above rates reflect reimbursement for medical
surgical services ONLY. 

(These rates DO NOT include any Behavioral Health
Units).

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

65

 

ADDENDUM H

 

OCCUPATIONALLY ILL/INJURED OR WORKERS’ COMPENSATION BENEFIT
PROGRAMS

 

NOT APPLICABLE TO THIS AGREEMENT

 

66Exhibit
10.150

 

CaliforniaCare

 

MEDICAL SERVICES AGREEMENT

 

 

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

 

 

CALIFORNIACARE

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.

  	
  NON-CAPITATED SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  X.

  	
  OUTPATIENT
  PRESCRIPTION DRUG EXPENSE

  	
   

  
	
   

  	
   

  	
   

  
	
  XI.

  	
  QUALITY MANAGEMENT BONUS

  	
   

  
	
   

  	
   

  	
   

  
	
  XII.

  	
  BILLING
  FOR HMO-USA AWAY FROM HOME CARE SERVICES

  	
   

  
	
   

  	
   

  	
   

  
	
  XIII.

  	
  TERM OF AGREEMENT,
  TERMINATION

  	
   

  
	
   

  	
   

  	
   

  
	
  XIV.

  	
  ARBITRATION
  OF DISPUTES BETWEEN BLUE CROSS AND PARTICIPATING MEDICAL GROUP

  	
   

  
	
   

  	
   

  	
   

  
	
  XV.

  	
  CALIFORNIACARE
  MEMBER GRIEVANCE SYSTEM

  	
   

  
	
   

  	
   

  	
   

  
	
  XVI.

  	
  MISCELLANEOUS PROVISIONS

  	
   

  

 

EXHIBITS

 

	
  Exhibit A

  	
   

  	
  Covered Medical Services

  
	
   

  	
   

  	
   

  
	
  Exhibit A(1)

  	
   

  	
  Division of Financial Responsibilities

  
	
   

  	
   

  	
   

  
	
  Exhibit B

  	
   

  	
  CALIFORNIACARE Hospitals

  
	
   

  	
   

  	
   

  
	
  Exhibit C

  	
   

  	
  Administrative Responsibilities of
  PARTICIPATING MEDICAL GROUP

  
	
   

  	
   

  	
   

  
	
  Exhibit D

  	
   

  	
  Capitation

  
	
   

  	
   

  	
   

  
	
  Exhibit E

  	
   

  	
  Physician Fee Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit F

  	
   

  	
  Non-Capitated Performance Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit G

  	
   

  	
  Compensation for Services to BLUE CROSS PLUS
  Members

  
	
   

  	
   

  	
   

  
	
  Exhibit G-1

  	
   

  	
  BLUE CROSS PLUS 1997 Baseline Capitation

  
	
   

  	
   

  	
   

  
	
  Exhibit H

  	
   

  	
  Outpatient Prescription Drug Performance
  Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit I

  	
   

  	
  Quality Management Bonus Schedule

  
	
   

  	
   

  	
   

  
	
  Exhibit J

  	
   

  	
  PARTICIPATING MEDICAL GROUP Facilities

  

 

 

CALIFORNIACARE

 

MEDICAL SERVICES
AGREEMENT

 

This AGREEMENT is effective on January 1, 1997
between BLUE CROSS OF CALIFORNIA and Affiliates (jointly and severally “BLUE
CROSS”) and NORTHWEST ORANGE COUNTY 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 Professional 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’
CALIFORNIACARE programs.

 

II.            DEFINITIONS

 

2.01      “Adjusted Per
Member Per Month Non-Capitated Expense” means the PARTICIPATING MEDICAL GROUP’s Per
Member Per Month Non-Capitated Expense after adjustments for the PARTICIPATING
MEDICAL GROUP’s mix of Member age/sex and plan, and the PARTICIPATING MEDICAL
GROUP’s stop-loss and regional relativities for use in identifying the
PARTICIPATING MEDICAL GROUP’s Non-Capitated Performance Settlement.

 

2.02      “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.

 

2.03      “Age/Sex Factors” means the factors
used to adjust PARTICIPATING MEDICAL GROUP’s Per Member Per Month Non-Capitated
Expenses to account for cost variations attributable to the mix of Member age
and sex.

 

2.04      “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.

 

1

 

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

 

2.06      “Attachment Point” is the point at
which no settlement shall be made if the PARTICIPATING MEDICAL GROUP’s Adjusted
Per Member Per Month Non-Capitated Expense equals or exceeds that amount.  The Attachment Point is shown in the
Non-Capitated Performance Settlement Schedule as set forth in Exhibit F.

 

2.07      “Away From Home
Care” means urgent care, Away from Home Emergency Care, routine care, and
follow-up care as defined in the HMO-USA member’s plan certificate or benefit
agreement.

 

2.08      “Benefit
Agreement(s)” means the written agreement(s) entered into between BLUE CROSS and
groups or individuals, under which BLUE CROSS provides, indemnifies, or
administers health benefits to persons enrolled in BLUE CROSS programs
including, but not limited to, the CALIFORNIACARE programs or the BLUE CROSS
PLUS program. “Benefit Agreement(s)” also mean arrangements established by BLUE
CROSS and/or one or more of its Affiliates, or by persons or entities utilizing
the BLUE CROSS Managed Care Network pursuant to a contract with BLUE CROSS
and/or one or more of its Affiliates. 
Subject to the terms hereof, BLUE CROSS and/or one or more of its Affiliates
may contract, on PARTICIPATING MEDICAL GROUP’s behalf, with Other Payors
wishing to utilize the services of the BLUE CROSS Managed Care Network,
incorporating the terms and conditions of this Agreement.

 

2.09      “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 CALIFORNIACARE, BLUE
CROSS PLUS and other programs that are to be conducted pursuant to Benefit
Agreements.

 

2.10      “BLUE CROSS PLUS” means a point of
service option benefit plan offered by BLUE CROSS under which enrolled Members
may, at the time benefits are selected, elect to receive benefits from either a
CALIFORNIACARE provider or another licensed provider.

 

2.11      “CALIFORNIACARE” means direct care
prepayment plan(s) offered by BLUE CROSS.

 

2.12      “CALIFORNIACARE
Case Manager” means a CALIFORNIACARE employee charged with assisting PARTICIPATING
MEDICAL GROUPs in case management.

 

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

 

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

 

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

 

2.16      “Capitation” means a uniform
prepayment fee per Member per month, adjusted by age-sex, based on the Benefit
Agreement issued to each Subscriber and the services due thereunder.

 

2.17      “Capitation
Services” means all CALIFORNIACARE Covered Medical Services which are not
otherwise defined in this Agreement [ILLEGIBLE] the Division of Financial
Responsibilities (Exhibit A-1 hereto) as Non-Capitated Services.

 

2

 

2.18      “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.

 

2.19      “Case Management Stop-Loss Threshold” means the level at
which stop-loss under Section 9.03 herein shall apply to PARTICIPATING
MEDICAL GROUP’s Non-Capitated Performance Settlement.

 

2.20      “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).

 

2.21      “Covered Persons” means Members,
enrollees, dependents and other beneficiaries who are covered by an Affiliate’s
Benefit Agreement or by an Other Payor.

 

2.22      “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.

 

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

 

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

 

B.    Serious impairment to bodily functions,

 

C.    Other serious medical consequences, or

 

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

 

2.24      “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.

 

2.25      “Extension of Benefits” means extended
benefits which may be available to Members who are totally disabled on the date
of termination of their Benefit Agreement. 
Extended benefits shall have the meaning set forth in the group coverage
agreement applicable to the Member.

 

3

 

2.26      “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.

 

2.27      “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.

 

2.28      “HMO-USA” means a nationwide
network of Blue Cross and Blue Shield Plan HMOs (Participating Plans) sponsored
by Blue Cross and Blue Shield Association (BCBSA).  BCBSA Participating Plan HMOs have entered into Agreements to provide
each other’s members with guest memberships, urgent care and Emergency care,
routine care, and follow-up care as pre-approved and authorized by BLUE CROSS
when the member is traveling away from his or her Home HMO-USA participating
plan.

