"ALL SECTIONS MARKED WITH TWO ASTERISKS ("**") REFLECT PORTIONS WHICH HAVE
BEEN REDACTED AND FILED SEPARATELY WITH THE SECURITIES AND EXCHANGE
COMMISSION BY PROSPECT MEDICAL HOLDINGS, INC. AS PART OF A REQUEST FOR
CONFIDENTIAL TREATMENT."
AMENDMENT TO
PACIFICARE IPA MEDICARE SHARED RISK SERVICES
AGREEMENT
The undersigned parties to the PacifiCare IPA Medicare Shared Risk Services
Agreement between PacifiCare of California ("PacifiCare") and Santa Xxx
Xxxxxx Physicians Group ("IPA") do hereby amend said Agreement as follows:
1. Paragraph 1.32 is added to read as follows:
1.32 RETIREE SUBSCRIBER - is a Subscriber enrolled in the Secure
Horizons Retiree Health Plan, who meets all the eligibility requirements for
membership in such plan and for whom all applicable premiums have been paid
and received by PacifiCare.
2. Paragraph 1.25 is amended in full to read as follows:
1.25 SECURE HORIZONS MEDICAL AND HOSPITAL PLAN - is the prepaid
health services plan offered by PacifiCare as described in the Secure
Horizons Medical and Hospital Subscriber Agreement, and attachments,
addendums and amendments thereto, a copy of which is attached hereto as
Attachment C, incorporated herein by reference. For purposes of this
Agreement, the Secure Horizons Medical and Hospital Plan shall include the
Secure Horizons Retiree Health Plan.
3. Paragraph 1.33 is added to read as follows:
1.33 SECURE HORIZONS RETIREE HEALTH PLAN - is the health benefits
plan available for Retiree Subscribers. The benefits of the Secure Horizons
Retiree Health Plan are attached hereto as Attachment C and incorporated
herein by reference.
4. Paragraph 1.27 is amended in full to read as follows:
1.27 SUBSCRIBER - is an individual who is enrolled in the
Secure Horizons Medical and Hospital Plan, who meets all the eligibility
requirements for membership in such plan and for whom all applicable Member
Premiums have been paid and received by PacifiCare. For purposes of this
Agreement, Subscribers shall include Retiree Subscribers.
5. Paragraph 5.01 is amended in full to read as follows:
5.01 CAPITATION PAYMENTS - PacifiCare shall make monthly Capitation
Payments to IPA based on the number of Subscribers eligible to receive
Medical Services from IPA.
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A. MONTHLY HCFA PAYMENT
[ ** ] of the Monthly HCFA Payment and LESS [ ** ] of the
Monthly HCFA Payment as payment for the premium for Individual Stop Loss
coverage specified in Attachment E of this Agreement less [ ** ] for the
Pharmacy Control program as specified in Attachment E. The payment per
Subscriber per month by PacifiCare to IPA shall be increased or decreased to
reflect increases of decreases made by HCFA in the Monthly HCFA Payment.
PacifiCare shall make monthly retroactive adjustments to reflect adjustments
made by HCFA, if any.
B. RETIREE SUBSCRIBER COMPENSATION
IPA shall receive an additional per month payment from PacifiCare
for certain Retiree Subscribers whose benefit plans permit a lesser
Copayment. This additional amount shall be determined by PacifiCare based on
the number of Retiree Subscribers enrolled each month in each of the
Copayment categories set forth below.
For Retiree Subscribers residing in Los Angeles, Orange, San
Bernardino, or Riverside Counties (standard Copayment = [ ** ])
Copayment Paid Monthly Payment
By Retiree Subscriber Per Retiree Subscriber
--------------------- ----------------------
$ 0 $ [ ** ]
$ 1 $ [ ** ]
$ 2 $ [ ** ]
$ 3 $ [ ** ]
$ 4 $ [ ** ]
$ 5 $ [ ** ]
For Retiree Subscribers residing in San Diego and Ventura
Counties (standard Copayment = $5.00):
Copayment Paid Monthly Payment
By Retiree Subscriber Per Retiree Subscriber
--------------------- ----------------------
$ 0 $ [ ** ]
$ 1 $ [ ** ]
$ 2 $ [ ** ]
$ 3 $ [ ** ]
$ 4 $ [ ** ]
$ 5 $ [ ** ]
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C. MAMMOGRAPHY
IPA shall receive [ ** ] for each screening and diagnostic
mammography study performed above the 1987 PacifiCare-wide baseline, specific
to the Secure Horizons program, for such studies. (This baseline equals 267
studies per 1,000 adult females.) The amount due to IPA shall be calculated
based upon utilization data submitted by IPA and shall be paid within one
hundred and fifty (150) days of the end of the current calendar year.
