Document:

Exhibit 10.120

 

 

HEALTH
NET®

California’s Health Plan

 

 

January
25, 2001

 

 

Catherine
Medel

Prospect
Medical Group

1920
E. 17th Street, #200

Santa
Ana, CA 92705-8626

 

RE:              Amendment
to the Provider Services Agreement to add NCQA Language

 

Dear
Catherine:

 

Health
Net of California, Inc. Affiliates (“Health Net”) has decided to amend the
Provider Services Agreement (“Agreement”) between your Medical Group/IPA
(“PPG”) and Health Net, Inc. Affiliates (“HNI”) to include certain National
Committee for Quality Assurance, (NCQA) language.  Please note that the NCQA language is italicized, and such
language is the only revision we are seeking by this Amendment.  Health Net is requesting your agreement to
the following revisions:

 

The
following language of the Agreement is added to or replaces the contract
language as applicable:

 

1.               PPG Contracts.  No agreement between PPG and a Participating
Provider shall contain any incentive plan that includes a specific payment
made, in any type or form, as an inducement to deny, reduce, or limit Covered
Services to a Member.  PPG shall comply
and shall cause its Participating Providers to comply with State and federal
law regarding physician incentives and Stop loss insurance requirements, where
applicable.  PPG shall furnish HNI with
all PPG’s contracting templates for HNI’s 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 HNI’s request.  Upon
request, PPG shall furnish HNI with copies of any amendments to a contract with
a Participating Provider within ten (10) days of execution.  In
addition, any agreement or amendment between PPG and a Member Physician shall
not restrict the rights and obligations of Member Physician to communicate
freely with Members regarding their medical condition and treatment
alternatives including medication treatment options, regardless of benefit
coverage limitations.

 

2.               Medical and Other Records.  PPG shall prepare and maintain
all medical and other books and records required by law in accordance with the
general standards applicable.  PPG shall
maintain such records for at least seven (7) years after the rendering of
Contracted Services and records of a minor child shall be kept for at least one
(1) year after the minor has reached the age of eighteen (18), but in no event
less than seven (7) years. 
Additionally, PPG shall maintain such financial, administrative and
other records as may be necessary for compliance by HNI with all applicable
local, State, and federal laws, rules and regulations and accreditation
agencies.  PPG agrees to the policies established by HNI that describe personal
health information, including medical records, claims benefits and other
administrative data that are personally identifiable.  The HNI  policies
include:  provisions for inclusions in
routine consent, care and treatment of Members who  are unable to give consent, member access to their
medical records, protection of privacy in all setting, use of measurement data,
information for employers and the sharing of personal health information with
employers.  The HNI policies
are

 

2525
Cherry Avenue, Suite 160, Signal Hill, California 90806 Tel (562) 490-4300 Fax (562) 424-7707

 

 

further
defined in the PPG Operations Manual. 
PPG agrees to submit upon request such reports and financial information
as is necessary for HNI to comply with regulatory requirements to monitor the
financial viability of PPG.  PPG shall
comply with all confidentiality and Member record accuracy requirements.

 

Except as so amended, all
other provisions of the Agreement shall remain unchanged and in effect.

 

After you have had the
opportunity to review this Amendment, please sign in the space provided below
and return this Amendment no later than February 28, 2001 to the following
address:

 

Health Net, Inc.

2525 Cherry Avenue, #160

Signal Hill, CA 90806

 

If you have any questions
please contact me at 562-490-4336.

 

	
  Sincerely

  
	
  /s/ Richard Gors

  	
   

  
	
  Richard Gors

  
	
  Contract Manager

  

 

	
  Prospect Medical Group

  	
  HEALTH NET, INC. AFFILIATES

  
	
   

  	
   

  
	
  /s/ Peter G.
  Goll

  	
   

  	
  /s/ Christopher Ciano

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  Peter G. Goll

  	
   

  	
  Christopher
  Ciano

  
	
  First Name

  	
   

  
	
   

  	
   

  
	
  Senior Vice President

  	
   

  	
  Senior Vice
  President & General Manager

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  1-31-01

  	
   

  	
   

  	
  CHRISTOPHER CIANO

  	
   

  
	
  Date

  	
  Date

  	
  FEB 19 2001

  	
   

  
	
   

  	
   

