EXHIBIT 10.1
STATE OF CALIFORNIA
STANDARD AGREEMENT -- APPROVED BY THE CONTRACT NUMBER AM. NO.
STD.2(REV.5-91) ATTORNEY GENERAL 95-23637
TAXPAYER'S FEDERAL
EMPLOYER IDENTIFICATION NO.
00-0000000
THIS AGREEMENT, made and entered into this 2nd day of April, 1996 in the State
of California, by and between State of California, through its duly elected
or appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
Xxxxxx Medical Centers, hereafter called the Contract:
WTTNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter express does
hereby agree to furnish to the State services and materials as follows: (Set
forth service to be rendered by Contractor, amount to be paid Contract time for
performance or completion, and attach plans and specifications, if any.)
ARTICLE 1 - PREAMBLE
This Contract is entered into under the provisions of Section 14087.3,
Welfare and Institutions (W&I) Code.
WHERE AS, it is the best interest of all parties to enter into this
Contract,
NOW THEREFORE, this contract is amended as follows:
[SEAL]
CONTINUED ON 125 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
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STATE OF CALIFORNIA CONTRACTOR
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AGENCY CONTRACTOR (If other than an individual, state whether a corporation, partnership, etc.)
Department of Health Service Xxxxxx Medical Centers
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BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ /s/
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PRINTED NAME OF PERSON SIGNING PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx Xxxx Xxxxxx, X.X. - Chief Administrative Officer
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TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
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AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE Department of General
DOCUMENT Section 14157 W&I Code Care Deposit Services Use Only
$ 32,080,630 ---------------------------------------------------------------------- Exempt From PCC per
------------------------------ (OPTIONAL USE) W&I Code 14087.4
PRIOR AMOUNT ENCUMBERED FOR Federal Cat. 93778 4260-101-001 & 890 50% Fed & 50% State
THIS CONTRACT ------------------------------------------------------------
$ -0- ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 303 1995 1995-96
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------
$ 32,080,630 OBJECT OF EXPENDITURE (CODE AND TITLE)
N/A
----------------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
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SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ 4/2/96
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[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91) (REVERSE)
1. The Contractor agrees to indemnify, defend and save harmless the State,
its officers, agents and employees from any and all claims and losses
accruing or resulting to any and all contractors, subcontracters
materialmen, laborers and any other person, firm or corporation
furnishing or supplying work services, materials or supplies in
connection with the performance of this contract, and from any and all
claims losses accruing or resulting to any person, firm or corporation
who may be injured or damaged by Contractor in the performance of this
contract
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and
not as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment
of any consideration to Contractor should Contractor fail to perform
the covenants herein contained at the time and in the manner herein
provided. In the event of such termination the State may proceed with
the work in any manner deemed proper by the State. The cost to the
State shall be deducted from any sum due the Contractor under this
agreement, and the balance, if any, shall be paid the Contractor upon
demand.
4. Without the written consent of the State, this agreement is not
assignable by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid
unless made in writing and signed the parties hereto, and no oral
understanding or agreement not incorporated herein, shall be binding on
any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in
compensation for all of Contractor's expenses incurred in the
performance hereof, including travel and per diem, unless otherwise
expressly so provided.