D. INSTITUTION-TO-INSTITUTION TRANSFERS
IPA shall xxxx PacifiCare and PacifiCare shall pay for Medical
Services Provided to Subscribers who enroll with IPA through a transfer from
another PacifiCare contracted-IPA and who are in a skilled nursing facility,
acute care hospital, or are receiving any other type of acute institutional
care at time of enrollment with IPA. Medical Services provided to such
Subscribers shall be reimbursed under this special program until the
Subscriber is discharged from the institutions noted above. If Subscriber is
discharged from such institution to home with home health services being
provided in-lieu of hospitalization, such home health services will be
covered under this program as well. Reimbursement to IPA for these Medical
Services shall be at the Cost-of-Care rates included in Attachment F. See
Policy and Procedure Manual for billing instructions.
6. ATTACHMENT A "HOSPITAL SERVICES" is amended in full to read as follows:
See Exhibit 1, attached hereto and incorporated herein by this reference.
7. ATTACHMENT B "MEDICAL SERVICES" is amended in full to read as follows:
See Exhibit 2, attached hereto and incorporated herein by this reference.
8. ATTACHMENT C "SECURE HORIZONS MEDICAL AND HOSPITAL SUBSCRIBER AGREEMENT"
is amended in full to read as follows:
See Exhibit 3, attached hereto and incorporated herein by this reference.
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The effective date of this Amendment is January 1, 1990.
By signing below, both parties hereto have executed and agreed to this
Amendment.
PACIFICARE OF CALIFORNIA IPA Santa Xxx- Tustin
Physicians Group, Inc.
By: /s/ Xxxxxxx Xxxxxxx By: /s/ Xxxxxx X. Xxxxx
--------------------------- ---------------------------
Xxxxxxx Xxxxxxx, President Title: President
-------------------------
Date: 2-12-90 Date: 3/10/90
------------------------- -------------------------
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Exhibit 1
ATTACHMENT A
HOSPITAL SERVICES
Hospital Services are authorized by IPA, are initially paid by PacifiCare
and, except as otherwise indicated, are the financial responsibility of
PacifiCare and IPA. A summary of most Hospital Services includes the
following:
1. INPATIENT HOSPITAL CARE - Medically Necessary inpatient hospital
care, as defined by Medicare, but limited to a total of one hundred
fifty (150) days per Subscriber per Year. Unlimited days of
inpatient hospital care shall be provided to Subscribers, but
PacifiCare shall be financially responsible for days in excess of
one hundred fifty (150) days. Subscriber shall be assigned
semi-private units, unless medical necessity dictates private
accommodations. Where the Subscriber requests private accommodations,
not required for medical purposes, the incremental difference in
fee-for-service rates shall be the responsibility of the Subscriber.
A summary of inpatient care includes:
a. Medical/Surgical Care, Intensive Care, Cardiac Care and other
special care units (including Hospital Services associated with
non-experimental transplants as defined by Medicare);
b. Inpatient psychiatric;
c. Nursing Services, meals, drugs, medications (excluding
take-home medications), blood transfusions;
d. Medical and Surgical supplies and appliances;
e. Inpatient rehabilitation services, such as: inpatient physical,
occupational and speech therapy;
f. Inpatient alcohol and drug treatment and rehabilitation.
