Document:

Exhibit
10.137

 

	
  BLUE SHIELD OF CALIFORNIA

  	
  DEC [ILLEGIBLE] 1995

  
	
  HMO

  	
  PROSPECT MEDICAL GROUP

  
	
  IPA AGREEMENT

  	
   

  

 

This Agreement is made and entered into as of November 1, 1995 between California
Physicians’ Service, dba Blue Shield of California, a California nonprofit
corporation, licensed as a health care service plan, and Prospect Medical Group, Inc., referred to
herein as IPA, a legal entity comprised of individuals appropriately licensed
as providers of health care services in the State of California.

 

RECITALS

 

A.                                   Blue
Shield of California desires to make a comprehensive prepaid health maintenance
organization plan (BSC-HMO) available to its Members who select BSC-HMO.

 

B.                                     Blue
Shield of California desires to contract with IPA, an independent practice association
of physicians and other health care providers which desires to enter into a
service agreement with BSC-HMO to arrange for the provision of certain Benefits
in accordance with this Agreement and the BSC-HMO Health Services Contract.

 

C.                                     IPA is
eligible to be an HMO IPA as described in Paragraph B above.

 

D.                                    IPA
Physicians and Blue Shield of California currently have an agreement, entitled
“Physician Member Application and Agreement” under which individual IPA
Physicians have agreed to provide professional services to Blue Shield
Members.  That agreement shall remain in
effect for all Blue Shield Members other than BSC-HMO Members.  This BSC-HMO Agreement is not intended to
amend or otherwise effect the “Physician Member Application and Agreement” in any
manner.

 

I. DEFINITIONS

 

1.1                                 Terms
used throughout this Agreement are defined as fallows:

 

Agreement Year - a
period beginning at 12:01 a.m. on effective date of Agreement and ending at
12:01 a.m. the same date in the following year.

 

Authorization - the
procedure for obtaining the Plan’s prior approval for all services provided to
Members under the terms of their Health Services Contract other than Primary
Care Physician and Emergency services.

 

Benefits -
those health care services which a Member is entitled to receive pursuant to
the terms of their Health Services Contract.

 

Calendar Year - a
period beginning at 12:01 a.m. on January 1 and ending at 12:01 a.m. January 1
of the next year.

 

Capitated Services - all
Benefits set forth in Schedule A when covered in the Member’s Health Services
Contract.

 

Capitation Fees - the
amount prepaid by BSC-HMO to IPA in exchange for IPA’s obligation to render the
Benefits set forth in Schedule A.

 

Contractholder - that
entity to which the Health Services Contract is issued.

 

Copayment - an
amount which a Member is required to pay for certain Benefits.

 

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

 

 

Dependent -

 

1.               a
Subscriber’s spouse who is not covered for Benefits as a Subscriber, is not
legally separated from the Subscriber, and is not a member of the Armed Forces;
and who has been enrolled and accepted by Plan as a dependent and has
maintained membership in accord with the Health Services Contract; or

 

2.               a
Subscriber’s unmarried child (including stepchild or legally adopted child) who
is primarily dependent upon the Subscriber for support and maintenance, is less
than 23 years of age, is not covered for Benefits as a Subscriber and is not a
member of the Armed Forces; and who has been enrolled and accepted by Plan as a
dependent and has maintained membership in accord with the Health Services
Contract.

 

Eligibility List - the
list of Members, determined by BSC-HMO to be eligible for Benefits, and for whom
Plan Providers are compensated.

 

Emergency -
medical condition means a medical condition manifesting itself by acute
symptoms of sufficient severity (including severe pain) such that the absence
of immediate medical attention could reasonably be expected to result in any of
the following:

 

(a)          placing the Member’s health in
serious jeopardy;

 

(b)         serious impairment to bodily
functions;

 

(c)          serious dysfunction of any bodily
organ or part.

 

Health Services
Contract (Contract) - the contract issued by Blue Shield to the
Contractholder that establishes the Benefits Members are entitled to receive
from the Plan.

 

Hospital -
either 1,2, 3, or 4 below:

 

1.               a
licensed and accredited health facility which is primarily engaged in providing
for compensation, medical, diagnostic and surgical facilities for the care and
treatment of sick and injured patients on an Inpatient basis, and which
provides such facilities under the supervision of a staff of Physicians and 24
hour a day nursing service by registered nurses.  A facility which is principally a rest home, nursing home or home
for the aged is not included; or

 

2.               a
psychiatric hospital licensed as a health facility and accredited by the Joint
Commission; or

 

3.               a
licensed health facility operated primarily for the treatment of alcoholism
and/or drug abuse accredited by the Joint Commission; or

 

4.               a
“psychiatric health facility” as defined in Section 1250.2 of the Health and
Safety Code.

 

Inpatient - a
patient admitted to a Hospital as a registered bed patient and who requires the
acute bed-patient (overnight) setting.

 

Institutional
Services - all Benefits provided that are not capitated or
out-of-area services.

 

IPA Provider - IPA
Physician or other provider appropriately licensed to provide health care
services who contracts with IPA to provide Benefits to Plan Members in
accordance with their Health Services Contract.

 

Medically
Necessary - Benefits are provided only for services which are medically
necessary.  Services which are medically
necessary include those which have been established as safe and effective and
are furnished in accordance with generally accepted professional standards to
treat an illness or injury, and which, as determined by Blue Shield, are

 

2

 

1.               consistent
with Blue Shield medical policy; and

 

2.               consistent
with the symptoms or diagnosis; and

 

3.               not
furnished primarily for the convenience of the patient, the attending Physician
or other provider; and

 

4.               furnished
at the most appropriate level which can be provided safely and effectively to
the patient.

 

Blue Shield reserves the right to
review all services to determine whether they are medically necessary.

 

Member -
either a Subscriber or a Dependent.

 

Open Enrollment Period - that
period of time set forth in the Health Services Contract during which eligible
individuals and their Dependents may enroll in the Plan.

 

Outpatient - an
individual receiving Benefits under the direction of a Plan Provider, but not
as an Inpatient.

 

Physician - an
individual licensed to engage in the practice of medicine (M.D.) or osteopathy
(D.O.).

 

Plan - the
Blue Shield of California Health Maintenance Organization Health Plan
(BSC-HMO).

 

Plan Hospital - a
Hospital licensed under applicable state law, contracting with Blue Shield
specifically to provide Plan Benefits to Members under the Plan.

 

Plan Provider - a
provider who has an agreement with Blue Shield to provide Plan Benefits to
Members.

 

Primary Care
Physician (PCP) - a general practitioner, board-certified or eligible
family practitioner, internist, obstetrician-gynecologist or pediatrician who
has contracted with Blue Shield through IPA to provide primary care Benefits to
Members and to refer, authorize, supervise and coordinate the provision of all
Benefits to Members in accordance with their Health Services Contract.

 

Service Area - that
geographic area served by the Plan as set forth in Schedule B.

 

Specialist - a
board-certified or eligible Physician, other than a PCP, who has an agreement
with Blue Shield to provide Services to Members on referral by a PCP.

 

Subscriber - an
individual who satisfies the eligibility requirements of the Health Services
Contract, who is enrolled and accepted by the Plan.

 

Surcharge - an
additional fee which is charged to a Member for a Benefit which is not provided
for in the Health Services Contract or disclosed in the Evidence of Coverage
(or the disclosure form used as the Evidence of Coverage).

 

II.  IPA OBLIGATIONS

 

2.1                                 Benefits.  IPA shall provide or arrange for all
Capitated Services described in Schedule A, subject to the Benefits covered in
the Member’s Health Services Contract. 
Further, IPA and/or IPA Providers shall make available to BSC-HMO
Members, at no charge, those health education programs routinely provided by
IPA and/or IPA Providers.

 

2.2                                 Availability.  IPA shall ensure that Benefits are readily
available during regular business hours and that emergency services are
available twenty-four (24) hours per day, seven (7) days per week, including
holidays.  IPA shall provide such
services in the same manner, in accordance with the same standards, and within
the same time availability as such services are provided to other patients, and
without regard to the degree or frequency of utilization of such Benefits by
Member.

 

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2.3                                 Standard
of Care.  IPA shall comply
with all applicable federal and state laws, licensing requirements and
professional standards and shall provide Benefits in accordance with generally accepted
medical and surgical practices and standards prevailing in the applicable
professional community at the time of treatment.  In addition, IPA and IPA Providers shall comply with the
professional and technical standards adopted by the BSC-HMO quality and
utilization management program set forth in the Provider Manual.

 

2.4                                 IPA
Provider Licensure and Medical Staff Requirements.  IPA warrants and represents as a material
term of this Agreement that all IPA Providers, as applicable, are and will
continue to be, as long as this Agreement remains in effect, the holders of
currently valid, unrestricted licenses to practice in the State of California,
and further, that IPA Physicians are members in “good standing” on the medical
staff of at least one Plan Hospital. 
IPA agrees to admit Members only to such Plan Hospital(s) unless BSC-HMO
agrees that circumstances require otherwise.

 

2.5                                 Capacity.  Each Member shall select a PCP in accordance
with the procedures set forth in the Health Services Contract and IPA shall
cooperate with BSC-HMO to assist Members in selecting a PCP. IPA shall at all
times maintain a sufficient number of PCPs to guarantee a patient load per
Physician ratio of no more than 1,200 patients enrolled per full-time
equivalent PCP.  All PCPs shall be IPA
Physicians.  IPA agrees that BSC-HMO
shall have no obligation to guarantee any minimum number of Members to IPA and
that each PCP bound by the terms of this Agreement shall accept all patients
enrolling as BSC-HMO Members.

 

2.6                                 Blue
Shield Physician Members. 
As a condition precedent to this Agreement, IPA Physicians must be Blue
Shield Physician Members.  IPA
Physicians agree to remain Blue Shield Physician Members throughout the term of
this Agreement.

 

2.7                                 Institutional
Services and Admissions.  
IPA agrees to comply with BSC-HMO service authorization procedures as
set forth in the Provider Manual.

 

2.8                                 Capitated
Services Referrals.   In providing or
arranging for the Medically Necessary Benefits listed in Schedule A, IPA shall
limit referrals of Members to IPA Providers or employees as outlined below:

 

(a)          Referral
Specialists.  IPA shall maintain
contracts in force with referral specialists in the specialty areas outlined in
the Provider Manual.  All contracting
specialists must be in compliance with Paragraph 2.4 herein.

 

(b)         Nursing
and Other Ancillary Health Care Personnel. 
IPA Providers, as appropriate, must provide or contract for qualified
nursing and other personnel in sufficient number to serve all BSC-HMO Members.  All allied health care personnel must be
appropriately qualified, certified, and/or licensed.

 

(c)          Laboratory,
Imaging and Other Diagnostic Services. 
IPA or IPA Providers, as applicable, must operate or contract with
readily accessible facilities that are under the supervision of an
appropriately board-certified or eligible Physician.  Technical supervision must be by an appropriately certified
technician.  Equipment must be
maintained in compliance with all applicable state and federal laws.

 

IPA agrees to comply with the
BSC-HMO Service Authorization procedures set forth in the Provider Manual.  In the event an IPA Provider must refer to a
provider who is not a Plan Provider or IPA contractor, IPA shall obtain
BSC-HMO’s approval prior to such referral.

 

2.9                                 IPA
Provider Contracts.  IPA shall require
that all IPA Providers comply with the applicable terms of this Agreement,
including, but not limited to, the following:

 

(a)          provide
Benefits in accordance with generally accepted medical and surgical practices
and standards prevailing in the applicable professional community at the time
of treatment; and

 

(b)         provide
services to Members upon authorized referral from IPA; and

 

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(c)          comply
with all applicable federal and state laws including but not limited to the
provisions set forth in Article VI of this Agreement; and

 

(d)         accept
payment from IPA as payment in full for services rendered to Members, except
for Copayments, and must agree not to seek from the Member any Surcharge or
other additional payment not provided for in the Health Services Contract
regardless of whether or not payment is received from IPA.  Members shall not be liable to contracting
provider for any sums owed to provider by IPA; and

 

(e)          not
bill or collect from a Member any charges in connection with health care
services even though those services are not Benefits, unless contractor has
obtained an executed Acknowledgment of Financial Responsibility Form from the
Member or the Member’s legal representative prior to the time that such
services are provided to the Member; and

 

(f)            provide
Institutional Services only with the Authorization of IPA and BSC-HMO, as
applicable; and

 

(g)         maintain
adequate professional liability insurance through an insurer acceptable to
BSC-HMO and provide evidence of such coverage to BSC-HMO upon request; and

 

(h)         comply
with, and accept as final, the decisions of the BSC-HMO quality and utilization
management program; and

 

(i)             follow
the procedures established by BSC-HMO for verifying eligibility of Members and
authorizing Benefits; and

 

(j)             provide
and maintain sufficient facilities, equipment, personnel and services within
the Service Area in order to provide specified Benefits to Members; and

 

(k)          continue
to provide Benefits to Members under the same terms and conditions as agreed to
by IPA under Paragraph 8.4 of this Agreement.

 

The standard IPA contract with
providers shall be prepared or arranged in a manner which permits confidential
treatment of provider payment without concealment or misunderstanding of other
terms and provisions of the contract and shall contain all of the above
obligations and prohibitions.  The
standard IPA contract between IPA and its contracting providers is set forth in
Schedule G.  IPA shall provide copies of
the executed signature page of each such contract to BSC-HMO.

 

2.10                           Reciprocity.  IPA shall participate in the statewide
BSC-HMO health services delivery network and offer reciprocal agreements to
other Plan Providers.  IPA Providers
also agree to provide services to Members in the Blue Cross/Blue Shield
national HMO network (HMO-USA) as set forth in the Provider Manual.  Services rendered under the provisions of
this paragraph shall be paid as set forth in Paragraph IV of this Agreement.

 

2.11                           Facilities
and Equipment.  IPA Providers
shall provide and maintain facilities and equipment which are of adequate
capacity, clean, safe, readily accessible to Members and, where appropriate,
properly licensed and/or registered.

 

2.12                           Administrative
Services.  IPA shall perform
or contract for all services incident to the administration of IPA’s
responsibilities in accordance with this Agreement and as set forth in the
Provider Manual.

 

2.13                           BSC-HMO
Grievance Procedures.  
IPA shall cooperate with BSC-HMO in identifying, processing and
resolving all Member complaints and grievances pursuant to the grievance
procedures set forth in the Provider Manual. 
IPA and IPA Providers also agree to use the grievance procedure described
in the Provider Manual, in the event IPA or an IPA Provider has a complaint
against a Member.

 

5

 

2. 14                        Verification
of Eligibility.  IPA and/or IPA
Providers shall verify a Member’s eligibility to receive Benefits by requesting
the Member to present his BSC-HMO identification card and by checking the
Eligibility List provided by BSC-HMO in accordance with this Agreement.  For patients claiming enrollment in the
Plan, but not appearing on the Eligibility List, IPA and/or IPA Providers shall
confirm eligibility by telephoning BSC-HMO or shall obtain a Conditional
Coverage Form from the patient according to the procedure set forth in the
Provider Manual.  Until such Member’s
name appears on the Eligibility List, IPA and/or IPA Providers shall limit the
provision of services to Emergency services unless prior approval is obtained
from BSC-HMO.

 

2.15                           Prescriptions.  Unless otherwise required by a Member’s
specific medical needs, IPA Providers shall utilize the drug formulary adopted
by BSC-HMO.

 

2.16         Termination
of the Physician/Patient Relationship.

 

(a)          IPA may
terminate its professional relationship with a Member if the Member refuses to
follow the course of medical treatment prescribed by an IPA Provider and, in
the treating provider’s professional opinion, no acceptable alternative exists,
or the Member becomes unnecessarily disruptive or abusive.  IPA shall provide a written request for
termination to BSC-HMO, describing the circumstances and reasons for such
termination.  Such termination requests
shall be processed in accordance with the termination procedures as set forth
in the Provider Manual.  If approved by
BSC-HMO, IPA shall give the Member written notice of the termination of the
provider/patient relationship.   IPA may
not terminate its relationship with a Member because of such Member’s medical
condition, or the amount, variety, or cost of Benefits that are required by the
Member.

 

(b)         IPA
acknowledges that a Member may request transfer between IPAs in accordance with
the Member’s Health Services Contract, (1) at the Open Enrollment Period, (2)
if the Member changes residence, (3) one other time during the Calendar Year,
and (4) if the IPA discontinues its participation in the Plan.  As appropriate, IPA further agrees to accept
the transfer of a Member to IPA at the request of BSC-HMO.  In either situation, IPA shall provide
patient records, reports and other documentation regarding such Member to
BSC-HMO or new IPA upon request and shall facilitate any approved transfers of
responsibility.  If approved by BSC-HMO,
a transfer shall become effective as of the first day of the month following
BSC-HMO’s approval or at an earlier time if circumstances, in the opinion of
BSC-HMO, justify such earlier transfer.

 

2.17                           Required
Disclosures. IPA shall notify BSC-HMO immediately in writing upon the
occurrence or disclosure of any of the following events:

 

(a)          An IPA
Provider’s license to practice in California is suspended, revoked, terminated
or subject to terms of probation or other restriction; or

 

(b)         An IPA
Provider’s medical staff privileges at any hospital are denied, suspended,
restricted, revoked or voluntarily relinquished in lieu of disciplinary action;
or

 

(c)          An IPA
Provider becomes the subject of any disciplinary proceeding or action before
the Board of Medical Quality Assurance or a similar agency in any state; or

 

(d)         An IPA
Provider fails to remain a Blue Shield Physician Member; or

 

(e)          An IPA
Provider is convicted of a fraud or felony; or

 

(f)            There
is a change in the bylaws, membership, ownership, and/or officers of IPA; or

 

(g)         An act
of nature or any event beyond IPA’s reasonable control occurs, which
substantially interrupts all or a portion of IPA’s business or an IPA
Provider’s practice or which has a materially adverse effect on IPA’s ability
to perform its obligations hereunder; or

 

6

 

(h)         IPA
and/or IPA Providers fail to maintain the insurance coverage required under
Article VII of this Agreement, or to replace coverage which is canceled or
terminated, as specified therein; or

 

(i)             IPA
and/or IPA Provider learns of any malpractice action against IPA and/or IPA
Provider; or becomes aware of a malpractice judgment or settlement against IPA
and/or IPA Provider; or

 

(j)             There
is a change in IPA’s or IPA Provider’s business address; or

 

(k)          There
is a change in IPA’s or IPA Provider’s contract; or

 

(1)          Any
other situation arises which could reasonably be expected to affect IPA’s or an
IPA Provider’s ability to carry out its obligations under this Agreement.

 

2.18                           Encounter
and Claims Data.   IPA shall provide
BSC-HMO with encounter/claims data as set forth in Schedule C of this Agreement
and in accordance with the procedures set forth in the Provider Manual.  Required data shall be delivered by IPA to
BSC-HMO not later than forty-five (45) days following the end of the month in
which care was rendered.  Under no
circumstances shall IPA bill a Member for Benefits or make a Member responsible
for submitting such bill to BSC-HMO.

 

2.19                           IPA Physician/Provider
List.  IPA shall provide BSC-HMO with the name,
address, specialty, board status, professional license number, curriculum
vitae, history and proof of current professional liability insurance, phone
number and office hours of each IPA Provider. 
IPA shall use its best efforts to notify BSC-HMO a minimum of thirty
(30) days in advance of any change in this information or of the addition or
termination of an IPA Provider.  IPA
agrees that BSC-HMO may list the name, specialty, address and telephone number
of IPA and IPA Providers in BSC-HMO publications provided to Plan employees,
Providers, Members and Contractholders and may use such information in
advertising and marketing materials.

 

III. BSC-HMO OBLIGATIONS

 

3.1                                 Provider
Manual.  BSC-HMO shall make
available to IPA and IPA Providers the Blue Shield HMO Physician Manual,
herein referred to as Provider Manual, describing Plan policies and
procedures.  The Provider Manual, which
is incorporated herein by reference, shall be updated by BSC-HMO on a periodic
basis and in accordance with this Agreement.

 

3.2                                 Payment.  BSC-HMO shall pay IPA directly for Benefits
in accordance with Article IV of this Agreement.

 

3.3                                 Identification
Cards.  BSC-HMO shall
issue Plan identification cards to Members as set forth in the Provider Manual.

 

3.4                                 Eligibility
Determination.  BSC-HMO shall
confirm eligibility and provide Eligibility Lists to IPA as set forth in the
Provider Manual.

 

3.5                                 Service
Authorizations.  BSC-HMO shall
authorize Benefits as set forth in the Provider Manual and in accordance with
IPA procedures.

 

3.6                                 Out-of-Area
Services.  Out-of-area
Emergency services are those services provided outside the Service Area of the
Plan in conjunction with an Emergency. 
BSC-HMO shall assume costs associated with out-of-area Emergency
services.

 

3.7                                 Administrative
Services.  BSC-HMO shall
perform or contract for those services incident to the administration of the
Plan including, but not limited to, the processing of enrollment applications,
assignment of Members to their PCPs, provision of data to IPA regarding
Members’ utilization of Benefits and the administration of claims for Benefits
which are not Capitated Services under this Agreement.

 

7

 

3.8                                 BSC-HMO
Health Services Delivery Advisory Committee.  BSC-HMO may establish a health services delivery advisory
committee(s) within a defined geographic area to advise BSC-HMO on a variety of
issues from an HMO perspective.  IPA may
be requested from time to time by BSC-HMO to appoint IPA Providers to serve as
members on the health services delivery advisory committee(s).

 

IV. COMPENSATION

 

4. l                                 Capitation
Fees.  Except as otherwise provided in this Article
IV, BSC-HMO shall pay IPA the Capitation Fees set forth in Schedule E on a
monthly basis no later than the twentieth (20th) day of each month.  Those Capitation Fees paid shall be for all
Members eligible from the first (1st) day of the month for which the payment is
made, who have chosen an IPA Physician as their PCP.  Such Capitation Fees shall be payment in full for Benefits as set
forth in Schedule A, except for Copayments, and third party collection as set
forth in Paragraph 4.8.  If the
encounter/claims information required under Paragraph 2.18 herein is not submitted
to BSC-HMO in a timely manner, then Capitation Fees will be withheld by BSC-HMO
until the required encounter/claims information is received.  These rates are effective from November 1, 1995, and thereafter, until
such time as the parties agree on new rates. 
Any material modification to the services set forth in Schedule A made
by BSC-HMO shall be accompanied by an appropriate modification of the
Capitation Fees set forth in Schedule E.

 

4.2                                 Other
Fees.  BSC-HMO shall pay IPA for Benefits rendered
to Members which are not included in the Capitation Fees at the rates set forth
in Schedule D, reduced by any applicable Copayments.  IPA also agrees to accept the fees set forth in Schedule D,
reduced by any applicable Copayments, for Benefits rendered to Members on
referral from other Plan Providers. 
Such fees shall be payment in full for services rendered except for
third party collections as set forth in Paragraph 4.8.

 

4.3                                 Stop
Loss.  The financial liability of IPA under the
Capitation Fees paid in accordance with Paragraph 4.1 above for Benefits
rendered to any one Member during a specified twelve (12) month period shall be
limited to the amount set forth in Schedule D.

 

4.4                                 Institutional
Incentive.  BSC-HMO will
establish a budget for Institutional Services in accordance with generally
accepted actuarial practices.  The
financial liability of BSC-HMO and IPA for authorized Benefits rendered to
Members assigned to IPA shall be determined in accordance with the provisions
set forth in Schedule F.

 

4.5                                 Copayments.  IPA shall diligently pursue and have sole
responsibility for collection of any applicable Copayments from Members and
shall in no event offer, publicize or advertise any waiver or other reduction
of any Copayments, unless specifically authorized in writing by BSC-HMO.  All Copayments shall be as specified in the
Health Services Contract and the amounts of the Copayments which IPA is
authorized to collect from the Member shall not exceed the amounts so specified.

 

4.6                                 Prohibition
Against Member Billings and Collections.  IPA agrees to accept those fees set forth in Schedules D and E as
payment in full for Benefits and not to seek from the Member any Surcharge or
other additional payment not provided for in the Member’s Health Services
Contract regardless of whether or not payment is received from BSC-HMO.  Whenever BSC-HMO receives notice of such
Surcharges it shall take appropriate action. 
Members shall not be liable to IPA or IPA Providers for any sums owed to
IPA or IPA Providers by BSC-HMO.  This
prohibition shall not apply to Copayments or third party collections in
accordance with the applicable Health Services Contract and Paragraph 4.8.

 

4.7                                 Non-Covered
Services.   IPA or IPA
Providers shall not bill or collect from a Member any charges in connection
with health care services, even though those services are not Benefits, unless
an executed Acknowledgment of Financial Responsibility Form has been obtained
from the Member or the Member’s legal representative prior to the time that
such services are provided to the Member. 
A copy of the Acknowledgment of Financial Responsibility Form is set
forth in the Provider Manual.

 

8

 

4.8                                 Third
Party Collections.  IPA and IPA
Providers shall cooperate with BSC-HMO for the proper coordination of Benefits
and in the collection of third party payments including workers’ compensation,
third party liens and other third party liability according to the procedures
set forth in the Provider Manual.

 

4.9                                 Care to
Canceled or Ineligible Persons. 
BSC-HMO shall discourage retroactive cancellation from the Plan of any
Member by a Contractholder after the applicable monthly billing is
reconciled.  Where no significant services
have been rendered, however, BSC-HMO may make occasional exceptions due to
legitimate administrative processing requirements.

 

Subject to IPA’s compliance with
the verification of eligibility procedures set forth in Paragraph 2.14 of this
Agreement, BSC-HMO shall be financially responsible for all care provided by
IPA Providers to an ineligible person or a retroactively canceled Member due to
erroneous, incomplete or delayed BSC-HMO Eligibility Lists; BSC-HMO’s financial
responsibility is contingent upon the PCP providing BSC-HMO with evidence that
it has unsuccessfully sought payment for all, or a portion of, such charges
from the patient or the person having legal responsibility for such patient,
through two (2) billing cycles immediately following notice of ineligibility or
retroactive cancellation.  In the event
that a Member is declared ineligible or is retroactively canceled, the
financial responsibility assumed by BSC-HMO under this Paragraph 4.9 shall be
the fee for service amount for Capitated Services rendered based on the
Equivalent Values set forth in Schedule D.

 

BSC-HMO shall deduct from IPA’s
next month’s Capitation Fees those amounts which have been paid to IPA for
ineligible or retroactively canceled persons for whom no Capitated Services
were rendered or from whom IPA has collected fee for service charges.

 

V.  QUALITY AND UTILIZATION MANAGEMENT

 

5.1                                 BSC-HMO’s
Responsibilities.  BSC-HMO is
obligated under law to conduct quality and utilization management activities
that identity, evaluate and remedy problems relating to access, continuity and
quality of care, utilization and the cost of services.  Accordingly, BSC-HMO shall conduct a quality
and utilization management program as set forth in the Provider Manual.  BSC-HMO’s program shall include the
establishment of peer review committees to conduct quality of care and
utilization review activities in accordance with the California Health and
Safety Code Sections 1370 and 1370.1. 
All quality and utilization management forms, records and other
information in BSC-HMO’s possession shall remain the property of BSC-HMO and
shall remain confidential.

 

5.2                                 IPA’s
Responsibilities.  IPA and IPA
Providers shall cooperate with BSC-HMO in monitoring quality and utilization
management activities delegated to IPA by BSC-HMO.  IPA shall have a written quality and utilization review plan and
shall have, and operate at its sole expense, a quality and utilization review
committee which shall identify, evaluate and remedy problems relating to
access, continuity, quality of care, utilization and the cost of services
provided or authorized by IPA.  IPA
shall keep records and minutes of the committee meetings and peer review
activities.

 

5.3                                 Shared
Records.  Upon request, IPA
shall make any records of its quality assurance and utilization review
activities pertaining to BSC-HMO Members available to BSC-HMO’s quality and
utilization review committee.  Such
sharing of records between the two committees shall be in accordance with, and
limited to, Sections 1157 of the California Evidence Code and 1370 of the
California Health and Safety Code and shall not be construed as a waiver of any
rights or privileges conferred on either party by those statutes.

 

VI.  RECORDS

 

6.1                                 Member’s
Medical Record.  IPA shall ensure
that a central medical record is established and maintained for each
Member.  At a minimum, the record shall
include all information about the Member and a description of all services
rendered to Plan Member as dictated by generally accepted medical and surgical
practices and standards and as required by the Provider Manual.

 

9

 

6.2                                 Access
to Medical Records.  Subject to
compliance with applicable federal and state laws and professional standards
regarding the confidentiality of medical records, IPA and IPA Providers shall
assist BSC-HMO in achieving continuity of care for Members through the maximum
sharing of medical records for services rendered to Members.  IPA’s obligations under this Paragraph 6.2
shall include, without limitation:

 

(a)          providing
BSC-HMO with copies of Member medical records that are in the custody of IPA or
IPA Providers; and

 

(b)         allowing
BSC-HMO authorized personnel access to such records on IPA’s or IPA Provider’s
premises during regular business hours; and

 

(c)          transmitting
information from Members’ medical records by telephone to BSC-HMO for purposes
of Authorization or other quality and utilization management activities; and

 

(d)         upon
reasonable request, providing copies of a Member’s medical records to any other
Plan Provider treating such Member.

 

6.3                                 Access
to Financial Records. 
BSC-HMO shall have access at reasonable times, upon demand, to the
books, records and papers of IPA and IPA Providers relating to Benefits
provided to Members, including, but not limited to, the financial condition of
IPA and any charges to, or payments received from, Members by IPA or IPA
Providers.

 

6.4                                 Confidentiality.  BSC-HMO and IPA agree to keep confidential
and to take the usual precautions to prevent the unauthorized disclosure of any
and all medical and/or contractual records and information required to be
prepared or maintained by IPA, IPA Providers or BSC-HMO under this Agreement.

 

6.5                                 Regulatory
Compliance.  IPA and IPA
Providers shall maintain such records and provide such information to BSC-HMO,
the United States Department of Health and Human Services, the State of
California Department of Health Services and the California Department of
Corporations as may be necessary for compliance by BSC-HMO with federal and
state law including, but not limited to, the California Knox-Keene Health Care
Service Plan Act of 1975, as amended, and the rules and regulations duly
promulgated thereunder, for a period of at least five (5) years.  This obligation of IPA and IPA Providers
does not cease upon termination of this Agreement whether by rescission or
otherwise.  All records, books and
papers of IPA and IPA Providers pertaining to Members shall be open to
inspection during normal business hours by BSC-HMO and state and federal
authorities.