  	
  Senior VP/GM South

  	
   

  
	
   

  	
   

  
	
  33-0718606

  	
   

  	
   

  
	
  Tax ID
  NumberExhibit 10.121

 

AMENDMENT

to the

PROVIDER SERVICES AGREEMENT

between

FOUNDATION HEALTH SYSTEMS AFFILIATES

And

PROSPECT MEDICAL GROUP

 

The
Provider Services Agreement (“Agreement”), dated January 1, 1998, between
Prospect Medical Group (“PPG”) and Foundation Health Systems Affiliate(s)
(“FHS”) subsequently amended July 1, 2000, and subsequently amended February
19, 2001, is hereby amended effective October 1, 2001.

 

FHS
and PPG hereby agree to amend the Agreement as follows:

 

1.            All references to Foundation Health
Systems Affiliates, (“FHS”) are hereby changed to read, Health Net Inc.,
Affiliates (“HNI”).

 

2.             All references to the California
Department of Corporations (“DOC”) shall hereby be deleted and replaced by the
California Department of Managed Health Care (“DMHC”).

 

3.             Section 2.17, Quality Improvement Program. shall be
deleted in its entirety and replaced by the following:

 

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

 

PPG
recognizes the importance of the establishment of health care measurement
systems to evaluate, along with the continuum of care, the performance of
hospitals, physicians, and other healthcare providers. PPG agrees to support
efforts to address quality, cost of care, access. Member satisfaction and
functional status through participation in the development of valid performance
measurement systems. Performance measurement systems should examine process and
outcome and incorporate the following criteria: standard indicators and
definitions, uniform data, accuracy, and state of the art risk adjustments. PPG
is aware that participation in the development of performance measurement
systems may require the commitment of financial and human resources.

 

4.             Section 4.9, Third Party Recoveries, Workers’ Compensation.
shall be deleted in its entirety and replaced by the following:

 

4.9          Third
Party Recoveries, Workers’ Compensation. In the event PPG provides services to HNI
Members for injuries resulting from the acts of third parties, or resulting
from work related injuries, PPG shall have the right to recover from any
settlement, award, or recovery from any responsible third-party the value of
Covered Services rendered pursuant to SB1471 and the applicable provisions of
the Coverage Certificate and as set forth in the Operations Manual. PPG shall
notify HNI of any third party payor and shall, upon request from HNI, provide
HNI with an accounting of all such sums recovered. In the event HNI has
compensated PPG for such Covered Services, PPG agrees to immediately refund
such amounts paid to HNI.

 

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

 

1

 

5.             Article VI TERM AND TERMINATION, Section 6.1
Term is deleted in its entirety and replaced as follows:

 

6.1          Term  The term of this Amendment shall
commence October 1, 2001, and shall continue in effect for a period of
twenty-six (26) months (“Initial Term”). 
Thereafter, this Agreement shall automatically renew for successive
one-year (1) 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              Article VI TERM AND TERMINATION,
Section 6.2 Without Cause Termination is deleted in its entirety and replaced
as follows:

 

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 HNI 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.

 

7.            Addendum B COMMERCIAL HEALTH
MAINTENANCE ORGANIZATION (HMO) AND COMMERCIAL POINT OF SERVICE (POS) BENEFIT
PROGRAMS is deleted in its entirety effective October 1, 2001, and replaced
with a new Addendum B, attached hereto.

 

8.            Addendum B.2, DIVISION OF
RESPONSIBILITY MATRIX OF HMO, PPG AND SHARED RISK/ HOSPITAL CAPITATED SERVICES,
COMMERCIAL HMO AND POINT OF SERVICE BENEFIT PROGRAMS, is deleted in its
entirety effective July 1, 2001, and replaced with a new Addendum B.2, attached
hereto.

 

Except as provided in this
Amendment, all other provisions of the Agreement between HNI and Provider not
inconsistent herewith shall remain in full force and effect.

 

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.

