Document:

Exhibit 10.145

 

 

1998

 

FHS

 

PARTICIPATING
PHYSICIAN GROUP

PROVIDER
SERVICES AGREEMENT

 

A.V.
MEDICAL GROUP

 

 

 

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

 

 

TABLE OF
CONTENTS:

 

	
  RECITALS

  	
   

  
	
   

  	
   

  
	
  DEFINITIONS

  	
   

  
	
   

  	
   

  
	
  REPRESENTATIONS
  AND DUTIES OF PPG

  	
   

  
	
   

  	
   

  
	
  DUTIES OF FHS

  	
   

  
	
   

  	
   

  
	
  COMPENSATION

  	
   

  
	
   

  	
   

  
	
  DELEGATION

  	
   

  
	
   

  	
   

  
	
  TERM AND TERMINATION

  	
   

  
	
   

  	
   

  
	
  RECORDS,
  AUDITS AND REGULATORY REQUIREMENTS

  	
   

  
	
   

  	
   

  
	
  GENERAL PROVISIONS

  	
   

  
	
   

  	
   

  
	
  ADDENDUM
  A

  	
   

  
	
  Benefit Programs

  	
   

  
	
  Affiliates

  	
   

  
	
   

  	
   

  
	
  ADDENDUM
  B COMMERCIAL HMO AND POS

  	
   

  
	
  A.

  	
  General
  Reimbursement Provisions

  	
   

  
	
  B.

  	
  Standard HMO

  	
   

  
	
  C.

  	
  Small Group HMO

  	
   

  
	
  D.

  	
  Individual HMO

  	
   

  
	
  E.

  	
  Access for Infants
  and Mothers

  	
   

  
	
  F.

  	
  Medicare Supplement

  	
   

  
	
  G.

  	
  Commercial POS

  	
   

  
	
  H.

  	
  Partnership Bonus

  	
   

  
	
  I.

  	
  QCIP

  	
   

  
	
  J.

  	
  Pharmacy Shared Risk
  Program

  	
   

  
	
  K.

  	
  Pharmacy Rebate Program

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  B.1

  	
  AGE,
  SEX AND BENEFIT PLAN FACTORS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM B.2

  	
  COMMERCIAL
  HMO and POS DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM C

  	
  MEDICARE HMO AND POS

  	
   

  
	
  A.

  	
  Definitions

  	
   

  
	
  B.

  	
  Medicare HMO Benefit Program

  	
   

  
	
  C.

  	
  Medicare POS Benefit
  Program

  	
   

  
	
  D.

  	
  Administration Of Shared Risk Budgets
  For HMO and POS

  	
   

  
	
  E.

  	
  Other Services

  	
   

  

 

DRAFT AGREEMENT PENDING DOC APPROVAL

 

ii

 

	
  ADDENDUM
  C.1

  	
  SUPPLEMENTAL
  BENEFITS COSTS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  C.2 

  	
  PHARMACY
  SHARED RISK BUDGETS

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  C.3 

  	
  MEDICARE
  DIVISION OF FINANCIAL RESPONSIBILITY MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  D

  	
  PPO, EPO AND POS

  	
   

  
	
  A.

  	
  Benefit Program
  Requirements

  	
   

  
	
  B.

  	
  PPO And EPO Benefit
  Programs

  	
   

  
	
  C.

  	
  POS Benefit
  Programs

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  E

  	
  FEE FOR SERVICE COMPENSATION

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F

  	
  MEDI-CAL BENEFIT PROGRAM

  	
   

  
	
  A.

  	
  Definitions

  	
   

  
	
  B.

  	
  Compensation Provisions

  	
   

  
	
  C.

  	
  General Provisions

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.1

  	
  FEE-FOR-SERVICE
  COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.2

  	
  CAPITATION
  COMPENSATION SCHEDULE

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.3

  	
  SHARED
  RISK PROGRAM DISTRIBUTION MATRIX

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.4

  	
  DIVISION
  OF FINANCIAL RESPONSIBILITY

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  F.5

  	
  DISCLOSURE
  FORM

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  G

  	
  CHAMPUS/TRICARE

  	
   

  
	
  A.

  	
  Definitions

  	
   

  
	
  B.

  	
  Programs And Regulations

  	
   

  
	
  C.

  	
  Other Governmental
  Programs

  	
   

  
	
  D.

  	
  Provider Obligations

  	
   

  
	
  E.

  	
  CHAMPUS
  PRIME and EXTRA Benefit Programs

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  H

  	
  WORKERS COMPENSATION

  	
   

  
	
  A.

  	
  Compensation

  	
   

  
	
  B.

  	
  Other Duties

  	
   

  
	
   

  	
   

  	
   

  
	
  ADDENDUM
  H.1

  	
  WORKERS’
  COMPENSATION RATE SCHEDULE

  	
   

  

 

iii

 

PARTICIPATING
PHYSICIAN GROUP

PROVIDER
SERVICES AGREEMENT

 

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

 

R E C I T A L S

 

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

 

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

 

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

 

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

 

A G R E E M
E N T

 

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

 

I.                                         DEFINITIONS

 

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

 

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

 

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

 

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

 

1.4                               Commercial HMO Member.  An
HMO Member whose premium is fully paid and enrolled in a commercial Benefit
Program, including 1) a Benefit Program offered to an employer other than a small
group employer (“Standard HMO Member”), 2) a Benefit Program offered to a small
group employer as defined in Section 1357(I) of the California Health and
Safety Code (“Small Group HMO Member”), 3) a Benefit Program offered to
individuals (“Individual HMO Member”), 4) a Benefit Program offered to an
individual participating in the Access for Infants and Mothers Program (“AIM
Member”), 5) a Benefit Program which is fully or partially self-funded
(“Flexible Funded HMO Member”), or 6) a Benefit Program offered to Members with
primary coverage through Medicare and health care coverage under an HMO or POS
Plan (“Medicare Supplement Member”).

 

1

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

(e)                                  The most appropriate supply or level of
service, including levels of acute care such as intensive care unit services or
regular acute medical and surgical services as determined by the clinical
status of the

 

2

 

Member,
which can safely be provided to the Member. 
For hospitalization, this means that the Member requires acute care as
an inpatient due to the nature of the services the Member is receiving, or the
severity of the Member’s condition, and that safe and adequate care cannot be
received as an outpatient or at a less intensified medical setting such as a
sub-acute unit or skilled nursing facility.

 

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

 

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

 

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

 

1.17                        Operations Manual.  All
Operations Manuals, including medical policy manuals, issued by FHS, as updated
from time to time, which are incorporated in this Agreement by this
reference.  In the event that any
provision to an Operations Manual or any updates thereto are clearly
inconsistent with the terms of this Agreement as amended, the terms of this
Agreement shall prevail.

 

1.18                        Participating Provider.  A
hospital, physician, physician, organization, Participating Physician Group,
Member Physician, other health care practitioner or other organization which
has a direct or indirect contractual relationship with FHS or another
Participating Provider to provide Covered Services to Members.  In the event PPG contracts with a health
care provider to render Covered Services under this Agreement, such provider is
a Participating Provider.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

3

 

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

 

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

 

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

 

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

 

1.30                        Shared Risk Claims. 
Shared Risk Claims shall include all claims for Shared Risk Services
including amounts for out of area services as set forth in the applicable
Addendum minus those amounts in excess of the Shared Risk Reinsurance threshold
which are payable under such program as set forth in the applicable Addendum
and minus any amounts received from third parties, including but not limited
to, Coordination of Benefits, workers’ compensation and Copayments.

 

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

 

1.32                        State.  The
State of California.

 

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

 

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

 

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

 

II.                                     REPRESENTATIONS AND DUTIES OF
PPG

 

2.1                               Representations of PPG.

 

(a)                                  PPG warrants that it has the authority to
contract on behalf of its Member Physicians and to bind them to all of the
terms and provisions of this Agreement. 
PPG will notify Member Physicians of their rights and duties under this
Agreement, and of all amendments and modifications thereto.

 

(b)                                 PPG shall provide FHS, upon request, with its
written applicable policies and procedures and its bylaws and articles of
incorporation and any modifications thereto.

 

(c)                                  PPG represents that the terms of this
Agreement do not conflict with the terms of its

 

4

 

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

 

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

 

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

 

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

 

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

 

(1)                                  Accepting Members upon referral from Member
Physicians.

 

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

 

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

 

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

 

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

 

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

 

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

 

(8)                                  Accepting all HMO Members when selected,
assigned or transferred to PPG,

 

5

 

provided
PPG and its Participating Providers have capacity to  provide Contracted Services under this Agreement and PPG
and Member Physicians continue to accept new patients from any other health
care service plan.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

6

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

(e)                                  The termination  procedures outlined in the Operations Manual when requesting
termination

 

7

 

of
a Member.  PPG shall not request, demand,
or require or otherwise seek, directly or indirectly, the removal of any Member
based on that Member’s need for, or utilization of, Covered Services:

 

(f)                                    The Member selection or assignment provisions
of this Agreement.  PPG agrees to accept
any and all Members who select or are assigned to PPG. PPG and Member
Physicians shall maintain a professional relationship with each Member to whom
PPG or Member Physician renders Contracted Services, and shall be solely
responsible to such Member for such services; and

 

(g)                                 The eligibility verification and notification
procedures as set forth in the Operations Manual.

 

2.9                               Offices and Hours. 
Member Physician shall maintain offices, equipment, and personnel as may
be necessary to provide Contracted Services under this Agreement, in accordance
with State law and as reasonably requested by FHS. Member Physician shall
provide Contracted Services under this Agreement during normal business hours,
and shall be available to Members by telephone twenty-four (24) hours a day,
seven (7) days a week on an Emergency basis and for consultation.

 

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

 

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

 

2.12                        Utilization/Care Management
Program.  PPG and Member Physicians agree to
participate in and cooperate fully with the provisions and all decisions
rendered in connection with FHS’ Utilization/Care Management Program.  PPG and Member Physician agrees to render Covered
Services at the most appropriate level of service (including levels of acute
care such as intensive care unit services or regular acute medical and surgical
services as determined by the clinical status of the Member) which can safely
be provided to the Member. For hospitalization, this means that the Member
requires acute care as an inpatient due to the nature of the services the
Member is receiving, or the seventy of the Member’s condition, and that safe
and adequate care cannot be received as an outpatient or at a less intensified
medical setting.  PPG and Member
Physicians also agree to provide such records and other information as may be
required or requested under such Utilization/Care Management Program as set
forth in the Operations Manual. FHS may, at its sole discretion, delegate certain
Utilization/Care Management Program activities.  If so determined qualified and delegated by FHS, the obligations
of PPG for delegation shall be as set forth herein.

 

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

 

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

 

8

 

obtained.
FHS shall retain the right to authorize Emergency services in accordance with
the Operations Manual.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

2.20                        Credentialing of PPG and/or
Participating Providers.
PPG shall submit to FHS the Credentials Application, as set forth in the
Operations Manual. Such application shall be completed on behalf of PPG, and/or
on behalf of each Participating Provider rendering Covered Services under this
Agreement. The submitted Credentials

 

9

 

Application
is construed to be a part of this Agreement. 
If so permitted by State law, and required and delegated by FHS, the
obligations of PPG in Article V also shall apply. PPG represents and
warrants that each Member Physician meets the credentialing and recredentialing
standards adopted by FHS set forth in the Operations Manual and that PPG shall
perform credentialing and recredentialing functions in accordance with the
Operations Manual.

 

2.21                        Notice of Adverse Action.  PPG
shall notify FHS in writing, within five days of receiving any notice of any
complaint, grievance, appeal, or adverse action, including, without limitation,
(i) any action against any license, certification under Title XVIII or Title
XIX or other applicable statute of the Social Security Act or other State law,
or DEA narcotic registration certificate; (ii) any action which results in the
filing of a report on a Member Physician under California Business &
Professions Code Section 805; (iii) any action by an insurance carrier
indicating that such carrier will cancel or not renew the insurance coverage
required to be carried by a Member Physician as specified in this Agreement;
(iv) any malpractice litigation or settlement involving a Member Physician; and
(v) any other event, occurrence or situation which might materially interfere
with, modify or alter performance of any of PPG’s duties or obligations under
this Agreement. PPG shall maintain a written record of any Member complaint and
provide such record to FHS promptly upon request.

 

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

 

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

 

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

 

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

 

2.23                        Conflict of Interest.  PPG
shall not, during the term of this Agreement, acquire, or make any commitment
to acquire a proprietary interest in any organization which is licensed as a
health care service plan or which has submitted an application for such
licensure except as to a health care service plan with waivers. This
restriction shall include any affiliated, subsidiary or parent organizations to
which PPG may belong in which thirty percent (30%) or more is  under common ownership. “Proprietary
Interest”, as used herein, shall not be deemed to include:

 

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

 

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

 

2.24                        Non-Solicitation. PPG and Member Physicians shall not, either
during or after the term of this Agreement, solicit any Member to enroll in any
other health care service plan or insurance program for the primary purpose of
securing financial gain.  FHS shall have
the right to review all correspondence or communications to Members prior to
dissemination or mailing.

 

10

 

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

 

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

 

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

 

III.                                 DUTIES OF FHS

 

3.1                               Enrollment List.  FHS
shall periodically provide PPG with a list of HMO Members assigned to PPG via
electronic transmission or magnetic media. FHS shall maintain a system to allow
PPG and Member Physicians to make telephonic or electronic inquiries regarding
Member eligibility.

 

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

 

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

 

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

 

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

 

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

 

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

 

11

 

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

 

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

 

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

 

IV.                                COMPENSATION

 

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

 

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

 

4.3                               Billing and Payment.

 

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

 

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

 

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

 

12

 

(c)                                  Adjustments and Appeals.  PPG
or Member Physicians shall submit requests for adjustments and/or appeals
regarding claim payments to FHS within sixty (60) calendar days after the date
of the payment of such claim to PPG or Member Physician. In the event PPG or
Member Physician fails to appeal a claim within such time period, PPG or Member
Physician shall not have the right 10 appeal such claim.

 

(d)                                 Offsetting.  FHS
shall have the right to offset any amounts owed to FHS by PPG. including but
not limited to, amounts owed by PPG under loans guaranteed by FHS, errors, or
FHS interim payment for Contracted Services, including Capitation payments.  Effective July 1, 1998 and notwithstanding
any other provision of this Agreement or any other contract to the contrary,
only deficits in the shared risk programs which provide financial incentives
for the control or management of Shared Risk Services’ expenses or utilization
will neither be collected from PPG by FHS nor offset against PPG Capitation;
provided however, that FHS shall not be restricted from (i) offsetting such
deficits against payments to PPG including, but not limited to, surpluses from
other shared risk programs, stop loss payments, bonus or other incentive
program payments; (ii) establishing reasonable withholds from Capitation
approved by DOC as set forth in the applicable Addendum to offset PPG liability
when the cost of Shared Risk Services exceed the Shared Risk Budget (Withhold
Fund); or (iii) carrying forward such shared risk program deficits to be
applied against future year’s program surpluses and Withhold Fund.  Each PPG numbered site shall be calculated
as a separate entity and any payments to or from PPG with multiple sites shall
be net amount due/owed from all sites.

 

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

 

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

 

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

 

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

 

13

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

14

 

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

 

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

 

V.                                    DELEGATION

 

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

 

5.2                               Termination of Delegation.  FHS
shall have the right to audit PPG’s performance of utilization management,
quality improvement, credentialing and recredentialing. Member grievance and
appeal, medical record review, and capitation and claims adjudication functions
from time to time. If FHS determines that deficiencies exist in PPG’s
performance, PPG shall accept consulting assistance from FHS. Failure to cure
any identified deficiencies within a reasonable period of time as defined by FHS
policies, or if FHS determines PPG does not have the ability to perform
delegated functions, or is not effectively performing delegated functions, FHS
may revoke delegation of all or any of these functions in accordance with
procedures set forth in the Operations Manual and re-assume the performance of
such functions itself. Should it become necessary for FHS to reassume delegated
functions, FHS shall charge the following administrative fees: utilization
management 4% of PPG Capitation; quality improvement 3% of PPG Capitation;
claims processing 3.5% of PPG Capitation.

 

VI.                                TERM AND TERMINATION

 

6.1                               Term.  The
term of this Agreement shall commence on the date set forth on the first page
of this Agreement and shall continue for a period of thirty (30) months. This
Agreement shall automatically renew for successive one year periods on the
annual renewal date, unless terminated as set forth herein. The term of this
Agreement shall remain the same for all Benefit Programs covered hereunder.

 

15

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

16

 

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

 

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

 

VII.                            RECORDS, AUDITS AND REGULATORY
REQUIREMENTS

 

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

 

7.2                               Access to Records; Audits.  The
records referred to above shall not be removed or transferred from PPG except
in accordance with applicable local, State, and federal laws, rules and
regulations.  Subject to applicable
State and federal confidentiality or privacy laws.  FHS or its designated representatives, and designated
representatives of local, State, and federal regulatory agencies having
jurisdiction over FHS shall have access to PPG’s records, at PPG’s place of
business on request during normal business hours, to inspect and review and
make copies of such records. Such governmental agencies shall include, but not
be limited to, when applicable to the Benefit Programs identified on Addendum
A, the DHS, the DHHS, the DOC, the DOD and the DOJ. When requested by PHS, PPG
shall produce copies of any such records at no cost.  Additionally, PPG agrees to permit FHS, and its designated
representatives, accreditation organizations, and designated representatives of
local, State, and federal regulatory agencies having jurisdiction over FHS or
any Payor, to conduct site evaluations and inspections of PPG’s offices and
service locations.

 

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

 

VIII.                        GENERAL PROVISIONS

 

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

 

17

 

8.2                               Separate Obligations.  The  rights and obligations of under this
Agreement shall apply to each Affiliate listed on Addendum A to this Agreement
only with respect to the Benefit Programs of such Affiliate. No such Affiliate
shall be responsible for the obligations of any other Affiliate under this
Agreement with respect to the other Affiliate’s Benefit Programs. The person
executing this Agreement has been duly authorized by each Affiliate to execute
this Agreement on such Affiliates behalf. In no event shall FHS or any FHS
Affiliate be responsible for any payment which is the financial responsibility
of a Payor and PPG shall seek compensation for such services only from Payor.

 

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

 

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

 

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

 

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

 

8.6                               Binding Arbitration.  PPG
and FHS agree to meet and confer in good faith to  resolve any problems or disputes that may arise under this
Agreement. Such good faith meet and confer shall be a condition precedent to
the filing of any arbitration demand by either party.  In addition, should the parties, prior to submitting a dispute to
arbitration, desire to utilize other impartial dispute settlement techniques
such as mediation or fact-finding, a joint request for such services may be
made to the American Arbitration Association (“AAA”), Judicial Arbitration and

 

18

 

Mediation
Services (“JAMS”), or the parties may initiate such other
procedures as they may mutually agree upon at such time. Notwithstanding the
foregoing, nothing contained herein is intended to require arbitration of
disputes for medical malpractice between a Member and the PPG.

 

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

 

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

 

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

 

8.7                               Indemnification of Parties.

 

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

 

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

 

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

 

8.9                               Cooperation of Parties.  The parties
shall cooperate in administering and determining Member benefits under the
applicable Coverage Certificate in accordance with the Operations Manual and as
agreed to by the parties. PPG understands and agrees that PPG is not authorized
to make nor shall it make any variances, alterations, or exceptions to the
provisions, terms, and conditions of a Member’s Coverage Certificate. FHS shall
have the final decision-making authority between the parties for payment of
claims for Covered Services rendered to Members,

 

19

 

determination
of Covered Services, including Medically Necessary Services, determination of
eligibility and determination of Members’ benefits under the applicable Benefit
Program. Notwithstanding the foregoing, PPG and Member Physicians shall be
solely responsible for providing Contracted Services to Members. The parties
shall refrain from unduly criticizing each other, especially in the presence of
third parties and shall attempt to resolve all issues in a cooperative and
professional manner.

 

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

 

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

 

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

 

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

 

FHS

C/O Health Net

21600 Oxnard Street

Woodland Hills, California 91367

Attention: Senior Vice President, Provider Network Management

 

PPG:

A.V. Medical Group

18200 Yorba Linda Blvd., Suite 409

Yorba Linda, CA 92686

Attn: Administrator / CEO

 

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

 

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

 

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

 

8.16                        Regulatory Approval.  If
FHS has not been licensed to provide, or provides services in connection with,
a particular Benefit Program in a particular State, or has not received all
required regulatory approvals for use of this Agreement with respect to the
Benefit Program in the State prior to the execution of this Agreement, this
Agreement shall be deemed to be a binding letter of intent with respect to such
Benefit Program in the State. In such event, this Agreement shall become
effective with respect to any such Benefit Program in the State on the date
that the required licensure and regulatory approvals are obtained. If FHS is
unable to obtain such licensure of regulatory approvals after due diligence,
FHS shall notify PPG and both parties shall be released from any liability
under this Agreement with

 

20

 

respect
to the Benefit Program in question in the applicable State; provided however,
that if such licensure or regulatory approval is conditioned upon amendment of
this Agreement, then this Agreement shall be amended automatically pursuant to
this Article.

 

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

 

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

 

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

 

21

 

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

 

 

	
  Participating Physician Group

  	
  Foundation Health System Affiliates

  
	
   

  	
   

  
	
   

  	
   

  
	
    /s/
  James M. Wilcox

  	
   

  	
    /s/
  Linda S. Pollnow

  	
   

  
	
  Signature

  	
   

  	
  Signature

  
	
   

  	
   

  	
   

  
	
    JAMES
  M. WILCOX

  	
   

  	
  Linda
  S. Pollnow

  
	
  Print
  Name

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Senior
  Vice President

  
	
  V.P./CONTRACTING

  	
   

  	
  Provider
  Network Management

  
	
  Title

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  6/12/98

  	
   

  	
  6-12-98

  	
   

  
	
  Date

  	
   

  	
  Date

  
	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Federal
  Tax Identification Number

  	
   

  
					

 

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

 

	
  Participating Physician Group

  
	
   

  
	
   

  
	
    /s/
  James M. Wilcox

  	
   

  
	
  Signature

  	
   

  
	
   

  	
   

  
	
    JAMES
  M. WILCOX

  	
   

  
	
  Print
  Name

  	
   

  
	
   

  	
   

  
	
   

  	
   

  
	
  V.P./CONTRACTING

  	
   

  
	
  Title

  	
   

  
	
   

  	
   

  
	
  6/12/98

  	
   

  
	
  Date

  	
   

  

 

22

 

ADDENDUM A

 

BENEFIT
PROGRAMS AND AFFILIATES

 

I.                                         BENEFIT PROGRAMS

 

Benefit Program participation included under this Agreement is as
follows:

 

	
  Standard
  HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Flex
  Funded HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Small
  Group HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Individual
  HMO

  	
   

  	
  B

  	
   

  	
  YES

  
	
  AIM

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare
  Supplement

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Commercial
  POS

  	
   

  	
  B

  	
   

  	
  YES

  
	
  Medicare
  HMO

  	
   

  	
  C

  	
   

  	
  YES

  
	
  Medicare
  POS

  	
   

  	
  C

  	
   

  	
  YES

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

  	
   

  	
  D

  	
   

  	
  YES

  
	
  Medi-Cal

  	
   

  	
  F

  	
   

  	
  NO

  
	
  CHAMPUS

  	
   

  	
  G

  	
   

  	
  YES

  
	
  Occupational
  Medicine

  	
   

  	
  H

  	
   

  	
  YES

  

 

II.                                     AFFILIATES

 

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

 

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

 

23

 

ADDENDUM B

 

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

 

A.                                    GENERAL REIMBURSEMENT
PROVISIONS.

 

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

 

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

•                  Commercial
HMO

•                  Standard HMO
•                  Flex Funded HMO

•                  Small Group HMO 

•                  Individual HMO

•                  AIM

•                  Medicare Supplement 

•                  Commercial
POS

 

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

 

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

 

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

 

6.                                      Division of Financial
Responsibility Changes.
In July 1998, HMO shall change the Division of Financial
Responsibility.  As a result, PPG shall
have a change in its Professional Capitation PMPM rates and its Shared Risk
Budgets; Hospital shall have a change in its Capitation rates, if applicable.

 

7.                                      Shared Risk Budget.  In
July 1998, PPGs Shared Risk Budgets shall be converted from a flat PMPM
amount to an age, sex and benefit plan adjusted structure.

 

24

 

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

 

B.                                    STANDARD HMO.

 

1.                                      Professional Capitation
Rates.

 

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

 

	
  Period

  	
   

  	
  Standard

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  PMPM

  

 

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

 

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

 

	
  Calendar
  Year

  	
   

  	
  Top
  33%

  	
   

  	
  Middle
  33%

  	
   

  	
  Lowest
  33%

  
	
  1999

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  
	
  2000

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  

 

Should results for PPG be unavailable or should results not be
statistically meaningful, PPG shall receive the increase amount for the lowest
tier. PPG shall have the right to examine HMO’s calculation of the Member
satisfaction survey results, subject to the blinding of other participating
physician groups’ names. PPG shall request any such examination within sixty
(60) calendar days following notification of survey results, tier ranking and
PMPM increase.

 

2.                                      Professional Stop Loss
Program.

 

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

 

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

 

25

 

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

 

	
  Period

  	
   

  	
  Standard

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

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

 

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

 

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

 

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

 

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

 

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

 

26

 

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:  twenty percent (20%)
of any amount over  *** up to ***; and
*** of any amount over ***.

 

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

 

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

 

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

 

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

 

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

 

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

 

27

 

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

 

Notwithstanding any other provision in this Agreement, HMO reserves the
right to discontinue this Program after calendar year 1998. In the event HMO
continues this Program, HMO shall communicate the reinsurance premiums for any
calendar year by December 15th of the prior year.

 

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

 

	
  •     AIDS Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •     Transplant Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •     Transfer Reinsurance

  	
   

  	
  ***
  PMPM

  

 

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

 

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

 

C.                                    SMALL GROUP HMO.

 

1.                                      Professional Capitation
Rates.

 

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

 

	
  Period

  	
   

  	
  Small
  Group

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  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.

 

28

 

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

 

	
  Period

  	
   

  	
  Small
  Group

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  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 Small Group Members
and place such amount in the Withhold Fund as described in the Agreement.