Xxxxxx Medical Centers 95-23637
Article VI
TABLE OF CONTENTS
ARTICLE I - PREAMBLE Pg 1
ARTICLE II - DEFINITIONS Pg 2
ARTICLE III GENERAL TERMS AND CONDITIONS Pg 14
3.1 Delegation of Authority Pg 14
3.2 Governing Authorities Pg 14
3.3 Authority of the State Pg 15
3.4 Fulfillment of Obligations Pg 15
3.5 Compliance with Protocols Pg 16
3.6 Equal Opportunity Employer Pg 16
3.7 Nondiscrimination Clause Compliance Pg.16
3.8 Discrimination Prohibition Pg 17
3.9 Discrimination Complaints Pg 18
3.10 Membership Diversity Pg 18
3.11 Inspection Rights Pg 18
3.12 Notices Pg 19
3.13 Contractor's National Labor Relations Board Declaration Pg 19
3.14 Term Pg 19
3.15 Contract Extension Pg 20
3.16 Turnover and Phaseout Requirements Pg 20
3.16.1 Objectives for Turnover and Phaseout Period Pg 20
3.16.2 Turnover Requirements Pg 21
3.16.3 Phaseout Requirements Pg 21
3.16.4 Turnover and Phaseout Period Pg 21
3.17 Termination Pg 21
3.17.1 Termination - State or Director Pg 21
3.17.2 Termination - Contractor Pg 22
3.17.3 Mandatory Termination Pg 22
3.17.4 Termination of Obligations Pg 23
3.17.5 Notice to Members of Transfer of Care Pg 23
3.18 Sanctions pg 23
3.19 Liquidated Damages Provisions Pg 23
3.19.1 General Pg 23
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3.19.2 Liquidated Damages for Violation of Contract Terms
Regarding the Implementation Period Pg 25
3.19.3 Liquidated Damages for Violation of Contract Terms or
Regulations Regarding the Operations Period Pg 25
3.19.4 Annual Medical Reviews Pg 26
3.19.5 Conditions for Termination of Liquidated Damages Pg 26
3.19.6 Severability of Individual Liquidated Damages Clauses Pg 26
3.20 Assignments Pg 26
3.21 Disputes and Appeals Pg 27
3.21.1 Disputes Resolution by Negotiation Pg 27
3.21.2 Notification of Dispute Pg 27
3.21.3 Contracting Officers Decision Pg 28
3.21.4 Contractor Duty to Perform Pg 29
3.21.5 Waiver of Claims Pg 29
3.22 Enrollment Pg 29
3.22.1 Enrollment - General Pg 30
3.22.2 Enrollment Totals Pg 30
3.22.3 Coverage Pg 30
3.22.4 Enrollment Restriction Pg 30
3.22.5 Disenrollment Pg 30
3.23 Standards Pg 31
3.24 Pharmaceutical Services and Prescribed Drugs Pg 32
3.25 Facilities Pg 32
3.26 Laboratory Certification Pg 32
3.27 Subcontracts Pg 33
3.27.1 Xxxx-Xxxxx and Regulations Pg 33
3.27.2 Subcontract Requirements Pg 33
3.27.3 Departmental Approval - Non-Federally Qualified HMOs Pg 35
3.27.4 Departmental Approval - Federally Qualified HMOs Pg 35
3.27.5 Compensation Pg 35
3.27.6 Federally Qualified Health Centers Pg 35
3.27.7 Public Records Pg 36
3.27.8 Disclosures Pg 36
3.27.9 Payment Pg 37
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3.28 Confidentiality of Data Pg 37
3.28.1 Confidentiality of Information Pg 37
3.28.2 Contractor's Duties to Maintain Confidentiality Pg 37
3.29 Key Personnel (Disclosure Form) Pg 38
3.30 Conflict of Interest - Current and Former State Employees Pg 38
3.31 Records Keeping, Audit/Inspection of Records Pg 38
3.31.1 Books and Records Pg 39
3.31.2 Records Retention Pg 39
3.32 Amendment of Contract Pg 39
3.33 Contractor Certifications Pg 39
3.34 Change Requirements Pg 40
3.34.1 General Provisions Pg 40
3.34.2 Contractor's Obligation to Implement Pg 40
3.35 Minority/Women//Disabled Veteran Business Enterprises
(M/W/DVBE) Pg 40
3.36 Drug Free Workplace Act of 1990 Pg 41
3.37 Indemnification Pg 41
3.37.1 Indemnification by Contractor Pg 41
3.38 Americans with Disabilities Act of 1990 Requirements Pg 41
3.39 Newborn Child Coverage Pg 41
3.40 Recovery from Other Sources or Providers Pg 41
3.41 Third-Party Tort Liability Pg 42