 

2.29      “Home HMO” means the
participating plan in which a HMO-USA participating plan member is enrolled.

 

2.30      “Hospice Services” means services
rendered to terminally ill patients, by a Medicare certified hospice provider
that are (a) covered by a Benefit Agreement and (b) ordered or authorized by
PARTICIPATING MEDICAL GROUP.

 

2.31      “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.

 

2.32      “Host HMO” means any
participating plan in whose Service Area a HMO-USA participating plan member
temporarily stays except the member’s Home HMO.

 

2.33      “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.

 

2.34      “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.

 

2.35      “Medically Necessary” means services or
supplies which, under the provisions of this Agreement, are determined to be:

 

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

 

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

 

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

 

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

 

4

 

E      The most
appropriate supply or level of service which can safely be provided.  For hospital stays, this means that acute
care as an inpatient is necessary due to the kinds of 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 in a less intensified medical
setting.

 

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

 

2.37      “Member Months” means a count that
records one Member month for each month the Member is enrolled in the
CALIFORNIACARE program or the BLUE CROSS PLUS program.

 

2.38      “Non-Capitated
Expenses” means the actual expenses incurred by BLUE CROSS to provide
Non-Capitated Services to Members, as ordered, authorized or referred by
PARTICIPATING MEDICAL GROUP Physicians.

 

2.39      “Non-Capitated
Performance Settlement” means amount paid to PARTICIPATING MEDICAL GROUP
for managing Non-Capitated Services.

 

2.40      “Non-Capitated
Performance Settlement Schedule” means a schedule of PMPM Non-Capitated
Performance Settlement amounts associated with varying PMPM Non-Capitated
Expenses.  The Non-Capitated Performance
Settlement Schedule is set forth in Exhibit F.

 

2.41      “Non-Capitated
Services” means the designated services set forth in Article IX and Exhibit
A-1.

 

2.42      “Operations Manual” means the
CaliforniaCare PMG Operations Manual.

 

2.43      “Other Payor” means persons or
entities utilizing the BLUE CROSS Managed Care Network pursuant to an agreement
with BLUE CROSS, including without limitation, other Blue Cross and/or Blue
Shield Plans, self-administered or self-insured programs providing health care
benefits, or employers or insurers.

 

2.44      “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 a 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.

 

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

 

2.46      “Outpatient
Prescription Drug Expense” means the benefit amount paid by BLUE CROSS for a
Member’s covered outpatient prescription drugs.

 

2.47      “Outpatient
Prescription Drug Settlement” means an amount paid to PARTICIPATING MEDICAL
GROUP for managing Outpatient Prescription Drug Expenses.

 

2.48      “Outpatient
Prescription Drug Settlement Schedule” means a schedule of outpatient
prescription drug settlement amounts associated with varying Per Member per
Month Outpatient Prescription Drug Expenses. 
The Schedule is set forth in Exhibit H.

 

5

 

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

 

2.50      “Per Member Per
Month (PMPM) Non-Capitated Expense” means the average monthly medical
Non-Capitated Expense per Member attributable to the PARTICIPATING MEDICAL
GROUP.

 

2.51      “Per Member Per
Month (PMPM) Outpatient Prescription Drug Expense” means the average
monthly Outpatient Prescription Drug Expenses per Member for PARTICIPATING
MEDICAL GROUP’s Members with outpatient prescription drug benefits.

 

2.52      “Plan Factors” means factors used
to adjust the PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations attributable to the mix of Member Benefit
Agreements.  The Non-Capitated Expense
Plan Factors include a durational factor for the durational plans.

 

2.53      “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.

 

2.54      “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.

 

2.55      “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.

 

2.56      “Related Hospital
Services” means services rendered to Members as part of, and concurrent with
Inpatient Hospital Services, Outpatient Hospital Services, Hemodialysis
Services, Skilled Nursing Facility Services, Alternative Birthing Center
Services and Hospice 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.

 

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

 

2.58      “Region Factor” means the factors
used to adjust PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations across BLUE CROSS corporate regions.

 

2.59      “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 CALIFORNIACARE Satellite Criteria set forth in the
Operations Manual and is approved by BLUE CROSS prior to being designated a
CALIFORNIACARE Satellite Facility.

 

2.60      “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.

 

2.61      “Skilled Nursing
Facility Services” means inpatient and related services provided by a licensed skilled
nursing facility.  Skilled Nursing
Facility Services excludes custodial care.

 

6

 

2.62      “Stop-Loss Factor” means the factor
used to adjust the PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense to
account for cost variations due to different Case Management Stop-Loss
thresholds.

 

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

 

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

 

2.65      “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 Non-Capitated Services.

 

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.

 

3.04      PARTICIPATING
MEDICAL GROUP consents to the memorializing of its legal obligations with BLUE
CROSS and each particular Affiliate in one or more separate written agreements
that shall not alter the substance of those obligations.

 

3.05      PARTICIPATING MEDICAL
GROUP agrees that each arrangement by which PARTICIPATING MEDICAL GROUP
performs services for Covered Persons that utilize the BLUE CROSS Managed Care
Network shall constitute an independent legal relationship between
PARTICIPATING MEDICAL GROUP and that Affiliate or Other Payor.

 

3.06      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.

 

7

 

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 to authorize or arrange for
the provision of all Non-Capitated 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 CALIFORNIACARE Hospitals shall be adequate to meet
the requirements for the CALIFORNIACARE 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 allied
health professionals, responsible for delivering Covered Medical Services to
Members.  A list of all referral physicians
to whom PARTICIPATING MEDICAL GROUP refers Members for Referral Services shall
be provided to BLUE CROSS upon request.

 

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.

 

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:

 

8

 

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 J (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 2.23 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 CALIFORNIACARE Hospital(s)
within PARTICIPATING MEDICAL GROUP’s Service Area.

 

E.     To admit, or
authorize admission of, Members solely to the CALIFORNIACARE 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 CALIFORNIACARE
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 CALIFORNIACARE Hospitals whose
transplant programs have been approved by BLUE CROSS and identified as such in
the Operations Manual.

 

9

 

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 a CALIFORNIACARE Hospital, the Member must be admitted to
a non-CaliforniaCare in-area or out-of-area facility for Hospital Services,
then until the Member is transferred to a CALIFORNIACARE Hospital, the
PARTICIPATING MEDICAL GROUP will be financially responsible for care the same
as if care had been provided in a CALIFORNIACARE Hospital, and the
Non-Capitated Services arrangement as set forth in Article IX, of this
Agreement will apply.

 

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)   Primary Care Physicians
who determine that a referral is necessary, may issue a referral without the
prior authorization of PARTICIPATING MEDICAL GROUP’s Utilization Management
Program to physicians in the following specialties: Cardiology, Dermatology,
Endocrinology, Ear, Nose and Throat, Gastroenterology, General Surgery,
Hematology, Neurology, Obstetrics-Gynecology, Oncology, Ophthalmology,
Orthopedic Surgery, Podiatry, Routine Laboratory, Routine X-ray and Urology.

(4)   For referrals to
specialists or providers, or services other than those listed in (3) above,
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.

 

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.

 

J.     To assure that
Members shall not be subject to discrimination in access to Covered Medical
Services.

 

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.

 

10

 

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 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 and
recredentialing of all PARTICIPATING MEDICAL GROUP Physicians and allied Health
Professional providers.

(2)   Credentialing and
recredentialing 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.

(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 as follows:

 

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

(2)   The CALIFORNIACARE
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.

 

11

 

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

 

D     PARTICIPATING
MEDICAL GROUP shall:

 

(1)   Make available to
BLUE CROSS summaries of 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
CALIFORNIACARE 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 CALIFORNIACARE 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 CALIFORNIACARE 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 MEDICAL GROUP agrees to allow
on-site review of Utilization Management Program by BLUE CROSS.

 

A.    The Utilization
Management Program shall:

 

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

(2)   Include
documentation 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
CALIFORNIACARE Hospitals.