 

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

 

If, upon final Shared Risk settlement, (i) a Shared Risk gain exists.
HMO shall refund the Withhold Fund, plus accrued interest, to PPG together with
the PPG’s share of the gain, or (ii) a Shared Risk deficit exists, subject to
Section 4.3, of the Agreement.  HMO
shall offset the Withhold Fund against PPG’s outstanding liability or any other
amounts payable to HMO. Any amount in the Withhold Fund not offset against such
PPG liability shall be refunded to PPG at the final Risk Sharing settlement.
However, as a contingency for any PPG liability under this Shared Risk Program,
HMO shall continue, at its sole discretion, to deduct up to five percent (5%)
of PPG’s Capitation for 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 my amounts remain in the
Withhold Fund following the reconciliation of any shared risk program, those
excess funds shall be paid to PPG by April 30 of the following year.

 

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

 

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

 

29

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

	
  •                  AIDS Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •                  Transplant Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •                  Transfer Reinsurance

  	
   

  	
  ***
  PMPM

  

 

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

 

D.                                    INDIVIDUAL HMO.

 

1.                                      Professional Capitation
Rates.

 

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

 

	
  Period

  	
   

  	
  Individual

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  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.

 

30

 

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

 

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

 

	
  Period

  	
   

  	
  Individual

  HMO

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  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 Individual Members and place such amount in the Withhold Fund as described
in the Agreement.

 

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

 

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

 

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

 

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

 

31

 

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: 2.3 % of
Shared Risk Budget.

 

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

 

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

 

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

 

	
  •     AIDS Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •     Transplant Reinsurance

  	
   

  	
  ***
  PMPM

  
	
  •     Transfer Reinsurance

  	
   

  	
  ***
  PMPM

  

 

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

 

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

 

1.                                      Compensation.  HMO
shall pay PPG a flat fee of *** for each adult AIM Member to cover the
professional services related to the birth of an infant. In addition to this
flat fee, HMO shall pay PPG *** PMPM for each adult AIM Member enrolled in the
AIM Program.  HMO shall pay PPG *** PMPM
during the first year of life for each infant AIM Member and *** PMPM during
the second year of life.

 

2.                                      Reinsurance Programs.  PPG’s
professional stop loss level shall be *** per AIM Member. The professional stop
loss level shall be provided to the PPG for AIM Members at no cost. All other
terms and conditions of the Agreement regarding Professional Stop Loss shall
apply to AIM Members.

 

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

 

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

 

32

 

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

 

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

 

	
  Period

  	
   

  	
  Medicare Supplement

  HMO

  	
   

  	
  Medicare Supplement

  POS

  
	
  June 1,
  1998 to June 30, 1998

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  
	
  July 1,
  1998

  	
   

  	
  ***
  PMPM

  	
   

  	
  ***
  PMPM

  

 

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

 

3.                                      Shared Risk Program.  HMO
shall be solely responsible for all Shared Risk services and for pharmacy
benefit costs of Medicare Supplement 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, 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.  In 1998, PPG shall be compensated for rendering
professional In-Network Services to Commercial POS Members at the PMPM amounts set forth for Commercial HMO
Members, less a fifty percent (50 %) 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 fifty percent subject to Section 4.3. PPG shall not
be subject to any downside.

 

33

 

6.                                      Institutional Shared Risk
Program.

 

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

 

	
  Period

  	
   

  	
  Standard HMO Shared

  Risk

  + 10%

  	
   

  	
  Small Group HMO

  Shared Risk

  + 10%

  	
   

  	
  Individual HMO

  Shared Risk

  + 10%

  
	
  June 1, 1998 to June 30, 1998

  	
   

  	
  *** PMPM +10%

  	
   

  	
  *** PMPM +10%

  	
   

  	
  *** PMPM +10%

  
	
  July 1, 1998

  	
   

  	
  *** PMPM +10%

  	
   

  	
  *** PMPM +10%

  	
   

  	
  *** PMPM +10%

  

 

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

 

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

 

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

 

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

 

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

 

(a)                                  Out-of-Area Emergency and Urgently Needed
Services *** 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 *** up to *** and *** of any amount
over ***.

 

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

 

34

 

(a)                                  In-Network Professional Stop Loss.

 

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

 

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

 

8.                                      AIDS and Transplant
Reinsurance.  As further defined in Section B.4 of
this Addendum, the 1998 AIDS Reinsurance rate shall be $ 0.19 PMPM, which shall
be deducted from PPG’s Capitation and *** PMPM shall be deducted from PPG’s
Professional Out-of-Network Risk-Sharing Budget. For the subsequent years,
these deductions shall fluctuate to correspond with the Professional
Out-of-Network Withhold percentage change. The 1998 Transplant Reinsurance
Program rate shall be *** PMPM, which, shall be deducted from PPG’s Capitation
and *** PMPM shall be deducted from PPG’s Professional Out-of-Network Risk
Sharing Budget. The Transplant Reinsurance Program’s deductions for subsequent
years shall also fluctuate to correspond with the Professional Out-of-Network
Withhold percentage change.

 

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

 

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

 

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

 

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

 

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

 

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

 

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

 

35

 

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

 

	
  Calendar Year

  	
   

  	
  Award

  
	
  1998

  	
   

  	
  Up to *** PMPM

  
	
  1999

  	
   

  	
  Up to *** PMPM

  
	
  2000

  	
   

  	
  Up to *** PMPM

  

 

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

 

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

 

1.                                      Pharmacy Budget.  In
accordance with the formula outlined in Section 2 below, PPG’s 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. 
Physician groups comprising the top third of lowest PEMPM normalized
costs. For eligible Commercial HMO Members, each month, HMO  shall fund the 1998 Pharmacy Budget at
*** per eligible Member per month (“PEMPM”) subject to the age, sex and benefit
plan factors set forth in Addendum B.

 

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

 

	
  Pharmacy
  Budget

  Year

  	
   

  	
  Percent
  Difference

  
	
  1998

  	
   

  	
  ***

  
	
  1999

  	
   

  	
  ***

  
	
  2000

  	
   

  	
  ***

  

 

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

 

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

 

36

 

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

 

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

 

	
  Tier

  	
   

  	
  Award

  
	
  Lowest
  Normalized Pharmacy Costs

  	
   

  	
  ***
  of Rebate PEMPM

  
	
  Middle
  Normalized Pharmacy Costs

  	
   

  	
  ***
  of Rebate PEMPM

  
	
  Highest
  Normalized Pharmacy Costs

  	
   

  	
  ***
  of Rebate PEMPM

  

 

37

 

ADDENDUM B.1

 

AGE, SEX AND BENEFIT PLAN FACTORS

 

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

 

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

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

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Pro

  Factor

  	
   

  	
  Inst

  Factor

  
	
  Female

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  
	
   

  	
   

  	
  2-4

  	
   

  	
  0.493

  	
   

  	
  0.370

  
	
   

  	
   

  	
  5-9

  	
   

  	
  0.436

  	
   

  	
  0.382

  
	
   

  	
   

  	
  10-14

  	
   

  	
  0.399

  	
   

  	
  0.390

  
	
   

  	
   

  	
  15-19

  	
   

  	
  0.421

  	
   

  	
  0.418

  
	
   

  	
   

  	
  20-24

  	
   

  	
  0.902

  	
   

  	
  0.999

  
	
   

  	
   

  	
  25-29

  	
   

  	
  1.525

  	
   

  	
  1.664

  
	
   

  	
   

  	
  30-34

  	
   

  	
  1.543

  	
   

  	
  1.478

  
	
   

  	
   

  	
  35-39

  	
   

  	
  1.547

  	
   

  	
  1.281

  
	
   

  	
   

  	
  40-44

  	
   

  	
  1.567

  	
   

  	
  1.272

  
	
   

  	
   

  	
  45-49

  	
   

  	
  1.630

  	
   

  	
  1.293

  
	
   

  	
   

  	
  50-54

  	
   

  	
  1.712

  	
   

  	
  1.448

  
	
   

  	
   

  	
  55-59

  	
   

  	
  1.982

  	
   

  	
  1.927

  
	
   

  	
   

  	
  60-64

  	
   

  	
  2.161

  	
   

  	
  2.260

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.251

  	
   

  	
  2.025

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  
	
  Male

  	
   

  	
  0

  	
   

  	
  1.774

  	
   

  	
  3.843

  
	
   

  	
   

  	
  1

  	
   

  	
  0.664

  	
   

  	
  0.463

  
	
   

  	
   

  	
  2-4

  	
   

  	
  0.493

  	
   

  	
  0.370

  
	
   

  	
   

  	
  5-9

  	
   

  	
  0.436

  	
   

  	
  0.382

  
	
   

  	
   

  	
  10-14

  	
   

  	
  0.399

  	
   

  	
  0.390

  
	
   

  	
   

  	
  15-19

  	
   

  	
  0.421

  	
   

  	
  0.418

  
	
   

  	
   

  	
  20-24

  	
   

  	
  0.432

  	
   

  	
  0.447

  
	
   

  	
   

  	
  25-29

  	
   

  	
  0.492

  	
   

  	
  0.486

  
	
   

  	
   

  	
  30-34

  	
   

  	
  0.569

  	
   

  	
  0.536

  
	
   

  	
   

  	
  35-39

  	
   

  	
  0.667

  	
   

  	
  0.673

  
	
   

  	
   

  	
  40-44

  	
   

  	
  0.780

  	
   

  	
  0.800

  
	
   

  	
   

  	
  45-49

  	
   

  	
  0.933

  	
   

  	
  0.975

  
	
   

  	
   

  	
  50-54

  	
   

  	
  1.251

  	
   

  	
  1.415

  
	
   

  	
   

  	
  55-59

  	
   

  	
  1.625

  	
   

  	
  1.998

  
	
   

  	
   

  	
  60-64

  	
   

  	
  2.177

  	
   

  	
  2.928

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.276

  	
   

  	
  2.658

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  

 

38

 

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

Effective
September 1, 1998

 

	
  Sex

  	
   

  	
  Age

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  Child

  	
   

  	
  0

  	
   

  	
  2.008

  	
   

  	
  5.228

  
	
   

  	
   

  	
  1

  	
   

  	
  1.075

  	
   

  	
  0.644

  
	
   

  	
   

  	
  2-4

  	
   

  	
  0.598

  	
   

  	
  0.406

  
	
   

  	
   

  	
  5-9

  	
   

  	
  0.439

  	
   

  	
  0.296

  
	
   

  	
   

  	
  10-14

  	
   

  	
  0.418

  	
   

  	
  0.338

  
	
   

  	
   

  	
  15-19

  	
   

  	
  0.590

  	
   

  	
  0.607

  
	
  Female

  	
   

  	
  20-24

  	
   

  	
  1.195

  	
   

  	
  1.066

  
	
   

  	
   

  	
  25-29

  	
   

  	
  1.653

  	
   

  	
  1.431

  
	
   

  	
   

  	
  30-34

  	
   

  	
  1.509

  	
   

  	
  1.315

  
	
   

  	
   

  	
  35-39

  	
   

  	
  1.378

  	
   

  	
  1.143

  
	
   

  	
   

  	
  40-44

  	
   

  	
  1.322

  	
   

  	
  1.031

  
	
   

  	
   

  	
  45-49

  	
   

  	
  1.386

  	
   

  	
  1.102

  
	
   

  	
   

  	
  50-54

  	
   

  	
  1.551

  	
   

  	
  1.338

  
	
   

  	
   

  	
  55-59

  	
   

  	
  1.794

  	
   

  	
  1.741

  
	
   

  	
   

  	
  60-64

  	
   

  	
  2.090

  	
   

  	
  2.313

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.414

  	
   

  	
  2.907

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  
	
  Male

  	
   

  	
  20-24

  	
   

  	
  0.398

  	
   

  	
  0.477

  
	
   

  	
   

  	
  25-29

  	
   

  	
  0.477

  	
   

  	
  0.486

  
	
   

  	
   

  	
  30-34

  	
   

  	
  0.546

  	
   

  	
  0.506

  
	
   

  	
   

  	
  35-39

  	
   

  	
  0.626

  	
   

  	
  0.589

  
	
   

  	
   

  	
  40-44

  	
   

  	
  0.734

  	
   

  	
  0.768

  
	
   

  	
   

  	
  45-49

  	
   

  	
  0.890

  	
   

  	
  1.087

  
	
   

  	
   

  	
  50-54

  	
   

  	
  1.139

  	
   

  	
  1.580

  
	
   

  	
   

  	
  55-59

  	
   

  	
  1.516

  	
   

  	
  2.203

  
	
   

  	
   

  	
  60-64

  	
   

  	
  2.009

  	
   

  	
  2.880

  
	
   

  	
   

  	
  65+

  	
   

  	
  2.561

  	
   

  	
  3.586

  
	
   

  	
   

  	
  Medicare Eligible

  	
   

  	
  1.000

  	
   

  	
  1.000

  

 

39

 

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

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  HA

  	
   

  	
  1.0740

  	
   

  	
  0.9697

  
	
  A1

  	
   

  	
  1.0857

  	
   

  	
  0.9751

  
	
  A2

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  
	
  A3

  	
   

  	
  1.0831

  	
   

  	
  0.9846

  
	
  A4

  	
   

  	
  1.0740

  	
   

  	
  0.9806

  
	
  A5

  	
   

  	
  1.0857

  	
   

  	
  0.9782

  
	
  A6

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  
	
  A7

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  
	
  A8

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  
	
  A9

  	
   

  	
  1.0411

  	
   

  	
  1.0408

  
	
  HB

  	
   

  	
  1.0039

  	
   

  	
  0.8702

  
	
  BB

  	
   

  	
  1.0039

  	
   

  	
  0.8709

  
	
  B1

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  
	
  B2

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  
	
  B3

  	
   

  	
  0.9007

  	
   

  	
  0.8262

  
	
  B4

  	
   

  	
  0.9027

  	
   

  	
  0.8252

  
	
  B5

  	
   

  	
  0.9007

  	
   

  	
  0.8371

  
	
  B6

  	
   

  	
  1.0039

  	
   

  	
  0.8812

  
	
  B7

  	
   

  	
  0.9732

  	
   

  	
  1.0271

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0165

  
	
  B9

  	
   

  	
  0.9646

  	
   

  	
  1.0408

  
	
  HC

  	
   

  	
  1.0840

  	
   

  	
  1.0122

  
	
  C1

  	
   

  	
  1.0769

  	
   

  	
  1.0122

  
	
  C2

  	
   

  	
  1.0954

  	
   

  	
  1.0238

  
	
  C3

  	
   

  	
  1.0067

  	
   

  	
  1.0122

  
	
  C6

  	
   

  	
  1.0095

  	
   

  	
  1.0408

  
	
  C7

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  
	
  C8

  	
   

  	
  0.9459

  	
   

  	
  0.9755

  
	
  C9

  	
   

  	
  0.9047

  	
   

  	
  1.0408

  
	
  HD

  	
   

  	
  1.1158

  	
   

  	
  1.0232

  
	
  D1

  	
   

  	
  1.0769

  	
   

  	
  1.0232

  
	
  D2

  	
   

  	
  1.0249

  	
   

  	
  1.0290

  
	
  D3

  	
   

  	
  0.9007

  	
   

  	
  0.8259

  
	
  D4

  	
   

  	
  0.9493

  	
   

  	
  0.8696

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9806

  
	
  D6

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  
	
  D7

  	
   

  	
  0.9655

  	
   

  	
  1.0326

  
	
  D8

  	
   

  	
  1.0274

  	
   

  	
  1.0220

  
	
  D9

  	
   

  	
  1.0456

  	
   

  	
  1.0442

  
	
  HE

  	
   

  	
  1.0320

  	
   

  	
  1.0417

  
	
  E1

  	
   

  	
  1.0166

  	
   

  	
  0.9761

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0408

  
	
  E3

  	
   

  	
  1.0067

  	
   

  	
  0.9806

  
	
  E4

  	
   

  	
  0.9487

  	
   

  	
  0.9934

  
	
  W3

  	
   

  	
  0.9493

  	
   

  	
  1.0487

  
	
  E5

  	
   

  	
  1.0522

  	
   

  	
  1.0439

  
	
  E6

  	
   

  	
  0.9587

  	
   

  	
  0.9761

  
	
  E7

  	
   

  	
  0.9942

  	
   

  	
  1.0439

  
	
  E8

  	
   

  	
  1.0178

  	
   

  	
  1.0238

  
	
  E9

  	
   

  	
  0.9735

  	
   

  	
  0.9806

  
	
  EA

  	
   

  	
  0.9715

  	
   

  	
  1.0372

  
	
  EB

  	
   

  	
  0.9036

  	
   

  	
  0.8192

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0408

  
	
  ED

  	
   

  	
  1.0053

  	
   

  	
  0.9940

  
	
  EE

  	
   

  	
  1.0078

  	
   

  	
  0.9831

  
	
  EF

  	
   

  	
  1.0479

  	
   

  	
  1.0442

  
	
  EG

  	
   

  	
  0.9999

  	
   

  	
  1.0442

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0226

  
	
  EI

  	
   

  	
  0.9914

  	
   

  	
  0.9794

  
	
  EJ

  	
   

  	
  1.0578

  	
   

  	
  1.0499

  
	
  EK

  	
   

  	
  0.9180

  	
   

  	
  1.0408

  
	
  EL

  	
   

  	
  1.0522

  	
   

  	
  0.9779

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0475

  
	
  EN

  	
   

  	
  0.9797

  	
   

  	
  0.9767

  
	
  EO

  	
   

  	
  0.9749

  	
   

  	
  0.9961

  
	
  EP

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  
	
  EQ

  	
   

  	
  0.9769

  	
   

  	
  1.0274

  
	
  ES

  	
   

  	
  0.9729

  	
   

  	
  1.0436

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0071

  
	
  F1

  	
   

  	
  1.0161

  	
   

  	
  1.0095

  
	
  F2

  	
   

  	
  1.0166

  	
   

  	
  0.9779

  
	
  F3

  	
   

  	
  1.0070

  	
   

  	
  0.9806

  
	
  F4

  	
   

  	
  0.9808

  	
   

  	
  1.0332

  
	
  F5

  	
   

  	
  1.0218

  	
   

  	
  0.9812

  
	
  F6

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  
	
  F7

  	
   

  	
  1.1087

  	
   

  	
  0.9925

  
	
  F8

  	
   

  	
  0.9050

  	
   

  	
  0.9697

  
	
  F9

  	
   

  	
  1.0522

  	
   

  	
  1.0445

  
	
  FA

  	
   

  	
  1.0269

  	
   

  	
  1.0341

  
	
  FB

  	
   

  	
  1.0277

  	
   

  	
  1.0487

  
	
  FC

  	
   

  	
  1.0164

  	
   

  	
  1.0372

  
	
  FD

  	
   

  	
  1.0309

  	
   

  	
  1.0366

  
	
  FE

  	
   

  	
  0.9635

  	
   

  	
  1.0341

  
	
  FF

  	
   

  	
  0.9703

  	
   

  	
  1.0396

  
	
  FG

  	
   

  	
  0.9635

  	
   

  	
  1.0016

  
	
  FH

  	
   

  	
  0.9712

  	
   

  	
  1.0341

  
	
  FI

  	
   

  	
  0.9749

  	
   

  	
  1.0341

  
	
  FJ

  	
   

  	
  0.9203

  	
   

  	
  1.0341

  
	
  FK

  	
   

  	
  0.9749

  	
   

  	
  0.9885

  
	
  1H

  	
   

  	
  1.0348

  	
   

  	
  0.9469

  
	
  FL

  	
   

  	
  0.9203

  	
   

  	
  0.9572

  
	
  HG

  	
   

  	
  1.0039

  	
   

  	
  0.9697

  
	
  G1

  	
   

  	
  0.9459

  	
   

  	
  0.9697

  
	
  G2

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  
	
  G3

  	
   

  	
  1.0155

  	
   

  	
  0.9806

  
	
  G4

  	
   

  	
  0.9459

  	
   

  	
  0.9806

  
	
  G5

  	
   

  	
  0.8965

  	
   

  	
  0.9694

  
	
  G6

  	
   

  	
  1.0164

  	
   

  	
  1.0211

  
	
  G9

  	
   

  	
  1.0039

  	
   

  	
  0.9806

  
	
  13

  	
   

  	
  0.9644

  	
   

  	
  1.0442

  
	
  14

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  
	
  15

  	
   

  	
  0.9553

  	
   

  	
  1.0113

  
	
  16

  	
   

  	
  1.0448

  	
   

  	
  0.9551

  
	
  17

  	
   

  	
  1.0513

  	
   

  	
  1.0411

  
	
  18

  	
   

  	
  0.9573

  	
   

  	
  1.0268

  
	
  19

  	
   

  	
  0.9891

  	
   

  	
  1.0408

  
	
  J3

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  
	
  J4

  	
   

  	
  1.0294

  	
   

  	
  0.9879

  
	
  J5

  	
   

  	
  1.0130

  	
   

  	
  0.9809

  
	
  J6

  	
   

  	
  0.9766

  	
   

  	
  0.9800

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0305

  
	
  J8

  	
   

  	
  0.9729

  	
   

  	
  0.9852

  
	
  J9

  	
   

  	
  1.1604

  	
   

  	
  1.0667

  
	
  HK

  	
   

  	
  1.0840

  	
   

  	
  1.0411

  
	
  K1

  	
   

  	
  1.0138

  	
   

  	
  1.0411

  
	
  K2

  	
   

  	
  0.9720

  	
   

  	
  0.9806

  
	
  K3

  	
   

  	
  1.0237

  	
   

  	
  1.0414

  
	
  K4

  	
   

  	
  1.0956

  	
   

  	
  1.0411

  
	
  K6

  	
   

  	
  0.9698

  	
   

  	
  1.0420

  
	
  K7

  	
   

  	
  0.9905

  	
   

  	
  1.0180

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0223

  
	
  K9

  	
   

  	
  0.9459

  	
   

  	
  0.9548

  
	
  KI

  	
   

  	
  0.9635

  	
   

  	
  1.0347

  
	
  KJ

  	
   

  	
  1.0269

  	
   

  	
  1.0347

  
	
  KK

  	
   

  	
  0.9749

  	
   

  	
  0.9894

  
	
  KL

  	
   

  	
  0.9632

  	
   

  	
  1.0098

  
	
  KM

  	
   

  	
  0.9317

  	
   

  	
  1.0347

  
	
  L1

  	
   

  	
  0.9939

  	
   

  	
  1.0442

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9806

  
	
  L3

  	
   

  	
  0.9601

  	
   

  	
  0.9806

  
	
  L4

  	
   

  	
  0.9801

  	
   

  	
  0.9803

  
	
  L5

  	
   

  	
  0.9459

  	
   

  	
  0.9818

  
	
  L6

  	
   

  	
  1.0039

  	
   

  	
  0.9818

  
	
  L7

  	
   

  	
  1.0334

  	
   

  	
  0.9809

  
	
  7Q

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  
	
  L8

  	
   

  	
  1.0192

  	
   

  	
  0.9697

  
	
  L9

  	
   

  	
  0.9558

  	
   

  	
  1.0411

  
	
  HM

  	
   

  	
  1.1684

  	
   

  	
  1.0609

  
	
  M1

  	
   

  	
  0.9791

  	
   

  	
  1.0417

  
	
  M2

  	
   

  	
  1.1834

  	
   

  	
  1.0609

  
	
  M3

  	
   

  	
  1.0070

  	
   

  	
  1.0414

  
	
  M4

  	
   

  	
  1.0070

  	
   

  	
  1.0408

  
	
  M5

  	
   

  	
  1.0246

  	
   

  	
  1.0268

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9666

  
	
  M7

  	
   

  	
  0.9493

  	
   

  	
  0.8754

  
	
  M8

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  
	
  M9

  	
   

  	
  1.0769

  	
   

  	
  1.0411

  
	
  HN

  	
   

  	
  1.0067

  	
   

  	
  1.0408

  
	
  N1

  	
   

  	
  1.0218

  	
   

  	
  1.0427

  
	
  N2

  	
   

  	
  1.0124

  	
   

  	
  1.0408

  
	
  N3

  	
   

  	
  1.0161

  	
   

  	
  1.0420

  
	
  N4

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  
	
  N5

  	
   

  	
  1.0067

  	
   

  	
  1.0232

  
	
  N6

  	
   

  	
  1.0184

  	
   

  	
  1.0232

  
	
  N7

  	
   

  	
  1.0184

  	
   

  	
  1.0408

  
	
  N8

  	
   

  	
  1.0357

  	
   

  	
  1.0387

  
	
  N9

  	
   

  	
  1.0124

  	
   

  	
  1.0259

  
	
  HO

  	
   

  	
  0.9487

  	
   

  	
  1.0408

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0408

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0031

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0420

  
	
  O4

  	
   

  	
  1.0184

  	
   

  	
  1.0031

  
	
  O5

  	
   

  	
  0.9487

  	
   

  	
  1.0080

  
	
  O6

  	
   

  	
  1.0380

  	
   

  	
  1.0539

  
	
  O7

  	
   

  	
  1.0402

  	
   

  	
  1.0393

  
	
  O8

  	
   

  	
  1.0053

  	
   

  	
  0.9761

  
	
  O9

  	
   

  	
  0.9752

  	
   

  	
  1.0420

  
	
  HP

  	
   

  	
  1.0064

  	
   

  	
  1.0122

  
	
  P1

  	
   

  	
  1.0161

  	
   

  	
  1.0156

  
	
  P2

  	
   

  	
  0.9081

  	
   

  	
  0.9426

  
	
  P3

  	
   

  	
  0.9516

  	
   

  	
  0.9806

  
	
  P4

  	
   

  	
  1.0070

  	
   

  	
  1.0518

  
	
  P5

  	
   

  	
  0.8965

  	
   

  	
  0.9755

  
	
  P6

  	
   

  	
  1.1008

  	
   

  	
  0.9867

  
	
  P7

  	
   

  	
  1.0243

  	
   

  	
  1.0408

  
	
  P8

  	
   

  	
  0.9789

  	
   

  	
  0.9882

  
	
  P9

  	
   

  	
  1.0155

  	
   

  	
  0.9855

  
	
  HR

  	
   

  	
  1.1684

  	
   

  	
  1.0624

  
	
  R1

  	
   

  	
  1.0252

  	
   

  	
  1.0252

  
	
  R2

  	
   

  	
  0.9502

  	
   

  	
  1.0439

  
	
  R3

  	
   

  	
  0.9644

  	
   

  	
  1.0408

  
	
  R4

  	
   

  	
  0.8976

  	
   

  	
  0.8985

  
	
  R5

  	
   

  	
  1.0053

  	
   

  	
  0.9806

  
	
