Common use of ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS Clause in Contracts

ADDITIONAL INFORMATION ABOUT HOW WE REIMBURSE PROVIDERS. Our HMO reimbursement programs for health care Providers are intended to encourage the provision of quality, cost-effective care for our Members. Set forth below is a general description of our HMO reimbursement programs. Please note that these programs may change from time to time, and the arrangements with particular providers may be modified as new contracts are negotiated. If after reading this material you have any questions about how your health care provider is compensated, please contact Keystone at the telephone number provided on your ID card. PROFESSIONAL PROVIDERS Primary Care Physicians Most Primary Care Providers (PCPs) are paid in advance for their services, receiving a set dollar amount per Member, per month for each Member selecting that PCP. This is called a capitation payment and it covers most of the care delivered by the PCP. Covered Services not included under capitation are paid fee-for-service according to the current HMO fee schedule. Capitated PCPs, are also eligible to receive additional payments for meeting certain medical quality, patient service and other performance standards. Referred Specialists Most Referred Specialists are paid on a fee-for-service basis, meaning that payment is made according to our current HMO fee schedule for the specific medical services that the Referred Specialist performs. Obstetricians are paid global fees that cover most of their professional services for prenatal care and for delivery. PCP referrals to Referred Specialists are generally valid for ninety (90) days and apply to all Covered Services provided by a Referred Specialist in his/her office. Accountable Care Program Arrangements The HMO and some primary care physician or specialty physician groups participate in an Accountable Care Program arrangement (ACP). The ACP is a collaboration between a physician group and the HMO designed to incent high quality patient care, increased physician patient satisfaction, and more efficient and cost effective services. Under an ACP arrangement, the HMO may pay the physicians an incentive payment to focus on spending more time with their patients or on coordinating treatment plans for their more chronically ill patients, along with support services provided by the HMO to the physician. Although a Member whose physician participates in an ACP arrangement experiences no change in their benefit levels, the expectation is that such Members’ physicians coordinate their referrals and management of their patients in a high-quality, cost efficient manner.