Document:

Exhibit 10.175

 

 

AMENDMENT

to the

PROVIDER SERVICES AGREEMENT

between

FOUNDATION HEALTH SYSTEMS AFFILIATES

and

STARCARE MEDICAL GROUP DBA GATEWAY MEDICAL GROUP

 

The Provider Services
Agreement (“Agreement”), effective March 1, 1999, between StarCare Medical
Group dba Gateway Medical Group (“PPG”) and Foundation Health Systems
Affiliate(s) (“FHS”) is hereby amended effective July 1, 2000.

 

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

 

1)   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.  FHS 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.

 

2)  Addendum B Section B 1.1, STANDARD HMO.  Professional Capitation Rates. 
Capitation Rates, is deleted in its entirety and replaced as follows:

 

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

  
	
  July
  1, 2000

  	
   

  	
  January
  1 2001

  
	
  ***

  	
   

  	
  ***

  

 

3)  Addendum B, Section B.3.1 STANDARD HMO, Shared Risk Budget is
deleted in its entirety effective January 1, 2001 and replaced as follows:

 

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

  
	
  January
  1, 2001

  
	
  ***

  

 

Gateway Medical Group

Contract effective March 1, 1999

Amendment effective July 1, 2000

 

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

 

1

 

4)  Addendum B, Section B.3.2 STANDARD HMO, Shared Risk
Administration, deleted in its entirety and replaced as follows:

 

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

 

In the event the 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.

 

5)  Addendum B, Section C.1, SMALL GROUP, Professional Capitation
Rates.  Capitation Rates, is deleted in
its entirety and replaced as follows:

 

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

  
	
  July
  1, 2000

  
	
  ***

  

 

6)  Addendum B, Section C.3.2, SMALL GROUP, Shared Risk
Administration is deleted in its entirety and replaced as follows:

 

3.2       Shared Risk Administration.  As a
contingency for any PPG liability under this Shared Risk Program, HMO shall
deduct one percent (1%) of PPG’s Capitation for Standard HMO Members and place
such amount in the Withhold Fund as described in the Agreement.

 

2

 

In [ILLEGIBLE] event the shared risk claims exceed the shared
[ILLEGIBLE] 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 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.

 

7) Addendum B, Section D.1
INDIVIDUAL HMO, Professional Capitation Rates. 
Capitation Rates, is deleted in its entirety and replaced as follows:

 

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

  
	
  July
  1, 2000

  
	
  ***

  

 

8)  Addendum D, Section B.3.2 INDIVIDUAL HMO, Shared Risk
Administration, is deleted in its entirety and replaced as follows:

 

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

 

In the event the 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

 

3

 

*** of [ILLEGIBLE] capitation
for Standard HMO Members and [ILLEGIBLE] 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.

 

9)  Addendum B, Section G. 4. Commercial POS, Professional Capitation
Rate.  Professional Capitation Rates is
deleted in its entirety and replaced as follows:

 

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

 

10)  Addendum B, Section G. 6.1 Commercial POS,
Institutional Shared Risk Program, POS Shared Risk Budgets, is deleted in its
entirety effective January 1, 2001 and replaced as follows:

 

6.             Institutional Shared Risk Program.

 

6.1          POS Shared Risk Budgets.  The
budgets shall be determined for each Commercial POS population: Standard POS,
Small Group POS and, at a later date, Individual POS Members.  Each Budget shall cover In-Network,
Out-of-Network and Out-of-Area Shared Risk Services.  Each of the normalized Shared Risk Budgets
shall be equal to the normalized HMO Shared Risk Budget, or institutional
capitation PMPM, if applicable, and multiplied by one hundred ten percent
(110%).  Actual Shared Risk Budget shall
fluctuate from month to month to the extent that PPG’s age, sex and benefit
plan mix fluctuates.

 

	
  Effective Date

  	
   

  	
  Standard
  HMO Shared

  Risk

  + 10% =

  	
   

  	
  Small
  Group HMO

  Shared Risk

  + 10% =

  	
   

  	
  Individual
  HMO

  Shared Risk

  + 10% =

  	
   

  
	
  January 1,
  2001

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

11)  Addendum B, Section I. Pharmacy Shared Risk Program is deleted in
its entirety effective January 1, 2001 and replaced as follows:

 

I.              Pharmacy Shared Risk Program.  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

 

4

 

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 2001 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, 2001.  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.