  R6

  	
   

  	
  1.0053

  	
   

  	
  0.9429

  
	
  R7

  	
   

  	
  0.8965

  	
   

  	
  0.9043

  
	
  R8

  	
   

  	
  0.9672

  	
   

  	
  1.0265

  
	
  R9

  	
   

  	
  0.9019

  	
   

  	
  0.8262

  
	
  HS

  	
   

  	
  1.0956

  	
   

  	
  1.0238

  
	
  S1

  	
   

  	
  1.1428

  	
   

  	
  1.0685

  
	
  S2

  	
   

  	
  1.0303

  	
   

  	
  1.0296

  
	
  S3

  	
   

  	
  1.0559

  	
   

  	
  1.0530

  
	
  S4

  	
   

  	
  0.9459

  	
   

  	
  0.9332

  
	
  S5

  	
   

  	
  0.9007

  	
   

  	
  0.8377

  
	
  S6

  	
   

  	
  1.0840

  	
   

  	
  1.0232

  
	
  S7

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  
	
  S8

  	
   

  	
  1.0169

  	
   

  	
  0.9806

  
	
  S9

  	
   

  	
  1.0169

  	
   

  	
  0.9429

  
	
  HT

  	
   

  	
  1.0769

  	
   

  	
  1.0408

  
	
  T1

  	
   

  	
  1.0826

  	
   

  	
  1.0408

  
	
  T2

  	
   

  	
  1.0885

  	
   

  	
  1.0408

  
	
  T3

  	
   

  	
  1.0192

  	
   

  	
  1.0235

  
	
  T4

  	
   

  	
  1.0147

  	
   

  	
  1.0214

  
	
  T5

  	
   

  	
  1.0115

  	
   

  	
  1.0417

  
	
  T7

  	
   

  	
  0.9257

  	
   

  	
  0.9867

  
	
  T8

  	
   

  	
  1.0144

  	
   

  	
  0.9855

  
	
  T9

  	
   

  	
  1.0388

  	
   

  	
  1.0278

  
	
  TA

  	
   

  	
  0.9797

  	
   

  	
  0.9879

  
	
  TB

  	
   

  	
  0.9914

  	
   

  	
  0.9767

  
	
  TC

  	
   

  	
  1.0076

  	
   

  	
  0.9770

  
	
  HU

  	
   

  	
  1.0365

  	
   

  	
  1.0503

  
	
  U1

  	
   

  	
  1.0243

  	
   

  	
  0.9937

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9429

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.9697

  
	
  U4

  	
   

  	
  1.0863

  	
   

  	
  1.0256

  
	
  U5

  	
   

  	
  0.9490

  	
   

  	
  1.0442

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0326

  
	
  U7

  	
   

  	
  0.9772

  	
   

  	
  1.0299

  
	
  U8

  	
   

  	
  1.0277

  	
   

  	
  1.0442

  
	
  U9

  	
   

  	
  1.0320

  	
   

  	
  1.0524

  
	
  HV

  	
   

  	
  1.0925

  	
   

  	
  1.0454

  
	
  HW

  	
   

  	
  1.0536

  	
   

  	
  0.9697

  
	
  W1

  	
   

  	
  1.0442

  	
   

  	
  0.9697

  
	
  W2

  	
   

  	
  1.0232

  	
   

  	
  1.0214

  

 

40

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  W4

  	
   

  	
  0.9328

  	
   

  	
  0.9910

  
	
  W5

  	
   

  	
  1.0371

  	
   

  	
  1.0329

  
	
  W6

  	
   

  	
  0.9516

  	
   

  	
  0.9840

  
	
  W7

  	
   

  	
  0.9760

  	
   

  	
  1.0156

  
	
  W8

  	
   

  	
  1.0002

  	
   

  	
  1.0408

  
	
  W9

  	
   

  	
  0.9021

  	
   

  	
  1.0408

  
	
  HX

  	
   

  	
  0.9459

  	
   

  	
  0.9320

  
	
  X1

  	
   

  	
  0.9493

  	
   

  	
  0.8699

  
	
  X2

  	
   

  	
  0.9575

  	
   

  	
  0.9320

  
	
  X3

  	
   

  	
  0.9459

  	
   

  	
  0.9429

  
	
  X4

  	
   

  	
  0.9581

  	
   

  	
  0.9426

  
	
  X5

  	
   

  	
  1.0164

  	
   

  	
  1.0320

  
	
  X6

  	
   

  	
  1.0127

  	
   

  	
  1.0408

  
	
  X7

  	
   

  	
  0.8965

  	
   

  	
  0.9803

  
	
  X8

  	
   

  	
  1.0155

  	
   

  	
  0.9809

  
	
  X9

  	
   

  	
  0.8965

  	
   

  	
  0.9645

  
	
  HY

  	
   

  	
  0.8965

  	
   

  	
  0.8934

  
	
  Y1

  	
   

  	
  0.8993

  	
   

  	
  0.9627

  
	
  Y2

  	
   

  	
  0.8965

  	
   

  	
  0.9317

  
	
  Y3

  	
   

  	
  0.8965

  	
   

  	
  1.0028

  
	
  Y4

  	
   

  	
  0.9081

  	
   

  	
  1.0028

  
	
  Y5

  	
   

  	
  0.9487

  	
   

  	
  0.9630

  
	
  Y6

  	
   

  	
  0.8965

  	
   

  	
  0.9426

  
	
  Y7

  	
   

  	
  1.0107

  	
   

  	
  0.9806

  
	
  Y8

  	
   

  	
  1.0252

  	
   

  	
  1.0408

  
	
  Y9

  	
   

  	
  1.0260

  	
   

  	
  1.0211

  
	
  ZA

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  
	
  ZB

  	
   

  	
  0.9797

  	
   

  	
  0.8660

  
	
  ZC

  	
   

  	
  1.0499

  	
   

  	
  0.9654

  
	
  ZG

  	
   

  	
  0.9797

  	
   

  	
  0.9654

  
	
  ZK

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  
	
  ZM

  	
   

  	
  1.1005

  	
   

  	
  0.9882

  
	
  ZN

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  
	
  ZO

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  
	
  ZS

  	
   

  	
  1.0615

  	
   

  	
  0.9770

  
	
  ZZ

  	
   

  	
  0.9922

  	
   

  	
  0.9770

  
	
  1A

  	
   

  	
  0.9987

  	
   

  	
  1.0198

  
	
  1B

  	
   

  	
  1.0343

  	
   

  	
  1.0232

  
	
  1C

  	
   

  	
  1.0385

  	
   

  	
  1.0256

  
	
  1D

  	
   

  	
  0.9709

  	
   

  	
  1.0423

  
	
  1E

  	
   

  	
  1.0348

  	
   

  	
  1.0271

  
	
  1F

  	
   

  	
  1.0348

  	
   

  	
  1.0232

  
	
  1G

  	
   

  	
  1.0348

  	
   

  	
  1.0220

  
	
  1J

  	
   

  	
  1.0348

  	
   

  	
  1.0393

  
	
  1K

  	
   

  	
  1.0198

  	
   

  	
  1.0271

  
	
  1L

  	
   

  	
  1.0368

  	
   

  	
  0.9803

  
	
  1M

  	
   

  	
  1.0274

  	
   

  	
  1.0083

  
	
  1N

  	
   

  	
  1.0274

  	
   

  	
  1.0423

  
	
  1P

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  
	
  1Q

  	
   

  	
  1.0274

  	
   

  	
  0.9469

  
	
  1R

  	
   

  	
  1.0996

  	
   

  	
  1.0423

  
	
  1S

  	
   

  	
  0.9709

  	
   

  	
  1.0049

  
	
  1T

  	
   

  	
  0.9627

  	
   

  	
  1.0049

  
	
  1U

  	
   

  	
  0.9271

  	
   

  	
  1.0031

  
	
  1V

  	
   

  	
  1.0232

  	
   

  	
  1.0214

  
	
  1W

  	
   

  	
  0.9678

  	
   

  	
  0.9803

  
	
  1X

  	
   

  	
  1.0243

  	
   

  	
  0.9803

  
	
  1Y

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  
	
  1Z

  	
   

  	
  1.0192

  	
   

  	
  1.0049

  
	
  2A

  	
   

  	
  0.9709

  	
   

  	
  0.9469

  
	
  2B

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  
	
  2C

  	
   

  	
  1.1377

  	
   

  	
  1.0074

  
	
  2D

  	
   

  	
  0.9405

  	
   

  	
  1.0056

  
	
  2E

  	
   

  	
  1.0956

  	
   

  	
  1.0423

  
	
  2F

  	
   

  	
  1.0235

  	
   

  	
  1.0214

  
	
  6A

  	
   

  	
  1.0615

  	
   

  	
  0.9709

  
	
  6G

  	
   

  	
  0.9217

  	
   

  	
  0.9654

  
	
  6H

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  
	
  6R

  	
   

  	
  0.9334

  	
   

  	
  0.9764

  
	
  6S

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  
	
  6T

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  
	
  6V

  	
   

  	
  0.9217

  	
   

  	
  0.9615

  
	
  6W

  	
   

  	
  0.9700

  	
   

  	
  0.9797

  
	
  6Z

  	
   

  	
  0.9252

  	
   

  	
  0.8657

  
	
  7C

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  
	
  7E

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  
	
  7F

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  
	
  7G

  	
   

  	
  1.0499

  	
   

  	
  0.9764

  
	
  7H

  	
   

  	
  0.9217

  	
   

  	
  0.9079

  
	
  7I

  	
   

  	
  0.9854

  	
   

  	
  0.9770

  
	
  7J

  	
   

  	
  0.8723

  	
   

  	
  0.9000

  
	
  7K

  	
   

  	
  0.9811

  	
   

  	
  0.9764

  
	
  7L

  	
   

  	
  1.0053

  	
   

  	
  0.9882

  
	
  7M

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  
	
  7N

  	
   

  	
  0.9794

  	
   

  	
  0.9764

  
	
  7O

  	
   

  	
  0.8723

  	
   

  	
  0.9761

  
	
  7R

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  
	
  7S

  	
   

  	
  0.8723

  	
   

  	
  0.9384

  
	
  7T

  	
   

  	
  0.9217

  	
   

  	
  0.9466

  
	
  7U

  	
   

  	
  0.9618

  	
   

  	
  0.9764

  
	
  7V

  	
   

  	
  0.9811

  	
   

  	
  0.9387

  
	
  7W

  	
   

  	
  0.9232

  	
   

  	
  0.9387

  
	
  7X

  	
   

  	
  1.1155

  	
   

  	
  0.9882

  
	
  7Y

  	
   

  	
  1.0363

  	
   

  	
  0.9882

  
	
  7Z

  	
   

  	
  0.9217

  	
   

  	
  0.9764

  
	
  9A

  	
   

  	
  0.9797

  	
   

  	
  0.9764

  
	
  9B

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  
	
  9C

  	
   

  	
  0.9735

  	
   

  	
  0.9764

  
	
  9E

  	
   

  	
  0.9968

  	
   

  	
  0.9770

  
	
  9F

  	
   

  	
  1.0615

  	
   

  	
  0.9764

  
	
  9G

  	
   

  	
  0.9945

  	
   

  	
  0.9764

  
	
  9H

  	
   

  	
  0.9530

  	
   

  	
  0.9764

  
	
  9I

  	
   

  	
  0.9820

  	
   

  	
  0.9764

  
	
  9J

  	
   

  	
  0.8766

  	
   

  	
  0.8313

  
	
  9M

  	
   

  	
  0.9928

  	
   

  	
  0.9764

  
	
  9N

  	
   

  	
  0.9334

  	
   

  	
  0.9387

  
	
  9O

  	
   

  	
  0.9368

  	
   

  	
  0.9764

  
	
  9P

  	
   

  	
  1.0007

  	
   

  	
  0.9785

  
	
  9Q

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  
	
  9R

  	
   

  	
  0.9959

  	
   

  	
  0.9837

  
	
  9S

  	
   

  	
  0.9914

  	
   

  	
  0.9764

  
	
  9T

  	
   

  	
  0.9797

  	
   

  	
  0.9767

  
	
  9U

  	
   

  	
  0.9789

  	
   

  	
  0.9803

  
	
  9W

  	
   

  	
  0.9217

  	
   

  	
  0.9566

  
	
  9X

  	
   

  	
  0.8840

  	
   

  	
  0.9764

  

 

41

 

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

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  C4

  	
   

  	
  0.7692

  	
   

  	
  0.7857

  
	
  C5

  	
   

  	
  0.6886

  	
   

  	
  0.7740

  
	
  Q1

  	
   

  	
  0.9857

  	
   

  	
  0.9697

  
	
  Q2

  	
   

  	
  0.9285

  	
   

  	
  0.9315

  
	
  Q3

  	
   

  	
  0.8792

  	
   

  	
  0.8692

  
	
  Q4

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  
	
  Q5

  	
   

  	
  1.0160

  	
   

  	
  1.0230

  
	
  Q6

  	
   

  	
  0.9095

  	
   

  	
  1.0076

  
	
  Q7

  	
   

  	
  0.8447

  	
   

  	
  0.8206

  
	
  Q8

  	
   

  	
  0.9285

  	
   

  	
  0.9697

  
	
  QT

  	
   

  	
  0.7737

  	
   

  	
  0.7841

  
	
  QU

  	
   

  	
  0.6971

  	
   

  	
  0.7709

  
	
  QV

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  
	
  QW

  	
   

  	
  0.6903

  	
   

  	
  0.7302

  
	
  QX

  	
   

  	
  0.7237

  	
   

  	
  0.7808

  
	
  QY

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  
	
  QZ

  	
   

  	
  0.7617

  	
   

  	
  0.7864

  
	
  V1

  	
   

  	
  1.0104

  	
   

  	
  0.9940

  
	
  V2

  	
   

  	
  0.9409

  	
   

  	
  0.9853

  
	
  V3

  	
   

  	
  0.8406

  	
   

  	
  0.9783

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  
	
  Shasta 5

  	
   

  	
  0.9886

  
	
  Shasta 7

  	
   

  	
  0.9639

  
	
  HMO Advantage 10

  	
   

  	
  0.9124

  
	
  Shasta 15

  	
   

  	
  0.8616

  
	
  Shasta Classic

  	
   

  	
  0.8054

  

 

Medicare Supplement HMO

 

	
  Plan

  	
   

  	
  Prof 

  Factor

  
	
  Medicare Conversion Plan J

  	
   

  	
  1.2467

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1604

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6676

  

 

Medicare Supplement POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1604

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6676

  

 

42

 

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

Effective July 1, 1998

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  HA

  	
   

  	
  1.0754

  	
   

  	
  0.9716

  
	
  A1

  	
   

  	
  1.0869

  	
   

  	
  0.9752

  
	
  A2

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  
	
  A3

  	
   

  	
  1.0843

  	
   

  	
  0.9830

  
	
  A4

  	
   

  	
  1.0754

  	
   

  	
  0.9791

  
	
  A5

  	
   

  	
  1.0869

  	
   

  	
  0.9782

  
	
  A6

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  
	
  A7

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  
	
  A8

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  
	
  A9

  	
   

  	
  1.0420

  	
   

  	
  1.0387

  
	
  HB

  	
   

  	
  1.0901

  	
   

  	
  0.8737

  
	
  BB

  	
   

  	
  1.0042

  	
   

  	
  0.8746

  
	
  B1

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  
	
  B2

  	
   

  	
  0.8999

  	
   

  	
  0.8300

  
	
  B3

  	
   

  	
  0.8999

  	
   

  	
  0.8303

  
	
  B4

  	
   

  	
  0.9019

  	
   

  	
  0.8291

  
	
  B5

  	
   

  	
  0.8999

  	
   

  	
  0.8377

  
	
  B6

  	
   

  	
  1.0042

  	
   

  	
  0.8812

  
	
  B7

  	
   

  	
  0.9745

  	
   

  	
  1.0285

  
	
  B8

  	
   

  	
  0.9607

  	
   

  	
  1.0163

  
	
  B9

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  
	
  HC

  	
   

  	
  1.0855

  	
   

  	
  1.0139

  
	
  C1

  	
   

  	
  1.0783

  	
   

  	
  1.0139

  
	
  C2

  	
   

  	
  1.0967

  	
   

  	
  1.0252

  
	
  C3

  	
   

  	
  1.0071

  	
   

  	
  1.0139

  
	
  C6

  	
   

  	
  1.0103

  	
   

  	
  1.0387

  
	
  C7

  	
   

  	
  1.0855

  	
   

  	
  1.0211

  
	
  C8

  	
   

  	
  0.9457

  	
   

  	
  0.9758

  
	
  C9

  	
   

  	
  0.9042

  	
   

  	
  1.0387

  
	
  HD

  	
   

  	
  1.1174

  	
   

  	
  1.0211

  
	
  D1

  	
   

  	
  1.0783

  	
   

  	
  1.0211

  
	
  D2

  	
   

  	
  1.0255

  	
   

  	
  1.0303

  
	
  D3

  	
   

  	
  0.9002

  	
   

  	
  0.8300

  
	
  D4

  	
   

  	
  0.9492

  	
   

  	
  0.8731

  
	
  D5

  	
   

  	
  0.9575

  	
   

  	
  0.9791

  
	
  D6

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  
	
  D7

  	
   

  	
  0.9659

  	
   

  	
  1.0306

  
	
  D8

  	
   

  	
  1.0316

  	
   

  	
  1.0199

  
	
  D9

  	
   

  	
  1.0466

  	
   

  	
  1.0456

  
	
  HE

  	
   

  	
  1.0325

  	
   

  	
  1.0431

  
	
  E1

  	
   

  	
  1.0226

  	
   

  	
  0.9746

  
	
  E2

  	
   

  	
  0.9860

  	
   

  	
  1.0387

  
	
  E3

  	
   

  	
  1.0071

  	
   

  	
  0.9791

  
	
  E4

  	
   

  	
  0.9486

  	
   

  	
  0.9920

  
	
  E5

  	
   

  	
  1.0587

  	
   

  	
  1.0417

  
	
  E6

  	
   

  	
  0.9639

  	
   

  	
  0.9746

  
	
  E7

  	
   

  	
  0.9999

  	
   

  	
  1.0417

  
	
  E8

  	
   

  	
  1.0183

  	
   

  	
  1.0235

  
	
  E9

  	
   

  	
  0.9734

  	
   

  	
  0.9791

  
	
  EA

  	
   

  	
  0.9716

  	
   

  	
  1.0350

  
	
  EB

  	
   

  	
  0.9033

  	
   

  	
  0.8215

  
	
  EC

  	
   

  	
  0.9607

  	
   

  	
  1.0386

  
	
  ED

  	
   

  	
  1.0056

  	
   

  	
  0.9926

  
	
  EE

  	
   

  	
  1.0079

  	
   

  	
  0.9811

  
	
  EF

  	
   

  	
  1.0482

  	
   

  	
  1.0419

  
	
  EG

  	
   

  	
  1.0002

  	
   

  	
  1.0419

  
	
  EH

  	
   

  	
  0.9490

  	
   

  	
  1.0204

  
	
  EI

  	
   

  	
  0.9916

  	
   

  	
  0.9775

  
	
  EJ

  	
   

  	
  1.0582

  	
   

  	
  1.0477

  
	
  EK

  	
   

  	
  0.9179

  	
   

  	
  1.0386

  
	
  EL

  	
   

  	
  1.0528

  	
   

  	
  0.9760

  
	
  EM

  	
   

  	
  0.9490

  	
   

  	
  1.0489

  
	
  EN

  	
   

  	
  0.9799

  	
   

  	
  0.9748

  
	
  EO

  	
   

  	
  0.9762

  	
   

  	
  0.9978

  
	
  EP

  	
   

  	
  0.9333

  	
   

  	
  0.9745

  
	
  EQ

  	
   

  	
  0.9782

  	
   

  	
  1.0253

  
	
  ES

  	
   

  	
  0.9730

  	
   

  	
  1.0413

  
	
  HF

  	
   

  	
  0.9618

  	
   

  	
  1.0088

  
	
  F1

  	
   

  	
  1.0169

  	
   

  	
  1.0112

  
	
  F2

  	
   

  	
  1.0172

  	
   

  	
  0.9764

  
	
  F3

  	
   

  	
  1.0074

  	
   

  	
  0.9791

  
	
  F4

  	
   

  	
  0.9820

  	
   

  	
  1.0345

  
	
  F5

  	
   

  	
  1.0284

  	
   

  	
  0.9788

  
	
  F6

  	
   

  	
  1.0077

  	
   

  	
  1.0387

  
	
  F7

  	
   

  	
  1.1102

  	
   

  	
  0.9908

  
	
  F8

  	
   

  	
  0.9041

  	
   

  	
  0.9727

  
	
  F9

  	
   

  	
  1.0532

  	
   

  	
  1.0423

  
	
  FA

  	
   

  	
  1.0285

  	
   

  	
  1.0356

  
	
  FB

  	
   

  	
  1.0313

  	
   

  	
  1.0501

  
	
  FC

  	
   

  	
  1.0199

  	
   

  	
  1.0386

  
	
  FD

  	
   

  	
  1.0345

  	
   

  	
  1.0380

  
	
  FE

  	
   

  	
  0.9647

  	
   

  	
  1.0356

  
	
  FF

  	
   

  	
  0.9716

  	
   

  	
  1.0410

  
	
  FG

  	
   

  	
  0.9647

  	
   

  	
  1.0032

  
	
  FH

  	
   

  	
  0.9725

  	
   

  	
  1.0356

  
	
  FI

  	
   

  	
  0.9762

  	
   

  	
  1.0356

  
	
  FJ

  	
   

  	
  0.9213

  	
   

  	
  1.0356

  
	
  FK

  	
   

  	
  0.9762

  	
   

  	
  0.9902

  
	
  FL

  	
   

  	
  0.9213

  	
   

  	
  0.9588

  
	
  HG

  	
   

  	
  1.0042

  	
   

  	
  0.9716

  
	
  G1

  	
   

  	
  0.9457

  	
   

  	
  0.9716

  
	
  G2

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  
	
  G3

  	
   

  	
  1.0160

  	
   

  	
  0.9791

  
	
  G4

  	
   

  	
  0.9457

  	
   

  	
  0.9791

  
	
  G5

  	
   

  	
  0.8956

  	
   

  	
  0.9713

  
	
  G6

  	
   

  	
  1.0172

  	
   

  	
  1.0226

  
	
  G9

  	
   

  	
  1.0042

  	
   

  	
  0.9791

  
	
  I3

  	
   

  	
  0.9645

  	
   

  	
  1.0455

  
	
  I4

  	
   

  	
  0.9004

  	
   

  	
  0.8366

  
	
  I5

  	
   

  	
  0.9553

  	
   

  	
  1.0108

  
	
  I6

  	
   

  	
  1.0451

  	
   

  	
  0.9548

  
	
  I7

  	
   

  	
  1.0516

  	
   

  	
  1.0425

  
	
  I8

  	
   

  	
  0.9573

  	
   

  	
  1.0247

  
	
  I9

  	
   

  	
  0.9893

  	
   

  	
  1.0386

  
	
  J3

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  
	
  J4

  	
   

  	
  1.0301

  	
   

  	
  0.9896

  
	
  J5

  	
   

  	
  1.0134

  	
   

  	
  0.9794

  
	
  J6

  	
   

  	
  0.9765

  	
   

  	
  0.9818

  
	
  J7

  	
   

  	
  0.9806

  	
   

  	
  1.0318

  
	
  J8

  	
   

  	
  0.9783

  	
   

  	
  0.9869

  
	
  J9

  	
   

  	
  1.1627

  	
   

  	
  1.0642

  
	
  HK

  	
   

  	
  1.0855

  	
   

  	
  1.0390

  
	
  K1

  	
   

  	
  1.0146

  	
   

  	
  1.0390

  
	
  K2

  	
   

  	
  0.9719

  	
   

  	
  0.9791

  
	
  K3

  	
   

  	
  1.0247

  	
   

  	
  1.0393

  
	
  K4

  	
   

  	
  1.0973

  	
   

  	
  1.0390

  
	
  K6

  	
   

  	
  1.9699

  	
   

  	
  1.0399

  
	
  K7

  	
   

  	
  0.9941

  	
   

  	
  1.0196

  
	
  K8

  	
   

  	
  0.9584

  	
   

  	
  1.0205

  
	
  K9

  	
   

  	
  0.9457

  	
   

  	
  0.9570

  
	
  KI

  	
   

  	
  0.9647

  	
   

  	
  1.0362

  
	
  KJ

  	
   

  	
  1.0285

  	
   

  	
  1.0362

  
	
  KK

  	
   

  	
  0.9762

  	
   

  	
  0.9911

  
	
  KL

  	
   

  	
  0.9633

  	
   

  	
  1.0114

  
	
  KM

  	
   

  	
  0.9327

  	
   

  	
  1.0362

  
	
  L1

  	
   

  	
  0.9941

  	
   

  	
  1.0420

  
	
  L2

  	
   

  	
  0.9587

  	
   

  	
  0.9791

  
	
  L3

  	
   

  	
  0.9598

  	
   

  	
  0.9791

  
	
  L4

  	
   

  	
  0.9074

  	
   

  	
  0.9788

  
	
  L5

  	
   

  	
  0.9460

  	
   

  	
  0.9803

  
	
  L6

  	
   

  	
  1.0045

  	
   

  	
  0.9803

  
	
  L7

  	
   

  	
  1.0345

  	
   

  	
  0.9800

  
	
  L8

  	
   

  	
  1.0201

  	
   

  	
  0.9716

  
	
  L9

  	
   

  	
  0.9558

  	
   

  	
  1.0390

  
	
  HM

  	
   

  	
  1.1708

  	
   

  	
  1.0585

  
	
  M1

  	
   

  	
  0.9794

  	
   

  	
  1.0396

  
	
  M2

  	
   

  	
  1.1857

  	
   

  	
  1.0585

  
	
  M3

  	
   

  	
  1.0077

  	
   

  	
  1.0393

  
	
  M4

  	
   

  	
  1.0077

  	
   

  	
  1.0423

  
	
  M5

  	
   

  	
  1.0252

  	
   

  	
  1.0246

  
	
  M6

  	
   

  	
  0.9584

  	
   

  	
  0.9659

  
	
  M7

  	
   

  	
  0.9492

  	
   

  	
  0.8755

  
	
  M8

  	
   

  	
  1.0172

  	
   

  	
  1.0300

  
	
  M9

  	
   

  	
  1.0783

  	
   