 

	
  Prospect Medical Company

  	
  Health Net, Inc. Affiliates

  
	
   

  	
   

  
	
  /s/ Peter G.
  Goll

  	
   

  	
  /s/ Christopher Ciano

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  Peter G. Goll

  	
   

  	
  Christopher
  Ciano

  
	
  Print Name

  	
   

  
	
   

  	
   

  
	
  Senior Vice President

  	
   

  	
  Senior Vice
  President & General Manager, South

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  9-26-01

  	
   

  	
  11/08/01

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Tax ID #

  	
   

  
					

 

2

 

ADDENDUM B

 

COMMERCIAL HEALTH MAINTENANCE ORGANIZATION (HMO) AND

COMMERCIAL POINT OF SERVICE (POS) BENEFIT PROGRAMS

 

A.            GENERAL
REIMBURSEMENT PROVISIONS.

 

1.             PPG understands and agrees that the
obligations of HNI set forth in this Addendum are only the obligations of
Health Net (hereafter “HMO”) and not the obligations of HNI or any other
Affiliate of HNI. PPG shall be compensated according to this Addendum B and
this Addendum shall be applicable to only those Commercial HMO and Commercial
POS Members listed on the applicable Capitation remittance summaries.

 

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

•      Commercial HMO

•      Standard
HMO

•      Flex
Funded HMO

•      Small
Group HMO

•      Individual
HMO

•      AIM

•      Medicare
Supplement

•      Commercial POS

 

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

 

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

 

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

 

6.             Withhold
Fund and Determination of Maximum Downside of Shared Risk Deficits. 
Notwithstanding any provision in this Agreement or in any Addendum
hereto to the contrary, PPG’s total downside liability for all Shared Risk
Budget deficits shall not exceed twenty percent (20%) of PPG’s gross annual
Capitation. Any and all Withhold Fund amounts as set forth herein shall be
applied to offset such total downside liability.

 

3

 

B.            STANDARD
HMO.

 

1.             Professional
Capitation Rates.

 

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

 

	
  Standard HMO Capitation

  
	
  October
  1, 2001 Through December 31, 2001 $44.61 PMPM

  
	
  January
  1, 2002 Through December 31, 2002 $47.29 PMPM

  
	
  January
  1, 2003 *** PMPM

  

 

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

 

3.             Shared
Risk Program.  PPG shall participate in an incentive
program for Shared Risk Services, which shall reward PPG for effectively
coordinating such care.  Under this
Program, a budget shall be established for Shared Risk Services, and the actual
cost of such services shall be compared to the budget.

 

3.1          Shared
Risk Budget.  HMO shall fund the Shared Risk Budget for
Members with normalized rates. These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum B. Actual Shared Risk Budget shall fluctuate from month to month to
the extent that PPG’s age, sex and benefit plan mix fluctuates.

 

	
  Standard HMO Shared Risk Budget

  
	
  October
  1, 2001 Through December 31, 2001 $ *** PMPM

  
	
  January
  1, 2002, through December 31, 2002, $ *** PMPM

  
	
  January
  1, 2003 $48.94 PMPM

  

 

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 shared risk claims exceed the shared risk budget at the interim
settlement date, HMO may, at its sole discretion, withhold from PPG’s gross
monthly capitation up to ***  of PPG’s
monthly capitation and may continue such withhold until the final shared risk
settlement. The withheld amount shall be placed in the Withhold Fund as
described in the Agreement. If there is a deficit at the time of final
settlement, HMO may at it’s sole discretion, continue to withhold up to *** 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 Interim
Period, PPG’s share of the settlement shall be *** subject to Section 4.3 of
this Agreement.

 

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

 

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

 

4

 

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

 

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

 

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

 

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

 

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

 

Out-of-Area
Emergency and Urgently Needed Services are reimbursed at *** 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 ***.

 

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

 

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

 

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

 

•      AIDS Reinsurance effective January 1, 2001
***  PMPM

 

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

 

5

 

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.

 

	
  Small Group

  HMO Capitation

  
	
  October
  1, 2001, through December 31, 2001, $ *** PMPM

  
	
  January
  1, 2002 through December 31, 2002, $ *** PMPM

  
	
  January
  1, 2003, $*** PMPM

  

 

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

 

3.             Shared
Risk Budget.  HMO shall fund the Shared Risk Budget for
Members, with normalized rates. These normalized rates shall be adjusted for
PPG’s assigned Members by the age, sex and benefit plan factors as set forth in
Addendum B.  Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.