 

12)  Addendum C is amended by the addition of the following Section J.
HCFA REQUIRED LANGUAGE:

 

J. HCFA REQUIRED LANGUAGE

 

I. DEFINITIONS

 

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

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

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

 

II.
ACCESS:  RECORDS AND FACILITIES

 

Provider agrees:

 

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

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

 

III. ACCESS:
BENEFITS & COVERAGE

 

Provider agrees:

 

3.1.         To not
discriminate based on health status.

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

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

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

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

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

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

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

 

5

 

IV. MEMBER PROTECTIONS

 

Provider agrees:

 

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

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

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

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

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

 

V. DELEGATION

 

Provider agrees:

 

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

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

 

VI. PAYMENT AND
FEDERAL FUNDS

 

Provider agrees:

 

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

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

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

 

VII. REPORTING AND DISCLOSURE

 

Provider agrees:

 

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

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

 

VIII. QUALITY ASSURANCE / QUALITY IMPROVEMENT

 

Provider Agrees:

 

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

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

 

6

 

IX. COMPLIANCE

 

Provider
agrees:

 

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

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

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

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

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

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

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

 

X. PRIVATE FEE FOR SERVICE

 

Provider
agrees:

 

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

10.2.       That
Provider cannot charge more than cost sharing and balanced billing amounts
permitted under the applicable Health Net plan.  Health Net must specify cost sharing amounts, and balance billing
may not exceed fifteen percent (15%) of uniform payment rate.

 

XI. ADOPTION OF MEDICARE RISK PROGRAM CONTRACT
REQUIREMENTS

 

Provider
agrees:

 

11.1.       That all
contracts must be signed and dated.

11.2.       To serve
Members during the term of this Addendum.

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

 

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 is amended effective January 1, 2000 as follows:

 

	
  MATRIX EFFECTIVE 1/1/2000

  
	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL
SERVICES

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  •
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
   

  	
   

  
	
  •
  Organ Procurement

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  Covered Immunosuppressive

  	
   

  	
  ***

  	
   

  	
   

  	
   

  	
  ***

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  TRANSPLANT EVALUATIONS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility

  	
   

  	
   

  	
   

  	
   

  	
   

  	
  ***

  	
   

  

 

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

 

 

7

 

14)  Addendum C, Section D.2. ADMINISTRATION OF SHARED RISK BUDGET FOR
MEDICARE HMO AND POS, Pharmacy Reconciliation For Medicare HMO Members, is
deleted in its entirety effective January 1, 2001 and replaced as follows:

 

2.             Pharmacy Shared Risk Program.  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 2001 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, 2001. 
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.

 

15)  Addendum D PREFERRED PROVIDER ORGANIZATION (PPO), EXCLUSIVE
PROVIDER ORGANIZATION (EPO), POINT OF SERVICE (POS), BENEFIT PROGRAMS shall be
amended by the addition of the following section D MEDICARE SELECT BENEFIT
PROGRAMS, Medicare Select Programs.

 

D.            MEDICARE SELECT BENEFIT PROGRAMS

 

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

 

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

 

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

 

8

 

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.

 

	
  Gateway Medical Group

  	
  Foundation
  Health Systems Affiliates

  
	
   

  	
   

  
	
   

  	
   

  
	
  /s/ RAJ
  TAKHAR

  	
   

  	
  /s/ CHRISTOPHER CIANO

  	
   

  
	
  Signature

  	
  Signature

  
	
   

  	
   

  
	
  RAJ TAKHAR

  	
   

  	
  Christopher
  Ciano

  	
   

  
	
  Print Name

  	
   

  	
   

  
	
   

  	
   

  
	
  Chief Executive Officer

  	
   

  	
   

  
	
  Title

  	
  Senior Vice President and
  General Manager- South

  
	
   

  	
   

  
	
  11/9/00

  	
   

  	
  12-07-00

  	
   

  
	
  Date

  	
  Date

  
	
   

  	
   

  
	
  33-0843-838

  	
   

  	
   

  
	
  Federal Tax Identification
  Number

  	
   

  

 

9Exhibit
10.176

 

Amendment to the
Participating Physician Group Provider Services Agreement between Foundation
Health Systems Affiliates and StarCare Medical Group dba Gateway Medical Group,
effective October 10, 2000

 

*** Confidential
Treatment Requested

 

 

ORIGINAL

 

AMENDMENT

to the

PROVIDER SERVICES AGREEMENT

between

FOUNDATION HEALTH SYSTEMS AFFILIATES

and

STARCARE MEDICAL GROUP DBA GATEWAY MEDICAL GROUP

 

 

The Provider Services Agreement
(“Agreement”), effective March 1, 1999, between StarCare Medical Group dba
Gateway Medical Group (“PPG”) and Foundation Health Systems Affiliate(s)
(“FHS”) subsequently amended July 1, 2000 is hereby amended effective
October 10, 2000.