(6)   Encompass
inpatient, outpatient and ancilary 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,

 

12

 

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 as follows:

 

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

(2)   The CALIFORNIACARE
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 summaries of 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
CALIFORNIACARE 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 CALIFORNIACARE 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 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

 

13

 

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 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.

 

14

 

4.08      Administrative
Responsibilities

 

A.    To comply with all
CALIFORNIACARE 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 a CALIFORNIACARE
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 CALIFORNIACARE and
intended for Members.

 

E.     To continually meet
all criteria for PARTICIPATING MEDICAL GROUPs, 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 either directly or
through PARTICIPATING MEDICAL GROUP’s billing agent in the file format as shown
in the Operations Manual.

 

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.

 

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

 

15

 

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 CALIFORNIACARE Case
Management Department of all cases that reach the Enrollment Protection or Case
Management Stop-Loss levels specified herein.

 

E.     To pay all Health
Professionals and hospitals who have rendered authorized Referral Services or
Out-of-Area Emergency 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.

 

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 16.08 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 16.08 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

 

16

 

Labor Code. 
As payment for such medical services rendered, PARTICIPATING MEDICAL
GROUP agrees to accept, as payment in full, compensation in accordance with the
fee schedule set forth in Exhibit E of the Agreement (incorporated by
reference herein) 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.

 

E.     When the BLUE CROSS
Managed Care Network is utilized by an Affiliate or Other Payor, PARTICIPATING
MEDICAL GROUP agrees to provide services to Covered Persons of that Affiliate
or Other Payor in accordance with the terms of this Agreement.  BLUE CROSS shall compensate PARTICIPATING
MEDICAL GROUP in accordance with the terms of this Agreement for services
provided to Covered Persons of any such Other Payor.  When an Other Payor utilizes the Managed Care Network, such Other
Payor shall comply with the terms of this Agreement.

 

In the event the BLUE CROSS Managed Care
Network is to be utilized by an Other Payor that has operational requirements
that are materially different from those required under this Agreement, BLUE
CROSS agrees to notify PARTICIPATING MEDICAL GROUP in writing thirty (30) days
prior to the commencement of such utilization. 
PARTICIPATING MEDICAL GROUP may decline to provide services to such
Other Payor by providing written notice of such decision to BLUE CROSS within
ten (10) days of receipt of notice by BLUE CROSS referenced above.

 

17

 

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 CALIFORNIACARE
program, and to issue an identification card to each Subscriber or to each
Subscriber and one additional eligible Member covered under a two-party or
family contract as described in the Operations Manual.

 

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 Non-Capitated 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 notify
PARTICIPATING MEDICAL GROUP of any CALIFORNIACARE Group Benefit Agreements
between BLUE CROSS and employers, government agencies, or any other groups,
which may substantially affect enrollment at PARTICIPATING MEDICAL GROUP.

 

5.07      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 at the Member’s open enrollment period, or 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.

 

5.08      To exercise
reasonable efforts to negotiate special rates with hospitals and other
providers who contract with BLUE CROSS to render Non-Capitated Services to
Members and to pay hospitals in accord with those agreements.

 

5.09      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.

 

5.10      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.

 

18

 

5.11      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).

 

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

 

5.13      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 of employer groups 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 by an employer group 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 by an employer
group 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

 

19

 

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.

 

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 Exhibit E or the
actual billed amount, whichever is less. 
The obligations of BLUE CROSS under this Subsection D shall be
conditioned upon the 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.

 

VII.          COMPENSATION TO
PARTICIPATING MEDICAL GROUP

 

7.01      Exhibits D, G and
G-1 (all incorporated by reference herein), set forth Capitation payments for
new and renewing business.  The
applicable Capitation payment for each Member assigned to PARTICIPATING MEDICAL
GROUP, shall be paid monthly, prorated in accordance with Member eligibility.

 

Such Capitation payment shall be adjusted for
Member age, sex and Benefit Agreement in accordance with age, sex and plan
relativities that have been developed by BLUE CROSS based upon actuarial
assumptions and BLUE CROSS’ utilization experience.  BLUE CROSS reserves the right to adjust such relativity factors,
upon contract renewal, based upon BLUE CROSS’ experience.

 

7.02      Capitation shall be
paid in consideration for providing Capitation Services and arranging
Non-Capitated Services for each Member assigned to PARTICIPATING MEDICAL GROUP,
and in consideration for all Capitation 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 group and individual
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.

 

20

 

7.04      PARTICIPATING
MEDICAL GROUP agrees to continue to provide or arrange for all Covered Medical
Services and benefits to any Member, or former Member, who is eligible for
coverage under the Extension of Benefits provision of the Benefit Agreements,
in exchange for the then current Capitation amount per Member per month of the
Benefit Agreement type under which the Member is, or was, enrolled.  Under the circumstances described in this
Section 7.04 BLUE CROSS shall be financially responsible for Non-Capitated
Services.

 

7.05      PARTICIPATING
MEDICAL GROUP agrees to be responsible for professional and technical charges,
as described in Exhibit A-1 (incorporated by reference herein), for laboratory,
radiology and diagnostic testing procedures and diagnostic imaging examinations
rendered to Members, as a part of, and concurrent with benefits set forth in
this Agreement, whether billed by the hospital or by a qualified health
professional.

 

7.06      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.

 

VIII.        ENROLLMENT
PROTECTION

 

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

 

8.02      For PARTICIPATING
MEDICAL GROUPs with less than two thousand (2,000) Members, on the effective
date of this Agreement, the liability of PARTICIPATING MEDICAL GROUP for
expenses for Capitation Services rendered to any single Member during the
calendar year shall be limited to the first SIX THOUSAND DOLLARS ($6,000.00) of
such expenses.

 

8.03      If PARTICIPATING
MEDICAL GROUP’s assigned CALIFORNIACARE and BLUE CROSS PLUS enrollment is two
thousand (2,000) or more Members, on the effective date of this Agreement,
PARTICIPATING MEDICAL GROUP agrees to accept risk under either
Subsection A or Subsection B, as indicated below.

 

A.    The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first EIGHT
THOUSAND DOLLARS ($8,000.00) of Capitation Services expenses, which have been
incurred by PARTICIPATING MEDICAL GROUP for that Member, or

 

B.    The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered to
any single Member during the calendar year, shall be limited to the first
TWENTY-FIVE THOUSAND DOLLARS (S25,000.00) of Capitation Services expenses which
have been incurred by PARTICIPATING MEDICAL GROUP for that Member.

 

PARTICIPATING MEDICAL GROUP hereby elects to
accept risk pursuant to Section 8.03.

 

21

 

(Check one)

A     ý

B     o

 

8.04      Notwithstanding Section 8.02 or 8.03
above, the liability of PARTICIPATING MEDICAL GROUP for expenses for Capitation
Services for Members who have been diagnosed as having Acquired Immune
Deficiency Syndrome (AIDS) shall be limited to FIFTEEN HUNDRED DOLLARS ($1,500.00)
for any Member who has been diagnosed as having AIDS according to the most
current criteria established by the Center for Disease Control (CDC) at the
time of the diagnosis.

 

8.05      The total expenses of PARTICIPATING MEDICAL
GROUP for Capitation Services rendered to any single Member during the calendar
year shall be calculated according to the fee schedule set forth in
Exhibit E.  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.

 

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

 

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

 

C.    Services for which payment is obtained from
BLUE CROSS through any coverage other than CALIFORNIACARE.

 

All co-payments applicable to 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 co-payments under the
Coordination of Benefits rules in the Member’s Benefit Agreement.

 

8.07      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
calendar year 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,
8.04, 8.05 and 8.06.  Reimbursement to
PARTICIPATING MEDICAL GROUP for Enrollment Protection shall be made by BLUE CROSS
in accordance with the lesser of actual billed charges or the fee
schedule set forth in Exhibit E, 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 Exhibit E shall be reimbursed by BLUE CROSS at the actual
charges paid by PARTICIPATING MEDICAL GROUP.

 

8.08      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.

