Document:

Exhibit
10.92

 

1999

 

FHS

 

 

PARTICIPATING
PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

 

Professional
Care Medical Group IPA

 

 

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 FHS

  	
   

  
	
   

  	
   

  
	
  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

  	
   

  
	
  A.

  	
  Definitions

  	
   

  
	
  B.

  	
  Medicare HMO Benefit
  Program

  	
   

  
	
  C.

  	
  Medicare POS Benefit
  Program

  	
   

  
	
  D.

  	
  Administration
  Of Shared Risk Budgets For HMO and POS

  	
   

  
	
  E.

  	
  Medicare Select
  Benefit Programs

  	
   

  
	
  F.

  	
  Other Services

  	
   

  
					

 

ii

 

	
  ADDENDUM C.1

  	
  SUPPLEMENTAL
  BENEFITS COSTS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM C.2

  	
  PHARMACY
  SHARED RISK BUDGETS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM C.3

  	
  MEDICARE
  DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  D

  	
  PPO,
  EPO AND POS

  	
   

  
	
  A.

  	
  Benefit Program
  Requirements

  	
   

  
	
  B.

  	
  PPO And EPO Benefit
  Programs

  	
   

  
	
  C.

  	
  POS Benefit
  Programs

  	
   

  
	
  ADDENDUM
  E

  	
  FEE
  FOR SERVICE COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F

  	
  MEDI-CAL
  BENEFIT PROGRAM

  	
   

  
	
  A.

  	
  Definitions

  	
   

  
	
  B.

  	
  Compensation Provisions

  	
   

  
	
  C.

  	
  General Provisions

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F.1

  	
  MEDI-CAL
  FEE-FOR-SERVICE COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F.2

  	
  MEDI-CAL
  CAPITATION COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F.3

  	
  MEDI-CAL
  SHARED RISK PROGRAM DISTRIBUTION MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F.4

  	
  MEDI-CAL
  DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM F.5

  	
  MEDI-CAL
  DISCLOSURE FORM

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  G

  	
  CHAMPUS/TRICARE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  H

  	
  WORKERS
  COMPENSATION BENEFIT PROGRAM

  	
   

  
					

 

iii

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

This Participating Physician Group
Provider Services Agreement (“Agreement”) is made and entered into by and
between the Foundation Health Systems Affiliate(s) (“FHS”) identified in
Addendum A to this Agreement and Professional Care Medical Group IPA, a
Participating Physician Group (“PPG”), to be effective March 1, 1999.

 

RECITALS

 

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

 

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

 

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

 

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

 

AGREEMENT

 

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

 

I.                                       DEFINITIONS

 

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

 

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

 

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

 

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

 

1.4                               Commercial HMO Member. 
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 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

 

1

 

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 duly 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 aMember is obligated to pay under a particular Benefit Program,
including deductible 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 pan.  FHS shall have the final
authority in decisions regarding emergencies and emergency services.

 

1.11                        HMO Member.  A
person who is eligible to receive Covered Services under those Benefit Programs
offered by an Affiliate which is a health care service plan licensed under the
Knox Keene Act, and whose premium has been fully paid.  An HMO Member shall be a person enrolled in
a Medicare Benefit Program as set forth in Addendum C (“Medicate HMO Member”),
a person enrolled in a Medicaid Benefit Program as set forth in Addendum ?
(“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 FHS in addition to the Capitation paid.  Such Insured Services are set forth in the
applicable Addendum.

 

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

 

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

 

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

 

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

 

(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 Providers; and

 

2

 

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

 

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

 

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

 

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

 

1.17                        Operations Manual.  All
Operations Manuals, including medical policy manuals, issued by FHS, as updated
from time to lime, 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 FHS or another Participating Provider to provide
Covered Services to Members.  In the
event PPG contracts with a health care provider to render Covered Services
under this Agreement, such provider is a Participating Provider

 

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

 

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

 

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

 

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

 

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

 

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

 

3

 

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

 

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

 

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

 

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

 

1.29                        Shared Risk 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 in  serious deterioration
of an HMO Member’s health that results from an unforeseen illness or injury it
(i) such Member is temporarily absent from the Service Area and (ii) receipt of
the health care service cannot be delayed until the Member’s return to the
Service Area.

 

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

 

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 FHS, upon request, with its written applicable policies and
procedures

 

4

 

and its bylaws and articles of incorporation and any modifications
thereto.

 

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

 

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

 

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

 

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

 

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

 

(1)                                  Accepting Members upon referral from Member
Physicians.

 

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

 

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

 

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

 

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

 

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

 

(7)                                  Maintaining offices in a condition which
conforms to FHS’ standards for safety,

 

5

 

appearance and accessibility of services.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

6

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

7

 

(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 FHS.  Member Physician shall provide Contracted Services under this
Agreement during normal business hours, and shall be available to Members by
telephone twenty-four (24) hours a day, seven (7) days a week on an Emergency
basis and for consultation.

 

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

 

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

 

During
the term of this Agreement, PPG 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.  PPG and its subcontractors also shall ensure
that the evaluation and treatment of their employees and applicants for
employment are free of such discrimination. 
PPG 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.  PPG 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 FHS’ Utilization/Care Management Program.  PPG and Member Physician agrees to render
Covered Services at the most appropriate level of service (including levels of
acute care such as intensive care unit services or regular acute medical and surgical
services as determined by the clinical status of the Member) which can safely
be provided to the Member.  For
hospitalization, this means that the Member requires acute care as an inpatient
due to the nature of the services the Member is receiving, or the severity of
the Member’s condition, and that safe and adequate care cannot be received as
an outpatient or at a less intensified medical setting.  PPG and Member Physicians also agree to
provide such records and other information as may be required or requested
under such Utilization/Care Management Program as set forth in the Operations
Manual.  FHS may, at its sole
discretion, delegate certain Utilization/Care Management Program activities.  If so determined qualified and delegated by
FHS, the obligations of PPG for delegation shall be as set forth herein.

 

2.13                        Prior Authorization and Referrals.  PPG and Member Physicians agree to comply
with prior

 

8

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

9

 

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

 

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

 

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

 

2.21                        Notice of Adverse Action.  PPG shall
notify FHS in writing, within five (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 FHS promptly upon request.

 

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

 

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

 

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

 

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

 

2.23                        Conflict of Interest.  PPG shall not,
during the term of this Agreement, acquire, or make any commitment to acquire a
proprietary interest in any organization which is licensed as a health care
service plan or which

 

10

 

has
submitted an application for such licensure except as to a health care service
plan with waivers.  This restriction
shall include  any  affiliated, subsidiary or parent organizations
to which PPG may belong in which thirty percent (30%) or more is under common
ownership.  “Proprietary Interest”, as
used herein, shall not be deemed to include:

 

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

 

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

 

2.24                        Non-Solicitation.  PPG
and Member Physicians shall not, either during or after the term of this
Agreement, solicit any Member to enroll in any other health care service plan
or insurance program for the primary purpose of securing financial gain.  Liquidated damages for such solicitation
resulting in disenrollment of Members from FHS shall be fifteen hundred dollars
($1,500) for a commercial Member, twenty- five hundred dollars ($2,500) for a
Medicare Member and one thousand dollars ($1,000) for a Medi-Cal Member.  PPG and FHS agree that the amounts stated as
liquidated damages are reasonable under the circumstances existing at the time
that this Agreement is executed.  FHS
shall have the right to review all correspondence or communications to Members
prior to dissemination or mailing.

 

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

 

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

 

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

 

III.                               DUTIES OF FHS

 

3.1                               Enrollment List.  FHS
shall periodically but not less than monthly provide PPG with a  list of HMO Members assigned to PPG via
electronic transmission or magnetic media. 
FHS shall maintain a system to allow PPG and Member Physicians to make
telephonic or electronic inquiries regarding Member eligibility.

 

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

 

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

 

3.4                               Insurance.  FHS
shall maintain appropriate insurance programs or policies including a policy of
bodily injury and personal injury coverage which includes persons serving on
FHS committees as insured by definition.

 

11

 

In the event that a policy or program
is terminated or the coverage of committee persons is materially changed, FHS
shall so notify PPG

 

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

 

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

 

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

 

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

 

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

 

3.10          Marketing
Activities. 
FHS shall make reasonable efforts to market the Benefit Programs.  Nothing in this Agreement shall require FHS
to conduct any specific marketing activities on behalf of PPG or to identity
PPG in any specific FHS 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 FHS or a Payor
as set forth in the applicable Addendum to this Agreement. Except when PPG is
paid Capitation, PPG may require Member Physicians to bill and accept
compensation as payment in full.  PPG
shall bill and accept payment for Contracted Services rendered by Member
Physicians, and be responsible for administering such funds and compensating
Member Physicians therefrom.  When PPG
is paid Capitation, FHS reserves the right to create new benefit plans and to
establish capitation rates for new benefit plans based on actuarial assumptions
that are consistent with existing actuarial assumptions FHS shall adjust the
actuarial assumptions which support the rates in the applicable Addenda on a  periodic basis, and shall advise PPG of
any such adjustments in methodology. 
Capitation may also be adjusted in the event benefits are added or deleted
from PPG Capitated Services.

 

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

 

12

 

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

 

4.3          Billing and Payment.

 

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

 

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

 

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

 

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

 

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

 

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

 

PPG agrees that FHS may allow the compensation rates set forth in this Agreement to be used by other
Participating Providers who may from lime 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

 

13

 

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

 

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

 

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

 

4.7          Member Held Harmless.  PPG agrees that in no event, including, but
not limited to, non-payment by FHS, insolvency of FHS, or breach of this
Agreement, shall PPG bill, charge, collect a deposit from, seek compensation,
remuneration, or reimbursement from, or have any recourse against Members, the
State, or persons other than FHS for Covered Services provided pursuant to this
Agreement.  This provision shall not
prohibit collection of Copayments or any amounts due for services which are
determined not to be Covered Services in accordance with the terms of the
applicable Benefit Program.

 

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

 

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

 

14

 

accordance with the applicable Evidence of Coverage and FHS’ policies
set forth in the Operations Manual.

 

4.9          Third Party Recoveries, Worker’s
Compensation.  In
the event PPG provides services to FHS Members, for injuries resulting from the
acts of third parties, or resulting from work related injuries. PPG shall have
the right to recover from any settlement, award, or recovery from any
responsible third-party the 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 FHS of any third party payor and shall,
upon request from FHS, provide FHS with an accounting of all such sums
recovered.

 

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

 

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

 

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

 

PPG shall submit
claims under the applicable stop loss and reinsurance programs in accordance
with the procedures set forth in the Operations Manual but no later than sixty
(60) calendar days following the end of the calendar year. For purposes of
calculating stop loss and reinsurance thresholds, the following shall apply:
(i) for PPG and Member Physicians, the compensation schedule set forth in
Addendum E  shall be utilized;
(ii) for any other Provider who is subcontracted to PPG, such subcontract rates
shall be utilized: (iii) for a Participating Provider who is not subcontracted
with PPG but is contracted with FHS, FHS’ contract rate shall be utilized; or
(iv) the actual charges paid by PPG when none of the above applies. FHS shall
compensate PPG for claims in excess of the stop loss threshold at seventy-five
percent (75%) of the fee-for-service rates in Addendum E unless otherwise
provided for in an applicable Addendum, less applicable Copayments,
coinsurance, deductibles and payments from third parties or Coordination of
Benefits.

 

V.            DELEGATION

 

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

 

5.2          Termination of Delegation.  FHS shall have the right to audit PPG’s
performance of utilization management, credentialing and recredentialing,
Member grievance and appeal, medical record review, and capitation and claims
adjudication functions from time to time. 
If FHS determines that deficiencies exist in PPG’s performance,

 

15

 

PPG shall accept consulting assistance from FHS. Failure to cure any
identified deficiencies within a reasonable period of time as defined by FHS
policies, or if FHS determines PPG does not have the ability to perform
delegated functions, or is not effectively performing delegated functions.  FHS may revoke delegation of all or any of
these functions in accordance with procedures set forth in the Operations
Manual and re-assume the performance of such functions itself. Should it become
necessary for FHS to reassume delegated functions, FHS shall charge the
following administrative fees: utilization management 5% of PPG Capitation.
claims processing 4.5%  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.  Either
party may terminate this Agreement at the scheduled renewal date upon one
hundred twenty (120) days prior written notice to the other party.  In the event FHS provides PPG with such
notice, FHS may, at its option, begin to transition Members immediately under
this Agreement to another Participating Provider after such notice.

 

6.3          Immediate Termination.  FHS may terminate this
Agreement immediately upon notice to PPG, in the event of: (a) PPG’s violation
of any applicable law, rule or regulation; (b) PPG’s failure to maintain the
professional liability insurance coverage specified hereunder; (c) PPG’s
failure to comply with the terms, conditions or determinations of any
Utilization/Care Improvement Program or Quality Improvement Program, or Benefit
Program; or, (d) FHS’ determination that the health, safety or welfare of any
Member may be in jeopardy if this Agreement is not terminated.

 

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

 

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

 

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

 

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

 

16

 

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

 

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

 

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

 

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

 

VII.         RECORDS, AUDlTS AND REGULATORY REQUIREMENTS

 

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

 

7.2          Access to Records; Audits.  The records referred to above shall not be
removed or transferred from PPG except in accordance with applicable local,
State, and federal laws, rules and regulations.  Subject to applicable State and federal confidentiality or privacy
laws, FHS or is designated representatives, and designated representatives of
local, State, and federal regulatory agencies having jurisdiction over FHS
shall have access to PPG’s records, at PPG’s place of business on request
during normal business hours to inspect and review and make copies of such
records. Such governmental agencies shall include, but not be limited to, when
applicable to the Benefit Program identified on Addendum A, the DHS, the DHHS,
the DOC, the DOD and the DOJ.  When
requested by FHS.  PPG shall produce

 

17

 

copies of any such records at no cost. Additionally, PPG agrees to
permit FHS, and its designated representatives, accreditation organizations,
and designated representatives of local, State, and federal regulatory agencies
having jurisdiction over FHS or any Payor, to conduct site evaluations and
inspections of PPG’s offices and service locations.

 

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

 

VIII.      GENERAL
PROVISIONS

 

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

 

8.2          Separate
Obligations.  The
rights and obligations of under this Agreement shall apply to each Affiliate
listed on Addendum A to this Agreement only with respect to the Benefit Program
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 FHS or any FHS
Affiliate be responsible for any payment which is the financial responsibility
of a Payor and PPG shall seek compensation for such services only from Payor.

 

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

 

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

 

8.4          Confidentiality.  FHS and PPG agree to hold all confidential
or proprietary information or trade secrets of each other in trust and
confidence and agree that such information shall be used only for the purposes
contemplated herein, and not for any other purpose. Specifically, PPG
acknowledges that the names, addresses and other identifying information
concerning Members and employers and other groups contracting with FHS
constitute confidential information which derives independent economic value
from not being generally known or readily accessible to others who can obtain
economic value from its disclosure or use. FHS acknowledges that the names,
contracts, addresses, and other information concerning Member Physicians,
employees and other providers and other groups contracting with PPG constitute
proprietary information of PPG.  FHS
shall use such information only as necessary and appropriate for the
performance of its obligations under this Agreement.  In the event FHS could obtain such information from a source
other than PPG, such information shall not be proprietary to PPG.  Neither PPG, a

 

18

 

Member Physician, nor FHS shall disclose the terms of this Agreement
except as may be required by law; provided, however, nothing herein shall
prohibit PPG or a Member Physician from disclosing to a Member any information
the PPG or Member Physician determines is relevant to the Member’s care
including the basic method of reimbursement and whether financial bonuses or
incentives are used.

 

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

 

8.6          Binding Arbitration.  PPG and FHS agree to meet
and confer in good faith to resolve any problems or disputes that may arise
under this Agreement. Such good faith meet and confer shall be a condition
precedent to the filing of any arbitration demand by either party.  In addition, should the parties, prior to
submitting a dispute to arbitration, desire to utilize other impartial dispute
settlement techniques such as mediation or fact-finding, a joint request for
such services may be made to the American Arbitration Association (“AAA”).
Judicial Arbitration and Mediation Services (“JAMS”), or the parties may
initiate such other procedures as they may mutually agree upon at such
time.  Notwithstanding the foregoing,
nothing contained herein is intended to require arbitration of disputes for
medical malpractice between a Member and the PPG.

 

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

 

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

 

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

 

8.7          Indemnification of Parties.

 

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

 

19

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

	
  FHS

  
	
  C/O Health Net

  
	
  21600 Oxnard Street

  
	
  Woodland Hills, California
  91367

  
	
  Attention: Vice President,
  Provider Network Management

  
	
   

  	
   

  
	
  PPG:

  	
  Professional
  Care Medical Group IPA

  c/o Medical Pathways

  12750 Center Court Drive, Suite 300

  Cerritos,
  CA 90703

  

 

20

 

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

 

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

 

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

 

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

 

21

 

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.

 

 

	
  Professional Care Medical Group IPA

  	
   

  	
  Foundation Health Systems
  Affiliates

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  /s/ Edward Rotan

  	
   

  	
  /s/
  Christopher Ciano

  	
   

  
	
  Signature

  	
   

  	
  Signature
  

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Edward Rotan

  	
   

  	
  Christopher
  Ciano

  	
   

  
	
  Print
  Name

  	
   

  	
  Print
  Name

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  President

  	
   

  	
  Senior Vice President & General
  Manager South

  	
   

  
	
  Title

  	
   

  	
  Title

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  5-19-99

  	
   

  	
  06-02-99

  	
   

  
	
  Date

  	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  95-4378353

  	
   

  	
   

  	
   

  
	
  Federal Tax Identification Number

  	
   

  	
   

  	
   

  

 

22

 

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

  	
   

  	
  No

  
	
  AIM

  	
   

  	
  B

  	
   

  	
  Yes

  
	
  Medicare Supplement

  	
   

  	
  B

  	
   

  	
  Yes

  
	
  Commercial POS

  	
   

  	
  B

  	
   

  	
  Yes

  
	
  Medicare HMO

  	
   

  	
  C

  	
   

  	
  Yes

  
	
  Medicare POS

  	
   

  	
  C

  	
   

  	
  Yes

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

  	
   

  	
  D

  	
   

  	
  Yes

  
	
  Medi Cal

  	
   

  	
  F

  	
   

  	
  Yes

  
	
  CHAMPUS

  	
   

  	
  G

  	
   

  	
  No

  
	
  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: Foundation Health, a California Health Plan; Health Net Life
Insurance Company; Qualmed Life and Health Insurance Company; Foundation Health
National Life Insurance Company; Business Insurance Group, Inc.: Business
Insurance Company: California Compensation Insurance Company: Combined Benefits
Insurance Company; Commercial Compensation Insurance Company: Foundation Health
Federal Services Inc.; Foundation Health Medical Resource Management; Preferred
Health Network 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 FHS not listed above may access the rates
set forth in this Agreement and Addenda. This would include Members of
non-California based affiliates who may be treated by PPG.