  	
  1.0390

  
	
  HN

  	
   

  	
  1.0074

  	
   

  	
  1.0387

  
	
  N1

  	
   

  	
  1.0226

  	
   

  	
  1.0405

  
	
  N2

  	
   

  	
  1.0131

  	
   

  	
  1.0387

  
	
  N3

  	
   

  	
  1.0169

  	
   

  	
  1.0399

  
	
  N4

  	
   

  	
  1.0071

  	
   

  	
  1.0211

  
	
  N5

  	
   

  	
  1.0074

  	
   

  	
  1.0211

  
	
  N6

  	
   

  	
  1.0189

  	
   

  	
  1.0211

  
	
  N7

  	
   

  	
  1.0192

  	
   

  	
  1.0387

  
	
  N8

  	
   

  	
  1.0365

  	
   

  	
  1.0366

  
	
  N9

  	
   

  	
  1.0131

  	
   

  	
  1.0240

  
	
  HO

  	
   

  	
  0.9489

  	
   

  	
  1.0387

  
	
  O1

  	
   

  	
  0.9604

  	
   

  	
  1.0387

  
	
  O2

  	
   

  	
  0.9604

  	
   

  	
  1.0016

  
	
  O3

  	
   

  	
  0.9581

  	
   

  	
  1.0399

  
	
  O4

  	
   

  	
  1.0189

  	
   

  	
  1.0016

  
	
  O5

  	
   

  	
  0.9486

  	
   

  	
  1.0064

  
	
  O6

  	
   

  	
  1.0388

  	
   

  	
  1.0516

  
	
  O7

  	
   

  	
  1.0411

  	
   

  	
  1.0372

  
	
  O8

  	
   

  	
  1.0056

  	
   

  	
  0.9746

  
	
  O9

  	
   

  	
  0.9754

  	
   

  	
  1.0399

  
	
  HP

  	
   

  	
  1.0068

  	
   

  	
  1.0139

  
	
  P1

  	
   

  	
  1.0166

  	
   

  	
  1.0172

  
	
  P2

  	
   

  	
  0.9071

  	
   

  	
  0.9417

  
	
  P3

  	
   

  	
  0.9515

  	
   

  	
  0.9791

  
	
  P4

  	
   

  	
  1.0077

  	
   

  	
  1.0495

  
	
  P5

  	
   

  	
  0.8956

  	
   

  	
  0.9740

  
	
  P6

  	
   

  	
  1.1025

  	
   

  	
  0.9866

  
	
  P7

  	
   

  	
  1.0252

  	
   

  	
  1.0387

  
	
  P8

  	
   

  	
  0.9800

  	
   

  	
  0.9899

  
	
  P9

  	
   

  	
  1.0175

  	
   

  	
  0.9872

  
	
  HR

  	
   

  	
  1.1708

  	
   

  	
  1.0600

  
	
  R1

  	
   

  	
  1.0258

  	
   

  	
  1.0243

  
	
  R2

  	
   

  	
  0.9503

  	
   

  	
  1.0417

  
	
  R3

  	
   

  	
  0.9647

  	
   

  	
  1.0387

  
	
  R4

  	
   

  	
  0.8967

  	
   

  	
  0.8980

  
	
  R5

  	
   

  	
  1.0056

  	
   

  	
  0.9791

  
	
  R6

  	
   

  	
  1.0056

  	
   

  	
  0.9420

  
	
  R7

  	
   

  	
  1.8956

  	
   

  	
  0.9039

  
	
  R8

  	
   

  	
  0.9670

  	
   

  	
  1.0243

  
	
  R9

  	
   

  	
  0.9010

  	
   

  	
  0.8300

  
	
  HS

  	
   

  	
  1.0973

  	
   

  	
  1.0220

  
	
  S1

  	
   

  	
  1.1445

  	
   

  	
  1.0660

  
	
  S2

  	
   

  	
  1.0324

  	
   

  	
  1.0309

  
	
  S3

  	
   

  	
  1.0569

  	
   

  	
  1.0507

  
	
  S4

  	
   

  	
  0.9457

  	
   

  	
  0.9357

  
	
  S5

  	
   

  	
  0.8999

  	
   

  	
  0.8380

  
	
  S6

  	
   

  	
  1.0872

  	
   

  	
  1.0211

  
	
  S7

  	
   

  	
  1.0267

  	
   

  	
  1.0208

  
	
  S8

  	
   

  	
  1.0175

  	
   

  	
  0.9791

  
	
  S9

  	
   

  	
  1.0175

  	
   

  	
  0.9420

  
	
  HT

  	
   

  	
  1.0783

  	
   

  	
  1.0387

  
	
  T1

  	
   

  	
  1.0840

  	
   

  	
  1.0387

  
	
  T2

  	
   

  	
  1.0901

  	
   

  	
  1.0387

  
	
  T3

  	
   

  	
  1.0198

  	
   

  	
  1.0232

  
	
  T4

  	
   

  	
  1.0152

  	
   

  	
  1.0211

  
	
  T5

  	
   

  	
  1.0123

  	
   

  	
  1.0396

  
	
  T7

  	
   

  	
  0.9264

  	
   

  	
  0.9887

  
	
  T8

  	
   

  	
  1.0160

  	
   

  	
  0.9872

  
	
  T9

  	
   

  	
  1.0408

  	
   

  	
  1.0291

  
	
  TA

  	
   

  	
  0.9799

  	
   

  	
  0.9860

  
	
  TB

  	
   

  	
  0.9916

  	
   

  	
  0.9748

  
	
  TC

  	
   

  	
  1.0079

  	
   

  	
  0.9784

  
	
  HU

  	
   

  	
  1.0376

  	
   

  	
  1.0486

  
	
  U1

  	
   

  	
  1.0252

  	
   

  	
  0.9926

  
	
  U2

  	
   

  	
  0.9590

  	
   

  	
  0.9420

  
	
  U3

  	
   

  	
  0.9590

  	
   

  	
  0.9716

  
	
  U4

  	
   

  	
  1.0878

  	
   

  	
  1.0238

  
	
  U5

  	
   

  	
  0.9492

  	
   

  	
  1.0456

  
	
  U6

  	
   

  	
  0.9584

  	
   

  	
  1.0306

  
	
  U7

  	
   

  	
  0.9771

  	
   

  	
  1.0312

  
	
  U8

  	
   

  	
  1.0284

  	
   

  	
  1.0420

  
	
  U9

  	
   

  	
  1.0327

  	
   

  	
  1.0501

  
	
  HV

  	
   

  	
  1.0941

  	
   

  	
  1.0432

  
	
  HW

  	
   

  	
  1.0546

  	
   

  	
  0.9716

  
	
  W1

  	
   

  	
  1.0454

  	
   

  	
  0.9716

  
	
  W2

  	
   

  	
  1.0238

  	
   

  	
  1.0211

  
	
  W3

  	
   

  	
  0.9495

  	
   

  	
  1.0465

  
	
  W4

  	
   

  	
  0.9322

  	
   

  	
  0.9929

  
	
  W5

  	
   

  	
  1.0379

  	
   

  	
  1.0342

  
	
  W6

  	
   

  	
  0.9515

  	
   

  	
  0.9824

  
	
  W7

  	
   

  	
  0.9763

  	
   

  	
  1.0154

  

 

43

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  
	
  W8

  	
   

  	
  1.0007

  	
   

  	
  1.0390

  
	
  W9

  	
   

  	
  0.9013

  	
   

  	
  1.0390

  
	
  HX

  	
   

  	
  0.9457

  	
   

  	
  0.9345

  
	
  X1

  	
   

  	
  0.9492

  	
   

  	
  0.8734

  
	
  X2

  	
   

  	
  0.9572

  	
   

  	
  0.9345

  
	
  X3

  	
   

  	
  0.9457

  	
   

  	
  0.9420

  
	
  X4

  	
   

  	
  0.9584

  	
   

  	
  0.9420

  
	
  X5

  	
   

  	
  1.0172

  	
   

  	
  1.0300

  
	
  X6

  	
   

  	
  1.0134

  	
   

  	
  1.0387

  
	
  X7

  	
   

  	
  0.8956

  	
   

  	
  0.9788

  
	
  X8

  	
   

  	
  1.0160

  	
   

  	
  0.9794

  
	
  X9

  	
   

  	
  0.8956

  	
   

  	
  0.9665

  
	
  HY

  	
   

  	
  0.8956

  	
   

  	
  0.8965

  
	
  Y1

  	
   

  	
  0.8985

  	
   

  	
  0.9618

  
	
  Y2

  	
   

  	
  0.8956

  	
   

  	
  0.9342

  
	
  Y3

  	
   

  	
  0.8956

  	
   

  	
  1.0013

  
	
  Y4

  	
   

  	
  0.9074

  	
   

  	
  1.0013

  
	
  Y5

  	
   

  	
  0.9489

  	
   

  	
  0.9620

  
	
  Y6

  	
   

  	
  0.8956

  	
   

  	
  0.9417

  
	
  Y7

  	
   

  	
  1.0111

  	
   

  	
  0.9791

  
	
  Y8

  	
   

  	
  1.0258

  	
   

  	
  1.0387

  
	
  Y9

  	
   

  	
  1.0264

  	
   

  	
  1.0208

  
	
  ZA

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  
	
  ZB

  	
   

  	
  0.9800

  	
   

  	
  0.8695

  
	
  ZC

  	
   

  	
  1.0509

  	
   

  	
  0.9674

  
	
  ZG

  	
   

  	
  0.9800

  	
   

  	
  0.9674

  
	
  ZK

  	
   

  	
  1.0509

  	
   

  	
  0.9749

  
	
  ZM

  	
   

  	
  1.1022

  	
   

  	
  0.9863

  
	
  ZN

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  
	
  ZO

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  
	
  ZS

  	
   

  	
  1.0627

  	
   

  	
  0.9755

  
	
  ZZ

  	
   

  	
  0.9924

  	
   

  	
  0.9788

  
	
  1A

  	
   

  	
  1.0022

  	
   

  	
  1.0214

  
	
  1B

  	
   

  	
  1.0382

  	
   

  	
  1.0246

  
	
  1C

  	
   

  	
  1.0428

  	
   

  	
  1.0270

  
	
  1D

  	
   

  	
  0.9742

  	
   

  	
  1.0438

  
	
  1E

  	
   

  	
  1.0388

  	
   

  	
  1.0285

  
	
  1F

  	
   

  	
  1.0388

  	
   

  	
  1.0246

  
	
  1G

  	
   

  	
  1.0388

  	
   

  	
  1.0235

  
	
  1H

  	
   

  	
  1.0388

  	
   

  	
  0.9498

  
	
  1J

  	
   

  	
  1.0391

  	
   

  	
  1.0408

  
	
  1K

  	
   

  	
  1.0258

  	
   

  	
  1.0285

  
	
  1L

  	
   

  	
  1.0445

  	
   

  	
  0.9818

  
	
  1M

  	
   

  	
  1.0316

  	
   

  	
  1.0100

  
	
  1N

  	
   

  	
  1.0316

  	
   

  	
  1.0438

  
	
  1P

  	
   

  	
  1.0284

  	
   

  	
  0.9818

  
	
  1Q

  	
   

  	
  1.0316

  	
   

  	
  0.9498

  
	
  1R

  	
   

  	
  1.1048

  	
   

  	
  1.0438

  
	
  1S

  	
   

  	
  0.9742

  	
   

  	
  1.0067

  
	
  1T

  	
   

  	
  0.9659

  	
   

  	
  1.0067

  
	
  1U

  	
   

  	
  0.9299

  	
   

  	
  1.0052

  
	
  1V

  	
   

  	
  1.0273

  	
   

  	
  1.0235

  
	
  1W

  	
   

  	
  0.9711

  	
   

  	
  0.9818

  
	
  1X

  	
   

  	
  1.0284

  	
   

  	
  0.9818

  
	
  1Y

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  
	
  1Z

  	
   

  	
  1.0232

  	
   

  	
  1.0073

  
	
  2A

  	
   

  	
  0.9742

  	
   

  	
  0.9498

  
	
  2B

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  
	
  2C

  	
   

  	
  1.1465

  	
   

  	
  1.0088

  
	
  2D

  	
   

  	
  0.9431

  	
   

  	
  1.0085

  
	
  2E

  	
   

  	
  1.1004

  	
   

  	
  1.0438

  
	
  2F

  	
   

  	
  1.0275

  	
   

  	
  1.0229

  
	
  6A

  	
   

  	
  1.0627

  	
   

  	
  0.9710

  
	
  6G

  	
   

  	
  0.9215

  	
   

  	
  0.9674

  
	
  6H

  	
   

  	
  0.9803

  	
   

  	
  0.9749

  
	
  6R

  	
   

  	
  0.9330

  	
   

  	
  0.9749

  
	
  6S

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  
	
  6T

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  
	
  6V

  	
   

  	
  0.9215

  	
   

  	
  0.9603

  
	
  6W

  	
   

  	
  0.9702

  	
   

  	
  0.9779

  
	
  6Z

  	
   

  	
  0.9250

  	
   

  	
  0.8692

  
	
  7C

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  
	
  7E

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  
	
  7F

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  
	
  7G

  	
   

  	
  1.0509

  	
   

  	
  0.9749

  
	
  7H

  	
   

  	
  0.9215

  	
   

  	
  0.9069

  
	
  7I

  	
   

  	
  0.9858

  	
   

  	
  0.9755

  
	
  7J

  	
   

  	
  0.8714

  	
   

  	
  0.8998

  
	
  7K

  	
   

  	
  0.9814

  	
   

  	
  0.9749

  
	
  7L

  	
   

  	
  1.0062

  	
   

  	
  0.9863

  
	
  7M

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  
	
  7N

  	
   

  	
  0.9797

  	
   

  	
  0.9749

  
	
  7O

  	
   

  	
  0.8714

  	
   

  	
  0.9746

  
	
  7Q

  	
   

  	
  0.9215

  	
   

  	
  0.9749

  
	
  7R

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  
	
  7S

  	
   

  	
  0.8711

  	
   

  	
  0.9375

  
	
  7T

  	
   

  	
  0.9215

  	
   

  	
  0.9456

  
	
  7U

  	
   

  	
  0.9621

  	
   

  	
  0.9749

  
	
  7V

  	
   

  	
  0.9814

  	
   

  	
  0.9378

  
	
  7W

  	
   

  	
  0.9229

  	
   

  	
  0.9378

  
	
  7X

  	
   

  	
  1.1172

  	
   

  	
  0.9863

  
	
  7Y

  	
   

  	
  1.0371

  	
   

  	
  0.9863

  
	
  7Z

  	
   

  	
  0.9215

  	
   

  	
  0.9782

  
	
  9A

  	
   

  	
  0.9800

  	
   

  	
  0.9749

  
	
  9B

  	
   

  	
  0.9918

  	
   

  	
  0.9749

  
	
  9C

  	
   

  	
  0.9739

  	
   

  	
  0.9749

  
	
  9E

  	
   

  	
  0.9970

  	
   

  	
  0.9788

  
	
  9F

  	
   

  	
  1.0627

  	
   

  	
  0.9749

  
	
  9G

  	
   

  	
  0.9950

  	
   

  	
  0.9749

  
	
  9H

  	
   

  	
  0.9535

  	
   

  	
  0.9746

  
	
  9I

  	
   

  	
  0.9823

  	
   

  	
  0.9749

  
	
  9J

  	
   

  	
  0.8757

  	
   

  	
  0.8318

  
	
  9M

  	
   

  	
  0.9933

  	
   

  	
  0.9749

  
	
  9N

  	
   

  	
  0.9330

  	
   

  	
  0.9378

  
	
  9O

  	
   

  	
  0.9365

  	
   

  	
  0.9749

  
	
  9P

  	
   

  	
  1.0010

  	
   

  	
  0.9803

  
	
  9Q

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  
	
  9R

  	
   

  	
  0.9961

  	
   

  	
  0.9854

  
	
  9S

  	
   

  	
  0.9918

  	
   

  	
  0.9782

  
	
  9T

  	
   

  	
  0.9800

  	
   

  	
  0.9752

  
	
  9U

  	
   

  	
  0.9791

  	
   

  	
  0.9788

  
	
  9W

  	
   

  	
  0.9215

  	
   

  	
  0.9552

  
	
  9X

  	
   

  	
  0.8836

  	
   

  	
  0.9745

  
	
  9Y

  	
   

  	
  1.0449

  	
   

  	
  0.9597

  

 

44

 

 

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

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.7696

  	
   

  	
  0.7841

  	
   

  
	
  C5

  	
   

  	
  0.6881

  	
   

  	
  0.7728

  	
   

  
	
  Q1

  	
   

  	
  0.9862

  	
   

  	
  0.9700

  	
   

  
	
  Q2

  	
   

  	
  0.9282

  	
   

  	
  0.9324

  	
   

  
	
  Q3

  	
   

  	
  0.8783

  	
   

  	
  0.8711

  	
   

  
	
  Q4

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q5

  	
   

  	
  1.0165

  	
   

  	
  1.0212

  	
   

  
	
  Q6

  	
   

  	
  0.9088

  	
   

  	
  1.0059

  	
   

  
	
  Q7

  	
   

  	
  0.8430

  	
   

  	
  0.8233

  	
   

  
	
  Q8

  	
   

  	
  0.9282

  	
   

  	
  0.9700

  	
   

  
	
  QT

  	
   

  	
  0.7766

  	
   

  	
  0.7825

  	
   

  
	
  QU

  	
   

  	
  0.6991

  	
   

  	
  0.7696

  	
   

  
	
  QV

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QW

  	
   

  	
  0.6922

  	
   

  	
  0.7325

  	
   

  
	
  QX

  	
   

  	
  0.7261

  	
   

  	
  0.7823

  	
   

  
	
  QY

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  QZ

  	
   

  	
  0.7647

  	
   

  	
  0.7876

  	
   

  
	
  V1

  	
   

  	
  1.0111

  	
   

  	
  0.9926

  	
   

  
	
  V2

  	
   

  	
  0.9421

  	
   

  	
  0.9829

  	
   

  
	
  V3

  	
   

  	
  0.8417

  	
   

  	
  0.9762

  	
   

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

Medicare Supplement HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan J

  	
   

  	
  1.2513

  	
   

  
	
  Medicare COB $0 Copay

  	
   

  	
  1.1627

  	
   

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6580

  	
   

  

 

Medicare Supplement POS

 

	
  Plan

  	
   

  	
  Prof
  Factor

  	
   

  
	
  POS Medicare COB $0 Copay

  	
   

  	
  1.1627

  	
   

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6580

  	
   

  

 

45

 

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

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  HA

  	
   

  	
  1.0595

  	
   

  	
  0.9673

  	
   

  
	
  A1

  	
   

  	
  1.0628

  	
   

  	
  0.9725

  	
   

  
	
  A2

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A3

  	
   

  	
  1.0619

  	
   

  	
  0.9810

  	
   

  
	
  A4

  	
   

  	
  1.0595

  	
   

  	
  0.9776

  	
   

  
	
  A5

  	
   

  	
  1.0628

  	
   

  	
  0.9752

  	
   

  
	
  A6

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  A7

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  A8

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  A9

  	
   

  	
  1.0257

  	
   

  	
  1.0076

  	
   

  
	
  HB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  BB

  	
   

  	
  1.0047

  	
   

  	
  0.8655

  	
   

  
	
  B1

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B2

  	
   

  	
  0.9198

  	
   

  	
  0.8252

  	
   

  
	
  B3

  	
   

  	
  0.9198

  	
   

  	
  0.8254

  	
   

  
	
  B4

  	
   

  	
  0.9198

  	
   

  	
  0.8460

  	
   

  
	
  B5

  	
   

  	
  0.9198

  	
   

  	
  0.8357

  	
   

  
	
  B6

  	
   

  	
  1.0047

  	
   

  	
  0.8758

  	
   

  
	
  B7

  	
   

  	
  0.9743

  	
   

  	
  1.0085

  	
   

  
	
  B8

  	
   

  	
  0.9644

  	
   

  	
  0.9941

  	
   

  
	
  B9

  	
   

  	
  0.9690

  	
   

  	
  1.0076

  	
   

  
	
  HC

  	
   

  	
  1.0639

  	
   

  	
  0.9919

  	
   

  
	
  C1

  	
   

  	
  1.0613

  	
   

  	
  0.9919

  	
   

  
	
  C2

  	
   

  	
  1.0668

  	
   

  	
  1.0032

  	
   

  
	
  C3

  	
   

  	
  1.0066

  	
   

  	
  0.9919

  	
   

  
	
  C6

  	
   

  	
  1.0162

  	
   

  	
  1.0076

  	
   

  
	
  C7

  	
   

  	
  1.0639

  	
   

  	
  1.0022

  	
   

  
	
  C8

  	
   

  	
  0.9463

  	
   

  	
  0.9695

  	
   

  
	
  C9

  	
   

  	
  0.9243

  	
   

  	
  1.0076

  	
   

  
	
  HD

  	
   

  	
  1.0807

  	
   

  	
  1.0031

  	
   

  
	
  D1

  	
   

  	
  1.0613

  	
   

  	
  1.0022

  	
   

  
	
  D2

  	
   

  	
  1.0182

  	
   

  	
  1.0041

  	
   

  
	
  D3

  	
   

  	
  0.9327

  	
   

  	
  0.8259

  	
   

  
	
  D4

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  D5

  	
   

  	
  0.9599

  	
   

  	
  0.9776

  	
   

  
	
  D6

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  D7

  	
   

  	
  0.9897

  	
   

  	
  1.0074

  	
   

  
	
  D8

  	
   

  	
  1.0189

  	
   

  	
  1.0056

  	
   

  
	
  D9

  	
   

  	
  1.0319

  	
   

  	
  1.0076

  	
   

  
	
  HE

  	
   

  	
  1.0286

  	
   

  	
  1.0105

  	
   

  
	
  E1

  	
   

  	
  1.0137

  	
   

  	
  0.9737

  	
   

  
	
  E2

  	
   

  	
  0.9836

  	
   

  	
  1.0050

  	
   

  
	
  E3

  	
   

  	
  1.0064

  	
   

  	
  0.9776

  	
   

  
	
  E4

  	
   

  	
  0.9584

  	
   

  	
  0.9706

  	
   

  
	
  W3

  	
   

  	
  0.9715

  	
   

  	
  1.0128

  	
   

  
	
  E5

  	
   

  	
  1.0403

  	
   

  	
  1.0037

  	
   

  
	
  E6

  	
   

  	
  0.9656

  	
   

  	
  0.9737

  	
   

  
	
  E7

  	
   

  	
  0.9905

  	
   

  	
  1.0037

  	
   

  
	
  E8

  	
   

  	
  1.0180

  	
   

  	
  0.9985

  	
   

  
	
  E9

  	
   

  	
  0.9690

  	
   

  	
  0.9801

  	
   

  
	
  EA

  	
   

  	
  0.9755

  	
   

  	
  1.0033

  	
   

  
	
  EB

  	
   

  	
  0.9023

  	
   

  	
  0.8278

  	
   

  
	
  EC

  	
   

  	
  0.9604

  	
   

  	
  1.0076

  	
   

  
	
  ED

  	
   

  	
  1.0061

  	
   

  	
  0.9805

  	
   

  
	
  EE

  	
   

  	
  0.9951

  	
   

  	
  0.9793

  	
   

  
	
  EF

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EG

  	
   

  	
  1.0307

  	
   

  	
  1.0063

  	
   

  
	
  EH

  	
   

  	
  0.9585

  	
   

  	
  1.0018

  	
   

  
	
  EI

  	
   

  	
  0.9966

  	
   

  	
  0.9805

  	
   

  
	
  EJ

  	
   

  	
  1.0329

  	
   

  	
  1.0118

  	
   

  
	
  EK

  	
   

  	
  0.9310

  	
   

  	
  1.0050

  	
   

  
	
  EL

  	
   

  	
  1.0481

  	
   

  	
  0.9786

  	
   

  
	
  EM

  	
   

  	
  0.9714

  	
   

  	
  1.0135

  	
   

  
	
  EN

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  
	
  EO

  	
   

  	
  0.9727

  	
   

  	
  0.9633

  	
   

  
	
  EP

  	
   

  	
  0.9486

  	
   

  	
  0.9777

  	
   

  
	
  EQ

  	
   

  	
  0.9740

  	
   

  	
  1.0035

  	
   

  
	
  ES

  	
   

  	
  0.9796

  	
   

  	
  1.0076

  	
   

  
	
  HF

  	
   

  	
  0.9682

  	
   

  	
  0.9875

  	
   

  
	
  F1

  	
   

  	
  1.0230

  	
   

  	
  0.9893

  	
   

  
	
  F2

  	
   

  	
  1.0084

  	
   

  	
  0.9737

  	
   

  
	
  F3

  	
   

  	
  1.0071

  	
   

  	
  0.9776

  	
   

  
	
  F4

  	
   

  	
  0.9731

  	
   

  	
  1.0074

  	
   

  
	
  F5

  	
   

  	
  1.0087

  	
   

  	
  0.9780

  	
   

  
	
  F6

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  F7

  	
   

  	
  1.0804

  	
   

  	
  0.9903

  	
   

  
	
  F8

  	
   

  	
  0.8346

  	
   

  	
  0.8083

  	
   

  
	
  F9

  	
   

  	
  1.0350

  	
   

  	
  1.0037

  	
   

  
	
  FA

  	
   

  	
  1.0203

  	
   

  	
  1.0008

  	
   

  
	
  FB

  	
   

  	
  1.0213

  	
   

  	
  1.0145

  	
   

  
	
  FC

  	
   

  	
  1.0234

  	
   

  	
  1.0039

  	
   

  
	
  FD

  	
   

  	
  1.0241

  	
   

  	
  1.0023

  	
   

  
	
  FE

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FF

  	
   

  	
  0.9709

  	
   

  	
  1.0062

  	
   

  
	
  FG

  	
   

  	
  0.9694

  	
   

  	
  0.9858

  	
   

  
	
  FH

  	
   

  	
  0.9708

  	
   

  	
  1.0008

  	
   

  
	
  FI

  	
   

  	
  0.9727

  	
   

  	
  1.0008

  	
   

  
	
  FJ

  	
   

  	
  0.9260

  	
   

  	
  1.0008

  	
   

  
	
  FK

  	
   

  	
  0.9727

  	
   

  	
  0.9581

  	
   

  
	
  IK

  	
   

  	
  1.0138

  	
   

  	
  1.0056

  	
   

  
	