 

22

 

IX.           NON-CAPITATED
SERVICES

 

9.01      Non-Capitated
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
Non-Capitated 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.     Skilled Nursing
Facility Services.

 

G.    Ambulance Services.

 

H.    Home Health
Services.

 

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

 

J.     Ten percent (10%)
of expenses related to Out-of-Area Emergency Services (Facility and
Professional Expenses).

 

K.    Durable Medical
Equipment and prosthetic devices.

 

L.     Hospice Services.

 

M.   Fifty percent (50%)
of the average wholesale price (AWP) related to chemotherapy drugs
(intravenously administered) and injectable medications administered during a
visit to the physician’s office (excluding take-home insulin).

 

N.    Mammography
Services.

 

23

 

 

9.02      Billing for
Non-Capitated Services shall be as follows:

 

A.    The provider of
Non-Capitated Services may bill BLUE CROSS directly, in which case, BLUE CROSS
shall reimburse said provider within forty-five (45) working days following
receipt of a clean, undisputed claim accompanied by an authorization from
PARTICIPATING MEDICAL GROUP; or

 

B.    The provider of
Non-Capitated Services may bill PARTICIPATING MEDICAL GROUP, in which case,
PARTICIPATING MEDICAL GROUP shall bill BLUE CROSS for reimbursement.  BLUE CROSS shall reimburse PARTICIPATING
MEDICAL GROUP within forty-five (45) working days following BLUE CROSS’s
receipt of a clean undisputed claim from PARTICIPATING MEDICAL GROUP, on the
condition that such claim shall be submitted to BLUE CROSS no later than twelve
(12) months after the date of service. 
This section shall only apply for the following Non-Capitated
Services:  mammography services, DME,
prosthetics and injectable medications (including chemotherapy drugs and
infused substances).

 

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

 

9.03      Case Management
Stop-Loss.

 

A     The Case Management
Program is a program in which a Member’s medical needs are assessed by PARTICIPATING
MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and
coordinate treatment alternatives. 
PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case
Manager prior to the Member achieving the applicable Case Management Stop-Loss
Threshold, as described below.

 

B.    For PARTICIPATING
MEDICAL GROUPs with enrollment of Twenty-Four Thousand (24,000) or more Member
Months for the calendar year, the Case Management Stop-Loss Threshold for an
individual Member shall be SIXTY THOUSAND DOLLARS ($60,000.00) of Non-Capitated
Expenses.

 

For PARTICIPATING MEDICAL GROUPs with
enrollment of less than Twenty-Four Thousand (24,000) Member Months, the Case
Management Stop-Loss Threshold shall be THIRTY-FIVE THOUSAND DOLLARS ($35,000.00)
of Non-Capitated Expenses.

 

C.    Authorized expenses
for Member’s Non-Capitated Services, up to the Case Management Stop-Loss
Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expenses. 
Additionally, ten percent (10%) of expenses between the applicable Case
Management Stop-loss Threshold and ONE HUNDRED AND FIFTY THOUSAND DOLLARS
($150,000) incurred by an individual Member will be accrued toward
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.  Non-Capitated expenses greater than ONE
HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) for any individual Member will
not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.

 

24

 

D.    The Case Management
Stop-loss Thresholds described above will apply to Members whose treatment
includes transplants (solid organ and bone marrow/stem cell), except in those
cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as
described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to
provide such notice, all of that Member’s Non-Capitated Expenses will be
included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.

 

9.04      Calculating
PARTICIPATING MEDICAL GROUP PMPM Non-Capitated Expenses.

 

The Non-Capitated Expenses shall include
actual expenses incurred by BLUE CROSS to provide Non-Capitated Services to
Members, as authorized or referred by the PARTICIPATING MEDICAL GROUP. Expenses
above the Case Management Stop-Loss Threshold, as set forth in
Section 9.03, and expenses incurred by Members or former Members covered
under the Extension of Benefits provision of the Benefit Agreements are
excluded from PARTICIPATING MEDICAL GROUP’s Non-Capitated Expenses for purposes
of determining the Non-Capitated Performance Settlement.

 

BLUE CROSS shall accrue Non-Capitated
Expenses by each PARTICIPATING MEDICAL GROUP by the calendar year the services
were incurred and paid through one hundred and twenty (120) days
(April 30) after year-end.  Beginning in year two (2) of this Agreement, any claims received
after calculation of the final Non-Capitated Performance Settlement will be
charged to the following year’s Non-Capitated Expenses. Any Non-Capitated
Services treatments that begin in one calendar year and extend into the next
year shall accrue to the year the treatment began. Notwithstanding the
aforementioned, any claims for Non-Capitated Services or Shared Risk Services
(as defined in the CALIFORNIACARE Medical Services Agreement in effect for
years prior to 1997) paid after April 30, 1997 will be charged to the 1997
Non-Capitated Expense.

 

PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense is the quotient of PARTICIPATING MEDICAL GROUP’s
Non-Capitated Expenses divided by PARTICIPATING MEDICAL GROUP’s calendar year
Member Months.

 

BLUE CROSS shall provide PARTICIPATING
MEDICAL GROUP with quarterly reports advising them of their Non-Capitated
Expenses. The Operations Manual describes the PARTICIPATING MEDICAL GROUP
reports.

 

9.05      Non-Capitated
Performance Settlement Schedule.

 

Non-Capitated Performance Settlement
Schedule shall mean a schedule that will be the basis for determining
the Non-Capitated Performance Settlement. This schedule presents BLUE
CROSS’s prior year aggregate PMPM Non-Capitated Expenses adjusted by factors to
account for medical inflation. Exhibit F (incorporated by reference herein)
sets forth the Non-Capitated Performance Settlement Schedule.

 

9.06      Calculating the
Non-Capitated Performance Settlement.

 

A.    PARTICIPATING
MEDICAL GROUP’s Adjusted PMPM Non-Capitated Expense.

 

PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expenses is the quotient of PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses divided by the composite of PARTICIPATING MEDICAL GROUP’s
Age/Sex, Plan, Stop-Loss and Region Factors.

 

25

 

The PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expense is adjusted to account for the PARTICIPATING MEDICAL
GROUP’s mix of Members and make the PARTICIPATING MEDICAL GROUP’s PMPM
Non-Capitated Expenses comparable to the Non-Capitated Performance Settlement
Schedule, as set forth in Exhibit F.

 

B.    Non-Capitated
Performance Settlement.

 

If the PARTICIPATING MEDICAL GROUP’s Adjusted
PMPM Non-Capitated Expense is equal to or greater than the Attachment Point,
the PARTICIPATING MEDICAL GROUP will not receive a Non-Capitated Performance
Settlement. If the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated
Expense is less than the Attachment Point, the PARTICIPATING MEDICAL GROUP will
receive a Non-Capitated Performance Settlement.

 

The PMPM Non-Capitated Performance Settlement
is determined by allocating a portion of the difference between the Attachment
Point and the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM Non-Capitated
Expense. The proportion of the difference allocated to the PMPM Non-Capitated
Performance Settlement is according to the Non-Capitated Performance Settlement
Schedule, set forth in Exhibit F. The PMPM Non-Capitated Performance Settlement
amount multiplied by the PARTICIPATING MEDICAL GROUP’s calendar year Member
Months determines the total Non-Capitated Performance Settlement.

 

Within forty-five (45) working days after
April 30, BLUE CROSS shall pay the Non-Capitated Performance Settlement if
a Non-Capitated Performance Settlement amount is due to the PARTICIPATING
MEDICAL GROUP.

 

Notwithstanding the above, in the event this
Agreement is terminated, BLUE CROSS shall calculate the Non-Capitated
Performance Settlement in accordance with this Article IX and shall pay
PARTICIPATING MEDICAL GROUP a preliminary Non-Capitated Performance Settlement
equal to eighty percent (80%) of any amount due PARTICIPATING MEDICAL GROUP
based upon this calculation. Twelve (12) months following the calculation and
payment of the preliminary Non-Capitated Performance Settlement, BLUE CROSS
shall calculate a final Non-Capitated Performance Settlement in accordance with
this Article IX and shall pay any amount due PARTICIPATING MEDICAL GROUP,
less any amounts paid at the time of preliminary Non-Capitated Performance
Settlement. In the event monies paid PARTICIPATING MEDICAL GROUP at the time of
the preliminary Non-Capitated Performance Settlement exceed the final
Non-Capitated Performance Settlement, PARTICIPATING MEDICAL GROUP shall
reimburse BLUE CROSS any amounts owed within forty-five (45) working days of
notification from BLUE CROSS.