2. SKILLED NURSING - Medically Necessary Skilled Nursing Facility care,
as defined by Medicare, but limited to one hundred (100) days per Subscriber
per calendar year and also limited to Subscriber admissions immediately
following three (3) or more days of hospitalization. Subscribers are entitled
to receive one hundred fifty (150) days of Skilled Nursing Care per calendar
year, but PacifiCare shall be financially responsible for days one hundred
one (101) through one hundred fifty (150). In addition, PacifiCare shall be
financially responsible for skilled nursing facility care for Subscribers who
are admitted from home, from a hospital emergency room or from the Hospital
if Subscriber was hospitalized for less than three (3) days. Refer to Policy
and Procedures Manual for admit notification procedures. Patients shall be
assigned semi-private units, unless medical necessity dictates private
accommodations. Where the Subscriber requests private accommodations, not
required for medical purposes, the incremental difference in the fee-for-
service rates shall be the
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responsibility of the Subscriber. Skilled nursing facilities must be
Medicare licensed and approved.
3. HOSPITAL BASED PHYSICIAN SERVICE - All hospital based physician
services where the physician provides the professional component of an
inpatient hospital based service, the hospital outpatient surgery
center service, or a free-standing surgery center service. The charges
of an anesthesiologist are not included as a Hospital Service. (See
paragraph 8 below in this Attachment A1).
4. TRANSPORTATION EXPENSES - Medicare approved ambulance services
provided within the IPA Service Area for Subscribers. When a transfer
of Subscriber from one facility to another is authorized by IPA or
PacifiCare, the cost of such transfer shall be a Hospital service.
The method of transfer shall be determined by IPA, but IPA shall
coordinate all Subscriber transfers to or from Hospital with
designated Hospital personnel. Also included are paramedic services
in emergency cases in the IPA Service Area.
5. EMERGENCY SERVICES IN THE IPA SERVICE AREA - IPA Service Area
Emergency Services include emergency room charges and associated
emergency room physician and ancillary charges, inpatient medical
and other Medical Services which may not be delayed until facilities
or physicians of the Hospital or IPA (or alternatives authorized by
IPA) can be used without possible serious effects to the health of
the Subscriber. Such services must be Medically Necessary Emergency
Services.
6. HOME HEALTH CARE - As determined to be Medically Necessary, as
defined by Medicare and provided in lieu of hospitalization, as
mutually agreed to by IPA, Hospital and PacifiCare, including any
required DME and IV Therapy Services.
7. HOSPICE CARE - Should be coordinated with Medicare for special
reimbursement provisions.
8. OUTPATIENT SURGERY - Facility, supply charges and the professional
component of a hospital based physician service (as noted in
paragraph 3 above) for outpatient surgery done either at Hospital
or a free-standing surgery center.
9. END STAGE RENAL DISEASE - Facility and professional charges for
inpatient and outpatient dialysis services for Subscribers who are
medically determined to have End Stage Renal Disease after enrollment
in one of PacifiCare's health plans.
10. OTHER HOSPITAL SERVICES
a. Devices surgically implanted during a hospital confinement or
during an outpatient surgery performed at the Hospital outpatient
surgery center or a free-standing surgery center.
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b. Treatment programs for outpatient substance abuse as defined by
Medicare.
c. Appealed Services - Hospital Services denied by IPA and PacifiCare
which are found on appeal or arbitration through the Subscriber
grievance resolution process to be Hospital Services which the
Subscriber was entitled to have furnished under the PacifiCare
Secure Horizons health care delivery system.
d. Chemotherapy Drugs (inpatient and outpatient).
11. HOSPITAL SERVICES EXCLUDE THE FOLLOWING:
a. Durable Medical Equipment, except as provided in paragraphs 6
and 10(a) above.
b. Medical Services in the IPA Service Area as defined by Attachment
A2 hereto.
c. Outpatient prescription drugs, including immunosuppressive drugs.
d. All out-of-IPA Service Area expenses, except those elective
referrals as authorized by IPA. PacifiCare, in conjunction with
IPA, shall make all decisions regarding the duration of a
Subscriber's care at the out-of-IPA Service Area facility and
transfer of the Subscriber to an IPA Service Area facility.
e. Vision materials (lenses and frames) except for those surgically
implanted during cataract surgery.
f. Anesthesiology services (inpatient and outpatient).
g. Experimental procedures, including any type of procedure not
generally recognized as of value by the medical community and its
societies, as determined by PacifiCare and IPA, in conformance
with state and federal law.
h. Cosmetic Surgery, except when performed to correct or repair the
physical functioning of a body part as a result of a functional
disorder or accidental injury.
i. Inpatient hospital care in excess of one hundred fifty (150) days
per Subscriber per Year, except as provided in Paragraph 1 of this
Attachment A1.