3.42 Obtaining DHS Approval Pg 43
3.43 Pilot Projects Pg 44
ARTICLE IV DUTIES OF THE STATE Pg 45
4.1 Payment for Services Pg 45
4.2 Medical Reviews Pg 45
4.3 Facility Inspections Pg 45
4.4 Enrollment Processing Pg 45
4.5 Disenrollment Processing Pg 46
4.6 Testing and Certification of Enrollment Representatives Pg 46
4.7 Approval Process Pg 46
4.8 Program Information Pg 46
4.9 Sanctions Pg 46
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4.10 Catastrophic Coverage Limitation Pg 46
4.11 Risk Limitation Pg 47
4.12 Notice of Termination of Contract Pg 47
4.13 Access Requirements and State's Right to Monitor Pg 47
ARTICLE V PAYMENT PROVISIONS Pg 48
5.0 Payment Provisions Pg 48
5.1 Contractor Risk in Providing Services Pg 48
5.2 Amounts Payable Pg 48
5.3 Capitation Rates Pg 49
5.4 Capitation Rates Constitute Payment in Full Pg 49
5.5 Determination of Rates Pg 50
5.6 Redetermination of Rates - Obligation Changes Pg 51
5.7 Reinsurance Pg 51
5.8 Catastrophic Coverage Limitation Pg 53
5.9 Financial Security Pg 53
5.10 Limitation to Federal Financial Participation Pg 53
5.11 Recovery of Capitation Payments Pg 54
ARTICLE VI SCOPE OF WORK Pg 55
6.0 Organization Pg 55
6.1 Legal Capacity Pg 55
6.2 Administration/Staffing Pg 55
6.2.1 Contract Performance Pg 55
6.2.2 Medical Director Pg 55
6.2.3 Medical Decisions Pg 56
6.2.4 Medical Director Changes Pg 56
6.2.5 Administrative Duties/Responsibilities Pg 56
6.2.6 Member Representation Pg 57
6.3 Financial Information Pg 57
6.3.1 Financial Viability/Standards Compliance Pg 57
6.3.2 Financial Audit/Reports Pg 57
6.3.3 Monthly Financial Statements Pg 59
6.3.4 Compliance with Audit Requirements Pg 59
6.3.5 Submittal of Financial Information Pg 59
6.4 Management Information System Pg 59
6.4.1 Management Information System (MIS) Capability Pg 59
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6.4.2 Encounter Data Submittal Pg 60
6.4.3 Access to MIS Pg 60
6.4.4 Late Reports Pg 60
6.4.5 Inaccurate/Insufficient Reports Pg 60
6.5 Quality Improvement System Pg 60
6.5.1 General Requirement Pg 60
6.5.1.1 Written Description Pg 61
6.5.2 QIP Administrative Services Pg 62
6.5.2.1 Accountability Pg 62
6.5.2.2 Governing Body Pg 62
6.5.2.3 Quality Improvement Committee Pg 63
6.5.2.4 Medical Director Pg 63
6.5.2.5 Provider Participation Pg 63
6.5.2.6 Delegation of QIP Activities Pg 63
6.5.2.7 Coordination With Other Management Activities Pg 64
6.5.3 Systematic Process of Quality Improvement Pg 64
6.5.3.1 General Requirement Pg 64
6.5.3.2 Quality of Care Studies Pg 65
6.5.3.3 Standards and Guidelines Pg 65
6.5.3.4 Quality Indicators Pg 66
6.5.3.5 Reports Pg 67
6.5.4 Credentialing and Recredentialing Pg 68
6.5.4.1 General Requirements Pg 68
6.5.4.2 Credentialing Pg 68
6.5.4.3 Recredentialing Pg 69
6.5.4.4 Delegated Credentialing Pg 69
6.5.4.5 Disciplinary Actions Pg 69
6.5.5 Facility Review Pg 69
6.5.5.1 General Requirement Pg 69
6.5.5.2 Facility Review Procedures Pg 70
6.5.5.3 Number of Sites to be Reviewed Prior to Operation Pg 71
6.5.5.4 Number of Sites to be Reviewed After Operations Begin Pg 71
6.5.5.5 DHS Facility Inspections Pg 71
6.5.5.6 Corrective Actions Pg 71
6.5.5.7 Continuing Oversight Pg 71
6.5.6 Members Rights and Responsibilities Pg 72
6.5.6.1 General Requirement Pg 72
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6.5.6.2 Written Policy: Member's Rights Pg 72
6.5.6.3 Written Policy: Member's Responsibilities Pg 72
6.5.6.4 Member's Grievance System Pg 72
6.5.6.5 Member's Right to Confidentiality Pg 73