 

23

 

III.           MAIN/SATELLITE
OFFICES

 

 

	
  PPG # Main
  and Satellite Offices

  	
   

  	
  Addresses

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  

 

24

 

ADDENDUM B

 

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

 

A.            GENERAL
REIMBURSEMENT PROVISIONS.

 

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

 

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

•                  Commercial HMO

•                  Standard HMO

•                  Flex Funded HMO

•                  Small Group HMO

•                  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.

 

25

 

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.

 

	
   

  	
  Standard

  HMO Capitation

  	
   

  
	
   

  	
  ***
  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
tinder this Shared Risk Program, HMO shall deduct up to  ***  of
PPG’s Capitation for Standard HMO Members and place such amount in the Withhold
fund as described in the Agreement.

 

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

 

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

 

26

 

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

 

(b)           In-Area Shared Risk Services: 2.97% of Shared Risk Budget.

 

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

 

(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, Transplant and Transfer Reinsurance Programs.  On a network wide basis, reinsurance programs shall be established by HMO to cover
the cost of organ transplants for Members, the payment of expenses incurred in
the treatment of Members who have been diagnosed with Acquired Immune
Deficiency Syndrome (“AIDS Members”), 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          Transplant Reinsurance.  Professional and
institutional costs related to organ transplantation shall be the financial
responsibility of HMO, as set forth in the Operations Manual.  PPG shall refer Members to HMO’s designated
regional transplant centers to qualify for payment of the organ transplant
costs under this Program.  In the event
PPG refers a transplant case to a facility that is not an HMO-designated
regional transplant center, those claims shall not be eligible for payment
under this Program.

 

4.3          Transfer Reinsurance.  Professional and
institutional costs incurred by Members undergoing medical

 

27

 

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: I) 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.

 

This Program shall cover eligible Members who accumulate more than ***
in PPG Capitated Services or *** 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 *** of PPG
Capitated Services.  *** 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 or
Transplant Reinsurance Programs 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,

 

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

 

	
  •

  	
   

  	
  AIDS Reinsurance

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  •

  	
   

  	
  Transplant Reinsurance

  	
   

  	
  $

  	
  *** PMPM

  	
   

  
	
  •

  	
   

  	
  Transfer Reinsurance

  	
   

  	
  $

  	
  *** PMPM

  	
   

  

 

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

 

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

 

C.            SMALL GROUP HMO.

 

1.             Professional Capitation Rates.

 

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

 

28

 

	
   

  	
  Small Group

  HMO Capitation 

  	
   

  
	
   

  	
  $

  	
  *** 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 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 up to *** of PPG’s Capitation for
Small Group Members and place such amount in the Withhold Fund as described in
the Agreement.

 

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

 

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

 

3.3          Shared Risk Budget Surplus.  In the event of a Shared Risk Budget
surplus, PPG’s share of the surplus shall be limited to the lesser of (a) ***
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:

 

29

 

(a)           Out-of-Area Emergency and Urgently
Needed Services: 4.58% of Shared Risk Budget.

 

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

 

(b)           In-Area Shared Risk Services: 2.97 % of Shared Risk Budget.

 

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

 

(c)           Transfer Reinsurance: $0.15
PMPM.  shall be deducted from the Shared
Risk Budget.  Ten (10%) of eligible charges shall be
charged against the Shared Risk Budget.

 

4.             AIDS, Transplant, 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

  	
   

  
	
  •

  	
   

  	
  Transplant Reinsurance

  	
   

  	
  $

  	
   ***PMPM

  	
   

  
	
  •

  	
   

  	
  Transfer Reinsurance

  	
   

  	
  $

  	
   ***PMPM

  	
   

  

 

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

 

D.            INDIVIDUAL HMO.

 

Not Applicable to this Agreement.

 

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 slop 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 he included in the AIDS Reinsurance Program, the Transplant Reinsurance

 

30

 

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 fur Medicare Supplement
Members shall be at the following PMPM levels, subject to age, sex and benefit plan
(Victors set forth in Addendum B:

 

	
  Medicare

  Supplement HMO

  	
   

  	
  Medicare
  Supplement

  POS

  
	
  $

  	
   *** PMPM

  	
   

  	
  $

  	
   *** PMPM

  
					

 

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

 

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, and Flex Funded HMO Members may be eligible for Commercial POS
Benefit Programs.

 

2.             Definitions.

 

2.1          In-Network Services.  PPG Capitated Services and Shared Risk
Services provided or 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 *** withhold
(Professional Capitation).  This
Withhold shall partially fund the professional Out-of-Network Budget.

 

31

 

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

 

Each year. HMO
shall settle the risk sharing program by calculating the difference between the
budget and the actual claims. If a surplus remains. PPG’s share shall he fifty
percent 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. and Small Group
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, and multiplied by 110% 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

  + ***

  	
   

  	
  Small
  Group HMO

  Shared Risk

  + ***

  	
   

  
	
  ***

  	
   

  	
  $ ***

  	
   

  

 

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

 

Shared Risk Claims with dates of service within the
Reconciliation Period and paid by March 31 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) ***, or (b) an amount not to exceed *** of the annual gross PPG Capitation.

 

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

 

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

 

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

 

Out-of-Area
Emergency and Urgently Needed Services shall be reimbursed at *** % of
cost.

 

32

 

and the remaining *** of the cost shall be charged against the POS
Shared Risk Budget.

 

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

 

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

 

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

 

(a)           In-Network Professional Stop Loss.

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

 

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

 

8.     AIDS and Transplant Reinsurance.  As further defined in Section 8.4 of this
Addendum, the AIDS Reinsurance rate shall be *** PMPM. which shall be deducted
from PPG’s Capitation and $*** PMPM shall be deducted from PPG’s Professional
Out-of-Network Risk Sharing Budget, For the subsequent years, these deductions
shall fluctuate to correspond with the Professional Out-of-Network Withhold
percentage change. The Transplant Reinsurance Program rate shall be $ *** PMPM,
which, shall be deducted from PPG’s Capitation and $ ***  PMPM shall be deducted from PPG’s
Professional Out-of-Network Risk Sharing Budget. The Transplant Reinsurance
Program’s deductions for subsequent years shall also fluctuate to correspond
with the Professional Out-of-Network Withhold percentage change.

 

11.          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 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

  	
   

  

 

1.             Pharmacy
Shared Risk Program.  The Pharmacy Shared Risk Program shall he applicable to the
following Members: Standard HMO, Flex Funded HMO, and small Group HMO.

 

1.             Pharmacy Budget.  Each month HMO shall fund the Pharmacy
Budget at *** per eligible

 

33

 

Member per month (“PEMPM”) subject to the age, sex and benefit plan
factors set forth in Addendum B. The Pharmacy Budget shall he 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 ***. In the event pharmacy claims exceed the Pharmacy Budget, PPG’s
share of the Pharmacy Budget deficit shall be ***%).

 

HMO shall perform
an interim and final settlement for the Pharmacy Risk Sharing Program.  The timing of these settlements shall
correspond to the interim and final settlements of other 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.

 

34

 

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, 1999

 

	
  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

  

 

35

 

A. 2 Benefit Plan Factors for PPG
Capitation and Hospital Capitation/Shared Risk Budgets Effective January 1,
1999

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  1A

  	
   

  	
  0.9803

  	
   

  	
  0.9966

  	
   

  	
  7H

  	
   

  	
  0.9452

  	
   

  	
  0.9319

  	
   

  	
  A7

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  	
  EH

  	
   

  	
  0.9585

  	
   

  	
  1.0018

  	
   

  	
  G5

  	
   

  	
  0.9095

  	
   

  	
  0.9671

  	
   

  
	
  1B

  	
   

  	
  1.0012

  	
   

  	
  1.0012

  	
   

  	
  7I

  	
   

  	
  0.9988

  	
   

  	
  0.9776

  	
   

  	
  A8

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  	
  EI

  	
   

  	
  0.9966

  	
   

  	
  0.9805

  	
   

  	
  G6

  	
   

  	
  1.0231

  	
   

  	
  0.9967

  	
   

  
	
  1C

  	
   

  	
  1.0311

  	
   

  	
  1.0012

  	
   

  	
  7I

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  	
  A9

  	
   

  	
  1.0257

  	
   

  	
  1.0076

  	
   

  	
  EJ

  	
   

  	
  1.0329

  	
   

  	
  1.0118

  	
   

  	
  G9

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  1D

  	
   

  	
  0.9805

  	
   

  	
  1.0064

  	
   

  	
  7K

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	
  B1

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  	
  EK

  	
   

  	
  0.9310

  	
   

  	
  1.0050

  	
   

  	
  HA

  	
   

  	
  1.0595

  	
   

  	
  0.9673

  	
   

  
	
  1E

  	
   

  	
  1.0186

  	
   

  	
  1.0056

  	
   

  	
  7L

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  	
  B2

  	
   

  	
  0.9198

  	
   

  	
  0.8252

  	
   

  	
  EL

  	
   

  	
  1.0481

  	
   

  	
  0.9786

  	
   

  	
  HB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  1F

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  	
  7M

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	
  B3

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  	
  EM

  	
   

  	
  0.9714

  	
   

  	
  1.0135

  	
   

  	
  HC

  	
   

  	
  1.0639

  	
   

  	
  0.9919

  	
   

  
	
  1G

  	
   

  	
  1.0149

  	
   

  	
  1.0004

  	
   

  	
  7N

  	
   

  	
  0.9836

  	
   

  	
  0.9779

  	
   

  	
  B4

  	
   

  	
  0.9198

  	
   

  	
  0.8460

  	
   

  	
  EN

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  	
  HD

  	
   

  	
  1.0807

  	
   

  	
  1.0031

  	
   

  
	
  1H

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  	
  7O

  	
   

  	
  0.8981

  	
   

  	
  0.9774

  	
   

  	
  B5

  	
   

  	
  0.9198

  	
   

  	
  0.8357

  	
   

  	
  EO

  	
   

  	
  0.9727

  	
   

  	
  0.9633

  	
   

  	
  HE

  	
   

  	
  1.0286

  	
   

  	
  1.0105

  	
   

  
	
  1I

  	
   

  	
  1.0059

  	
   

  	
  0.9903

  	
   

  	
  7Q

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	
  B6

  	
   

  	
  1.0047

  	
   

  	
  0.8758

  	
   

  	
  EP

  	
   

  	
  0.9486

  	
   

  	
  0.9777

  	
   

  	
  HF

  	
   

  	
  0.9682

  	
   

  	
  0.9875

  	
   

  
	
  IJ

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  	
  7R

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	
  B7

  	
   

  	
  0.9743

  	
   

  	
  1.0085

  	
   

  	
  EQ

  	
   

  	
  0.9740

  	
   

  	
  1.0035

  	
   

  	
  HG

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  1K

  	
   

  	
  1.0138

  	
   

  	
  1.0056

  	
   

  	
  7S

  	
   

  	
  0.8884

  	
   

  	
  0.9396

  	
   

  	
  B8

  	
   

  	
  0.9644

  	
   

  	
  0.9941

  	
   

  	
  ER

  	
   

  	
  1.0858

  	
   

  	
  1.0032

  	
   

  	
  HK

  	
   

  	
  1.0784

  	
   

  	
  1.0076

  	
   

  
	
  1L

  	
   

  	
  1.0292

  	
   

  	
  1.0021

  	
   

  	
  7T

  	
   

  	
  0.9452

  	
   

  	
  0.9474

  	
   

  	
  B9

  	
   

  	
  0.9690

  	
   

  	
  1.0076

  	
   

  	
  ES

  	
   

  	
  0.9796

  	
   

  	
  1.0076

  	
   

  	
  HM

  	
   

  	
  1.1360

  	
   

  	
  1.0225

  	
   

  
	
  1M

  	
   

  	
  1.0152

  	
   

  	
  0.9854

  	
   

  	
  7U

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	
  BB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  	
  ET

  	
   

  	
  0.9163

  	
   

  	
  0.9774

  	
   

  	
  HN

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  1N

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  	
  7V

  	
   

  	
  0.9934

  	
   

  	
  0.9399

  	
   

  	
  C1

  	
   

  	
  1.0613

  	
   

  	
  0.9919

  	
   

  	
  EU

  	
   

  	
  0.9617

  	
   

  	
  0.9863

  	
   

  	
  HO

  	
   

  	
  0.9714

  	
   

  	
  1.0076

  	
   

  
	
  1O

  	
   

  	
  1.0524

  	
   

  	
  1.0156

  	
   

  	
  7W

  	
   

  	
  0.9452

  	
   

  	
  0.9399

  	
   

  	
  C2

  	
   

  	
  1.0668

  	
   

  	
  1.0032

  	
   

  	
  EV

  	
   

  	
  1.0046

  	
   

  	
  0.9628

  	
   

  	
  HP

  	
   

  	
  1.0049

  	
   

  	
  0.9919

  	
   

  
	
  1P

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  	
  7X

  	
   

  	
  1.0942

  	
   

  	
  0.9903

  	
   

  	
  C3

  	
   

  	
  1.0066

  	
   

  	
  0.9919

  	
   

  	
  EW

  	
   

  	
  1.0104

  	
   

  	
  1.0108

  	
   

  	
  HR

  	
   

  	
  1.1304

  	
   

  	
  1.0233

  	
   

  
	
  1Q

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  	
  7Y

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  	
  C6

  	
   

  	
  1.0162

  	
   

  	
  1.0076

  	
   

  	
  EX

  	
   

  	
  0.9277

  	
   

  	
  0.8955

  	
   

  	
  HS

  	
   

  	
  1.0817

  	
   

  	
  1.0022

  	
   

  
	
  1R

  	
   

  	
  1.0863

  	
   

  	
  1.0064

  	
   

  	
  7Z

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	
  C7

  	
   

  	
  1.0639

  	
   

  	
  1.0022

  	
   

  	
  EY

  	
   

  	
  0.9746

  	
   

  	
  0.9281

  	
   

  	
  HT

  	
   

  	
  1.0743

  	
   

  	
  1.0076

  	
   

  
	
  1S

  	
   

  	
  0.9661

  	
   

  	
  0.9820

  	
   

  	
  9A

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	
  C8

  	
   

  	
  0.9463

  	
   

  	
  0.9695

  	
   

  	
  EZ

  	
   

  	
  0.9230

  	
   

  	
  0.8441

  	
   

  	
  HU

  	
   

  	
  1.0443

  	
   

  	
  1.0165

  	
   

  
	
  1T

  	
   

  	
  0.9629

  	
   

  	
  0.9820

  	
   

  	
  9B

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	
  C9

  	
   

  	
  0.9243

  	
   

  	
  1.0076

  	
   

  	
  F1

  	
   

  	
  1.0230

  	
   

  	
  0.9893

  	
   

  	
  HV

  	
   

  	
  1.0907

  	
   

  	
  1.0107

  	
   

  
	
  IU

  	
   

  	
  0.9208

  	
   

  	
  0.9617

  	
   

  	
  9C

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	
  D1

  	
   

  	
  1.0613

  	
   

  	
  1.0022

  	
   

  	
  F2

  	
   

  	
  1.0084

  	
   

  	
  0.9737

  	
   

  	
  HW

  	
   

  	
  1.0524

  	
   

  	
  0.9681

  	
   

  
	
  1V

  	
   

  	
  1.0337

  	
   

  	
  0.9678

  	
   

  	
  9E

  	
   

  	
  0.9908

  	
   

  	
  0.9780

  	
   

  	
  D2

  	
   

  	
  1.0182

  	
   

  	
  1.0041

  	
   

  	
  F3

  	
   

  	
  1.0071

  	
   

  	
  0.9776

  	
   

  	
  HX

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  1W

  	
   

  	
  0.9661

  	
   

  	
  1.0012

  	
   

  	
  9F

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  	
  D3

  	
   

  	
  0.9327

  	
   

  	
  0.8259

  	
   

  	
  F4

  	
   

  	
  0.9731

  	
   

  	
  1.0074

  	
   

  	
  HY

  	
   

  	
  0.8997

  	
   

  	
  0.8921

  	
   

  
	
  1X

  	
   

  	
  1.0187

  	
   

  	
  1.0012

  	
   

  	
  9G

  	
   

  	
  1.0012

  	
   

  	
  0.9776

  	
   

  	
  D4

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  	
  F5

  	
   

  	
  1.0087

  	
   

  	
  0.9780

  	
   

  	
  I3

  	
   

  	
  0.9909

  	
   

  	
  1.0106

  	
   

  
	
  1Y

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  	
  9H

  	
   

  	
  0.9967

  	
   

  	
  0.9805

  	
   

  	
  D5

  	
   

  	
  0.9599

  	
   

  	
  0.9776

  	
   

  	
  F6

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  	
  I4

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  1Z

  	
   

  	
  1.0119

  	
   

  	
  0.9582

  	
   

  	
  9I

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	
  D6

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  	
  F7

  	
   

  	
  1.0804

  	
   

  	
  0.9903

  	
   

  	
  I5

  	
   

  	
  0.9677

  	
   

  	
  1.0044

  	
   

  
	
  2A

  	
   

  	
  0.9661

  	
   

  	
  0.9228

  	
   

  	
  9J

  	
   

  	
  0.9084

  	
   

  	
  0.8363

  	
   

  	
  D7

  	
   

  	
  0.9897

  	
   

  	
  1.0074

  	
   

  	
  F8

  	
   

  	
  0.8346

  	
   

  	
  0.8083

  	
   

  	
  I6

  	
   

  	
  1.0338

  	
   

  	
  0.9745

  	
   

  
	
  2B

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  	
  9M

  	
   

  	
  0.9967

  	
   

  	
  0.9777

  	
   

  	
  D8

  	
   

  	
  1.0189

  	
   

  	
  1.0056

  	
   

  	
  F9

  	
   

  	
  1.0350

  	
   

  	
  1.0037

  	
   

  	
  I7

  	
   

  	
  1.0022

  	
   

  	
  1.0076

  	
   

  
	
  2C

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  	
  9N

  	
   

  	
  0.9485

  	
   

  	
  0.9398

  	
   

  	
  D9

  	
   

  	
  1.0319

  	
   

  	
  1.0076

  	
   

  	
  FA

  	
   

  	
  1.0203

  	
   

  	
  1.0008

  	
   

  	
  I8

  	
   

  	
  0.9746

  	
   

  	
  0.9916

  	
   

  
	
  2D

  	
   

  	
  0.9181

  	
   

  	
  0.9228

  	
   

  	
  9O

  	
   

  	
  0.9560

  	
   

  	
  0.9776

  	
   

  	
  E1

  	
   

  	
  1.0137

  	
   

  	
  0.9737

  	
   

  	
  FB

  	
   

  	
  1.0213

  	
   

  	
  1.0145

  	
   

  	
  I9

  	
   

  	
  0.9851

  	
   

  	
  1.0037

  	
   

  
	
  2E

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  	
  9P

  	
   

  	
  0.9876

  	
   

  	
  0.9795

  	
   

  	
  E2

  	
   

  	
  0.9836

  	
   

  	
  1.0050

  	
   