j. Skilled nursing care in excess of one hundred (100) days per
Subscriber per Year, except as provided in Paragraph 2 of this
Attachment A1.
k. Respite Care
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EXHIBIT 2
ATTACHMENT B
MEDICAL SERVICES
I. Medical Services, other than Hospital Services, provided in the IPA
Service Area are the financial responsibility of IPA. A summary of most
Medical Services includes the following:
1. PHYSICIAN SERVICES - Subscribers shall be entitled to Medically
Necessary covered inpatient and outpatient physician services
included in the PacifiCare's Secure Horizons Medical and Hospital
Plan. A summary of some physician services includes the following:
a. IPA Service Area inpatient services (including anesthesiology
services and physician services associated with non-
experimental transplants, as defined by Medicare) and
outpatient physician care.
b. Professional component of inpatient mental health.
c. Outside referrals to consultants including Emergency Room
consultants (not including emergency room charges).
d. Out-of-IPA Service Area physician services when such
Medical Services are rendered on an elective basis and upon
approval of IPA.
2. OUTPATIENT SERVICES - Such services include, among others:
a. Outpatient pathology and radiology.
b. Outpatient mental health (professional services only).
c. Short term, Medically Necessary rehabilitation (speech,
physical and occupational) therapy.
d. Health education and social services.
e. Immunizations when determined Medically Necessary by an IPA
Member Physician as recommended by the California Department
of Health Services Adult Immunization Recommendations.
f. Periodic health evaluations.
g. Hearing screening, including audiogram.
h. Allergy testing and treatment, including allergy serum.
i. Home health care, except when provided in lieu of
hospitalization.
j. Lenses and frames required after cataract surgery, except
lenses surgically implanted during an outpatient surgery
performed at Hospital or at a free-standing surgery center.
k. Anesthesiology services.
l. Mammography screening, as defined by state and federal law.
3. DURABLE MEDICAL EQUIPMENT, PROSTHETIC DEVICES AND MEDICAL SUPPLIES
a. Durable Medical Equipment ("DME") as defined by Medicare. IPA
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agrees to provide such devices and aids on an outpatient
basis, determined Medically Necessary.
b. Prosthetic devices, as defined by Medicare, except devices
surgically implanted during a Hospital confinement or
outpatient surgery performed at Hospital or free-standing
surgery center.
c. Medical Supplies - Supplies used in connection with
treatment or to aid in the recovery of a medical condition
when considered a covered expense by Medicare.
4. OTHER SERVICES - Medical Services denied by the Participating
Medical Group and PacifiCare which are found on appeal or
arbitration through the Subscriber grievance resolution process
to be Medical Services which Subscriber was entitled to have
furnished through the Secure Horizons Medical and Hospital Plan.
II. Medical Services exclude the following:
a. Professional components on all hospital based physicians for
inpatient procedures and outpatient surgeries, except anesthesiology
as noted in paragraphs I(1)(a) and I(2)(k) above.
b. Outpatient mental health visits in excess of twenty (20) visits per
Subscriber Year.
c. Outpatient prescription drugs, including immunosuppressive drugs.
d. Chemotherapy drugs.
e. Out-of-IPA Service Area expenses, except pursuant to paragraph
I(1)(d) above. PacifiCare, in consultation with IPA, shall make all
decisions regarding the duration of a Subscriber's care at the
out-of-IPA Service Area facility and transfer of the Subscriber to
an IPA Service Area facility consistent with state and federal law.
f. Vision materials (lenses and frames), except following cataract
surgery.
g. Immunizations for foreign travel and unexpected mass immunizations.
h. Experimental procedures, including any type of procedure not generally
recognized as of value by the medical community and its societies,
as determined by PacifiCare in accordance with state and federal law
and in connection with IPA.
i. Cosmetic Surgery, except when performed to correct or repair the
physical functioning of a body part as a result of a functional
disorder or an accidental injury.
j. Respite Care.
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EXHIBIT 3
ATTACHMENT C
SECURE HORIZONS MEDICAL AND HOSPITAL SUBSCRIBER AGREEMENT
Secure Horizons Medical and Hospital Subscriber Agreement is available upon
request. A summary of the Schedule of Benefits is attached.
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