 

VII.  INSURANCE

 

7.1                                 Insurance.  IPA and IPA Providers shall secure and
maintain from insurance companies approved to conduct business in the State of
California and acceptable to BSC-HMO, professional and general liability
insurance to insure it and its partners, shareholders, officers, members,
employees and agents.  Such insurance
shall have limits of coverage considered to be reasonably adequate for the risk
insured against.  IPA shall provide
certificates of coverage as requested by BSC-HMO, and shall, as set forth in
the Provider Manual, obligate the carrier of each such insurance policy to give
BSC-HMO written notice by registered mail at least thirty (30) days prior to
cancellation or other termination of such policy.

 

VIII. TERM AND TERMINATION

 

8.1                                 Term.  When executed by both parties, this
Agreement shall become effective as of the date noted on page 1 hereof and
shall continue in effect until terminated hereunder.

 

8.2                                 Termination.  Either party may terminate this Agreement,
with or without cause, by giving the other party at least one hundred eighty
(180) calendar days written notice.

 

10

 

8.3                                 Immediate
Termination.    After review of
all pertinent information, BSC-HMO may, at its option, immediately terminate
this Agreement with IPA and/or IPA Provider by written notice, upon the
occurrence of any of the conditions outlined in Paragraph 2.17, or if IPA
and/or IPA Provider is determined not to be in compliance with Paragraph 2.3,
or if BSC-HMO determines that the health, safety or welfare of Members is
jeopardized by continuation of this Agreement.

 

8.4                                 Effect
of Termination.  As of the date of
termination, this Agreement shall be considered of no further force or effect
whatsoever and each of the parties shall be relieved and discharged herefrom,
except that:

 

(a)          Termination
shall not effect any rights or obligations hereunder which have previously
accrued or shall hereafter 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.

 

(b)         IPA
agrees, at BSC-HMO’s option, to provide Benefits to Members assigned to IPA
PCPs, including any Members who become eligible during the notice period set
forth in Paragraph 8.2  above,
under the terms of the Member’s Health Services Contract until the annual
anniversary dates of those Contracts. 
IPA shall be compensated for Benefits rendered in accordance with this
Paragraph 8.4 at the fees set forth in Schedule E of this Agreement, until such
time as:

 

1.               appropriate
transfer of Members is achieved; or

 

2.               an
alternate source of payment for Benefits, acceptable to IPA has been found.

 

(c)          Each
party shall be responsible for the costs of completing any arbitration
proceedings initiated pursuant to this Agreement as set forth in Paragraph 9.9,
including requests for arbitration of disputes arising between the parties
after the effective date of termination.

 

(d)         IPA
shall maintain such records and provide such information to BSC-HMO as set
forth in Article VI of this Agreement. 
These records shall be maintained for at least five (5) years regardless
of the termination date of this Agreement.

 

IX.  MISCELLANEOUS PROVISIONS

 

9.1                                 Partial
Invalidity.  If for any reason,
any provision of this Agreement is held invalid, the remaining provisions shall
remain in full force and effect.

 

9.1                                 Waiver
of Breach.   The waiver of any
breach of this Agreement by either party shall not constitute a continuing
waiver of any subsequent breach of either the same or any other provision of
this Agreement.

 

9.3                                 Schedules.  All Schedules referenced in this Agreement
and attached hereto are incorporated herein by this reference.

 

9.4                                 Amendments.  Unless otherwise specifically provided
herein, this Agreement may be amended or changed only by mutual written consent
of BSC-HMO and IPA’s duly authorized representatives.  Notice to, or consent of, Members shall not be required for any
amendments to this Agreement.

 

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

 

9.6                                 Entire
Agreement.  This Agreement,
together with the Schedules hereto and the standards, policies and procedures
established by BSC-HMO and incorporated herein by reference, contains the
entire understanding between the parties and supersedes all prior agreements,
either oral or in writing, with respect to the subject matter hereof.

 

11

 

9.7                                 Independent
Parties. In the performance of the work, duties and obligations assumed
under this Agreement, it is mutually understood and agreed that each party, its
agents, employees or representatives are at all times acting and performing as
independent contractors and that neither party shall consider itself or act as
the agent, employee or representative of the other.

 

9.8                                 Cooperation
of Parties.  IPA and BSC-HMO
agree to meet and confer in  good
faith on common problems including, but not limited to, utilization of
services, problems concerning credentialing, authorization, encounters/claims
or reporting procedures and information and forms provided to IPA for use in
conjunction with Members.

 

9.9                                 Arbitration.   Disputes between BSC-HMO and IPA arising
out of this Agreement shall be resolved by arbitration, which shall be
conducted according to the Commercial Rules of Arbitration of the American
Arbitration Association (AAA), and under the auspices of the AAA.  The award must be based on proof properly
received into evidence and must be according to law.  The cost of arbitration shall be divided equally between the
parties.

 

9.10                           Attorneys’
Fees.    If proceedings other than arbitration are
necessary to enforce this Agreement, the prevailing party shall be entitled to
reasonable attorneys’ fees in addition to any other relief it may obtain.

 

9.11                           Advertising.  The name of IPA and/or IPA Provider is the
sole and exclusive property of IPA, IPA and IPA Provider hereby expressly
consent to Plan’s including IPA and/or IPA Provider’s name in any document
prepared for the purpose of marketing BSC-HMO. 
IPA and/or IPA Provider may identify itself as a Plan IPA or Plan
Provider.  IPA and/or IPA Provider shall
have no other right to use the name BSC-HMO in any advertisement or otherwise
without the express written consent of BSC-HMO.

 

9.12                           Notices.  Any notice required to be given pursuant to
the terms of this Agreement shall be in writing and shall be sent, postage
prepaid, by certified mail, return receipt requested, to BSC-HMO or IPA at the
address below.  The notice shall be
effective on the date of delivery indicated on the return receipt.

 

	
  If to Blue Shield of California:

  	
   

  	
  BLUE SHIELD Of
  California

  
	
   

  	
   

  	
  6701 Center Dr. West, Suite 800

  
	
   

  	
   

  	
  Los Angeles, CA 90045

  
	
   

  	
   

  	
  Attention:

  	
  Alan Puzarne

  
	
   

  	
   

  	
   

  	
  Vice President, Southern California

  
	
   

  	
   

  	
   

  
	
  If to IPA:

  	
   

  	
  Prospect Medical
  Group, Inc.

  
	
   

  	
   

  	
  18200 Yorba Linda Blvd.

  
	
   

  	
   

  	
  Yorba Linda, CA 92686

  
	
   

  	
   

  	
  Attention:

  	
  Katie Caropino

  
					

 

9.13                           Captions.  The captions contained herein are for
reference purposes only and shall not affect the meaning of this Agreement.

 

9.14                           Assignment.  Neither BSC-HMO nor IPA shall assign or
transfer its rights, duties or obligations under this Agreement without the
prior written consent of the other party.

 

9.15                           Genders
and Numbers.  The masculine,
feminine or neuter gender and the singular or plural numbers shall be deemed to
include the others whenever the context so indicates or requires.

 

IN WITNESS WHEREOF, the
undersigned have executed this Agreement as of the date(s) written below.

 

	
  BLUE
  SHIELD OF CALIFORNIA

  	
   

  	
  PROSPECT
  MEDICAL GROUP, INC.

  
	
   

  	
   

  	
   

  
	
  By:

  	
  /s/ Alan Puzarne

  	
   

  	
   

  	
  By:

  	
  /s/  Gregg DeNicola

  	
   

  
	
   

  	
  (Alan Puzarne)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Title:

  	
  VP/Chief
  Executive, Southern Region

  	
   

  	
   

  	
  Title:

  	
  CEO

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Date:

  	
  12/6/95

  	
   

  	
   

  	
  Date:

  	
  11/13/95

  	
   

  

 

12

 

SCHEDULE
A

 

Prospect
Medical Group, Inc.

 

FULL
PROFESSIONAL SERVICE CAPITATION DEFINITION

 

FOR IPAs

 

Effective Date: November 1, 1995

 

“Full Professional Service” for the
purposes of capitation is defined as  all
covered outpatient and Inpatient professional health care services provided by
a Physician or other appropriate health care provider and all covered
outpatient diagnostic and treatment services, supplies, materials, drugs, and
medicines, used or administered in the office, or other outpatient setting,
except the facility charges for ambulatory surgery and in-area Emergency
services.  Capitated Services include
the following specific services:

 

1.               HEALTH
MAINTENANCE/PREVENTION

 

All office visits for well baby
care; periodic/routine screenings and examinations for children, adolescents
and adults; immunizations and injections, including the cost of injectables,
when provided as part of acceptable medical care; vision and hearing exams for
Members up to age 18, including:

 

a.               preventive
care - routine physical exams

 

b.              eye/ear
screenings up to age 18

 

c.               immunizations/serum

 

d.              therapeutic
injections/injectables

 

e.               health
screening and monitoring - HMO Health Incentive Program

 

2.               PATIENT
COUNSELING/HEALTH EDUCATION

 

All Member counseling and patient
health education regarding personal health behavior, health care and use of
health care services; patient counseling for family planning, family planning
services and genetic counseling; when indicated, all health education services
and classes provided or sponsored by IPA, or IPA Providers and, when indicated,
referrals to other health education services or classes and referral follow-up.

 

3.               OFFICE/OUTPATIENT
MEDICAL AND SURGICAL SERVICES

 

All office visits and outpatient
services provided by an IPA Provider for the purpose of treatment of an illness
or injury; and office visits and outpatient services for the purpose of
diagnosis and triage of a patient whose condition warrants the care of an IPA
Provider.  All supplies, materials,
orthotics/prosthetics under $50, drugs and medicines administered in the office
or other outpatient setting.

 

a.               office
medical services - diagnosis, treatment, triage

 

b.              consultations
and second opinions

 

c.               minor
procedures - all minor procedures or surgery performed in an office setting and
professional services for facility based ambulatory surgery

 

d.              mental
health - all outpatient services rendered by mental health professionals for
mental health or alcohol or drug abuse services

 

e.               outpatient
physical rehabilitation - all outpatient physical therapy, occupational therapy
and speech therapy

 

f.                 outpatient
radiation therapy, chemotherapy and chemotherapy drugs, outpatient hemodialysis
and other outpatient treatments and therapies, including facility-based day
care treatment

 

13

 

g.              nutritional
counseling by a nutritionist or dietitian

 

h.              medical
social services

 

i.                  other
health care professionals

 

4.               OFFICE/OUTPATIENT
MEDICAL AND SURGICAL VISITS - CHRONIC CARE

 

All office visits and outpatient
services provided by an IPA Provider for the purpose of monitoring all chronic
conditions.  All supplies, materials,
orthotics/prosthetics under $50, drugs and medicines administered in the office
or other outpatient setting.

 

5.               DIAGNOSTIC
TESTS

 

All outpatient diagnostic tests
necessary for the provision of the services outlined in items 1 - 4 above,
including the technical and professional services for laboratory, diagnostic
x-ray, preadmission testing, nuclear medicine, ultrasounds, CT and NMR scans,
angiograms and other major diagnostic imaging, electrodiagnostic services,
pulmonary function and cardiac testing and other outpatient diagnostic
procedures.

 

6.               HOSPITAL/SNF
MEDICAL CARE

 

Hospital/SNF admissions; all
Inpatient visits or other professional service by an IPA Provider for the
purpose of providing Inpatient medical or surgical care, including the
professional component for Inpatient radiology, pathology and anesthesiology;
determining and arranging for necessary Inpatient care provided in a Hospital/SNF
by an IPA Provider; monitoring care provided in a Hospital/SNF by an IPA
Provider; making appropriate discharge plans; and Hospital/SNF discharges.

 

7.               HOME
MEDICAL SERVICES

 

Home or convalescent home visits
when Medically Necessary; and determining, arranging and monitoring home health
care treatment plans provided by a Plan Home Health Agency.

 

8.               IN-AREA
URGENT/EMERGENCY MEDICAL SERVICES

 

a.               Emergency
triage on a 24-hour a day basis to the most appropriate location for emergency
treatment; and

 

b.              telephone
advice, as medically appropriate, on a 24-hour a day basis for treatment of
minor illnesses and injuries; and

 

c.               all
professional charges for in-area Emergency services on a 24-hour a day basis,
provided by a Hospital.  (The Plan
covers the facility portion of Service Area Emergency room services.)

 

9.              OUT-OF-AREA/OUT
OF PLAN NON-EMERGENCY SERVICES

 

All services outlined in 1 - 7
above rendered out-of-area or out of Plan, because needed services are not
available within the IPA, service area or Plan network.  The Plan covers all professional and
facility charges for out-of-area Emergency services.

 

10.         CASE
MANAGEMENT/HMO ADMINISTRATION

 

All telephone consultations and
coordination with, and written correspondence to Plan personnel, IPA Providers
and Hospitals required for case management and the BSC-HMO quality and
utilization management program, as per this Agreement.

 

14

 

SCHEDULE B

 

Prospect Medical
Group, Inc.

 

SERVICE AREA

 

Effective Date: November 1, 1995

 

The Service Area consists of the
following geographic area (city/zip code):

 

	
  Alhambra  

  	
  91801-805  

  
	
   

  	
  91899  

  
	
  Altadena  

  	
  91001-002  

  
	
  Anaheim  

  	
  92801-808  

  
	
   

  	
  92817  

  
	
  Arcadia  

  	
  91006  

  
	
  Artesia  

  	
  90701-703  

  
	
  Atwood  

  	
  92601  

  
	
  Azusa  

  	
  91702  

  
	
  Baldwin Park  

  	
  91706  

  
	
  Bell  

  	
  90201  

  
	
  Bellflower  

  	
  90706-707  

  
	
  Buena Park  

  	
  90620-624  

  
	
  Brea  

  	
  92621  

  
	
  Chino  

  	
  91708-710  

  
	
  Claremont  

  	
  91711  

  
	
  Compton  

  	
  90220-224  

  
	
  Corona  

  	
  91718-720  

  
	
  Corona del Mar  

  	
  92625  

  
	
  Costa Mesa  

  	
  92626 -628  

  
	
  Covina  

  	
  91722-724  

  
	
   

  	
  91790-793  

  
	
  Culver City  

  	
  90230-232  

  
	
  Cypress  

  	
  90630  

  
	
  Dana Point  

  	
  92629  

  
	
  Downey  

  	
  90240-242  

  
	
  Duarte  

  	
  91010  

  
	
  El Monte  

  	
  91731-735  

  
	
  El Segundo  

  	
  90245  

  
	
  El Toro  

  	
  92630  

  
	
  Fullerton  

  	
  92631-635  

  
	
  Garden Grove  

  	
  92640-645  

  
	
  Gardena  

  	
  90247-249  

  
	
  Glendale  

  	
  91201-210  

  
	
  Glendora  

  	
  91740  

  
	
  Harbor City  

  	
  90710

  
	
  Hawthorne  

  	
  90250-251  

  
	
  Huntington Beach

  	
  92605

  
	
   

  	
  92615

  
	
   

  	
  92646-650

  
	
  Huntington Park

  	
  90255

  
	
  Inglewood

  	
  90301-313

  
	
  Irvine

  	
  92710-720

  
	
   

  	
  92730

  
	
  Lake Forest

  	
  92630

  
	
  La Brea

  	
  92621-622

  
	
  La Habra

  	
  90631-633

  
	
  La Mirada  

  	
  90637-639

  
	
  La Puente  

  	
  91744-749  

  
	
  La Verne  

  	
  91750  

  
	
  Laguna Beach  

  	
  92651-654  

  
	
   

  	
  92656  

  
	
   

  	
  92677  

  
	
  Lakewood  

  	
  90711-716  

  
	
  Lawndale  

  	
  90260-261  

  
	
  Lomita  

  	
  90717  

  
	
  Long Beach  

  	
  90745-747  

  
	
   

  	
  90749  

  
	
   

  	
  90801-815  

  
	
   

  	
  90822  

  
	
   

  	
  90840-848  

  
	
   

  	
  90853  

  
	
   

  	
  90884  

  
	
   

  	
  90888  

  
	
  Los Alamitos  

  	
  90720-721  

  
	
  Los Angeles  

  	
  90001-023  

  
	
   

  	
  90026-045  

  
	
   

  	
  90047-048  

  
	
   

  	
  90050-063  

  
	
   

  	
  90065  

  
	
   

  	
  90067-068  

  
	
   

  	
  90070-076  

  
	
   

  	
  90078-093  

  
	
   

  	
  90095-101  

  
	
  Lynwood  

  	
  90262  

  
	
  Manhattan Beach  

  	
  90266  

  
	
  Maywood  

  	
  90270  

  
	
  Midway City  

  	
  92655  

  
	
  Mira Loma  

  	
  91752  

  
	
  Monrovia  

  	
  91016  

  
	
  Montclair  

  	
  91763  

  
	
  Montebello  

  	
  90640  

  
	
  Monterey Park  

  	
  91754-756  

  
	
  Newport Beach

  	
  92658-663  

  
	
  Norco  

  	
  91760

  
	
  Norwalk  

  	
  90650-659  

  
	
  Ontario  

  	
  91761-762  

  
	
   

  	
  91764  

  
	
  Orange  

  	
  92613  

  
	
   

  	
  92664-669  

  
	
  Palos Verdes

  	
  90274  

  
	
  Paramount

  	
  90723  

  
	
  Pasadena  

  	
  91030  

  
	
   

  	
  91050-051  

  
	
   

  	
  91101-109  

  
	
   

  	
  91121-129  

  
	
   

  	
  91131  

  
	
   

  	
  91182-184  

  
	
   

  	
  91188-189  

  
	
  Pico Rivera  

  	
  90660  

  
	
   

  	
  90665-666  

  
	
  Placentia  

  	
  92670  

  
	
  Pomona  

  	
  91766-769  

  
	
  Rancho Cucamonga

  	
  91730  

  
	
  Redondo Beach  

  	
  90254  

  
	
   

  	
  90277-278  

  
	
  Rosemead  

  	
  91770-772  

  
	
  San Dimas  

  	
  91773  

  
	
  San Gabriel  

  	
  91775-776  

  
	
  San Juan Capistrano

  	
  92675

  
	
   

  	
  92679  

  
	
   

  	
  92688  

  
	
   

  	
  92690-693  

  
	
  San Pedro  

  	
  90731-734  

  
	
  Santa Ana  

  	
  92701-709  

  
	
   

  	
  92711  

  
	
   

  	
  92712  

  
	
   

  	
  92721-728  

  
	
   

  	
  92799  

  
	
  Santa Fe Springs  

  	
  90670-671  

  
	
  Seal Beach  

  	
  90740  

  
	
  Sierra Madre  

  	
  91024  

  
	
  Silverado  

  	
  92676  

  
	
  South Gate  

  	
  90280  

  
	
  Stanton  

  	
  90680  

  
	
  Sunset Beach  

  	
  90742  

  
	
  Surfside  

  	
  90743  

  
	
  Temple City  

  	
  91780  

  
	
  Torrance  

  	
  90501-510  

  
	
  Trabuco Canyon  

  	
  92678  

  
	
  Tustin  

  	
  92680-681  

  
	
  Upland  

  	
  91785-786  

  
	
  Walnut  

  	
  91788-789  

  
	
  West Covina  

  	
  91790-793  

  
	
  Westminster  

  	
  92683-684  

  
	
  Whittier  

  	
  90604-612  

  
	
  Wilmington  

  	
  90744  

  
	
   

  	
  90748  

  
	
  Yorba Linda  

  	
  92686  

  

 

The Service Area outlined in this
Schedule B may be updated periodically to reflect changes in IPA Provider
locations and/or Zip Code additions or deletions identified by Plan or the U.S.
Postal Service.

 

15

 

SCHEDULE C

 

Prospect Medical
Group, Inc.

 

ENCOUNTER AND CLAIMS REPORTING
REQUIREMENTS

 

Effective Date: November 1, 1995

 

In order to qualify for consideration
for settlement and/or other utilization or compensation evaluation purposes,
encounter and claims data for properly authorized Benefits must be submitted to
Plan as  set forth in the Provider
Manual with the following information as a minimum:

 

•                                          BSC-HMO
Member Number

•                                          Member
Name

•                                          Member
Date of Birth

•                                          Servicing
Provider Name

•                                          BSC-HMO
Provider Number (Servicing Provider)

•                                          Service
Date(s)*

•                                          Diagnosis
(ICD9 Diagnosis Codes)

•                                          CPT
Code(s)

•                                          CPT
Modifier(s)

•                                          Quantity
(Units of Service)

•                                          Billed
Amount(s)

•                                          Referring
Physician Name

 

*Plan will not include encounter and
claims data submitted more than ninety (90) days following the date of service
for consideration for settlement and/or other utilization or compensation
evaluation purposes.

 

16

 

SCHEDULE D

 

Prospect Medical Group, Inc.

 

PLAN EQUIVALENT VALUES &  STOP LOSS

 

Effective Date: November 1, 1995

 

1.                                       Plan
Equivalent Values For Capitated Services (Conversion Factors)

 

	
  Medicine

  	
   

  	
   

  	
  ***

  	
   

  
	
  Surgery

  	
   

  	
   

  	
  ***

  	
   

  
	
  Anesthesiology

  	
   

  	
   

  	
  ***

  	
   

  
	
  Pathology

  	
   

  	
   

  	
  ***

  	
   

  
	
  Radiology

  	
   

  	
   

  	
  ***

  	
   

  
	
  Asst. Surgeon

  	
   

  	
   

  	
  ***

  	
   

  

 

17

 

SCHEDULE E

 

Prospect Medical Group, Inc.

 

CAPITATION FEES FOR PLAN CAPITATED SERVICES

 

Effective Date: November
1, 1995

 

The
following Capitation Fees by age & sex category will be used to calculate
the total capitation payment due to IPA. 
The sum of the Members in each category will be multiplied by the
corresponding rates and the category totals will be added to determine the IPA’s
capitation payment for any given month.

 

	
  Age &
  Sex Categories and Capitation Fees1-3

  	
   

  
	
  Age/Sex
Category

  	
   

  	
  Professional
Capitation

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  PMPM

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child < 1

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child 1-4

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child 5-18

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 19-39

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 40-54

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 55-64

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 65-69

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 65-69*

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 70+

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 70+*

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 19-39

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 40-54

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 55-64

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 65-69

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 65-69*

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 70+

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 70+*

  	
   

  	
   

  	
  ***

  	
   

  

*  Medicare carveout

 

1.                                       Inpatient Mental Health.  In addition to these capitation fees, Inpatient mental health
Capitated Services for Inpatient professional services will be paid at $.38 per
Member per month for eligible Members.

 

2.                                       Plan IFP Reimbursement.  Professional Capitation fees for Plan Individual and Family
Health Plan (IFP) Members will be paid at *** of the per Member per month
Professional Capitation Fees set forth in this Schedule.

 

3.                                       Stop Loss.   IPA has exercised the option of purchasing its own stop loss
protection and therefore no deduction for stop loss is applicable.  IPA agrees to give BSC-HMO written notice of
any cancellation or other termination of such stop loss coverage by registered
mall.  BSC-HMO shall have the right to
review and approve such stop loss coverage in advance.

 

 

18

 

SCHEDULE
F

 

Prospect
Medical Group, Inc.

 

PLAN INSTITUTIONAL
SERVICES SHARED RISK/SAVINGS

 

Effective Date: November 1, 1995

 

The
following amounts by age & sex category will be used to calculate the Institutional
Services Budget for both the IPA and the institutions IPA uses to admit Plan
Members:

 

	
  Age &
  Sex Categories and Institutional Services Budget

  	
   

  
	
  Age/Sex

  Category

  	
   

  	
  Gross Institutional Services

  Budget

  	
   

  	
  Net Institutional Services

  Budget

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  PMPM

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child < 1

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child 1-4

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Child 5-18

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 19-39

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 40-54

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 55-64

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 65-69

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 65-69*

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 70+

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Male 70+*

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 19-39

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 40-54

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 55-64

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 65-69

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 65-69*

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 70+

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  
	
  Female 70+*

  	
   

  	
   

  	
  ***

  	
   

  	
   

  	
  ***

  	
   

  

 

By
month, the sum of the Members assigned to IPA in each category will be
multiplied by the corresponding rates and the category totals will be added to
determine the IPA’s Institutional Services Budget for any given Agreement
Year.  The Institutional Services Budget
may be updated quarterly based on negotiated rate changes to the institutional
provider network.

 

If
the actual cost of authorized Institutional Services for IPA Members during an
Agreement Year is less than the Plan budgeted amount as outlined above, then
Plan shall pay IPA *** of the IPA Institutional Services Budget savings.

 

In
no event shall the total amount payable to IPA by Plan pursuant to this
Schedule exceed *** of the Capitation Fees paid to IPA during such Agreement
Year.

 

If
the actual cost of authorized Institutional Services for IPA Members during an
Agreement Year is more than the Plan budgeted amount as outlined above, then
IPA shall pay Plan 50% of the excess.

 

In
no event shall the total amount payable to Plan from IPA pursuant to this
Schedule exceed 15% of the Capitation Fees made to IPA during such Agreement
Year.

 

Upon
settlement of the Institutional Services Budget as provided for under the term
of this Schedule F, any payment due IPA or BSC-HMO shall be determined by
BSC-HMO within ninety days following the end of the Agreement Year and paid
within thirty days thereafter.

 

* Medicare carveout

 

19

 

 

Institutional Stop Loss.  In the event that there is a deficit in the
IPA’s Institutional Service Fund, the following stop loss provision would
apply.

 

During any agreement year, the charges
against the fund for benefits rendered to any one member during any one
hospital admission will be limited according to the following schedule:

 

	
  BSC-HMO Membership in IPA

  	
   

  	
  Stop Loss
  Amount

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  up to 500
  Members

  	
   

  	
   

  	
  ***

  	
   

  
	
  501 Members to 1000 Members

  	
   

  	
   

  	
  ***

  	
   

  
	
  1001 Members to 2000 Members

  	
   

  	
   

  	
  ***

  	
   

  
	
  Over 2000 Members

  	
   

  	
  -0-

  	
   

  

 

This Institutional Stop Loss will apply
only up to the point that actual costs of authorized Institutional Services for
IPA Members during an Agreement year, adjusted for this Stop Loss provision,
continues to be more than the Plan budgeted amount as set forth in Schedule
F.  Plan shall deduct a premium of $.50 per
month per Member for the Institutional Stop Loss for Members.

 

The following factors will be utilized
in determining the PMPM amount in the Institutional Service Budget:

 

Inpatient Costs:

 

•                                          Hospital
Utilization:

 

	
  St Jude Medical Center

  	
   

  	
  ***

  
	
  St. Joseph Hospital of Orange

  	
   

  	
  ***

  

 

•                                          Per
Diem Rate - As negotiated between Blue Shield and Hospital.

 

Non-inpatient Costs:

 

All other Non-Capitated Services
including:

 

•                                          Hospital
Outpatient Charges

•                                          SNF

•                                          Ambulance

•                                          Home
Health

•                                          Others

 

20

 

SCHEDULE G

 

Prospect Medical
Group, Inc.

 

IPA PROVIDER CONTRACT

 

Effective Date: November 1, 1995

 

Attached is the standard IPA
contract for IPA contracting Providers.

 

21Exhibit 10.138

 

[GRAPHIC]

 

1998

FHS

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

SIERRA MEDICAL GROUP

 

 

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

 

 

TABLE OF CONTENTS:

 

	
  RECITALS

  	
   

  
	
   

  	
   

  
	
  DEFINITIONS

  	
   

  
	
   

  	
   

  
	
  REPRESENTATIONS AND
  DUTIES OF PPG

  	
   

  
	
   

  	
   

  
	
  DUTIES
  OF FHS

  	
   

  
	
   

  	
   

  
	
  COMPENSATION

  	
   

  
	
   

  	
   

  
	
  DELEGATION

  	
   

  
	
   

  	
   

  
	
  TERM
  AND TERMINATION

  	
   

  
	
   

  	
   

  
	
  RECORDS, AUDITS AND REGULATORY REQUIREMENTS

  	
   

  
	
   

  	
   

  
	
  GENERAL PROVISIONS

  	
   

  
	
   

  	
   

  
	
  ADDENDUM A

  	
   

  
	
   

  	
  Benefit Programs

  	
   

  
	
   

  	
  Affiliates

  	
   

  
	
   

  	
   

  
	
  ADDENDUM
  B COMMERCIAL HMO AND POS

  	
   

  
	
   

  	
  A.

  	
  General Reimbursement
  Provisions

  	
   

  
	
   

  	
  B.

  	
  Standard
  HMO

  	
   

  
	
   

  	
  C.

  	
  Small Group HMO

  	
   

  
	
   

  	
  D.

  	
  Individual HMO

  	
   

  
	
   

  	
  E.

  	
  Access for Infants and Mothers 

  	
   

  
	
   

  	
  F.

  	
  Medicare Supplement

  	
   

  
	
   

  	
  G.

  	
  Commercial POS

  	
   

  
	
   

  	
  H.

  	
  Partnership Bonus

  	
   

  
	
   

  	
  I.

  	
  QCIP

  	
   

  
	
   

  	
  J.

  	
  Pharmacy Shared Risk
  Program

  	
   

  
	
   

  	
  K.

  	
  Pharmacy Rebate Program

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  B.1

  	
  AGE,
  SEX AND BENEFIT PLAN FACTORS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  B.2

  	
  COMMERCIAL
  HMO and POS DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  C

  	
   

  	
  MEDICARE
  HMO AND POS

  	
   

  
	
   

  	
  A.

  	
  Definitions 

  	
   

  
	
   

  	
  B.

  	
  Medicare HMO Benefit
  Program

  	
   

  
	
   

  	
  C.

  	
  Medicare POS Benefit
  Program

  	
   

  
	
   

  	
  D.

  	
  Administration
  Of Shared Risk Budgets For HMO and POS

  	
   

  
	
   

  	
  E.

  	
  Other Services

  	
   

  
					

 

 

	
  ADDENDUM
  C.1

  	
  SUPPLEMENTAL
  BENEFITS COSTS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  C.2

  	
  PHARMACY
  SHARED RISK BUDGETS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  C.3

  	
  MEDICARE
  DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  
	
  ADDENDUM
  D

  	
  PPO,
  EPO AND POS

  	
   

  
	
   

  	
  A.

  	
  Benefit Program
  Requirements

  	
   

  
	
   

  	
  B.

  	
  PPO And EPO Benefit
  Programs

  	
   

  
	
   

  	
  C.