  	
  FC

  	
   

  	
  1.0234

  	
   

  	
  1.0039

  	
   

  	
  J3

  	
   

  	
  1.0165

  	
   

  	
  0.9849

  	
   

  
	
  2F

  	
   

  	
  1.0091

  	
   

  	
  1.0000

  	
   

  	
  9Q

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	
  E3

  	
   

  	
  1.0064

  	
   

  	
  0.9776

  	
   

  	
  FD

  	
   

  	
  1.0241

  	
   

  	
  1.0023

  	
   

  	
  J4

  	
   

  	
  1.0108

  	
   

  	
  0.9849

  	
   

  
	
  6A

  	
   

  	
  1.0514

  	
   

  	
  0.9725

  	
   

  	
  9R

  	
   

  	
  0.9970

  	
   

  	
  0.9849

  	
   

  	
  E4

  	
   

  	
  0.9584

  	
   

  	
  0.9706

  	
   

  	
  FE

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  	
  J5

  	
   

  	
  1.0071

  	
   

  	
  0.9778

  	
   

  
	
  6G

  	
   

  	
  0.9452

  	
   

  	
  0.9673

  	
   

  	
  9S

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	
  E5

  	
   

  	
  1.0403

  	
   

  	
  1.0037

  	
   

  	
  FF

  	
   

  	
  0.9709

  	
   

  	
  1.0062

  	
   

  	
  J6

  	
   

  	
  0.9714

  	
   

  	
  0.9783

  	
   

  
	
  6H

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  	
  9T

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  	
  E6

  	
   

  	
  0.9656

  	
   

  	
  0.9737

  	
   

  	
  FG

  	
   

  	
  0.9694

  	
   

  	
  0.9858

  	
   

  	
  J7

  	
   

  	
  0.9756

  	
   

  	
  1.0085

  	
   

  
	
  6R

  	
   

  	
  0.9485

  	
   

  	
  0.9776

  	
   

  	
  9U

  	
   

  	
  0.9866

  	
   

  	
  0.9811

  	
   

  	
  E7

  	
   

  	
  0.9905

  	
   

  	
  1.0037

  	
   

  	
  FH

  	
   

  	
  0.9708

  	
   

  	
  1.0008

  	
   

  	
  J8

  	
   

  	
  0.9666

  	
   

  	
  0.9839

  	
   

  
	
  6S

  	
   

  	
  0.9452

  	
   

  	
  0.9398

  	
   

  	
  9W

  	
   

  	
  0.9460

  	
   

  	
  0.9592

  	
   

  	
  E8

  	
   

  	
  1.0180

  	
   

  	
  0.9985

  	
   

  	
  FI

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  	
  J9

  	
   

  	
  1.1169

  	
   

  	
  1.0283

  	
   

  
	
  6T

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	
  9X

  	
   

  	
  0.9014

  	
   

  	
  0.9776

  	
   

  	
  E9

  	
   

  	
  0.9690

  	
   

  	
  0.9801

  	
   

  	
  FJ

  	
   

  	
  0.9260

  	
   

  	
  1.0008

  	
   

  	
  K1

  	
   

  	
  1.0236

  	
   

  	
  1.0076

  	
   

  
	
  6V

  	
   

  	
  0.9452

  	
   

  	
  0.9625

  	
   

  	
  9Y

  	
   

  	
  1.0327

  	
   

  	
  0.9334

  	
   

  	
  EA

  	
   

  	
  0.9755

  	
   

  	
  1.0033

  	
   

  	
  FK

  	
   

  	
  0.9727

  	
   

  	
  0.9581

  	
   

  	
  K2

  	
   

  	
  0.9663

  	
   

  	
  0.9801

  	
   

  
	
  6W

  	
   

  	
  0.9851

  	
   

  	
  0.9819

  	
   

  	
  A1

  	
   

  	
  1.0628

  	
   

  	
  0.9725

  	
   

  	
  EB

  	
   

  	
  0.9023

  	
   

  	
  0.8278

  	
   

  	
  FL

  	
   

  	
  0.9260

  	
   

  	
  0.9633

  	
   

  	
  K3

  	
   

  	
  1.0255

  	
   

  	
  1.0080

  	
   

  
	
  6Z

  	
   

  	
  0.9524

  	
   

  	
  0.8651

  	
   

  	
  A2

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  	
  EC

  	
   

  	
  0.9604

  	
   

  	
  1.0076

  	
   

  	
  FM

  	
   

  	
  0.9755

  	
   

  	
  1.0058

  	
   

  	
  K4

  	
   

  	
  1.0817

  	
   

  	
  1.0076

  	
   

  
	
  7C

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	
  A3

  	
   

  	
  1.0619

  	
   

  	
  0.9810

  	
   

  	
  ED

  	
   

  	
  1.0061

  	
   

  	
  0.9805

  	
   

  	
  G1

  	
   

  	
  0.9566

  	
   

  	
  0.9673

  	
   

  	
  K6

  	
   

  	
  0.9782

  	
   

  	
  1.0054

  	
   

  
	
  7E

  	
   

  	
  0.9987

  	
   

  	
  0.9776

  	
   

  	
  A4

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  	
  EE

  	
   

  	
  0.9951

  	
   

  	
  0.9793

  	
   

  	
  G2

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  	
  K7

  	
   

  	
  0.9845

  	
   

  	
  0.9966

  	
   

  
	
  7F

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  	
  A5

  	
   

  	
  1.0628

  	
   

  	
  0.9752

  	
   

  	
  EF

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  	
  G3

  	
   

  	
  1.0080

  	
   

  	
  0.9776

  	
   

  	
  K8

  	
   

  	
  0.9749

  	
   

  	
  0.9844

  	
   

  
	
  7G

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  	
  A6

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  	
  EG

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  	
  G4

  	
   

  	
  0.9566

  	
   

  	
  0.9776

  	
   

  	
  K9

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  

 

36

 

	
  Standard HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  KF

  	
   

  	
  1.0209

  	
   

  	
  0.9776

  	
   

  	
  O5

  	
   

  	
  0.9584

  	
   

  	
  0.9864

  	
   

  	
  TR

  	
   

  	
  1.0823

  	
   

  	
  0.9888

  	
   

  	
  X1

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KI

  	
   

  	
  0.9727

  	
   

  	
  1.0010

  	
   

  	
  O6

  	
   

  	
  1.0327

  	
   

  	
  1.0149

  	
   

  	
  TT

  	
   

  	
  0.8910

  	
   

  	
  0.8277

  	
   

  	
  X2

  	
   

  	
  0.9533

  	
   

  	
  0.9295

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KJ

  	
   

  	
  1.0203

  	
   

  	
  1.0010

  	
   

  	
  O7

  	
   

  	
  1.0317

  	
   

  	
  1.0033

  	
   

  	
  TU

  	
   

  	
  0.9676

  	
   

  	
  1.0000

  	
   

  	
  X3

  	
   

  	
  0.9500

  	
   

  	
  0.9398

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KK

  	
   

  	
  0.9727

  	
   

  	
  0.9583

  	
   

  	
  O8

  	
   

  	
  1.0050

  	
   

  	
  0.9733

  	
   

  	
  TV

  	
   

  	
  1.0211

  	
   

  	
  1.0075

  	
   

  	
  X4

  	
   

  	
  0.9821

  	
   

  	
  0.9058

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KL

  	
   

  	
  0.9763

  	
   

  	
  0.9864

  	
   

  	
  O9

  	
   

  	
  0.9822

  	
   

  	
  1.0076

  	
   

  	
  TW

  	
   

  	
  0.9707

  	
   

  	
  0.9742

  	
   

  	
  X5

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KM

  	
   

  	
  0.9260

  	
   

  	
  1.0010

  	
   

  	
  P1

  	
   

  	
  1.0121

  	
   

  	
  0.9949

  	
   

  	
  TX

  	
   

  	
  1.0811

  	
   

  	
  1.0156

  	
   

  	
  X6

  	
   

  	
  1.0240

  	
   

  	
  1.0076

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KN

  	
   

  	
  1.0961

  	
   

  	
  1.0239

  	
   

  	
  P2

  	
   

  	
  0.9030

  	
   

  	
  0.9396

  	
   

  	
  TY

  	
   

  	
  0.9328

  	
   

  	
  1.0067

  	
   

  	
  X7

  	
   

  	
  0.9095

  	
   

  	
  0.9774

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KO

  	
   

  	
  1.0349

  	
   

  	
  1.0079

  	
   

  	
  P3

  	
   

  	
  0.9649

  	
   

  	
  0.9776

  	
   

  	
  TZ

  	
   

  	
  0.9777

  	
   

  	
  1.0084

  	
   

  	
  X8

  	
   

  	
  1.0043

  	
   

  	
  0.9779

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KP

  	
   

  	
  0.9039

  	
   

  	
  0.9383

  	
   

  	
  P4

  	
   

  	
  1.0195

  	
   

  	
  1.0186

  	
   

  	
  U1

  	
   

  	
  1.0260

  	
   

  	
  0.9805

  	
   

  	
  X9

  	
   

  	
  0.9095

  	
   

  	
  0.9627

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KQ

  	
   

  	
  0.9695

  	
   

  	
  0.9978

  	
   

  	
  P5

  	
   

  	
  0.9095

  	
   

  	
  09731

  	
   

  	
  U2

  	
   

  	
  0.9599

  	
   

  	
  0.9399

  	
   

  	
  Y1

  	
   

  	
  0.9145

  	
   

  	
  0.9280

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KR

  	
   

  	
  1.0227

  	
   

  	
  1.0075

  	
   

  	
  P6

  	
   

  	
  1.0823

  	
   

  	
  0.9838

  	
   

  	
  U3

  	
   

  	
  0.9599

  	
   

  	
  0.9673

  	
   

  	
  Y2

  	
   

  	
  0.8997

  	
   

  	
  0.9293

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KS

  	
   

  	
  0.8981

  	
   

  	
  0.9317

  	
   

  	
  P7

  	
   

  	
  1.0273

  	
   

  	
  1.0076

  	
   

  	
  U4

  	
   

  	
  1.0778

  	
   

  	
  1.0022

  	
   

  	
  Y3

  	
   

  	
  0.9145

  	
   

  	
  0.9674

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KT

  	
   

  	
  1.0099

  	
   

  	
  1.0021

  	
   

  	
  P8

  	
   

  	
  0.9614

  	
   

  	
  0.9828

  	
   

  	
  U5

  	
   

  	
  0.9714

  	
   

  	
  1.0106

  	
   

  	
  Y4

  	
   

  	
  0.9178

  	
   

  	
  0.9674

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KU

  	
   

  	
  1.0336

  	
   

  	
  1.0170

  	
   

  	
  P9

  	
   

  	
  1.0165

  	
   

  	
  0.9833

  	
   

  	
  U6

  	
   

  	
  0.9750

  	
   

  	
  1.0074

  	
   

  	
  Y5

  	
   

  	
  0.9714

  	
   

  	
  0.9282

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KV

  	
   

  	
  1.0367

  	
   

  	
  1.0101

  	
   

  	
  R1

  	
   

  	
  1.0121

  	
   

  	
  1.0052

  	
   

  	
  U7

  	
   

  	
  0.9731

  	
   

  	
  1.0085

  	
   

  	
  Y6

  	
   

  	
  0.8997

  	
   

  	
  0.9396

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  KZ

  	
   

  	
  1.0231

  	
   

  	
  1.0092

  	
   

  	
  R2

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  	
  U8

  	
   

  	
  1.0263

  	
   

  	
  1.0080

  	
   

  	
  Y7

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  	
  R3

  	
   

  	
  0.9909

  	
   

  	
  1.0076

  	
   

  	
  U9

  	
   

  	
  1.0210

  	
   

  	
  1.0141

  	
   

  	
  Y8

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L2

  	
   

  	
  0.9599

  	
   

  	
  0.9777

  	
   

  	
  R4

  	
   

  	
  0.9003

  	
   

  	
  0.9029

  	
   

  	
  UA

  	
   

  	
  1.0790

  	
   

  	
  0.9776

  	
   

  	
  Y9

  	
   

  	
  0.9985

  	
   

  	
  1.0000

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L3

  	
   

  	
  0.9566

  	
   

  	
  0.9777

  	
   

  	
  R5

  	
   

  	
  1.0047

  	
   

  	
  0.9777

  	
   

  	
  UB

  	
   

  	
  0.9459

  	
   

  	
  0.9733

  	
   

  	
  ZA

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L4

  	
   

  	
  0.9128

  	
   

  	
  0.9974

  	
   

  	
  R6

  	
   

  	
  1.0047

  	
   

  	
  0.9399

  	
   

  	
  UD

  	
   

  	
  0.9707

  	
   

  	
  1.0064

  	
   

  	
  ZB

  	
   

  	
  0.9934

  	
   

  	
  0.8655

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L5

  	
   

  	
  0.9695

  	
   

  	
  0.9776

  	
   

  	
  R7

  	
   

  	
  0.8997

  	
   

  	
  0.9025

  	
   

  	
  UF

  	
   

  	
  0.9540

  	
   

  	
  0.9805

  	
   

  	
  ZC

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L6

  	
   

  	
  1.0177

  	
   

  	
  0.9776

  	
   

  	
  R8

  	
   

  	
  0.9640

  	
   

  	
  1.0052

  	
   

  	
  UH

  	
   

  	
  1.0262

  	
   

  	
  1.0110

  	
   

  	
  ZG

  	
   

  	
  0.9934

  	
   

  	
  0.9673

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L7

  	
   

  	
  1.0424

  	
   

  	
  0.9756

  	
   

  	
  R9

  	
   

  	
  0.9198

  	
   

  	
  0.8412

  	
   

  	
  UI

  	
   

  	
  1.0080

  	
   

  	
  0.8467

  	
   

  	
  ZK

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L8

  	
   

  	
  1.0243

  	
   

  	
  0.9673

  	
   

  	
  S1

  	
   

  	
  1.0973

  	
   

  	
  1.0283

  	
   

  	
  UJ

  	
   

  	
  1.0080

  	
   

  	
  0.7479

  	
   

  	
  ZM

  	
   

  	
  1.0941

  	
   

  	
  0.9903

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  L9

  	
   

  	
  0.9755

  	
   

  	
  1.0076

  	
   

  	
  S2

  	
   

  	
  1.0259

  	
   

  	
  1.0091

  	
   

  	
  UK

  	
   

  	
  0.9598

  	
   

  	
  0.8467

  	
   

  	
  ZN

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  	
  S3

  	
   

  	
  1.0485

  	
   

  	
  1.0156

  	
   

  	
  UL

  	
   

  	
  0.9598

  	
   

  	
  0.7479

  	
   

  	
  ZO

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M2

  	
   

  	
  1.1361

  	
   

  	
  1.0225

  	
   

  	
  S4

  	
   

  	
  0.9629

  	
   

  	
  0.9295

  	
   

  	
  UN

  	
   

  	
  1.0228

  	
   

  	
  0.7688

  	
   

  	
  ZS

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M3

  	
   

  	
  1.0195

  	
   

  	
  1.0108

  	
   

  	
  S5

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  	
  UO

  	
   

  	
  1.0228

  	
   

  	
  0.8722

  	
   

  	
  ZZ

  	
   

  	
  0.9870

  	
   

  	
  0.9780

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M4

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  	
  S6

  	
   

  	
  1.0658

  	
   

  	
  1.0022

  	
   

  	
  UQ

  	
   

  	
  0.9746

  	
   

  	
  0.8722

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M5

  	
   

  	
  1.0124

  	
   

  	
  1.0054

  	
   

  	
  S7

  	
   

  	
  1.0085

  	
   

  	
  1.0000

  	
   

  	
  UR

  	
   

  	
  0.9746

  	
   

  	
  0.7688

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M6

  	
   

  	
  0.9749

  	
   

  	
  0.9175

  	
   

  	
  S8

  	
   

  	
  1.0080

  	
   

  	
  0.9777

  	
   

  	
  US

  	
   

  	
  1.0080

  	
   

  	
  0.9122

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M7

  	
   

  	
  0.9671

  	
   

  	
  0.8754

  	
   

  	
  S9

  	
   

  	
  1.0080

  	
   

  	
  0.9399

  	
   

  	
  UT

  	
   

  	
  1.0080

  	
   

  	
  0.7838

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M8

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  	
  T1

  	
   

  	
  1.0759

  	
   

  	
  1.0076

  	
   

  	
  UU

  	
   

  	
  0.9598

  	
   

  	
  0.9122

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  M9

  	
   

  	
  1.0743

  	
   

  	
  1.0078

  	
   

  	
  T2

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  	
  UV

  	
   

  	
  0.9598

  	
   

  	
  0.7838

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N1

  	
   

  	
  1.0246

  	
   

  	
  1.0076

  	
   

  	
  T3

  	
   

  	
  1.0187

  	
   

  	
  0.9985

  	
   

  	
  UW

  	
   

  	
  1.0209

  	
   

  	
  0.9400

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N2

  	
   

  	
  1.0211

  	
   

  	
  1.0076

  	
   

  	
  T4

  	
   

  	
  1.0156

  	
   

  	
  0.9985

  	
   

  	
  UX

  	
   

  	
  1.0209

  	
   

  	
  0.8070

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N3

  	
   

  	
  1.0230

  	
   

  	
  1.0076

  	
   

  	
  T5

  	
   

  	
  1.0212

  	
   

  	
  1.0078

  	
   

  	
  UY

  	
   

  	
  0.9729

  	
   

  	
  0.9400

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N4

  	
   

  	
  1.0066

  	
   

  	
  1.0022

  	
   

  	
  T7

  	
   

  	
  0.9229

  	
   

  	
  0.9673

  	
   

  	
  UZ

  	
   

  	
  0.9729

  	
   

  	
  0.8070

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N5

  	
   

  	
  1.0082

  	
   

  	
  1.0022

  	
   

  	
  T8

  	
   

  	
  1.0086

  	
   

  	
  0.9833

  	
   

  	
  W1

  	
   

  	
  1.0542

  	
   

  	
  0.9681

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N6

  	
   

  	
  1.0099

  	
   

  	
  1.0022

  	
   

  	
  T9

  	
   

  	
  1.0245

  	
   

  	
  1.0079

  	
   

  	
  W2

  	
   

  	
  1.0067

  	
   

  	
  1.0000

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N7

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  	
  TA

  	
   

  	
  0.9966

  	
   

  	
  0.9894

  	
   

  	
  W3

  	
   

  	
  0.9715

  	
   

  	
  1.0128

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N8

  	
   

  	
  1.0294

  	
   

  	
  1.0033

  	
   

  	
  TB

  	
   

  	
  0.9929

  	
   

  	
  0.9778

  	
   

  	
  W4

  	
   

  	
  0.9287

  	
   

  	
  0.9680

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  N9

  	
   

  	
  1.0207

  	
   

  	
  0.9916

  	
   

  	
  TC

  	
   

  	
  1.0104

  	
   

  	
  0.9780

  	
   

  	
  W5

  	
   

  	
  1.0266

  	
   