 

X.            OUTPATIENT
PRESCRIPTION DRUG EXPENSE

 

10.01    Calculating PARTICIPATING MEDICAL GROUP PMPM
Outpatient Prescription Drug Expenses (“PMPM OPDE”).

 

The Outpatient Prescription Drug Expense
(“OPDE”) shall include expenses incurred by BLUE CROSS to provide covered
outpatient prescription drugs to Members assigned to PARTICIPATING MEDICAL
GROUP.

 

BLUE CROSS shall accrue OPDE for each
PARTICIPATING MEDICAL GROUP by the calendar year the services were incurred and
paid through one hundred and twenty (120) days after year-end. Beginning in
year two (2) of this Agreement, any claims received after calculation of the
final Outpatient Prescription Drug Settlement will be charged to the following
year’s OPDE. Notwithstanding the aforementioned, any claims for outpatient
prescription drug services incurred

 

26

 

prior to 1997 but paid after the final
Non-Capitated Performance Settlement calculation for 1996 and if applicable,
for subsequent years, will be charged to the following year’s OPDE.

 

PARTICIPATING MEDICAL GROUP’s PMPM OPDE is
the quotient of PARTICIPATING MEDICAL GROUP’s OPDE divided by the PARTICIPATING
MEDICAL GROUP’s calendar year Member Months for Members with outpatient
prescription drug benefits.

 

BLUE CROSS shall provide PARTICIPATING
MEDICAL GROUP with quarterly reports advising them of their OPDE. Report
formats are described in the Operations Manual.

 

10.02    Outpatient
Prescription Drug Settlement Schedule.

 

The Outpatient Prescription Drug Settlement
Schedule set forth at Exhibit H (incorporated by reference herein) will be
the basis for determining PARTICIPATING MEDICAL GROUP’s Outpatient Prescription
Drug Settlement.

 

10.03    Calculating the
Outpatient Prescription Drug Settlement.

 

If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is
less than the Outpatient Prescription Drug Expense Target, the PARTICIPATING
MEDICAL GROUP will receive an Outpatient Prescription Drug Settlement. If the
PARTICIPATING MEDICAL GROUP’s PMPM Outpatient Prescription Drug Expense is
equal to or greater than the Outpatient Prescription Drug Expense Target, the
PARTICIPATING MEDICAL GROUP will not receive an Outpatient Prescription Drug
Settlement.

 

A.    Outpatient
Prescription Drug Settlement.

 

The PMPM Outpatient Prescription Drug
Settlement is determined by allocating a portion of the difference between the
OPDE Target, and the PARTICIPATING MEDICAL GROUP’s PMPM Outpatient Prescription
Drug Expense. The proportion of the difference allocated to the PMPM Outpatient
Prescription Drug Settlement is determined in accordance with the Outpatient
Prescription Drug Schedule, set forth in Exhibit H.

 

B.    Formulary Utilization
Incentive.

 

If PARTICIPATING MEDICAL GROUP’s use of the
BLUE CROSS Outpatient Prescription Drug Formulary (the “Formulary”) is equal to
or greater than ninety-five percent (95%), as described in Exhibit H, and
PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an
additional $0.10 PMPM will be added to PARTICIPATING MEDICAL GROUP’s PMPM
Outpatient Prescription Drug Settlement.

 

The amount of the Outpatient Prescription
Drug Settlement and Formulary utilization incentive will be based on the
applicable PMPM Settlement calculation under Exhibit H multiplied by
PARTICIPATING MEDICAL GROUP’s Member Months for Members with outpatient
prescription drug benefits. Within forty-five (45) working days after
April 30, BLUE CROSS will pay any Outpatient Prescription Drug Settlement
that is due PARTICIPATING MEDICAL GROUP for the previous year.

 

Notwithstanding the above, in the event this
Agreement is terminated, BLUE CROSS shall calculate the Outpatient Prescription
Drug Settlement in accordance with this Article X and shall pay
PARTICIPATING MEDICAL GROUP a preliminary Outpatient Prescription Drug
Settlement equal to eighty percent (80%) of any amount due PARTICIPATING
MEDICAL GROUP based upon this calculation. Twelve (12) months following the
calculation and payment of the preliminary Outpatient Prescription Drug
Settlement, BLUE CROSS shall calculate a final

 

27

 

Outpatient Prescription Drug Settlement in
accordance with this Article X and shall pay any amount due PARTICIPATING
MEDICAL GROUP, less any amounts paid at the time of preliminary Outpatient
Prescription Drug Settlement. In the event monies paid PARTICIPATING MEDICAL
GROUP at the time of the preliminary Outpatient Prescription Drug Settlement
exceed the final Outpatient Prescription Drug Settlement, PARTICIPATING MEDICAL
GROUP shall reimburse BLUE CROSS any amounts owed within forty-five (45)
working days of notification from BLUE CROSS.

 

XI.           QUALITY MANAGEMENT BONUS

 

Blue Cross will evaluate PARTICIPATING
MEDICAL GROUP’s Quality Management Program and Member quality of care using a
scorecard.  PARTICIPATING MEDICAL GROUP
will be notified of the scorecard parameters and scoring methodology prior to
the start of each year, as described in the Operations Manual.

 

PARTICIPATING MEDICAL GROUP must meet minimum
eligibility criteria to receive a scorecard score and therefore to be eligible
for a Quality Management Bonus. These criteria include a minimum of 12,000
Member months for a calendar year and submission to BLUE CROSS of all necessary
encounter data.

 

A Quality Management Bonus will be paid if
PARTICIPATING MEDICAL GROUP’s performance on the scorecard is average or above
average. No Quality Management Bonus will be paid if PARTICIPATING MEDICAL
GROUP’s scorecard performance is below average. BLUE CROSS will notify
PARTICIPATING MEDICAL GROUP of the scorecard results sixty (60) days following
the end of the calendar year.

 

The Quality Management Bonus paid to
PARTICIPATING MEDICAL GROUP, should a payment be due in accordance with the
PMPM Quality Management Bonus Schedule shown in Exhibit I (incorporated by
reference herein), will be made by the fifteenth of June following the end
of the calendar year for which it is based.

 

XII.         BILLING FOR HMO-USA
AWAY FROM HOME CARE SERVICES

 

12.01    PARTICIPATING
MEDICAL GROUP agrees to render or refer urgent care, Emergency services,
follow-up care and routine services, as Host HMO to out-of-state members of
HMO-USA participating plans, when such care is prearranged by BLUE CROSS.
Urgent care as it relates to the HMO-USA Away From Home Care Program means
outpatient medical care which the Host HMO determines is required for an
unexpected illness or injury that is not life threatening, but which cannot
reasonably be postponed until the HMO-USA participating plan member returns to
the service area of the member’s Home HMO.

 

All medical services rendered at
PARTICIPATING MEDICAL GROUP or Satellite Facilities and all Referral Services
rendered to members of HMO-USA participating plans, due to unavailability of
the required services at PARTICIPATING MEDICAL GROUP, shall be paid by BLUE
CROSS. For services PARTICIPATING MEDICAL GROUP provides directly to members of
HMO-USA participating plans.  BLUE CROSS
shall reimburse PARTICIPATING MEDICAL GROUP at PARTICIPATING MEDICAL GROUP’s
invoiced amount, not to exceed reimbursement in accordance with Exhibit E of
this Agreement For Referral Services. 
PARTICIPATING MEDICAL GROUP may instruct providers of Referrral Services
to bill BLUE CROSS directly or, such providers may bill PARTICIPATING MEDICAL
GROUP, in which case, PARTICIPATING MEDICAL GROUP shall be reimbursed by BLUE
CROSS. In all cases, PARTICIPATING MEDICAL GROUP or provider of Referral
Services shall note on the claim that services were

 

28

 

rendered to a member of an HMO-USA
participating plan. Neither PARTICIPATING MEDICAL GROUP nor provider of
Referral Services shall bill members of HMO-USA participating plans.