  	
  POS Benefit  Programs

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  E

  	
  FEE
  FOR SERVICE COMPENSATION

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F

  	
  MEDICAL
  BENEFIT PROGRAM

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  
	
   

  	
  B.

  	
  Compensation Provisions

  	
   

  
	
   

  	
  C.

  	
  General Provisions

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.1 

  	
  FEE-FOR-SERVICE
  COMPENSATION SCHEDULE 

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.2 

  	
  CAPITATION
  COMPENSATION SCHEDULE 

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.3 

  	
  SHARED
  RISK PROGRAM DISTRIBUTION MATRIX 

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.4 

  	
  DIVISION
  OF FINANCIAL RESPONSIBILITY 

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.5

  	
  DISCLOSURE
  FORM

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  G

  	
  CHAMPUS/TRICARE

  	
   

  
	
   

  	
  A.

  	
  Definitions

  	
   

  
	
   

  	
  B.

  	
  Programs And Regulations

  	
   

  
	
   

  	
  C.

  	
  Other
  Governmental Programs

  	
   

  
	
   

  	
  D.

  	
  Provider Obligations

  	
   

  
	
   

  	
  E.

  	
  CHAMPUS
  PRIME and EXTRA Benefit Programs

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  ADDENDUM
  H

  	
  WORKERS
  COMPENSATION

  	
   

  
	
   

  	
  A.

  	
  Compensation

  	
   

  
	
   

  	
  B.

  	
  Other Duties

  	
   

  
	
   

  	
   

  	
   

  	
   

  

	
  ADDENDUM
  H-1

  	
  WORKERS’
  COMPENSATION RATE SCHEDULE

  	
   

  

 

 

PARTlCIPATING 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 Sierra
Medical Group Inc., a Participating Physician Group (“PPG”), to be
effective January 1, 1998.

 

R E C I T A
L S

 

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

A G R E E M E N T

 

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

 

I.             DEFINITIONS

 

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

 

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

 

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

 

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

 

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

 

1

 

PARTICIPATING PHYSICIAN GROUP

PROVIDER SERVICES AGREEMENT

 

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

 

R E C I T A L S

 

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.

 

A G R E E M E N T

 

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

 

1.            DEFINITIONS

 

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

 

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

 

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

 

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

 

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

 

1

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

2

 

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

 

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

 

(e)                                  The most appropriate supply or level of
service, including levels of acute care such as intensive care unit services of
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 selling 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 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 [ILLEGIBLE] or associate of PPG.

 

1.17                        Operations Manual. All Operations Manuals, including medical
policy manuals, issued by FHS, as updated from time to time, which are
incorporated in this Agreement by this reference.  In the event that any provision in an Operations Manual or any
updates thereto are clearly inconsistent with the items  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 Cart Physician (PCP).  A Member Physician who is responsible for
providing and/or coordinating the delivery of Covered Services to an HMO Member
pursuant to the applicable Benefit Program. 
Primary Care Physicians include general practitioners, family
practitioners, internists, pediatricians,

 

3

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

1.30                        Shared Risk Claim. 
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.

 

1.3l                                Shared Risk Services.  The
Covered Services set forth in the attached matrix under the heading “Shared
Risk Services”.

 

1.32                             State.  The
State of California.

 

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

 

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

 

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

 

4

 

11.                               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 practices and procedures and its bylaws and articles of
incorporation and any modifications thereto.

 

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

 

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

 

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

 

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

 

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

 

(1)                                  Accepting Members upon referral from Member
Physicians.

 

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

 

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

 

5

 

 

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

 

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

 

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

 

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

 

(8)           Accepting 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 loan, 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 their
medical condition and treatment alternatives. 
In the event PPG enters into a contract with a Participating Provider,
PPG will provide FHS with documentation thereof as set forth in the Operations
Manual.

 

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

 

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

 

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

 

6

 

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

 

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

 

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

 

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

 

PPG further understands and
agrees that FHS may deny participation under this Agreement to any new Member
Physician(s).  FHS shall afford Member
Physician such rights to appeal and due process, if any, is 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 restrictive to the date
of any merger or acquisition.

 

2.5          Member
Physician Termination.  Whenever possible, PPG shall
notify PHS in writing at  least
ninety (90)  days prior to any
action by PPG 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 excess standards as set forth in the Operations Manual.

 

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

 

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

 

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

 

7

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

8

 

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

 

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

 

Prior authorizations or
referrals may be issued by FHS, PPG, a Participating Provider, or Member
Physician in accordance with the applicable Benefit Program.  For non-emergent services, PPG or
Participating Provider agrees to obtain prior authorization or a referral
before providing or ordering Covered Services if required by the applicable
Benefit Program.  In an Emergency, PPG
agrees to attempt to obtain prior authorization or a referral, by telephone if
necessary, before providing or ordering Covered Services.  If prior authorization or a referral cannot
be obtained, PPG agrees to notify FHS and the appropriate Participating
Provider, as soon as possible, but no later than twenty four (24) hours after
admission.  In the 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.

 

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

 

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

 

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

 

9

 

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

 

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

 

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

 

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

 

2.21          Notice
of Adverse Action.  PPG
shall notify FHS in writing, within five days of receiving any notice of any
complaint, grievance, appeal, or  adverse
action, including, without limitation, (1) 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 efforts and

 

10

 

omissions insurance, or other risk protection
program, in the amounts required by law but not 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.

 

(h)           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 requirements of applicable provisions
of the California Labor Code.

 

2.23        Conflict
of Interest.  PPG shall not during the term of this
Agreement, acquire, or make any commitment to acquire a proprietary interest in
any organization which is licensed as a  health
care service plan or which has submitted an application for such licensure
except as to a health care service plan with waivers.  This restriction shall include any affiliated, subsidiary of  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 prepared 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-Specification.  PPG
and Member Physicians shall not, either during or after the term of this
Agreement, solicit any Member to enroll in any other health care service plan
or insurance program for the primary purpose of securing financial gain.  FHS shall have the right to  review all correspondence or
communications to Members prior to dissemination or mailing.

 

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

 

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

 

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

 

III.           DUTIES OF FHS

 

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

 

11

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

12

 

IV.           COMPENSATION

 

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

 

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

 

4.3          Billing
and Payment

 

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

 

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

 

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

 

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

 

(d)           Offsetting.
FHS shall have the right to offset any amount 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 (1)
offsetting such deficits against payments to PPG including, but not limited to,
surpluses from other shared risk programs, stop loss payments, bonus or other
incentive program payments, (ii) establishing reasonable withholds from Capitation
approved by DOC as set forth in the applicable Addendum to offset PPG

 

13

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

14

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

15

 

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

 

V.            DELEGATION

 

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

 

5.2          Termination
of Delegation. FHS
shall have the right to audit PPG’s performance of utilization management,
quality improvement, credentialing and recredentialing, Member grievance and
appeal, medical record review, and capitation and claims adjudication functions
from time to time.  If FHS determines
that deficiencies exist in PPG’s performance, PPG shall accept consulting
assistance from FHS.  Failure to cure
any identified deficiencies within a reasonable period of time as defined by
FHS policies, or if FHS determines PPG does not have the ability to perform
delegated functions, or  is not
effectively performing delegated functions, FHS may revoke delegation of all or
any of these functions in accordance with procedures set forth in the
Operations Manual and re-assume the performance of such functions itself.  Should it become necessary for FHS to
reassume delegated functions, FHS shall charge the following administrative
fees utilization management 4% of PPG Capitation; quality improvement 3% of PPG
Capitation; claims processing 3.5%  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 thirty six (36) months.  This
Agreement shall automatically renew for successive one year periods on the
annual renewal date unless terminated as set forth herein.  The term of this Agreement shall remain the
same for all Benefit Programs covered hereunder.

 

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

 

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

 

16

 

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 solely by PPG. In the
event such independent audit results in findings different from FHS’s findings,
the parties shall meet and confer to resolve such differences.

 

VII.         RECORDS, AUDITS AND REGULATORY
REQUIREMENTS

 

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

 

7.2          Access
to Records; Audits.  The records referred to above shall not be removed or transferred
from PPG except in accordance with applicable local, State, and federal laws,
rules and regulations. Subject to applicable State and federal confidentiality
or privacy laws, FHS or its designated representatives, and designated representatives
of local, State, and federal regulatory agencies having jurisdiction over FHS
shall have access to PPG’s records, at PPG’s place of business on request
during normal business hours, to inspect and review and make copies of such
records. Such governmental agencies shall include, but not be limited to, when
applicable to the Benefit Programs identified on Addendum A, the DHS, the DHHS,
the DOC, the DOD and the DOJ. When requested by FHS, PPG shall produce copies
of any such records at no cost. Additionally, PPG agrees to permit FHS, and its
designated representatives, accrediation 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 Programs of such Affiliate. No such Affiliate shall be responsible for
the obligations of any other Affiliate under this Agreement with respect to the
other Affiliate’s Benefit Programs. The person executing this Agreement has
been duly authorized by each

 

18

 

Affiliate to execute this
Agreement on such Affiliate 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 as 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 provided prior written notice to FHS of its intent to either
sell, transfer or convey its business assets to another entity or enter into a
management contract with a physician practice management entity which does not
manage PPG as of the effective date of this Agreement.

 

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

 

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

 

19

 

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

 

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

 

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

 

8.7          Indemnification
of Parties.

 

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

 

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

 

8.8          Status
as Independent Entities.  None of the provisions of this Agreement is intended to create of
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
[ILLEGIBLE] 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,

 

20

 

 

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
Service’s 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 of
responsibilities of PPG or FHS with respect to such Members.

 

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

 

FHS

C/O
Health Net

21600
Oxnard Street

Woodland
Hills, California 91367

Attention:
Senior Vice President, Provider Network Management

 

PPG

Prospect
Medical Group

18200
Yorba Linda Blvd., Suite
409

Yorba
Linda, CA 92686

Attn:
Administrator / CEO

 

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

 

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

 

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

 

21

 

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 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 interpretation of this Agreement.

 

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

 

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

 

22

 

IN WITNESS WHEREOF, the parties hereto have executed this Agreement by their officers duly authorized to 

be
effective on the date and year first written above.

 

	
  Participating Physician Group

  	
  Foundation Health Systems Affiliates

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ Jay Jayakumar

  	
   

  	
  /s/ Linda S. Pollnow

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  Jay Jayakumar

  	
   

  	
   

  
	
  Print
  Name

  	
  Linda
  S Pollnow

  
	
   

  	
   

  
	
   

  	
  Senior
  Vice President

  
	
  Vice President, Contracting

  	
   

  	
  Provider Network Management

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  5/14/98

  	
   

  	
  5-20-98

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
  95-392 9309

  	
   

  	
   

  
	
  Federal Tax Identification Number

  	
   

  
						

 

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

 

	
  Participating Physician Group

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Signature

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Print
  Name

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  Vice President, Contracting

  	
   

  	
   

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  5/14/98

  	
   

  	
   

  
	
  Date

  	
   

  

 

23

 

 

ADDENDUM A

 

BENEFIT PROGRAMS AND AFFILIATES

 

I.                                         BENEFIT PROGRAMS

 

Benefit
Program participation included under this Agreement is as follows:

	
  BENEFIT PROGRAM

  	
   

  	
  ADDENDUM

  	
   

  	
  PPG

  PARTICIPATION

  
	
  Standard HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Flex Funded HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Small Group HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Individual HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  AIM

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare Supplement

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Commercial POS

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare HMO

  	
   

  	
  C

  	
   

  	
  YES

  
	
  Medicare POS

  	
   

  	
  C

  	
   

  	
  YES

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

  	
   

  	
  D

  	
   

  	
  YES

  
	
  Medi-Cal

  	
   

  	
  F

  	
   

  	
  NO

  
	
  CHAMPUS

  	
   

  	
  G

  	
   

  	
  YES

  
	
  Occupational Medicine

  	
   

  	
  H

  	
   

  	
  YES

  

 

II.                                     AFFILIATES

 

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

 

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

 

24

 

ADDENDUM B

 

COMMERCIAL HEALTH MAINTENANCE ORGANIZATION (HMO) AND
COMMERCIAL POINT OF

SERVICE (POS) BENEFIT PROGRAMS

 

A.                                    GENERAL REIMBURSEMENT PROVISIONS.

 

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

 

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

•                Commercial HMO

•     Standard HMO

•     Flex Funded HMO

•     Small Group HMO

•     Individual HMO

•                     AIM

•                     Medicare Supplement

•    Commercial POS

 

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

 

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

 

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

 

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

 

25

 

 

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

 

7.                                      Shared Risk Budget.  In
July1998, PPGs shared Risk Budgets shall be converted from a flat PMPM amount
to an age, sex and benefit plan adjusted structure.  Such conversion shall be revenue neutral (before Division of
Financial Responsibility change.

 

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

 

B.                                    STANDARD
HMO.

 

1.                                      Professional Capitation
Rates.

 

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

 

	
  Period

  	
   

  	
  Standard

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $ PMPM (See section A8 above

  	
  )

  

 

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

 

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

 

	
  Calendar

  Year

  	
   

  	
  Top 33%

  	
   

  	
  Middle 33%

  	
   

  	
  Lowest 33%

  	
   

  
	
  1999

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  
	
  2000

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  

 

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

 

26

 

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

 

2.                                      Professional Stop Loss
Program.

 

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

 

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

 

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

 

	
  Period

  	
   

  	
  Standard

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $ PMPM

  (See Section A7 above

  	
  )

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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

 

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

 

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

 

Each
Reconciliation Period, HMO shall calculate Shared Risk Claims in accordance
with the Operations Manual and compare such claim cost to the corresponding
Shared Risk Budget.  HMO shall perform
both an interim and final settlement. 
In the event that such claims are less than the Shared Risk Budget for
the

 

27

 

Interim
Period.  PPG’s share of the settlement
shall be seventy-five percent (75%), subject to Section 4.3 of this Agreement.

 

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

 

3.3                               Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a) fifty percent (50%) of the Shared Risk Budget
surplus, or (b) an amount not to exceed twenty percent (20%) of the annual
gross PPG Capitation.  Subject to
Section 4.3 of the Agreement, the Shared Risk Budget surplus shall be
offset against any amounts payable by PPG. 
Any surplus remaining shall be paid to PPG by April 30 of the
following year.

 

3.4                               Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit, PPG’s share of the deficit shall be
limited to the lesser of (a) fifty percent (50%) of the Shared Risk Budget
deficit, or (b) an amount not to exceed twenty percent (20%) of the annual gross
PPG Capitation.  Subject to
Section 4.3, of the Agreement, any amounts payable by PPG shall be offset
against the Withhold Fund and any other amounts payable by HMO.

 

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

 

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

 

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

 

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

 

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 *** amount over.

 

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

 

4.1                               AIDS Reinsurance.  Professional,
institutional, and  pharmacy costs
for AIDS Members shall be the financial responsibility of HMO, as set forth in
the Operations Manual.  Additionally,
the pharmacy cost for HIV drugs shall be the financial responsibility of HMO
under this Program.  PPG shall receive
prior authorization from HMO for an elective inpatient admission of an AIDS
Member.  In addition, PPG shall provide
HMO with timely notification of any urgent/emergent admission of any AIDS
Member who is receiving anti-viral home treatments, or of any AIDS Member who
is receiving total parenteral nutrition. 
For purposes of this paragraph, timely notification is within
twenty-four (24) hours of an admission of 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.

 

28

 

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

 

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

 

	
  •

  	
   

  	
  AIDS
  Reinsurance

  	
   

  	
  $*** PMPM

  
	
  •

  	
   

  	
  Transplant
  Reinsurance

  	
   

  	
  $*** PMPM

  

 

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

 

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

 

C.                                 SMALL GROUP HMO.

 

1.                                      Professional Capitation
Rates.

 

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

 

	
  Period

  	
   

  	
  Small Group

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $PMPM

  (See Section A8 above

  	
  )

  

 

2.                                      Professional Stop Loss
Program.

 

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

 

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

 

 

29

 

	
  Period

  	
   

  	
  Small Group

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $ PMPM

  (See Section A7 above

  	
  )

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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

 

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

 

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

 

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

 

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

 

3.3                               Shared Risk Budget Surplus.  In
the event of a Shared Risk Budget surplus, PPG’s share of the surplus shall be
limited to the lesser of (a)  fifty
percent (50%) of the Shared Risk Budget surplus, or (b) an amount not to exceed
twenty percent (20%) of the annual gross PPG Capitation.  Subject to Section 4.3 of the
Agreement, the Shared Risk Budget surplus shall be offset against any amounts
payable by PPG.  Any surplus remaining
shall be paid to PPG by April 30 of the following year.

 

3.4                               Shared Risk Budget Deficit.  In
the event of a Shared Risk Budget deficit, PPG’s share of the deficit
shall be limited to the lesser of (a) fifty percent (50%) of the Shared Risk
Budget deficit, or (b) an amount not to exceed twenty percent (20%) of the
amount 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.

 

30

 

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

 

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

 

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

 

(b)                                  In-Area Shared Risk
Services: 2.3% of Shared Risks Budget.

 

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

 

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

 

	
  •

  	
   

  	
  AIDS
  Reinsurance

  	
   

  	
  $*** PMPM

  
	
  •

  	
   

  	
  Transplant
  Reinsurance

  	
   

  	
  $*** PMPM

  

 

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

 

 

D.                                    INDIVIDUAL HMO.

 

1.                                      Professional Capitation Rates.

 

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

 

	
  Period

  	
   

  	
  Individual

  HMO

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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.

 

31

 

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

 

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

 

	
  Period

  	
   

  	
  Individual

  HMO

  	
   

  
	
  January1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $ PMPM

  (See Section A7 above

  	
  )

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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

 

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

 

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

 

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

 

32

 

In the event any amounts remain in the Withhold Fund following the
reconciliation of any shared risk program, those excess funds shall be paid to
PPG by April 30 of the following year.

 

3.3                               Shared Risk Budget Surplus.  In the event of a Shared Risk Budget
surplus, PPG’s share of the surplus shall be limited to the lesser of (a) fifty
percent (50%) of the Shared Risk Budget surplus, or (b) an amount not to exceed
twenty percent (20%) of the annual gross PPG Capitation.  Subject to Section 4.3 of the
Agreement, the Shared Risk Budget surplus shall be offset against any amounts
payable by PPG.  Any surplus remaining
shall be paid to PPG by April 30 of the following year.

 

3.4                               Shared Risk Budget Deficit.  In the event of a Shared Risk Budget
deficit, PPG’s share of the deficit shall be limited to the lesser of (a) fifty
percent (50%) of the Shared Risk Budget deficit, or (b) an amount not to exceed
twenty percent (20%) of the annual gross PPG Capitation.  Subject to Section 4.3. of the
Agreement, any amounts payable by PPG shall be offset against the Withhold Fund
and any other amounts payable by HMO.

 

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

 

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

 

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

 

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

 

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

 

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

 

	
  •

  	
   

  	
  AIDS
  Reinsurance

  	
   

  	
  $***PMPM

  
	
  •

  	
   

  	
  Transplant
  Reinsurance

  	
   

  	
  $***PMPM

  

 

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

 

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

 

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

 

33

 

Program.  HMO shall pay PPG ***
PMPM during the first year of life for each infant AIM Member and *** PMPM
during the second year of life.

 

2.                                      Reinsurance Programs.  PPG’s professional stop loss level shall be
six thousand dollars ($6,000.00) per AIM Member.  The professional stop loss level shall be provided to the PPG for
AIM Members at no cost.  All other terms
and conditions of the Agreement regarding Professional Stop Loss shall apply to
AIM Members.

 

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

 

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

 

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

 

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

 

	
  Period

  	
   

  	
  Medicare
  Supplement

  HMO

  	
   

  	
  Medicare
  Supplement

  POS

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See Section A8 above

  	
  )

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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

 

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

 

G.                                    COMMERCIAL POS.

 

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

 

2.                                      Definitions.

 

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

 

34

 

Provider.  Out-of-Network
Services may be provided in area or out of area.

 

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

 

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

 

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

 

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

 

6.                                      Institutional Shared Risk Program.

 

6.1                               POS Shared Risk Budgets.  The budgets shall be determined for each
Commercial POS population:  Standard
POS, Small Group POS and at a later date, Individual POS Members.  Each Budget shall cover In-Network, Out-of-Network
and Out-of-Area Shared Risk Services. 
The Shared Risk Budgets effective January 1, 1998 shall be a flat
amount.  Each of the Shared Risk Budgets
shall be equal to the HMO Shared Risk Budget, or institutional capitation PMPM,
if applicable, and multiplied by 110%.

 

	
  Period

  	
   

  	
  Standard
  HMO 

  Shared Risk

  +10%

  	
   

  	
  Small
  Group HMO

  Shared Risk

  +10%

  	
   

  	
  Individual
  HMO

  Shared Risk

  +10%

  	
   

  
	
  January 1, 1998 to June 30, 1998

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  	
  $*** PMPM

  	
   

  
	
  July 1, 1998 to August 31, 1998

  	
   

  	
  $ PMPM

  (See Section A 7 above

  	
  )

  	
  $ PMPM

  (See Section A7 above

  	
  )

  	
  $ PMPM

  (See Section A7 above

  	
  )

  
	
  September 1, 1998

  	
   

  	
  $ PMPM

  (See section A8 above

  	
  )

  	
  $ PMPM

  (See Section A8 above

  	
  )

  	
  $ PMPM

  (See Section A8 above

  	
  )

  

 

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

 

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

 

35

 

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

 

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

 

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

 

(a)                                  Out-of-Area
Emergency and Urgently Needed Services : 
1.07% of POS Shared Risk Budget.

 

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

 

(b)                                  In-Network
and Out-of-Network POS Shared Risk Services: 
1.61% 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 $ 0.61 PMPM, which, shall be deducted
from PPG’s Out-of-Network Risk Sharing Budget.

 

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

 

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

 

36

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

	
  Calendar Year

  	
   

  	
  Award

  	
   

  
	
  1998

  	
   

  	
  Up to *** PMPM

  	
   

  
	
  1999

  	
   

  	
  Up to *** PMPM

  	
   

  
	
  2000

  	
   

  	
  Up to *** PMPM

  	
   

  

 

The Aim for Wellness Program, shall be a component of QCIP.  The above PMPM award includes funding for
the Aim for Wellness Program.  In 1998,
Compensation for the Aim for Wellness Program shall be payable at $0.20 PMPM
and shall be distributed to PPG monthly with Capitation.  HMO reserves the right to alter components
and measurements of QCIP annually.

 

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

 

1.                                      Pharmacy Budget.  In accordance with the formula outlined in
Section 2 below PPG’s

 

37

 

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

 

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

 

	
  Pharmacy Budget

  Year

  	
   

  	
  Percent
  Difference

  	
   

  
	
  1998

  	
   

  	
  ***

  	
   

  
	
  1999

  	
   

  	
  ***

  	
   

  
	
  2000

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

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

 

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

 

PPG is eligible for a lump sum award as determined and identified
below.  Such sum is payable in
April following the calendar year of the Rebate Fund, beginning
April 1999.  PPG’s PEMPM award
shall be determined by PPG’s cost performance relative to other participating
physician groups.  Cost performance
shall be determined by the normalized pharmacy cost for each calendar year for
each participating physician groups. 
Three performance tiers shall be established; each tier shall represent
approximately one third of the total Commercial HMO Members, provided, however,
that any participating physician group with assigned Commercial HMO Members
less than 7200 or exceeding 600,000 annual Member months shall be excluded from
the tier determination.  PPG’s PEMPM
award for eligible Commercial HMO Members shall be as follows based upon PPG’s
tier ranking:

 

	
  Tier

  	
   

  	
  Award

  	
   

  
	
  Lowest Normalized Pharmacy Costs

  	
   

  	
  *** of Rebate PEMPM

  	
   

  
	
  Middle Normalized Pharmacy Costs

  	
   

  	
  *** of Rebate PEMPM

  	
   

  
	
  Highest Normalized Pharmacy Costs

  	
   

  	
  *** of Rebate PEMPM

  	
   

  

 

38

 

ADDENDUM B.1

 

AGE,
SEX AND BENEFIT PLAN FACTORS

 

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

 

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

A.1 Age Sex factors for PPG Capitation and
Hospital Capitation Shared Risk Budgets Effective January 1, 1998 through
August 31, 1998

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Female

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  	
   

  
	
   

  	
   

  	
  3 - 4

  	
   

  	
  0.493

  	
   

  	
  0.370

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.436

  	
   

  	
  0.382

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.399

  	
   

  	
  0.390

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.421

  	
   

  	
  0.418

  	
   

  
	
   

  	
   

  	
  20 - 24

  	
   

  	
  0.902

  	
   

  	
  0.999

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  1.525

  	
   

  	
  1.664

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  1.543

  	
   

  	
  1.478

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  1.547

  	
   

  	
  1.281

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  1.567

  	
   

  	
  1.272

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  1.630

  	
   

  	
  1.293

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.712

  	
   

  	
  1.448

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.982

  	
   

  	
  1.927

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.161

  	
   

  	
  2.260

  	
   

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.251

  	
   

  	
  2.025

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  
	
  Male

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  	
   

  
	
   

  	
   

  	
  2 - 4

  	
   

  	
  0.493

  	
   

  	
  0.370

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.436

  	
   

  	
  0.382

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.399

  	
   

  	
  0.390

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.421

  	
   

  	
  0.418

  	
   

  
	
   

  	
   

  	
  20 - 24

  	
   

  	
  0.432

  	
   

  	
  0.447

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  0.492

  	
   

  	
  0.486

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  0.569

  	
   

  	
  0.536

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  0.667

  	
   

  	
  0.673

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  0.780

  	
   

  	
  0.800

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  0.933

  	
   

  	
  0.975

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.261

  	
   

  	
  1.415

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.625

  	
   

  	
  1.998

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.117

  	
   

  	
  2.928

  	
   

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.276

  	
   

  	
  2.658

  	
   

  
	
   

  	
   

  	
  Medicare
  Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  

 

39

 

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

Effective September 1, 1998

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Child

  	
   

  	
  0

  	
   

  	
  2.008

  	
   

  	
  5.228

  	
   

  
	
   

  	
   

  	
  1

  	
   

  	
  1.075

  	
   

  	
  0.644

  	
   

  
	
   

  	
   

  	
  2 - 4

  	
   

  	
  0.598

  	
   

  	
  0.406

  	
   

  
	
   

  	
   

  	
  5 - 9

  	
   

  	
  0.439

  	
   

  	
  0.296

  	
   

  
	
   

  	
   

  	
  10 - 14

  	
   

  	
  0.418

  	
   

  	
  0.338

  	
   

  
	
   

  	
   

  	
  15 - 19

  	
   

  	
  0.590

  	
   

  	
  0.607

  	
   

  
	
  Female

  	
   

  	
  20 - 24

  	
   

  	
  1.195

  	
   

  	
  1.066

  	
   

  
	
   

  	
   

  	
  25 - 29

  	
   

  	
  1.653

  	
   

  	
  1.431

  	
   

  
	
   

  	
   

  	
  30 - 34

  	
   

  	
  1.509

  	
   

  	
  1.315

  	
   

  
	
   

  	
   

  	
  35 - 39

  	
   

  	
  1.378

  	
   

  	
  1.143

  	
   

  
	
   

  	
   

  	
  40 - 44

  	
   

  	
  1.322

  	
   

  	
  1.031

  	
   

  
	
   

  	
   

  	
  45 - 49

  	
   

  	
  1.386

  	
   

  	
  1.102

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.551

  	
   

  	
  1.338

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.794

  	
   

  	
  1.741

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.090

  	
   

  	
  2.313

  	
   

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.251

  	
   

  	
  2.025

  	
   

  
	
   

  	
   

  	
  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

  	
   

  	
  0.087

  	
   

  
	
   

  	
   

  	
  50 - 54

  	
   

  	
  1.139

  	
   

  	
  1.580

  	
   

  
	
   

  	
   

  	
  55 - 59

  	
   

  	
  1.516

  	
   

  	
  1.203

  	
   

  
	
   

  	
   

  	
  60 - 64

  	
   

  	
  2.009

  	
   

  	
  2.880

  	
   

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.561

  	
   

  	
  3.586

  	
   

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  	
   

  

 

40

 

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

 

	
  Standard
  HMO

  	
   

  
	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0740

  	
   

  	
  0.9697

  	
   

  
	
  A1

  	
   

  	
  1.0857

  	
   

  	
  0.9751

  	
   

  
	
  A2

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  	
   

  
	
  A3

  	
   

  	
  1.0831

  	
   

  	
  0.9846

  	
   

  
	
  A4

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  	
   

  
	
  A5

  	
   

  	
  1.0857

  	
   

  	
  0.9782

  	
   

  
	
  A6

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  	
   

  
	
  A7

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  	
   

  
	
  A8

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  	
   

  
	
  A9

  	
   

  	
  1.0111

  	
   

  	
  1.0408

  	
   

  
	
  HB

  	
   

  	
  1.0039

  	
   

  	
  0.8702

  	
   

  
	
  BB

  	
   

  	
  1.0039

  	
   

  	
  0.8709

  	
   

  
	
  B1

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  	
   

  
	
  B2

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  	
   

  
	
  B3

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  	
   

  
	
  B4

  	
   

  	
  0.9027

  	
   

  	
  0.8252

  	
   

  
	
  B5

  	
   

  	
  0.9007

  	
   

  	
  0.8371

  	
   

  
	
  B6

  	
   

  	
  1.0039

  	
   

  	
  0.8812

  	
   

  
	
  B7

  	
   

  	
  0.9732

  	
   

  	
  1.0271

  	
   

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0165

  	
   

  
	
  B9

  	
   

  	
  0.9646

  	
   

  	
  1.0408

  	
   

  
	
  HC

  	
   

  	
  1.0840

  	
   

  	
  1.0122

  	
   

  
	
  C1

  	
   

  	
  1.0769

  	
   

  	
  1.0122

  	
   

  
	
  C2

  	
   

  	
  1.0954

  	
   

  	
  1.0238

  	
   

  
	
  C3

  	
   

  	
  1.0067

  	
   

  	
  1.0122

  	
   

  
	
  C6

  	
   

  	
  1.0095

  	
   

  	
  1.0408

  	
   

  
	
  C7

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  	
   

  
	
  C8

  	
   

  	
  0.9459

  	
   

  	
  0.9755

  	
   

  
	
  C9

  	
   

  	
  0.9047

  	
   

  	
  1.0408

  	
   

  
	
  HD

  	
   

  	
  1.1158

  	
   

  	
  1.0232

  	
   

  
	
  D1

  	
   

  	
  1.0769

  	
   