  	
  1.0095

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  O1

  	
   

  	
  0.9747

  	
   

  	
  1.0076

  	
   

  	
  TD

  	
   

  	
  1.0164

  	
   

  	
  1.0000

  	
   

  	
  W6

  	
   

  	
  0.9649

  	
   

  	
  0.9806

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  O2

  	
   

  	
  0.9714

  	
   

  	
  0.9676

  	
   

  	
  TE

  	
   

  	
  1.1100

  	
   

  	
  1.0239

  	
   

  	
  W7

  	
   

  	
  0.9839

  	
   

  	
  0.9941

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  O3

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  	
  TF

  	
   

  	
  0.9965

  	
   

  	
  0.9805

  	
   

  	
  W8

  	
   

  	
  1.0162

  	
   

  	
  0.9776

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  O4

  	
   

  	
  1.0195

  	
   

  	
  0.9676

  	
   

  	
  TQ

  	
   

  	
  0.9856

  	
   

  	
  1.0075

  	
   

  	
  W9

  	
   

  	
  0.9112

  	
   

  	
  0.9774

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  

 

37

 

 

A.3
Benefit Plan Factors for PPG Capitation and Hospital Capitation/Shared Risk
Budgets Effective January 1, 1999

 

	
  Small
  Group HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof
  Factor

  	
   

  	
  Inst
  Factor

  	
   

  
	
  C4

  	
   

  	
  0.9958

  	
   

  	
  1.0075

  	
   

  
	
  C5

  	
   

  	
  0.9016

  	
   

  	
  0.9893

  	
   

  
	
  Q1

  	
   

  	
  0.9877

  	
   

  	
  0.9749

  	
   

  
	
  Q2

  	
   

  	
  0.9350

  	
   

  	
  0.9367

  	
   

  
	
  Q3

  	
   

  	
  0.8834

  	
   

  	
  0.8703

  	
   

  
	
  Q4

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q5

  	
   

  	
  0.9958

  	
   

  	
  1.0103

  	
   

  
	
  Q6

  	
   

  	
  0.9016

  	
   

  	
  0.9921

  	
   

  
	
  Q7

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q8

  	
   

  	
  0.9350

  	
   

  	
  0.9747

  	
   

  
	
  QT

  	
   

  	
  0.9867

  	
   

  	
  1.0057

  	
   

  
	
  QU

  	
   

  	
  0.8977

  	
   

  	
  0.9898

  	
   

  
	
  QV

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QW

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QX

  	
   

  	
  0.9476

  	
   

  	
  0.9927

  	
   

  
	
  QY

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  QZ

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  V1

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  
	
  V4

  	
   

  	
  0.7968

  	
   

  	
  0.7147

  	
   

  
	
  V5

  	
   

  	
  0.9970

  	
   

  	
  0.9726

  	
   

  
	
  V6

  	
   

  	
  0.9607

  	
   

  	
  1.0101

  	
   

  
	
  V7

  	
   

  	
  0.8943

  	
   

  	
  0.8767

  	
   

  
	
  V8

  	
   

  	
  0.9454

  	
   

  	
  0.9726

  	
   

  

 

	
  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

  	
   

  

 

38

 

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

Effective January 1, 1999

 

	
  Standard
  POS

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  	
  CL

  	
   

  	
  0.8844

  	
   

  	
  0.7791

  	
   

  	
  FZ

  	
   

  	
  0.9421

  	
   

  	
  0.9429

  	
   

  	
  LS

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  	
  PK

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  AB

  	
   

  	
  1.0431

  	
   

  	
  0.8885

  	
   

  	
  CM

  	
   

  	
  0.8440

  	
   

  	
  0.7398

  	
   

  	
  GA

  	
   

  	
  0.9485

  	
   

  	
  0.9309

  	
   

  	
  LT

  	
   

  	
  0.8658

  	
   

  	
  0.7138

  	
   

  	
  PL

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  AD

  	
   

  	
  0.9452

  	
   

  	
  0.8996

  	
   

  	
  CN

  	
   

  	
  0.8473

  	
   

  	
  0.7398

  	
   

  	
  GB

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  	
  LU

  	
   

  	
  0.9095

  	
   

  	
  0.9242

  	
   

  	
  PM

  	
   

  	
  0.9485

  	
   

  	
  0.9276

  	
   

  
	
  AG

  	
   

  	
  0.8981

  	
   

  	
  0.9255

  	
   

  	
  CO

  	
   

  	
  0.8326

  	
   

  	
  0.7398

  	
   

  	
  GC

  	
   

  	
  0.9791

  	
   

  	
  0.9478

  	
   

  	
  LV

  	
   

  	
  0.9584

  	
   

  	
  0.9325

  	
   

  	
  PN

  	
   

  	
  0.9452

  	
   

  	
  0.9498

  	
   

  
	
  AH

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  	
  CP

  	
   

  	
  0.8359

  	
   

  	
  0.7398

  	
   

  	
  GD

  	
   

  	
  0.9300

  	
   

  	
  0.9485

  	
   

  	
  LW

  	
   

  	
  0.9714

  	
   

  	
  0.9325

  	
   

  	
  PO

  	
   

  	
  0.9485

  	
   

  	
  0.9303

  	
   

  
	
  AJ

  	
   

  	
  0.8981

  	
   

  	
  0.9242

  	
   

  	
  DA

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  	
  GE

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  	
  LX

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  	
  PP

  	
   

  	
  1.0313

  	
   

  	
  0.9405

  	
   

  
	
  AW

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  	
  DB

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  	
  GF

  	
   

  	
  0.9858

  	
   

  	
  0.9489

  	
   

  	
  LY

  	
   

  	
  0.9599

  	
   

  	
  0.9485

  	
   

  	
  PQ

  	
   

  	
  0.9452

  	
   

  	
  0.8554

  	
   

  
	
  BA

  	
   

  	
  0.9480

  	
   

  	
  0.9247

  	
   

  	
  DC

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  	
  GG

  	
   

  	
  1.0245

  	
   

  	
  0.9604

  	
   

  	
  LZ

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  	
  PR

  	
   

  	
  0.9485

  	
   

  	
  0.9282

  	
   

  
	
  BC

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  	
  DD

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  	
  GH

  	
   

  	
  0.9786

  	
   

  	
  0.9489

  	
   

  	
  NP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  	
  PS

  	
   

  	
  0.9934

  	
   

  	
  0.9014

  	
   

  
	
  BD

  	
   

  	
  0.9485

  	
   

  	
  0.9489

  	
   

  	
  DE

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  	
  GI

  	
   

  	
  0.9242

  	
   

  	
  0.9292

  	
   

  	
  OA

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  	
  PT

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  BE

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  	
  DF

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  	
  GJ

  	
   

  	
  1.0269

  	
   

  	
  0.9511

  	
   

  	
  OB

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  	
  PU

  	
   

  	
  0.9933

  	
   

  	
  0.9002

  	
   

  
	
  BF

  	
   

  	
  0.8981

  	
   

  	
  0.9475

  	
   

  	
  DG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  	
  GK

  	
   

  	
  0.9567

  	
   

  	
  0.9483

  	
   

  	
  OC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  	
  PV

  	
   

  	
  0.9095

  	
   

  	
  0.8420

  	
   

  
	
  BG

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  	
  DH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  	
  GL

  	
   

  	
  0.9746

  	
   

  	
  0.9483

  	
   

  	
  OD

  	
   

  	
  0.9128

  	
   

  	
  0.8481

  	
   

  	
  PW

  	
   

  	
  1.0270

  	
   

  	
  0.9511

  	
   

  
	
  BH

  	
   

  	
  0.9485

  	
   

  	
  0.9486

  	
   

  	
  DI

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  	
  GM

  	
   

  	
  0.9712

  	
   

  	
  0.9065

  	
   

  	
  OE

  	
   

  	
  0.9112

  	
   

  	
  0.8481

  	
   

  	
  PX

  	
   

  	
  0.9714

  	
   

  	
  0.9287

  	
   

  
	
  BI

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  	
  DJ

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  	
  GN

  	
   

  	
  0.9251

  	
   

  	
  0.9405

  	
   

  	
  OF

  	
   

  	
  0.9714

  	
   

  	
  0.9065

  	
   

  	
  PY

  	
   

  	
  0.9599

  	
   

  	
  0.8420

  	
   

  
	
  BJ

  	
   

  	
  0.9747

  	
   

  	
  0.9483

  	
   

  	
  DK

  	
   

  	
  0.9095

  	
   

  	
  0.9274

  	
   

  	
  GQ

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  	
  OG

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  	
  PZ

  	
   

  	
  0.9128

  	
   

  	
  0.8420

  	
   

  
	
  BK

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  	
  DL

  	
   

  	
  0.9714

  	
   

  	
  0.9293

  	
   

  	
  GR

  	
   

  	
  0.9493

  	
   

  	
  0.9060

  	
   

  	
  OI

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  	
  XA

  	
   

  	
  0.9452

  	
   

  	
  0.8725

  	
   

  
	
  BL

  	
   

  	
  0.9966

  	
   

  	
  0.9515

  	
   

  	
  DM

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  	
  GS

  	
   

  	
  0.9094

  	
   

  	
  0.9489

  	
   

  	
  OK

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  	
  XB

  	
   

  	
  0.8298

  	
   

  	
  0.9195

  	
   

  
	
  BM

  	
   

  	
  0.9934

  	
   

  	
  0.9289

  	
   

  	
  DN

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  	
  GT

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  	
  OL

  	
   

  	
  0.9452

  	
   

  	
  0.9500

  	
   

  	
  XC

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  BN

  	
   

  	
  0.9095

  	
   

  	
  0.9489

  	
   

  	
  DO

  	
   

  	
  0.9795

  	
   

  	
  0.8941

  	
   

  	
  GU

  	
   

  	
  0.9242

  	
   

  	
  0.9242

  	
   

  	
  OM

  	
   

  	
  0.9452

  	
   

  	
  0.9468

  	
   

  	
  XD

  	
   

  	
  0.9566

  	
   

  	
  0.8328

  	
   

  
	
  BO

  	
   

  	
  0.9792

  	
   

  	
  0.9478

  	
   

  	
  DP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  	
  KA

  	
   

  	
  0.9823

  	
   

  	
  0.9425

  	
   

  	
  ON

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  	
  XE

  	
   

  	
  0.9422

  	
   

  	
  0.7891

  	
   

  
	
  BP

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  	
  DQ

  	
   

  	
  0.9892

  	
   

  	
  0.9492

  	
   

  	
  KB

  	
   

  	
  0.9730

  	
   

  	
  0.9247

  	
   

  	
  OO

  	
   

  	
  0.9452

  	
   

  	
  0.9303

  	
   

  	
  XF

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  BQ

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  	
  DR

  	
   

  	
  0.9485

  	
   

  	
  0.8680

  	
   

  	
  KC

  	
   

  	
  0.9850

  	
   

  	
  0.8643

  	
   

  	
  OP

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  	
  XG

  	
   

  	
  1.0793

  	
   

  	
  0.9494

  	
   

  
	
  BR

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  	
  DS

  	
   

  	
  0.9747

  	
   

  	
  0.9520

  	
   

  	
  KD

  	
   

  	
  0.9789

  	
   

  	
  0.9279

  	
   

  	
  OQ

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  	
  XI

  	
   

  	
  1.0793

  	
   

  	
  0.9298

  	
   

  
	
  BS

  	
   

  	
  0.9485

  	
   

  	
  0.8420

  	
   

  	
  DT

  	
   

  	
  0.9128

  	
   

  	
  0.9481

  	
   

  	
  KE

  	
   

  	
  0.9832

  	
   

  	
  0.9305

  	
   

  	
  OR

  	
   

  	
  0.9460

  	
   

  	
  0.8256

  	
   

  	
  XJ

  	
   

  	
  0.8981

  	
   

  	
  0.8275

  	
   

  
	
  BT

  	
   

  	
  0.9014

  	
   

  	
  0.8420

  	
   

  	
  DU

  	
   

  	
  0.9014

  	
   

  	
  0.9481

  	
   

  	
  LA

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  	
  OS

  	
   

  	
  0.9452

  	
   

  	
  0.9533

  	
   

  	
  XK

  	
   

  	
  0.9782

  	
   

  	
  0.8426

  	
   

  
	
  BU

  	
   

  	
  0.9747

  	
   

  	
  0.9266

  	
   

  	
  DV

  	
   

  	
  0.9788

  	
   

  	
  0.9577

  	
   

  	
  LB

  	
   

  	
  0.9566

  	
   

  	
  0.9485

  	
   

  	
  OT

  	
   

  	
  1.0098

  	
   

  	
  0.9405

  	
   

  	
  XL

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  
	
  BV

  	
   

  	
  0.9271

  	
   

  	
  0.9286

  	
   

  	
  DW

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  	
  LC

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  	
  OU

  	
   

  	
  0.9526

  	
   

  	
  0.9484

  	
   

  	
  XM

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  BW

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  	
  DX

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  	
  LD

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  	
  OV

  	
   

  	
  0.9124

  	
   

  	
  0.9286

  	
   

  	
  XN

  	
   

  	
  0.9452

  	
   

  	
  0.9183

  	
   

  
	
  BX

  	
   

  	
  0.9452

  	
   

  	
  0.9014

  	
   

  	
  DY

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  	
  LE

  	
   

  	
  0.9714

  	
   

  	
  0.9305

  	
   

  	
  OW

  	
   

  	
  0.9452

  	
   

  	
  0.9309

  	
   

  	
  XO

  	
   

  	
  0.8564

  	
   

  	
  0.9195

  	
   

  
	
  BY

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  	
  DZ

  	
   

  	
  0.9886

  	
   

  	
  0.9372

  	
   

  	
  LF

  	
   

  	
  0.9714

  	
   

  	
  0.9331

  	
   

  	
  OX

  	
   

  	
  0.9452

  	
   

  	
  0.8654

  	
   

  	
  XP

  	
   

  	
  0.9819

  	
   

  	
  0.8661

  	
   

  
	
  BZ

  	
   

  	
  0.9590

  	
   

  	
  0.9468

  	
   

  	
  FN

  	
   

  	
  0.9832

  	
   

  	
  0.9247

  	
   

  	
  LG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  	
  OY

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  	
  XQ

  	
   

  	
  0.8981

  	
   

  	
  0.7513

  	
   

  
	
  CA

  	
   

  	
  0.9950

  	
   

  	
  0.9448

  	
   

  	
  FO

  	
   

  	
  0.9832

  	
   

  	
  0.9496

  	
   

  	
  LH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  	
  OZ

  	
   

  	
  0.9452

  	
   

  	
  0.9313

  	
   

  	
  XR

  	
   

  	
  0.8493

  	
   

  	
  0.9195

  	
   

  
	
  CB

  	
   

  	
  0.9983

  	
   

  	
  0.9448

  	
   

  	
  FP

  	
   

  	
  0.9347

  	
   

  	
  0.8485

  	
   

  	
  LI

  	
   

  	
  0.9714

  	
   

  	
  0.9068

  	
   

  	
  PA

  	
   

  	
  0.9452

  	
   

  	
  0.9323

  	
   

  	
  XS

  	
   

  	
  0.9681

  	
   

  	
  0.7837

  	
   

  
	
  CC

  	
   

  	
  0.9837

  	
   

  	
  0.9448

  	
   

  	
  FQ

  	
   

  	
  0.9347

  	
   

  	
  0.8471

  	
   

  	
  LJ

  	
   

  	
  0.9243

  	
   

  	
  0.9242

  	
   

  	
  PB

  	
   

  	
  0.9307

  	
   

  	
  0.8654

  	
   

  	
  XT

  	
   

  	
  0.9452

  	
   

  	
  0.9022

  	
   

  
	
  CD

  	
   

  	
  0.9870

  	
   

  	
  0.9448

  	
   

  	
  FR

  	
   

  	
  0.9808

  	
   

  	
  0.9247

  	
   

  	
  LK

  	
   

  	
  0.8981

  	
   

  	
  0.8677

  	
   

  	
  PC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  	
  XU

  	
   

  	
  0.9452

  	
   

  	
  0.8934

  	
   

  
	
  CE

  	
   

  	
  0.9432

  	
   

  	
  0.8441

  	
   

  	
  FS

  	
   

  	
  0.9621

  	
   

  	
  0.9254

  	
   

  	
  LL

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  	
  PD

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  	
  XV

  	
   

  	
  0.9452

  	
   

  	
  0.9113

  	
   

  
	
  CF

  	
   

  	
  0.9465

  	
   

  	
  0.8441

  	
   

  	
  FT

  	
   

  	
  0.9619

  	
   

  	
  0.9454

  	
   

  	
  LM

  	
   

  	
  0.9452

  	
   

  	
  0.9378

  	
   

  	
  PE

  	
   

  	
  0.9453

  	
   

  	
  0.9465

  	
   

  	
  XW

  	
   

  	
  0.9452

  	
   

  	
  0.9229

  	
   

  
	
  CG

  	
   

  	
  0.9318

  	
   

  	
  0.8441

  	
   

  	
  FU

  	
   

  	
  0.9743

  	
   

  	
  0.9499

  	
   

  	
  LN

  	
   

  	
  0.9452

  	
   

  	
  0.9397

  	
   

  	
  PF

  	
   

  	
  0.9960

  	
   

  	
  0.9312

  	
   

  	
  XY

  	
   

  	
  0.9782

  	
   

  	
  0.8502

  	
   

  
	
  CH

  	
   

  	
  0.9351

  	
   

  	
  0.8441

  	
   

  	
  FV

  	
   

  	
  0.9813

  	
   

  	
  0.9119

  	
   

  	
  LO

  	
   

  	
  0.8948

  	
   

  	
  0.9176

  	
   

  	
  PG

  	
   

  	
  1.0367

  	
   

  	
  0.9405

  	
   

  	
  XZ

  	
   

  	
  0.9966

  	
   

  	
  0.9289

  	
   

  
	
  CI

  	
   

  	
  0.8924

  	
   

  	
  0.7791

  	
   

  	
  FW

  	
   

  	
  0.9667

  	
   

  	
  0.9416

  	
   

  	
  LP

  	
   

  	
  0.9566

  	
   

  	
  0.8996

  	
   

  	
  PH

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CJ

  	
   

  	
  0.8957

  	
   

  	
  0.7791

  	
   

  	
  FX

  	
   

  	
  0.9565

  	
   

  	
  0.9287

  	
   

  	
  LQ

  	
   

  	
  0.9243

  	
   

  	
  0.9291

  	
   

  	
  PI

  	
   

  	
  0.9492

  	
   

  	
  0.9099

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  CK

  	
   

  	
  0.8811

  	
   

  	
  0.7791

  	
   

  	
  FY

  	
   

  	
  0.9394

  	
   

  	
  0.8970

  	
   

  	
  LR

  	
   

  	
  0.9714

  	
   

  	
  0.9356

  	
   

  	
  PJ

  	
   

  	
  0.9714

  	
   

  	
  0.9473

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  

 

39

 

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

Effective January 1, 1999

 