  FL

  	
   

  	
  0.9260

  	
   

  	
  0.9633

  	
   

  
	
  HG

  	
   

  	
  1.0047

  	
   

  	
  0.9673

  	
   

  
	
  G1

  	
   

  	
  0.9566

  	
   

  	
  0.9673

  	
   

  
	
  G2

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  G3

  	
   

  	
  1.0080

  	
   

  	
  0.9776

  	
   

  
	
  G4

  	
   

  	
  0.9566

  	
   

  	
  0.9776

  	
   

  
	
  G5

  	
   

  	
  0.9095

  	
   

  	
  0.9671

  	
   

  
	
  G6

  	
   

  	
  1.0231

  	
   

  	
  0.9967

  	
   

  
	
  G9

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  I3

  	
   

  	
  0.9909

  	
   

  	
  1.0106

  	
   

  
	
  I4

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  I5

  	
   

  	
  0.9677

  	
   

  	
  1.0044

  	
   

  
	
  I6

  	
   

  	
  1.0338

  	
   

  	
  0.9745

  	
   

  
	
  I7

  	
   

  	
  1.0022

  	
   

  	
  1.0076

  	
   

  
	
  I8

  	
   

  	
  0.9746

  	
   

  	
  0.9916

  	
   

  
	
  I9

  	
   

  	
  0.9851

  	
   

  	
  1.0037

  	
   

  
	
  J3

  	
   

  	
  1.0165

  	
   

  	
  0.9849

  	
   

  
	
  J4

  	
   

  	
  1.0108

  	
   

  	
  0.9849

  	
   

  
	
  J5

  	
   

  	
  1.0071

  	
   

  	
  0.9778

  	
   

  
	
  J6

  	
   

  	
  0.9714

  	
   

  	
  0.9783

  	
   

  
	
  J7

  	
   

  	
  0.9756

  	
   

  	
  1.0085

  	
   

  
	
  J8

  	
   

  	
  0.9666

  	
   

  	
  0.9839

  	
   

  
	
  J9

  	
   

  	
  1.1169

  	
   

  	
  1.0283

  	
   

  
	
  HK

  	
   

  	
  1.0784

  	
   

  	
  1.0076

  	
   

  
	
  K1

  	
   

  	
  1.0236

  	
   

  	
  1.0076

  	
   

  
	
  K2

  	
   

  	
  0.9663

  	
   

  	
  0.9801

  	
   

  
	
  K3

  	
   

  	
  1.0255

  	
   

  	
  1.0080

  	
   

  
	
  K4

  	
   

  	
  1.0817

  	
   

  	
  1.0076

  	
   

  
	
  K6

  	
   

  	
  0.9782

  	
   

  	
  1.0054

  	
   

  
	
  K7

  	
   

  	
  0.9845

  	
   

  	
  0.9966

  	
   

  
	
  K8

  	
   

  	
  0.9749

  	
   

  	
  0.9844

  	
   

  
	
  K9

  	
   

  	
  0.9566

  	
   

  	
  0.9521

  	
   

  
	
  KI

  	
   

  	
  0.9727

  	
   

  	
  1.0010

  	
   

  
	
  KJ

  	
   

  	
  1.0203

  	
   

  	
  1.0010

  	
   

  
	
  KK

  	
   

  	
  0.9727

  	
   

  	
  0.9583

  	
   

  
	
  KL

  	
   

  	
  0.9763

  	
   

  	
  0.9864

  	
   

  
	
  KM

  	
   

  	
  0.9260

  	
   

  	
  1.0010

  	
   

  
	
  L1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  L2

  	
   

  	
  0.9599

  	
   

  	
  0.9777

  	
   

  
	
  L3

  	
   

  	
  0.9566

  	
   

  	
  0.9777

  	
   

  
	
  L4

  	
   

  	
  0.9128

  	
   

  	
  0.9774

  	
   

  
	
  L5

  	
   

  	
  0.9695

  	
   

  	
  0.9776

  	
   

  
	
  L6

  	
   

  	
  1.0177

  	
   

  	
  0.9776

  	
   

  
	
  L7

  	
   

  	
  1.0424

  	
   

  	
  0.9756

  	
   

  
	
  7U

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  L8

  	
   

  	
  1.0243

  	
   

  	
  0.9673

  	
   

  
	
  L9

  	
   

  	
  0.9755

  	
   

  	
  1.0076

  	
   

  
	
  HM

  	
   

  	
  1.1360

  	
   

  	
  1.0225

  	
   

  
	
  M1

  	
   

  	
  0.9825

  	
   

  	
  1.0061

  	
   

  
	
  M2

  	
   

  	
  1.1361

  	
   

  	
  1.0225

  	
   

  
	
  M3

  	
   

  	
  1.0195

  	
   

  	
  1.0108

  	
   

  
	
  M4

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  M5

  	
   

  	
  1.0124

  	
   

  	
  1.0054

  	
   

  
	
  M6

  	
   

  	
  0.9749

  	
   

  	
  0.9175

  	
   

  
	
  M7

  	
   

  	
  0.9671

  	
   

  	
  0.8754

  	
   

  
	
  M8

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  M9

  	
   

  	
  1.0743

  	
   

  	
  1.0078

  	
   

  
	
  HN

  	
   

  	
  1.0195

  	
   

  	
  1.0076

  	
   

  
	
  N1

  	
   

  	
  1.0246

  	
   

  	
  1.0076

  	
   

  
	
  N2

  	
   

  	
  1.0211

  	
   

  	
  1.0076

  	
   

  
	
  N3

  	
   

  	
  1.0230

  	
   

  	
  1.0076

  	
   

  
	
  N4

  	
   

  	
  1.0066

  	
   

  	
  1.0022

  	
   

  
	
  N5

  	
   

  	
  1.0082

  	
   

  	
  1.0022

  	
   

  
	
  N6

  	
   

  	
  1.0099

  	
   

  	
  1.0022

  	
   

  
	
  N7

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  N8

  	
   

  	
  1.0294

  	
   

  	
  1.0033

  	
   

  
	
  N9

  	
   

  	
  1.0207

  	
   

  	
  0.9916

  	
   

  
	
  HO

  	
   

  	
  0.9714

  	
   

  	
  1.0076

  	
   

  
	
  O1

  	
   

  	
  0.9747

  	
   

  	
  1.0076

  	
   

  
	
  O2

  	
   

  	
  0.9714

  	
   

  	
  0.9676

  	
   

  
	
  O3

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  O4

  	
   

  	
  1.0195

  	
   

  	
  0.9676

  	
   

  
	
  O5

  	
   

  	
  0.9584

  	
   

  	
  0.9864

  	
   

  
	
  O6

  	
   

  	
  1.0327

  	
   

  	
  1.0149

  	
   

  
	
  O7

  	
   

  	
  1.0317

  	
   

  	
  1.0033

  	
   

  
	
  O8

  	
   

  	
  1.0050

  	
   

  	
  0.9733

  	
   

  
	
  O9

  	
   

  	
  0.9822

  	
   

  	
  1.0076

  	
   

  
	
  HP

  	
   

  	
  1.0049

  	
   

  	
  0.9919

  	
   

  
	
  P1

  	
   

  	
  1.0121

  	
   

  	
  0.9949

  	
   

  
	
  P2

  	
   

  	
  0.9030

  	
   

  	
  0.9396

  	
   

  
	
  P3

  	
   

  	
  0.9649

  	
   

  	
  0.9776

  	
   

  
	
  P4

  	
   

  	
  1.0195

  	
   

  	
  1.0186

  	
   

  
	
  P5

  	
   

  	
  0.9095

  	
   

  	
  0.9731

  	
   

  
	
  P6

  	
   

  	
  1.0823

  	
   

  	
  0.9838

  	
   

  
	
  P7

  	
   

  	
  1.0273

  	
   

  	
  1.0076

  	
   

  
	
  P8

  	
   

  	
  0.9614

  	
   

  	
  0.9828

  	
   

  
	
  P9

  	
   

  	
  1.0165

  	
   

  	
  0.9833

  	
   

  
	
  HR

  	
   

  	
  1.1304

  	
   

  	
  1.0233

  	
   

  
	
  R1

  	
   

  	
  1.0121

  	
   

  	
  1.0052

  	
   

  
	
  R2

  	
   

  	
  0.9749

  	
   

  	
  1.0076

  	
   

  
	
  R3

  	
   

  	
  0.9909

  	
   

  	
  1.0076

  	
   

  
	
  R4

  	
   

  	
  0.9003

  	
   

  	
  0.9029

  	
   

  
	
  R5

  	
   

  	
  1.0047

  	
   

  	
  0.9777

  	
   

  
	
  R6

  	
   

  	
  1.0047

  	
   

  	
  0.9399

  	
   

  
	
  R7

  	
   

  	
  0.8997

  	
   

  	
  0.9025

  	
   

  
	
  R8

  	
   

  	
  0.9640

  	
   

  	
  1.0052

  	
   

  
	
  R9

  	
   

  	
  0.9198

  	
   

  	
  0.8412

  	
   

  
	
  HS

  	
   

  	
  1.0817

  	
   

  	
  1.0022

  	
   

  
	
  S1

  	
   

  	
  1.0973

  	
   

  	
  1.0283

  	
   

  
	
  S2

  	
   

  	
  1.0259

  	
   

  	
  1.0091

  	
   

  
	
  S3

  	
   

  	
  1.0485

  	
   

  	
  1.0156

  	
   

  
	
  S4

  	
   

  	
  0.9629

  	
   

  	
  0.9295

  	
   

  
	
  S5

  	
   

  	
  0.9198

  	
   

  	
  0.8442

  	
   

  
	
  S6

  	
   

  	
  1.0658

  	
   

  	
  1.0022

  	
   

  
	
  S7

  	
   

  	
  1.0085

  	
   

  	
  1.0000

  	
   

  
	
  S8

  	
   

  	
  1.0080

  	
   

  	
  0.9777

  	
   

  
	
  S9

  	
   

  	
  1.0080

  	
   

  	
  0.9399

  	
   

  
	
  HT

  	
   

  	
  1.0743

  	
   

  	
  1.0076

  	
   

  
	
  T1

  	
   

  	
  1.0759

  	
   

  	
  1.0076

  	
   

  
	
  T2

  	
   

  	
  1.0776

  	
   

  	
  1.0076

  	
   

  
	
  T3

  	
   

  	
  1.0187

  	
   

  	
  0.9985

  	
   

  
	
  T4

  	
   

  	
  1.0156

  	
   

  	
  0.9985

  	
   

  
	
  T5

  	
   

  	
  1.0212

  	
   

  	
  1.0078

  	
   

  
	
  T7

  	
   

  	
  0.9229

  	
   

  	
  0.9673

  	
   

  
	
  T8

  	
   

  	
  1.0086

  	
   

  	
  0.9833

  	
   

  
	
  T9

  	
   

  	
  1.0245

  	
   

  	
  1.0079

  	
   

  
	
  TA

  	
   

  	
  0.9966

  	
   

  	
  0.9894

  	
   

  
	
  TB

  	
   

  	
  0.9929

  	
   

  	
  0.9778

  	
   

  
	
  TC

  	
   

  	
  1.0104

  	
   

  	
  0.9780

  	
   

  
	
  HU

  	
   

  	
  1.0443

  	
   

  	
  1.0165

  	
   

  
	
  U1

  	
   

  	
  1.0260

  	
   

  	
  0.9805

  	
   

  
	
  U2

  	
   

  	
  0.9599

  	
   

  	
  0.9399

  	
   

  
	
  U3

  	
   

  	
  0.9599

  	
   

  	
  0.9673

  	
   

  
	
  U4

  	
   

  	
  1.0778

  	
   

  	
  1.0022

  	
   

  
	
  U5

  	
   

  	
  0.9714

  	
   

  	
  1.0106

  	
   

  
	
  U6

  	
   

  	
  0.9750

  	
   

  	
  1.0074

  	
   

  
	
  U7

  	
   

  	
  0.9731

  	
   

  	
  1.0085

  	
   

  
	
  U8

  	
   

  	
  1.0263

  	
   

  	
  1.0080

  	
   

  
	
  U9

  	
   

  	
  1.0210

  	
   

  	
  1.0141

  	
   

  
	
  HV

  	
   

  	
  1.0907

  	
   

  	
  1.0107

  	
   

  
	
  HW

  	
   

  	
  1.0524

  	
   

  	
  0.9681

  	
   

  
	
  W1

  	
   

  	
  1.0542

  	
   

  	
  0.9681

  	
   

  
	
  W2

  	
   

  	
  1.0067

  	
   

  	
  1.0000

  	
   

  

 

46

 

Standard HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  W4

  	
   

  	
  0.9287

  	
   

  	
  0.9680

  	
   

  
	
  W5

  	
   

  	
  1.0266

  	
   

  	
  1.0095

  	
   

  
	
  W6

  	
   

  	
  0.9649

  	
   

  	
  0.9806

  	
   

  
	
  W7

  	
   

  	
  0.9839

  	
   

  	
  0.9941

  	
   

  
	
  W8

  	
   

  	
  1.0162

  	
   

  	
  0.9776

  	
   

  
	
  W9

  	
   

  	
  0.9112

  	
   

  	
  0.9774

  	
   

  
	
  HX

  	
   

  	
  0.9500

  	
   

  	
  0.9295

  	
   

  
	
  X1

  	
   

  	
  0.9638

  	
   

  	
  0.8651

  	
   

  
	
  X2

  	
   

  	
  0.9533

  	
   

  	
  0.9295

  	
   

  
	
  X3

  	
   

  	
  0.9500

  	
   

  	
  0.9398

  	
   

  
	
  X4

  	
   

  	
  0.9821

  	
   

  	
  0.9058

  	
   

  
	
  X5

  	
   

  	
  1.0231

  	
   

  	
  1.0074

  	
   

  
	
  X6

  	
   

  	
  1.0240

  	
   

  	
  1.0076

  	
   

  
	
  X7

  	
   

  	
  0.9095

  	
   

  	
  0.9774

  	
   

  
	
  X8

  	
   

  	
  1.0043

  	
   

  	
  0.9779

  	
   

  
	
  X9

  	
   

  	
  0.9095

  	
   

  	
  0.9627

  	
   

  
	
  HY

  	
   

  	
  0.8997

  	
   

  	
  0.8921

  	
   

  
	
  Y1

  	
   

  	
  0.9145

  	
   

  	
  0.9280

  	
   

  
	
  Y2

  	
   

  	
  0.8997

  	
   

  	
  0.9293

  	
   

  
	
  Y3

  	
   

  	
  0.9145

  	
   

  	
  0.9674

  	
   

  
	
  Y4

  	
   

  	
  0.9178

  	
   

  	
  0.9674

  	
   

  
	
  Y5

  	
   

  	
  0.9714

  	
   

  	
  0.9282

  	
   

  
	
  Y6

  	
   

  	
  0.8997

  	
   

  	
  0.9396

  	
   

  
	
  Y7

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  Y8

  	
   

  	
  1.0228

  	
   

  	
  1.0076

  	
   

  
	
  Y9

  	
   

  	
  0.9985

  	
   

  	
  1.0000

  	
   

  
	
  ZA

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZB

  	
   

  	
  0.9934

  	
   

  	
  0.8655

  	
   

  
	
  ZC

  	
   

  	
  1.0481

  	
   

  	
  0.9673

  	
   

  
	
  ZG

  	
   

  	
  0.9934

  	
   

  	
  0.9673

  	
   

  
	
  ZK

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  
	
  ZM

  	
   

  	
  1.0941

  	
   

  	
  0.9903

  	
   

  
	
  ZN

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  ZO

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  ZS

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  
	
  ZZ

  	
   

  	
  0.9870

  	
   

  	
  0.9780

  	
   

  
	
  1A

  	
   

  	
  0.9803

  	
   

  	
  0.9966

  	
   

  
	
  1B

  	
   

  	
  1.0012

  	
   

  	
  1.0012

  	
   

  
	
  1C

  	
   

  	
  1.0311

  	
   

  	
  1.0012

  	
   

  
	
  1D

  	
   

  	
  0.9805

  	
   

  	
  1.0064

  	
   

  
	
  1E

  	
   

  	
  1.0186

  	
   

  	
  1.0056

  	
   

  
	
  1F

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  
	
  1G

  	
   

  	
  1.0149

  	
   

  	
  1.0004

  	
   

  
	
  1H

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  
	
  1J

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  
	
  1L

  	
   

  	
  1.0292

  	
   

  	
  1.0021

  	
   

  
	
  1M

  	
   

  	
  1.0152

  	
   

  	
  0.9854

  	
   

  
	
  1N

  	
   

  	
  1.0295

  	
   

  	
  1.0064

  	
   

  
	
  1P

  	
   

  	
  1.0152

  	
   

  	
  1.0012

  	
   

  
	
  1Q

  	
   

  	
  1.0152

  	
   

  	
  0.9228

  	
   

  
	
  1R

  	
   

  	
  1.0863

  	
   

  	
  1.0064

  	
   

  
	
  1S

  	
   

  	
  0.9661

  	
   

  	
  0.9820

  	
   

  
	
  1T

  	
   

  	
  0.9629

  	
   

  	
  0.9820

  	
   

  
	
  1U

  	
   

  	
  0.9208

  	
   

  	
  0.9617

  	
   

  
	
  1V

  	
   

  	
  1.0337

  	
   

  	
  0.9678

  	
   

  
	
  1W

  	
   

  	
  0.9661

  	
   

  	
  1.0012

  	
   

  
	
  1X

  	
   

  	
  1.0187

  	
   

  	
  1.0012

  	
   

  
	
  1Y

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  
	
  1Z

  	
   

  	
  1.0119

  	
   

  	
  0.9582

  	
   

  
	
  2A

  	
   

  	
  0.9661

  	
   

  	
  0.9228

  	
   

  
	
  2B

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  
	
  2C

  	
   

  	
  1.0963

  	
   

  	
  1.0053

  	
   

  
	
  2D

  	
   

  	
  0.9181

  	
   

  	
  0.9228

  	
   

  
	
  2E

  	
   

  	
  1.0710

  	
   

  	
  1.0012

  	
   

  
	
  2F

  	
   

  	
  1.0091

  	
   

  	
  1.0000

  	
   

  
	
  6A

  	
   

  	
  1.0514

  	
   

  	
  0.9725

  	
   

  
	
  6G

  	
   

  	
  0.9452

  	
   

  	
  0.9673

  	
   

  
	
  6H

  	
   

  	
  1.0047

  	
   

  	
  0.9776

  	
   

  
	
  6R

  	
   

  	
  0.9485

  	
   

  	
  0.9776

  	
   

  
	
  6S

  	
   

  	
  0.9452

  	
   

  	
  0.9398

  	
   

  
	
  6T

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  6V

  	
   

  	
  0.9452

  	
   

  	
  0.9625

  	
   

  
	
  6W

  	
   

  	
  0.9851

  	
   

  	
  0.9819

  	
   

  
	
  6Z

  	
   

  	
  0.9524

  	
   

  	
  0.8651

  	
   

  
	
  7C

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  7E

  	
   

  	
  0.9987

  	
   

  	
  0.9776

  	
   

  
	
  7F

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  
	
  7G

  	
   

  	
  1.0481

  	
   

  	
  0.9776

  	
   

  
	
  7H

  	
   

  	
  0.9452

  	
   

  	
  0.9319

  	
   

  
	
  7I

  	
   

  	
  0.9988

  	
   

  	
  0.9776

  	
   

  
	
  7J

  	
   

  	
  0.8921

  	
   

  	
  0.9025

  	
   

  
	
  7K

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7L

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  
	
  7M

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7N

  	
   

  	
  0.9836

  	
   

  	
  0.9779

  	
   

  
	
  7O

  	
   

  	
  0.8981

  	
   

  	
  0.9774

  	
   

  
	
  7Q

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  7R

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  7S

  	
   

  	
  0.8884

  	
   

  	
  0.9396

  	
   

  
	
  7T

  	
   

  	
  0.9452

  	
   

  	
  0.9474

  	
   

  
	
  7V

  	
   

  	
  0.9934

  	
   

  	
  0.9399

  	
   

  
	
  7W

  	
   

  	
  0.9452

  	
   

  	
  0.9399

  	
   

  
	
  7X

  	
   

  	
  1.0942

  	
   

  	
  0.9903

  	
   

  
	
  7Y

  	
   

  	
  1.0334

  	
   

  	
  0.9903

  	
   

  
	
  7Z

  	
   

  	
  0.9452

  	
   

  	
  0.9776

  	
   

  
	
  9A

  	
   

  	
  0.9934

  	
   

  	
  0.9776

  	
   

  
	
  9B

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9C

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9E

  	
   

  	
  0.9908

  	
   

  	
  0.9780

  	
   

  
	
  9F

  	
   

  	
  1.0514

  	
   

  	
  0.9776

  	
   

  
	
  9G

  	
   

  	
  1.0012

  	
   

  	
  0.9776

  	
   

  
	
  9H

  	
   

  	
  0.9967

  	
   

  	
  0.9805

  	
   

  
	
  9I

  	
   

  	
  0.9934

  	
   

  	
  0.9777

  	
   

  
	
  9J

  	
   

  	
  0.9084

  	
   

  	
  0.8363

  	
   

  
	
  9M

  	
   

  	
  0.9967

  	
   

  	
  0.9777

  	
   

  
	
  9N

  	
   

  	
  0.9485

  	
   

  	
  0.9398

  	
   

  
	
  9O

  	
   

  	
  0.9560

  	
   

  	
  0.9776

  	
   

  
	
  9P

  	
   

  	
  0.9876

  	
   

  	
  0.9795

  	
   

  
	
  9Q

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9R

  	
   

  	
  0.9970

  	
   

  	
  0.9849

  	
   

  
	
  9S

  	
   

  	
  0.9967

  	
   

  	
  0.9776

  	
   

  
	
  9T

  	
   

  	
  0.9934

  	
   

  	
  0.9778

  	
   

  
	
  9U

  	
   

  	
  0.9866

  	
   

  	
  0.9811

  	
   

  
	
  9W

  	
   

  	
  0.9460

  	
   

  	
  0.9592

  	
   

  
	
  9X

  	
   

  	
  0.9014

  	
   

  	
  0.9776

  	
   

  
	
  9Y

  	
   

  	
  1.0327

  	
   

  	
  0.9334

  	
   

  

 

47

 

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

 

Small Group HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  C4

  	
   

  	
  0.9958

  	
   

  	
  1.0075

  	
   

  
	
  C5

  	
   

  	
  0.9016

  	
   

  	
  0.9893

  	
   

  
	
  Q1

  	
   

  	
  0.9877

  	
   

  	
  0.9749

  	
   

  
	
  Q2

  	
   

  	
  0.9350

  	
   

  	
  0.9367

  	
   

  
	
  Q3

  	
   

  	
  0.8834

  	
   

  	
  0.8703

  	
   

  
	
  Q4

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q5

  	
   

  	
  0.9958

  	
   

  	
  1.0103

  	
   

  
	
  Q6

  	
   

  	
  0.9016

  	
   

  	
  0.9921

  	
   

  
	
  Q7

  	
   

  	
  0.8346

  	
   

  	
  0.8179

  	
   

  
	
  Q8

  	
   

  	
  0.9350

  	
   

  	
  0.9747

  	
   

  
	
  QT

  	
   

  	
  0.9867

  	
   

  	
  1.0057

  	
   

  
	
  QU

  	
   

  	
  0.8977

  	
   

  	
  0.9898

  	
   

  
	
  QV

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QW

  	
   

  	
  0.9001

  	
   

  	
  0.9297

  	
   

  
	
  QX

  	
   

  	
  0.9476

  	
   

  	
  0.9927

  	
   

  
	
  QY

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  QZ

  	
   

  	
  0.9960

  	
   

  	
  1.0086

  	
   

  
	
  V1

  	
   

  	
  0.9926

  	
   

  	
  0.9833

  	
   

  
	
  V2

  	
   

  	
  0.9291

  	
   

  	
  0.9335

  	
   

  
	
  V3

  	
   

  	
  0.8135

  	
   

  	
  0.8226

  	
   

  

 

Individual HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  Shasta 5

  	
   

  	
  0.9656

  	
   

  	
  0.8895

  	
   

  
	
  Shasta 7

  	
   

  	
  0.9412

  	
   

  	
  0.8810

  	
   

  
	
  HMO Advantage 10

  	
   

  	
  0.8901

  	
   

  	
  0.8872

  	
   

  
	
  Shasta 15

  	
   

  	
  0.8399

  	
   

  	
  0.8644

  	
   

  
	
  Shasta Classic

  	
   

  	
  0.7842

  	
   

  	
  0.7665

  	
   

  

 

Medicare Supplement HMO

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  Medicare Conversion Plan J

  	
   

  	
  1.2018

  	
   

  
	
  Medicare COB $O Copay

  	
   

  	
  1.1169

  	
   

  
	
  Medicare COB $5 and up Copay

  	
   

  	
  0.6326

  	
   

  

 

Medicare Supplement POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  POS Medicare COB $O Copay

  	
   

  	
  1.1169

  	
   

  
	
  POS Medicare COB $5 and up Copay

  	
   

  	
  0.6326

  	
   

  

 

48

 

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

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9217

  	
   

  
	
  AD

  	
   

  	
  0.9217

  	
   

  
	
  AG

  	
   

  	
  0.8723

  	
   

  
	
  AH

  	
   

  	
  0.9217

  	
   

  
	
  AJ

  	
   

  	
  0.8723

  	
   

  
	
  AW

  	
   

  	
  0.9217

  	
   

  
	
  BA

  	
   

  	
  0.9357

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  
	
  BD

  	
   

  	
  0.9334

  	
   

  
	
  BE

  	
   

  	
  0.9459

  	
   

  
	
  BF

  	
   

  	
  0.8723

  	
   

  
	
  BG

  	
   

  	
  0.8965

  	
   

  
	
  BH

  	
   

  	
  0.9334

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  
	
  BK

  	
   

  	
  1.0184

  	
   

  
	
  BL

  	
   

  	
  0.9942

  	
   

  
	
  BM

  	
   

  	
  1.0036

  	
   

  
	
  BN

  	
   

  	
  0.8965

  	
   

  
	
  BO

  	
   

  	
  0.9629

  	
   

  
	
  BP

  	
   

  	
  0.8965

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  
	
  BR

  	
   

  	
  0.9820

  	
   

  
	
  BS

  	
   

  	
  0.9348

  	
   

  
	
  BT

  	
   