6.5.6.6 Minor's Rights and Services Pg 73
6.5.6.7 Member Satisfaction Surveys Pg 73
6.5.7 Availability and Accessibility Pg 74
6.5.7.1 General Requirement Pg 74
6.5.7.2 Emergency Care Pg 74
6.5.7.3 Urgent Care Pg 74
6.5.7.4 First Prenatal Visit Pg 74
6.5.7.5 Waiting Times Pg 74
6.5.7.6 Telephone Procedures Pg 74
6.5.7.7 After Hours Calls Pg 74
6.5.7.8 Sensitive Services Pg 75
6.5.7.9 Access for Disabled Members Pg 75
6.5.7.10 Unusual Specialty Services Pg 75
6.5.8 Medical Records Pg 75
6.5.8.1 General Requirement Pg 75
6.5.8.2 Medical Records Procedures Pg 75
6.5.8.3 On-Site Medical Records Pg 76
6.5.8.4 Member Medical Records Pg 76
6.5.8.5 Medical Records Review Pg 77
6.5.9 Utilization Management Pg 77
6.5.9.1 General Requirement Pg 77
6.5.9.2 Under and Over-Utilization Pg 77
6.5.9.3 Pre-Authorization/Review Procedures Pg 78
6.5.9.4 Exceptions to Prior Authorization Requirement Pg 78
6.5.9.5 Delegating UM Activities Pg 78
6.5.10 Continuity of Care and Case Management Pg 78
6.5.10.1 Medical Case Management Pg 78
6.5.10.2 Initial Health Assessment Pg 78
6.5.10.3 Referrals and Follow-Up Care Pg 79
6.5.10.4 Coordination of Care Pg 79
6.5.10.5 Missed/Broken Appointments Pg 79
6.5.10.6 Continuity of Care Pg 79
6.5.11 Inpatient Care Pg 79
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6.5.11.1 General Requirement Pg 79
6.5.12 Infection Control Pg 79
6.5.12.1 Infection Control Plan Pg 79
6.5.12.2 Infection Control Policies & Procedures Pg 80
6.5.12.3 Review of Patient Infections Pg 80
6.5.12.4 Reporting Procedures Pg 80
6.5.12.5 Subcontractors Pg 80
6.6 Provider Network and Geographic Access Pg 80
6.6.1 Time and Distance Standard Pg 80
6.6.2 Network Capacity Pg 81
6.6.3 Network Composition Pg 81
6.6.4 Access Requirements Pg 81
6.6.5 Specialists Pg 81
6.6.6 Provider to Member Ratios Pg 81
6.6.7 Physician Supervisor to Non-Physician Medical
Practitioner Ratios Pg 82
6.6.8 Subcontracts Pg 82
6.6.9 Traditional and Safety-Net Provider Participation Pg 82
6.6.10 Traditional and Safety-Net Provider Capacity Pg 82
6.6.11 Existing Patient-Physician Relationships Pg 82
6.6.12 Monthly Report Pg 83
6.6.13 Contract and Employment Terminations Pg 83
6.6.14 Utilization of DSH Hospitals Pg 83
6.6.15 Adequate Facilities and Personnel Pg 83
6.6.16 Emergency Service Providers Pg 83
6.6.17 Users Manual and Bulletins Pg 84
6.6.18 Provider Training Pg 85
6.6.19 FQHC Services Pg 85
6.6.20 FQHC Subcontracts Pg 85
6.6.21 Indian Health Services Facilities Pg 86
6.6.22 Vision Care Services Pg 86
6.6.23 Subcontractor Services Pg 86
6.6.24 Emergency Department Protocols Pg 86
6.7 Scope of Services/Medical Standards/ Health Education Pg 87
6.7.1 Covered Services Pg 87
6.7.1.1 General Requirement Pg 87
6.7.1.2 Referral Services Pg 87
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6.7.2 Excluded Services: Circumstances Under Which Member
Disenrolled Pg 87
6.7.2.1 Major Organ Transplants Pg 88
6.7.2.2 Waiver Programs Pg 88
6.7.2.3 Long Term Care (LTC) Pg 89
6.7.3 Excluded Services: Circumstances Under Which Member
Enrolled with Service Carve Out Pg 89
6.7.3.1 Miscellaneous Service Carve Outs Pg 89
6.7.3.2 California Children Services Pg 90
6.7.3.3 Mental Health Pg 90
6.7.3.4 Alcohol and Drug Treatment Pg 90
6.7.3.5 Dental Pg 91
6.7.3.6 Vision Care - Lenses Pg 91
6.7.3.7 Direct Observed Therapy (DOT) for Treatment of
Tuberculosis Pg 91
6.7.3.8 Department of Developmental Services Administered
Medicaid Home and Community Based Services Waiver Pg 91
6.7.4 Capitated Services: Services with Special Arrangements
and/or Payment of Out-Of-Plan Providers Pg 92