 

12.02    BLUE CROSS agrees
to pay PARTICIPATING MEDICAL GROUP within forty-five (45) working days of
receipt of a completed professional services claim form for authorized services
rendered to members of HMO-USA participating plans.

 

XIII.        TERM OF AGREEMENT,
TERMINATION

 

13.01    This Agreement
shall be in effect for a one 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.

 

13.02    Should this
Agreement be terminated pursuant to Section 13.01 above, PARTICIPATING
MEDICAL GROUP agrees to continue to provide Capitation Services and to arrange
Non-Capitated Services for all Members assigned to PARTICIPATING MEDICAL GROUP,
including any Members who become eligible during the notice period set forth in
Section 13.01 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 Exhibit E,
until the annual anniversary dates of the Benefit Agreements of Members
assigned to PARTICIPATING MEDICAL GROUP.

 

In the event this Agreement is terminated,
BLUE CROSS shall have the right, but not the obligation, to directly pay any
bills for expenses for Referral Services rendered to Members assigned to
PARTICIPATING MEDICAL GROUP which remain outstanding on the date of
termination. BLUE CROSS shall immediately be notified in writing of all such
outstanding bills for Referral Services and BLUE CROSS shall have the right to
set off the amount of such payments against any amount due PARTICIPATING
MEDICAL GROUP for Capitation and Non-Capitated Services pursuant to
Article IX, or any other payments due 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.

 

13.03    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, PARTICIPATING MEDICAL GROUP shall continue to provide and be
compensated under the terms of this Agreement for Covered Medical Services
provided to each Member who is under the care of PARTICIPATING MEDICAL GROUP at
the time of that termination, 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.

 

29

 

13.04    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.

 

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

 

14.01    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.

 

14.02    Any problem or
dispute arising under this Agreement and/or concerning the terms of this
Agreement that is not satisfactorily resolved under Section 14.01 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.  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.

 

14.03    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.

 

14.04    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.

 

14.05    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.

 

14.06    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 BLUE CROSS or
PARTICIPATING MEDICAL GROUP, respectively, shall be considered the initiating
party for the purposes of Section 14.03 hereof.

 

14.07    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.

 

30

 

XV.         CALIFORNIACARE MEMBER GRIEVANCE
SYSTEM

 

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

 

15.02    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 CALIFORNIACARE Quality Management Representative.

 

15.03    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.

 

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

 

XVI.        MISCELLANEOUS
PROVISIONS

 

16.01    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.

 

16.02    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.

 

16.03    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, 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.

 

16.04    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.

 

31

 

16.05    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.

 

16.06    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.

 

16.07    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 its principal office or at the
address provided in writing to the other. 
Notices shall be effective when received.

 

16.08    Maximum Capacity.  The Maximum Capacity of PARTICIPATING
MEDICAL GROUP during the term of this Agreement shall be 10,000 Members.

 

16.09    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.

 

16.10    Solicitation of
Members.  The business relationship
between BLUE CROSS and its Members, and BLUE CROSS and the employer groups with
which it contracts, shall be deemed the property of BLUE CROSS.  Similarly, all lists of Members accepted by
PARTICIPATING MEDICAL GROUP under the provisions of this Agreement and of the
employer groups to which they belong, 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 or employer groups to disenroll from BLUE CROSS;
(3) solicit such Member or employer group 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.

 

16.11    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.

 

16.12    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.

 

32

 

16.13    Governing Law. This Agreement
shall be construed and enforced in accordance with the laws of the State of
California.

 

	
  BLUE
  CROSS OF CALIFORNIA

  	
   

  	
  NORTHWEST
  ORANGE COUNTY MEDICAL

  GROUP, INC.

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature:

  	
  /s/ Ferial Bahremand

  	
   

  	
   

  	
  Signature:

  	
  /s/ Pratibha Patel

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Name:

  	
  Ferial Bahremand

  	
   

  	
   

  	
  Name:

  	
  Pratibha Patel, MD

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  Vice President

  	
   

  	
   

  	
  Title:

  	
  President

  	
   

  
	
   

  	
  Network Development
  & Management

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  3/3/97

  	
   

  	
   

  	
  Date:

  	
  2/10/97

  	
   

  

 

33

 

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 copayment directly to the physician for each such
visit

 

(2)   Hospital or Skilled
Nursing Facility

 

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.

 

A-1

 

E.     Infertility studies for Members aged 18 or
over.

 

F.     Ear examinations.

 

G.    Health education services as follows:

 

(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.

 

H.    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.

 

I.      Allergy testing and administration of
injections.

 

A-2

 

EXHIBIT A(1)

CALIFORNIACARE

 

DIVISION OF FINANCIAL RESPONSIBILITIES

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  

 

*      As set forth in the applicable Benefit
Agreement

 

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

 

A(1)-1

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  CHEMOTHERAPY DRUGS (intravenously administered)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Chemotherapy Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  

 

*      As set forth in the
applicable Benefit Agreement

 

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

 

A(1)-2

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  	 

	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	 

	
   

  	
  EMERGENCY ROOM: Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  EMPLOYMENT PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  (required by third party or
  outside-agency)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   *

  	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEARING SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient / Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
									

 

*      As set forth in the
applicable Benefit Agreement.

**   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 the division of financial
responsibility have been deleted.

 

A(1)-3

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HEPATITIS B VACCINE / GAMMA GLOBULIN

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HOME HEALTH (including medications)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  HOSPICE (in lieu of acute inpatient or SNF care)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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)

  	
   

  	
  ***

  	
   

  	
  ***

  
								

 

*      As set forth in the applicable Benefit
Agreement

 

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

 

A(1)-4

 

	 
	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	 
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMEDIATE CARE

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMUNIZATION SERUMS (pediatric)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  IMMUNIZATION SERUMS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  INFANT APNEA MONITOR (DME)

  (in conjunction with or concurrent with authorized
  inpatient admission)

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
									

 

*      As set forth in the
applicable Benefit Agreement

 

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

 

A(1)-5

 

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  MENTAL HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  *Outpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  NUTRITIONIST / DIETITIAN

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OBSTETRICAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Diagnostic
  Services

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
								

 

*      As set forth in the
applicable Benefit Agreement

 

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

 

A(1)-6

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component
  for:

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Anesthesiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Audiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
									

 

*      As set forth in the applicable Benefit
Agreement

 

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

 

A(1)-7

 

 

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pediatrics

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Physical Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Pulmonary Medicine

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiation Oncology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Radiology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Urology

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PRE-EXISTING PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  

 

*      As set forth in the applicable Benefit
Agreement

 

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

 

A(1)-8

 

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PREGNANCY SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  PROSTHETIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  RADIATION THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Inpatient Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Hospital
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Outpatient Clinic
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
  (Short Term: 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

  	
   

  	
  ***

  	
   

  	
  ***

  

 

*      As set forth in the applicable Benefit
Agreement

 

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

 

A(1)-9

 

 

	
  List of Benefits / Services

  	
   

  	
  Capitation

  	
   

  	
  Non-

  Capitated

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
  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)

  	
   

  	
  ***

  	
   

  	
  ***

  

 

*      As set
forth in the applicable Benefit Agreement

 

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

 

A(1)-10

 

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

 

*** Confidential
Treatment requested

 

C-1

 

CALIFORNIACARE HEALTH PLANS

 

SCHEDULE D

 

1997 AGE/SEX ADJUSTED CAPITATION

 

ODN: NORTHWEST ORANGE COUNTY MEDICAL GROUP, INC. FOR
DURATIONALS

 

PLAN IC - DURATION YEAR 1 PROFESSIONAL CAPITATION

BASED ON $21.91 PMPM

 