  	
  0.8854

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  
	
  BV

  	
   

  	
  0.9030

  	
   

  
	
  BW

  	
   

  	
  0.9655

  	
   

  
	
  BX

  	
   

  	
  0.9220

  	
   

  
	
  BY

  	
   

  	
  0.9612

  	
   

  
	
  BZ

  	
   

  	
  0.9553

  	
   

  
	
  CA

  	
   

  	
  1.0004

  	
   

  
	
  CB

  	
   

  	
  1.0121

  	
   

  
	
  CC

  	
   

  	
  0.9763

  	
   

  
	
  CD

  	
   

  	
  0.9879

  	
   

  
	
  CE

  	
   

  	
  0.9425

  	
   

  
	
  CF

  	
   

  	
  0.9541

  	
   

  
	
  CG

  	
   

  	
  0.9183

  	
   

  
	
  CH

  	
   

  	
  0.9300

  	
   

  
	
  CI

  	
   

  	
  0.8916

  	
   

  
	
  CJ

  	
   

  	
  0.9033

  	
   

  
	
  CK

  	
   

  	
  0.8675

  	
   

  
	
  CL

  	
   

  	
  0.8791

  	
   

  
	
  CM

  	
   

  	
  0.8499

  	
   

  
	
  CN

  	
   

  	
  0.8615

  	
   

  
	
  CO

  	
   

  	
  0.8257

  	
   

  
	
  CP

  	
   

  	
  0.8374

  	
   

  
	
  DA

  	
   

  	
  0.9459

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  
	
  DC

  	
   

  	
  0.9459

  	
   

  
	
  DD

  	
   

  	
  0.8965

  	
   

  
	
  DE

  	
   

  	
  0.9490

  	
   

  
	
  DF

  	
   

  	
  0.9490

  	
   

  
	
  DG

  	
   

  	
  0.8996

  	
   

  
	
  DH

  	
   

  	
  0.9459

  	
   

  
	
  DI

  	
   

  	
  0.9459

  	
   

  
	
  DJ

  	
   

  	
  0.8965

  	
   

  
	
  DK

  	
   

  	
  0.8965

  	
   

  
	
  DL

  	
   

  	
  0.9490

  	
   

  
	
  DM

  	
   

  	
  0.8965

  	
   

  
	
  DN

  	
   

  	
  0.8541

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  
	
  DP

  	
   

  	
  0.9897

  	
   

  
	
  DQ

  	
   

  	
  0.9729

  	
   

  
	
  DR

  	
   

  	
  0.9334

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  
	
  DT

  	
   

  	
  0.9081

  	
   

  
	
  DU

  	
   

  	
  0.8840

  	
   

  
	
  DV

  	
   

  	
  0.9851

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  
	
  DX

  	
   

  	
  0.9220

  	
   

  
	
  DY

  	
   

  	
  0.9459

  	
   

  
	
  DZ

  	
   

  	
  1.0024

  	
   

  
	
  FN

  	
   

  	
  0.9928

  	
   

  
	
  FO

  	
   

  	
  0.9928

  	
   

  
	
  FP

  	
   

  	
  0.9436

  	
   

  
	
  FQ

  	
   

  	
  0.9436

  	
   

  
	
  FR

  	
   

  	
  0.9902

  	
   

  
	
  FS

  	
   

  	
  0.9851

  	
   

  
	
  FT

  	
   

  	
  0.9843

  	
   

  
	
  FU

  	
   

  	
  0.9939

  	
   

  
	
  FV

  	
   

  	
  0.9825

  	
   

  
	
  FW

  	
   

  	
  0.9885

  	
   

  
	
  FS

  	
   

  	
  0.9806

  	
   

  
	
  FY

  	
   

  	
  0.9516

  	
   

  
	
  FZ

  	
   

  	
  0.9567

  	
   

  
	
  GA

  	
   

  	
  0.9334

  	
   

  
	
  GB

  	
   

  	
  0.8965

  	
   

  
	
  GK

  	
   

  	
  0.9459

  	
   

  
	
  KA

  	
   

  	
  0.9939

  	
   

  
	
  KB

  	
   

  	
  0.9610

  	
   

  
	
  KC

  	
   

  	
  1.0027

  	
   

  
	
  LA

  	
   

  	
  0.9487

  	
   

  
	
  LB

  	
   

  	
  0.9459

  	
   

  
	
  LC

  	
   

  	
  0.9459

  	
   

  
	
  LD

  	
   

  	
  0.9487

  	
   

  
	
  LE

  	
   

  	
  0.9487

  	
   

  
	
  LF

  	
   

  	
  0.9487

  	
   

  
	
  LG

  	
   

  	
  0.8993

  	
   

  
	
  LH

  	
   

  	
  0.9459

  	
   

  
	
  LI

  	
   

  	
  0.9487

  	
   

  
	
  LJ

  	
   

  	
  0.8993

  	
   

  
	
  LK

  	
   

  	
  0.8723

  	
   

  
	
  LL

  	
   

  	
  0.9459

  	
   

  
	
  LM

  	
   

  	
  0.9217

  	
   

  
	
  LN

  	
   

  	
  0.9487

  	
   

  
	
  LP

  	
   

  	
  0.9459

  	
   

  
	
  LQ

  	
   

  	
  0.8993

  	
   

  
	
  LR

  	
   

  	
  0.9487

  	
   

  
	
  LS

  	
   

  	
  0.8965

  	
   

  
	
  LT

  	
   

  	
  0.8572

  	
   

  
	
  LU

  	
   

  	
  0.8965

  	
   

  
	
  LV

  	
   

  	
  0.9487

  	
   

  
	
  LW

  	
   

  	
  0.9487

  	
   

  
	
  LX

  	
   

  	
  0.8965

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  
	
  LZ

  	
   

  	
  0.8541

  	
   

  
	
  NP

  	
   

  	
  0.9897

  	
   

  
	
  OZ

  	
   

  	
  0.9234

  	
   

  
	
  OB

  	
   

  	
  0.9217

  	
   

  
	
  OC

  	
   

  	
  0.9217

  	
   

  
	
  OD

  	
   

  	
  0.9092

  	
   

  
	
  OE

  	
   

  	
  0.9036

  	
   

  
	
  OF

  	
   

  	
  0.9490

  	
   

  
	
  OG

  	
   

  	
  0.9655

  	
   

  
	
  OK

  	
   

  	
  0.8723

  	
   

  
	
  OL

  	
   

  	
  0.9217

  	
   

  
	
  OM

  	
   

  	
  0.9217

  	
   

  
	
  ON

  	
   

  	
  0.9217

  	
   

  
	
  OO

  	
   

  	
  0.9217

  	
   

  
	
  OP

  	
   

  	
  0.9217

  	
   

  
	
  OQ

  	
   

  	
  0.9217

  	
   

  
	
  OR

  	
   

  	
  0.9578

  	
   

  
	
  OS

  	
   

  	
  0.9217

  	
   

  
	
  OT

  	
   

  	
  1.0178

  	
   

  
	
  OU

  	
   

  	
  0.9575

  	
   

  
	
  OV

  	
   

  	
  0.9107

  	
   

  
	
  OW

  	
   

  	
  0.9217

  	
   

  
	
  OX

  	
   

  	
  0.9217

  	
   

  
	
  OY

  	
   

  	
  0.9217

  	
   

  
	
  OZ

  	
   

  	
  0.9217

  	
   

  
	
  PA

  	
   

  	
  0.9217

  	
   

  
	
  PB

  	
   

  	
  0.9067

  	
   

  
	
  PC

  	
   

  	
  0.9232

  	
   

  
	
  PD

  	
   

  	
  0.8737

  	
   

  
	
  PE

  	
   

  	
  0.9217

  	
   

  
	
  PF

  	
   

  	
  0.9914

  	
   

  
	
  PG

  	
   

  	
  1.0522

  	
   

  
	
  PH

  	
   

  	
  0.9612

  	
   

  
	
  PI

  	
   

  	
  0.9655

  	
   

  
	
  PJ

  	
   

  	
  0.9487

  	
   

  
	
  PK

  	
   

  	
  0.9459

  	
   

  
	
  PL

  	
   

  	
  0.9183

  	
   

  
	
  PM

  	
   

  	
  0.9334

  	
   

  
	
  PN

  	
   

  	
  0.9217

  	
   

  
	
  PO

  	
   

  	
  0.9334

  	
   

  
	
  PP

  	
   

  	
  1.0701

  	
   

  
	
  PQ

  	
   

  	
  0.9217

  	
   

  
	
  PR

  	
   

  	
  0.9334

  	
   

  
	
  PS

  	
   

  	
  1.0013

  	
   

  
	
  PT

  	
   

  	
  0.9183

  	
   

  
	
  PU

  	
   

  	
  0.9797

  	
   

  
	
  PV

  	
   

  	
  0.8979

  	
   

  
	
  PW

  	
   

  	
  1.0269

  	
   

  
	
  PX

  	
   

  	
  0.9490

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  
	
  PZ

  	
   

  	
  0.9095

  	
   

  
	
  XA

  	
   

  	
  0.9217

  	
   

  
	
  XB

  	
   

  	
  0.8371

  	
   

  
	
  XC

  	
   

  	
  0.9402

  	
   

  
	
  XD

  	
   

  	
  0.9459

  	
   

  
	
  XE

  	
   

  	
  0.9573

  	
   

  
	
  XF

  	
   

  	
  0.9246

  	
   

  
	
  XG

  	
   

  	
  1.1008

  	
   

  
	
  XI

  	
   

  	
  1.1008

  	
   

  
	
  XJ

  	
   

  	
  0.8743

  	
   

  
	
  XK

  	
   

  	
  0.9698

  	
   

  
	
  XL

  	
   

  	
  0.9962

  	
   

  
	
  XM

  	
   

  	
  0.9575

  	
   

  
	
  XN

  	
   

  	
  0.9220

  	
   

  
	
  XO

  	
   

  	
  0.8683

  	
   

  
	
  XP

  	
   

  	
  0.9740

  	
   

  
	
  XQ

  	
   

  	
  0.8746

  	
   

  
	
  XR

  	
   

  	
  0.8464

  	
   

  
	
  XS

  	
   

  	
  0.9408

  	
   

  
	
  XT

  	
   

  	
  0.9220

  	
   

  
	
  XU

  	
   

  	
  0.9220

  	
   

  
	
  XV

  	
   

  	
  0.9220

  	
   

  
	
  XW

  	
   

  	
  0.9220

  	
   

  
	
  XY

  	
   

  	
  0.9743

  	
   

  

 

49

 

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

 

Small Group

POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9857

  	
   

  
	
  QB

  	
   

  	
  0.9285

  	
   

  
	
  QC

  	
   

  	
  0.8447

  	
   

  

 

50

 

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

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9215

  	
   

  	
  0.9300

  	
   

  
	
  AD

  	
   

  	
  0.9215

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8714

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8714

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9215

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9355

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9644

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9330

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9457

  	
   

  	
  0.9489

  	
   

  
	
  BF

  	
   

  	
  0.8714

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.8956

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9330

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9607

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0192

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9947

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  1.0039

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.8956

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9662

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.8956

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9820

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9821

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9345

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.8843

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9607

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9025

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9653

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9218

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9552

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  1.0007

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  1.0126

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9765

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9881

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0.9423

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9538

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9178

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9296

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8907

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.9022

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8662

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8780

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8480

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8598

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8238

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8353

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9458

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.8961

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.8992

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9458

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.8961

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.8961

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9489

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.8961

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8535

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9658

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9730

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9332

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9607

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9078

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.8835

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9850

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9607

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9218

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9458

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  1.0038

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9961

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9961

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9447

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9447

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9915

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9864

  	
   

  	
  0.9254

  	
   

  
	
  FT

  	
   

  	
  0.9855

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9952

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9858

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9898

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9784

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9527

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9578

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9332

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.8961

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9457

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9952

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9609

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  1.0041

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9489

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9457

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9489

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9489

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9489

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.8987

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9489

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.8987

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8714

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9457

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9215

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9483

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9457

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.8987

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9489

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.8956

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8558

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.8956

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9486

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9489

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.8956

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9575

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8526

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9895

  	
   

  	
  0.9405

  	
   

  
	
  OA

  	
   

  	
  0.9232

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9215

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9085

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9028

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9492

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9653

  	
   

  	
  0.9138

  	
   

  
	
  OK

  	
   

  	
  0.8714

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9215

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9215

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OO

  	
   

  	
  0.9215

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OQ

  	
   

  	
  0.9215

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9575

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9215

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0238

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9572

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9100

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9215

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9215

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9215

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9215

  	
   

  	
  0.9313

  	
   

  
	
  PA

  	
   

  	
  0.9215

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9062

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9229

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8728

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9215

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9918

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0584

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9610

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9653

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9489

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9457

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9330

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9215

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9330

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0711

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9215

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9330

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  1.0016

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9178

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9800

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.8970

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0275

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9492

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9590

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9088

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9215

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8405

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9399

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9457

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9569

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9244

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.1022

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.1022

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8734

  	
   

  	
  0.8275

  	
   

  
	
  XK

  	
   

  	
  0.9699

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  1.0039

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9572

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9218

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8722

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9742

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8741

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8509

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9407

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9218

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9218

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9218

  	
   

  	
  0.9113

  	
   

  
	
  XW

  	
   

  	
  0.9218

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9744

  	
   

  	
  0.8502

  	
   

  
								

 

51

 

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

Effective July 1, 1998

 

Small Group POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9862

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9282

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8430

  	
   

  	
  0.7381

  	
   

  
								

 

52

 

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

Effective September 1, 1998

 

Standard POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  AA

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  AD

  	
   

  	
  0.9452

  	
   

  	
  0.8996

  	
   

  
	
  AG

  	
   

  	
  0.8981

  	
   

  	
  0.9255

  	
   

  
	
  AH

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  AJ

  	
   

  	
  0.8981

  	
   

  	
  0.9242

  	
   

  
	
  AW

  	
   

  	
  0.9452

  	
   

  	
  0.9325

  	
   

  
	
  BA

  	
   

  	
  0.9480

  	
   

  	
  0.9247

  	
   

  
	
  BC

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BD

  	
   

  	
  0.9485

  	
   

  	
  0.9489

  	
   

  
	
  BE

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  BF

  	
   

  	
  0.8981

  	
   

  	
  0.9475

  	
   

  
	
  BG

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  BH

  	
   

  	
  0.9485

  	
   

  	
  0.9486

  	
   

  
	
  BI

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  BJ

  	
   

  	
  0.9747

  	
   

  	
  0.9483

  	
   

  
	
  BK

  	
   

  	
  1.0228

  	
   

  	
  0.9504

  	
   

  
	
  BL

  	
   

  	
  0.9966

  	
   

  	
  0.9515

  	
   

  
	
  BM

  	
   

  	
  0.9934

  	
   

  	
  0.9289

  	
   

  
	
  BN

  	
   

  	
  0.9095

  	
   

  	
  0.9489

  	
   

  
	
  BO

  	
   

  	
  0.9792

  	
   

  	
  0.9478

  	
   

  
	
  BP

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  BQ

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BR

  	
   

  	
  0.9774

  	
   

  	
  0.9501

  	
   

  
	
  BS

  	
   

  	
  0.9485

  	
   

  	
  0.8420

  	
   

  
	
  BT

  	
   

  	
  0.9014

  	
   

  	
  0.8420

  	
   

  
	
  BU

  	
   

  	
  0.9747

  	
   

  	
  0.9266

  	
   

  
	
  BV

  	
   

  	
  0.9271

  	
   

  	
  0.9286

  	
   

  
	
  BW

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  
	
  BX

  	
   

  	
  0.9452

  	
   

  	
  0.9014

  	
   

  
	
  BY

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  BZ

  	
   

  	
  0.9590

  	
   

  	
  0.9468

  	
   

  
	
  CA

  	
   

  	
  0.9950

  	
   

  	
  0.9448

  	
   

  
	
  CB

  	
   

  	
  0.9983

  	
   

  	
  0.9448

  	
   

  
	
  CC

  	
   

  	
  0.9837

  	
   

  	
  0.9448

  	
   

  
	
  CD

  	
   

  	
  0.9870

  	
   

  	
  0.9448

  	
   

  
	
  CE

  	
   

  	
  0.9432

  	
   

  	
  0.8441

  	
   

  
	
  CF

  	
   

  	
  0.9465

  	
   

  	
  0.8441

  	
   

  
	
  CG

  	
   

  	
  0.9318

  	
   

  	
  0.8441

  	
   

  
	
  CH

  	
   

  	
  0.9351

  	
   

  	
  0.8441

  	
   

  
	
  CI

  	
   

  	
  0.8924

  	
   

  	
  0.7791

  	
   

  
	
  CJ

  	
   

  	
  0.8957

  	
   

  	
  0.7791

  	
   

  
	
  CK

  	
   

  	
  0.8811

  	
   

  	
  0.7791

  	
   

  
	
  CL

  	
   

  	
  0.8844

  	
   

  	
  0.7791

  	
   

  
	
  CM

  	
   

  	
  0.8440

  	
   

  	
  0.7398

  	
   

  
	
  CN

  	
   

  	
  0.8473

  	
   

  	
  0.7398

  	
   

  
	
  CO

  	
   

  	
  0.8326

  	
   

  	
  0.7398

  	
   

  
	
  CP

  	
   

  	
  0.8359

  	
   

  	
  0.7398

  	
   

  
	
  DA

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DB

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DC

  	
   

  	
  0.9566

  	
   

  	
  0.9489

  	
   

  
	
  DD

  	
   

  	
  0.9095

  	
   

  	
  0.9475

  	
   

  
	
  DE

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  DF

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  DG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  DH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  DI

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DJ

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  DK

  	
   

  	
  0.9095

  	
   

  	
  0.9274

  	
   

  
	
  DL

  	
   

  	
  0.9714

  	
   

  	
  0.9293

  	
   

  
	
  DM

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  DN

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  DO

  	
   

  	
  0.9795

  	
   

  	
  0.8941

  	
   

  
	
  DP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  
	
  DQ

  	
   

  	
  0.9892

  	
   

  	
  0.9492

  	
   

  
	
  DR

  	
   

  	
  0.9485

  	
   

  	
  0.8680

  	
   

  
	
  DS

  	
   

  	
  0.9747

  	
   

  	
  0.9520

  	
   

  
	
  DT

  	
   

  	
  0.9128

  	
   

  	
  0.9481

  	
   

  
	
  DU

  	
   

  	
  0.9014

  	
   

  	
  0.9481

  	
   

  
	
  DV

  	
   

  	
  0.9788

  	
   

  	
  0.9577

  	
   

  
	
  DW

  	
   

  	
  0.9747

  	
   

  	
  0.9489

  	
   

  
	
  DX

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  DY

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  DZ

  	
   

  	
  0.9886

  	
   

  	
  0.9372

  	
   

  
	
  FN

  	
   

  	
  0.9832

  	
   

  	
  0.9247

  	
   

  
	
  FO

  	
   

  	
  0.9832

  	
   

  	
  0.9496

  	
   

  
	
  FP

  	
   

  	
  0.9347

  	
   

  	
  0.8485

  	
   

  
	
  FQ

  	
   

  	
  0.9347

  	
   

  	
  0.8471

  	
   

  
	
  FR

  	
   

  	
  0.9808

  	
   

  	
  0.9247

  	
   

  
	
  FS

  	
   

  	
  0.9621

  	
   

  	
  0.9254

  	
   

  
	
  FT

  	
   

  	
  0.9619

  	
   

  	
  0.9454

  	
   

  
	
  FU

  	
   

  	
  0.9743

  	
   

  	
  0.9499

  	
   

  
	
  FV

  	
   

  	
  0.9813

  	
   

  	
  0.9119

  	
   

  
	
  FW

  	
   

  	
  0.9667

  	
   

  	
  0.9416

  	
   

  
	
  FX

  	
   

  	
  0.9565

  	
   

  	
  0.9287

  	
   

  
	
  FY

  	
   

  	
  0.9394

  	
   

  	
  0.8970

  	
   

  
	
  FZ

  	
   

  	
  0.9421

  	
   

  	
  0.9429

  	
   

  
	
  GA

  	
   

  	
  0.9485

  	
   

  	
  0.9309

  	
   

  
	
  GB

  	
   

  	
  0.9095

  	
   

  	
  0.9499

  	
   

  
	
  GK

  	
   

  	
  0.9567

  	
   

  	
  0.9483

  	
   

  
	
  KA

  	
   

  	
  0.9823

  	
   

  	
  0.9425

  	
   

  
	
  KB

  	
   

  	
  0.9730

  	
   

  	
  0.9247

  	
   

  
	
  KC

  	
   

  	
  0.9850

  	
   

  	
  0.8643

  	
   

  
	
  LA

  	
   

  	
  0.9714

  	
   

  	
  0.9300

  	
   

  
	
  LB

  	
   

  	
  0.9566

  	
   

  	
  0.9485

  	
   

  
	
  LC

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LD

  	
   

  	
  0.9714

  	
   

  	
  0.8996

  	
   

  
	
  LE

  	
   

  	
  0.9714

  	
   

  	
  0.9305

  	
   

  
	
  LF

  	
   

  	
  0.9714

  	
   

  	
  0.9331

  	
   

  
	
  LG

  	
   

  	
  0.9243

  	
   

  	
  0.9255

  	
   

  
	
  LH

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  LI

  	
   

  	
  0.9714

  	
   

  	
  0.9068

  	
   

  
	
  LJ

  	
   

  	
  0.9243

  	
   

  	
  0.9242

  	
   

  
	
  LK

  	
   

  	
  0.8981

  	
   

  	
  0.8677

  	
   

  
	
  LL

  	
   

  	
  0.9566

  	
   

  	
  0.9300

  	
   

  
	
  LM

  	
   

  	
  0.9452

  	
   

  	
  0.9378

  	
   

  
	
  LN

  	
   

  	
  0.9452

  	
   

  	
  0.9397

  	
   

  
	
  LP

  	
   

  	
  0.9566

  	
   

  	
  0.8996

  	
   

  
	
  LQ

  	
   

  	
  0.9243

  	
   

  	
  0.9291

  	
   

  
	
  LR

  	
   

  	
  0.9714

  	
   

  	
  0.9356

  	
   

  
	
  LS

  	
   

  	
  0.9095

  	
   

  	
  0.9255

  	
   

  
	
  LT

  	
   

  	
  0.8658

  	
   

  	
  0.7138

  	
   

  
	
  LU

  	
   

  	
  0.9095

  	
   

  	
  0.9242

  	
   

  
	
  LV

  	
   

  	
  0.9584

  	
   

  	
  0.9325

  	
   

  
	
  LW

  	
   

  	
  0.9714

  	
   

  	
  0.9325

  	
   

  
	
  LX

  	
   

  	
  0.9095

  	
   

  	
  0.7851

  	
   

  
	
  LY

  	
   

  	
  0.9599

  	
   

  	
  0.9485

  	
   

  
	
  LZ

  	
   

  	
  0.8643

  	
   

  	
  0.7138

  	
   

  
	
  NP

  	
   

  	
  0.9777

  	
   

  	
  0.9405

  	
   

  
	
  OA

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OB

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  OD

  	
   

  	
  0.9128

  	
   

  	
  0.8481

  	
   

  
	
  OE

  	
   

  	
  0.9112

  	
   

  	
  0.8481

  	
   

  
	
  OF

  	
   

  	
  0.9714

  	
   

  	
  0.9065

  	
   

  
	
  OG

  	
   

  	
  0.9492

  	
   

  	
  0.9138

  	
   

  
	
  OK

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  OL

  	
   

  	
  0.9452

  	
   

  	
  0.9500

  	
   

  
	
  OM

  	
   

  	
  0.9452

  	
   

  	
  0.9468

  	
   

  
	
  ON

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OO

  	
   

  	
  0.9452

  	
   

  	
  0.9303

  	
   

  
	
  OP

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OQ

  	
   

  	
  0.9452

  	
   

  	
  0.9300

  	
   

  
	
  OR

  	
   

  	
  0.9460

  	
   

  	
  0.8256

  	
   

  
	
  OS

  	
   

  	
  0.9452

  	
   

  	
  0.9533

  	
   

  
	
  OT

  	
   

  	
  1.0098

  	
   

  	
  0.9405

  	
   

  
	
  OU

  	
   

  	
  0.9526

  	
   

  	
  0.9484

  	
   

  
	
  OV

  	
   

  	
  0.9124

  	
   

  	
  0.9286

  	
   

  
	
  OW

  	
   

  	
  0.9452

  	
   

  	
  0.9309

  	
   

  
	
  OX

  	
   

  	
  0.9452

  	
   

  	
  0.8654

  	
   

  
	
  OY

  	
   

  	
  0.9452

  	
   

  	
  0.9276

  	
   

  
	
  OZ

  	
   

  	
  0.9452

  	
   

  	
  0.9313

  	
   

  
	
  PA

  	
   

  	
  0.9452

  	
   

  	
  0.9323

  	
   

  
	
  PB

  	
   

  	
  0.9307

  	
   

  	
  0.8654

  	
   

  
	
  PC

  	
   

  	
  0.9452

  	
   

  	
  0.8420

  	
   

  
	
  PD

  	
   

  	
  0.8981

  	
   

  	
  0.8420

  	
   

  
	
  PE

  	
   

  	
  0.9453

  	
   

  	
  0.9465

  	
   

  
	
  PF

  	
   

  	
  0.9960

  	
   

  	
  0.9312

  	
   

  
	
  PG

  	
   

  	
  1.0367

  	
   

  	
  0.9405

  	
   

  
	
  PH

  	
   

  	
  0.9501

  	
   

  	
  0.8256

  	
   

  
	
  PI

  	
   

  	
  0.9492

  	
   

  	
  0.9099

  	
   

  
	
  PJ

  	
   

  	
  0.9714

  	
   

  	
  0.9473

  	
   

  
	
  PK

  	
   

  	
  0.9566

  	
   

  	
  0.9325

  	
   

  
	
  PL

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PM

  	
   

  	
  0.9485

  	
   

  	
  0.9276

  	
   

  
	
  PN

  	
   

  	
  0.9452

  	
   

  	
  0.9498

  	
   

  
	
  PO

  	
   

  	
  0.9485

  	
   

  	
  0.9303

  	
   

  
	
  PP

  	
   

  	
  1.0313

  	
   

  	
  0.9405

  	
   

  
	
  PQ

  	
   

  	
  0.9452

  	
   

  	
  0.8554

  	
   

  
	
  PR

  	
   