	
  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

  	
   

  

 

40

 

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

 

B.1
Age/Sex Factors for Pharmacy Budgets Effective January 1, 1999

 

 

	
  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

  	
   

  

 

41

 

B.2
Benefit Plan Factors for Pharmacy Budgets Effective January 1, 1999

 

	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  	
  PLAN

  	
   

  	
  FACTOR

  	
   

  
	
  01

  	
   

  	
  1.3376

  	
   

  	
  1L

  	
   

  	
  0.8989ss

  	
   

  	
  35

  	
   

  	
  1.1102

  	
   

  	
  4R

  	
   

  	
  1.1000

  	
   

  	
  67

  	
   

  	
  1.1637

  	
   

  	
  7L

  	
   

  	
  0.8989

  	
   

  	
  9H

  	
   

  	
  0.7675

  	
   

  	
  18

  	
   

  	
  1.1798

  	
   

  
	
  02

  	
   

  	
  1.1000

  	
   

  	
  1M

  	
   

  	
  0.7564

  	
   

  	
  36

  	
   

  	
  1.1102

  	
   

  	
  4S

  	
   

  	
  1.1102

  	
   

  	
  68

  	
   

  	
  1.1000

  	
   

  	
  7M

  	
   

  	
  0.8371

  	
   

  	
  9I

  	
   

  	
  0.7269

  	
   

  	
  19

  	
   

  	
  0.6448

  	
   

  
	
  03

  	
   

  	
  0.6448

  	
   

  	
  1N

  	
   

  	
  0.8625

  	
   

  	
  37

  	
   

  	
  1.1102

  	
   

  	
  4T

  	
   

  	
  1.1000

  	
   

  	
  69

  	
   

  	
  0.8989

  	
   

  	
  7N

  	
   

  	
  0.9368

  	
   

  	
  9J

  	
   

  	
  0.7232

  	
   

  	
  OH

  	
   

  	
  1.7578

  	
   

  
	
  04

  	
   

  	
  1.1000

  	
   

  	
  1O

  	
   

  	
  0.6845

  	
   

  	
  38

  	
   

  	
  1.2135

  	
   

  	
  4U

  	
   

  	
  0.7398

  	
   

  	
  6A

  	
   

  	
  0.9917

  	
   

  	
  7O

  	
   

  	
  0.8989

  	
   

  	
  9L

  	
   

  	
  1.7495

  	
   

  	
  P3

  	
   

  	
  0.5134

  	
   

  
	
  05

  	
   

  	
  0.7255

  	
   

  	
  1P

  	
   

  	
  0.5991

  	
   

  	
  39

  	
   

  	
  0.8791

  	
   

  	
  4V

  	
   

  	
  1.0945

  	
   

  	
  6B

  	
   

  	
  1.1157

  	
   

  	
  7P

  	
   

  	
  0.8948

  	
   

  	
  9M

  	
   

  	
  0.6411

  	
   

  	
  P4

  	
   

  	
  0.6517

  	
   

  
	
  06

  	
   

  	
  1.1102

  	
   

  	
  1Q

  	
   

  	
  1.1000

  	
   

  	
  3A

  	
   

  	
  1.3311

  	
   

  	
  4W

  	
   

  	
  1.2135

  	
   

  	
  6C

  	
   

  	
  0.9967

  	
   

  	
  7Q

  	
   

  	
  0.7527

  	
   

  	
  9N

  	
   

  	
  0.7048

  	
   

  	
  P9

  	
   

  	
  1.1157

  	
   

  
	
  07

  	
   

  	
  0.6448

  	
   

  	
  1R

  	
   

  	
  0.9368

  	
   

  	
  3B

  	
   

  	
  1.2458

  	
   

  	
  4X

  	
   

  	
  1.1000

  	
   

  	
  6D

  	
   

  	
  1.0945

  	
   

  	
  7R

  	
   

  	
  1.7578

  	
   

  	
  9O

  	
   

  	
  0.6448

  	
   

  	
  Q4

  	
   

  	
  0.7255

  	
   

  
	
  08

  	
   

  	
  1.1000

  	
   

  	
  1S

  	
   

  	
  1.0945

  	
   

  	
  3C

  	
   

  	
  1.3376

  	
   

  	
  4Y

  	
   

  	
  0.7269

  	
   

  	
  6E

  	
   

  	
  0.9750

  	
   

  	
  7S

  	
   

  	
  1.7578

  	
   

  	
  9P

  	
   

  	
  0.6411

  	
   

  	
  S1

  	
   

  	
  1.1277

  	
   

  
	
  09

  	
   

  	
  1.1000

  	
   

  	
  1T

  	
   

  	
  1.1157

  	
   

  	
  3D

  	
   

  	
  1.2518

  	
   

  	
  51

  	
   

  	
  0.7255

  	
   

  	
  6F

  	
   

  	
  1.0424

  	
   

  	
  7T

  	
   

  	
  1.1102

  	
   

  	
  9Q

  	
   

  	
  0.6411

  	
   

  	
  S2

  	
   

  	
  1.8025

  	
   

  
	
  0A

  	
   

  	
  1.7495

  	
   

  	
  1U

  	
   

  	
  0.9119

  	
   

  	
  3E

  	
   

  	
  1.3311

  	
   

  	
  52

  	
   

  	
  0.7292

  	
   

  	
  6G

  	
   

  	
  0.6005

  	
   

  	
  7U

  	
   

  	
  1.1102

  	
   

  	
  9R

  	
   

  	
  0.7527

  	
   

  	
  S3

  	
   

  	
  0.8768

  	
   

  
	
  0B

  	
   

  	
  1.6378

  	
   

  	
  1V

  	
   

  	
  1.1000

  	
   

  	
  3F

  	
   

  	
  1.3376

  	
   

  	
  53

  	
   

  	
  0.6448

  	
   

  	
  6H

  	
   

  	
  1.1577

  	
   

  	
  7V

  	
   

  	
  1.1102

  	
   

  	
  9S

  	
   

  	
  0.6411

  	
   

  	
  S4

  	
   

  	
  1.6378

  	
   

  
	
  0C

  	
   

  	
  1.7578

  	
   

  	
  1W

  	
   

  	
  1.1102

  	
   

  	
  3G

  	
   

  	
  1.3311

  	
   

  	
  54

  	
   

  	
  0.5166

  	
   

  	
  6I

  	
   

  	
  1.1102

  	
   

  	
  7W

  	
   

  	
  1.1102

  	
   

  	
  9T

  	
   

  	
  0.9409

  	
   

  	
  S5

  	
   

  	
  1.1102

  	
   

  
	
  0D

  	
   

  	
  1.6457

  	
   

  	
  1X

  	
   

  	
  0.8989

  	
   

  	
  3I

  	
   

  	
  0.8989

  	
   

  	
  55

  	
   

  	
  0.7292

  	
   

  	
  6J

  	
   

  	
  1.1102

  	
   

  	
  7X

  	
   

  	
  1.1102

  	
   

  	
  9U

  	
   

  	
  1.2135

  	
   

  	
  S6

  	
   

  	
  1.1102

  	
   

  
	
  0E

  	
   

  	
  1.7827

  	
   

  	
  1Y

  	
   

  	
  1.2135

  	
   

  	
  3J

  	
   

  	
  0.8989

  	
   

  	
  56

  	
   

  	
  0.6448

  	
   

  	
  6K

  	
   

  	
  0.8989

  	
   

  	
  7Y

  	
   

  	
  1.1102

  	
   

  	
  9W

  	
   

  	
  0.6448

  	
   

  	
  S7

  	
   

  	
  1.7578

  	
   

  
	
  0F

  	
   

  	
  0.5134

  	
   

  	
  1Z

  	
   

  	
  1.1000

  	
   

  	
  3K

  	
   

  	
  1.1157

  	
   

  	
  57

  	
   

  	
  0.5166

  	
   

  	
  6L

  	
   

  	
  0.8989

  	
   

  	
  7Z

  	
   

  	
  1.7495

  	
   

  	
  9X

  	
   

  	
  1.1102

  	
   

  	
  S8

  	
   

  	
  0.8768

  	
   

  
	
  0G

  	
   

  	
  0.9368

  	
   

  	
  20

  	
   

  	
  0.7292

  	
   

  	
  3L

  	
   

  	
  0.6448

  	
   

  	
  58

  	
   

  	
  0.7255

  	
   

  	
  6M

  	
   

  	
  1.1180

  	
   

  	
  82

  	
   

  	
  1.1000

  	
   

  	
  9Y

  	
   

  	
  1.1000

  	
   

  	
  S9

  	
   

  	
  1.7495

  	
   

  
	
  0H

  	
   

  	
  0.7255

  	
   

  	
  23

  	
   

  	
  0.9368

  	
   

  	
  3M

  	
   

  	
  0.8671

  	
   

  	
  59

  	
   

  	
  0.6448

  	
   

  	
  6N

  	
   

  	
  1.1180

  	
   

  	
  8A

  	
   

  	
  1.1102

  	
   

  	
  9Z

  	
   

  	
  1.0424

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0I

  	
   

  	
  0.8948

  	
   

  	
  24

  	
   

  	
  1.1157

  	
   

  	
  3N

  	
   

  	
  1.2135

  	
   

  	
  5A

  	
   

  	
  1.0945

  	
   

  	
  6O

  	
   

  	
  1.1102

  	
   

  	
  8B

  	
   

  	
  0.8989

  	
   

  	
  A1

  	
   

  	
  1.7578

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0J

  	
   

  	
  1.7578

  	
   

  	
  26

  	
   

  	
  1.1000

  	
   

  	
  3O

  	
   

  	
  1.4704

  	
   

  	
  5B

  	
   

  	
  1.1157

  	
   

  	
  6P

  	
   

  	
  1.0424

  	
   

  	
  8C

  	
   

  	
  0.8948

  	
   

  	
  B1

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0P

  	
   

  	
  1.1577

  	
   

  	
  2A

  	
   

  	
  1.4635

  	
   

  	
  3P

  	
   

  	
  0.8989

  	
   

  	
  5C

  	
   

  	
  1.1000

  	
   

  	
  6Q

  	
   

  	
  0.9280

  	
   

  	
  8E

  	
   

  	
  0.7869

  	
   

  	
  B2

  	
   

  	
  0.7564

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0R

  	
   

  	
  1.1577

  	
   

  	
  2B

  	
   

  	
  1.3699

  	
   

  	
  3Q

  	
   

  	
  1.4912

  	
   

  	
  5D

  	
   

  	
  1.0299

  	
   

  	
  6R

  	
   

  	
  1.1637

  	
   

  	
  8F

  	
   

  	
  0.8404

  	
   

  	
  B3

  	
   

  	
  0.7564

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0S

  	
   

  	
  1.0470

  	
   

  	
  2C

  	
   

  	
  1.4704

  	
   

  	
  3R

  	
   

  	
  0.6882

  	
   

  	
  5E

  	
   

  	
  1.0834

  	
   

  	
  6S

  	
   

  	
  0.8805

  	
   

  	
  8G

  	
   

  	
  1.1102

  	
   

  	
  B4

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0T

  	
   

  	
  0.6771

  	
   

  	
  2D

  	
   

  	
  1.3768

  	
   

  	
  3S

  	
   

  	
  0.5166

  	
   

  	
  5F

  	
   

  	
  1.1577

  	
   

  	
  6T

  	
   

  	
  1.1102

  	
   

  	
  8H

  	
   

  	
  1.0032

  	
   

  	
  B5

  	
   

  	
  0.8989

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0U

  	
   

  	
  1.1577

  	
   

  	
  2E

  	
   

  	
  1.4912

  	
   

  	
  3T

  	
   

  	
  0.7292

  	
   

  	
  5G

  	
   

  	
  1.1637

  	
   

  	
  6U

  	
   

  	
  1.1102

  	
   

  	
  8I

  	
   

  	
  0.8989

  	
   

  	
  B6

  	
   

  	
  1.1798

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0V

  	
   

  	
  1.1577

  	
   

  	
  2F

  	
   

  	
  0.9409

  	
   

  	
  3U

  	
   

  	
  1.6378

  	
   

  	
  5H

  	
   

  	
  1.1798

  	
   

  	
  6V

  	
   

  	
  1.1102

  	
   

  	
  8J

  	
   

  	
  0.8989

  	
   

  	
  B7

  	
   

  	
  1.1637

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0W

  	
   

  	
  0.7232

  	
   

  	
  2G

  	
   

  	
  0.6448

  	
   

  	
  3V

  	
   

  	
  0.7255

  	
   

  	
  5I

  	
   

  	
  1.1180

  	
   

  	
  6W

  	
   

  	
  1.1102

  	
   

  	
  8K

  	
   

  	
  0.8989

  	
   

  	
  B8

  	
   

  	
  0.7255

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0X

  	
   

  	
  0.9409

  	
   

  	
  2H

  	
   

  	
  1.1000

  	
   

  	
  3X

  	
   

  	
  0.7398

  	
   

  	
  5J

  	
   

  	
  0.6005

  	
   

  	
  6X

  	
   

  	
  1.1102

  	
   

  	
  8L

  	
   

  	
  1.6115

  	
   

  	
  B9

  	
   

  	
  0.7255

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0Y

  	
   

  	
  0.6411

  	
   

  	
  2I

  	
   

  	
  0.6448

  	
   

  	
  3Y

  	
   

  	
  0.9967

  	
   

  	
  5K

  	
   

  	
  1.1821

  	
   

  	
  6Y

  	
   

  	
  1.7578

  	
   

  	
  8M

  	
   

  	
  0.9986

  	
   

  	
  C2

  	
   

  	
  0.6536

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  0Z

  	
   

  	
  1.0945

  	
   

  	
  2J

  	
   

  	
  0.6882

  	
   

  	
  3Z

  	
   

  	
  0.5590

  	
   

  	
  5L

  	
   

  	
  1.1577

  	
   

  	
  6Z

  	
   

  	
  1.2241

  	
   

  	
  8N

  	
   

  	
  0.9548

  	
   

  	
  C3

  	
   

  	
  0.6536

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  10

  	
   

  	
  0.7564

  	
   

  	
  2L

  	
   

  	
  1.1761

  	
   

  	
  40

  	
   

  	
  0.7292

  	
   

  	
  5M

  	
   

  	
  1.1000

  	
   

  	
  71

  	
   

  	
  1.1102

  	
   

  	
  8P

  	
   

  	
  1.1000

  	
   

  	
  C5

  	
   

  	
  0.9091

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  11

  	
   

  	
  0.5166

  	
   

  	
  2M

  	
   

  	
  1.1157

  	
   

  	
  41

  	
   

  	
  0.9119

  	
   

  	
  5N

  	
   

  	
  1.0834

  	
   

  	
  72

  	
   

  	
  1.1102

  	
   

  	
  8R

  	
   

  	
  1.7864

  	
   

  	
  C7

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  12

  	
   

  	
  0.4105

  	
   

  	
  2N

  	
   

  	
  1.1157

  	
   

  	
  42

  	
   

  	
  1.1637

  	
   

  	
  5O

  	
   

  	
  0.7292

  	
   

  	
  73

  	
   

  	
  0.8948

  	
   

  	
  8S

  	
   

  	
  1.0618

  	
   

  	
  C8

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  13

  	
   

  	
  0.4806

  	
   

  	
  2O

  	
   

  	
  0.7412

  	
   

  	
  46

  	
   

  	
  1.1637

  	
   

  	
  5P

  	
   

  	
  1.1577

  	
   

  	
  74

  	
   

  	
  1.1102

  	
   

  	
  8T

  	
   

  	
  0.5590

  	
   

  	
  C9

  	
   

  	
  0.7412

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  14

  	
   

  	
  0.5590

  	
   

  	
  2P

  	
   

  	
  1.1577

  	
   

  	
  47

  	
   

  	
  1.3588

  	
   

  	
  5Q

  	
   

  	
  0.5973

  	
   

  	
  75

  	
   

  	
  0.9368

  	
   

  	
  8U

  	
   

  	
  1.6346

  	
   

  	
  D1

  	
   

  	
  0.7412

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  16

  	
   

  	
  1.0821

  	
   

  	
  2Q

  	
   

  	
  1.1102

  	
   

  	
  48

  	
   

  	
  0.9368

  	
   

  	
  5R

  	
   

  	
  0.7292

  	
   

  	
  76

  	
   

  	
  0.8989

  	
   

  	
  8V

  	
   

  	
  1.1637

  	
   

  	
  D2

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  17

  	
   

  	
  0.6411

  	
   

  	
  2R

  	
   

  	
  1.1102

  	
   

  	
  49

  	
   

  	
  1.2310

  	
   

  	
  5S

  	
   

  	
  0.7255

  	
   

  	
  77

  	
   

  	
  0.9368

  	
   

  	
  8X

  	
   

  	
  0.6448

  	
   

  	
  D3

  	
   

  	
  0.7689

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  18

  	
   

  	
  0.7292

  	
   

  	
  2S

  	
   

  	
  0.8989

  	
   

  	
  4A

  	
   

  	
  1.2080

  	
   

  	
  5T

  	
   

  	
  1.1000

  	
   

  	
  78

  	
   

  	
  0.9409

  	
   

  	
  8Y

  	
   

  	
  0.7255

  	
   

  	
  D4

  	
   

  	
  0.7689

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  19

  	
   

  	
  1.1000

  	
   

  	
  2T

  	
   

  	
  0.7292

  	
   

  	
  4B

  	
   

  	
  1.1305

  	
   

  	
  5U

  	
   

  	
  1.1157

  	
   

  	
  79

  	
   

  	
  0.8948

  	
   

  	
  8Z

  	
   

  	
  0.7527

  	
   

  	
  D5

  	
   

  	
  0.7689

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1A

  	
   

  	
  1.6037

  	
   

  	
  2U

  	
   

  	
  0.8989

  	
   

  	
  4E

  	
   

  	
  1.2015

  	
   

  	
  5V

  	
   

  	
  1.1000

  	
   

  	
  7A

  	
   

  	
  0.8948

  	
   

  	
  91

  	
   

  	
  1.2135

  	
   

  	
  D6

  	
   

  	
  0.7195

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1B

  	
   

  	
  1.5013

  	
   

  	
  2V

  	
   

  	
  0.7269

  	
   

  	
  4F

  	
   

  	
  1.2836

  	
   

  	
  5W

  	
   

  	
  1.1157

  	
   

  	
  7B

  	
   

  	
  0.8371

  	
   

  	
  92

  	
   

  	
  1.1577

  	
   

  	
  E2

  	
   

  	
  0.7721

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1C

  	
   

  	
  1.6115

  	
   

  	
  2W

  	
   

  	
  0.8989

  	
   

  	
  4G

  	
   

  	
  1.1000

  	
   

  	
  5X

  	
   

  	
  0.7412

  	
   

  	
  7C

  	
   

  	
  0.8989

  	
   

  	
  93

  	
   

  	
  0.7292

  	
   

  	
  E3

  	
   

  	
  0.8989

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1D

  	
   

  	
  1.5087

  	
   