6.7.4.1 School Linked CHDP Services: Coordination of Care Pg 92
6.7.4.2 School Linked CHDP Services: Cooperative Arrangements Pg 92
6.7.4.3 School Linked CHDP Services: Subcontracts Pg 93
6.7.4.4 Early and Periodic Screening, Diagnosis and Treatment
EPSDT Supplemental Services, Excluding Case Management
Services Pg 93
6.7.4.5 Family Planning: General Requirement Pg 93
6.7.4.6 Family Planning: Informed Consent Pg 94
6.7.4.7 Family Planning: Out-Of-Network Reimbursement Pg 94
6.7.4.8 Family Planning: Reimbursement Rate Pg 95
6.7.4.9 Sexually Transmitted Diseases (STD) Pg 95
6.7.4.10 Early Intervention Services Pg 95
6.7.4.11 Services for Persons with Developmental Disabilities Pg 95
6.7.4.12 Confidential HIV Testing Pg 96
6.7.4.13 Immunizations Pg 96
6.7.4.14 Nurse Midwife Services Pg 96
6.7.5 Required Referral Arrangements Pg 96
6.7.5.1 Women, Infants, and Children WIC Supplemental Food
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Program: General Requirements Pg 96
6.7.5.2 WIC Supplemental Food Program: Medical Records Pg 97
6.7.6 Medical Standards - Clinical Preventive Service Pg 97
6.7.6.1 Initial Health Assessment Pg 97
6.7.6.2 Children Pg 97
6.7.6.3 Pregnant Women: Minimum Standards Pg 99
6.7.6.4 Pregnant Women: Provider Credentialing Standards Pg 99
6.7.6.5 Pregnant Women: Risk Assessment Pg 99
6.7.6.6 Pregnant Women: Referrals to Specialists Pg 99
6.7.6.7 Adults Pg 100
6.7.6.8 Tuberculosis (Tb) Pg 101
6.7.7 Health Education Pg 101
6.7.7.1 General Requirements Pg 101
6.7.7.2 Health Educator Pg 102
6.7.7.3 Behavioral Assessments Pg 102
6.7.7.4 Health Education Policies and Procedures Pg 103
6.7.7.5 Health Education Standards Pg 103
6.7.7.6 Health Education and QIP Pg 103
6.7.7.7 Group Needs Assessment Pg 103
6.7.7.8 Health Education Workplan Pg 103
6.7.7.9 Health Education Reading Level Pg 104
6.7.8 Local Health Department Coordination Pg 104
6.7.8.1 Subcontract Pg 104
6.8 Marketing and Enrollment Pg 105
6.8.1 Marketing Representatives Pg 105
6.8.2 Liability Pg 105
6.8.3 Certification of Marketing Representatives Pg 105
6.8.4 Enrollment Program Pg 106
6.8.5 Disenrollment Forms Pg 106
6.8.6 Marketing Plan Pg 106
6.8.7 DHS Approval Pg 106
6.9 Member Services/Grievance System Pg 106
6.9.1 System Capacity Pg 106
6.9.2 Member Services Employee Training Pg 106
6.9.3 Disclosure Forms Pg 106
6.9.4 Member Identification Card Pg 107
6.9.5 Membership Services Guide Pg 107
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6.9.6 Enrollee Information Pg 109
6.9.7 Distribution of Member Services Information Pg 110
6.9.8 Changes in Availability or Location of Covered Services Pg 110
6.9.9 Primary Care Physician Selection Pg 110
6.9.10 Primary Care Physician Assignment Pg 110
6.9.11 Continuity of Care Pg 110
6.9.12 Disclosure Pg 110
6.9.13 Member Compliant/Grievance System Pg 110
6.9.14 Disenrollments Pg 110
6.9.15 Denial, Deferral or Modifications of Prior Authorization Pg 111
Requests
6.10 Cultural and Linguistic Services Requirement Pg 112
6.10.1 Civil Rights Act of 1964 Pg 112
6.10.2 Linguistic Services Pg 112
6.10.3 Linguistic Capability of Employees Pg 113
6.10.4 Subcontracts Pg 113
6.10.5 Community Advisory Committee Pg 113
6.10.6 Cultural and Linguistic Services Plan Pg 114
6.10.7 Implementation Workplan Pg 114
6.10.8 Standards and Performance Requirements Pg 114
6.10.9 Interpreter Coordination Pg 115
6.11 Implementation Plans Pg 115
6.11.1 Time Frames Pg 115
6.11.2 Implementation Plan Oversight Pg 115
6.11.3 Monthly Progress Reports Pg 115