  	
  1.0232

  	
   

  
	
  D2

  	
   

  	
  1.0249

  	
   

  	
  0.0290

  	
   

  
	
  D3

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  	
   

  
	
  D4

  	
   

  	
  0.9493

  	
   

  	
  0.8696

  	
   

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9806

  	
   

  
	
  D6

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  	
   

  
	
  D7

  	
   

  	
  0.9655

  	
   

  	
  1.0326

  	
   

  
	
  D8

  	
   

  	
  1.0274

  	
   

  	
  1.0220

  	
   

  
	
  D9

  	
   

  	
  1.0456

  	
   

  	
  1.0442

  	
   

  
	
  HE

  	
   

  	
  1.0320

  	
   

  	
  1.0417

  	
   

  
	
  E1

  	
   

  	
  1.0166

  	
   

  	
  0.97?1

  	
   

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0408

  	
   

  
	
  E3

  	
   

  	
  1.0057

  	
   

  	
  0.9806

  	
   

  
	
  E4

  	
   

  	
  0.9487

  	
   

  	
  0.9934

  	
   

  
	
  E5

  	
   

  	
  1.0522

  	
   

  	
  1.0439

  	
   

  
	
  E6

  	
   

  	
  0.9587

  	
   

  	
  0.9761

  	
   

  
	
  E7

  	
   

  	
  0.9942

  	
   

  	
  1.0439

  	
   

  
	
  E8

  	
   

  	
  1.0178

  	
   

  	
  1.0238

  	
   

  
	
  E9

  	
   

  	
  0.9735

  	
   

  	
  0.9806

  	
   

  
	
  EA

  	
   

  	
  0.9715

  	
   

  	
  1.0372

  	
   

  
	
  EB

  	
   

  	
  0.9036

  	
   

  	
  0.8192

  	
   

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0408

  	
   

  
	
  ED

  	
   

  	
  1.0053

  	
   

  	
  0.9940

  	
   

  
	
  EE

  	
   

  	
  1.0078

  	
   

  	
  0.9831

  	
   

  
	
  EF

  	
   

  	
  1.0479

  	
   

  	
  1.0442

  	
   

  
	
  EG

  	
   

  	
  0.9999

  	
   

  	
  1.0442

  	
   

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0226

  	
   

  
	
  EI

  	
   

  	
  0.9914

  	
   

  	
  0.9794

  	
   

  
	
  EJ

  	
   

  	
  1.0578

  	
   

  	
  1.0499

  	
   

  
	
  EK

  	
   

  	
  0.9180

  	
   

  	
  1.0408

  	
   

  
	
  EL

  	
   

  	
  1.0522

  	
   

  	
  0.9779

  	
   

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0475

  	
   

  
	
  EN

  	
   

  	
  0.9797

  	
   

  	
  0.9767

  	
   

  
	
  EO

  	
   

  	
  0.9749

  	
   

  	
  0.9961

  	
   

  
	
  EP

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  	
   

  
	
  EQ

  	
   

  	
  0.9769

  	
   

  	
  1.0274

  	
   

  
	
  ES

  	
   

  	
  0.9729

  	
   

  	
  1.0436

  	
   

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0071

  	
   

  
	
  F1

  	
   

  	
  1.0161

  	
   

  	
  1.0095

  	
   

  
	
  F2

  	
   

  	
  1.0166

  	
   

  	
  0.9779

  	
   

  
	
  F3

  	
   

  	
  1.0070

  	
   

  	
  0.9806

  	
   

  
	
  F4

  	
   

  	
  0.9808

  	
   

  	
  1.0332

  	
   

  
	
  F5

  	
   

  	
  1.0218

  	
   

  	
  0.9812

  	
   

  
	
  F6

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  	
   

  
	
  F7

  	
   

  	
  1.1087

  	
   

  	
  0.9925

  	
   

  
	
  F8

  	
   

  	
  0.9050

  	
   

  	
  0.9697

  	
   

  
	
  F9

  	
   

  	
  1.0522

  	
   

  	
  1.0445

  	
   

  
	
  FA

  	
   

  	
  1.0269

  	
   

  	
  1.0341

  	
   

  
	
  FB

  	
   

  	
  1.0277

  	
   

  	
  1.0487

  	
   

  
	
  FC

  	
   

  	
  1.0164

  	
   

  	
  1.0372

  	
   

  
	
  FD

  	
   

  	
  1.0309

  	
   

  	
  1.0366

  	
   

  
	
  FE

  	
   

  	
  0.9635

  	
   

  	
  1.0341

  	
   

  
	
  FF

  	
   

  	
  0.9703

  	
   

  	
  1.0396

  	
   

  
	
  FG

  	
   

  	
  0.9635

  	
   

  	
  1.0016

  	
   

  
	
  FH

  	
   

  	
  0.9712

  	
   

  	
  1.0341

  	
   

  
	
  FI

  	
   

  	
  0.9749

  	
   

  	
  1.0341

  	
   

  
	
  FJ

  	
   

  	
  0.9203

  	
   

  	
  1.0341

  	
   

  
	
  FK

  	
   

  	
  0.9749

  	
   

  	
  0.9885

  	
   

  
	
  FL

  	
   

  	
  0.9203

  	
   

  	
  0.9572

  	
   

  
	
  HG

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  	
   

  
	
  G1

  	
   

  	
  0.9459

  	
   

  	
  0.9697

  	
   

  
	
  G2

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  	
   

  
	
  G3

  	
   

  	
  1.0155

  	
   

  	
  0.9806

  	
   

  
	
  G4

  	
   

  	
  0.9459

  	
   

  	
  0.9806

  	
   

  
	
  G5

  	
   

  	
  0.8965

  	
   

  	
  0.9694

  	
   

  
	
  G6

  	
   

  	
  1.0164

  	
   

  	
  1.0211

  	
   

  
	
  G9

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  	
   

  
	
  I3

  	
   

  	
  0.9644

  	
   

  	
  1.0442

  	
   

  
	
  I4

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  	
   

  
	
  I5

  	
   

  	
  0.9553

  	
   

  	
  1.0113

  	
   

  
	
  I6

  	
   

  	
  1.0448

  	
   

  	
  0.9551

  	
   

  
	
  I7

  	
   

  	
  1.0513

  	
   

  	
  1.0411

  	
   

  
	
  I8

  	
   

  	
  0.9573

  	
   

  	
  1.0268

  	
   

  
	
  I9

  	
   

  	
  0.9891

  	
   

  	
  1.0408

  	
   

  
	
  J3

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  	
   

  
	
  J4

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  	
   

  
	
  J5

  	
   

  	
  1.0130

  	
   

  	
  0.9809

  	
   

  
	
  J6

  	
   

  	
  0.9766

  	
   

  	
  0.9800

  	
   

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0305

  	
   

  
	
  J8

  	
   

  	
  0.9729

  	
   

  	
  0.9852

  	
   

  
	
  J9

  	
   

  	
  1.1604

  	
   

  	
  1.0667

  	
   

  
	
  HK

  	
   

  	
  1.0840

  	
   

  	
  1.0411

  	
   

  
	
  K1

  	
   

  	
  1.0138

  	
   

  	
  1.0411

  	
   

  
	
  K2

  	
   

  	
  0.9720

  	
   

  	
  0.9806

  	
   

  
	
  K3

  	
   

  	
  1.0237

  	
   

  	
  1.0414

  	
   

  
	
  K4

  	
   

  	
  1.0956

  	
   

  	
  1.0411

  	
   

  
	
  K6

  	
   

  	
  0.9698

  	
   

  	
  1.0420

  	
   

  
	
  K7

  	
   

  	
  0.9905

  	
   

  	
  1.0180

  	
   

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0223

  	
   

  
	
  K9

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  	
   

  
	
  KI

  	
   

  	
  0.9635

  	
   

  	
  1.0347

  	
   

  
	
  KJ

  	
   

  	
  1.0269

  	
   

  	
  1.0347

  	
   

  
	
  KK

  	
   

  	
  0.9749

  	
   

  	
  0.9894

  	
   

  
	
  KL

  	
   

  	
  0.9632

  	
   

  	
  1.0098

  	
   

  
	
  KM

  	
   

  	
  0.9317

  	
   

  	
  1.0347

  	
   

  
	
  L1

  	
   

  	
  0.9939

  	
   

  	
  1.0442

  	
   

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9806

  	
   

  
	
  L3

  	
   

  	
  0.9601

  	
   

  	
  0.9806

  	
   

  
	
  L4

  	
   

  	
  0.9081

  	
   

  	
  0.9807

  	
   

  
	
  L5

  	
   

  	
  0.9459

  	
   

  	
  0.9818

  	
   

  
	
  L6

  	
   

  	
  1.0039

  	
   

  	
  0.9818

  	
   

  
	
  L7

  	
   

  	
  1.0331

  	
   

  	
  0.98??

  	
   

  
	
  L8

  	
   

  	
  0.0192

  	
   

  	
  0.9697

  	
   

  
	
  L9

  	
   

  	
  0.0558

  	
   

  	
  1.0411

  	
   

  
	
  HM

  	
   

  	
  1.1684

  	
   

  	
  1.0609

  	
   

  
	
  M1

  	
   

  	
  0.9791

  	
   

  	
  1.0417

  	
   

  
	
  M2

  	
   

  	
  1.1834

  	
   

  	
  1.0609

  	
   

  
	
  M3

  	
   

  	
  1.0070

  	
   

  	
  1.0414

  	
   

  
	
  M4

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  	
   

  
	
  M5

  	
   

  	
  1.0246

  	
   

  	
  1.0268

  	
   

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9666

  	
   

  
	
  M7

  	
   

  	
  0.9493

  	
   

  	
  0.8754

  	
   

  
	
  M8

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  	
   

  
	
  M9

  	
   

  	
  1.0769

  	
   

  	
  1.0411

  	
   

  
	
  HN

  	
   

  	
  1.0067

  	
   

  	
  1.0408

  	
   

  
	
  N1

  	
   

  	
  1.0218

  	
   

  	
  1.0427

  	
   

  
	
  N2

  	
   

  	
  1.0124

  	
   

  	
  1.0408

  	
   

  
	
  N3

  	
   

  	
  1.0161

  	
   

  	
  1.0420

  	
   

  
	
  N4

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  	
   

  
	
  N5

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  	
   

  
	
  N6

  	
   

  	
  1.0184

  	
   

  	
  1.0232

  	
   

  
	
  N7

  	
   

  	
  1.0184

  	
   

  	
  1.0408

  	
   

  
	
  N8

  	
   

  	
  1.0357

  	
   

  	
  1.0387

  	
   

  
	
  N9

  	
   

  	
  1.0124

  	
   

  	
  1.0259

  	
   

  
	
  HO

  	
   

  	
  0.9487

  	
   

  	
  1.0408

  	
   

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0408

  	
   

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0031

  	
   

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0420

  	
   

  
	
  O4

  	
   

  	
  1.0184

  	
   

  	
  1.0031

  	
   

  
	
  O5

  	
   

  	
  0.9487

  	
   

  	
  1.0080

  	
   

  
	
  O6

  	
   

  	
  1.0380

  	
   

  	
  1.0539

  	
   

  
	
  O7

  	
   

  	
  1.0402

  	
   

  	
  1.0393

  	
   

  
	
  O8

  	
   

  	
  1.0053

  	
   

  	
  0.9761

  	
   

  
	
  O9

  	
   

  	
  0.9752

  	
   

  	
  1.0420

  	
   

  
	
  HP

  	
   

  	
  1.0064

  	
   

  	
  1.0122

  	
   

  
	
  P1

  	
   

  	
  1.0161

  	
   

  	
  1.0156

  	
   

  
	
  P2

  	
   

  	
  0.9081

  	
   

  	
  0.9426

  	
   

  
	
  P3

  	
   

  	
  0.9516

  	
   

  	
  0.9806

  	
   

  
	
  P4

  	
   

  	
  1.0070

  	
   

  	
  1.0518

  	
   

  
	
  P5

  	
   

  	
  0.8965

  	
   

  	
  0.9755

  	
   

  
	
  P6

  	
   

  	
  1.1008

  	
   

  	
  0.9867

  	
   

  
	
  P7

  	
   

  	
  1.0243

  	
   

  	
  1.0408

  	
   

  
	
  P8

  	
   

  	
  0.9789

  	
   

  	
  0.9882

  	
   

  
	
  P9

  	
   

  	
  1.0155

  	
   

  	
  0.9855

  	
   

  
	
  HR

  	
   

  	
  1.1684

  	
   

  	
  1.0624

  	
   

  
	
  R1

  	
   

  	
  1.0252

  	
   

  	
  1.0265

  	
   

  
	
  R2

  	
   

  	
  0.9502

  	
   

  	
  1.0439

  	
   

  
	
  R3

  	
   

  	
  0.9644

  	
   

  	
  1.0408

  	
   

  
	
  R4

  	
   

  	
  0.8976

  	
   

  	
  0.8955

  	
   

  
	
  R5

  	
   

  	
  1.0053

  	
   

  	
  0.9806

  	
   

  
	
  R6

  	
   

  	
  1.0053

  	
   

  	
  0.9429

  	
   

  
	
  R7

  	
   

  	
  0.8965

  	
   

  	
  0.9043

  	
   

  
	
  R8

  	
   

  	
  0.9672

  	
   

  	
  1.0265

  	
   

  
	
  R9

  	
   

  	
  0.9019

  	
   

  	
  0.8262

  	
   

  
	
  HS

  	
   

  	
  1.0956

  	
   

  	
  1.0238

  	
   

  
	
  S1

  	
   

  	
  1.1428

  	
   

  	
  1.0655

  	
   

  
	
  S2

  	
   

  	
  1.0303

  	
   

  	
  1.0296

  	
   

  
	
  S3

  	
   

  	
  1.0559

  	
   

  	
  1.0530

  	
   

  
	
  S4

  	
   

  	
  0.9459

  	
   

  	
  0.9332

  	
   

  
	
  S5

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  	
   

  
	
  S6

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  	
   

  
	
  S7

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  	
   

  
	
  S8

  	
   

  	
  1.0169

  	
   

  	
  0.9806

  	
   

  
	
  S9

  	
   

  	
  1.0169

  	
   

  	
  0.9429

  	
   

  
	
  HT

  	
   

  	
  1.0769

  	
   

  	
  1.0408

  	
   

  
	
  T1

  	
   

  	
  1.0826

  	
   

  	
  1.0408

  	
   

  
	
  T2

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  	
   

  
	
  T3

  	
   

  	
  1.0192

  	
   

  	
  1.0235

  	
   

  
	
  T4

  	
   

  	
  1.0147

  	
   

  	
  1.0214

  	
   

  
	
  T5

  	
   

  	
  1.0115

  	
   

  	
  1.0412

  	
   

  
	
  T7

  	
   

  	
  0.9257

  	
   

  	
  0.9867

  	
   

  
	
  T8

  	
   

  	
  1.0144

  	
   

  	
  0.9855

  	
   

  
	
  T9

  	
   

  	
  1.0388

  	
   

  	
  1.0278

  	
   

  
	
  TA

  	
   

  	
  0.9797

  	
   

  	
  0.9879

  	
   

  
	
  TB

  	
   

  	
  0.9914

  	
   

  	
  0.9767

  	
   

  
	
  TC

  	
   

  	
  1.0076

  	
   

  	
  0.9770

  	
   

  
	
  HU

  	
   

  	
  1.0365

  	
   

  	
  1.0503

  	
   

  
	
  U1

  	
   

  	
  1.0243

  	
   

  	
  0.9937

  	
   

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9429

  	
   

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.9697

  	
   

  
	
  U4

  	
   

  	
  1.0863

  	
   

  	
  1.0256

  	
   

  
	
  U5

  	
   

  	
  0.9490

  	
   

  	
  1.0442

  	
   

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0326

  	
   

  
	
  U7

  	
   

  	
  0.9772

  	
   

  	
  1.0299

  	
   

  
	
  U8

  	
   

  	
  1.0277

  	
   

  	
  1.0442

  	
   

  
	
  U9

  	
   

  	
  1.0320

  	
   

  	
  1.0524

  	
   

  
	
  HV

  	
   

  	
  1.0925

  	
   

  	
  1.0454

  	
   

  
	
  HW

  	
   

  	
  1.0536

  	
   

  	
  0.9697

  	
   

  
	
  W1

  	
   

  	
  1.0242

  	
   

  	
  0.9697

  	
   

  
	
  W2

  	
   

  	
  1.0232

  	
   

  	
  1.0211

  	
   

  

 

41

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W3

  	
   

  	
  0.9493

  	
   

  	
  1.0487

  	
   

  
	
  W4

  	
   

  	
  0.9328

  	
   

  	
  0.9910

  	
   

  
	
  W5

  	
   

  	
  1.0371

  	
   

  	
  1.0329

  	
   

  
	
  W6

  	
   

  	
  0.9516

  	
   

  	
  0.9840

  	
   

  
	
  W7

  	
   

  	
  0.9760

  	
   

  	
  1.0156

  	
   

  
	
  W8

  	
   

  	
  1.0002

  	
   

  	
  1.0408

  	
   

  
	
  W9

  	
   

  	
  0.9021

  	
   

  	
  1.0408

  	
   

  
	
  HX

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  	
   

  
	
  X1

  	
   

  	
  0.9493

  	
   

  	
  0.8699

  	
   

  
	
  X2

  	
   

  	
  0.9575

  	
   

  	
  0.9320

  	
   

  
	
  X3

  	
   

  	
  0.9459

  	
   

  	
  0.9429

  	
   

  
	
  X4

  	
   

  	
  0.9581

  	
   

  	
  0.9426

  	
   

  
	
  X5

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  	
   

  
	
  X6

  	
   

  	
  1.0127

  	
   

  	
  1.0408

  	
   

  
	
  X7

  	
   

  	
  0.8965

  	
   

  	
  0.9803

  	
   

  
	
  X8

  	
   

  	
  1.0155

  	
   

  	
  0.9809

  	
   

  
	
  X9

  	
   

  	
  0.8965

  	
   

  	
  0.9645

  	
   

  
	
  HY

  	
   

  	
  0.8965

  	
   

  	
  0.8934

  	
   

  
	
  Y1

  	
   

  	
  0.8993

  	
   

  	
  0.9627

  	
   

  
	
  Y2

  	
   

  	
  0.8965

  	
   

  	
  0.9317

  	
   

  
	
  Y3

  	
   

  	
  0.8965

  	
   

  	
  1.0028

  	
   

  
	
  Y4

  	
   

  	
  0.9081

  	
   

  	
  1.0028

  	
   

  
	
  Y5

  	
   

  	
  0.9487

  	
   

  	
  0.9630

  	
   

  
	
  Y6

  	
   

  	
  0.8965

  	
   

  	
  0.9426

  	
   

  
	
  Y7

  	
   

  	
  1.0107

  	
   

  	
  0.9806

  	
   

  
	
  Y8

  	
   

  	
  1.0252

  	
   

  	
  1.0408

  	
   

  
	
  Y9

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  	
   

  
	
  ZA

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  	
   

  
	
  ZB

  	
   

  	
  0.9797

  	
   

  	
  0.8660

  	
   

  
	
  ZC

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  	
   

  
	
  ZG

  	
   

  	
  0.9797

  	
   

  	
  0.9654

  	
   

  
	
  ZK

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  	
   

  
	
  ZM

  	
   

  	
  1.1005

  	
   

  	
  0.9882

  	
   

  
	
  ZN

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  ZO

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  ZS

  	
   

  	
  1.0615

  	
   

  	
  0.9770

  	
   

  
	
  ZZ

  	
   

  	
  0.9922

  	
   

  	
  0.9770

  	
   

  
	
  1A

  	
   

  	
  0.9987

  	
   

  	
  1.0198

  	
   

  
	
  1B

  	
   

  	
  1.0343

  	
   

  	
  1.0232

  	
   

  
	
  1C

  	
   

  	
  1.0385

  	
   

  	
  1.0256

  	
   

  
	
  1D

  	
   

  	
  0.9709

  	
   

  	
  1.0423

  	
   

  
	
  1E

  	
   

  	
  1.0348

  	
   

  	
  1.0271

  	
   

  
	
  1F

  	
   

  	
  1.0348

  	
   

  	
  1.0232

  	
   

  
	
  1G

  	
   

  	
  1.0348

  	
   

  	
  1.0220

  	
   

  
	
  1H

  	
   

  	
  1.0348

  	
   

  	
  0.9469

  	
   

  
	
  1J

  	
   

  	
  1.0348

  	
   

  	
  1.0393

  	
   

  
	
  1K

  	
   

  	
  1.0198

  	
   

  	
  1.0271

  	
   

  
	
  1L

  	
   

  	
  1.0368

  	
   

  	
  1.9803

  	
   

  
	
  1M

  	
   

  	
  1.0274

  	
   

  	
  1.0083

  	
   

  
	
  1N

  	
   

  	
  1.0274

  	
   

  	
  1.0423

  	
   

  
	
  1P

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  	
   

  
	
  1Q

  	
   

  	
  1.0274

  	
   

  	
  0.9469

  	
   

  
	
  1R

  	
   

  	
  1.0996

  	
   

  	
  1.0423

  	
   

  
	
  1S

  	
   

  	
  0.9709

  	
   

  	
  1.0049

  	
   

  
	
  1T

  	
   

  	
  0.9627

  	
   

  	
  1.0049

  	
   

  
	
  1U

  	
   

  	
  0.9271

  	
   

  	
  1.0031

  	
   

  
	
  1V

  	
   

  	
  1.0232

  	
   

  	
  1.0214

  	
   

  
	
  1W

  	
   

  	
  0.9678

  	
   

  	
  0.9803

  	
   

  
	
  1X

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  	
   

  
	
  1Y

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  	
   

  
	
  1Z

  	
   

  	
  1.0192

  	
   

  	
  1.0049

  	
   

  
	
  2A

  	
   

  	
  0.9709

  	
   

  	
  0.9469

  	
   

  
	
  2B

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  	
   

  
	
  2C

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  	
   

  
	
  2D

  	
   

  	
  0.9405

  	
   

  	
  1.0056

  	
   

  
	
  2E

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  	
   

  
	
  2F

  	
   

  	
  1.0235

  	
   

  	
  1.0214

  	
   

  
	
  6A

  	
   

  	
  1.0615

  	
   

  	
  0.9709

  	
   

  
	
  6G

  	
   

  	
  0.9217

  	
   

  	
  0.9654

  	
   

  
	
  6H

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  6R

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  	
   

  
	
  6S

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  	
   

  
	
  6T

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  6V

  	
   

  	
  0.9217

  	
   

  	
  0.9615

  	
   

  
	
  6W

  	
   

  	
  0.9700

  	
   

  	
  0.9797

  	
   

  
	
  6Z

  	
   

  	
  0.9252

  	
   

  	
  0.8657

  	
   

  
	
  7C

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  	
   

  
	
  7E

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  	
   

  
	
  7F

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  	
   

  
	
  7G

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  	
   

  
	
  7H

  	
   

  	
  0.9217

  	
   

  	
  0.9079

  	
   

  
	
  7I

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  	
   

  
	
  7J

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  	
   

  
	
  7K

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  	
   

  
	
  7L

  	
   

  	
  1.0053

  	
   

  	
  0.9882

  	
   

  
	
  7M

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  7N

  	
   

  	
  0.9794

  	
   

  	
  0.9764

  	
   

  
	
  7O

  	
   

  	
  0.8729

  	
   

  	
  0.9764

  	
   

  
	
  7Q

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  7R

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  7S

  	
   

  	
  0.8723

  	
   

  	
  0.9384

  	
   

  
	
  7T

  	
   

  	
  0.9217

  	
   

  	
  0.9466

  	
   

  
	
  7U

  	
   

  	
  0.9618

  	
   

  	
  0.9764

  	
   

  
	
  7V

  	
   

  	
  0.9811

  	
   

  	
  0.9387

  	
   

  
	
  7W

  	
   

  	
  0.9232

  	
   

  	
  0.9387

  	
   

  
	
  7X

  	
   

  	
  1.1155

  	
   

  	
  0.9882

  	
   

  
	
  7Y

  	
   

  	
  1.0363

  	
   

  	
  0.9882

  	
   

  
	
  7Z

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  	
   

  
	
  9A

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  	
   

  
	
  9B

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9C

  	
   

  	
  0.9735

  	
   

  	
  0.9764

  	
   

  
	
  9E

  	
   

  	
  0.9968

  	
   

  	
  0.9770

  	
   

  
	
  9F

  	
   

  	
  1.0615

  	
   

  	
  0.9764

  	
   

  
	
  9G

  	
   

  	
  0.9945

  	
   

  	
  0.9764

  	
   

  
	
  9H

  	
   

  	
  0.9530

  	
   

  	
  0.9764

  	
   

  
	
  9I

  	
   

  	
  0.9820

  	
   

  	
  0.9764

  	
   

  
	
  9J

  	
   

  	
  0.8766

  	
   

  	
  0.8313

  	
   

  
	
  9M

  	
   

  	
  0.9928

  	
   

  	
  0.9764

  	
   

  
	
  9N

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  	
   

  
	
  9O

  	
   

  	
  0.9368

  	
   

  	
  0.9764

  	
   

  
	
  9P

  	
   

  	
  1.0007

  	
   

  	
  0.9785

  	
   

  
	
  9Q

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9R

  	
   

  	
  0.9959

  	
   

  	
  0.9837

  	
   

  
	
  9S

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  	
   

  
	
  9T

  	
   

  	
  0.9792

  	
   

  	
  0.9767

  	
   

  
	
  9U

  	
   

  	
  0.9789

  	
   

  	
  0.9803

  	
   

  
	
  9W

  	
   

  	
  0.9217

  	
   

  	
  0.9565

  	
   

  
	
  9X

  	
   

  	
  0.8840

  	
   

  	
  0.9764

  	
   

  

 

42

 

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

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.7692

  	
   

  	
  0.7857

  	
   

  
	
  C5

  	
   

  	
  0.6886

  	
   

  	
  0.7740

  	
   

  
	
  Q1

  	
   

  	
  0.9857

  	
   

  	
  0.9697

  	
   

  
	
  Q2

  	
   

  	
  0.9285

  	
   

  	
  0.9315

  	
   

  
	
  Q3

  	
   

  	
  0.8792

  	
   

  	
  0.8692

  	
   

  
	
  Q4

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  	
   

  
	
  Q5

  	
   

  	
  1.0160

  	
   

  	
  1.0230

  	
   

  
	
  Q6

  	
   

  	
  0.9095

  	
   

  	
  1.0076

  	
   

  
	
  Q7

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  	
   

  
	
  Q8

  	
   

  	
  0.9285

  	
   

  	
  0.9697

  	
   

  
	
  QT

  	
   

  	
  0.7737

  	
   

  	
  0.7841

  	
   

  
	
  QU

  	
   

  	
  0.6971

  	
   

  	
  0.7709

  	
   

  
	
  QV

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  	
   

  
	
  QW

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  	
   

  
	
  QX

  	
   

  	
  0.7237

  	
   

  	
  0.7808

  	
   

  
	
  QY

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  	
   

  
	
  QZ

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  	
   

  
	
  V1

  	
   

  	
  1.0104

  	
   

  	
  0.9940

  	
   

  
	
  V2

  	
   

  	
  0.9409

  	
   

  	
  0.9853

  	
   

  
	
  V3

  	
   

  	
  0.8406

  	
   

  	
  0.9783

  	
   

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9886

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9639

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.9124

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8616

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.8054

  	
   

  

 

Medicare Supplement
HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan 1

  	
   

  	
  1.2467

  	
   

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1604

  	
   

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6676

  	
   

  

 

Medicare Supplement
POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1604

  	
   

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6676

  	
   

  

 

43

 

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

Effective July 1, 1998

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0754

  	
   

  	
  0.9716

  	
   

  
	
  A1

  	
   

  	
  1.0869

  	
   

  	
  0.9752

  	
   

  
	
  A2

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  	
   

  
	
  A3

  	
   

  	
  1.0843

  	
   

  	
  0.9830

  	
   

  
	
  A4

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  	
   

  
	
  A5

  	
   

  	
  1.0869

  	
   

  	
  0.9782

  	
   

  
	
  A6

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  	
   

  
	
  A7

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  	
   

  
	
  A8

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  	
   

  
	
  A9

  	
   

  	
  1.0420

  	
   

  	
  1.0387

  	
   

  
	
  HB

  	
   

  	
  1.0042

  	
   

  	
  0.8737

  	
   

  
	
  BB

  	
   

  	
  1.0042

  	
   

  	
  0.8746

  	
   

  
	
  B1

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  	
   

  
	
  B2

  	
   

  	
  0.8999

  	
   

  	
  0.8300

  	
   

  
	
  B3

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  	
   

  
	
  B4

  	
   

  	
  0.9019

  	
   

  	
  0.8291

  	
   

  
	
  B5

  	
   

  	
  0.8999

  	
   

  	
  0.8377

  	
   

  
	
  B6

  	
   

  	
  1.0042

  	
   

  	
  0.8812

  	
   

  
	
  B7

  	
   

  	
  0.9745

  	
   

  	
  1.0285

  	
   

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0163

  	
   

  
	
  B9

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  	
   

  
	
  HC

  	
   

  	
  1.0855

  	
   

  	
  1.0139

  	
   

  
	
  C1

  	
   

  	
  1.0783

  	
   

  	
  1.0139

  	
   

  
	
  C2

  	
   

  	
  1.0967

  	
   

  	
  1.0252

  	
   

  
	
  C3

  	
   

  	
  1.0071

  	
   

  	
  1.0139

  	
   

  
	
  C6

  	
   

  	
  1.0103

  	
   

  	
  1.0387

  	
   

  
	
  C7

  	
   

  	
  1.0855

  	
   

  	
  1.0211

  	
   

  
	
  C8

  	
   

  	
  0.9457

  	
   

  	
  0.9758

  	
   

  
	
  C9

  	
   

  	
  0.9042

  	
   

  	
  1.0387

  	
   

  
	
  HD

  	
   

  	
  1.1174

  	
   

  	
  1.0211

  	
   

  
	
  D1

  	
   

  	
  1.0783

  	
   

  	
  1.0211

  	
   

  
	
  D2

  	
   

  	
  1.0255

  	
   

  	
  1.0303

  	
   

  
	
  D3

  	
   

  	
  0.9002

  	
   

  	
  0.8300

  	
   

  
	
  D4

  	
   

  	
  0.9492

  	
   

  	
  0.8731

  	
   

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9791

  	
   

  
	
  D6

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  	
   

  
	
  D7

  	
   