  	
  2X

  	
   

  	
  0.6448

  	
   

  	
  4H

  	
   

  	
  1.1000

  	
   

  	
  5Y

  	
   

  	
  0.7412

  	
   

  	
  7D

  	
   

  	
  0.8768

  	
   

  	
  96

  	
   

  	
  0.9368

  	
   

  	
  E5

  	
   

  	
  0.7412

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1E

  	
   

  	
  1.1102

  	
   

  	
  2Y

  	
   

  	
  0.7269

  	
   

  	
  4I

  	
   

  	
  1.1102

  	
   

  	
  5Z

  	
   

  	
  1.7495

  	
   

  	
  7E

  	
   

  	
  0.8768

  	
   

  	
  9A

  	
   

  	
  0.7232

  	
   

  	
  E7

  	
   

  	
  1.1157

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1F

  	
   

  	
  1.1102

  	
   

  	
  2Z

  	
   

  	
  1.2135

  	
   

  	
  4K

  	
   

  	
  1.0032

  	
   

  	
  61

  	
   

  	
  1.1102

  	
   

  	
  7F

  	
   

  	
  0.9368

  	
   

  	
  9B

  	
   

  	
  0.6771

  	
   

  	
  F1

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1G

  	
   

  	
  0.7412

  	
   

  	
  30

  	
   

  	
  1.1102

  	
   

  	
  4L

  	
   

  	
  1.0945

  	
   

  	
  62

  	
   

  	
  1.1102

  	
   

  	
  7G

  	
   

  	
  0.9409

  	
   

  	
  9C

  	
   

  	
  0.7269

  	
   

  	
  F3

  	
   

  	
  0.7412

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1H

  	
   

  	
  0.7412

  	
   

  	
  31

  	
   

  	
  1.1102

  	
   

  	
  4M

  	
   

  	
  0.9917

  	
   

  	
  63

  	
   

  	
  1.7578

  	
   

  	
  7H

  	
   

  	
  1.1102

  	
   

  	
  9D

  	
   

  	
  0.7232

  	
   

  	
  F4

  	
   

  	
  0.7292

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1I

  	
   

  	
  1.1102

  	
   

  	
  32

  	
   

  	
  0.7255

  	
   

  	
  4N

  	
   

  	
  0.9331

  	
   

  	
  64

  	
   

  	
  0.9409

  	
   

  	
  7I

  	
   

  	
  1.1102

  	
   

  	
  9E

  	
   

  	
  0.7048

  	
   

  	
  F7

  	
   

  	
  0.7398

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1J

  	
   

  	
  0.7564

  	
   

  	
  33

  	
   

  	
  0.7260

  	
   

  	
  4P

  	
   

  	
  0.9548

  	
   

  	
  65

  	
   

  	
  0.7292

  	
   

  	
  7J

  	
   

  	
  0.9409

  	
   

  	
  9F

  	
   

  	
  0.7527

  	
   

  	
  12

  	
   

  	
  1.0106

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  1K

  	
   

  	
  1.1102

  	
   

  	
  34

  	
   

  	
  1.1102

  	
   

  	
  4Q

  	
   

  	
  0.9548

  	
   

  	
  66

  	
   

  	
  1.1637

  	
   

  	
  7K

  	
   

  	
  0.9368

  	
   

  	
  9G

  	
   

  	
  0.7564

  	
   

  	
  13

  	
   

  	
  0.6171

  	
   

  	
   

  	
   

  	
   

  	
   

  

 

42

 

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 1/1/99

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  In
  Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Out
  of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Drugs, including Epogen, 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 division of responsibility have been deleted.

 

43

 

	
   

  	
   

  	
  PPG CAPITATED SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED RISK/HOSPITAL CAPITATED SERVICES

  	
   

  
	
  COSMETIC
  SURGERY

  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES

  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC
  TESTING - Outpatient Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - Out of
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - In
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Epogen,
  Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

44

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS - 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Inpatient,
  Ambulatory Surgery or Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES,
  SELF APMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  1VF
  &  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY
  - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •   Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

45

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  PATHOLOGY
  -  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE
  ADMISSION - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory,
  X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (within 72 hrs.
  or  related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES-  Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to an Outpatient Office Visit:
  Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •   Related to a Hospital Stay: Surgical
  Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Chem. Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  -Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY-Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY -
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY:
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

46

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Covered Inmunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE VISITS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE VISITS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Exams and
  Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Implanted
  Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Lenses and
  Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

47

 

ADDENDUM C

 

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

 

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

 

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

 

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

 

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

 

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

 

B.            MEDICARE HMO BENEFIT PROGRAMS.

 

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

 

2.             Capitation:
PPG Capitated Services.

 

2.1          Compensation
for PPG Capitated Services.  As compensation for rendering PPG Capitated Services as defined herein, HMO
shall pay PPG Capitation at *** of Monthly Revenue as set forth below for each
Medicare HMO Member eligible to receive such services from PPG during any
particular month.  Capitation shall be
computed on the basis of the most current information available and shall be
paid by HMO by wire transfer on or before the fifteenth (I5th) day of each
month or the first business day following the fifteenth if the fifteenth is a
holiday or on a weekend or within two (2) days of HCFA’s payment to HMO,
whichever is later.  Each Capitation
payment shall be accompanied by a remittance summary.  The remittance summary identifies the total Capitation payable
and those Medicare HMO Members for whom Capitation is being paid.  In the event of a Capitation error resulting
in an over payment or underpayment to PPG, HMO shall adjust subsequent
Capitation to offset such error.

 

48

 

2.2          Professional Stop Loss Program

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

 

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

 

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

 

	
  Supplemental Benefit

  	
   

  	
  PMPM

  	
   

  
	
  $5 office visit
  & specialist consultation copay waived

  	
   

  	
  $

  	
  ***

  	
   

  
	
  $5 vision and
  hearing exam copay waived

  	
   

  	
  $

  	
  ***

  	
   

  
	
  $20 outpatient
  mental health copay waived

  	
   

  	
  $

  	
  ***

  	
   

  
	
  $20 outpatient
  substance abuse copay waived

  	
   

  	
  $

  	
  ***

  	
   

  

 

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

 

3.             Shared Risk Program.

 

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

 

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

 

3.3          Shared Risk Budget Deficit.  In the event of a Shared Risk Budget
deficit.  PPG’s share of the
deficit shall be limited to the lesser of (a) 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.

 

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

 

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

 

49

 

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

 

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

 

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

 

4.               Pharmacy
Budget.  Each mouth. 
HMO shall fund the Pharmacy Budget as set forth in this

Addendum C for applicable Medicare HMO Members.

 

C.           MEDICARE POS BENEFIT PROGRAM.

 

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

 

2.             Definitions.

 

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

 

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

 

3.               Capitation: PPG Capitated
Services.

 

3.1          Capitation Rate.  PPG  shall be compensated for rendering
professional In-Network Services to Medicare POS Members at the percent of
Monthly Revenue for Medicare HMO-Members as set forth in this Addendum C.  less a fifty percent  (50%) withhold
(Professional Out-of-Network Withhold), for each Medicare POS Member eligible
to receive such services from PPG during any particular month.

 

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

 

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

 

50

 

offset
such error.

 

3.2          Professional Stop Loss Program.

 

(a)           In-Network professional Stop Loss.

 

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

 

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

 

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

 

4.             POS Shared Risk.

 

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

 

4.2          POS Shared Risk Budget Surplus.  In the event of a POS Shared Risk Budget
surplus, PPG’s share of the surplus shall be the lesser of fifty percent (50%),
or an amount not to exceed twenty percent (20%) of (he annual gross PPG
Capitation.

 

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

 

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

 

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

 

Out-of-Area Emergency and
Urgently Needed Services are 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: 0.34% of applicable Medicare POS
Member’s HCFA payment and county premium, if any.

 

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

 

51

 

D.            ADMINISTRATION
OF SHARED RISK BUDGET FOR MEDICARE POS.

 

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

 

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

 

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

 

E.            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 but and accept payment from Medicare as payment
in full for such services, except for applicable Copayments and
deductible.  PPG shall but HMO and not
Members for such Copayments and deductibles or for Contracted Services rendered
that are not covered under Medicare, but which are covered tinder 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.

 

F.            OTHER
SERVICES.

 

1.             Contracted Services.  PPG and Member Physicians shall render
Contracted Services which are not PPG Capitated Services to Members covered
under this Addendum C and shall he 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.

 

52

 

ADDENDUM C.1

 

SUPPLEMENTAL
BENEFITS COSTS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  6.58

  	
  %

  
	
  Buite

  	
   

  	
  0.00

  	
  %

  
	
  Colusa

  	
   

  	
  0,00

  	
  %

  
	
  Contra Costa

  	
   

  	
  7.58

  	
  %

  
	
  El Dorado

  	
   

  	
  5.66

  	
  %

  
	
  Fresno

  	
   

  	
  6.17

  	
  %

  
	
  Glenn

  	
   

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  12.26

  	
  %

  
	
  Los Angeles

  	
   

  	
  7.42

  	
  %

  
	
  Madera

  	
   

  	
  5.93

  	
  %

  
	
  Marin

  	
   

  	
  4.66

  	
  %

  
	
  Mariposa

  	
   

  	
  6.23

  	
  %

  
	
  Napa

  	
   

  	
  0.00

  	
  %

  
	
  Orange

  	
   

  	
  8.80

  	
  %

  
	
  Placer

  	
   

  	
  7.48

  	
  %

  
	
  Plumas

  	
   

  	
  0.00

  	
  %

  
	
  Riverside

  	
   

  	
  6.13

  	
  %

  
	
  Sacramento

  	
   

  	
  9.06

  	
  %

  
	
  San Bernardino

  	
   

  	
  6.17

  	
  %

  
	
  San Diego

  	
   

  	
  9.70

  	
  %

  
	
  San Francisco

  	
   

  	
  6.09

  	
  %

  
	
  San Joaquin

  	
   

  	
  8.56

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  0.00

  	
  %

  
	
  San Mateo

  	
   

  	
  7.82

  	
  %

  
	
  Sonta Barbara

  	
   

  	
  8.58

  	
  %

  
	
  Santa Clara

  	
   

  	
  8.11

  	
  %

  
	
  Sierra

  	
   

  	
  0.00

  	
  %

  
	
  Solano

  	
   

  	
  0.00

  	
  %

  
	
  Sonoma

  	
   

  	
  4.83

  	
  %

  
	
  Slanislaus

  	
   

  	
  7.26

  	
  %

  
	
  Sutter

  	
   

  	
  0.00

  	
  %

  
	
  Tulare

  	
   

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  6.24

  	
  %

  
	
  Yolo

  	
   

  	
  7.12

  	
  %

  
	
  Yuha

  	
   

  	
  0.00

  	
  %

  

 

53

 

ADDENDUM C.2

 

PHARMACY SHARED
RISK BUDGETS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  5.40

  	
  %

  
	
  Buite

  	
   

  	
  0.00

  	
  %

  
	
  Colusa

  	
   

  	
  0.00

  	
  %

  
	
  Contra Costa

  	
   

  	
  6.40

  	
  %

  
	
  El Dorado

  	
   

  	
  5.05

  	
  %

  
	
  Fresno

  	
   

  	
  5.56

  	
  %

  
	
  Glenn

  	
   

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  10.86

  	
  %

  
	
  Los Angeles

  	
   

  	
  6.32

  	
  %

  
	
  Madera

  	
   

  	
  5.32

  	
  %

  
	
  Marin

  	
   

  	
  4.17

  	
  %

  
	
  Mariposa

  	
   

  	
  5.60

  	
  %

  
	
  Napa

  	
   

  	
  0.00

  	
  %

  
	
  Orange

  	
   

  	
  7.61

  	
  %

  
	
  Placer

  	
   

  	
  6.16

  	
  %

  
	
  Plumas

  	
   

  	
  0.00

  	
  %

  
	
  Riverside

  	
   

  	
  5.61

  	
  %

  
	
  Sacramento

  	
   

  	
  7.84

  	
  %

  
	
  San Bernadino

  	
   

  	
  5.67

  	
  %

  
	
  San Diego

  	
   

  	
  8.36

  	
  %

  
	
  San Francisco

  	
   

  	
  4.88

  	
  %

  
	
  San Joaquin

  	
   

  	
  7.19

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  0.00

  	
  %

  
	
  San Mateo

  	
   

  	
  6.35

  	
  %

  
	
  Santa Barbara

  	
   

  	
  7.97

  	
  %

  
	
  Santa Clara

  	
   

  	
  6.71

  	
  %

  
	
  Sierra

  	
   

  	
  0.00

  	
  %

  
	
  Solano

  	
   

  	
  0.00

  	
  %

  
	
  Sonoma

  	
   

  	
  4.30

  	
  %

  
	
  Stanislaus

  	
   

  	
  5.84

  	
  %

  
	
  Sutter

  	
   

  	
  0.00

  	
  %

  
	
  Tulare

  	
   

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  5.73

  	
  %

  
	
  Yolo

  	
   

  	
  6.50

  	
  %

  
	
  Yuba

  	
   

  	
  0.00

  	
  %

  

 

54

 

ADDENDUM C.3

DIVISION
OF FINANCIAL RESPONSIBILITY

MATRIX OF HMO
AND PPG CAPITATED SERVICES

MEDICARE BENEFIT
PROGRAM

 

The following matrix outlines the
division of financial responsibility between 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 1/1/99

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL CAPITATED SERVICES

  	
   

  
	
  AIDS -  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  In Area (30 Mile
  Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD
  PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Storage and
  Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Drugs, including Epogen,
  Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC
  SURGERY

  (Medically Necessary) 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

55

 

 

MATRIX
EFFECTIVE 1/1/99

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL CAPITATED SERVICES

  	
   

  
	
  DENTAL SERVICES

  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC
  TESTING - Outpatient Facility &  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component 
  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS - Inpatient, Ambulatory Surgery or
  Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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.

 

56

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL CAPITATED SERVICES

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Professional
  Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY
  - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Outpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE
  ADMISSION - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory,
  X-ray

  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Outpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

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

 

57

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL CAPITATED SERVICES

  	
   

  
	
  RADIOLOGY
  - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH
  AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES-
  Medical, Surgical, Office 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Related to an Outpatient Office Visit: Splints,
  Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Related to a  Hospital
  Stay: Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Chem, Strips,
  Lancet, Needles, Syringes Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Outpatient 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY: Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE VISITS - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Exams and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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.

 

58

 

ADDENDUM D

 

PREFERRED
PROVIDER ORGANIZATION (PPO)

EXCLUSIVE
PROVIDER ORGANIZATION (EPO)

POINT OF SERVICE
(POS)

 

BENEFIT PROGRAMS

 

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

 

A.            BENEFIT PROGRAM REQUIREMENTS

 

PPG agrees:

 

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

 

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

 

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

 

a)             Provider
or facility is non-participating:

 

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

 

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

 

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

 

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

 

59

 

B.            PPO AND EPO BENEFIT PROGRAMS

 

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

 

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

 

C.            POINT OF SERVICE BENEFIT PROGRAMS

 

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

 

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

 

60

 

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) *** the
Medicare allowable charges based on the Medicare Resource Based Relative Value
Scale (RBRVS) unit values and HCFA Geographical Practice Cost Indices as published
in the most current published edition of the Federal Register: (b) *** of PPG’s
allowable billed charges; or (c) such other fee schedules as may be established
or adopted from time to time by FHS.

 

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

 

Anesthesiology Services:

 

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

 

Assistant Surgeons:

 

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

amnimocentesis

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

oilier 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

 

61

 

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

 

62

 

ADDENDUM F

 

MEDI-CAL BENEFIT PROGRAM

 

PPG understands and agrees that
the obligations of FHS set forth in this Addendum shall be the obligations of
HEALTH NET an Affiliate of FHS; and not the obligations of FHS or any other
Affiliate of FHS.  HEALTH NET has
entered into one or more Medi-Cal prepaid health plan agreements with the
California Department of Health Services (“DHS”) For the purposes of this amendment.  HEALTH NET’s Medi-Cal agreements with the
DHS and its subcontracts with Medi-Cal prepaid health plans, arc hereinafter
collectively referred to as the Medi-Cal Agreement.  HEALTH NET has agreed, under the Medi-Cal Agreement, to arrange
certain medical services covered under California’s Medi-Cal Program, including
PPG Capitated Services, to Medi-Cal HMO Members enrolled in or otherwise
assigned to HEALTH NET, on a prepaid basis. 
The provisions of the Addendum are required to appear in all subcontracts
under the Medi-Cal Agreement by the terms of the Medi-Cal Agreement and by
Medi-Cal law and may not be altered. 
Fur purposes of this Addendum F, any per Member per month calculation
shall be based on Medi-Cal HMO Members only.

 

Notwithstanding any provision in
the Agreement to the contrary, PPG understands and agrees that it shall arrange
and provide health care services to Members in accordance with the benefits and
program requirements of the applicable Medi-Cal Agreement Benefits under Health
Net’s Healthy San Diego Plan and Sacramento GMC Plan are substantially
identical to the benefits under Health Net’s Mainstream Plan, except that
chiropractic, acupuncture and spiritual healing services are not covered under
the Mainstream Plan, PPG understands that Evidence of Coverage documents are
subject to change and approval by the DHS and PPG hereby agrees to arrange and
provide health care services in accordance with such changes.

 

A.            DEFINITIONS.

 

1.  The following definitions for Shared Risk
services apply when PPG is paid Capitation for Medi-Cal HMO Members assigned to
PPG and the acute care hospital(s) associated with PPG is(are) paid by HEALTH
NET on a fee-for service or per diem basis. 
When the acute care hospital(s) associated with PPG is capitated all
shared risk definitions and references to a shared risk contractual
relationship shall not apply.

 

a) Insured
Services.  PPG Capitated Services
that are provided and paid for by PPG but which arc reimbursable by HEALTH NET
in addition to the Capitation paid. 
Such Insured Services are set forth on the applicable Exhibit to this
Addendum.

 

b) Reconciliation
Period.  The 12 month period used
for the purpose of calculating a Shared Risk payable or receivable amount.  The first Reconciliation Period will be the
12-month period beginning on the date that Medi-Cal HMO Members are first
assigned to PPG for Capitation under this Agreement Subsequent Reconciliation
Periods will be for each 12 month period thereafter.

 

c) Shared
Risk Budget.  The sum of all of the
individual Medi-Cal HMO Member Shared Risk Targets.  The Shared Risk Budget will be compared to Shared Risk Claims to
determine whether PPG is eligible for a Shared Risk payment.

 

d) Shared.
Risk Claims.  Claims for Shared Risk
Services which arc rendered during a Reconciliation Period.  HEALTH NET will adjudicate and pay these
claims.  Shared Risk Claims will include
all claims with dates of services within the Reconciliation Period and paid
within ninety (90) days after the end of the Reconciliation Period.

 

e) Shared
Risk/Hospital Capitated Services. 
The Covered Services provided at a medical facility to a Medi-Cal HMO
Member assigned to PPG which arc set forth in the attached applicable “Matrix
of HEALTH NET.  PPG and Shared
Risk/Hospital Capitated Services” Exhibit hereto.