	
  AGE    BAND

  	
   

  	
  MALE

  	
   

  	
  FEMALE

  	
   

  
	
  < 1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  1 - 4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  5 - 14

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  15 - 19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  20 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 +

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 + MP *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*      EMPLOYER INSURANCE
IS SECONDARY PAYER TO MEDICARE

 

ENROLLMENT
PROTECTION THRESHOLD OF  $6,000 @ $0.00
PMPM

 

1

 

	
  Effective December 1, 1996

  	
   

  	
  Blue Cross of California

  
	
   

  	
   

  	
  Prudent Buyer Plan

  

 

EXHIBIT E

 

PHYSICIAN PAYMENT STRUCTURE

 

AREA 5

 

Blue Cross of California
establishes and, from time to time, revises unit values based on observed
charge patterns by CPT-4 procedure code. The maximum allowable for physician
claims shall be calculated using the unit values as in effect, multiplied by
the following conversion factors: *

 

CONVERSION FACTORS

 

	
  Anesthesia Medicine

  	
  ***

  
	
   

  	
   

  
	
  Pathology

  	
   

  
	
  CPT
  codes 88100-88399

  	
  ***

  
	
  All
  other CPT codes

  	
  ***

  
	
   

  	
   

  
	
  Radiology

  	
  ***

  
	
   

  	
   

  
	
  Surgery

  	
   

  	
   

  
	
  CPT-4
  codes 59400-59622

  	
  ***

  
	
  All
  other CPT-4 codes

  	
  ***

  
			

 

*      When PHYSICIAN does not
submit claims electronically in a format specified by BLUE CROSS, a handling
fee of $0.50 per OCR scannable claim and $1.00 per paper claim will be deducted
from payment due PHYSICIAN. PHYSICIAN will not charge Members for the handling
fee.

 

REIMBURSEMENT FOR HCPCS LEVEL II CODES

 

Pharmacy (including infusion
therapy drugs): Maximum Allowable reimbursement based on Average
Wholesale Price (AWP) according to published market data (such as Drug Topics Red Book, American Druggist Blue Book, or
Medispan). Oral prescription drugs dispensed in the physician’s
office will be denied as not payable, and the Member may not be billed by
physician.

 

Durable Medical Equipment,
Supplies (including, but not limited to, infusion therapy supplies),
Prosthetics and Orthotics: Maximum Allowable Reimbursement not to
exceed the lesser of the average retail price or the Medicare regional
allowable reimbursement rates applied to California for the appropriate code
ranges. The average retail price will be determined annually from claims data
and/or external data. Reimbursement rates will be based on whether the
equipment is new, used or rented as identified by the CPT code modifier. Codes
not identified by modifier will be considered as rentals.

 

All other HCPCS Codes: For all other
HCPCS codes the Maximum Allowable will be determined by Blue Cross using claims
data and/or external data.

 

*** Confidential
Treatment requested

 

 

EXHIBIT F

 

NON-CAPITATED PERFORMANCE SETTLEMENT SCHEDULE

For Non-Capitated Medical Services

 

Based on Plan C,
$60.000 Stop Loss, Age/Sex Factor = 1.00 and Regional Factor = 1.00

 

Non-Capitated Performance
Settlement Calculation Method:

 

1)     Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.

 

2)     Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value of
the payment band

 

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

 

4)     Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement

 

5)     Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the Non-Capitated Performance Settlement

 

	
  Payment Bands

  	
   

  	
  Non-Capitated
  Expense Ranges

  (PMPM Non-Capitated Expense)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Low

  	
   

  	
  High

  	
   

  	
  Multiplier

  	
   

  	
  Minimum
  Payment Amount

  	
   

  
	
  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0%

  	
   

  	
  ***

  	
   

  
	
  2

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  25%

  	
   

  	
  ***

  	
   

  
	
  3

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40%

  	
   

  	
  ***

  	
   

  
	
  4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  55%

  	
   

  	
  ***

  	
   

  
	
  5

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65%

  	
   

  	
  ***

  	
   

  
	
  6

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  75%

  	
   

  	
  ***

  	
   

  
	
  7

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  65%

  	
   

  	
  ***

  	
   

  
	
  8

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  50%

  	
   

  	
  ***

  	
   

  
	
  9

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  40%

  	
   

  	
  ***

  	
   

  
	
  10

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  0%

  	
   

  	
  ***

  	
   

  
											

 

* Attachment Point

 

Example of Non-Capitated
Performance Settlement Calculation

 

Assume:  PARTICIPATING MEDICAL GROUP has an PMPM Non-Capitated Expense of
$26.63; and there are 100,000 member months

 

(1)   Identify the
payment band that contains the PARTICIPATING MEDICAL GROUP’s Adjusted PMPM
Non-Capitated Expense.

The PARTICIPATING MEDICAL GROUP’s
PMPM Non-Capitated Expense of $26.63 falls between the low and high values of
payment band 5

(2)   Subtract the
PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expense from the high value
for the payment band $27.63 - $26.63 = $1.00

(3)   Multiply the result
from Step 2 by the multiplier for the payment band. $1.00 x 65% = $0.65

(4)   Add the result from
Step 3 to the minimum payment amount for the payment band to get the PMPM
Non-Capitated Performance Settlement. $0.65 +
$1.59 = $2.24 PMPM Non-Capitated Performance Settlement

(5)   Multiply the PMPM
Non-Capitated Performance Settlement from Step 4 by the PARTICIPATING MEDICAL
GROUP’s Member Months to calculate the Non-Capitated Performance Settlement.

 

$2.24 PMPM Non-Capitated
Performance Settlement x 100,000 member months = $224,000 Non-Capitated
Performance Settlement

 

F-1

 

EXHIBIT G

 

COMPENSATION FOR SERVICES TO BLUE CROSS PLUS MEMBERS

 

In consideration for the mutual promises herein set
forth, PARTICIPATING MEDICAL GROUP and BLUE CROSS hereby agree as follows:

 

I.              DEFINITIONS

 

A.    “Advance
Supplemental Capitation Payment” means a supplemental Capitation payment
apportioned monthly and paid in advance of the date it is earned. Advance
Supplemental Capitation Payments are subject to recoupment by BLUE CROSS if not
actually earned prior to the end of the calendar quarter.

 

B.    “Baseline
Capitation Payment” means the monthly Capitation payment for each Member
covered by a BLUE CROSS PLUS Benefit Agreement and assigned to PARTICIPATING
MEDICAL GROUP.

 

C.    “In-Network
Services” means those services which are provided, arranged by, referred or
authorized by PARTICIPATING MEDICAL GROUP for BLUE CROSS PLUS Members and which
would be CALIFORNIACARE Capitation Services if they had been rendered under the
Agreement to a CALIFORNIACARE Member.

 

D.    “In-Network
Utilization Factor” means the quotient of the Baseline Capitation Payment,
divided by the sum of Baseline Capitation Payments plus expenses for Out-of-
Network Services, modified each calendar quarter to allow for incurred but not
reported expenses (IBNR) based on BLUE CROSS’s overall BLUE CROSS PLUS
experience, as follows:

 

	
  Baseline Capitation Payment

  	
   

  	
  = A

  
	
   

  	
   

  	
   

  
	
  Expenses for Out-of-Network Services

  	
   

  	
  = B

  
	
  (Modified to allow for IBNR)

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  In-Network Utilization Factor

  	
   

  	
  = C

  

 

	
  C = 

  	
  A

  	
   

  
	
  A + B

  	
   

  

 

E.     “Non-Participating
Provider” means a Health Professional, hospital, emergency facility,
skilled nursing facility, ambulance service, home health agency, or Alternate
Birthing Center that has rendered services to a BLUE CROSS PLUS Member without
authorization from the PARTICIPATING MEDICAL GROUP to which the Member is
assigned.