  	
  0.9659

  	
   

  	
  1.0306

  	
   

  
	
  D8

  	
   

  	
  1.0316

  	
   

  	
  1.0199

  	
   

  
	
  D9

  	
   

  	
  1.0466

  	
   

  	
  1.0456

  	
   

  
	
  HE

  	
   

  	
  1.0?25

  	
   

  	
  1.0431

  	
   

  
	
  E1

  	
   

  	
  1.0?26

  	
   

  	
  0.9746

  	
   

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0387

  	
   

  
	
  E3

  	
   

  	
  1.0071

  	
   

  	
  0.9791

  	
   

  
	
  E4

  	
   

  	
  0.9486

  	
   

  	
  0.99?0

  	
   

  
	
  E5

  	
   

  	
  1.0587

  	
   

  	
  1.0417

  	
   

  
	
  E6

  	
   

  	
  0.9639

  	
   

  	
  0.9746

  	
   

  
	
  E7

  	
   

  	
  0.9999

  	
   

  	
  1.0417

  	
   

  
	
  E8

  	
   

  	
  1.0183

  	
   

  	
  1.0235

  	
   

  
	
  E9

  	
   

  	
  0.9734

  	
   

  	
  0.9791

  	
   

  
	
  EA

  	
   

  	
  0.9716

  	
   

  	
  1.0350

  	
   

  
	
  EB

  	
   

  	
  0.9033

  	
   

  	
  0.8215

  	
   

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0386

  	
   

  
	
  ED

  	
   

  	
  1.0056

  	
   

  	
  0.9926

  	
   

  
	
  EE

  	
   

  	
  1.0079

  	
   

  	
  0.9811

  	
   

  
	
  EF

  	
   

  	
  1.0482

  	
   

  	
  1.0419

  	
   

  
	
  EG

  	
   

  	
  1.0002

  	
   

  	
  1.0419

  	
   

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0204

  	
   

  
	
  EI

  	
   

  	
  0.9916

  	
   

  	
  0.9775

  	
   

  
	
  EJ

  	
   

  	
  1.0582

  	
   

  	
  1.0477

  	
   

  
	
  EK

  	
   

  	
  0.9179

  	
   

  	
  1.0386

  	
   

  
	
  EL

  	
   

  	
  1.0528

  	
   

  	
  0.9760

  	
   

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0489

  	
   

  
	
  EN

  	
   

  	
  0.9799

  	
   

  	
  0.9748

  	
   

  
	
  EO

  	
   

  	
  0.9762

  	
   

  	
  0.9978

  	
   

  
	
  EP

  	
   

  	
  0.9333

  	
   

  	
  0.9745

  	
   

  
	
  EQ

  	
   

  	
  0.9782

  	
   

  	
  1.0253

  	
   

  
	
  ES

  	
   

  	
  0.9730

  	
   

  	
  1.0413

  	
   

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0088

  	
   

  
	
  F1

  	
   

  	
  1.0169

  	
   

  	
  1.0112

  	
   

  
	
  F2

  	
   

  	
  1.0172

  	
   

  	
  0.9764

  	
   

  
	
  F3

  	
   

  	
  1.0074

  	
   

  	
  0.9791

  	
   

  
	
  F4

  	
   

  	
  0.9820

  	
   

  	
  1.0345

  	
   

  
	
  F5

  	
   

  	
  1.0284

  	
   

  	
  0.9788

  	
   

  
	
  F6

  	
   

  	
  1.0077

  	
   

  	
  1.0387

  	
   

  
	
  F7

  	
   

  	
  1.1102

  	
   

  	
  0.9908

  	
   

  
	
  F8

  	
   

  	
  0.9041

  	
   

  	
  0.9727

  	
   

  
	
  F9

  	
   

  	
  1.0532

  	
   

  	
  1.0423

  	
   

  
	
  FA

  	
   

  	
  1.0285

  	
   

  	
  1.0356

  	
   

  
	
  FB

  	
   

  	
  1.0313

  	
   

  	
  1.0501

  	
   

  
	
  FC

  	
   

  	
  1.0199

  	
   

  	
  1.0386

  	
   

  
	
  FD

  	
   

  	
  1.0345

  	
   

  	
  1.0380

  	
   

  
	
  FE

  	
   

  	
  0.9647

  	
   

  	
  1.0356

  	
   

  
	
  FF

  	
   

  	
  0.9716

  	
   

  	
  1.0410

  	
   

  
	
  FG

  	
   

  	
  0.9647

  	
   

  	
  1.0032

  	
   

  
	
  FH

  	
   

  	
  0.9725

  	
   

  	
  1.0356

  	
   

  
	
  FI

  	
   

  	
  0.9762

  	
   

  	
  1.0356

  	
   

  
	
  FJ

  	
   

  	
  0.9213

  	
   

  	
  1.0356

  	
   

  
	
  FK

  	
   

  	
  0.9762

  	
   

  	
  0.9902

  	
   

  
	
  FL

  	
   

  	
  0.9213

  	
   

  	
  0.9588

  	
   

  
	
  HG

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  	
   

  
	
  G1

  	
   

  	
  0.9457

  	
   

  	
  0.9716

  	
   

  
	
  G2

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  	
   

  
	
  G3

  	
   

  	
  1.0160

  	
   

  	
  0.9791

  	
   

  
	
  G4

  	
   

  	
  0.9457

  	
   

  	
  0.9791

  	
   

  
	
  G5

  	
   

  	
  0.8986

  	
   

  	
  0.9713

  	
   

  
	
  G6

  	
   

  	
  1.0172

  	
   

  	
  1.0336

  	
   

  
	
  G9

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  	
   

  
	
  I3

  	
   

  	
  0.9645

  	
   

  	
  1.0455

  	
   

  
	
  I4

  	
   

  	
  0.9004

  	
   

  	
  0.8366

  	
   

  
	
  I5

  	
   

  	
  0.9553

  	
   

  	
  1.0108

  	
   

  
	
  I6

  	
   

  	
  1.0451

  	
   

  	
  0.9548

  	
   

  
	
  I7

  	
   

  	
  1.0516

  	
   

  	
  1.0425

  	
   

  
	
  I8

  	
   

  	
  0.9573

  	
   

  	
  1.0247

  	
   

  
	
  I9

  	
   

  	
  0.9893

  	
   

  	
  1.0386

  	
   

  
	
  J3

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  	
   

  
	
  J4

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  	
   

  
	
  J5

  	
   

  	
  1.0134

  	
   

  	
  0.9794

  	
   

  
	
  J6

  	
   

  	
  0.9765

  	
   

  	
  0.9818

  	
   

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0318

  	
   

  
	
  J8

  	
   

  	
  0.9783

  	
   

  	
  0.9869

  	
   

  
	
  J9

  	
   

  	
  1.1627

  	
   

  	
  1.0642

  	
   

  
	
  HK

  	
   

  	
  1.0855

  	
   

  	
  1.0393

  	
   

  
	
  K1

  	
   

  	
  1.0146

  	
   

  	
  1.0390

  	
   

  
	
  K2

  	
   

  	
  0.9719

  	
   

  	
  0.9791

  	
   

  
	
  K3

  	
   

  	
  1.0247

  	
   

  	
  1.0393

  	
   

  
	
  K4

  	
   

  	
  1.0973

  	
   

  	
  1.0390

  	
   

  
	
  K6

  	
   

  	
  0.9699

  	
   

  	
  1.0399

  	
   

  
	
  K7

  	
   

  	
  0.9941

  	
   

  	
  1.0196

  	
   

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0205

  	
   

  
	
  K9

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  	
   

  
	
  KI

  	
   

  	
  0.9647

  	
   

  	
  1.0362

  	
   

  
	
  KJ

  	
   

  	
  1.0285

  	
   

  	
  1.0362

  	
   

  
	
  KK

  	
   

  	
  0.9762

  	
   

  	
  0.9911

  	
   

  
	
  KL

  	
   

  	
  0.9633

  	
   

  	
  1.0104

  	
   

  
	
  KM

  	
   

  	
  0.9327

  	
   

  	
  1.0362

  	
   

  
	
  L1

  	
   

  	
  0.9941

  	
   

  	
  1.0420

  	
   

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9791

  	
   

  
	
  L3

  	
   

  	
  0.9598

  	
   

  	
  0.9791

  	
   

  
	
  L4

  	
   

  	
  0.9074

  	
   

  	
  0.9788

  	
   

  
	
  L5

  	
   

  	
  0.9460

  	
   

  	
  0.9803

  	
   

  
	
  L6

  	
   

  	
  1.0045

  	
   

  	
  0.9803

  	
   

  
	
  L7

  	
   

  	
  1.0345

  	
   

  	
  0.9800

  	
   

  
	
  L8

  	
   

  	
  1.0201

  	
   

  	
  0.9716

  	
   

  
	
  L9

  	
   

  	
  0.9558

  	
   

  	
  1.0390

  	
   

  
	
  HM

  	
   

  	
  1.1708

  	
   

  	
  1.0585

  	
   

  
	
  M1

  	
   

  	
  0.9794

  	
   

  	
  1.0396

  	
   

  
	
  M2

  	
   

  	
  1.1857

  	
   

  	
  1.0585

  	
   

  
	
  M3

  	
   

  	
  1.0077

  	
   

  	
  1.0393

  	
   

  
	
  M4

  	
   

  	
  1.0077

  	
   

  	
  1.0423

  	
   

  
	
  M5

  	
   

  	
  1.0252

  	
   

  	
  1.0246

  	
   

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9659

  	
   

  
	
  M7

  	
   

  	
  0.9492

  	
   

  	
  0.8755

  	
   

  
	
  M8

  	
   

  	
  1.0172

  	
   

  	
  1.0390

  	
   

  
	
  M9

  	
   

  	
  1.0783

  	
   

  	
  1.0390

  	
   

  
	
  HN

  	
   

  	
  1.0074

  	
   

  	
  1.0387

  	
   

  
	
  N1

  	
   

  	
  1.0226

  	
   

  	
  1.0405

  	
   

  
	
  N2

  	
   

  	
  1.0131

  	
   

  	
  1.0387

  	
   

  
	
  N3

  	
   

  	
  1.0169

  	
   

  	
  1.0399

  	
   

  
	
  N4

  	
   

  	
  1.0071

  	
   

  	
  1.0211

  	
   

  
	
  N5

  	
   

  	
  1.0074

  	
   

  	
  1.0211

  	
   

  
	
  N6

  	
   

  	
  1.0189

  	
   

  	
  1.0211

  	
   

  
	
  N7

  	
   

  	
  1.0192

  	
   

  	
  1.0387

  	
   

  
	
  N8

  	
   

  	
  1.0365

  	
   

  	
  1.0366

  	
   

  
	
  N9

  	
   

  	
  1.0131

  	
   

  	
  1.0240

  	
   

  
	
  HO

  	
   

  	
  0.9489

  	
   

  	
  1.0387

  	
   

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0387

  	
   

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0016

  	
   

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0399

  	
   

  
	
  O4

  	
   

  	
  1.0189

  	
   

  	
  1.0016

  	
   

  
	
  O5

  	
   

  	
  0.9486

  	
   

  	
  1.0064

  	
   

  
	
  O6

  	
   

  	
  1.0388

  	
   

  	
  1.0516

  	
   

  
	
  O7

  	
   

  	
  1.0411

  	
   

  	
  1.0372

  	
   

  
	
  O8

  	
   

  	
  1.0056

  	
   

  	
  0.9746

  	
   

  
	
  O9

  	
   

  	
  0.9751

  	
   

  	
  1.0399

  	
   

  
	
  HP

  	
   

  	
  1.0068

  	
   

  	
  1.0139

  	
   

  
	
  P1

  	
   

  	
  1.0166

  	
   

  	
  1.0172

  	
   

  
	
  P2

  	
   

  	
  0.9071

  	
   

  	
  0.9417

  	
   

  
	
  P3

  	
   

  	
  0.9515

  	
   

  	
  0.9791

  	
   

  
	
  P4

  	
   

  	
  1.0077

  	
   

  	
  1.0495

  	
   

  
	
  P5

  	
   

  	
  0.8956

  	
   

  	
  0.9740

  	
   

  
	
  P6

  	
   

  	
  1.1025

  	
   

  	
  0.9866

  	
   

  
	
  P7

  	
   

  	
  1.0252

  	
   

  	
  1.0387

  	
   

  
	
  P8

  	
   

  	
  0.9800

  	
   

  	
  0.9899

  	
   

  
	
  P9

  	
   

  	
  1.0175

  	
   

  	
  0.9872

  	
   

  
	
  HR

  	
   

  	
  1.1708

  	
   

  	
  1.0600

  	
   

  
	
  R1

  	
   

  	
  1.0258

  	
   

  	
  1.0243

  	
   

  
	
  R2

  	
   

  	
  0.9503

  	
   

  	
  1.0417

  	
   

  
	
  R3

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  	
   

  
	
  R4

  	
   

  	
  0.8967

  	
   

  	
  0.8980

  	
   

  
	
  R5

  	
   

  	
  1.0056

  	
   

  	
  0.9791

  	
   

  
	
  R6

  	
   

  	
  1.0056

  	
   

  	
  0.9420

  	
   

  
	
  R7

  	
   

  	
  0.8956

  	
   

  	
  0.9039

  	
   

  
	
  R8

  	
   

  	
  0.9670

  	
   

  	
  1.0243

  	
   

  
	
  R9

  	
   

  	
  0.9010

  	
   

  	
  0.8300

  	
   

  
	
  HS

  	
   

  	
  1.0973

  	
   

  	
  1.0220

  	
   

  
	
  S1

  	
   

  	
  1.1445

  	
   

  	
  1.0660

  	
   

  
	
  S2

  	
   

  	
  1.0324

  	
   

  	
  1.0309

  	
   

  
	
  S3

  	
   

  	
  1.0569

  	
   

  	
  1.0507

  	
   

  
	
  S4

  	
   

  	
  0.9457

  	
   

  	
  0.9357

  	
   

  
	
  S5

  	
   

  	
  0.8999

  	
   

  	
  0.8380

  	
   

  
	
  S6

  	
   

  	
  1.0872

  	
   

  	
  1.0211

  	
   

  
	
  S7

  	
   

  	
  1.0267

  	
   

  	
  1.0208

  	
   

  
	
  S8

  	
   

  	
  1.0175

  	
   

  	
  0.9791

  	
   

  
	
  S9

  	
   

  	
  1.0175

  	
   

  	
  0.9420

  	
   

  
	
  HT

  	
   

  	
  1.0783

  	
   

  	
  1.0387

  	
   

  
	
  T1

  	
   

  	
  1.0840

  	
   

  	
  1.0387

  	
   

  
	
  T2

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  	
   

  
	
  T3

  	
   

  	
  1.0198

  	
   

  	
  1.0232

  	
   

  
	
  T4

  	
   

  	
  1.0152

  	
   

  	
  1.0211

  	
   

  
	
  T5

  	
   

  	
  1.0123

  	
   

  	
  1.0396

  	
   

  
	
  T7

  	
   

  	
  0.9264

  	
   

  	
  0.9887

  	
   

  
	
  T8

  	
   

  	
  1.0160

  	
   

  	
  0.9872

  	
   

  
	
  T9

  	
   

  	
  1.0408

  	
   

  	
  1.0291

  	
   

  
	
  TA

  	
   

  	
  0.9799

  	
   

  	
  0.9866

  	
   

  
	
  TB

  	
   

  	
  0.9916

  	
   

  	
  0.9748

  	
   

  
	
  TC

  	
   

  	
  1.0079

  	
   

  	
  0.9781

  	
   

  
	
  HU

  	
   

  	
  1.0376

  	
   

  	
  1.0486

  	
   

  
	
  U1

  	
   

  	
  1.0252

  	
   

  	
  0.9926

  	
   

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9720

  	
   

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.971?

  	
   

  
	
  U4

  	
   

  	
  1.0878

  	
   

  	
  1.0238

  	
   

  
	
  U5

  	
   

  	
  0.9492

  	
   

  	
  1.0?56

  	
   

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0306

  	
   

  
	
  U7

  	
   

  	
  0.9771

  	
   

  	
  1.0312

  	
   

  
	
  U8

  	
   

  	
  1.0284

  	
   

  	
  1.0420

  	
   

  
	
  U9

  	
   

  	
  1.0327

  	
   

  	
  1.0501

  	
   

  
	
  HV

  	
   

  	
  1.0941

  	
   

  	
  1.0432

  	
   

  
	
  HW

  	
   

  	
  1.0546

  	
   

  	
  0.9716

  	
   

  
	
  W1

  	
   

  	
  1.0454

  	
   

  	
  0.9716

  	
   

  
	
  W2

  	
   

  	
  1.0238

  	
   

  	
  1.0211

  	
   

  
	
  W3

  	
   

  	
  0.9495

  	
   

  	
  1.0465

  	
   

  
	
  W4

  	
   

  	
  0.9322

  	
   

  	
  0.9929

  	
   

  
	
  W5

  	
   

  	
  1.0379

  	
   

  	
  1.0342

  	
   

  
	
  W6

  	
   

  	
  0.5615

  	
   

  	
  0.9821

  	
   

  
	
  W7

  	
   

  	
  0.9763

  	
   

  	
  1.0154

  	
   

  

 

44

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W8

  	
   

  	
  1.0007

  	
   

  	
  1.0390

  	
   

  
	
  W9

  	
   

  	
  0.9013

  	
   

  	
  1.0390

  	
   

  
	
  HX

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  	
   

  
	
  X1

  	
   

  	
  0.9492

  	
   

  	
  0.87?4

  	
   

  
	
  X2

  	
   

  	
  0.9572

  	
   

  	
  0.9345

  	
   

  
	
  X3

  	
   

  	
  0.9457

  	
   

  	
  0.9420

  	
   

  
	
  X4

  	
   

  	
  0.9584

  	
   

  	
  0.9420

  	
   

  
	
  X5

  	
   

  	
  1.0172

  	
   

  	
  1.0300

  	
   

  
	
  X6

  	
   

  	
  1.0134

  	
   

  	
  1.0387

  	
   

  
	
  X7

  	
   

  	
  0.8956

  	
   

  	
  0.9788

  	
   

  
	
  X8

  	
   

  	
  1.0160

  	
   

  	
  0.9794

  	
   

  
	
  X9

  	
   

  	
  0.8956

  	
   

  	
  0.9665

  	
   

  
	
  HY

  	
   

  	
  0.8956

  	
   

  	
  0.8965

  	
   

  
	
  Y1

  	
   

  	
  0.8985

  	
   

  	
  0.9618

  	
   

  
	
  Y2

  	
   

  	
  0.8956

  	
   

  	
  0.9342

  	
   

  
	
  Y3

  	
   

  	
  0.8956

  	
   

  	
  1.0013

  	
   

  
	
  Y4

  	
   

  	
  0.9074

  	
   

  	
  1.0013

  	
   

  
	
  Y5

  	
   

  	
  0.9489

  	
   

  	
  0.9620

  	
   

  
	
  Y6

  	
   

  	
  0.8956

  	
   

  	
  0.9417

  	
   

  
	
  Y7

  	
   

  	
  1.0111

  	
   

  	
  0.9791

  	
   

  
	
  Y8

  	
   

  	
  1.0258

  	
   

  	
  1.0387

  	
   

  
	
  Y9

  	
   

  	
  1.0264

  	
   

  	
  1.0208

  	
   

  
	
  ZA

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  	
   

  
	
  ZB

  	
   

  	
  0.9800

  	
   

  	
  0.8695

  	
   

  
	
  ZC

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  	
   

  
	
  ZG

  	
   

  	
  0.9800

  	
   

  	
  0.9674

  	
   

  
	
  ZK

  	
   

  	
  1.0509

  	
   

  	
  0.9749

  	
   

  
	
  ZM

  	
   

  	
  1.1022

  	
   

  	
  0.9863

  	
   

  
	
  ZN

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  ZO

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  ZS

  	
   

  	
  1.0627

  	
   

  	
  0.9755

  	
   

  
	
  ZZ

  	
   

  	
  0.9924

  	
   

  	
  0.9788

  	
   

  
	
  1A

  	
   

  	
  1.0022

  	
   

  	
  1.0214

  	
   

  
	
  1B

  	
   

  	
  1.0382

  	
   

  	
  1.0246

  	
   

  
	
  1C

  	
   

  	
  1.0428

  	
   

  	
  1.0270

  	
   

  
	
  1D

  	
   

  	
  0.9742

  	
   

  	
  1.0438

  	
   

  
	
  1E

  	
   

  	
  1.0388

  	
   

  	
  1.0285

  	
   

  
	
  1F

  	
   

  	
  1.0388

  	
   

  	
  1.0246

  	
   

  
	
  1G

  	
   

  	
  1.0388

  	
   

  	
  1.0235

  	
   

  
	
  1H

  	
   

  	
  1.0388

  	
   

  	
  0.9498

  	
   

  
	
  1J

  	
   

  	
  1.0391

  	
   

  	
  1.0408

  	
   

  
	
  1K

  	
   

  	
  1.0258

  	
   

  	
  1.0285

  	
   

  
	
  1L

  	
   

  	
  1.0445

  	
   

  	
  0.9818

  	
   

  
	
  1M

  	
   

  	
  1.0316

  	
   

  	
  1.0100

  	
   

  
	
  1N

  	
   

  	
  1.0316

  	
   

  	
  1.0438

  	
   

  
	
  1Q

  	
   

  	
  1.0316

  	
   

  	
  0.9498

  	
   

  
	
  1R

  	
   

  	
  1.1048

  	
   

  	
  1.0438

  	
   

  
	
  1S

  	
   

  	
  0.9742

  	
   

  	
  1.0067

  	
   

  
	
  1T

  	
   

  	
  0.9659

  	
   

  	
  1.0067

  	
   

  
	
  1U

  	
   

  	
  0.9299

  	
   

  	
  1.0052

  	
   

  
	
  1V

  	
   

  	
  1.0273

  	
   

  	
  1.0235

  	
   

  
	
  1W

  	
   

  	
  0.9711

  	
   

  	
  0.9818

  	
   

  
	
  1X

  	
   

  	
  1.0284

  	
   

  	
  0.9818

  	
   

  
	
  1Y

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  	
   

  
	
  1Z

  	
   

  	
  1.0232

  	
   

  	
  1.0073

  	
   

  
	
  2A

  	
   

  	
  0.9742

  	
   

  	
  0.9498

  	
   

  
	
  2B

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  	
   

  
	
  2C

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  	
   

  
	
  2D

  	
   

  	
  0.9431

  	
   

  	
  1.0085

  	
   

  
	
  2E

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  	
   

  
	
  2F

  	
   

  	
  1.0275

  	
   

  	
  1.0229

  	
   

  
	
  6A

  	
   

  	
  1.0627

  	
   

  	
  0.9710

  	
   

  
	
  6G

  	
   

  	
  0.9215

  	
   

  	
  0.9674

  	
   

  
	
  6H

  	
   

  	
  0.9803

  	
   

  	
  0.9749

  	
   

  
	
  6R

  	
   

  	
  0.9330

  	
   

  	
  0.9749

  	
   

  
	
  6S

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  	
   

  
	
  6T

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  6V

  	
   

  	
  0.9215

  	
   

  	
  0.9603

  	
   

  
	
  6W

  	
   

  	
  0.9702

  	
   

  	
  0.9779

  	
   

  
	
  6Z

  	
   

  	
  0.9250

  	
   

  	
  0.8692

  	
   

  
	
  7C

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  	
   

  
	
  7E

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  	
   

  
	
  7F

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  	
   

  
	
  7G

  	
   

  	
  1.509

  	
   

  	
  0.9749

  	
   

  
	
  7H

  	
   

  	
  0.9215

  	
   

  	
  0.9069

  	
   

  
	
  7I

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  	
   

  
	
  7J

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  	
   

  
	
  7K

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  	
   

  
	
  7L

  	
   

  	
  1.0062

  	
   

  	
  0.9863

  	
   

  
	
  7M

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  7N

  	
   

  	
  0.9797

  	
   

  	
  0.9749

  	
   

  
	
  7O

  	
   

  	
  0.8714

  	
   

  	
  0.9746

  	
   

  
	
  7Q

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  	
   

  
	
  7R

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  7S

  	
   

  	
  0.8711

  	
   

  	
  0.9375

  	
   

  
	
  7T

  	
   

  	
  0.9215

  	
   

  	
  0.9456

  	
   

  
	
  7U

  	
   

  	
  0.9621

  	
   

  	
  0.9749

  	
   

  
	
  7V

  	
   

  	
  0.9814

  	
   

  	
  0.9378

  	
   

  
	
  7W

  	
   

  	
  0.9229

  	
   

  	
  0.9378

  	
   

  
	
  7X

  	
   

  	
  1.1172

  	
   

  	
  0.9867

  	
   

  
	
  7Z

  	
   

  	
  0.9215

  	
   

  	
  0.9782

  	
   

  
	
  9A

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  	
   

  
	
  9B

  	
   

  	
  0.9918

  	
   

  	
  0.9749

  	
   

  
	
  9C

  	
   

  	
  0.9739

  	
   

  	
  0.9749

  	
   

  
	
  9E

  	
   

  	
  0.9970

  	
   

  	
  0.9788

  	
   

  
	
  9F

  	
   

  	
  1.0627

  	
   

  	
  0.9749

  	
   

  
	
  9G

  	
   

  	
  0.9950

  	
   

  	
  0.9749

  	
   

  
	
  9H

  	
   

  	
  0.9535

  	
   

  	
  0.9746

  	
   

  
	
  9I

  	
   

  	
  0.9823

  	
   

  	
  0.9749

  	
   

  
	
  9J

  	
   

  	
  0.8767

  	
   

  	
  0.8318

  	
   

  
	
  9M

  	
   

  	
  0.9933

  	
   

  	
  0.9749

  	
   

  
	
  9N

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  	
   

  
	
  9O

  	
   

  	
  0.9365

  	
   

  	
  0.9749

  	
   

  
	
  9P

  	
   

  	
  1.0010

  	
   

  	
  0.9803

  	
   

  
	
  9Q

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  	
   

  
	
  9R

  	
   

  	
  0.9961

  	
   

  	
  0.9854

  	
   

  
	
  9S

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  	
   

  
	
  9T

  	
   

  	
  0.9800

  	
   

  	
  0.9752

  	
   

  
	
  9U

  	
   

  	
  0.9791

  	
   

  	
  0.9788

  	
   

  
	
  9W

  	
   

  	
  0.9215

  	
   

  	
  0.9552

  	
   

  
	
  9X

  	
   

  	
  0.8836

  	
   

  	
  0.9745

  	
   

  
	
  9Y

  	
   

  	
  1.0449

  	
   

  	
  0.9597

  	
   

  

 

45

 

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

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.7696

  	
   

  	
  0.7841

  	
   

  
	
  C5

  	
   

  	
  0.6881

  	
   

  	
  0.7728

  	
   

  
	
  Q1

  	
   

  	
  0.9862

  	
   

  	
  0.9700

  	
   

  
	
  Q2

  	
   

  	
  0.9282

  	
   

  	
  0.9324

  	
   

  
	
  Q3

  	
   

  	
  0.8783

  	
   

  	
  0.8711

  	
   

  
	
  Q4

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q5

  	
   

  	
  1.0165

  	
   

  	
  1.0212

  	
   

  
	
  Q6

  	
   

  	
  0.9088

  	
   

  	
  1.0059

  	
   

  
	
  Q7

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q8

  	
   

  	
  0.9282

  	
   

  	
  0.9700

  	
   

  
	
  QT

  	
   

  	
  0.7766

  	
   

  	
  0.7825

  	
   

  
	
  QU

  	
   

  	
  0.6991

  	
   

  	
  0.7696

  	
   

  
	
  QV

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QW

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QX

  	
   

  	
  0.7261

  	
   

  	
  0.7823

  	
   

  
	
  QY

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  QZ

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  V1

  	
   

  	
  1.0111

  	
   

  	
  0.9926

  	
   

  
	
  V2

  	
   

  	
  0.9421

  	
   

  	
  0.9829

  	
   

  
	
  V3

  	
   

  	
  0.8417

  	
   

  	
  0.9762

  	
   

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

Medicare Supplement
HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan J

  	
   

  	
  1.2513

  	
   

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1627

  	
   

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6580

  	
   

  

 

Medicare Supplement
POS

 

	
  Plan

  	
   

  	
  Prof
  Factor

  	
   

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1627

  	
   

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6580

  	
   

  

 

46

 

A.5 Benefit Plan Factors for PPG Capitation
and Hospital Capitation/Shared Risk Budgets Effective September 1, 1998

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0595

  	
   

  	
  0.9673

  	
   

  
	
  A1

  	
   

  	
  1.0628

  	
   

  	
  0.9725

  	
   

  
	
  A2

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A3

  	
   

  	
  1.0619

  	
   

  	
  0.9810

  	
   

  
	
  A4

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A5

  	
   

  	
  1.0628

  	
   

  	
  0.9752

  	
   

  
	
  A6

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  A7

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  A8

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  A9

  	
   

  	
  1.0257

  	
   

  	
  1.0076

  	
   

  
	
  HB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  BB

  	
   

  	
  0.0047

  	
   

  	
  0.8655

  	
   

  
	
  B1

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B2

  	
   

  	
  0.9198

  	
   

  	
  0.8252

  	
   

  
	
  B3

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B4

  	
   

  	
  0.9198

  	
   

  	
  0.8460

  	
   

  
	
  B5

  	
   

  	
  0.9198

  	
   

  	
  0.8357

  	
   

  
	
  B6

  	
   

  	
  1.0047

  	
   

  	
  0.8758

  	
   

  
	
  B7

  	
   

  	
  0.9743

  	
   

  	
  1.0085

  	
   

  
	
  B8

  	
   

  	
  0.9644

  	
   

  	
  0.9941

  	
   

  
	
  B9

  	
   

  	
  0.9690

  	
   

  	
  1.0076

  	
   

  
	
  HC

  	
   

  	
  1.0639

  	
   

  	
  0.9919

  	
   

  
	
  C1

  	
   

  	
  1.0613

  	
   

  	
  0.9919

  	
   

  
	
  C2

  	
   

  	
  1.0668

  	
   

  	
  1.0032

  	
   

  
	
  C3

  	
   

  	
  1.0066

  	
   

  	
  0.9919

  	
   

  
	
  C6

  	
   

  	
  1.0162

  	
   

  	
  1.0076

  	
   

  
	
  C7

  	
   

  	
  1.0639

  	
   

  	
  1.0022

  	
   

  
	
  C8

  	
   

  	
  0.9163

  	
   