 

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)     Addendum
C is deleted in its entirety and replaced as attached hereto.

 

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

 

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

 

 

	
  Gateway Medical
  Group

  	
   

  	
  Health Net Inc., Affiliates

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  /s/
  MIKE OLSON

  	
   

  	
  /s/ CHRISTOPHER CIANO

  	
   

  
	
  Signature

  	
   

  	
  Christopher Ciano

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Mike
  Olson

  	
   

  	
   

  
	
  Print Name

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Network
  Development Director

  	
   

  	
  Senior Vice President & General
  Manager, South

  
	
  Title

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  8/29/01

  	
   

  	
  11-5-01

  	
   

  
	
  Date

  	
   

  	
  Date

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  33-0843838

  	
   

  	
   

  
	
  Federal Tax Identification Number

  	
   

  	
   

  

 

 

	
  PPG
  Agreement

  	
   

  	
   

  
	
  Jan
  2001 California

  	
   

  	
  Gateway
  Medical Group

  

 

1

 

ADDENDUM
C

 

MEDICARE
HEALTH MAINTENANCE ORGANIZATION (HMO) AND MEDICARE POINT OF

SERVICE (POS) BENEFIT PROGRAMS

 

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 C and this Addendum shall be applicable to only
those Medicare HMO and Medicare POS Members listed on the applicable Capitation
remittance summaries.

 

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

 

1.             Downstream Providers. 
A Participating Provider who or which is contracted with Provider to
render services to Members.

 

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

 

3.             In-Network Services.  Covered Services provided or arranged for
through a Member’s selected or assigned PCP or PPG.

 

4.             Medicare +Choice (M+C) Organization or M+CO.  A health plan, Provider or Downstream
Provider sponsored organization, who has entered into an agreement with HCFA to
provide Medicare beneficiaries with health care options.

 

5.             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.)

 

6.             Medicare HMO Member. 
An individual who has enrolled in or elected coverage in Health Net
Seniority Plus, an M+C Organization.

 

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

 

B.            MEDICARE HMO BENEFIT PROGRAMS.

 

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

 

2.             Capitation: PPG Capitated Services.

 

2.1          Compensation for PPG Capitated Services.  As compensation for
rendering PPG Capitated Services as defined herein, HMO shall pay PPG
Capitation at *** of Monthly Revenue as set forth below for each Medicare HMO
Member eligible to receive such services from PPG during any particular
month.  Capitation shall be computed on
the basis of the most current information available and shall be paid by HMO by
wire transfer on or before the fifteenth (15th) day of each month, or the first
business day following the fifteenth, if the fifteenth is a

 

2

 

holiday or on a weekend or within two
(2) days of HCFA’s payment to HMO, whichever is later.  Each Capitation payment shall be accompanied
by a remittance summary.  The remittance
summary identifies the total Capitation payable and those Medicare HMO Members
for whom Capitation is being paid.  In
the event of a Capitation error, resulting in an overpayment or underpayment to
PPG, HMO shall adjust subsequent Capitation to offset such error.

 

Effective September 1, 2001,
as compensation for rendering PPG Capitated Services as defined herein, HMO
shall pay PPG Capitation at *** of Monthly Revenue as set forth below for each
Medicare HMO Member eligible to receive such services from PPG during any
particular month.  Capitation shall be
computed on the basis of the most current information available and shall be
paid by HMO by wire transfer on or before the fifteenth (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 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.  PPG shall receive adjusted capitation for
benefits sold to Employer Group Retirees that differ from the Individual member
benefits for Medicare +Choice. 
Following are examples of these adjustments:

 

	
  PPG Supplemental
  Benefit Adjustments

  	
   

  	
  PMPM

  
	
  $5 office visit & specialist
  consultation copay reduction*

  	
   

  	
  ***

  
	
  $5 office visit & specialist
  consultation copay increase.

  	
   

  	
  ***

  
	
  $5 vision and hearing exam copay
  reduction.

  	
   

  	
  ***

  
	
  $20 outpatient mental health copay
  reduction.

  	
   

  	
  ***

  
	
  $20 outpatient substance abuse copay
  reduction.

  	
   

  	
  ***

  

 

* For example, some retiree group
members who reside in a county where the office visit copay for Individuals is
$5.00 could have an employer-sponsored plan with higher or lower copays.  The appropriate cap adjustment is +/-$0.632
for each $1 difference in the group benefit copay from the county benefit
copay.  Other copay adjustments, such as
the examples given above would be similarly applied pro rata for other dollar
amounts.

 

Health Net will develop and adjust
supplemental benefits PMPM rates on a calendar year basis and forward such
rates to Provider 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 0.0% 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 40.5% of Monthly Revenue.