  	
  0.9485

  	
   

  	
  0.9282

  	
   

  
	
  PS

  	
   

  	
  0.9934

  	
   

  	
  0.9014

  	
   

  
	
  PT

  	
   

  	
  0.9340

  	
   

  	
  0.8680

  	
   

  
	
  PU

  	
   

  	
  0.9933

  	
   

  	
  0.9002

  	
   

  
	
  PV

  	
   

  	
  0.9095

  	
   

  	
  0.8420

  	
   

  
	
  PW

  	
   

  	
  1.0270

  	
   

  	
  0.9511

  	
   

  
	
  PX

  	
   

  	
  0.9714

  	
   

  	
  0.9287

  	
   

  
	
  PY

  	
   

  	
  0.9599

  	
   

  	
  0.8420

  	
   

  
	
  PZ

  	
   

  	
  0.9128

  	
   

  	
  0.8420

  	
   

  
	
  XA

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XB

  	
   

  	
  0.8298

  	
   

  	
  0.9195

  	
   

  
	
  XC

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XD

  	
   

  	
  0.9566

  	
   

  	
  0.8328

  	
   

  
	
  XE

  	
   

  	
  0.9422

  	
   

  	
  0.7891

  	
   

  
	
  XF

  	
   

  	
  0.9452

  	
   

  	
  0.8275

  	
   

  
	
  XG

  	
   

  	
  1.0793

  	
   

  	
  0.9494

  	
   

  
	
  XI

  	
   

  	
  1.0793

  	
   

  	
  0.9298

  	
   

  
	
  XJ

  	
   

  	
  0.8981

  	
   

  	
  0.8275

  	
   

  
	
  XK

  	
   

  	
  0.9782

  	
   

  	
  0.8426

  	
   

  
	
  XL

  	
   

  	
  0.9942

  	
   

  	
  0.8972

  	
   

  
	
  XM

  	
   

  	
  0.9451

  	
   

  	
  0.9022

  	
   

  
	
  XN

  	
   

  	
  0.9452

  	
   

  	
  0.9183

  	
   

  
	
  XO

  	
   

  	
  0.8564

  	
   

  	
  0.9195

  	
   

  
	
  XP

  	
   

  	
  0.9819

  	
   

  	
  0.8661

  	
   

  
	
  XQ

  	
   

  	
  0.8981

  	
   

  	
  0.7513

  	
   

  
	
  XR

  	
   

  	
  0.8493

  	
   

  	
  0.9195

  	
   

  
	
  XS

  	
   

  	
  0.9681

  	
   

  	
  0.7837

  	
   

  
	
  XT

  	
   

  	
  0.9452

  	
   

  	
  0.9022

  	
   

  
	
  XU

  	
   

  	
  0.9452

  	
   

  	
  0.8934

  	
   

  
	
  XV

  	
   

  	
  0.9452

  	
   

  	
  0.9113

  	
   

  
	
  XW

  	
   

  	
  0.9452

  	
   

  	
  0.9229

  	
   

  
	
  XY

  	
   

  	
  0.9782

  	
   

  	
  0.8502

  	
   

  

 

53

 

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

Effective September 1, 1998

 

Small Group POS

 

	
  Plan

  	
   

  	
  Prof

  Factor

  	
   

  	
  Inst

  Factor

  	
   

  
	
  QA

  	
   

  	
  0.9877

  	
   

  	
  0.9427

  	
   

  
	
  QB

  	
   

  	
  0.9350

  	
   

  	
  0.8421

  	
   

  
	
  QC

  	
   

  	
  0.8346

  	
   

  	
  0.7381

  	
   

  

 

54

 

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

 

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

 

	
  Age

  	
   

  	
  Male

  	
   

  	
  Female

  	
   

  
	
  0

  	
   

  	
  0.231

  	
   

  	
  0.231

  	
   

  
	
  1

  	
   

  	
  0.366

  	
   

  	
  0.366

  	
   

  
	
  2-4

  	
   

  	
  0.323

  	
   

  	
  0.323

  	
   

  
	
  5-9

  	
   

  	
  0.289

  	
   

  	
  0.289

  	
   

  
	
  10-14

  	
   

  	
  0.276

  	
   

  	
  0.276

  	
   

  
	
  15-19

  	
   

  	
  0.408

  	
   

  	
  0.408

  	
   

  
	
  20-24

  	
   

  	
  0.280

  	
   

  	
  0.714

  	
   

  
	
  25-29

  	
   

  	
  0.382

  	
   

  	
  0.868

  	
   

  
	
  30-34

  	
   

  	
  0.547

  	
   

  	
  0.919

  	
   

  
	
  35-39

  	
   

  	
  0.756

  	
   

  	
  1.067

  	
   

  
	
  40-44

  	
   

  	
  0.974

  	
   

  	
  1.265

  	
   

  
	
  45-49

  	
   

  	
  1.295

  	
   

  	
  1.654

  	
   

  
	
  50-54

  	
   

  	
  1.746

  	
   

  	
  2.198

  	
   

  
	
  55-59

  	
   

  	
  2.133

  	
   

  	
  2.573

  	
   

  
	
  60-64

  	
   

  	
  2.610

  	
   

  	
  3.000

  	
   

  
	
  65

  	
  +

  	
  3.175

  	
   

  	
  3.467

  	
   

  

 

55

 

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

 

	
  Plan

  	
   

  	
  Factor

  	
   

  
	
  01

  	
   

  	
  1.3376

  	
   

  
	
  02

  	
   

  	
  1.1000

  	
   

  
	
  03

  	
   

  	
  0.6448

  	
   

  
	
  04

  	
   

  	
  1.1000

  	
   

  
	
  05

  	
   

  	
  0.7255

  	
   

  
	
  06

  	
   

  	
  1.1102

  	
   

  
	
  07

  	
   

  	
  0.6448

  	
   

  
	
  08

  	
   

  	
  1.1000

  	
   

  
	
  09

  	
   

  	
  1.1000

  	
   

  
	
  0A

  	
   

  	
  1.7495

  	
   

  
	
  0B

  	
   

  	
  1.6378

  	
   

  
	
  0C

  	
   

  	
  1.7578

  	
   

  
	
  0D

  	
   

  	
  1.6457

  	
   

  
	
  0E

  	
   

  	
  1.7827

  	
   

  
	
  0F

  	
   

  	
  0.5134

  	
   

  
	
  0G

  	
   

  	
  0.9368

  	
   

  
	
  0H

  	
   

  	
  0.7255

  	
   

  
	
  0I

  	
   

  	
  0.8948

  	
   

  
	
  0J

  	
   

  	
  1.7578

  	
   

  
	
  0P

  	
   

  	
  1.1577

  	
   

  
	
  0R

  	
   

  	
  1.1577

  	
   

  
	
  0S

  	
   

  	
  1.0470

  	
   

  
	
  0T

  	
   

  	
  0.6771

  	
   

  
	
  0U

  	
   

  	
  1.1577

  	
   

  
	
  0V

  	
   

  	
  1.1577

  	
   

  
	
  0W

  	
   

  	
  0.7232

  	
   

  
	
  0X

  	
   

  	
  0.9409

  	
   

  
	
  0Y

  	
   

  	
  0.6411

  	
   

  
	
  0Z

  	
   

  	
  1.0945

  	
   

  
	
  10

  	
   

  	
  0.7564

  	
   

  
	
  11

  	
   

  	
  0.5166

  	
   

  
	
  12

  	
   

  	
  0.4105

  	
   

  
	
  13

  	
   

  	
  0.4806

  	
   

  
	
  14

  	
   

  	
  0.5590

  	
   

  
	
  16

  	
   

  	
  1.0821

  	
   

  
	
  17

  	
   

  	
  0.6411

  	
   

  
	
  18

  	
   

  	
  0.7292

  	
   

  
	
  19

  	
   

  	
  1.1000

  	
   

  
	
  1A

  	
   

  	
  1.6037

  	
   

  
	
  1B

  	
   

  	
  1.5013

  	
   

  
	
  1C

  	
   

  	
  1.6115

  	
   

  
	
  1D

  	
   

  	
  1.5087

  	
   

  
	
  1E

  	
   

  	
  1.1102

  	
   

  
	
  1F

  	
   

  	
  1.1102

  	
   

  
	
  1G

  	
   

  	
  0.7412

  	
   

  
	
  1H

  	
   

  	
  0.7412

  	
   

  
	
  1I

  	
   

  	
  1.1102

  	
   

  
	
  1J

  	
   

  	
  0.7564

  	
   

  
	
  1K

  	
   

  	
  1.1102

  	
   

  
	
  1L

  	
   

  	
  0.8989

  	
   

  
	
  1M

  	
   

  	
  0.7564

  	
   

  
	
  1N

  	
   

  	
  0.8625

  	
   

  
	
  1O

  	
   

  	
  0.6845

  	
   

  
	
  1P

  	
   

  	
  0.5991

  	
   

  
	
  1Q

  	
   

  	
  1.1000

  	
   

  
	
  14

  	
   

  	
  0.9368

  	
   

  
	
  1S

  	
   

  	
  1.0945

  	
   

  
	
  1T

  	
   

  	
  1.1157

  	
   

  
	
  1U

  	
   

  	
  0.9119

  	
   

  
	
  1V

  	
   

  	
  1.1000

  	
   

  
	
  1W

  	
   

  	
  1.1102

  	
   

  
	
  1X

  	
   

  	
  0.??89

  	
   

  
	
  1Y

  	
   

  	
  0.??35

  	
   

  
	
  1Z

  	
   

  	
  0.??00

  	
   

  
	
  20

  	
   

  	
  0.??92

  	
   

  
	
  23

  	
   

  	
  0.??68

  	
   

  
	
  24

  	
   

  	
  1.??57

  	
   

  
	
  26

  	
   

  	
  1.??00

  	
   

  
	
  2A

  	
   

  	
  1.??35

  	
   

  
	
  2B

  	
   

  	
  1.??99

  	
   

  
	
  2C

  	
   

  	
  1.4704

  	
   

  
	
  2D

  	
   

  	
  1.3768

  	
   

  
	
  2E

  	
   

  	
  1.4912

  	
   

  
	
  2F

  	
   

  	
  0.9409

  	
   

  
	
  2G

  	
   

  	
  0.6448

  	
   

  
	
  2H

  	
   

  	
  1.1000

  	
   

  
	
  2I

  	
   

  	
  0.6448

  	
   

  
	
  2J

  	
   

  	
  0.6882

  	
   

  
	
  2L

  	
   

  	
  1.1761

  	
   

  
	
  2M

  	
   

  	
  1.1157

  	
   

  
	
  2N

  	
   

  	
  1.1157

  	
   

  
	
  2O

  	
   

  	
  0.7412

  	
   

  
	
  2P

  	
   

  	
  1.1577

  	
   

  
	
  2Q

  	
   

  	
  1.1102

  	
   

  
	
  2R

  	
   

  	
  1.1102

  	
   

  
	
  2S

  	
   

  	
  0.8989

  	
   

  
	
  2T

  	
   

  	
  0.7292

  	
   

  
	
  2U

  	
   

  	
  0.8989

  	
   

  
	
  2V

  	
   

  	
  0.7269

  	
   

  
	
  2W

  	
   

  	
  0.8989

  	
   

  
	
  2X

  	
   

  	
  0.6448

  	
   

  
	
  2Y

  	
   

  	
  0.7269

  	
   

  
	
  2Z

  	
   

  	
  1.2135

  	
   

  
	
  30

  	
   

  	
  1.1102

  	
   

  
	
  31

  	
   

  	
  1.1102

  	
   

  
	
  32

  	
   

  	
  0.7255

  	
   

  
	
  33

  	
   

  	
  0.7269

  	
   

  
	
  34

  	
   

  	
  1.1102

  	
   

  
	
  35

  	
   

  	
  1.1102

  	
   

  
	
  36

  	
   

  	
  1.1102

  	
   

  
	
  37

  	
   

  	
  1.1102

  	
   

  
	
  38

  	
   

  	
  1.2135

  	
   

  
	
  39

  	
   

  	
  0.8791

  	
   

  
	
  3A

  	
   

  	
  1.3311

  	
   

  
	
  3B

  	
   

  	
  1.2458

  	
   

  
	
  3C

  	
   

  	
  1.3376

  	
   

  
	
  3D

  	
   

  	
  1.2518

  	
   

  
	
  3E

  	
   

  	
  1.3311

  	
   

  
	
  3F

  	
   

  	
  1.3376

  	
   

  
	
  3G

  	
   

  	
  1.3311

  	
   

  
	
  3I

  	
   

  	
  0.8989

  	
   

  
	
  3J

  	
   

  	
  0.8989

  	
   

  
	
  3K

  	
   

  	
  1.1157

  	
   

  
	
  3L

  	
   

  	
  0.6448

  	
   

  
	
  3M

  	
   

  	
  0.8671

  	
   

  
	
  3N

  	
   

  	
  1.2135

  	
   

  
	
  3O

  	
   

  	
  1.4704

  	
   

  
	
  3P

  	
   

  	
  0.8989

  	
   

  
	
  3Q

  	
   

  	
  1.4912

  	
   

  
	
  3R

  	
   

  	
  0.6882

  	
   

  
	
  3S

  	
   

  	
  0.5166

  	
   

  
	
  3T

  	
   

  	
  0.7292

  	
   

  
	
  3U

  	
   

  	
  1.6378

  	
   

  
	
  3V

  	
   

  	
  0.7255

  	
   

  
	
  3X

  	
   

  	
  0.7398

  	
   

  
	
  3Y

  	
   

  	
  0.9967

  	
   

  
	
  3Z

  	
   

  	
  0.5590

  	
   

  
	
  40

  	
   

  	
  0.7292

  	
   

  
	
  41

  	
   

  	
  0.9119

  	
   

  
	
  42

  	
   

  	
  1.1637

  	
   

  
	
  46

  	
   

  	
  1.1637

  	
   

  
	
  47

  	
   

  	
  1.3588

  	
   

  
	
  48

  	
   

  	
  0.9368

  	
   

  
	
  49

  	
   

  	
  1.2310

  	
   

  
	
  4A

  	
   

  	
  1.2080

  	
   

  
	
  4B

  	
   

  	
  1.1305

  	
   

  
	
  4E

  	
   

  	
  1.2015

  	
   

  
	
  4F

  	
   

  	
  1.2836

  	
   

  
	
  4G

  	
   

  	
  1.1000

  	
   

  
	
  4H

  	
   

  	
  1.1000

  	
   

  
	
  4I

  	
   

  	
  1.1102

  	
   

  
	
  4K

  	
   

  	
  1.0032

  	
   

  
	
  4L

  	
   

  	
  1.0945

  	
   

  
	
  4M

  	
   

  	
  0.9917

  	
   

  
	
  4N

  	
   

  	
  0.9331

  	
   

  
	
  4P

  	
   

  	
  0.9548

  	
   

  
	
  4Q

  	
   

  	
  0.9548

  	
   

  
	
  4R

  	
   

  	
  1.1000

  	
   

  
	
  4S

  	
   

  	
  1.1102

  	
   

  
	
  4T

  	
   

  	
  1.1000

  	
   

  
	
  4U

  	
   

  	
  0.7398

  	
   

  
	
  4V

  	
   

  	
  1.0945

  	
   

  
	
  4W

  	
   

  	
  1.2135

  	
   

  
	
  4X

  	
   

  	
  1.1000

  	
   

  
	
  4Y

  	
   

  	
  0.7269

  	
   

  
	
  51

  	
   

  	
  0.7255

  	
   

  
	
  52

  	
   

  	
  0.7292

  	
   

  
	
  53

  	
   

  	
  0.6448

  	
   

  
	
  54

  	
   

  	
  0.5166

  	
   

  
	
  55

  	
   

  	
  0.7292

  	
   

  
	
  56

  	
   

  	
  0.6448

  	
   

  
	
  57

  	
   

  	
  0.5166

  	
   

  
	
  58

  	
   

  	
  0.7255

  	
   

  
	
  59

  	
   

  	
  0.6448

  	
   

  
	
  5A

  	
   

  	
  1.0945

  	
   

  
	
  5B

  	
   

  	
  1.1157

  	
   

  
	
  5C

  	
   

  	
  1.1000

  	
   

  
	
  5D

  	
   

  	
  1.0299

  	
   

  
	
  5E

  	
   

  	
  1.0834

  	
   

  
	
  5F

  	
   

  	
  1.1577

  	
   

  
	
  5G

  	
   

  	
  1.1637

  	
   

  
	
  5H

  	
   

  	
  1.1798

  	
   

  
	
  5I

  	
   

  	
  1.1180

  	
   

  
	
  5J

  	
   

  	
  0.6005

  	
   

  
	
  5K

  	
   

  	
  1.8121

  	
   

  
	
  5L

  	
   

  	
  1.1577

  	
   

  
	
  5M

  	
   

  	
  1.1000

  	
   

  
	
  5N

  	
   

  	
  1.0834

  	
   

  
	
  5O

  	
   

  	
  0.7292

  	
   

  
	
  5P

  	
   

  	
  1.1577

  	
   

  
	
  5Q

  	
   

  	
  0.5973

  	
   

  
	
  5R

  	
   

  	
  0.7292

  	
   

  
	
  5S

  	
   

  	
  0.7255

  	
   

  
	
  5T

  	
   

  	
  1.1000

  	
   

  
	
  5U

  	
   

  	
  1.1157

  	
   

  
	
  5V

  	
   

  	
  1.1000

  	
   

  
	
  5W

  	
   

  	
  1.1157

  	
   

  
	
  5X

  	
   

  	
  0.7412

  	
   

  
	
  5Y

  	
   

  	
  0.7412

  	
   

  
	
  5Z

  	
   

  	
  1.7495

  	
   

  
	
  61

  	
   

  	
  1.1102

  	
   

  
	
  62

  	
   

  	
  1.1102

  	
   

  
	
  63

  	
   

  	
  1.7578

  	
   

  
	
  64

  	
   

  	
  0.9409

  	
   

  
	
  65

  	
   

  	
  0.7292

  	
   

  
	
  66

  	
   

  	
  1.1637

  	
   

  
	
  67

  	
   

  	
  1.1637

  	
   

  
	
  68

  	
   

  	
  1.1000

  	
   

  
	
  69

  	
   

  	
  0.8989

  	
   

  
	
  6A

  	
   

  	
  0.9917

  	
   

  
	
  6B

  	
   

  	
  1.1157

  	
   

  
	
  6C

  	
   

  	
  0.9967

  	
   

  
	
  6D

  	
   

  	
  1.0945

  	
   

  
	
  6E

  	
   

  	
  0.9750

  	
   

  
	
  6F

  	
   

  	
  1.0424

  	
   

  
	
  6G

  	
   

  	
  0.6005

  	
   

  
	
  6H

  	
   

  	
  1.1577

  	
   

  
	
  6I

  	
   

  	
  1.1102

  	
   

  
	
  6J

  	
   

  	
  1.1102

  	
   

  
	
  6K

  	
   

  	
  0.8989

  	
   

  
	
  6L

  	
   

  	
  0.8989

  	
   

  
	
  6M

  	
   

  	
  1.1180

  	
   

  
	
  6N

  	
   

  	
  1.1180

  	
   

  
	
  6O

  	
   

  	
  1.1102

  	
   

  
	
  6P

  	
   

  	
  1.0424

  	
   

  
	
  6Q

  	
   

  	
  0.9280

  	
   

  
	
  6R

  	
   

  	
  1.1637

  	
   

  
	
  6S

  	
   

  	
  0.8805

  	
   

  
	
  6T

  	
   

  	
  1.1102

  	
   

  
	
  6U

  	
   

  	
  1.1102

  	
   

  
	
  6V

  	
   

  	
  1.1102

  	
   

  
	
  6W

  	
   

  	
  1.1102

  	
   

  
	
  6X

  	
   

  	
  1.1102

  	
   

  
	
  6Y

  	
   

  	
  1.7578

  	
   

  
	
  6Z

  	
   

  	
  1.2241

  	
   

  
	
  71

  	
   

  	
  1.1102

  	
   

  
	
  72

  	
   

  	
  1.1102

  	
   

  
	
  73

  	
   

  	
  0.8948

  	
   

  
	
  74

  	
   

  	
  1.1102

  	
   

  
	
  75

  	
   

  	
  0.9368

  	
   

  
	
  76

  	
   

  	
  0.8989

  	
   

  
	
  77

  	
   

  	
  0.9368

  	
   

  
	
  78

  	
   

  	
  0.9409

  	
   

  
	
  79

  	
   

  	
  0.8948

  	
   

  
	
  7A

  	
   

  	
  0.8948

  	
   

  
	
  7B

  	
   

  	
  0.8371

  	
   

  
	
  7C

  	
   

  	
  0.8989

  	
   

  
	
  7D

  	
   

  	
  0.8768

  	
   

  
	
  7E

  	
   

  	
  0.8768

  	
   

  
	
  7F

  	
   

  	
  0.9368

  	
   

  
	
  7G

  	
   

  	
  0.9409

  	
   

  
	
  7H

  	
   

  	
  1.1102

  	
   

  
	
  7I

  	
   

  	
  1.1102

  	
   

  
	
  7J

  	
   

  	
  0.9409

  	
   

  
	
  7K

  	
   

  	
  0.9368

  	
   

  
	
  7L

  	
   

  	
  0.8989

  	
   

  
	
  7M

  	
   

  	
  0.8371

  	
   

  
	
  7N

  	
   

  	
  0.9368

  	
   

  
	
  7O

  	
   

  	
  0.8989

  	
   

  
	
  7P

  	
   

  	
  0.8948

  	
   

  
	
  7Q

  	
   

  	
  0.7527

  	
   

  
	
  7R

  	
   

  	
  1.7578

  	
   

  
	
  7S

  	
   

  	
  1.7578

  	
   

  
	
  7T

  	
   

  	
  1.1102

  	
   

  
	
  7U

  	
   

  	
  1.1102

  	
   

  
	
  7V

  	
   

  	
  1.1102

  	
   

  
	
  7W

  	
   

  	
  1.1102

  	
   

  
	
  7X

  	
   

  	
  1.1102

  	
   

  
	
  7Y

  	
   

  	
  1.1102

  	
   

  
	
  7Z

  	
   

  	
  1.7495

  	
   

  
	
  82

  	
   

  	
  1.1000

  	
   

  
	
  8A

  	
   

  	
  1.1102

  	
   

  
	
  8B

  	
   

  	
  0.8989

  	
   

  
	
  8C

  	
   

  	
  0.8948

  	
   

  
	
  8E

  	
   

  	
  0.7869

  	
   

  
	
  8F

  	
   

  	
  0.8404

  	
   

  
	
  8G

  	
   

  	
  1.1102

  	
   

  
	
  8H

  	
   

  	
  1.0032

  	
   

  
	
  8I

  	
   

  	
  0.8989

  	
   

  
	
  8J

  	
   

  	
  0.8989

  	
   

  
	
  8K

  	
   

  	
  0.8989

  	
   

  
	
  8L

  	
   

  	
  1.6115

  	
   

  
	
  8M

  	
   

  	
  0.9986

  	
   

  
	
  8N

  	
   

  	
  0.9548

  	
   

  
	
  8P

  	
   

  	
  1.1000

  	
   

  
	
  8R

  	
   

  	
  1.7864

  	
   

  
	
  8S

  	
   

  	
  1.0618

  	
   

  
	
  8T

  	
   

  	
  0.5590

  	
   

  
	
  8U

  	
   

  	
  1.6346

  	
   

  
	
  8V

  	
   

  	
  1.1637

  	
   

  
	
  8X

  	
   

  	
  0.6448

  	
   

  
	
  8Y

  	
   

  	
  0.7255

  	
   

  
	
  8Z

  	
   

  	
  0.7527

  	
   

  
	
  91

  	
   

  	
  1.2135

  	
   

  
	
  92

  	
   

  	
  1.1577

  	
   

  
	
  93

  	
   

  	
  0.7292

  	
   

  
	
  96

  	
   

  	
  0.9368

  	
   

  
	
  9A

  	
   

  	
  0.7232

  	
   

  
	
  9B

  	
   

  	
  0.6771

  	
   

  
	
  9C

  	
   

  	
  0.7269

  	
   

  
	
  9D

  	
   

  	
  0.7232

  	
   

  
	
  9E

  	
   

  	
  0.7048

  	
   

  
	
  9F

  	
   

  	
  0.7527

  	
   

  
	
  9G

  	
   

  	
  0.7564

  	
   

  
	
  9H

  	
   

  	
  0.7675

  	
   

  
	
  9I

  	
   

  	
  0.7269

  	
   

  
	
  9J

  	
   

  	
  0.7232

  	
   

  
	
  9L

  	
   

  	
  1.7495

  	
   

  
	
  9M

  	
   

  	
  0.6411

  	
   

  
	
  9N

  	
   

  	
  0.7048

  	
   

  
	
  9O

  	
   

  	
  0.6448

  	
   

  
	
  9P

  	
   

  	
  0.6411

  	
   

  
	
  9Q

  	
   

  	
  0.6411

  	
   

  
	
  9R

  	
   

  	
  0.7527

  	
   

  
	
  9S

  	
   

  	
  0.6411

  	
   

  
	
  9T

  	
   

  	
  0.9409

  	
   

  
	
  9U

  	
   

  	
  1.2135

  	
   

  
	
  9W

  	
   

  	
  0.6448

  	
   

  
	
  9X

  	
   

  	
  1.1102

  	
   

  
	
  9Y

  	
   

  	
  1.1000

  	
   

  
	
  9Z

  	
   

  	
  1.0424

  	
   

  
	
  A1

  	
   

  	
  1.7578

  	
   

  
	
  B1

  	
   

  	
  0.7292

  	
   

  
	
  B2

  	
   

  	
  0.7564

  	
   

  
	
  B3

  	
   

  	
  0.7564

  	
   

  
	
  B4

  	
   

  	
  0.7292

  	
   

  
	
  B5

  	
   

  	
  0.8989

  	
   

  
	
  B6

  	
   

  	
  1.1798

  	
   

  
	
  B7

  	
   

  	
  1.1637

  	
   

  
	
  B8

  	
   

  	
  0.7255

  	
   

  
	
  B9

  	
   

  	
  0.7255

  	
   

  
	
  C2

  	
   

  	
  0.6536

  	
   

  
	
  C3

  	
   

  	
  0.6536

  	
   

  
	
  C5

  	
   

  	
  0.9091

  	
   

  
	
  C7

  	
   