 

F.     “Out-of-Network
Services” means those services rendered to BLUE CROSS PLUS Members by a
Non-Participating Provider, and which would be Capitation Services if rendered
by PARTICIPATING MEDICAL GROUP under the Agreement to CALIFORNIACARE Members,
except for Out-of-Area Emergency Services

 

 

G-1

 

G     “Supplemental
Capitation Payment” means a Capitation payment per BLUE CROSS PLUS Member
per month, which may be earned based on the In-Network Utilization Factor as
set forth in Exhibit G-1.

 

G-2

 

II.            COMPENSATION FOR SERVICES TO BLUE CROSS PLUS
MEMBERS

 

The parties agree that the terms of Exhibit D
of the Agreement shall apply only to CALIFORNIACARE Members. BLUE CROSS shall
compensate PARTICIPATING MEDICAL GROUP for services to BLUE CROSS PLUS Members
as follows:

 

A.    BLUE CROSS shall
pay a Baseline Capitation Payment per Member per month in the amounts set forth
in Exhibit G-1, adjusted to account for age and sex characteristics of the
Member, and Member Benefit Agreement.

 

B.    PARTICIPATING
MEDICAL GROUP may earn Supplemental Capitation Payments by achieving an
In-Network Utilization Factor greater than 0.42 in any calendar quarter, as set
forth in Exhibit G-1. For any calendar quarter in which PARTICIPATING MEDICAL
GROUP achieves an In-Network Utilization Factor of 0.42 or above, BLUE CROSS
shall make a Supplemental Capitation Payment in accordance with Exhibit G-1 due
sixty (60) working days after the end of such calendar quarter.

 

C.    PARTICIPATING
MEDICAL GROUP may elect to receive advance Supplemental Capitation Payments
prior to the time PARTICIPATING MEDICAL GROUP’s In-Network Utilization Factor
is known, i.e., during the applicable calendar quarter. However, if at the end
of such calendar quarter, PARTICIPATING MEDICAL GROUP’s In-Network Utilization
Factor is below 0.42, then BLUE CROSS shall have the right to set off the
amount of advance Supplemental Capitation Payments made during such quarter
from Capitation payments due PARTICIPATING MEDICAL GROUP in subsequent months.

 

D.    BLUE CROSS shall
calculate the In-Network Utilization Factor on a PARTICIPATING MEDICAL GROUP
specific basis for each PARTICIPATING MEDICAL GROUP with 1200 or more BLUE
CROSS PLUS Member Months for the applicable calendar quarter. All PARTICIPATING
MEDICAL GROUPs with 450 to 1199 BLUE CROSS PLUS Member Months, for the
applicable calendar quarter, will be pooled for determining the In-Network
Utilization Factor.  All PARTICIPATING
MEDICAL GROUPS with fewer than 450 BLUE CROSS PLUS Member Months, for the
applicable calendar quarter, will be grouped into a second pool for determining
the In-Network Utilization Factor.

 

E.     Total claims for
Out-of-Network Expenses rendered to any single BLUE CROSS PLUS Member during
the calendar year shall be limited to 140% of the Enrollment Protection level
selected by PARTICIPATING MEDICAL GROUP for CALIFORNIACARE and BLUE CROSS PLUS
Members under Article VIII, Sections 8.02 or 8.03 of the Agreement.

 

F.     The liability of
PARTICIPATING MEDICAL GROUP for expenses for Capitation Services rendered
during the calendar year to any single Member enrolled in BLUE CROSS PLUS shall
be limited to the applicable Enrollment Protection amount defined in Sections
8.02, 8.03 and 8.04. Expenses considered under Enrollment Protection shall
include expenses incurred by PARTICIPATING MEDICAL GROUP.  Expenses for out-of-network services are not
included.

 

G.    BLUE CROSS may
complete an audit of BLUE CROSS PLUS capitation payments within six (6) months
after the end of the calendar year to reconcile any annual over or
underpayments.

 

G-3

 

CALIFORNIACARE
HEALTH PLANS

 

SCHEDULE G-l

 

1997
AGE/SEX ADJUSTED CAPITATION FOR NEW AND RENEWING EMPLOYER GROUPS

 

ODN:
NORTHWEST ORANGE COUNTY MEDICAL GROUP, INC.

 

PLAN ZA
PROFESSIONAL CAPITATION BASED ON $16.96 PMPM (1)

 

	
  AGE BAND

  	
   

  	
  MALE

  	
   

  	
  FEMALE

  	
   

  
	
       
  <  1

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
    1
  -   4

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
    5
  - 14

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  15 - 19

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  20 - 24

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  25 - 29

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  30 - 34

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  35 - 39

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  40 - 44

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  45 - 49

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  50 - 54

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  55 - 59

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  60 - 64

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 +

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  65 + MP *

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

*      EMPLOYER
INSURANCE IS SECONDARY PAYER TO MEDICARE

 

ENROLLMENT
PROTECTION THRESHOLD OF $6,000 @ $0.00 PMPM

 

	
  INUF

  	
   

  	
  SUPPLEMENTAL

  CAPITATION PAYMENT (2)

  	
   

  
	
  0 < = .42

  	
   

  	
  ***

  	
   

  
	
  .42 < .48

  	
   

  	
  ***

  	
   

  
	
  .48 < .55

  	
   

  	
  ***

  	
   

  
	
  .55 < .65

  	
   

  	
  ***

  	
   

  
	
  .65 < .80

  	
   

  	
  ***

  	
   

  
	
  > .80

  	
   

  	
  ***

  	
   

  

 

(1)   BASELINE
CAPITATION AMOUNT IS EQUAL TO FIFTY PERCENT (50%) OF THE TOTAL CAPITATION
PAYMENT.

(2)   SUPPLEMENTAL
CAPTATION PAYMENT AMOUNT IS EXPRESSED AS A PERCENT OF THE TOTAL CAPITATION
PAYMENT AND INCLUDES ANY ADVANCE SUPPLEMENTAL CAPITATION PAYMENT ALREADY PAID.

 

1

 

EXHIBIT H

 

OUTPATIENT PRESCRIPTION DRUG SETTLEMENT SCHEDULE

 

	
  PMPM Outpatient Prescription Drug Expense Target:

  	
  *** PMPM

  

 

	
  PMPM Expense Range

  	
   

  	
  Settlement
  Calculation

  	
   

  
	
  Greater than
  $10.45

  	
   

  	
  ***

  	
   

  
	
  $9.60 to $10.45

  	
   

  	
  (*** - PMPM OPDE
  ) x 45%

  	
   

  
	
  $8.75 to $9.59

  	
   

  	
  (*** - PMPM OPDE ) x 50%

  	
   

  
	
  Less than $8.75

  	
   

  	
  *** PMPM

  	
   

  

 

If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less
than the OPDE Target, an additional $0.10 PMPM will be due to PARTICIPATING
MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal
to or greater than 95%.

 

Formulary
Utilization:          Is the quotient of
the number of prescriptions for Members with outpatient prescription drug
benefits assigned to PARTICIPATING MEDICAL GROUP using drugs listed in the Blue
Cross of California Outpatient Prescription Drug Formulary divided by the total
number of prescriptions for Members with outpatient prescription drug benefits
assigned to PARTICIPATING MEDICAL GROUP.

 

*** Confidential
Treatment requested

 

H-1

 

EXHIBIT I

 

QUALITY MANAGEMENT BONUS SCHEDULE

 

	
  Quality Management Scorecard
  Rating

  	
   

  	
  PMPM
  Quality Bonus Settlement

  	
   

  
	
  Below Average

  	
   

  	
  ***

  	
   

  
	
  Average

  	
   

  	
  ***

  	
   

  
	
  Above Average

  	
   

  	
  ***

  	
   

  

 

Where:

 

“Average” is the numeric average of all
PARTICIPATING MEDICAL GROUP scorecard scores plus or minus one standard
deviation.

 

“Above Average” is a score that is greater than one
standard deviation above the numeric average of all PARTICIPATING MEDICAL GROUP
scorecard scores.

 

“Below Average” is a score that is less than one
standard deviation below the numeric average of all PARTICIPATING MEDICAL GROUP
scorecard scores.

 

*** Confidential
Treatment requested

 

I-1

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