 

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

 

3

 

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

 

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

 

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

 

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

 

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

 

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

 

The cost of In-Area Shared Risk
services utilized by a Medicare HMO Member in a Reconciliation Period shall be
charged against the Shared Risk Budget as follows: twenty percent (20%) of any
amount over $100,000.

 

Effective January 1, 2001,
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: 1.28% 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 eighty percent (80%) of cost, and
the remaining twenty percent (20%) of the cost shall be charged against the
Shared Risk Budget.

 

(b)           In-Area Shared Risk
services:  3.12% 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:  twenty percent (20%) of any amount over $100,000.

 

4.             Pharmacy Budget. 
Not Applicable.  Effective
January 1, 2001, PPG does not participate in the Pharmacy
Shared Risk Program.

 

C.   MEDICARE POS BENEFIT PROGRAM.

 

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

 

2.             Definitions.

 

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

 

4

 

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

 

3.             Capitation: PPG Capitated Services.

 

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

 

Effective September 1, 2001
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 zero (0.0%) withhold (Professional Out-of-Network
Withhold), for each Medicare POS Member eligible to receive such services from
PPG during any particular month.

 

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 $ 10,000 per Medicare POS Member during the
calendar year.  The cost to PPG for the
Out-of-Network Professional Stop Loss program shall be *** of applicable
Medicare POS Member’s HCFA payment and county premium, if any, which shall be
deducted from PPG’s Out-of-Network Risk Sharing Fund.

 

Effective January 1, 2001,
Out-of-Network Professional Stop Loss. 
PPG’s Out-of-Network Professional Stop Loss threshold shall be *** per
Medicare POS Member during the calendar year. 
The cost to PPG for the Out-of-Network Professional Stop Loss program
shall be 2.03% of applicable Medicare POS Member’s HCFA payment and county
premium, if any, which shall be deducted from PPG’s Out-of-Network Risk Sharing
Fund.

 

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

 

4.             POS Shared Risk.

 

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

 

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

 

5

 

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

 

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

 

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

 

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

 

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

 

Effective January 1, 2001,
In-Network and Out-of-Network POS Shared Risk Services: 3.78% of applicable
Medicare POS Member’s HCFA payment and county premium, if any.

 

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

 

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

 

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

 

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

 

2.             Withhold Fund and Determination of Maximum Downside 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.             Pharmacy Reconciliation For Medicare HMO Members.  Effective
January 1, 2001, 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.

 

6

 

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.

 

F.             ACCESS:  RECORDS AND
FACILITIES

 

Provider agrees:

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

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

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

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

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

 

G.            MEMBER PROTECTIONS/ACCESS: 
BENEFITS & COVERAGE

 

Provider agrees:

 

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

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

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

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

 

H.            COMPLIANCE

 

Provider agrees:

 

1.             That
Provider must notify any Participating Provider being terminated, in writing,
of the reason(s) for denial, suspension or termination determinations.

2.             To
comply with all applicable Health Net procedures and the Operations Manual
including, but not limited to, the accountability provisions.

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

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

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

 

I.              ADOPTION OF MEDICARE RISK PROGRAM CONTRACT REQUIREMENTS

 

Provider agrees:

 

1.             That
all contracts with Participating Providers must be signed and dated.

 

J.             DELEGATION

 

Provider agrees:

 

1.             To
maintain delegated functions consistent with Health Net’s requirements and compliant
with

 

7

 

M+C’s regulations and Health Net’s
policy and procedures as set forth in the Health Net Seniority Plus
Participating Provider Group Operations Manual.

 

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

 

K.            PAYMENT AND FEDERAL FUNDS

 

Provider agrees:

 

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

 

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

 

L.            REPORTING AND DISCLOSURE

 

Provider agrees:

 

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

 

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

 

M.           PRIVATE FEE FOR SERVICE

 

Provider agrees:

 

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

 

2.             That Provider
cannot charge more than cost sharing and balanced billing amounts permitted
under the applicable Health Net plan. 
Health Net must specify cost sharing amounts, and balance billing may
not exceed fifteen percent (15%) of uniform payment rate.