 

f) Shared
Risk Targets.  The expected costs of
Shared Risk Services, stated on a per Medi-Cal HMO Member-per-month (“PMPM”)
basis.  Each PMPM target is determined
by the age, sex and benefit plan of the Medi-

 

63

 

Cal HMO Member.  The targets will be established by HEALTH
NET actuarial personnel and will be subject to annual review and
modification.  Targets are attached to
this Addendum F

 

g)  PPG Capitated Services.  For purposes of this Addendum, PPG shall
render PPG Capitated Services set forth in Addendum F-4 to Medi-Cal HMO Members
eligible for coverage and enrolled in HEALTH NET under the Medi-Cal Agreement
who select or are assigned to PPG, as of the end of a particular month.

 

h) Encounter
Reporting Incentive Program.  PPG
may in HEALTHNET’s sole discretion, earn compensation in addition to the above
stated capitation for compliance with HEALTH NET’S Encounter Reporting
Incentive Program as set forth in future Operations Manuals and /or Medi-Cal
Provider Bulletins.  These terms will
include, but are not limited to, the timeliness accuracy and completeness of
encounter data reporting and PPG eligibility for the program.  HEALTH NET reserves the right to alter
components and measurements of the Encounter Reporting Incentive Program

 

i) Medi-Cal
Primary Hospital.  An acute care
hospital associated with a PPG with whom HEALTH NET contracts on a capitated
compensation basis under the Medi-Cal Risk Program to provide Shared/Hospital Capitated
Services to the Medi-Cal HMO Members assigned to both PPG and Medi-Cal Primary
Hospital.

 

B.            COMPENSATION PROVISIONS.

 

1.             Medical
Benefit Programs. 
PPG shall arrange and provide Contracted Services which are not PPG
Capitated Services to Medi-Cal HMO Members of HEALTH NET’ Benefit Programs
covered under this Addendum on a fee-for-service basis except for PPG Capitated
Services rendered to Medi-Cal HMO Members assigned to PPG under a Capitation
Compensation method. As compensation for providing such Contracted Services,
PPG shall be paid in accordance with the rates set forth in this Addendum. Such
compensation shall be paid within 45 working days of receipt of a complete and
accurate claim for Covered Services rendered to a Medi-Cal HMO Member.

 

2.             Capitation; PPG Capitated
Services.  HEALTH NET shall pay PPG the applicable
Capitation described in Exhibit 2  to
this Addendum for each Medi-Cal HMO Member entitled to receive PPG Capitated
Services from PPG during the month to which the Capitation applies by wire
transfer, on or before
the                        (           )
day following HEALTH NET’s receipt of payment for that month from the DHS.  Notwithstanding any provision in this
paragraph to the contrary, only one Capitation shall be paid by HEALTH NET for
both mother and newborn child during the child’s month of birth and the
following month

 

3.             Shared
Risk Program. 
For each Reconciliation Period, HEALTH NET will calculate Shared Risk
Claims and compare them to the corresponding Shared Risk Budget for the purpose
of determining whether PPG is entitled to a bonus payment.  In the event that Shared Risk Claims are
less than the Shared Risk Budget, HEALTH NET shall pay PPG the lesser of: (a)
*** of the differential between the Shared Risk Budget and the total Shared
Risk Claims; or (b) *** of the aggregate Capitation.  HEALTH NET will calculate the shared risk amount payable to PPG
ninety (90) days after the exhaustion of each Reconciliation Period.  Any amounts payable will be sent to PPG
within forty-five (45) days after said ninety (90) day claims runout
period.  Any Shared Risk Claims not paid
during the Reconciliation Period will be applied toward the next
reconciliation.

 

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

 

5.             Contracted
Services Reciprocity. 
When a Medi-Cal HMO Member not assigned to PPG under a Capitated
Compensation method receives services from PPG, then PPG shall accept
compensation based upon the rates

 

64

 

set forth in Addendum F.?

 

C.            GENERAL
PROVISIONS

 

1.             Provision of Covered Services.  PPG
shall arrange Covered Services for assigned Members.  For the purposes of this Addendum.  “Covered Services” means those health care services, supplies and
items set that are specified as being covered under the Medi-Cal
Agreement.  PPG shall arrange Covered
Services for Members, in accordance with the following, each of which is hereby
incorporated by reference as if set out in full herein:

 

1.1                                 The terms and conditions of this Addendum and
the Agreement.

 

1.2                                 The terms and conditions of the Medi-Cal
Agreement and the applicable Evidence of Coverage.

 

1.3                                 HEALTH NET’s Medi-Cal policies and procedures
and physician bulletins;

 

1.4                                 DHS Medi-Cal Managed Care Division (MMCD) Policy
Letters.

 

1.5                                 All laws applicable to PPG and HEALTH NET.

 

1.6                                 HEALTH NET’s Utilization Care Management
Program and Quality Improvement Program.

 

1.7                                 Standards requiring services to be provided in
the same manner, and with the same availability, as services are rendered to
other patients.

 

1.8                                 No less than the minimum clinical quality of
care and performance standards that are professionally recognized and/or
adopted, accepted or established by HEALTH NET.

 

2.             Subcontracting Under the
Agreement.  PPG shall not subcontract for the
performance of services under the Agreement without the prior written consent
of HEALTH NET.  Every such subcontract
shall provide that it is terminable with respect to Members by PPG upon HEALTH
NET’ request.  PPG shall furnish HEALTH
NET with copies of such subcontracts, and amendments thereto, within ten days
of execution.  Each such subcontracting
Physician shall meet HEALTH NET’ credentialing requirements, prior to the
subcontract becoming effective.  PPG
shall be solely responsible to pay any health care Physician permitted under
the subcontract, and shall hold, and ensure that health care Physicians hold,
HEALTH NET, Members and the State harmless from and against any and all claims
which may be made by such subcontracting Physicians in connection with services
rendered to Members under the subcontract. 
PPG shall maintain and make available to HEALTH NET, DHS, DHHS, DOC,
DOJ, and any other regulatory agency having jurisdiction over HEALTH NET,
copies of all PPG’s subcontracts under the Agreement and to ensure that all
such subcontracts are in writing and require that the subcontractor: (1) make
all applicable books and records available for inspection, examination or
copying by said entities; (2) retain such books and records for a term of at
least five years from the close of the fiscal year in which the subcontract is
in effect; and (3) maintain such books and records in a form maintained in
accordance with the general standards applicable to such book or record
keeping. [22 CCR § 53250(e)(3)]

 

3.             Preparation and Retention of  Records; Access to Records; Audits.  PPG
shall prepare and maintain medical and other books and records required by law
in a form maintained in accordance with the general standards applicable to
such book or record keeping.  PPG shall
maintain such financial, administrative and other records as may be necessary
for compliance by HEALTH NET with all applicable local, State and federal laws.  PPG shall retain such books and records and
all encounter data for a term of at least five years from the close of the

 

65

 

California State fiscal year in
which the Agreement is in effect.  PPG
shall make PPG’s books, records and encounter data pertaining to the goods and
services furnished under the terms of the Agreement, available for inspection,
examination or copying by HEALTH NET, DHS, the United States Department of
Health and Human Services (“DHHS”) the California Department of Corporations
(“DOC”), the United States Department of Justice (“DOJ”), and any other
regulatory agency having jurisdiction over HEALTH NET.  The records shall be available at PPG’s
place of business, or at such other mutually agreeable location in California.  When such entities request PPG’s records,
PPG shall produce copies of the requested records at no charge.  PPG shall permit HEALTH NET, and its
designated representatives, and designated representatives of local, State, and
federal regulatory agencies having jurisdiction over HEALTH NET, to conduct
site evaluations and inspections of PPG’s offices and service locations. [22
CCR § 53250(e)(1); W & I .§ 14452(c); Medi-Cal Agreement]

 

4.             Federal
Disclosure Form.  PPG
shall submit to HEALTH NET a completed Disclosure Form, attached to this Addendum,
for officers and other persons associated with PPG as required by California
Welfare and Institutions Code §
14452(a).  Please mail the completed
form to: Manager of Provider Contract Administration, 3400 Data Drive, Rancho
Cordova. CA 95670.

 

5.             Medi-Cal
HMO Member Education. 
PPG shall make health education materials and programs available to
Medi-Cal HMO Members on the same basis that it makes such materials and
programs available to the general public, and shall use its best efforts to
encourage Medi-Cal HMO Members to participate in such health education
programs. [Medi-Cal Agreement]

 

6.             Medi-Cal
HMO Members and State Held Harmless. PPG
agrees that in no event, including, but not limited to, non-payment by HEALTH
NET, the insolvency of HEALTH NET, or breach of the Agreement, shall PPG or a
subcontractor of Physician bill, charge, collect a deposit from, seek
compensation, remuneration, or reimbursement from, or have any recourse against
Members, the State of California, or persons other than HEALTH NET acting on  their behalf for services provided
pursuant to the Agreement.  PPG agrees:
(1) this provision shall survive the termination of the Agreement regardless of
the cause giving rise to termination and shall be construed to be for the
benefit of Medi-Cal HMO Members; and (2) this provision supersedes any oral or
written contrary agreement now existing or hereafter entered into between PPG
and Medi-Cal HMO 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
15 days after DHS has received written notice of such proposed change and has
approved such change. [22 CCR §
53250(e)(6)]

 

7.             Grievances
and Appeals. 
PPG shall resolve all grievances and appeals relating to the provision
of services to Medi-Cal HMO Members in accordance with the HEALTH NET Medi-Cal
grievance and appeal procedures.

 

8.             Relationship
of the Parties. 
PPG shall be solely responsible, without interference from HEALTH NET or
its agent, for providing PPG Capitated Services to Medi-Cal HMO Members, and
shall have the right to object to treating any individual who makes onerous the
relationship between PPG and Medi-Cal HMO Member.  In the event of a breakdown in such relationship, HEALTH NET
shall make reasonable efforts to assign the Medi-Cal HMO Member to another
Participating Provider.  If reassignment
is unsuccessful, a request may be filed with DHS to permit termination of services
to such Medi-Cal HMO Member.  Approval
from DHS must be obtained before PPG terminates services to such Medi-Cal HMO
Member.

 

9.             Governing
Law. The Agreement shall be governed by and construed and
enforced in accordance with all laws and contractual obligations incumbent upon
HEALTH NET.  PPG shall comply with all
applicable local, State, and federal laws, now or hereafter in effect, to the
extent that they directly or indirectly affect PPG or HEALTH NET, and bear upon
the subject matter of the Agreement. 
PPG shall comply with the provisions of the Medi-Cal Agreement, and
Chapters 3 and 4 of Subdivision 1 of Division 3 of Title 22 of the California
Code of Regulations.  In addition,
HEALTH NET is subject to the requirements of Chapter 2.2 of Division 2  of the California Health and Safety Code and
Subchapter 5.5 of Chapter 3 of Title 10 of the California Code of Regulations.
Any provision required to be in the Agreement by either of the above laws shall
bind the parties whether or not provided in the Agreement. [22 CCR §

 

66

 

53250(c)(2)]; W & I § 14452(a); Knox-Keene Act]

 

10.          Notice.  PPG
shall notify the DHS in the event this Agreement is amended or terminated.  Notice to DHS is considered given when
properly addressed and deposited with the United States Postal Service as first
class registered mail postage attached. [Knox-Keene Act and Medi-Cal Agreement]

 

11.          Reports.  PPG
shall provide HEALTH NET, within the time requested by HEALTH NET with all such
reports and information as HEALTH NET may require to allow to meet the
reporting requirements under the Medi-Cal Agreement or any applicable law. [22
CCR 53250(c)(5)]

 

12.          Confidentiality of Information.  Names
of persons receiving public social services are confidential and are to be
protected from unauthorized disclosure in accordance with Title 45, Code of
Federal Regulations, Section 205.50 and Section 14100.2 of the California
Welfare and Institutions Code and the regulations adopted thereunder.  For the purposes of this Agreement, all
information, records, data, and data elements collected and maintained for or
in connection with performance under this Agreement and pertaining to Medi-Cal
HMO Members shall be protected by PPG from unauthorized disclosure.  With respect to any identifiable information
concerning a Medi-Cal HMO Member under this Agreement that is obtained by PPG
or its subcontractors, PPG: (1) will not use any such information for any
purpose other than carrying out the express terms of this Agreement; (2) will
promptly transmit to HEALTH NET all requests for disclosure of such
information; (3) will not disclose, except as otherwise specifically permitted
by this Agreement, any such information to any party other than HEALTH NET
without HEALTH NET’s prior written authorization specifying that the
information is releasable under applicable law, and (4) will, at the expiration
or termination of this Agreement, return all such information to HEALTH NET or
maintain such information according to written procedures provided PPG by HEALTH
NET for this purpose.  PPG shall ensure
that its subcontractors comply with the provisions of this paragraph.

 

13.          Third Party Tort Liability.  PPG
shall make no claim for recovery for health care services rendered to a
Medi-Cal HMO Member when such recovery would result from an action involving
the tort liability of a third party or casualty liability insurance including,
workers’ compensation awards and uninsured motorist coverage.  Within five days of discovery, PPG shall
notify HEALTH NET of cases in which an action by the Medi-Cal HMO Member
involving the tort or workers’ compensation liability of  a third party could result in a recovery
by the Medi-Cal HMO Member.  PPG shall
promptly provide: (1) all information requested by HEALTH NET in connection with
the provision of health care services to a Medi-Cal HMO Member who may have an
action for recovery from any such third party; (2) copies of all requests by
subpo?na from attorneys, insurers or Medi-Cal HMO Members for copies of bills,
invoices or claims for health care services; and (3) copies of all documents
released as a result of such requests. 
PPG shall ensure that its subcontractors comply with the requirements of
this provision.

 

14.          Amendments.  When
required under Medi-Cal law, Amendments to the Agreement shall be submitted by
HEALTH NET to the DHS for prior approval at least 30 days before the effective
date of any proposed changes governing compensation, services or term.  Proposed changes, which are neither approved
nor disapproved by the Department, shall become effective by operation of law
30 days after the DHS has acknowledged receipt, or upon the date specified in
the amendment, whichever is later. 
Subcontracts between a prepaid health plan and a subcontractor shall be
public records on file with the DHS. [22 CCR §§ 53250(a), (c)(3), &  (e)(4); W & I § 14452(a)]

 

15.          Notice of Change in Availability or
Location of Covered Services.  HEALTH NET is obligated to
ensure Medi-Cal HMO Members are notified in writing of any changes in the
availability or location of Covered Services at least 30 days prior to the
effective date of such changes, or within 14 days prior to the change in cases
of unforeseeable circumstances.  Such
notifications must be approved by DHS prior to the release.  In order for HEALTH NET to meet this
requirement, PPG is obligated to notify HEALTH NET in writing of any changes in
the availability or location of Covered Services at least 40 days prior to the
effective date of such changes.

 

16.          Transfer of Care Upon Termination
of the Agreement.  PPG  shall,
pursuant to the requirements of the Medi-Cal Agreement, assist in the orderly
transfer of care of all Medi-Cal HMO Members under the care of

 

67

 

PPG in the event of the termination of the Agreement.

 

17.          Assignment
and Delegation. Assignment or delegation of the
Agreement shall be void unless prior written approval is obtained from the DHS
in those instances where prior approval by the DHS is required.  In addition, any assignment or delegation of
the Agreement by PPG shall be void unless prior written approval is obtained
from HEALTH NET.

 

18.          Local
Health Department Coordination. 
As more fully set out in the Medi-Cal Agreement, HEALTH NET or a contracting Medi-Cal plan has (or will) entered into
agreements for specified public health services with certain county health
departments (Los Angeles, Fresno, Tularc Riverside, San Bernardino San Diego,
and Sacramento counties).  The public health
agreements specify the scope and responsibilities of the local health
departments and HEALTH NET, billing and reimbursements, reporting
responsibilities, and medical record management to ensure coordinated health
care services.  The public health services
specified under the agreements are as follows:

 

18.1                        Family
planning services.

 

18.2                        Sexually
transmitted disease (“STD”) services diagnosis and treatment of disease episode
of the following STDs: syphilis, gonorrhea, chlamydia, herpes simplex,
chancroid, trichomoniasis, human papilloma virus, non-gonococeal urethritis,
lymphogranuloma venereum and granuloma inguinale.

 

18.3                        Confidential
HIV testing and counseling.

 

18.4                        Immunizations.

 

18.5                        Refugee
assessments

 

18.6                        California
Children Services.

 

18.7                        Maternal
and Child Health.

 

18.8                        Child Health
and Disability Prevention Program. 

 

18.9                        Tuberculosis
Direct Observed Therapy.

 

18.10                 Women,
Infants, and Children Supplemental Food Program.

 

18.11                 Population
based Prevention Programs: collaborate in local health department community
based prevention programs.

 

PPG shall, in accordance with the terms
and conditions of the public health agreements with the local health
departments and HEALTH NET’s related policies and procedures, be responsible
for the coordination and arrangement of the public health services for its
assigned Members.  The services
specified in Sections 18.1 through 18.4 above require reimbursement to the
applicable local health department.  The
services specified in Sections 18.5 through 18.11 above do not require
reimbursement to the applicable local health department [Medi-Cal Agreement]

 

19.          Cultural
and Linguistic Services. 
PPG shall, in accordance with the requirements of the Medi Cal Agreement
and HEALTH NET’s cultural and linguistic services policies, arrange at its sole
cost interpreter services for Members either through telephone language
services or interpreters.

 

20.          Surcharges
and No Copayments. 
PPG shall not charge a Member any fee, surcharge or Copayment for health
care services rendered pursuant to the Agreement.  In addition, PPG shall not collect a sales,

 

68

 

use or other applicable tax from
Members for the sale or delivery of medical services.  If HEALTH NET receives notice of any additional charge, PPG shall
fully cooperate with HEALTH NET to investigate such allegations and shall
promptly refund any payment deemed improper by HEALTH NET to the party who made
the payment.  [Knox-Keene Act and
Medi-Cal Agreement]

 

21.          EPSDT
Supplemental Services.  PPG
shall arrange for Early and Periodic Screening, Diagnosis and Treatment
Supplemental Services for Members under the age of 21 in accordance with the
requirements of the Medi-Cal
Agreement.

 

22.          CHDP
(Children’s Health and Disability Prevention) Program.  Health Net requires that all providers of
CHDP services be certified by the CHDP Program and adhere to the CHDP Program
requirements.

 

23.          CCS
(California Children’s Services).  PPG is
responsible for timely referral of children with potential CCS eligible
conditions.  Failure to appropriately
refer will result in PPG assuming financial responsibility for any related
charges.

 

24.          CPSP  (Comprehensive Perinatal Services Program).  PPG is required to develop formal
agreements with DHS-certified CPSP providers to ensure that all pregnant women
have access to care in accordance with DHS requirements.