 

	
  Small Group

  HMO Shared Risk Budget

  
	
  October
  1, 2001 through December 31, 2001 $*** PMPM

  
	
  January
  1, 2002, through December 31, 2002, $*** PMPM

  
	
  January
  1, 2003, $*** PMPM

  

 

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

 

In
the event the shared risk claims exceed the shared risk budget at the interim
settlement date, HMO may, at its sole discretion, withhold from PPG’s gross
monthly capitation up to *** of PPG’s monthly capitation and may continue such
withhold until the final shared risk settlement. The withheld amount shall be
placed in the Withhold Fund as described in the Agreement. If there is a
deficit at the time of final settlement, HMO may at it’s sole discretion,
continue to withhold up to *** 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.

 

6

 

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

 

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

 

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

 

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

 

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

 

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

 

(b)           In-Area Shared Risk Services: 1 ***
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 $ 100,000.

 

AIDS 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 effective January 1,
2001      *** PMPM

 

D.    INDIVIDUAL HMO.

 

1.             Professional
Capitation Rates.

 

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

 

	
  Individual

  HMO Capitation

  
	
  October
  1, 2001, through December 31, 2001, *** PMPM

  
	
  January
  1, 2002, through December 31, 2002, *** PMPM

  
	
  January
  1, 2003, $*** PMPM

  

 

7

 

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

 

3.             Shared
Risk Program.  PPG shall participate in an incentive
program for Shared Risk Services, which shall reward PPG for effectively
coordinating such care.  Under this
Program, a budget shall be established for Shared Risk Services, and the actual
cost of such services shall be compared to the budget.

 

3.1          Shared
Risk Budget. HMO
shall fund the Shared Risk Budget for Members, with normalized rates. These
normalized rates shall be adjusted for PPG’s assigned Members by the age, sex
and benefit plan factors as set forth in Addendum B. Actual Shared Risk Budget
shall fluctuate from month to month to the extent that PPG’s age, sex and
benefit plan mix fluctuates.

 

	
  Individual

  HMO Shared Risk Budget

  
	
  October
  1, 2001 through December 31, 2001 *** PMPM

  
	
  January
  1, 2002, through December 31, 2002, *** PMPM

  
	
  January
  1, 2003, $*** PMPM

  

 

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

 

In
the event the shared risk claims exceed the shared risk budget at the interim
settlement date, HMO may, at its sole discretion, withhold from PPG’s gross
monthly capitation up to five percent (5%) of PPG’s monthly capitation and may
continue such withhold until the final shared risk settlement. The withheld
amount shall be placed in the Withhold Fund as described in the Agreement. If
there is a deficit at the time of final settlement, HMO may at it’s sole
discretion, continue to withhold up to *** of PPG’s capitation for Individual
HMO Members and place such amount in the Withhold Fund as described in this
agreement.

 

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

 

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

 

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

 

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

 

8

 

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

 

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

 

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

 

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

 

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

 

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  $100,000.

 

4.             AIDS
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, effective
January, 2001 *** PMPM

 

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 one thousand eight hundred fifty dollars ($1,850)
for each adult AIM Member to cover the professional services related to the
birth of an infant.  In addition to this
flat fee, HMO shall pay PPG *** PMPM for each adult AIM Member enrolled in the
AIM Program.  HMO shall pay PPG ***  PMPM during the first year of life for
each infant AIM Member and ***  PMPM
during the second year of life.

 

2.             Reinsurance
Programs.  PPG’s
professional stop loss level shall be 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.

 

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

 

F.             MEDICARE
SUPPLEMENT.  The Medicare Supplement Benefit Programs are
provided to Members who have
primary coverage through Medicare. 
Capitation for Members enrolled in such Benefit Programs compensates PPG
for Co-payments 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:

 

9

 

	
  Medicare Supplement

  HMO

  	
   

  	
  Medicare

  Supplement POS

  
	
   

  	
   

  	
   

  
	
  $ *** PMPM

  	
   

  	
  $ *** PMPM

  

 

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

 

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

 

G.            COMMERCIAL
POS.

 

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

 

2.             Definitions.

 

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

 

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

 

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

 

4.             Professional
Capitation Rate.  Effective January 1, 2002, 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 10% of the
Commercial POS Professional Capitation prior to withhold.