 

8

 

ADDENDUM C.1

SUPPLEMENTAL BENEFITS COSTS

2001

 

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

 

	
  County

  	
   

  	
  Jan – Feb
  2001

  	
   

  	
  March 2001

  	
   

  
	
   

  	
   

  	
  Percent

  	
   

  	
  Percent

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Alameda

  	
   

  	
  5.41

  	
  %

  	
  5.35

  	
  %

  
	
  Contra
  Costa

  	
   

  	
  6.71

  	
  %

  	
  6.64

  	
  %

  
	
  El
  Dorado

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  13.76

  	
  %

  	
  13.61

  	
  %

  
	
  Los
  Angeles

  	
   

  	
  9.31

  	
  %

  	
  9.20

  	
  %

  
	
  Marin

  	
   

  	
  2.53

  	
  %

  	
  2.50

  	
  %

  
	
  Orange

  	
   

  	
  11.62

  	
  %

  	
  11.49

  	
  %

  
	
  Placer

  	
   

  	
  3.53

  	
  %

  	
  3.49

  	
  %

  
	
  Riverside

  	
   

  	
  4.29

  	
  %

  	
  4.24

  	
  %

  
	
  Sacramento

  	
   

  	
  3.58

  	
  %

  	
  3.54

  	
  %

  
	
  San
  Bernardino

  	
   

  	
  4.25

  	
  %

  	
  4.20

  	
  %

  
	
  San
  Diego

  	
   

  	
  8.26

  	
  %

  	
  8.16

  	
  %

  
	
  San
  Francisco

  	
   

  	
  6.13

  	
  %

  	
  6.06

  	
  %

  
	
  San
  Joaquin

  	
   

  	
  3.94

  	
  %

  	
  3.88

  	
  %

  
	
  San
  Mateo

  	
   

  	
  2.69

  	
  %

  	
  2.66

  	
  %

  
	
  Santa
  Barbara

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Santa
  Clara

  	
   

  	
  2.97

  	
  %

  	
  2.93

  	
  %

  
	
  Stanislaus

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Yolo

  	
   

  	
  3.49

  	
  %

  	
  3.39

  	
  %

  

 

9

 

ADDENDUM C.2

PHARMACY SHARED RISK BUDGETS

2001

 

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

 

	
  County

  	
   

  	
  Jan - Feb
  2001

  	
   

  	
  March 2001

  	
   

  
	
   

  	
   

  	
  Percent

  	
   

  	
  Percent

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Alameda

  	
   

  	
  5.41

  	
  %

  	
  5.35

  	
  %

  
	
  Contra Costa

  	
   

  	
  6.28

  	
  %

  	
  6.22

  	
  %

  
	
  El Dorado

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  12.54

  	
  %

  	
  12.40

  	
  %

  
	
  Los Angeles

  	
   

  	
  8.25

  	
  %

  	
  8.16

  	
  %

  
	
  Marin

  	
   

  	
  2.08

  	
  %

  	
  2.06

  	
  %

  
	
  Orange

  	
   

  	
  10.46

  	
  %

  	
  10.34

  	
  %

  
	
  Placer

  	
   

  	
  3.04

  	
  %

  	
  3.00

  	
  %

  
	
  Riverside

  	
   

  	
  3.77

  	
  %

  	
  3.72

  	
  %

  
	
  Sacramento

  	
   

  	
  3.13

  	
  %

  	
  3.09

  	
  %

  
	
  San Bernardino

  	
   

  	
  3.73

  	
  %

  	
  3.68

  	
  %

  
	
  San Diego

  	
   

  	
  7.77

  	
  %

  	
  7.68

  	
  %

  
	
  San Francisco

  	
   

  	
  5.70

  	
  %

  	
  5.64

  	
  %

  
	
  San Joaquin

  	
   

  	
  3.45

  	
  %

  	
  3.39

  	
  %

  
	
  San Mateo

  	
   

  	
  2.23

  	
  %

  	
  2.21

  	
  %

  
	
  Santa Barbara

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Santa Clara

  	
   

  	
  2.49

  	
  %

  	
  2.46

  	
  %

  
	
  Stanislaus

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Ventura

  	
   

  	
  0.00

  	
  %

  	
  0.00

  	
  %

  
	
  Yolo

  	
   

  	
  2.98

  	
  %

  	
  2.89

  	
  %

  

 

10

 

ADDENDUM C.3

DIVISION OF FINANCIAL RESPONSIBILITY

MATRIX OF HMO AND PPG CAPITATED SERVICES

MEDICARE BENEFIT PROGRAM

 

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

 

MATRIX
EFFECTIVE 1/1/00

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  AIDS – Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS – Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  In Area (30 Mile Radius)

  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Autologous/Homologous

  Blood Bank
Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Inpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Inpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Outpatient
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Outpatient
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Drugs, including
  Epogen, Neupogen and adjunctive therapies

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

11

 

	
   

  	
   

  	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Epogen, Neupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  • Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECT ABLES, SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  Facility Component

  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

12

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  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...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

13

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •
  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 financial responsibility have been deleted.

 

14

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"}]]