 

69

 

ADDENDUM F.1

 

FEE-FOR-SERVICE COMPENSATION SCHEDULE

 

UNASSIGNED MEDI-CAL HMO MEMBERS

 

HEALTH NET will reimburse PPG for
medically necessary covered contracted services for the lesser of: a) PPG’s
billed charges; or b) *** of the State of California Medi-Cal Fee Schedule rates in effect at
the time of service.

 

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

70

 

ADDENDUM F.2

 

CAPITATION COMPENSATION SCHEDULE

 

MEDI-CAL BENEFIT
PROGRAMS:

 

PPG shall accept the following Medi-Cal Capitation Payments as payment
in full from HEALTH NET for PPG Capitated Services provided to Medi-Cal HMO Members assigned to PPG:

 

$              *** Per Medi-Cal HMO Member Per Month (“PMPM”)

 

Medi-Cal Primary
Hospital:  DO NOT ACTIVATE UNTIL A
DUAL RISK HOSPITAL CONTRACT IS COMPLETE.

 

PPG SERVICE
AREA: 30 miles of PPG principle place of business.

 

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

71

 

ADDENDUM F.3

 

SHARED RISK PROGRAM DISTRIBUTION MATRIX

 

$  .00 Per Medi-Cal HMO Member Per Month

 

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

72

 

ADDENDUM F.4

DIVISION OF FINANCIAL RESPONSIBILITY

MATRIX OF HEALTH NET AND PPG RISK SERVICES

MEDI-CAL BENEFIT PROGRAM

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  ABORTION
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ABORTION
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ACUPUNCTURE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  TREATMENT AND SERUM

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN
  TESTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE
  (Air or Ground) In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE
  (Air or Ground) Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMNIOCENTESIS
  TESTING - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMNIOCENTESIS
  TESTING - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIA
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIA
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANGIOGRAPHY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANGIOPLASTY
  (PTCA)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  APNEA
  MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ARTIFICIAL
  EYES (Prosthetic)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ARTIFICIAL
  INSEMINATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ARTIFICIAL
  LIMBS (Prosthetic)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AUTOLOGOUS
  BLOOD DONATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD
  AND BLOOD PRODUCTS from a Blood Bank or provided in
  Hospital

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD
  TRANSFUSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BURN
  CARE - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BURN
  CARE - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CALIFORNIA
  CHILDREN’S SERVICES (CCS)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CARDIAC
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL
  DEPENDENCY - Acute Inpatient Overdose Treatment - Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL
  DEPENDENCY - Acute Inpatient Overdose Treatment -
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL
  DEPENDENCY - Detoxification and Rehabilitation - Inpatient
  and Outpatient Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

73

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  CHEMOTHERAPY
  ADMINISTRATION - Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY
  ADMINISTRATION - Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY
  ADMINISTRATION - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY
  DRUGS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHILD
  HEALTH AND DISABILITY PREVENTION SERVICES (CHDP)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CIRCUMCISION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CLINIC
  VISITS - Non-urgent Outpatient or Non-hospital -
  Professional and Facility Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY
  SUPPLIES - In conjunction with Home Health

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY
  SUPPLIES - Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY
  SUPPLIES - Outpatient Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC
  SURGERY - Medically Necessary - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC
  SURGERY - Medically Necessary - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL
  CARE VISITS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL
  SERVICES - Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL
  SERVICES - Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL
  SERVICES - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC
  TESTING - Outpatient &
  Office - Facility & Professional Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIALYSIS
  -Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIALYSIS
  - Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIALYSIS
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DRUGS/MEDICATIONS
  - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DRUGS/MEDICATIONS
  - Outpatient Injectibles

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DRUGS/MEDICATIONS
  - Outpatient Non-Injectibles

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DRUGS/MEDICATIONS
  - Outpatient, in lieu of Hospitalization

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DRUGS/MEDICATIONS
  - Take Home Medications

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

74

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  DURABLE
  MEDICAL EQUIPMENT (DME) - Inpatient, Outpatient Dispensing,
  and Surgically Implanted 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ELECTRO
  CONVULSIVE THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - In Area - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS - In Area - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM ADMISSIONS - Out of Area - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM ADMISSIONS - Out of Area - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - In Area - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - In Area - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - Out of Area - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ROOM VISITS - Out of Area - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMPLOYMENT
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ENDOSCOPIC
  STUDIES - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ENDOSCOPIC
  STUDIES - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ENTERAL
  THERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EPSDT
  “BASIC” SERVICES (e.g. CHDP Health Assessments)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (e)
  EPSDT SUPPLEMENTAL SERVICES when medically necessary,
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (e)
  EPSDT SUPPLEMENTAL SERVICES when medically necessary, Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (e)
  EPSDT SUPPLEMENTAL SERVICES (e.g. private duty nursing)
  when medically necessary, Ancillary Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXPERIMENTAL
  PROCEDURES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE FACILITY - Long Term (I) Hospitalization - Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE FACILITY Long Term (I) Hospitalization - Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE FACILITY - Short Term (I) Hospitalization - Facility
  Component -includes Ancillary Services while Hospitalized

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE FACILITY - Short Term (I) Hospitalization -
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FAMILY
  PLANNING - In Plan - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

75

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  FAMILY
  PLANNING - In Plan - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FAMILY
  PLANNING - Self-Referral to Out of Plan PPG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FETAL
  MONITORING - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  FETAL
  MONITORING - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GENETIC
  TESTING - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEALTH
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEALTH
  EVALUATIONS/PHYSICALS (Adult)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING
  SCREENING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEART
  CATHETERIZATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS
  B VACCINE - In Plan PPG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS
  B VACCINE - Self Referral to Out of Plan PPG

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HIV
  TESTING & COUNSELING - In Plan or County Health
  Department

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  HEALTH - includes Nursing Visits, IV Therapy Services and
  Medications, other Therapies, Supplies and Equipment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME
  VISITS by a Physician

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE
  CARE - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE
  CARE - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL
  BASED PHYSICIANS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITALIZATION
  - In Area and Non-emergency Out of Area - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITALIZATION
  - In Area and Non-emergency Out of Area - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IV
  THERAPY - Hospital Setting

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMEDIATE
  CARE SERVICES - In Area - Professional and Facility
  Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMEDIATE
  CARE SERVICES - Out of Area Professional and Facility Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS
  - Pediatric and Adult - In Plan Provider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS
  - Pediatric and Adult-Self-Referral to Out of Plan Provider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMPLANTS,
  SURGICAL

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INDIAN
  HEALTH CLINIC SERVICES 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFERTILITY
  TESTING & TREATMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLE
  MEDICATIONS - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLE
  MEDICATIONS - Outpatient (except Home Health)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

76

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  LABORATORY
  TESTS - Inpatient - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LABORATORY
  TESTS - Inpatient - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LABORATORY
  TESTS - Outpatient and Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LOCAL
  EDUCATION AGENCY (LEA) ASSESSMENT SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LOCAL
  EDUCATION AGENCY (LEA) pursuant to Individualized Education
  Plan/Individualized Family Service Plan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MAMMOGRAPHY
  - Facility and Professional Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES - 60 days Post-Partum care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES - Deliveries - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES - Deliveries - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES - Non-Deliveries - Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES -
  Non-Deliveries - Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY/OBSTETRICAL
  SERVICES - Non-Deliveries - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  SUPPLIES - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  SUPPLIES - Outpatient and Office 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  TRANSPORTATION - Emergency

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  TRANSPORTATION - Non- Emergency

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH - Inpatient & Outpatient - Facility and
  Professional Components

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  NUCLEAR
  MEDICINE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  NURSE
  MIDWIVES- In or Out of Plan

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  NURSERY
  - Routine through Neonatal - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  NURSERY
  - Routine through Neonatal - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  NUTRITION/DIET
  COUNSELING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OBSTETRICAL
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE
  VISIT SUPPLIES, CASTS, SPLINTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE
  VISITS - PCP and Specialist

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

77

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  ORGAN
  TRANSPLANTATION (when a Mainstream Benefit) -Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ORGAN
  TRANSPLANTATION (when a Mainstream Benefit) - Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PAIN
  MANAGEMENT - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  SERVICES - Inpatient - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  SERVICES - Inpatient - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  SERVICES - Outpatient and Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PEDIATRIC
  NEWBORN SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PHYSICAL
  THERAPY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PHYSICAL
  THERAPY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PHYSICIAN
  VISITS - Inpatient - Outpatient - 5NF, Office, Patient’s
  Home

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PODIATRY
  SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRAYER
  AND SPIRITUAL HEALING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE-ADMISSION
  DIAGNOSTIC TESTING - Facility and Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE-EXISTING
  PREGNANCY - Inpatient - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE-EXISTING
  PREGNANCY - Outpatient - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE-EXISTING
  PREGNANCY - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PREGNANCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETICS/ORTHOTICS
  - Inpatient and Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETICS/ORTHOTICS
  - Outpatient Dispensing

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIATION
  THERAPY - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIATION
  THERAPY  - Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Office includes Supplies and Medications

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Outpatient Facility Component, includes Supplies and Medications

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RECONSTRUCTIVE
  SURGERY - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RECONSTRUCTIVE
  SURGERY - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  REHABILITATION
  - Inpatient - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

78

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  REHABILITATION
  - Inpatient - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  REHABILITATION
  - Outpatient - Facility and Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  REHABILITATION
  - Short Term Outpatient P/T. O/T. Speech Therapy

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RESPIRATORY
  THERAPY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RESPIRATORY
  THERAPY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ROUTINE
  PHYSICAL EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SEXUALLY
  TRANSMITTED DISEASES SERVICES - In Plan Provider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SEXUALLY
  TRANSMITTED DISEASES SERVICES - Self Referral to Out of
  Plan Provider

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SKILLED
  NURSING FACILITY - Facility Component - includes Ancillary
  Services while Hospitalized

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (1)
  SKILLED NURSING FACILITY - Long Term Hospitalization-
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (1)
  SKILLED NURSING FACILITY - Long Term Hospitalization - Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SKILLED
  NURSING FACILITY - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH
  AND HEARING EXAMS, includes Speech Pathology Services

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPIRITUAL
  HEALING AND PRAYER

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  STERILIZATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Physician’s Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Surgery Center or Hospital - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGICAL
  SUPPLIES - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGICAL
  SUPPLIES - Outpatient & Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TMJ
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TMJ
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TUBERCULOSIS
  - Direct Observed Treatment

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ULTRASOUND

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE SERVICES - In Area -Facility and Professional Combined
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT
  CARE SERVICES - Out of Area - Facility and Professional
  Combined Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION
  CARE - Contact Lenses. Frames and Lenses, and Eye Exams for
  Refractive Diagnoses

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

79

 

	
   

  	
   

  	
  PPG/GROUP RISK

  SERVICES

  	
   

  	
  HEALTH NET RISK

  SERVICES

  	
   

  	
  SHARED/HOSPITAL

  RISK SERVICES

  	
   

  
	
  VISION
  CARE - Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE - Professional Component (excluding Refractions)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  WELL
  BABY EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

(e)     EPSDT Supplemental Services related to Alcohol and Drug Treatment,
Mental Health, and Dental Services are not covered under
this Agreement.

(1)     Long Term Care: Services
beyond the month of Admission plus one month are not covered under this
Agreement.

 

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

 

80

 

ADDENDUM F.5

 

DISCLOSURE
FORM

(Required by
California Welfare and Institutions Code Section 14452)

 

(Name of PPG)

 

	
  The undersigned hereby certifies that the following
  information regarding:

  
	
   

  
	
   

  
	
  (the “Organization”) is true and Correct as of the
  date set forth below:

  
	
   

  
	
  Officers/Directors/General Partners:

  
	
   

  
	
   

  
	
   

  
	
   

  
	
  Co-Owner(s):

  
	
   

  
	
   

  
	
   

  
	
  Stockholders owning more than ten percent of the
  stock of the Organization:

  
	
   

  
	
   

  
	
   

  
	
   

  
	
  Major creditors holding more than five percent of
  Organization’s debt:

  
	
   

  
	
   

  
	
   

  
	
   

  
	
  Form of Organization (Corporation, Partnership.  Sole Proprietorship, Individual, etc.):

  
	
   

  
	
   

  
	
   

  
	
   

  
	
  If not already disclosed above, is Organization,
  either directly or indirectly related to or affiliated with the Contracting
  Health Plan? Please explain:

  
	
   

  
	
   

  
	
   

  
	
   

  
	
   

  
	
  Dated:

  	
   

  	
   

  	
  Signature:

  	
   

  
	
   

  	
   

  
	
   

  	
  Name:

  	
   

  
	
   

  	
  (Please type or
  print)

  
	
   

  	
   

  
	
   

  	
  Title:

  	
   

  
	
   

  	
  (Please type or
  print)

  
							

 

81

 

ADDENDUM G

 

CHAMPUS/TRICARE AND OTHER GOVERNMENT BENEFIT PROGRAMS

 

NOT APPLICABLE

 

82

 

ADDENDUM H

 

OCCUPATIONALLY ILL/INJURED OR WORKERS’ COMPENSATION BENEFIT

PROGRAMS

 

NOT APPLICABLE

 

83

 

ADDENDUM C. 1

 

SUPPLEMENTAL BENEFITS COSTS

2001

 

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

 

	
  County

  	
   

  	
  Jan - Feb
  2001 *

  Percent

  	
   

  	
  Mar - Dec
  2001

  Percent

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Alameda

  	
   

  	
  5.41

  	
  %

  	
  5.35

  	
  %

  
	
  Contra Costa

  	
   

  	
  6.71

  	
  %

  	
  6.64

  	
  %

  
	
  El Dorado

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  13.76

  	
  %

  	
  13.61

  	
  %

  
	
  Los Angeles

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Marin

  	
   

  	
  2.53

  	
  %

  	
  2.50

  	
  %

  
	
  Orange

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Placer

  	
   

  	
  3.53

  	
  %

  	
  3.49

  	
  %

  
	
  Riverside

  	
   

  	
  4.29

  	
  %

  	
  4.24

  	
  %

  
	
  Sacramento

  	
   

  	
  3.58

  	
  %

  	
  3.54

  	
  %

  
	
  San Bernardino

  	
   

  	
  4.25

  	
  %

  	
  4.20

  	
  %

  
	
  San Diego

  	
   

  	
  8.26

  	
  %

  	
  8.16

  	
  %

  
	
  San Francisco

  	
   

  	
  6.13

  	
  %

  	
  6.06

  	
  %

  
	
  San Joaquin

  	
   

  	
  3.94

  	
  %

  	
  3.88

  	
  %

  
	
  San Mateo

  	
   

  	
  2.69

  	
  %

  	
  2.66

  	
  %

  
	
  Santa Barbara

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Santa Clara

  	
   

  	
  2.97

  	
  %

  	
  2.93

  	
  %

  
	
  Stanislaus

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Yolo

  	
   

  	
  3.49

  	
  %

  	
  3.39

  	
  %

  

 

* Previously released.  Updated
to reflect changes due to the Benefit Improvement and Protection Act of 2000.

 

 

ADDENDUM C.2

 

PHARMACY
SHARED RISK BUDGETS

2001

 

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

 

	
  County

  	
   

  	
  Jan - Feb 2001 *

  Percent

  	
   

  	
  Mar - Dec
  2001

  Percent

  	
   

  
	
  Alameda

  	
   

  	
  5.41

  	
  %

  	
  5.35

  	
  %

  
	
  Contra Costa

  	
   

  	
  6.28

  	
  %

  	
  6.22

  	
  %

  
	
  El Dorado

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  12.54

  	
  %

  	
  12.40

  	
  %

  
	
  Los Angeles

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Marin

  	
   

  	
  2.08

  	
  %

  	
  2.06

  	
  %

  
	
  Orange

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Placer

  	
   

  	
  3.04

  	
  %

  	
  3.00

  	
  %

  
	
  Riverside

  	
   

  	
  3.77

  	
  %

  	
  3.72

  	
  %

  
	
  Sacramento

  	
   

  	
  3.13

  	
  %

  	
  3.09

  	
  %

  
	
  San Bernardino

  	
   

  	
  3.73

  	
  %

  	
  3.68

  	
  %

  
	
  San Diego

  	
   

  	
  7.77

  	
  %

  	
  7.68

  	
  %

  
	
  San Francisco

  	
   

  	
  5.70

  	
  %

  	
  5.64

  	
  %

  
	
  San Joaquin

  	
   

  	
  3.45

  	
  %

  	
  3.39

  	
  %

  
	
  San Mateo

  	
   

  	
  2.23

  	
  %

  	
  2.21

  	
  %

  
	
  Santa Barbara

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Santa Clara

  	
   

  	
  2.49

  	
  %

  	
  2.46

  	
  %

  
	
  Stanislaus

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Yolo

  	
   

  	
  2.98

  	
  %

  	
  2.89

  	
  %

  

 

* Previously released.  Updated
to reflect changes due to the Benefit Improvement and Protection Act of 2000Exhibit 10.93

 

Health Net
Medicare+Choice (M+C)

Addendum to Provider Agreement

 

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

 

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

 

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

 

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

 

NOW, THEREFORE, the parties agree as follows:

 

I.
DEFINITIONS

 

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

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

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

 

II.
ACCESS:  RECORDS AND FACILITIES

 

Provider agrees:

 

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

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

 

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

 

1

 

III.
ACCESS:  BENEFITS & COVERAGE

 

Provider agrees:

 

3.1.                            To not
discriminate based on health status.

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

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

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

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

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

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

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

 

IV.
MEMBER PROTECTIONS

 

Provider agrees:

 

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

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

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

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

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

 

2

 

V.
DELEGATION

 

Provider agrees:

 

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

Manual.

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

 

VI. PAYMENT AND FEDERAL FUNDS

 

Provider agrees:

 

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

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

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

 

VII.
REPORTING AND DISCLOSURE

 

Provider agrees:

 

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

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

 

VIII.
QUALITY ASSURANCE / QUALITY IMPROVEMENT

 

Provider Agrees:

 

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

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

 

3

 

IX.
COMPLIANCE

 

Provider agrees:

 

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

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

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

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

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

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

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

 

X.
PRIVATE FEE FOR SERVICE

 

Provider agrees:

 

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

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

 

XI.
ADOPTION OF MEDICARE RISK PROGRAM CONTRACT REQUIREMENTS

 

Provider agrees:

 

11.1                         That all
contracts must be signed and dated.

11.2                         To serve
Members during the term of this Addendum.

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

 

4

 

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

 

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

 

 

	
  Professional Care IPA

  	
  Health Net

  
	
   

  	
   

  
	
   

  	
   

  
	
  By:

  	
  /s/ Ed Rotan

  	
   

  	
  By:

  	
  /s/ Christopher Ciano

  
	
   

  	
   

  
	
  Name:

  	
  Ed Rotan

  	
   

  	
  Name

  	
  Christopher Ciano

  
	
   

  	
   

  
	
  Title:

  	
  President

  	
   

  	
  Title:

  	
  Senior Vice President and

  General Manager

  
	
   

  	
   

  
	
  Date:

  	
  2-7-00

  	
   

  	
  Date:

  	
  3-7-00

  

 

5

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