  	
  0.9695

  	
   

  
	
  C9

  	
   

  	
  0.9243

  	
   

  	
  1.0076

  	
   

  
	
  HD

  	
   

  	
  1.0807

  	
   

  	
  1.0031

  	
   

  
	
  D1

  	
   

  	
  1.0613

  	
   

  	
  1.0022

  	
   

  
	
  D2

  	
   

  	
  1.0182

  	
   

  	
  1.0041

  	
   

  
	
  D3

  	
   

  	
  0.9327

  	
   

  	
  0.8259

  	
   

  
	
  D4

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  D5

  	
   

  	
  0.9599

  	
   

  	
  0.9776

  	
   

  
	
  D6

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  D7

  	
   

  	
  0.9897

  	
   

  	
  1.0074

  	
   

  
	
  D8

  	
   

  	
  1.0189

  	
   

  	
  1.0056

  	
   

  
	
  D9

  	
   

  	
  1.0319

  	
   

  	
  1.0076

  	
   

  
	
  HE

  	
   

  	
  1.0286

  	
   

  	
  1.0105

  	
   

  
	
  E1

  	
   

  	
  1.0137

  	
   

  	
  0.9737

  	
   

  
	
  E2

  	
   

  	
  0.9836

  	
   

  	
  1.0050

  	
   

  
	
  E3

  	
   

  	
  1.0064

  	
   

  	
  0.9776

  	
   

  
	
  E4

  	
   

  	
  0.9581

  	
   

  	
  0.9706

  	
   

  
	
  E5

  	
   

  	
  1.0403

  	
   

  	
  1.0037

  	
   

  
	
  E6

  	
   

  	
  0.9656

  	
   

  	
  0.9737

  	
   

  
	
  E7

  	
   

  	
  0.9905

  	
   

  	
  1.0037

  	
   

  
	
  E8

  	
   

  	
  1.0180

  	
   

  	
  0.9985

  	
   

  
	
  E9

  	
   

  	
  0.9690

  	
   

  	
  0.9801

  	
   

  
	
  EA

  	
   

  	
  0.9755

  	
   

  	
  1.0033

  	
   

  
	
  EB

  	
   

  	
  0.9023

  	
   

  	
  0.8278

  	
   

  
	
  EC

  	
   

  	
  0.9604

  	
   

  	
  1.0076

  	
   

  
	
  ED

  	
   

  	
  1.0061

  	
   

  	
  0.9805

  	
   

  
	
  EE

  	
   

  	
  0.9951

  	
   

  	
  0.9793

  	
   

  
	
  EF

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EG

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EH

  	
   

  	
  0.9585

  	
   

  	
  1.0018

  	
   

  
	
  EI

  	
   

  	
  0.9966

  	
   

  	
  0.9805

  	
   

  
	
  EJ

  	
   

  	
  1.0329

  	
   

  	
  1.0118

  	
   

  
	
  EK

  	
   

  	
  0.9310

  	
   

  	
  1.0050

  	
   

  
	
  EL

  	
   

  	
  1.0481

  	
   

  	
  0.9786

  	
   

  
	
  EM

  	
   

  	
  0.9714

  	
   

  	
  1.0135

  	
   

  
	
  EN

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  
	
  EO

  	
   

  	
  0.9727

  	
   

  	
  0.9633

  	
   

  
	
  EP

  	
   

  	
  0.9486

  	
   

  	
  0.9777

  	
   

  
	
  EQ

  	
   

  	
  0.9740

  	
   

  	
  1.0035

  	
   

  
	
  ES

  	
   

  	
  0.9796

  	
   

  	
  1.0076

  	
   

  
	
  HF

  	
   

  	
  0.9682

  	
   

  	
  0.9875

  	
   

  
	
  F1

  	
   

  	
  1.0230

  	
   

  	
  0.9893

  	
   

  
	
  F2

  	
   

  	
  1.0084

  	
   

  	
  0.9737

  	
   

  
	
  F3

  	
   

  	
  1.0071

  	
   

  	
  0.9776

  	
   

  
	
  F4

  	
   

  	
  0.9731

  	
   

  	
  1.0074

  	
   

  
	
  F5

  	
   

  	
  1.0087

  	
   

  	
  0.9780

  	
   

  
	
  F6

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  F7

  	
   

  	
  1.0804

  	
   

  	
  0.9903

  	
   

  
	
  F8

  	
   

  	
  0.8346

  	
   

  	
  0.8083

  	
   

  
	
  F9

  	
   

  	
  1.0350

  	
   

  	
  1.0037

  	
   

  
	
  FA

  	
   

  	
  1.0203

  	
   

  	
  1.0008

  	
   

  
	
  FB

  	
   

  	
  1.0213

  	
   

  	
  1.0145

  	
   

  
	
  FC

  	
   

  	
  1.0234

  	
   

  	
  1.0039

  	
   

  
	
  FD

  	
   

  	
  1.0241

  	
   

  	
  1.0023

  	
   

  
	
  FE

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FF

  	
   

  	
  0.9709

  	
   

  	
  1.0062

  	
   

  
	
  FG

  	
   

  	
  0.9694

  	
   

  	
  0.9858

  	
   

  
	
  FH

  	
   

  	
  0.9708

  	
   

  	
  1.0008

  	
   

  
	
  FI

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FJ

  	
   

  	
  0.9260

  	
   

  	
  1.0008

  	
   

  
	
  FK

  	
   

  	
  0.9727

  	
   

  	
  0.9581

  	
   

  
	
  FL

  	
   

  	
  0.9260

  	
   

  	
  0.9633

  	
   

  
	
  HG

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  G1

  	
   

  	
  0.9566

  	
   

  	
  0.9673

  	
   

  
	
  G2

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  G3

  	
   

  	
  1.0080

  	
   

  	
  0.9776

  	
   

  
	
  G4

  	
   

  	
  0.9566

  	
   

  	
  0.9776

  	
   

  
	
  G5

  	
   

  	
  0.9095

  	
   

  	
  0.9671

  	
   

  
	
  G6

  	
   

  	
  1.0231

  	
   

  	
  0.9967

  	
   

  
	
  G9

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  I3

  	
   

  	
  0.9909

  	
   

  	
  1.0106

  	
   

  
	
  I4

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  I5

  	
   

  	
  0.9677

  	
   

  	
  1.0044

  	
   

  
	
  I6

  	
   

  	
  1.0338

  	
   

  	
  0.9745

  	
   

  
	
  I7

  	
   

  	
  1.0022

  	
   

  	
  1.0076

  	
   

  
	
  I8

  	
   

  	
  0.9746

  	
   

  	
  0.9916

  	
   

  
	
  I9

  	
   

  	
  0.9851

  	
   

  	
  1.0037

  	
   

  
	
  J3

  	
   

  	
  1.0165

  	
   

  	
  0.9819

  	
   

  
	
  J4

  	
   

  	
  1.0108

  	
   

  	
  0.9849

  	
   

  
	
  J5

  	
   

  	
  1.0071

  	
   

  	
  0.9778

  	
   

  
	
  J6

  	
   

  	
  0.9714

  	
   

  	
  0.9783

  	
   

  
	
  J7

  	
   

  	
  0.9756

  	
   

  	
  1.0085

  	
   

  
	
  J8

  	
   

  	
  0.9666

  	
   

  	
  0.9839

  	
   

  
	
  J9

  	
   

  	
  1.1169

  	
   

  	
  1.0283

  	
   

  
	
  HK

  	
   

  	
  1.0784

  	
   

  	
  1.0076

  	
   

  
	
  K1

  	
   

  	
  1.0236

  	
   

  	
  1.0076

  	
   

  
	
  K2

  	
   

  	
  0.9663

  	
   

  	
  0.9801

  	
   

  
	
  K3

  	
   

  	
  1.0255

  	
   

  	
  1.0080

  	
   

  
	
  K4

  	
   

  	
  1.0817

  	
   

  	
  1.0076

  	
   

  
	
  K6

  	
   

  	
  0.9782

  	
   

  	
  1.0054

  	
   

  
	
  K7

  	
   

  	
  0.9845

  	
   

  	
  0.9966

  	
   

  
	
  K8

  	
   

  	
  0.9749

  	
   

  	
  0.9844

  	
   

  
	
  K9

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  KI

  	
   

  	
  1.0236

  	
   

  	
  1.0010

  	
   

  
	
  KJ

  	
   

  	
  1.0203

  	
   

  	
  1.0010

  	
   

  
	
  KK

  	
   

  	
  0.9727

  	
   

  	
  0.9583

  	
   

  
	
  KL

  	
   

  	
  0.9763

  	
   

  	
  0.9864

  	
   

  
	
  KM

  	
   

  	
  0.9260

  	
   

  	
  1.0010

  	
   

  
	
  L1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  L2

  	
   

  	
  0.9599

  	
   

  	
  0.9777

  	
   

  
	
  L3

  	
   

  	
  0.9566

  	
   

  	
  0.9777

  	
   

  
	
  L4

  	
   

  	
  0.9128

  	
   

  	
  0.9774

  	
   

  
	
  L5

  	
   

  	
  0.9695

  	
   

  	
  0.9776

  	
   

  
	
  L6

  	
   

  	
  1.0177

  	
   

  	
  0.9776

  	
   

  
	
  L7

  	
   

  	
  1.0424

  	
   

  	
  0.9756

  	
   

  
	
  L8

  	
   

  	
  1.0243

  	
   

  	
  0.9673

  	
   

  
	
  L9

  	
   

  	
  0.9755

  	
   

  	
  1.0076

  	
   

  
	
  HM

  	
   

  	
  1.1360

  	
   

  	
  1.0225

  	
   

  
	
  M1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  M2

  	
   

  	
  1.1361

  	
   

  	
  1.0225

  	
   

  
	
  M3

  	
   

  	
  1.0195

  	
   

  	
  1.0108

  	
   

  
	
  M4

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  M5

  	
   

  	
  1.0124

  	
   

  	
  1.0054

  	
   

  
	
  M6

  	
   

  	
  0.9749

  	
   

  	
  0.9175

  	
   

  
	
  M7

  	
   

  	
  0.9671

  	
   

  	
  0.8754

  	
   

  
	
  M8

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  M9

  	
   

  	
  1.0743

  	
   

  	
  1.0078

  	
   

  
	
  HN

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  N1

  	
   

  	
  1.0246

  	
   

  	
  1.0076

  	
   

  
	
  N2

  	
   

  	
  1.0211

  	
   

  	
  1.0076

  	
   

  
	
  N3

  	
   

  	
  1.0230

  	
   

  	
  1.0076

  	
   

  
	
  N4

  	
   

  	
  1.0066

  	
   

  	
  1.0022

  	
   

  
	
  N5

  	
   

  	
  1.0082

  	
   

  	
  1.0022

  	
   

  
	
  N6

  	
   

  	
  1.0099

  	
   

  	
  1.0022

  	
   

  
	
  N7

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  N8

  	
   

  	
  1.0294

  	
   

  	
  1.0033

  	
   

  
	
  N9

  	
   

  	
  1.0207

  	
   

  	
  0.9916

  	
   

  
	
  HO

  	
   

  	
  0.9714

  	
   

  	
  1.0076

  	
   

  
	
  O1

  	
   

  	
  0.9747

  	
   

  	
  1.0076

  	
   

  
	
  O2

  	
   

  	
  0.9714

  	
   

  	
  0.9676

  	
   

  
	
  O3

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  O4

  	
   

  	
  1.0095

  	
   

  	
  0.9676

  	
   

  
	
  O5

  	
   

  	
  0.9584

  	
   

  	
  0.9864

  	
   

  
	
  O6

  	
   

  	
  1.0327

  	
   

  	
  1.0149

  	
   

  
	
  O7

  	
   

  	
  1.0317

  	
   

  	
  1.0033

  	
   

  
	
  O8

  	
   

  	
  1.0050

  	
   

  	
  0.9733

  	
   

  
	
  O9

  	
   

  	
  0.9822

  	
   

  	
  1.0076

  	
   

  
	
  HP

  	
   

  	
  1.0049

  	
   

  	
  0.9919

  	
   

  
	
  P1

  	
   

  	
  1.0121

  	
   

  	
  0.9949

  	
   

  
	
  P2

  	
   

  	
  0.9030

  	
   

  	
  0.9396

  	
   

  
	
  P3

  	
   

  	
  0.9649

  	
   

  	
  0.9776

  	
   

  
	
  P4

  	
   

  	
  1.0195

  	
   

  	
  1.0186

  	
   

  
	
  P5

  	
   

  	
  0.9095

  	
   

  	
  0.9731

  	
   

  
	
  P6

  	
   

  	
  1.0823

  	
   

  	
  0.9838

  	
   

  
	
  P7

  	
   

  	
  1.0273

  	
   

  	
  1.0076

  	
   

  
	
  P8

  	
   

  	
  0.9614

  	
   

  	
  0.9828

  	
   

  
	
  P9

  	
   

  	
  1.0165

  	
   

  	
  0.9833

  	
   

  
	
  HR

  	
   

  	
  1.1304

  	
   

  	
  1.0233

  	
   

  
	
  R1

  	
   

  	
  1.0121

  	
   

  	
  1.0052

  	
   

  
	
  R2

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  R3

  	
   

  	
  0.9909

  	
   

  	
  1.0076

  	
   

  
	
  R4

  	
   

  	
  0.9003

  	
   

  	
  0.9029

  	
   

  
	
  R5

  	
   

  	
  1.0047

  	
   

  	
  0.9777

  	
   

  
	
  R6

  	
   

  	
  1.0047

  	
   

  	
  0.9399

  	
   

  
	
  R7

  	
   

  	
  0.8997

  	
   

  	
  0.9025

  	
   

  
	
  R8

  	
   

  	
  0.9640

  	
   

  	
  1.0052

  	
   

  
	
  R9

  	
   

  	
  0.9198

  	
   

  	
  0.8412

  	
   

  
	
  HS

  	
   

  	
  1.0817

  	
   

  	
  1.0022

  	
   

  
	
  S1

  	
   

  	
  1.0973

  	
   

  	
  1.0283

  	
   

  
	
  S2

  	
   

  	
  1.0259

  	
   

  	
  1.0091

  	
   

  
	
  S3

  	
   

  	
  1.0485

  	
   

  	
  1.0156

  	
   

  
	
  S4

  	
   

  	
  0.9629

  	
   

  	
  0.9295

  	
   

  
	
  S5

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  S6

  	
   

  	
  1.0658

  	
   

  	
  1.0022

  	
   

  
	
  S7

  	
   

  	
  1.0085

  	
   

  	
  1.0000

  	
   

  
	
  S8

  	
   

  	
  1.0080

  	
   

  	
  0.9777

  	
   

  
	
  S9

  	
   

  	
  1.0080

  	
   

  	
  0.9399

  	
   

  
	
  HT

  	
   

  	
  1.0743

  	
   

  	
  1.0076

  	
   

  
	
  T1

  	
   

  	
  1.0759

  	
   

  	
  1.0076

  	
   

  
	
  T2

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  T3

  	
   

  	
  1.0187

  	
   

  	
  0.9985

  	
   

  
	
  T4

  	
   

  	
  1.0156

  	
   

  	
  0.9985

  	
   

  
	
  T5

  	
   

  	
  1.0212

  	
   

  	
  1.0078

  	
   

  
	
  T7

  	
   

  	
  0.9229

  	
   

  	
  0.9673

  	
   

  
	
  T8

  	
   

  	
  1.0086

  	
   

  	
  0.9833

  	
   

  
	
  T9

  	
   

  	
  1.0245

  	
   

  	
  1.0079

  	
   

  
	
  TA

  	
   

  	
  0.9966

  	
   

  	
  0.9894

  	
   

  
	
  TB

  	
   

  	
  0.9929

  	
   

  	
  0.9778

  	
   

  
	
  TC

  	
   

  	
  1.0104

  	
   

  	
  0.9780

  	
   

  
	
  HU

  	
   

  	
  1.0443

  	
   

  	
  1.0165

  	
   

  
	
  U1

  	
   

  	
  1.0260

  	
   

  	
  0.9805

  	
   

  
	
  U2

  	
   

  	
  0.9599

  	
   

  	
  0.9399

  	
   

  
	
  U3

  	
   

  	
  0.9599

  	
   

  	
  0.9673

  	
   

  
	
  U4

  	
   

  	
  1.0778

  	
   

  	
  1.0022

  	
   

  
	
  U5

  	
   

  	
  0.9714

  	
   

  	
  1.0106

  	
   

  
	
  U6

  	
   

  	
  0.9750

  	
   

  	
  1.0074

  	
   

  
	
  U7

  	
   

  	
  0.9731

  	
   

  	
  1.0085

  	
   

  
	
  U8

  	
   

  	
  1.0263

  	
   

  	
  1.0080

  	
   

  
	
  U9

  	
   

  	
  1.0210

  	
   

  	
  1.0141

  	
   

  
	
  HV

  	
   

  	
  1.0907

  	
   

  	
  1.0107

  	
   

  
	
  HW

  	
   

  	
  1.0524

  	
   

  	
  0.9681

  	
   

  
	
  W1

  	
   

  	
  1.0542

  	
   

  	
  0.9681

  	
   

  
	
  W2

  	
   

  	
  1.0067

  	
   

  	
  1.0000

  	
   

  

 

48

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W3

  	
   

  	
  0.9715

  	
   

  	
  1.0128

  	
   

  
	
  W4

  	
   

  	
  0.9287

  	
   

  	
  0.9680

  	
   

  
	
  W5

  	
   

  	
  1.0266

  	
   

  	
  1.0095

  	
   

  
	
  W6

  	
   

  	
  0.9649

  	
   

  	
  0.9806

  	
   

  
	
  W7

  	
   

  	
  0.98?9

  	
   

  	
  0.9941

  	
   

  
	
  W8

  	
   

  	
  1.0162

  	
   

  	
  0.9776

  	
   

  
	
  W9

  	
   

  	
  0.9112

  	
   

  	
  0.9774

  	
   

  
	
  HX

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  X1

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  X2

  	
   

  	
  0.9533

  	
   

  	
  0.9295

  	
   

  
	
  X3

  	
   

  	
  0.9500

  	
   

  	
  0.9398

  	
   

  
	
  X4

  	
   

  	
  0.9821

  	
   

  	
  0.9058

  	
   

  
	
  X5

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  X6

  	
   

  	
  1.0240

  	
   

  	
  1.0076

  	
   

  
	
  X7

  	
   

  	
  0.9095

  	
   

  	
  0.9774

  	
   

  
	
  X8

  	
   

  	
  1.0043

  	
   

  	
  0.9779

  	
   

  
	
  X9

  	
   

  	
  0.9095

  	
   

  	
  0.9627

  	
   

  
	
  HY

  	
   

  	
  0.8997

  	
   

  	
  0.8921

  	
   

  
	
  Y1

  	
   

  	
  0.9145

  	
   

  	
  0.9280

  	
   

  
	
  Y2

  	
   

  	
  0.8997

  	
   

  	
  0.9293

  	
   

  
	
  Y3

  	
   

  	
  0.9145

  	
   

  	
  0.9674

  	
   

  
	
  Y4

  	
   

  	
  0.9178

  	
   

  	
  0.9674

  	
   

  
	
  Y5

  	
   

  	
  0.9714

  	
   

  	
  0.9282

  	
   

  
	
  Y6

  	
   

  	
  0.8997

  	
   

  	
  0.9396

  	
   

  
	
  Y7

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  Y8

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  Y9

  	
   

  	
  0.9985

  	
   

  	
  1.0000

  	
   

  
	
  ZA

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZB

  	
   

  	
  0.9934

  	
   

  	
  0.8655

  	
   

  
	
  ZC

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZG

  	
   

  	
  0.9934

  	
   

  	
  0.9673

  	
   

  
	
  ZK

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  
	
  ZM

  	
   

  	
  1.0941

  	
   

  	
  0.9903

  	
   

  
	
  ZN

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  ZO

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  ZS

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  
	
  ZZ

  	
   

  	
  0.9870

  	
   

  	
  0.9780

  	
   

  
	
  1A

  	
   

  	
  0.9803

  	
   

  	
  0.9966

  	
   

  
	
  1B

  	
   

  	
  1.0012

  	
   

  	
  1.0012

  	
   

  
	
  1C

  	
   

  	
  1.0311

  	
   

  	
  1.0012

  	
   

  
	
  1D

  	
   

  	
  0.9805

  	
   

  	
  1.0064

  	
   

  
	
  1E

  	
   

  	
  1.0186

  	
   

  	
  1.0056

  	
   

  
	
  1F

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  
	
  1G

  	
   

  	
  1.0149

  	
   

  	
  1.0004

  	
   

  
	
  1H

  	
   

  	
  1.01?2

  	
   

  	
  0.9228

  	
   

  
	
  1J

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  
	
  1K

  	
   

  	
  1.0138

  	
   

  	
  1.0056

  	
   

  	 

	
  1L

  	
   

  	
  1.0292

  	
   

  	
  1.0021

  	
   

  	 

	
  1M

  	
   

  	
  1.0152

  	
   

  	
  0.9854

  	
   

  	 

	
  1N

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  	 

	
  1P

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  	 

	
  1Q

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  	 

	
  1R

  	
   

  	
  1.0863

  	
   

  	
  1.0064

  	
   

  	 

	
  1S

  	
   

  	
  0.9661

  	
   

  	
  0.9820

  	
   

  	 

	
  1T

  	
   

  	
  0.9629

  	
   

  	
  0.9820

  	
   

  	 

	
  1U

  	
   

  	
  0.9208

  	
   

  	
  0.9617

  	
   

  	 

	
  1V

  	
   

  	
  1.0337

  	
   

  	
  0.9678

  	
   

  	 

	
  1W

  	
   

  	
  0.9661

  	
   

  	
  1.0012

  	
   

  	 

	
  1X

  	
   

  	
  1.0187

  	
   

  	
  1.0012

  	
   

  	 

	
  1Y

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  	 

	
  1Z

  	
   

  	
  1.0119

  	
   

  	
  0.9582

  	
   

  	 

	
  2A

  	
   

  	
  0.9661

  	
   

  	
  0.9228

  	
   

  	 

	
  2B

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  	 

	
  2C

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  	 

	
  2D

  	
   

  	
  0.9181

  	
   

  	
  0.9228

  	
   

  	 

	
  2E

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  	 

	
  2F

  	
   

  	
  1.0091

  	
   

  	
  1.0000

  	
   

  	 

	
  6A

  	
   

  	
  1.0514

  	
   

  	
  0.9725

  	
   

  	 

	
  6G

  	
   

  	
  0.9452

  	
   

  	
  0.9673

  	
   

  	 

	
  6H

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  	 

	
  6R

  	
   

  	
  0.9485

  	
   

  	
  0.9776

  	
   

  	 

	
  6S

  	
   

  	
  0.9452

  	
   

  	
  0.9398

  	
   

  	 

	
  6T

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	 

	
  6V

  	
   

  	
  0.9452

  	
   

  	
  0.9625

  	
   

  	 

	
  6W

  	
   

  	
  0.9851

  	
   

  	
  0.9819

  	
   

  	 

	
  6Z

  	
   

  	
  0.9524

  	
   

  	
  0.8651

  	
   

  	 

	
  7C

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	 

	
  7E

  	
   

  	
  0.9987

  	
   

  	
  0.9776

  	
   

  	 

	
  7F

  	
   

  	
  0.8921

  	
   

  	
  0.90?5

  	
   

  	 

	
  7G

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  	 

	
  7H

  	
   

  	
  0.9452

  	
   

  	
  0.9319

  	
   

  	 

	
  7I

  	
   

  	
  0.9988

  	
   

  	
  0.9776

  	
   

  	 

	
  7J

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  	 

	
  7K

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	 

	
  7L

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  	 

	
  7M

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	 

	
  7N

  	
   

  	
  0.9836

  	
   

  	
  0.9779

  	
   

  	 

	
  7O

  	
   

  	
  0.8981

  	
   

  	
  0.9774

  	
   

  	 

	
  7Q

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	 

	
  7R

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	 

	
  7S

  	
   

  	
  0.8884

  	
   

  	
  0.9396

  	
   

  	 

	
  7T

  	
   

  	
  0.9452

  	
   

  	
  0.9474

  	
   

  	 

	
  7U

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	 

	
  7V

  	
   

  	
  0.9934

  	
   

  	
  0.9399

  	
   

  	 

	
  7W

  	
   

  	
  0.9452

  	
   

  	
  0.9399

  	
   

  	 

	
  7X

  	
   

  	
  1.0942

  	
   

  	
  0.9903

  	
   

  	 

	
  7Y

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  	 

	
  7Z

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  	 

	
  9A

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  	 

	
  9B

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	 

	
  9C

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	 

	
  9E

  	
   

  	
  0.9908

  	
   

  	
  0.9780

  	
   

  	 

	
  9F

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  	 

	
  9G

  	
   

  	
  1.0012

  	
   

  	
  0.9776

  	
   

  	 

	
  9H

  	
   

  	
  0.9967

  	
   

  	
  0.9805

  	
   

  	 

	
  9I

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  	 

	
  9J

  	
   

  	
  0.9084

  	
   

  	
  0.8363

  	
   

  	 

	
  9M

  	
   

  	
  0.9967

  	
   

  	
  0.9777

  	
   

  	 

	
  9N

  	
   

  	
  0.9485

  	
   

  	
  0.9398

  	
   

  	 

	
  9O

  	
   

  	
  0.9560

  	
   

  	
  0.9776

  	
   

  	 

	
  9P

  	
   

  	
  0.9876

  	
   

  	
  0.9795

  	
   

  	 

	
  9Q

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	 

	
  9R

  	
   

  	
  0.9970

  	
   

  	
  0.9849

  	
   

  	 

	
  9S

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  	 

	
  9T

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  	 

	
  9U

  	
   

  	
  0.9866

  	
   

  	
  0.9811

  	
   

  	 

	
  9W

  	
   

  	
  0.9460

  	
   

  	
  0.9592

  	
   

  	 

	
  9X

  	
   

  	
  0.9014

  	
   

  	
  0.9776

  	
   

  	 

	
  9Y

  	
   

  	
  1.0327

  	
   

  	
  0.9334

  	
   

  	 

 

49

 

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

September 1, 1998

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.9958

  	
   

  	
  1.0075

  	
   

  
	
  C5

  	
   

  	
  0.9016

  	
   

  	
  0.9893

  	
   

  
	
  Q1

  	
   

  	
  0.9877

  	
   

  	
  0.9749

  	
   

  
	
  Q2

  	
   

  	
  0.9350

  	
   

  	
  0.9367

  	
   

  
	
  Q3

  	
   

  	
  0.8834

  	
   

  	
  0.8703

  	
   

  
	
  Q4

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q5

  	
   

  	
  0.9958

  	
   

  	
  1.0103

  	
   

  
	
  Q6

  	
   

  	
  0.9016

  	
   

  	
  0.9921

  	
   

  
	
  Q7

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q8

  	
   

  	
  0.9350

  	
   

  	
  0.9747

  	
   

  
	
  QT

  	
   

  	
  0.9867

  	
   

  	
  1.0057

  	
   

  
	
  QU

  	
   

  	
  0.8977

  	
   

  	
  0.9898

  	
   

  
	
  QV

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QW

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QX

  	
   

  	
  0.9476

  	
   

  	
  0.9927

  	
   

  
	
  QY

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  QZ

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  V1

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  
								

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

Medicare Supplement HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan

  	
   

  	
  1.2018

  	
   

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1169

  	
   

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6326

  	
   

  

 

Medicare Supplement POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1169

  	
   

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6326

  	
   

  

 

50

 

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

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9217

  	
   

  
	
  AD

  	
   

  	
  0.9217

  	
   

  
	
  AG

  	
   

  	
  0.8723

  	
   

  
	
  AH

  	
   

  	
  0.9217

  	
   

  
	
  AJ

  	
   

  	
  0.8723

  	
   

  
	
  AW

  	
   

  	
  0.9217

  	
   

  
	
  BA

  	
   

  	
  0.9357

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  
	
  BD

  	
   

  	
  0.9334

  	
   

  
	
  BE

  	
   

  	
  0.9459

  	
   

  
	
  BF

  	
   

  	
  0.8723

  	
   

  
	
  BG

  	
   

  	
  0.8965

  	
   

  
	
  BH

  	
   

  	
  0.9334

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  
	
  BK

  	
   

  	
  1.0184

  	
   

  
	
  BL

  	
   

  	
  0.9942

  	
   

  
	
  BM

  	
   

  	
  1.0036

  	
   

  
	
  BN

  	
   

  	
  0.8965

  	
   

  
	
  BO

  	
   

  	
  0.9629

  	
   

  
	
  BP

  	
   

  	
  0.8965

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  
	
  BR

  	
   

  	
  0.9820

  	
   

  
	
  BS

  	
   

  	
  0.9348

  	
   

  
	
  BT

  	
   

  	
  0.8854

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  
	
  BV

  	
   

  	
  0.9030

  	
   

  
	
  BW

  	
   

  	
  0.9655

  	
   

  
	
  BX

  	
   

  	
  0.9220

  	
   

  
	
  BY

  	
   

  	
  0.9612

  	
   

  
	
  BZ

  	
   

  	
  0.9553

  	
   

  
	
  CA

  	
   

  	
  1.0004

  	
   

  
	
  CB

  	
   

  	
  1.0121

  	
   

  
	
  CC

  	
   

  	
  0.9763

  	
   

  
	
  CD

  	
   

  	
  0.9879

  	
   

  
	
  CE

  	
   

  	
  0.9425

  	
   

  
	
  CF

  	
   

  	
  0.9541

  	
   

  
	
  CG

  	
   

  	
  0.9183

  	
   

  
	
  CH

  	
   

  	
  0.9300

  	
   

  
	
  CI

  	
   

  	
  0.8916

  	
   

  
	
  CJ

  	
   

  	
  0.9033

  	
   

  
	
  CK

  	
   

  	
  0.8675

  	
   

  
	
  CL

  	
   

  	
  0.8791

  	
   

  
	
  CM

  	
   

  	
  0.8499

  	
   

  
	
  CN

  	
   

  	
  0.8615

  	
   

  
	
  CO

  	
   

  	
  0.8257

  	
   

  
	
  CP

  	
   

  	
  0.8374

  	
   

  
	
  DA

  	
   

  	
  0.9499

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  
	
  DC

  	
   

  	
  0.9459

  	
   

  
	
  DD

  	
   

  	
  0.8965

  	
   

  
	
  DE

  	
   

  	
  0.9490

  	
   

  
	
  DF

  	
   