 

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

 

6.             Institutional
Shared Risk Program.

 

6.1          POS
Shared Risk Budgets.  The budgets shall be determined for each Commercial POS
population: Standard POS, Small Group POS and. at a later date, Individual POS
Members. Each Budget shall cover In-Network, Out-of-Network and Out-of-Area
Shared Risk Services. Each of the normalized

 

10

 

Shared
Risk Budgets shall be equal to the normalized HMO Shared Risk Budget, or
institutional capitation PMPM, if applicable, and multiplied by ***.  Actual Shared Risk Budget shall fluctuate
from month to month to the extent that PPG’s age, sex and benefit plan mix
fluctuates.

 

	
  Standard POS

  Shared Risk
 + 10% =

  	
   

  	
  Small
  Group POS

  Shared Risk
 + 10% =

  	
   

  	
  Individual
  POS Shared

  Risk

   + 10% =

  
	
  October
  1, 2001 through December 31, 2001 $45.12 PMPM

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***  PMPM

  
	
  January
  1, 2002, through December 31, 2002 $48.85 PMPM

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  
	
  January
  1,2003. $53.83 PMPM

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  

 

6.2          POS
Shared Risk Administration.  Each Reconciliation Period, HMO
shall calculate Shared Risk Claims in accordance with the Operations Manual and
compare such claim cost to the corresponding Shared Risk Budget.  HMO shall perform both an interim and final
settlement.  In the event any amounts
remain in the Withhold Fund following the reconciliation of any shared risk
program, those excess funds shall
be paid to PPG by April 30 of the following year. In the event that such claims
are less than the Shared Risk Budget for the Interim Period, PPG’s share of the
settlement shall be seventy-five percent (75%), subject to Section 4.3 of this
Agreement.

 

Shared Risk
Claims with dates of service within the Reconciliation Period, and paid by
March 31 of the following year shall be used in the calculation. Shared Risk
Services incurred within the Reconciliation Period but paid after March 31 of
the following year will be included in the next Reconciliation Period
calculation.

 

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

 

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

 

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

 

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

 

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

 

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

 

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.

 

11

 

(a)           In-Network
Professional Stop Loss.  PPG’s Professional Stop Loss
threshold shall be as set forth
in paragraph (b) below.  The cost to PPG
for the Professional Stop Loss Program shall be $0.11 PMPM, which, shall be
deducted from PPG’s Capitation.  PPG shall
report potential stop loss claims and receive payment for such claims in
accordance with procedures set forth in the Operations Manual.

 

(b)           Out-of-Network
Professional Stop Loss.  PPG’s Out-of-Network
Professional Stop Loss threshold shall be $25,000 per Commercial POS Member
during the calendar year.  The cost to
PPG for the Out-of-Network Professional Stop Loss program shall be $0.19 PMPM,
which, shall be deducted from PPG’s Out-of-Network Risk Sharing Budget.

 

8.             AIDS
Reinsurance.  As further defined in Section B.4 of this
Addendum, the AIDS Reinsurance rate shall be $0.41 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.

 

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

 

1.             Pharmacy
Budget. Effective January 1, 2001, in accordance with the
formula outlined below, PPG’s
Pharmacy Budget shall be the percent as set forth below of the difference
between PPG’s actual normalized pharmacy costs, and the actual pharmacy costs
experienced by those participating physician group’s membership, comprising the
top third of the lowest PEMPM normalized costs, based on current calendar year
experience. For eligible Commercial HMO Members, each month. HMO shall fund the
Pharmacy Budget at ***  per eligible
Member per month (“PEMPM”) subject to the age, sex and benefit plan factors set
forth in Addendum B. The Pharmacy Budget shall be adjusted according to the
aggregate PEMPM dollar change experienced by those participating physician groups
comprising the top third of the lowest PEMPM normalized costs, based on current
calendar year experience 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

  Period

  	
   

  	
  Percent

  Difference

  
	
  2001

  	
   

  	
  ***

  
	
  Subsequent
  Years

  	
   

  	
  ***

  

 

2.             Pharmacy
Reconciliation For Commercial HMO Members. 
Effective January 1, 2001,
for each Reconciliation Period, HMO shall calculate pharmacy claims subject to
this Program as outlined in the Operations Manual. HMO shall compare such
claims to the corresponding Pharmacy Budget. In the event pharmacy claims are
less than the Pharmacy Budget, PPG’s share of the Pharmacy Budget surplus shall
be ***.  In the event pharmacy claims
exceed the Pharmacy Budget, PPG’s share of the Pharmacy Budget deficit shall be
***