  	
  0.7292

  	
   

  
	
  C8

  	
   

  	
  0.7292

  	
   

  
	
  C9

  	
   

  	
  0.7412

  	
   

  
	
  D1

  	
   

  	
  0.7412

  	
   

  
	
  D2

  	
   

  	
  0.7292

  	
   

  
	
  D3

  	
   

  	
  0.7689

  	
   

  
	
  D4

  	
   

  	
  0.7689

  	
   

  
	
  D5

  	
   

  	
  0.7689

  	
   

  
	
  D6

  	
   

  	
  0.7195

  	
   

  
	
  E2

  	
   

  	
  0.7721

  	
   

  
	
  E3

  	
   

  	
  0.8989

  	
   

  
	
  E5

  	
   

  	
  0.7412

  	
   

  
	
  E7

  	
   

  	
  1.1157

  	
   

  
	
  F1

  	
   

  	
  0.7292

  	
   

  
	
  F3

  	
   

  	
  0.7412

  	
   

  
	
  F4

  	
   

  	
  0.7292

  	
   

  
	
  F7

  	
   

  	
  0.7398

  	
   

  
	
  12

  	
   

  	
  1.0106

  	
   

  
	
  13

  	
   

  	
  0.6171

  	
   

  
	
  18

  	
   

  	
  1.1798

  	
   

  
	
  19

  	
   

  	
  0.6448

  	
   

  
	
  OH

  	
   

  	
  1.7578

  	
   

  
	
  P3

  	
   

  	
  0.5134

  	
   

  
	
  P4

  	
   

  	
  0.6517

  	
   

  
	
  P9

  	
   

  	
  1.1157

  	
   

  
	
  Q4

  	
   

  	
  0.7255

  	
   

  
	
  S1

  	
   

  	
  1.1277

  	
   

  
	
  S2

  	
   

  	
  1.8025

  	
   

  
	
  S3

  	
   

  	
  0.8768

  	
   

  
	
  S4

  	
   

  	
  1.6378

  	
   

  
	
  S5

  	
   

  	
  1.1102

  	
   

  
	
  S6

  	
   

  	
  1.1102

  	
   

  
	
  S7

  	
   

  	
  1.7578

  	
   

  
	
  S8

  	
   

  	
  0.8768

  	
   

  
	
  S9

  	
   

  	
  1.7495

  	
   

  

 

56

 

 

ADDENDUM B.2

 

DIVISION OF RESPONSIBILITY

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

 

COMMERCIAL HMO AND POINT OF SERVICE BENEFIT
PROGRAMS

 

The
following matrix outlines the division of financial responsibility between FHS,
PPG and Hospital.  The matrix is
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 6/1/98 THROUGH 6/30/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  AIDS
  - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  •  Drugs, including Epogen, Nupogen and
  adjunctive therapies
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

57

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  COSMETIC SURGERY

  (Medically
  Necessary)
• 
  Professional Component
• 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES
(When a covered benefit)

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC TESTING
  - Outpatient Facility & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE MEDICAL EQUIPMENT
•  Outpatient

  • 
  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS
  - In-Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS -
  Out-of-Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS -
  In-Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS -
  Out-of-Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY
•  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS
•  Facility Component

  •  Professional Component

  •  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

58

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  HOSPICE
•  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED PHYSICIANS - 
Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES, SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT
•  Professional Component

  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY
•  Professional Component 

  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY –
  Deliveries and Non-Deliveries

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL ADMISSIONS

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH –
  Inpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH –
  Outpatient 

  •  Facility Component

  • 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY –
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY -
  Outpatient 

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

59

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION - Outpatient  Laboratory
  , X-ray

  (within 72 hrs or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES
•  Outpatient

  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Outpatient

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES- Medical, Surgical, Office

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

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES, DIABETIC
•  Chem. Strips, Lancet, Needles, Syringes

  •  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Inpatient
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY - Outpatient
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY: Physical, Occupational, Speech

  •  Inpatient 

  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  •  Facility Component

  •  Professional Component

  •  Organ Procurement

  •  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

60

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  TRANSPLANT
  EVALUATIONS
•  Professional

  •  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  - Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE

  •  Exams and Medically Necessary Care

  •  Implanted Lenses (Cataract Surgery)

  •  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

61

 

 

MATRIX
EFFECTIVE 7/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY
•  Inpatient Facility Component
•  Inpatient Professional Component

  • 
  Outpatient Facility Component
• 
  Outpatient Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  •  Drugs, including Epogen, Nupogen and
  adjunctive therapies
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC SURGERY

  (Medically Necessary)

  •  Professional
  Component
• 
  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL CARE
  VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES
(When a covered benefit)

  •  Facility
  Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DIAGNOSTIC TESTING
  - Outpatient Facility  & Professional

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

62

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  DURABLE MEDICAL EQUIPMENT

  •  Outpatient

  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS
  - In-Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS
  - Out of Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS
  - In Area

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS - Out-of-Area
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS
• 
  Facility Component
• 
  Professional Component
• 
  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE

  •  Facility Component

  •  Professional
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED PHYSICIANS
  -

  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES, SELF
  ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

63

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IVF & GIFT

  •  Professional Component

  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY
•  Professional Component

  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY -
  Deliveries and Non-Deliveries

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL ADMISSIONS

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH -
  Inpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH -
  Outpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY -
  Outpatient

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION -
  Outpatient

  Laboratory, X-ray

  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES

  •  Outpatient

  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

 

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

 

64

 

MATRIX
EFFECTIVE 7/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED

  RISK/HOSPITAL

  CAPITATED

  SERVICES

  	
   

  
	
  RADIOLOGY -
  Outpatient

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

   

   

  
	
  SPEECH AND HEARING
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES- Medical,
  Surgical, Office

  • 
  Related to an Outpatient Office Visit:

  Splints, Casts, Bandages, etc...

  • 
  Related to a Hospital Stay:

  Surgical Supplies, Equipment, etc...

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES, DIABETIC
•  Chem. Strips, Lancet, Needles, Syringes

  •  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY –
  Inpatient

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY –
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY –
  Outpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY:
  Physical, Occupational, Speech

  •  Inpatient

  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  •  Facility Component

  •  Professional Component

  •  Organ Procurement

  •  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT EVALUATIONS

  •  Professional

  •  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

   

   

  
	
  URGENT CARE VISITS
  – In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  – Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE
•  Exams and Medically Necessary Care

  •  Implanted Lenses (Cataract Surgery)

  •  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

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

 

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

 

65

 

ADDENDUM C

 

MEDICARE
HEALTH MAINTENANCE ORGANIZATION (HMO) AND MEDICARE POINT OF

SERVICE
(POS) BENEFIT PROGRAMS

 

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

 

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

 

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

 

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

 

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

 

B.                                    MEDICARE HMO BENEFIT
PROGRAMS.

 

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

 

2.                                      Capitation; PPG Capitated
Services.

 

2.1                               Compensation for PPG
Capitated Services.  As compensation for rendering PPG Capitated
Services as defined herein, HMO shall pay PPG Capitation at *** 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.

 

66

 

2.2                               Professional Stop Loss
Program.

 

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

 

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

 

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

 

	
  Supplemental Benefit

  	
   

  	
  PMPM

  	
   

  
	
  $5 office visit & specialist
  consultation copay waived

  	
   

  	
  ***

  	
   

  
	
  $5 vision and hearing exam copay waived

  	
   

  	
  ***

  	
   

  
	
  $20 outpatient mental health copay waived

  	
   

  	
  ***

  	
   

  
	
  $20 outpatient substance abuse copay waived

  	
   

  	
  ***

  	
   

  

 

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

 

3.                                      Shared Risk Program.

 

3.1                               Shared Risk Budget.  As a
contingency for any PPG liability under the Shared Risk Program, HMO shall
deduct zero percent (0 %) of PPG’s Capitation and place such amount in the
Withhold Fund as described in this Agreement. 
Each month, HMO shall fund the Shared Risk Budget for each eligible
Medicare HMO Member at *** Monthly Revenue.

 

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

 

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

 

67

 

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

 

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

 

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

 

(a)                                  Out-of-Area Emergency and Urgently Needed
services:   1.5 % of the applicable Medicare HMO Member’s
HCFA payment and county premium, if any.

 

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

 

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

 

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

 

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

 

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

 

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.

 

68

 

 

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

 

3.                                      Capitation; PPG Capitated
Services.

 

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

 

In the event PPG’s enrollment exceeds five hundred (500) Medicare POS
Members, the Professional Out-of-Network Withhold percentage shall be equal to
(i) PPG’s prior year’s professional Out-of-Network costs, divided by the total
of PPG’s Capitation for Medicare POS Members (prior to the Professional
Out-of-Network) rounded to the nearest multiple of five, plus ***, or (ii) ***
if there is no prior year experience or if PPO has 500 or less Medicare POS
Members.  On or before December 15th
of each year, HMO shall notify PPG of PPG’s Out-of-Network experience incurred
between July 1 of the previous year and June 30 of the current year
and the calculation noted above, and such shall be PPG’s Professional
Out-of-Network Withhold percentage for the following year.

 

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

 

3.2                               Professional Stop Loss
Program.

 

(a)                                  In-Network Professional Stop Loss.

 

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

 

(b)                                  Out-of-Network Professional Stop Loss.  PPG’s Out-of-Network Professional Stop Loss
threshold shall be ***  per
Medicare POS Member during the calendar year. 
The cost to PPG for the Out-of-Network Professional Stop Loss program
shall be eighteen one-hundredths percent (0.18 %)  of
applicable Medicare POS Member’s HCFA payment and county premium, if any, which
shall be deducted from PPG’s Out-of-Network Risk Sharing Fund.

 

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

 

69

 

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 ***, or an amount
not to exceed *** of the annual gross PPG Capitation.

 

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

 

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

 

(a)                                  Out-of-Area Emergency and Urgently Needed
Services:   *** 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 twenty percent (20%) of the cost shall be charged
against the POS Shared Risk Budget.

 

(b)                                  In-Network and Out-of-Network POS Shared Risk
Services: *** %  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 seventy-five percent (75%),
subject to Section 4.3 of this Agreement. 
Shared Risk Claims with dates of service within the Reconciliation
Period and paid by March 31 of the following year shall be used in the
calculation.  Shared Risk Services
incurred within the Reconciliation Period but paid after March 31 of the
following year will be included in the next Reconciliation Period calculation.

 

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

 

70

 

E.                                      OTHER
SERVICES.

 

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

 

71

 

ADDENDUM C.1

 

SUPPLEMENTAL
BENEFITS COSTS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  5.71

  	
  %

  
	
  Butte

  	
   

  	
  0.55

  	
  %

  
	
  Colusa

  	
   

  	
  0.52

  	
  %

  
	
  Contra Costa

  	
   

  	
  5.68

  	
  %

  
	
  El Dorado

  	
   

  	
  5.22

  	
  %

  
	
  Fresno

  	
   

  	
  5.11

  	
  %

  
	
  Glenn

  	
   

  	
  0.57

  	
  %

  
	
  Kern

  	
   

  	
  11.80

  	
  %

  
	
  Los Angeles

  	
   

  	
  9.27

  	
  %

  
	
  Madera

  	
   

  	
  4.90

  	
  %

  
	
  Marin

  	
   

  	
  4.09

  	
  %

  
	
  Mariposa

  	
   

  	
  5.42

  	
  %

  
	
  Napa

  	
   

  	
  0.48

  	
  %

  
	
  Orange

  	
   

  	
  10.03

  	
  %

  
	
  Placer

  	
   

  	
  6.71

  	
  %

  
	
  Plumas

  	
   

  	
  0.55

  	
  %

  
	
  Riverside

  	
   

  	
  12.08

  	
  %

  
	
  Sacramento

  	
   

  	
  6.01

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.57

  	
  %

  
	
  San Diego

  	
   

  	
  11.27

  	
  %

  
	
  San Francisco

  	
   

  	
  5.90

  	
  %

  
	
  San Joaquin

  	
   

  	
  7.03

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  11.37

  	
  %

  
	
  San Matco

  	
   

  	
  7.16

  	
  %

  
	
  Santa Barbara

  	
   

  	
  11.28

  	
  %

  
	
  Santa Clara

  	
   

  	
  6.68

  	
  %

  
	
  Sierra

  	
   

  	
  0.58

  	
  %

  
	
  Solano

  	
   

  	
  0.59

  	
  %

  
	
  Sonoma

  	
   

  	
  5.28

  	
  %

  
	
  Stanislaus

  	
   

  	
  7.09

  	
  %

  
	
  Sutter

  	
   

  	
  0.57

  	
  %

  
	
  Tulare

  	
   

  	
  4.91

  	
  %

  
	
  Ventura

  	
   

  	
  11.81

  	
  %

  
	
  Yolo

  	
   

  	
  5.35

  	
  %

  
	
  Yuba

  	
   

  	
  0.55

  	
  %

  

 

72

 

ADDENDUM C.2

 

PHARMACY SHARED RISK BUDGETS

 

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

 

	
  County

  	
   

  	
  Percent

  	
   

  
	
  Alameda

  	
   

  	
  4.48

  	
  %

  
	
  Butte

  	
   

  	
  0.00

  	
  %

  
	
  Colusa

  	
   

  	
  0.00

  	
  %

  
	
  Contra Costa

  	
   

  	
  4.45

  	
  %

  
	
  El Dorado

  	
   

  	
  4.60

  	
  %

  
	
  Fresno

  	
   

  	
  4.42

  	
  %

  
	
  Glenn

  	
   

  	
  0.00

  	
  %

  
	
  Kern

  	
   

  	
  10.35

  	
  %

  
	
  Los Angeles

  	
   

  	
  8.14

  	
  %

  
	
  Madera

  	
   

  	
  4.25

  	
  %

  
	
  Marin

  	
   

  	
  3.58

  	
  %

  
	
  Mariposa

  	
   

  	
  4.69

  	
  %

  
	
  Napa

  	
   

  	
  0.00

  	
  %

  
	
  Orange

  	
   

  	
  8.80

  	
  %

  
	
  Placer

  	
   

  	
  5.26

  	
  %

  
	
  Plumas

  	
   

  	
  0.00

  	
  %

  
	
  Riverside

  	
   

  	
  11.51

  	
  %

  
	
  Sacramento

  	
   

  	
  4.67

  	
  %

  
	
  San Bernadino

  	
   

  	
  11.02

  	
  %

  
	
  San Diego

  	
   

  	
  9.89

  	
  %

  
	
  San Francisco

  	
   

  	
  4.62

  	
  %

  
	
  San Josquin

  	
   

  	
  5.51

  	
  %

  
	
  San Luis Obispo

  	
   

  	
  10.66

  	
  %

  
	
  San Mateo

  	
   

  	
  5.61

  	
  %

  
	
  Santa Barbara

  	
   

  	
  10.58

  	
  %

  
	
  Santa Clara

  	
   

  	
  5.24

  	
  %

  
	
  Sierra

  	
   

  	
  0.00

  	
  %

  
	
  Solano

  	
   

  	
  0.00

  	
  %

  
	
  Sonoma

  	
   

  	
  4.70

  	
  %

  
	
  Stanislaus

  	
   

  	
  5.55

  	
  %

  
	
  Sutter

  	
   

  	
  0.00

  	
  %

  
	
  Talare

  	
   

  	
  4.25

  	
  %

  
	
  Ventura

  	
   

  	
  11.25

  	
  %

  
	
  Yolo

  	
   

  	
  4.71

  	
  %

  
	
  Yuba

  	
   

  	
  0.00

  	
  %

  

 

73

 

ADDENDUM C.3

DIVISION
OF FINANCIAL RESPONSIBILITY

MATRIX OF
HMO AND PPG CAPITATED SERVICES

MEDICARE BENEFIT PROGRAM

 

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

 

MATRIX
EFFECTIVE 6/1/98

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  AIDS - Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AIDS - Drugs

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY
  IMMUNOTHERAPY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALLERGY TESTING

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ALPHA-FETOPROTEIN

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  AMBULANCE

  In Area (30 Mile
  Radius)

  Out-of-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  ANESTHESIOLOGY

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BIOFEEDBACK

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  BLOOD/BLOOD PRODUCTS

  Blood Bank

  Autologous/Homologous

  Storage and Collection of Blood

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMICAL DEPENDENCY

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHEMOTHERAPY

  •  Drugs, including Epogen,
  Nupogen and adjunctive therapies

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CHIROPRACTIC (Medicare Approved)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COLOSTOMY SUPPLIES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CONSULTATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  COSMETIC SURGERY
(Medically
  Necessary) Professional Component Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  CRITICAL CARE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DENTAL SERVICES

  (When a covered benefit)
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

 

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

 

74

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  DIAGNOSTIC TESTING - Outpatient Facility & Professional 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  DURABLE MEDICAL EQUIPMENT
• 
  Outpatient
• 
  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS – In-Area
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ADMISSIONS - Out-of -Area
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS - In-Area
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EMERGENCY ROOM VISITS – Out-of-Area
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  EXTENDED CARE/SKILLED NURSING FACILITY

  • 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  GROWTH HORMONES

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEARING AIDS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEMODIALYSIS

  • 
  Facility Component
• 
  Professional Component
• 
  Epogen, Nupogen

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HEPATITIS-B

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME HEALTH

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOME VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPICE
• 
  Facility Component
• 
  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  HOSPITAL BASED PHYSICIANS –

  Inpatient, Ambulatory Surgery or Emergency Room
• 
  Professional Component
•  Technical
  Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  IMMUNIZATIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INFANT APNEA MONITOR

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INJECTIBLES, SELF ADMINISTERED

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  INPATIENT VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

 

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

 

75

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  IVF & GIFT
Professional Component

  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  LITHOTRIPSY

  Professional Component

  Facility Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MATERNITY -
  Deliveries and Non-Deliveries

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MEDICAL ADMISSIONS

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH -
  Inpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  MENTAL HEALTH -
  Outpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  OFFICE VISITS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATIENT EDUCATION

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY -
  Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PATHOLOGY
  - Outpatient

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PERIODIC EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PRE ADMISSION -
  Outpatient

  Laboratory, X-ray

  (within 72 hrs. or related admission)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  PROSTHETIC/ORTHOTIC DEVICES
•  Outpatient 

  •  Surgically Implanted

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Inpatient, Ambulatory Surgery or Emergency Room

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  RADIOLOGY -
  Outpatient

  •  Professional Component

  •  Technical Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SPEECH AND HEARING
  EXAMS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

 

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

 

76

 

	
   

  	
   

  	
  PPG
  CAPITATED

  SERVICES

  	
   

  	
  HMO RISK

  SERVICES

  	
   

  	
  SHARED
  RISK/HOSPITAL

  CAPITATED SERVICES

  	
   

  
	
  SUPPLIES- Medical,
  Surgical, Office

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

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

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SUPPLIES, DIABETIC

  Chem. Strips, Lancet, Needles, Syringes

  Glucometer

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY -
  Inpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY
  - Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  SURGERY -
  Outpatient

  •  Facility Component

  •  Professional Component

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPEUTIC
  INJECTIONS

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  THERAPY: Physical, Occupational, Speech

  •  Inpatient

  •  Outpatient/Office

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANTS
  (Non-experimental)

  •  Facility Component

  •  Professional Component

  •  Organ Procurement

  •  Covered Immunosupressives

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  TRANSPLANT EVALUATIONS

  •  Professional

  •  Facility

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  - In-Area

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  URGENT CARE VISITS
  -Out-of-Area 

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  
	
  VISION CARE
•  Exams and Medically Necessary Care

  •  Implanted Lenses (Cataract Surgery)

  •  Lenses and Frames (Non-Cataract)

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  	
  ***

  	
   

  

 

 

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

 

77

 

ADDENDUM D

 

PREFERRED
PROVIDER ORGANIZATION (PPO)

EXCLUSIVE
PROVIDER ORGANIZATION (EPO)

POINT OF
SERVICE (POS)

 

BENEFIT
PROGRAMS

 

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

 

A.                                    BENEFIT PROGRAM REQUIREMENTS

 

PPG agrees:

 

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

 

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

 

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

 

a)                                      Provider or facility is non-participating;

 

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

 

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

 

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

 

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

 

78

 

B.                                    PPO AND EPO BENEFIT PROGRAMS

 

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

 

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

 

C.                                    POINT
OF SERVICE BENEFIT PROGRAMS

 

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

 

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

 

79

 

ADDENDUM E

 

FEE-FOR-SERVICE
COMPENSATION SCHEDULE

 

PPG or Member Physician shall be compensated for non-capitated
Contracted Services, less applicable Copayments, in an amount equal to the
lesser of: (a) ninety percent (90%) of the Medicare allowable charges based on
the Medicare Resource Based Relative Value Scale (RBRVS) unit values and HCFA
Geographical Practice Cost Indices as published in the most current published
edition of the Federal Register; (b) seventy-five percent (75%) of PPG’s
allowable billed charges; or (c) such other fee schedules as may be established
or adopted from time to time by FHS.

 

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

 

Anesthesiology Services:

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

 

Assistant Surgeons:

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

 

Total Obstetrical Care:   (for HMO Benefit Programs)

 

Total OB care, vaginal delivery                                   *** global rate

Total OB care, Cesarean delivery                        *** global rate

 

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

Total OB care, vaginal delivery                                  *** global rate

Total OB care, Cesarean delivery                        *** global rate

 

Services included in global reimbursement for total
OB care:

office visits (sick care as well as routine)

consultations including initial OB consultation

emergency department visits

therapeutic injections

amniocentesis

fetal contraction stress test

fetal non-stress test

fetal monitoring, including initiation or supervision

version

delivery of placenta

ultrasound

laboratory tests

venipuncture

specimen collection and laboratory supplies

educational materials/nutritional counseling

OB standby

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

 

80

 

Antepartum
care only:

 

	
  First
  trimester only

  	
   

  	
  ***

  
	
  Second
  trimester only

  	
   

  	
  ***

  
	
  First
  and second trimester only

  	
   

  	
  ***

  
	
  Third
  trimester excluding delivery

  	
   

  	
  ***

  
	
  Third
  trimester including delivery

  	
   

  	
  ***

  

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

81

 

ADDENDUM F

 

MEDI-CAL
BENEFIT PROGRAM

 

 

(NOT
APPLICABLE)

 

82

 

ADDENDUM F.1

 

 

FEE-FOR-SERVICE
COMPENSATION SCHEDULE

 

ASSIGNED AND
UNASSIGNED MEDI-CAL HMO MEMBERS

 

 

(NOT
APPLICABLE)

 

83

 

ADDENDUM F.2

 

CAPITATION
COMPENSATION SCHEDULE

 

 

(NOT
APPLICABLE)

 

84

 

ADDENDUM F.3

 

SHARED RISK
PROGRAM DISTRIBUTION MATRIX

 

 

(NOT
APPLICABLE)

 

85

 

ADDENDUM F.4

 

DIVISION OF
FINANCIAL RESPONSIBILITY

MATRIX OF
FHS AND PPG RISK SERVICES

MEDI-CAL
BENEFIT PROGRAM

 

 

(NOT
APPLICABLE)

 

86

 

ADDENDUM F.5

 

DISCLOSURE
FORM

 

 

(NOT
APPLICABLE)

 

87

 

ADDENDUM G

 

CHAMPUS/TRICARE
AND OTHER GOVERNMENT BENEFIT PROGRAMS

 

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

 

A.                                    CHAMPUS/TRICARE DEFINITIONS,
PROGRAMS AND REGULATIONS

 

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

 

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

 

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

 

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

 

B.                                    CHAMPUS/TRICARE PROGRAMS AND REGULATIONS

 

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

 

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

 

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

 

88

 

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

 

D.                                    PROVIDER OBLIGATIONS

 

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

 

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

 

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

 

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

 

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

 

89

 

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

 

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

 

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

 

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

 

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

 

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

 

E.                                  CHAMPUS PRIME AND EXTRA
BENEFIT PROGRAMS AND COMPENSATION

 

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

 

90

 

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

 

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

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

91

 

ADDENDUM H

 

OCCUPATIONALLY
ILL/INJURED OR WORKERS’ COMPENSATION BENEFIT

PROGRAMS

 

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

 

A.                                    COMPENSATION.

 

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

 

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

 

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

 

B.                                 OTHER DUTIES

 

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

 

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

 

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

 

92

 

ADDENDUM H.1

 

OCCUPATIONALLY
ILL/INJURED OR WORKERS’ COMPENSATION RATE SCHEDULE

 

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

 

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

 

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

 

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

 

CONFIDENTIAL,
PROPRIETARY AND TRADE SECRET

 

93Exhibit 10.146

 

AMENDMENT

to the

PARTICIPATING PROVIDER SERVICES AGREEMENT

between

FOUNDATION HEALTH SYSTEMS AFFILIATES

and

A. V. MEDICAL GROUP

 

The Provider Services Agreement dated June 1,
1998 between A.V. Medical Group (“PPG”) and Foundation Health Systems
Affiliate(s) (“FHS”) is hereby amended effective July 1, 1999.

 

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

 

1.                                       Addendum C, the Medicare Health Maintenance
Organization (HMO) and Medicare Point of Service (POS) Benefit Programs, shall be
deleted in its entirety.

 

2.                                       Any references in the Agreement to the
Medicare Health Maintenance Organization (HMO) and Medicare Point of Service
(POS) Benefit Programs shall be deleted in their entirety.

 

3.                                       HMO shall perform the final settlement which shall
include any settlements for amounts under Addendum C, in accordance with
Section 4.3 (c) Offsetting of the Agreement.

 

4.                                       PPG agrees to participate in Health Net’s
Medicare Select Benefit Programs in accordance with the Operations Manual and
as set forth below:

 

MEDICARE SELECT BENEFIT PROGRAMS

 

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 Health Net and net 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
Health Net in accordance with the terms of the Agreement.

 

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

 

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

 

	
  A.V. Medical Group

  	
   

  	
  Foundation Health Systems Affiliates

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  /s/ Peter G.
  Goll

  	
   

  	
  /s/ David J.
  Fredman

  	
   

  
	
  Signature

  	
   

  	
  Signature

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Peter G. Goll

  	
   

  	
  DAVID J.
  FREDMAN

  	
   

  
	
  Print Name

  	
   

  	
  Print Name

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Senior Vice
  - President

  	
   

  	
   

  	
   

  
	
  Title

  	
   

  	
  Title

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  4-19-99

  	
   

  	
  19 May 1999

  	
   

  
	
  Date

  	
   

  	
  Date

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