  	
  0.9490

  	
   

  
	
  DG

  	
   

  	
  0.8996

  	
   

  
	
  DH

  	
   

  	
  0.9459

  	
   

  
	
  DI

  	
   

  	
  0.9459

  	
   

  
	
  DJ

  	
   

  	
  0.8965

  	
   

  
	
  DK

  	
   

  	
  0.8965

  	
   

  
	
  DL

  	
   

  	
  0.9490

  	
   

  
	
  DM

  	
   

  	
  0.8965

  	
   

  
	
  DN

  	
   

  	
  0.8541

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  
	
  DP

  	
   

  	
  0.9897

  	
   

  
	
  DQ

  	
   

  	
  0.9729

  	
   

  
	
  DR

  	
   

  	
  0.9334

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  
	
  DT

  	
   

  	
  0.9081

  	
   

  
	
  DU

  	
   

  	
  0.8840

  	
   

  
	
  DV

  	
   

  	
  0.9851

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  
	
  DX

  	
   

  	
  0.9220

  	
   

  
	
  DY

  	
   

  	
  0.9459

  	
   

  
	
  DZ

  	
   

  	
  1.0024

  	
   

  
	
  FN

  	
   

  	
  0.9928

  	
   

  
	
  FO

  	
   

  	
  0.9928

  	
   

  
	
  FP

  	
   

  	
  0.9436

  	
   

  
	
  FQ

  	
   

  	
  0.9436

  	
   

  
	
  FR

  	
   

  	
  0.9902

  	
   

  
	
  FS

  	
   

  	
  0.9851

  	
   

  
	
  FT

  	
   

  	
  0.9843

  	
   

  
	
  FU

  	
   

  	
  0.9939

  	
   

  
	
  FV

  	
   

  	
  0.9825

  	
   

  
	
  FW

  	
   

  	
  0.9885

  	
   

  
	
  FX

  	
   

  	
  0.9806

  	
   

  
	
  FY

  	
   

  	
  0.9516

  	
   

  
	
  FZ

  	
   

  	
  0.9567

  	
   

  
	
  GA

  	
   

  	
  0.9334

  	
   

  
	
  GB

  	
   

  	
  0.8965

  	
   

  
	
  GK

  	
   

  	
  0.9459

  	
   

  
	
  KA

  	
   

  	
  0.9939

  	
   

  
	
  KB

  	
   

  	
  0.9616

  	
   

  
	
  KC

  	
   

  	
  1.0027

  	
   

  
	
  LA

  	
   

  	
  0.9487

  	
   

  
	
  LB

  	
   

  	
  0.9459

  	
   

  
	
  LC

  	
   

  	
  0.9459

  	
   

  
	
  LD

  	
   

  	
  0.9487

  	
   

  
	
  LE

  	
   

  	
  0.9487

  	
   

  
	
  LF

  	
   

  	
  0.9487

  	
   

  
	
  LG

  	
   

  	
  0.8993

  	
   

  
	
  LH

  	
   

  	
  0.9459

  	
   

  
	
  LI

  	
   

  	
  0.9487

  	
   

  
	
  LJ

  	
   

  	
  0.8993

  	
   

  
	
  LK

  	
   

  	
  0.8723

  	
   

  
	
  LL

  	
   

  	
  0.9459

  	
   

  
	
  LM

  	
   

  	
  0.9217

  	
   

  
	
  LN

  	
   

  	
  0.9487

  	
   

  
	
  LP

  	
   

  	
  0.9459

  	
   

  
	
  LQ

  	
   

  	
  0.8993

  	
   

  
	
  LR

  	
   

  	
  0.9487

  	
   

  
	
  LS

  	
   

  	
  0.8965

  	
   

  
	
  LT

  	
   

  	
  0.8572

  	
   

  
	
  LU

  	
   

  	
  0.8965

  	
   

  
	
  LV

  	
   

  	
  0.9487

  	
   

  
	
  LW

  	
   

  	
  0.9487

  	
   

  
	
  LX

  	
   

  	
  0.8965

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  
	
  LZ

  	
   

  	
  0.8541

  	
   

  
	
  NP

  	
   

  	
  0.9897

  	
   

  
	
  OA

  	
   

  	
  0.9234

  	
   

  
	
  OB

  	
   

  	
  0.9217

  	
   

  
	
  OC

  	
   

  	
  0.9217

  	
   

  
	
  OD

  	
   

  	
  0.9092

  	
   

  
	
  OE

  	
   

  	
  0.9036

  	
   

  
	
  OF

  	
   

  	
  0.9490

  	
   

  
	
  OG

  	
   

  	
  0.9655

  	
   

  
	
  OK

  	
   

  	
  0.8723

  	
   

  
	
  OL

  	
   

  	
  0.9217

  	
   

  
	
  OM

  	
   

  	
  0.9217

  	
   

  
	
  ON

  	
   

  	
  0.9217

  	
   

  
	
  OO

  	
   

  	
  0.9217

  	
   

  
	
  OP

  	
   

  	
  0.9217

  	
   

  
	
  OQ

  	
   

  	
  0.9217

  	
   

  
	
  OR

  	
   

  	
  0.9578

  	
   

  
	
  OS

  	
   

  	
  0.9217

  	
   

  
	
  OT

  	
   

  	
  1.0178

  	
   

  
	
  OU

  	
   

  	
  0.9575

  	
   

  
	
  OV

  	
   

  	
  0.9107

  	
   

  
	
  OW

  	
   

  	
  0.9217

  	
   

  
	
  OX

  	
   

  	
  0.9217

  	
   

  
	
  OY

  	
   

  	
  0.9217

  	
   

  
	
  OZ

  	
   

  	
  0.9217

  	
   

  
	
  PA

  	
   

  	
  0.9217

  	
   

  
	
  PB

  	
   

  	
  0.9067

  	
   

  
	
  PC

  	
   

  	
  0.9232

  	
   

  
	
  PD

  	
   

  	
  0.8737

  	
   

  
	
  PE

  	
   

  	
  0.9217

  	
   

  
	
  PF

  	
   

  	
  0.9914

  	
   

  
	
  PG

  	
   

  	
  1.0522

  	
   

  
	
  PH

  	
   

  	
  0.9612

  	
   

  
	
  PI

  	
   

  	
  0.9655

  	
   

  
	
  PJ

  	
   

  	
  0.9487

  	
   

  
	
  PK

  	
   

  	
  0.9459

  	
   

  
	
  PL

  	
   

  	
  0.9183

  	
   

  
	
  PM

  	
   

  	
  0.9334

  	
   

  
	
  PN

  	
   

  	
  0.9217

  	
   

  
	
  PO

  	
   

  	
  0.9334

  	
   

  
	
  PP

  	
   

  	
  1.0701

  	
   

  
	
  PQ

  	
   

  	
  0.9217

  	
   

  
	
  PR

  	
   

  	
  0.9334

  	
   

  
	
  PS

  	
   

  	
  1.0013

  	
   

  
	
  PT

  	
   

  	
  0.9183

  	
   

  
	
  PU

  	
   

  	
  0.9297

  	
   

  
	
  PV

  	
   

  	
  0.8979

  	
   

  
	
  PW

  	
   

  	
  1.0269

  	
   

  
	
  PX

  	
   

  	
  0.9490

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  
	
  PZ

  	
   

  	
  0.9095

  	
   

  
	
  XA

  	
   

  	
  0.9217

  	
   

  
	
  XB

  	
   

  	
  0.8371

  	
   

  
	
  XC

  	
   

  	
  0.9402

  	
   

  
	
  XD

  	
   

  	
  0.9459

  	
   

  
	
  XE

  	
   

  	
  0.9573

  	
   

  
	
  XF

  	
   

  	
  0.9246

  	
   

  
	
  XG

  	
   

  	
  1.1008

  	
   

  
	
  XI

  	
   

  	
  1.1008

  	
   

  
	
  XJ

  	
   

  	
  0.8743

  	
   

  
	
  XK

  	
   

  	
  0.9698

  	
   

  
	
  XL

  	
   

  	
  0.9962

  	
   

  
	
  XM

  	
   

  	
  0.9575

  	
   

  
	
  XN

  	
   

  	
  0.9220

  	
   

  
	
  XO

  	
   

  	
  0.8683

  	
   

  
	
  XP

  	
   

  	
  0.9740

  	
   

  
	
  XQ

  	
   

  	
  0.8746

  	
   

  
	
  XR

  	
   

  	
  0.8464

  	
   

  
	
  XS

  	
   

  	
  0.9408

  	
   

  
	
  XT

  	
   

  	
  0.9220

  	
   

  
	
  XU

  	
   

  	
  0.9220

  	
   

  
	
  XV

  	
   

  	
  0.9220

  	
   

  
	
  XW

  	
   

  	
  0.9220

  	
   

  
	
  XY

  	
   

  	
  0.9743

  	
   

  

 

51

 

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

 

Small Group POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9857

  	
   

  
	
  QB

  	
   

  	
  0.9285

  	
   

  
	
  QC

  	
   

  	
  0.8447

  	
   

  

 

52

 

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

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9215

  	
   

  	
  0.9500

  	
   

  
	
  AD

  	
   

  	
  0.9215

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8714

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8714

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9355

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9330

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9457

  	
   

  	
  0.9489

  	
   

  
	
  BF

  	
   

  	
  0.8714

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.8956

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9330

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0192

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9947

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  1.0039

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.8956

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9662

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.8956

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9821

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9345

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.8854

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9025

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9653

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9218

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9552

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  1.0007

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  1.0126

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9765

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9881

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0.9423

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9538

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9178

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9296

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8907

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.9022

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8662

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8780

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8480

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8598

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8238

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8353

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9458

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.8961

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.8992

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9458

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.8961

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.8961

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9489

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.8961

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8535

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9730

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9332

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9078

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.8835

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9850

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9218

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  1.0038

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9961

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9961

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9447

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9447

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9915

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9864

  	
   

  	
  0.9254

  	
   

  
	
  FT

  	
   

  	
  0.9855

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9952

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9858

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9898

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9784

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9527

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9578

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9332

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.8961

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9457

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9952

  	
   

  	
  0.9125

  	
   

  
	
  KB

  	
   

  	
  0.9609

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  1.0041

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9457

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9489

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9489

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.8987

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9489

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.8987

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8714

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9215

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9483

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9457

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.8987

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9489

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.8956

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8558

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.8656

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9486

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9489

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.8956

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8526

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  OA

  	
   

  	
  0.9232

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9215

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9085

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9028

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9492

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9693

  	
   

  	
  0.9138

  	
   

  
	
  OK

  	
   

  	
  0.8714

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9215

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9215

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OO

  	
   

  	
  0.9215

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OQ

  	
   

  	
  0.9215

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9575

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9215

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0238

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9572

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9100

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9215

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9215

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9215

  	
   

  	
  0.93?3

  	
   

  
	
  PA

  	
   

  	
  0.9215

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9062

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9229

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8728

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9215

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9918

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0584

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9653

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9489

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9330

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9215

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9330

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0711

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9215

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9330

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  1.0016

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9800

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.8970

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0275

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9492

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9088

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9215

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8405

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9399

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9457

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9569

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9244

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.1022

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.1022

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8734

  	
   

  	
  0.8276

  	
   

  
	
  XK

  	
   

  	
  0.9699

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  1.0039

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9572

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9248

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8722

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9742

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8741

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8509

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9407

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9218

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9218

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9218

  	
   

  	
  0.9113

  	
   

  
	
  XW

  	
   

  	
  0.9218

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9744

  	
   

  	
  0.8502

  	
   

  

 

53

 

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

Effective July 1, 1998

 

Small Group POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9862

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9282

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8430

  	
   

  	
  0.7381

  	
   

  

 

55

 

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

Effective September 1, 1998

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  AD

  	
   

  	
  0.9452

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8981

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8981

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9480

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9485

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.8981

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9485

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9747

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9966

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  0.9904

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.9095

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9792

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9485

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.9014

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9747

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9271

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9452

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9500

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  0.9950

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  0.9983

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9817

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9870

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0,9432

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9465

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9318

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9351

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8924

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.8057

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8811

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8844

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8440

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8473

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8326

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8359

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.9095

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9714

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9795

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9892

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9485

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9747

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9128

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.9014

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9788

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  0.9886

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9832

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9832

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9347

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9347

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9808

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9621

  	
   

  	
  0.9254

  	
   

  
	
  FT

  	
   

  	
  0.9619

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9743

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9813

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9667

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9565

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9394

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9421

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9485

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9567

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9823

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9730

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  0.9850

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9566

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9714

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9714

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9714

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.9243

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8981

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9452

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9452

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9566

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.9243

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9714

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8658

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.9095

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9584

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9714

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9599

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9777

  	
   

  	
  0.9105

  	
   

  
	
  OA

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9128

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9112

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9714

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9492

  	
   

  	
  0.9118

  	
   

  
	
  OK

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9452

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9452

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9452

  	
   

  	
  0.9??6

  	
   

  
	
  OO

  	
   

  	
  0.9452

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9452

  	
   

  	
  0.9226

  	
   

  
	
  QQ

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9460

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9452

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0098

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9526

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9124

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9452

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9452

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9452

  	
   

  	
  0.9313

  	
   

  
	
  PA

  	
   

  	
  0.9452

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9?07

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9453

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9960

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0367

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9402

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9714

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9485

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9452

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9485

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0313

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9452

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9485

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  0.9934

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9933

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.9095

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0270

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9714

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9599

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9128

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8298

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9566

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9422

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.0793

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.0793

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8981

  	
   

  	
  0.8275

  	
   

  
	
  XK

  	
   

  	
  0.9782

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9452

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8564

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9810

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8981

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8493

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9681

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9452

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9452

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9452

  	
   

  	
  0.9112

  	
   

  
	
  XW

  	
   

  	
  0.9452

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9752

  	
   

  	
  0.8502

  	
   

  

 

56

 

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

Effective September 1, 1998

 

Small Group POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9877

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9360

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8346

  	
   

  	
  0.7381

  	
   

  

 

57

 

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

 

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

 

	
  Age

  	
   

  	
  Male

  	
   

  	
  Female

  	
   

  
	
  0

  	
   

  	
  0.231

  	
   

  	
  0.231

  	
   

  
	
  1

  	
   

  	
  0.366

  	
   

  	
  0.366

  	
   

  
	
  2 - 4

  	
   

  	
  0.323

  	
   

  	
  0.323

  	
   

  
	
  5 - 9

  	
   

  	
  0.289

  	
   

  	
  0.289

  	
   

  
	
  111 - 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

  	
   

  

 

58

 

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

 

	
  Plan

  	
   

  	
  Factor

  	
   

  
	
  01

  	
   

  	
  1.3376

  	
   

  
	
  02

  	
   

  	
  0.?000

  	
   

  
	
  03

  	
   

  	
  0.6448

  	
   

  
	
  04

  	
   

  	
  1.1000

  	
   

  
	
  05

  	
   

  	
  0.7255

  	
   

  
	
  06

  	
   

  	
  1.1102

  	
   

  
	
  07

  	
   

  	
  0.6448

  	
   

  
	
  08

  	
   

  	
  1.1000

  	
   

  
	
  09

  	
   

  	
  1.1000

  	
   

  
	
  OA

  	
   

  	
  1.7495

  	
   

  
	
  OB

  	
   

  	
  1.6378

  	
   

  
	
  OC

  	
   

  	
  1.7578

  	
   

  
	
  OD

  	
   

  	
  1.6457

  	
   

  
	
  OE

  	
   

  	
  1.7827

  	
   

  
	
  OF

  	
   

  	
  0.5134

  	
   

  
	
  OG

  	
   

  	
  0.9368

  	
   

  
	
  OH

  	
   

  	
  0.7255

  	
   

  
	
  01

  	
   

  	
  0.8948

  	
   

  
	
  01

  	
   

  	
  1.7578

  	
   

  
	
  OP

  	
   

  	
  1.1577

  	
   

  
	
  OR

  	
   

  	
  1.1577

  	
   

  
	
  OS

  	
   

  	
  1.0470

  	
   

  
	
  OT

  	
   

  	
  0.6771

  	
   

  
	
  OU

  	
   

  	
  1.1577

  	
   

  
	
  OV

  	
   

  	
  1.1577

  	
   

  
	
  OW

  	
   

  	
  0.7232

  	
   

  
	
  OX

  	
   

  	
  0.9409

  	
   

  
	
  OY

  	
   

  	
  0.6411

  	
   

  
	
  OZ

  	
   

  	
  1.0945

  	
   

  
	
  10

  	
   

  	
  0.7564

  	
   

  
	
  11

  	
   

  	
  0.5166

  	
   

  
	
  12

  	
   

  	
  0.4105

  	
   

  
	
  13

  	
   

  	
  0.4806

  	
   

  
	
  14

  	
   

  	
  0.5590

  	
   

  
	
  16

  	
   

  	
  1.0821

  	
   

  
	
  17

  	
   

  	
  0.6411

  	
   

  
	
  18

  	
   

  	
  0.7292

  	
   

  
	
  19

  	
   

  	
  1.1000

  	
   

  
	
  1A

  	
   

  	
  1.6037

  	
   

  
	
  1B

  	
   

  	
  1.5013

  	
   

  
	
  1C

  	
   

  	
  1.6115

  	
   

  
	
  1D

  	
   

  	
  1.5087

  	
   

  
	
  1E

  	
   

  	
  1.1102

  	
   

  
	
  1F

  	
   

  	
  1.1102

  	
   

  
	
  1G

  	
   

  	
  0.7412

  	
   

  
	
  1H

  	
   

  	
  0.7412

  	
   

  
	
  1I

  	
   

  	
  1.1102

  	
   

  
	
  1J

  	
   

  	
  0.7564

  	
   

  
	
  K

  	
   

  	
  1.1102

  	
   

  
	
  1L

  	
   

  	
  0.8989

  	
   

  
	
  1M

  	
   

  	
  0.7564

  	
   

  
	
  1N

  	
   

  	
  0.8625

  	
   

  
	
  1O

  	
   

  	
  0.6845

  	
   

  
	
  1P

  	
   

  	
  0.5991

  	
   

  
	
  1Q

  	
   

  	
  1.1000

  	
   

  
	
  1R

  	
   

  	
  0.9368

  	
   

  
	
  1S

  	
   

  	
  1.0945

  	
   

  
	
  1T

  	
   

  	
  1.1157

  	
   

  
	
  1U

  	
   

  	
  0.9119

  	
   

  
	
  1V

  	
   

  	
  1.1000

  	
   

  
	
  1W

  	
   

  	
  1.1102

  	
   

  
	
  1X

  	
   

  	
  0.8989

  	
   

  
	
  1Y

  	
   

  	
  1.2135

  	
   

  
	
  1Z

  	
   

  	
  1.1000

  	
   

  
	
  20

  	
   

  	
  0.7292

  	
   

  
	
  23

  	
   

  	
  0.9368

  	
   

  
	
  24

  	
   

  	
  1.1157

  	
   

  
	
  26

  	
   

  	
  1.1000

  	
   

  
	
  2A

  	
   

  	
  1.4635

  	
   

  
	
  2B

  	
   

  	
  1.3699

  	
   

  
	
  2C

  	
   

  	
  1.4704

  	
   

  
	
  2D

  	
   

  	
  1.3768

  	
   

  
	
  2E

  	
   

  	
  1.4912

  	
   

  
	
  2F

  	
   

  	
  0.9409

  	
   

  
	
  2G

  	
   

  	
  0.6448

  	
   

  
	
  2G

  	
   

  	
  1.1000

  	
   

  
	
  2I

  	
   

  	
  0.6448

  	
   

  
	
  2J

  	
   

  	
  0.6882

  	
   

  
	
  2?

  	
   

  	
  1.1761

  	
   

  
	
  2M

  	
   

  	
  1.1157

  	
   

  
	
  2N

  	
   

  	
  1.1157

  	
   

  
	
  2O

  	
   

  	
  0.7412

  	
   

  
	
  2P

  	
   

  	
  1.1577

  	
   

  
	
  2Q

  	
   

  	
  1.1102

  	
   

  
	
  2R

  	
   

  	
  1.1102

  	
   

  
	
  2S

  	
   

  	
  0.8989

  	
   

  
	
  2T

  	
   

  	
  0.7292

  	
   

  
	
  2U

  	
   

  	
  0.8989

  	
   

  
	
  2V

  	
   

  	
  0.7269

  	
   

  
	
  2W

  	
   

  	
  0.8989

  	
   

  
	
  2X

  	
   

  	
  0.6448

  	
   

  
	
  2Y

  	
   

  	
  0.7269

  	
   

  
	
  2Z

  	
   

  	
  1.2135

  	
   

  
	
  30

  	
   

  	
  1.1102

  	
   

  
	
  31

  	
   

  	
  1.1102

  	
   

  
	
  32

  	
   

  	
  0.7255

  	
   

  
	
  33

  	
   

  	
  0.7269

  	
   

  
	
  34

  	
   

  	
  1.1102

  	
   

  
	
  35

  	
   

  	
  0.1102

  	
   

  
	
  36

  	
   

  	
  0.1102

  	
   

  
	
  37

  	
   

  	
  0.1102

  	
   

  
	
  38

  	
   

  	
  1.2135

  	
   

  
	
  39

  	
   

  	
  0.8791

  	
   

  
	
  3A

  	
   

  	
  1.3311

  	
   

  
	
  3B

  	
   

  	
  1.2458

  	
   

  
	
  3C

  	
   

  	
  1.3376

  	
   

  
	
  3D

  	
   

  	
  1.2518

  	
   

  
	
  3E

  	
   

  	
  1.3311

  	
   

  
	
  3F

  	
   

  	
  1.3376

  	
   

  
	
  3G

  	
   

  	
  1.3311

  	
   

  
	
  3?

  	
   

  	
  0.8989

  	
   

  
	
  3J

  	
   

  	
  0.8989

  	
   

  
	
  3K

  	
   

  	
  1.1157

  	
   

  
	
  3L

  	
   

  	
  0.6448

  	
   

  
	
  3M

  	
   

  	
  0.8671

  	
   

  
	
  3N

  	
   

  	
  1.2135

  	
   

  
	
  3O

  	
   

  	
  1.4704

  	
   

  
	
  3P

  	
   

  	
  0.8989

  	
   

  
	
  3Q

  	
   

  	
  1.4912

  	
   

  
	
  3R

  	
   

  	
  0.6882

  	
   

  
	
  3S

  	
   

  	
  0.5166

  	
   

  
	
  3T

  	
   

  	
  0.7292

  	
   

  
	
  3U

  	
   

  	
  1.6378

  	
   

  
	
  3V

  	
   

  	
  0.7255

  	
   

  
	
  3X

  	
   

  	
  0.7398

  	
   

  
	
  3Y

  	
   

  	
  0.9967

  	
   

  
	
  3Z

  	
   

  	
  0.5590

  	
   

  
	
  40

  	
   

  	
  0.7292

  	
   

  
	
  41

  	
   

  	
  0.9119

  	
   

  
	
  42

  	
   

  	
  1.1637

  	
   

  
	
  46

  	
   

  	
  1.1637

  	
   

  
	
  47

  	
   

  	
  1.3588

  	
   

  
	
  48

  	
   

  	
  0.9368

  	
   

  
	
  49

  	
   

  	
  1.2310

  	
   

  
	
  4A

  	
   

  	
  1.2080

  	
   

  
	
  4B

  	
   

  	
  1.1305

  	
   

  
	
  4E

  	
   

  	
  1.2015

  	
   

  
	
  4F

  	
   

  	
  1.2836

  	
   

  
	
  4G

  	
   

  	
  1.1000

  	
   

  
	
  4H

  	
   

  	
  1.1000

  	
   

  
	
  4I

  	
   

  	
  1.1102

  	
   

  
	
  4K

  	
   

  	
  1.0032

  	
   

  
	
  4L

  	
   

  	
  1.0945

  	
   

  
	
  4M

  	
   

  	
  0.9917

  	
   

  
	
  4N

  	
   

  	
  0.9331

  	
   

  
	
  4P

  	
   

  	
  0.9548

  	
   

  
	
  4Q

  	
   

  	
  0.9548

  	
   

  
	
  4R

  	
   

  	
  1.1000

  	
   

  
	
  4S

  	
   

  	
  1.1102

  	
   

  
	
  4T

  	
   

  	
  1.1000

  	
   

  
	
  4U

  	
   

  	
  0.7398

  	
   

  
	
  4V

  	
   

  	
  1.0945

  	
   

  
	
  4W

  	
   

  	
  1.2135

  	
   

  
	
  4X

  	
   

  	
  1.1000

  	
   

  
	
  4Y

  	
   

  	
  0.7369

  	
   

  
	
  51

  	
   

  	
  0.7255

  	
   

  
	
  52

  	
   

  	
  0.7292

  	
   

  
	
  53

  	
   

  	
  0.6448

  	
   

  
	
  54

  	
   

  	
  0.5166

  	
   

  
	
  55

  	
   

  	
  0.7292

  	
   

  
	
  56

  	
   

  	
  0.6448

  	
   

  
	
  57

  	
   

  	
  0.6166

  	
   

  
	
  58

  	
   

  	
  0.7255

  	
   

  
	
  59

  	
   

  	
  0.6448

  	
   

  
	
  5A

  	
   

  	
  1.0945

  	
   

  
	
  5B

  	
   

  	
  1.1157

  	
   

  
	
  5C

  	
   

  	
  1.1000

  	
   

  
	
  5D

  	
   

  	
  1.0299

  	
   

  
	
  5E

  	
   

  	
  1.0834

  	
   

  
	
  5F

  	
   

  	
  1.1577

  	
   

  
	
  5G

  	
   

  	
  1.1637

  	
   

  
	
  5H

  	
   

  	
  1.1798

  	
   

  
	
  5I

  	
   

  	
  1.1180

  	
   

  
	
  5J

  	
   

  	
  0.6005

  	
   

  
	
  5K

  	
   

  	
  1.1821

  	
   

  
	
  5L

  	
   

  	
  1.1577

  	
   

  
	
  5M

  	
   

  	
  1.1000

  	
   

  
	
  5N

  	
   

  	
  1.0834

  	
   

  
	
  5O

  	
   

  	
  0.7292

  	
   

  
	
  5P

  	
   

  	
  1.1577

  	
   

  
	
  5Q

  	
   

  	
  0.5973

  	
   

  
	
  5R

  	
   

  	
  0.7293

  	
   

  
	
  5S

  	
   

  	
  0.7255

  	
   

  
	
  5T

  	
   

  	
  1.1000

  	
   

  
	
  5U

  	
   

  	
  1.1157

  	
   

  
	
  5V

  	
   

  	
  1.1000

  	
   

  
	
  5W

  	
   

  	
  1.1157

  	
   

  
	
  5X

  	
   

  	
  0.7412

  	
   

  
	
  5Y

  	
   

  	
  0.7412

  	
   

  
	
  5Z

  	
   

  	
  1.7495

  	
   

  
	
  61

  	
   

  	
  1.1102

  	
   

  
	
  62

  	
   

  	
  1.1102

  	
   

  
	
  63

  	
   

  	
  1.7578

  	
   

  
	
  64

  	
   

  	
  0.9409

  	
   

  
	
  65

  	
   

  	
  0.7202

  	
   

  
	
  66

  	
   

  	
  1.1637

  	
   

  
	
  67

  	
   

  	
  1.1637

  	
   

  
	
  68

  	
   

  	
  1.1000

  	
   

  
	
  69

  	
   

  	
  0.8989

  	
   

  
	
  6A

  	
   

  	
  0.9917

  	
   

  
	
  6B

  	
   

  	
  1.1157

  	
   

  
	
  6C

  	
   

  	
  0.9967

  	
   

  
	
  6D

  	
   

  	
  1.0945

  	
   

  
	
  6E

  	
   

  	
  0.9750

  	
   

  
	
  6F

  	
   

  	
  1.0424

  	
   

  
	
  6G

  	
   

  	
  0.6005

  	
   

  
	
  6H

  	
   

  	
  1.1577

  	
   

  
	
  6I

  	
   

  	
  1.1102

  	
   

  
	
  6J

  	
   

  	
  1.1102

  	
   

  
	
  6K

  	
   

  	
  0.8989

  	
   

  
	
  6L

  	
   

  	
  0.8989

  	
   

  
	
  6M

  	
   

  	
  1.1180

  	
   

  
	
  6N

  	
   

  	
  1.1180

  	
   

  
	
  6O

  	
   

  	
  1.1102

  	
   

  
	
  6P

  	
   

  	
  1.0424

  	
   

  
	
  6Q

  	
   

  	
  0.9280

  	
   

  
	
  6R

  	
   

  	
  1.1037

  	
   

  
	
  6S

  	
   

  	
  0.8805

  	
   

  
	
  6T

  	
   

  	
  1.1102

  	
   

  
	
  6U

  	
   

  	
  1.1102

  	
   

  
	
  6V

  	
   

  	
  1.1102

  	
   

  
	
  6W

  	
   

  	
  1.1102

  	
   

  
	
  6X

  	
   

  	
  1.1102

  	
   

  
	
  6Y

  	
   

  	
  1.7578

  	
   

  
	
  6Z

  	
   

  	
  1.2241

  	
   

  
	
  71

  	
   

  	
  1.1102

  	
   

  
	
  72

  	
   

  	
  1.1102

  	
   

  
	
  73

  	
   

  	
  0.8948

  	
   

  
	
  74

  	
   

  	
  1.1102

  	
   

  
	
  75

  	
   

  	
  0.9368

  	
   

  
	
  76

  	
   

  	
  0.8989

  	
   

  
	
  77

  	
   

  	
  0.9368

  	
   

  
	
  78

  	
   

  	
  0.9400

  	
   

  
	
  79

  	
   

  	
  0.8048

  	
   

  
	
  7A

  	
   

  	
  0.8048

  	
   

  
	
  7B

  	
   

  	
  0.8371

  	
   

  
	
  7C

  	
   

  	
  0.8989

  	
   

  
	
  7D

  	
   

  	
  0.8268

  	
   

  
	
  7E

  	
   

  	
  0.8268

  	
   

  
	
  7F

  	
   

  	
  0.9368

  	
   

  
	
  7G

  	
   

  	
  0.9400

  	
   

  
	
  7H

  	
   

  	
  1.1102

  	
   

  
	
  7I

  	
   

  	
  1.1102

  	
   

  
	
  7J

  	
   

  	
  0.9409

  	
   

  
	
  7K

  	
   

  	
  0.9368

  	
   

  
	
  7L

  	
   

  	
  0.8989

  	
   

  
	
  7M

  	
   