 

For 2002
Reconciliation Period, HMO shall calculate pharmacy claims subject to this
Program as outlined in the Operations Manual. HMO shall compare such claims to
the corresponding Pharmacy Budget. In the event pharmacy claims are less than
the Pharmacy Budget. PPG’s share of the Pharmacy Budget surplus shall be ***.
In the event pharmacy claims exceed the Pharmacy Budget, PPG’s share of the
Pharmacy Budget deficit shall be ***

 

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

 

12

 

Effective 2003 PPG shall not
participate in the Pharmacy Shared Risk Program.  PPG shall use its best efforts to have Member Physicians and
participating providers prescribe from the HMO drug formulary. PPG shall
cooperate with HMO recommendations for pharmacy treatment guidelines and shall
provide upon HMO’s request, documentation regarding its internal processes and
procedures for pharmacy utilization management. Furthermore, HMO shall notify
PPG of identified outlier Member Physicians. PPG shall cooperate in creating
and implementing action plans for improvement in pharmacy utilization for such
Member Physicians. HMO and appropriate PPG representatives shall meet quarterly
to review PPG’s pharmacy utilization, and to discuss opportunities and action
plans for pharmacy utilization improvement. PPG shall submit to Health Net a
2003 Pharmacy Performance Improvement action plan, documentation regarding its
internal processes and procedures for pharmacy utilization management, and
status of programs currently in various stages of implementation no later than
April 1, 2003. Upon review and approval by Health Net, progress of implemented
programs shall be monitored by Health Net on a bi-monthly basis. In addition,
the Health Net clinical pharmacy department will develop PPG specific programs
the group to review and incorporate into their action plan.

 

13

 

ADDENDUM B.2

DIVISION OF RESPONSIBILITY

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

 

COMMERCIAL HMO AND POINT OF SERVICE BENEFIT PROGRAMS

 

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

 

MATRIX EFFECTIVE 7/1/01

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  AIDS – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS –  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AIDS –  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  AMBULANCE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     In Area (30 Mile Radius)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Out of Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  BLOOD/BLOOD
  PRODUCTS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Autologous/Homologous

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Blood Bank

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMICAL
  DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Inpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Inpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Outpatient Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Inpatient Detox Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Inpatient Detox Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Drugs, including Epogen, Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  COLOSTOMY
  SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

14

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  COSMETIC SURGERY
(Medically
  Necessary)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  CRITICAL
  CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DENTAL
  SERVICES

  (When a covered
  benefit)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DIAGNOSTIC
  TESTING - Outpatient
  Facility &  Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  DURABLE
  MEDICAL EQUIPMENT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Surgically
  Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ADMISSIONS – Out of
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS – In
  Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EMERGENCY
  ROOM VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  EXTENDED
  CARE/SKILLED NURSING FACILITY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  GROWTH
  HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEARING
  AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEMODIALYSIS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Epogen,
  Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOME
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

15

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  
	
  HOSPITAL
  BASED PHYSICIANS -

  Inpatient, Ambulatory Surgery or Emergency Room Admissions

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INFANT
  APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  INJECTABLES,
  SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IN PATIENT
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  IVF &
  GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  LITHOTRIPSY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MATERNITY - Deliveries and Non-Deliveries

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MEDICAL
  ADMISSIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  MENTAL
  HEALTH – Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  OFFICE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATIENT
  EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  PATHOLOGY - Inpatient, Ambulatory Surgery or Emergency
  Room

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •     Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

16

 

	
   

  	
   

  	
  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 a Hospital Stay:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Surgical
  Supplies, Equipment, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Related
  to an Outpatient Office Visit:

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  Splints,
  Casts, Bandages, etc.

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SUPPLIES,
  DIABETIC

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Chem.
  Strips, Lancet, Needles, Syringes

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  SURGERY – 
  Outpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  THERAPY:
  Physical, Occupational, Speech

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Covered
  Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Organ
  Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  TRANSPLANT
  EVALUATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Facility
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  URGENT
  CARE VISITS –
  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  VISION
  CARE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Exams
  and Medically Necessary Care

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Implanted
  Lenses (Cataract Surgery)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  
	
  •      Lenses
  and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  

 

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

 

17

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"}]]