  	
  0.8371

  	
   

  
	
  7N

  	
   

  	
  0.9368

  	
   

  
	
  7O

  	
   

  	
  0.8989

  	
   

  
	
  7P

  	
   

  	
  0.8948

  	
   

  
	
  7Q

  	
   

  	
  0.7527

  	
   

  
	
  7R

  	
   

  	
  1.7578

  	
   

  
	
  7S

  	
   

  	
  1.7578

  	
   

  
	
  7T

  	
   

  	
  1.1102

  	
   

  
	
  7U

  	
   

  	
  1.1102

  	
   

  
	
  7V

  	
   

  	
  1.1102

  	
   

  
	
  7W

  	
   

  	
  1.1102

  	
   

  
	
  7X

  	
   

  	
  1.1102

  	
   

  
	
  7Y

  	
   

  	
  1.1102

  	
   

  
	
  7Z

  	
   

  	
  1.7495

  	
   

  
	
  82

  	
   

  	
  1.1000

  	
   

  
	
  8A

  	
   

  	
  1.1102

  	
   

  
	
  8B

  	
   

  	
  0.8989

  	
   

  
	
  8C

  	
   

  	
  0.8948

  	
   

  
	
  8E

  	
   

  	
  0.7869

  	
   

  
	
  8F

  	
   

  	
  0.8404

  	
   

  
	
  8G

  	
   

  	
  1.1102

  	
   

  
	
  8H

  	
   

  	
  1.0032

  	
   

  
	
  8I

  	
   

  	
  0.8989

  	
   

  
	
  8J

  	
   

  	
  0.8989

  	
   

  
	
  8K

  	
   

  	
  0.8989

  	
   

  
	
  8L

  	
   

  	
  1.6115

  	
   

  
	
  8M

  	
   

  	
  0.9986

  	
   

  
	
  8N

  	
   

  	
  0.9548

  	
   

  
	
  8P

  	
   

  	
  1.1000

  	
   

  
	
  8R

  	
   

  	
  1.7864

  	
   

  
	
  8S

  	
   

  	
  1.0618

  	
   

  
	
  8T

  	
   

  	
  0.5590

  	
   

  
	
  8U

  	
   

  	
  1.6346

  	
   

  
	
  8V

  	
   

  	
  1.1637

  	
   

  
	
  8X

  	
   

  	
  0.6448

  	
   

  
	
  8Y

  	
   

  	
  0.7255

  	
   

  
	
  8Z

  	
   

  	
  0.7527

  	
   

  
	
  91

  	
   

  	
  1.2135

  	
   

  
	
  92

  	
   

  	
  1.1577

  	
   

  
	
  93

  	
   

  	
  0.7292

  	
   

  
	
  96

  	
   

  	
  0.9368

  	
   

  
	
  9A

  	
   

  	
  0.7232

  	
   

  
	
  9B

  	
   

  	
  0.6771

  	
   

  
	
  9C

  	
   

  	
  0.7269

  	
   

  
	
  9D

  	
   

  	
  0.7232

  	
   

  
	
  9E

  	
   

  	
  0.7048

  	
   

  
	
  9F

  	
   

  	
  0.7527

  	
   

  
	
  9G

  	
   

  	
  0.7564

  	
   

  
	
  9H

  	
   

  	
  0.7675

  	
   

  
	
  9I

  	
   

  	
  0.7260

  	
   

  
	
  9J

  	
   

  	
  0.7232

  	
   

  
	
  9L

  	
   

  	
  1.7495

  	
   

  
	
  9M

  	
   

  	
  0.6411

  	
   

  
	
  9N

  	
   

  	
  0.7048

  	
   

  
	
  9O

  	
   

  	
  0.6448

  	
   

  
	
  9P

  	
   

  	
  0.6411

  	
   

  
	
  9Q

  	
   

  	
  0.6411

  	
   

  
	
  9R

  	
   

  	
  0.7527

  	
   

  
	
  9S

  	
   

  	
  0.6411

  	
   

  
	
  9T

  	
   

  	
  0.9409

  	
   

  
	
  9U

  	
   

  	
  1.2135

  	
   

  
	
  9W

  	
   

  	
  0.6448

  	
   

  
	
  9X

  	
   

  	
  1.1102

  	
   

  
	
  9Y

  	
   

  	
  1.1000

  	
   

  
	
  9Z

  	
   

  	
  1.0424

  	
   

  
	
  A1

  	
   

  	
  1.7578

  	
   

  
	
  B1

  	
   

  	
  0.7292

  	
   

  
	
  B2

  	
   

  	
  0.7564

  	
   

  
	
  B3

  	
   

  	
  0.7564

  	
   

  
	
  B4

  	
   

  	
  0.7292

  	
   

  
	
  B5

  	
   

  	
  0.8989

  	
   

  
	
  B6

  	
   

  	
  1.1798

  	
   

  
	
  B7

  	
   

  	
  1.1617

  	
   

  
	
  B8

  	
   

  	
  0.7255

  	
   

  
	
  B9

  	
   

  	
  0.7255

  	
   

  
	
  C2

  	
   

  	
  0.6536

  	
   

  
	
  C3

  	
   

  	
  0.6536

  	
   

  
	
  C5

  	
   

  	
  0.9091

  	
   

  
	
  C7

  	
   

  	
  0.7202

  	
   

  
	
  C8

  	
   

  	
  0.7202

  	
   

  
	
  C9

  	
   

  	
  0.7412

  	
   

  
	
  D1

  	
   

  	
  0.7412

  	
   

  
	
  D2

  	
   

  	
  0.7292

  	
   

  
	
  D3

  	
   

  	
  0.7689

  	
   

  
	
  D4

  	
   

  	
  0.7689

  	
   

  
	
  D5

  	
   

  	
  0.7689

  	
   

  
	
  D6

  	
   

  	
  0.7195

  	
   

  
	
  E2

  	
   

  	
  0.7721

  	
   

  
	
  E3

  	
   

  	
  0.8989

  	
   

  
	
  E5

  	
   

  	
  0.7412

  	
   

  
	
  E7

  	
   

  	
  1.1157

  	
   

  
	
  F1

  	
   

  	
  0.7292

  	
   

  
	
  F3

  	
   

  	
  0.7412

  	
   

  
	
  F4

  	
   

  	
  0.7292

  	
   

  
	
  F7

  	
   

  	
  0.7398

  	
   

  
	
  I2

  	
   

  	
  1.0106

  	
   

  
	
  I3

  	
   

  	
  0.6171

  	
   

  
	
  18

  	
   

  	
  1.1798

  	
   

  
	
  19

  	
   

  	
  0.6448

  	
   

  
	
  OH

  	
   

  	
  0.7578

  	
   

  
	
  P3

  	
   

  	
  0.5134

  	
   

  
	
  P4

  	
   

  	
  0.6517

  	
   

  
	
  P9

  	
   

  	
  1.1157

  	
   

  
	
  Q4

  	
   

  	
  0.7255

  	
   

  
	
  S1

  	
   

  	
  1.1277

  	
   

  
	
  S2

  	
   

  	
  1.8025

  	
   

  
	
  S3

  	
   

  	
  0.8768

  	
   

  
	
  S4

  	
   

  	
  1.6378

  	
   

  
	
  S5

  	
   

  	
  1.1102

  	
   

  
	
  S6

  	
   

  	
  1.1102

  	
   

  
	
  S7

  	
   

  	
  1.7578

  	
   

  
	
  S8

  	
   

  	
  0.8768

  	
   

  
	
  S9

  	
   

  	
  1.7495

  	
   

  

 

59

 

ADDENDUM B.2

 

DIVISION OF RESPONSIBILITY

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

 

COMMERCIAL HMO AND POINT OF SERVICE BENEFIT PROGRAMS

 

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

 

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

  
	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS -  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  • In Area (30
  Mile Radius)
• Out of Area

  	
   

  	
  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD PRODUCTS

  • Blood Bank
•
  Autologous/Homologous
•
  Storage and Collection
  of Blood

  	
   

  	
  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  
	
  CHEMICAL DEPENDENCY

  • Inpatient
  Facility Component
• Inpatient Professional Component
• Outpatient Facility Component
• Outpatient Professional Component

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  
	
  CHEMOTHERAPY

  • Drugs, including Epogen, Nupogen and

    adjunctive therapies
• Facility Component
•
  Professional Component

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  	
   

  	
  ***

  ***

  ***

  ***

  ***

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

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

 

 

60

 

	
   

  	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYS1S

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

61

 

	
   

  	
   

  	
  PPG
  CAPITATED 

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED PHYSICIANS -
  Inpatient, Ambulatory
  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA MONITOR 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES, SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

62

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  PATHOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY - Inpatient, Ambulatory

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to an Outpatient Office Visit:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to a Hospital Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES, DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Chem. Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY: Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

63

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  TRANSPLANTS (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS – Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Exams and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

64

 

MATRIX EFFECTIVE 7/1/98

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAP1TATED

  SERVICES

  	
   

  
	
  AIDS
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS
  – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Storage and
  Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Drugs, including Epogen,
  Nupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare
  Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC SURGERY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC TESTING - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

65

 

	
   

  	
   

  	
  PPG CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  DURABLE MEDICAL
  EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY
  ADMISSIONS – Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM
  VISITS – In Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS – Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED
  PHYSICIANS -

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient, Ambulatory
  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  INFANT APNEA
  MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

66

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  INJECTIBLES, SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY - Deliveries and
  Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL
  HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY - Inpatient,
  Ambulatory

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Surgery or Emergency
  Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE
  ADMISSION - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Laboratory, X-ray

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  (within 72 hrs. or
  related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

67

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  RADIOLOGY
  - Inpatient, Ambulatory

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES-
  Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to an Outpatient
  Office Visit:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Splints, Casts, Bandages, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Related to a Hospital Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Surgical
  Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES, DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Chem. Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY: Physical,
  Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  – Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

68

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  VISION CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Exams and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

 

69

 

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

 

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

 

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

 

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

 

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

 

B.            MEDICARE HMO BENEFIT
PROGRAMS.

 

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

 

2.             Capitation:
PPG Capitated Services.

 

2.1          Compensation
for PPG Capitated Services.  As  compensation
for rendering PPG Capitated Services as defined herein, HMO shall pay PPG
Capitation at  forty-one and
eighty-eight one hundredths percent (41.88%) of Monthly Revenue as set forth
below for each Medicare HMO Member eligible to receive such services from PPG
during any particular month.  Capitation
shall be computed on the basis of the most current information available and
shall be paid by HMO by wire transfer on or before the fifteenth (15th) day of
each month or the first business day following the fifteenth if the fifteenth
is a holiday or on a weekend or within two (2) days of HCFA’s payment to HMO,
whichever is later.  Each Capitation
payment shall be accompanied by a remittance summary.  The remittance summary identifies the total Capitation payable
and those Medicare HMO

 

70

 

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

 

2.2          Professional
Stop Loss Program.

 

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

 

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

 

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

 

	
  Supplemental Benefit

  	
   

  	
  PMPM

  	
   

  
	
  $ 5 office visit & specialist
  consultation copay waived

  	
   

  	
  ***

  	
   

  
	
  $ 5 vision and hearing exam copay waived

  	
   

  	
  ***

  	
   

  
	
  $ 20 outpatient mental health copay waived

  	
   

  	
  ***

  	
   

  
	
  $ 20 outpatient substance abuse copay
  waived

  	
   

  	
  ***

  	
   

  

 

HMO
shall develop and adjust supplemental benefits PMPM rates on a calendar year
basis and forward such rules 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 zero percent (0 %) 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 forty-four and nine one hundredths percent (44.09%) of
Monthly Revenue.

 

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

 

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

 

71

 

such
PPG liability shall be refunded to PPG at the final Risk Sharing
settlement.  However, as a contingency
for any PPG liability under this Shared Risk Program, HMO shall
continue, at its sole  discretion,
to deduct up to five percent (5%) of PPG’s Capitation for Medicare HMO
Members and place such amount in the Withhold Fund as described in this
Agreement.

 

3.2          Shared
Risk Budget Surplus.  In the event of a Shared Risk Budget
surplus, PPG’s share of the surplus shall be limited to the lesser of (a) ***
of the Shared Risk Budget surplus, or (b) an amount not to exceed *** 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
twenty percent (20%) of the annual gross PPG Capitation.

 

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

 

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

 

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

 

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

 

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

 

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

 

5.             Quality
of Care Improvement Program (QCIP).  QCIP as in the Operations Manual, rewards
PPG for meeting and exceeding quality standards and Member satisfaction
levels.  PPG is eligible for a lump sum
award up to $ 2.00 PMPM, if performance is achieved in all categories.  The lump sum shall be payable in September
following the calendar year in which the measurement was taken.  Wellness programs, as set forth in the
Operations Manual, are a component of QCIP. 
The above PMPM award includes funding for wellness programs.  Compensation for wellness programs for
eligible PPG’s contracted with HMO for a full twelve months shall be payable at
five-hundred dollars ($500.00) per class up to two-thousand dollars ($2000.00)
total until two thousand (2000) Medicare HMO members.  Thereafter, for Medicare HMO Members, $  20 PMPM shall be distributed to PPG monthly with the
Capitation.  HMO reserves the right to
after components and measurements of QCIP annually.  Wellness programs and wellness compensation shall be subject to
annual change by HMO.

 

72

 

C.            MEDICARE POS BENEFIT PROGRAM.

 

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

 

2.             Definitions.

 

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

 

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

 

3.             Capitation:  PPG Capitated Services.

 

3.1          Capitation
Rate.  For
Capitated Services, PPG shall be compensated for rendering professional
In-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 five hundred (500) Medicare POS Members, the
Professional Out-of-Network Withhold percentage shall be equal to (i) PPG’s
prior year’s professional Out-of-Network costs, divided by the total of PPG’s
Capitation for Medicare POS Members (prior to the Professional Out-of-Network
Withhold) rounded to the nearest multiple of five, plus ten percent (10%), or
(ii) fifty percent (50%) if there is no prior year experience or if PPG has 500
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 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 twenty-five thousand dollars ($25,000) per Medicare POS
Member during the

 

73

 

 

calendar year.  The cost to PPG for the Out-of-Network
Professional Stop Loss program shall be eighteen one hundredths percent (0.18%)
of applicable Medicare POS Members 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
fifty percent (50%). PPG shall not be subject to any downside.

 

4.             POS Shared Risk.

 

4.1          POS
Shared Risk Budget.  Each month, HMO shall fund the POS Shared
Risk Budget for POS Shared Risk Services, at the percent of Monthly Revenue for
Medicare HMO Members as 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 the annual gross PPG
Capitation.

 

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

 

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

 

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

 

Out-of-Area
Emergency and Urgently Needed Services are reimbursed 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 0.04 % of applicable Medicare POS Member’s HCFA payment and county
premium, if any.

 

The cost of
In-Network and Out-of-Network POS Shared Risk Services during the Reconciliation
Period shall be charged against the POS Shared Risk Budget as follows ten
percent (10%) of any amount over one hundred fifty thousand dollars
($150,000.00).

 

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

 

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

 

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

 

74

 

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

 

2.             Pharmacy
Reconciliation For Medicare HMO Members.  [This section does not apply
for Medicare POS Members.] For each Reconciliation Period, HMO shall calculate
pharmacy claims subject to this Program as outlined in the Operations Manual.
HMO shall compare such claims to the corresponding Pharmacy Budget. In the
event pharmacy claims are less than the Pharmacy Budget. PPG’s share of the
Pharmacy Budget surplus shall be fifty percent (50%). In the event pharmacy
claims exceed the Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit
shall be fifty percent (50%).  HMO shall
perform an interim and final settlement for the Pharmacy Risk Sharing Program.
The timing of these settlements shall correspond to the interim and final
settlements of other shared risk programs. Subject to Section 4.3 of this Agreement
any Pharmacy Budget deficit shall be offset against any amounts payable by HMO
or any amounts remaining in the Withhold Fund, or shall be offset against
Capitation.  In the event the Withhold
Fund eliminates the Pharmacy Budget deficit, any amounts remaining in the
Withhold Fund shall be paid to PPG within one hundred twenty (120) calendar
days after the end of the Reconciliation Period.

 

E.            OTHER SERVICES.

 

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

 

75

 

ADDENDUM C.1

 

SUPPLEMENTAL BENEFITS COSTS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  5.71

  	
  %

  
	
  Butte

  	
   

  	
  0.55

  	
  %

  
	
  Colusa

  	
   

  	
  0.52

  	
  %

  
	
  Contra Costa

  	
   

  	
  5.68

  	
  %

  
	
  El Dorado

  	
   

  	
  5.22

  	
  %

  
	
  Fresno

  	
   

  	
  5.11

  	
  %

  
	
  Glenn

  	
   

  	
  0.57

  	
  %

  
	
  Kern

  	
   

  	
  11.80

  	
  %

  
	
  Los Angeles

  	
   

  	
  9.27

  	
  %

  
	
  Madera

  	
   

  	
  4.90

  	
  %

  
	
  Marin

  	
   

  	
  4.09

  	
  %

  
	
  Mariposa

  	
   

  	
  5.42

  	
  %

  
	
  Napa

  	
   

  	
  0.48

  	
  %

  
	
  Orange

  	
   

  	
  10.03

  	
  %

  
	
  Placer

  	
   

  	
  6.71

  	
  %

  
	
  Plumas

  	
   

  	
  0.55

  	
  %

  
	
  Riverside

  	
   

  	
  12.08

  	
  %

  
	
  Sacramento

  	
   

  	
  6.01

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.57

  	
  %

  
	
  San Diego

  	
   

  	
  11.27

  	
  %

  
	
  San Francisco

  	
   

  	
  5.90

  	
  %

  
	
  San Joaquin

  	
   

  	
  7.03

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  11.37

  	
  %

  
	
  San Mateo

  	
   

  	
  7.16

  	
  %

  
	
  Santa Barbara

  	
   

  	
  11.28

  	
  %

  
	
  Santa Clara

  	
   

  	
  6.68

  	
  %

  
	
  Sierra

  	
   

  	
  0.58

  	
  %

  
	
  Solano

  	
   

  	
  0.59

  	
  %

  
	
  Sonoma

  	
   

  	
  5.28

  	
  %

  
	
  Stanislaus

  	
   

  	
  7.0?

  	
  %

  
	
  Sutter

  	
   

  	
  0.57

  	
  %

  
	
  Tulare

  	
   

  	
  4.91

  	
  %

  
	
  Ventura

  	
   

  	
  11.81

  	
  %

  
	
  Yolo

  	
   

  	
  5.35

  	
  %

  
	
  Yuba

  	
   

  	
  0.55

  	
  %

  

 

76

 

ADDENDUM
C.2

 

PHARMACY
SHARED RISK BUDGETS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  4.48

  	
  %

  
	
  Butte

  	
   

  	
  0.00

  	
  %

  
	
  Colusa

  	
   

  	
  0.00

  	
  %

  
	
  Contra Costa

  	
   

  	
  4.45

  	
  %

  
	
  El Dorado

  	
   

  	
  4.60

  	
  %

  
	
  Fresno

  	
   

  	
  4.42

  	
  %

  
	
  Glenn

  	
   

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  10.35

  	
  %

  
	
  Los Angeles

  	
   

  	
  8.14

  	
  %

  
	
  Madera

  	
   

  	
  4.25

  	
  %

  
	
  Marin

  	
   

  	
  3.58

  	
  %

  
	
  Mariposa

  	
   

  	
  4.69

  	
  %

  
	
  Napa

  	
   

  	
  0.00

  	
  %

  
	
  Orange

  	
   

  	
  8.80

  	
  %

  
	
  Placer

  	
   

  	
  5.26

  	
  %

  
	
  Plumas

  	
   

  	
  0.00

  	
  %

  
	
  Riverside

  	
   

  	
  11.51

  	
  %

  
	
  Sacramento

  	
   

  	
  4.67

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.02

  	
  %

  
	
  San Diego

  	
   

  	
  9.89

  	
  %

  
	
  San Francisco

  	
   

  	
  4.62

  	
  %

  
	
  San Joaquin

  	
   

  	
  5.51

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  10.66

  	
  %

  
	
  San Mateo

  	
   

  	
  5.61

  	
  %

  
	
  Santa Barbara

  	
   

  	
  10.58

  	
  %

  
	
  Santa Clara

  	
   

  	
  5.24

  	
  %

  
	
  Sierra

  	
   

  	
  0.00

  	
  %

  
	
  Solano

  	
   

  	
  0.00

  	
  %

  
	
  Sonoma

  	
   

  	
  4.70

  	
  %

  
	
  Stanislaus

  	
   

  	
  5.55

  	
  %

  
	
  Sutter

  	
   

  	
  0.00

  	
  %

  
	
  Tulare

  	
   

  	
  4.25

  	
  %

  
	
  Ventura

  	
   

  	
  11.25

  	
  %

  
	
  Yolo

  	
   

  	
  4.71

  	
  %

  
	
  Yuba

  	
   

  	
  0.00

  	
  %

  

 

77

 

ADDENDUM C.3

DIVISION OF FINANCIAL RESPONSIBILITY

MATRIX OF HMO AND PPG CAPITATED SERVICES

MEDICARE BENEFIT PROGRAM

 

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

 

MATRIX EFFECTIVE 1/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Drugs, including Epogen, Nupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC
  (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COSMETIC
  SURGERY

  (Medically Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  (When a covered benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

78

 

MATRIX EFFECTIVE 1/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  
	
  DIAGNOSTIC TESTING - Outpatient Facility &
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS -
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY ROOM VISITS – Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Facility Component 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPITAL BASED PHYSICIANS -

  Inpatient, Ambulatory Surgery or Emergency
  Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTIBLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

79

 

MATRIX EFFECTIVE 1/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF &
  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY
  

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facilily 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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Laboratorty, X-ray
(within 72 hrs.
  or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PROSTHETIC/ORTHOTIC
  DEVICES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Inpatient, Ambulatory Surgery or Emergency Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  RADIOLOGY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SPEECH AND
  HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

80

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO
  RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  
	
  SUPPLIES- Medical, Surgical, Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Related to an Outpatient Office Visit:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Splints, Casts, Bandages, etc.,

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Related to a Hospital Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Surgical Supplies, Equipment, etc.,

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Chem. Strips, Lancet, Needles, Syringes Glueometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY - Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY:
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT CARE VISITS –  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Exams and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  • 
  Implanted Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

81

 

ADDENDUM D

 

PREFERRED PROVIDER ORGANIZATION (PPO)

EXCLUSIVE PROVIDER ORGANIZATION (EPO)

POINT OF SERVICE (POS)

 

BENEFIT PROGRAMS

 

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

 

A.            BENEFIT PROGRAM REQUIREMENTS

 

PPG
agrees:

 

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

 

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

 

3.             That it PPG admits
or arranges for an inpatient admission in 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 hill 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 authorised by FHS prior to admission and the information
provided by PPG to FHS regarding the Member’s medical condition was
substantially true and accurate.

 

82

 

B.            PPO AND EPQ BENEFIT
PROGRAMS

 

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

 

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

 

C.            POINT OF SERVICE BENEFIT
PROGRAMS

 

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

 

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

 

83

 

ADDENDUM E

 

FEE-FOR-SERVICE COMPENSATION SCHEDULE

 

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

 

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

 

Anesthesiology Services:

 

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

 

Assistant
Surgeons:

 

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)

 

	
  Total
  OB care, vaginal delivery 

  	
   

  	
  ***
  global rate

  
	
  Total
  OB care, Cesarean delivery

  	
   

  	
  ***
  global rate

  

 

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

 

	
  Total
  OB care, vaginal delivery 

  	
   

  	
  ***
  global rate

  
	
  Total
  OB care, Cesarean delivery

  	
   

  	
  ***
  global rate

  

 

Services included in global reimbursement for total
OB care:

 

	
  office
  visits (sick care as well as routine)

  
	
  consultations
  including initial OB consultation

  
	
  emergency
  department visits

  
	
  therapeutic
  injections

  
	
  amniocentesis

  
	
  fetal
  contraction stress test

  
	
  fetal
  non-stress test

  
	
  fetal
  monitoring, including initiation or supervision

  
	
  version

  
	
  delivery
  of placenta

  
	
  ultrasound

  
	
  laboratory tests

  
	
  venipuncture

  
	
  specimen
  collection and laboratory supplies

  
	
  educational
  materials/nutritional) counseling

  
	
  OB
  standby

  
	
  other
  services which do not warrant extra charge: delivery of twins/multiple
  births, physician’s supervision of home Care, hospitalization during
  pregnancy for conditions such as pre-clethpsia.

  
	
  HTN

  

 

84

 

Antepartum care only:

 

	
  First
  trimester only

  	
  ***

  
	
  Second inmester only

  	
  ***

  
	
  First and second trimester
  only

  	
  ***

  
	
  Third trimester excluding
  delivery

  	
  ***

  
	
  Third trimester including
  delivery

  	
  ***

  

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

85

 

ADDENDUM
F

 

MEDI-CAL BENEFIT PROGRAM

 

 

(NOT APPLICABLE)

 

86

 

ADDENDUM
F.1

 

FEE-FOR-SERVICE COMPENSATION SCHEDULE

 

ASSIGNED AND UNASSIGNED MEDICAL HMO MEMBERS

 

 

(NOT APPLICABLE)

 

87

 

ADDENDUM
F.2

 

CAPITATION COMPENSATION SCHEDULE

 

 

(NOT APPLICABLE)

 

88

 

ADDENDUM
F.3

 

SHARED RISK PROGRAM DISTRIBUTION MATRIX

 

 

(NOT APPLICABLE)

 

89

 

ADDENDUM F.4

DIVISION OF FINANCIAL RESPONSIBILITY

MATRIX OF FHS AND PPG RISK SERVICES

MEDI-CAL BENEFIT PROGRAM

 

 

(NOT APPLICABLE)

 

90

 

ADDENDUM
F.5

 

DISCLOSURE FORM

 

 

(NOT APPLICABLE)

 

91

 

ADDENDUM
G

 

CHAMPUS/TRICARE AND OTHER GOVERNMENT BENEFIT
PROGRAMS

 

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

 

A.            CHAMPUS/TRlCARE DEFINITIONS, PROGRAMS AND REGULATIONS

 

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

 

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

 

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

 

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

 

B.            CHAMPUS/TRICARE PROGRAMS AND REGULATIONS

 

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

 

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

 

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

 

92

 

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

 

D.            PROVIDER OBLIGATIONS

 

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

 

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

 

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

 

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

 

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

 

93

 

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

 

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

 

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

 

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

 

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

 

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

 

E.             CHAMPUS PRIME AND EXTRA
BENEFIT PROGRAMS AND COMPENSATION

 

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

 

94

 

2.             Compensation.  Compensation to PPG for the delivery of
Medically Necessary Covered Contracted Services will be the lesser of *** of
the CHAMPUS Maximum Allowable Charges or *** of billed charges for those
services which have a defined Allowable. If there is no CMAC reimbursement
defined for a procedure code, reimbursement will be at the lesser of *** of
billed charges or *** of the CHAMPUS area prevailing rates. Services for which
a procedure code has not been assigned, or are unvalued by CHAMPUS/TRICARE,
compensation will be the lesser of Average Wholesale Price minus *** (***) or
65% of billed charges.

 

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

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

95

 

ADDENDUM
H

 

OCCUPATIONALLY ILL/INJURED OR WORKERS’
COMPENSATION BENEFIT

PROGRAMS

 

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

 

A.            COMPENSATION.

 

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

 

2.             Rates.  Reimbursements under the Agreement shall be
the lessor of:  (a) the physician’s
usual and customary charges (“UCR”). (b) eighty-five percent (85%) of the Fee
Schedule adopted by the State of California department of Industrial Relations,
Division of Workers’ Compensation; or (c) the allowable charge based on the
Medicare Resource Based Relative Value Scale (RBRVS) unit values and HCFA
Geographical Practice Cost Indices.

 

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

 

B.            OTHER DUTIES

 

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

 

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

 

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

 

96

 

ADDENDUM
H.1

 

OCCUPATIONALLY ILL/INJURED OR WORKERS’
COMPENSATION RATE SCHEDULE

 

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

 

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

 

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

 

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

 

CONFIDENTIAL, PROPRIETARY AND TRADE SECRET

 

97

 

HEALTH NET

 

May
12, 1998

 

James
Wilcox

Executive
Director

Prospect
Medical

18200
Yorba Linda Blvd., Suite 209

Yorba
Linda, CA 92886

 

Dear
Jim :

 

I
have attached two original sets of the 1998 Health Net Participating Physician
Group Provider Service Agreements (“PSA”) for Prospect Medical and Sierra
Medical Group for your final review and signature.  The 1998 Health Net program highlights include:

 

•      1998 Commercial Standard HMO professional
rate increase of *** PMPM for Prospect and *** PMPM for Sierra Medical Group.

 

•      1999 Commercial Standard HMO increase of ***
PMPM based on PPG Member Satisfaction.

 

•      2000 Commercial Standard HMO increase of ***
PMPM based on PPG Member Satisfaction.

 

•      Normalized Commercial Rx cost target of ***
PEMPM for Prospect and *** PEMPM for Sierra.

 

•      Annual Rx  cost target to reflect Rx inflation trend
factor

 

•      Rx Rebate Sharing
Program

 

•      Increased Commercial QCIP funding

 

	
  1998

  	
   

  	
  ***
  PMPM

  
	
  1999

  	
   

  	
  ***
  PMPM

  
	
  2000

  	
   

  	
  ***
  PMPM

  

 

•      (New Program) Medicare HMO QCIP  funding of *** PMPM

 

•      Partnership Bonus Potential

 

In order for Prospect (*** PMPM)
and Sierra (*** PMPM) to receive its Commercial rate increase retroactive to
January 1, 1998, it is essential that I receive confirmation of a signed
1998 PSA’s by close of business Friday, May 15. Please sign and return both
original copies of the contract sets to my attention.  Once Health Net signs, I will ensure that you receive a set of
fully executed originals for your files.

 

 

Sincerely,

 

	
  /s/
  [ILLEGIBLE]

  	
   

  

[ILLEGIBLE] 

Regional Network Director

 

98

 

A.6  Benefit Plan }

 

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

September 1, 1998

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Proof

  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

  	
   

  
	
  O8

  	
   

  	
  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

  	
   

  
	
  OY

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  QZ

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  V1

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Proof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

Medicare Supplement HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan I

  	
   

  	
  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

  	
   

  

 

99

Source: [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00067-of-00352.parquet"}, [{"source": "alea-institute/alea-institute/kl3m-data-edgar-agreements/train-00067-of-00352.parquet"}]]