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Article II
ARTICLE II - DEFINITIONS
As used in this Contract, unless otherwise expressly provided or the context
otherwise requires, the following definitions of terms will govern the
construction of this Contract:
A. Administrative Costs means only those costs which arise out of the
operation of the plan excluding direct and overhead costs incurred in the
furnishing of health care services which would ordinarily be incurred in
the provision of these services whether or not through a plan.
B. Affiliate means an organization or person that directly, or indirectly
through one or more intermediaries controls or is controlled by, or is
under control with the Contractor and that provides services to or receives
services from the Contractor.
C. Allied Health Personnel means specially trained, licensed, or credentialed
health workers other than Physicians, podiatrists and Nurses.
D. Ambulatory Care means the type of health services that are provided on an
outpatient basis. While many inpatients may be ambulatory, the term,
"Ambulatory Care" usually implies that the Member has come to a location
such as a clinic, health center, or Physician's office to receive services
and has departed the same day.
E. Beneficiary Identification Card (BIC) means a permanent plastic card issued
by the State to recipients of entitlement programs which is used by
contractors to verify health plan eligibility. Files are updated monthly.
F. California Children Services (CCS) means those services authorized by the
CCS program for the diagnosis and treatment of the CCS eligible conditions
of a specific Member.
G. California Children Services (CCS) Eligible Conditions means a physically
handicapping condition defined in Title 22, CCR, Section 41800.
H. California Children Services (CCS) Program means the public health program
which assures the delivery of specialized diagnostic, treatment, and
therapy services to financially and medically eligible children under the
age of 21 years who have CCS eligible conditions.
I. Claims and Eligibility Real-Time System (CERTS) means the mechanism for
verifying a recipient's Medi-Cal or County Medical Services Program (CMSP)
eligibility by computer.
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J. Confidential Information means specific facts or documents identified as
"confidential" by either law, regulations or contractual language.
K. Contract means this written agreement between DHS and the Contractor.
L. Contracting Providers means a Physician, Nurse, technician, teacher,
researcher, hospital, home health agency, nursing home, or any other
individual or institution that contracts with a health plan to provide
medical services to plan Members.
M. Corrective Actions means specific identifiable activities or undertakings
of the Contractor which address program deficiencies or problems identified
by formal audits or DHS monitoring activities.
N. County Department means the County Department of Social Services (DSS), or
other county agency responsible for determining the initial and continued
eligibility for the Medi-Cal program.
O. Covered Services means those services set forth in Title 22, CCR, Division
3, Subdivision 1, Chapter 3, beginning with Section 51301, and Title 17,
CCR, Chapter 4, Subchapter 13, Article 4, beginning with Section 6840.
Covered Services do not include:
1. Services for major organ transplants as specified in Section 6.7.2.1.
2. Long term care services as specified in Section 6.7.2.3.
3. Home and community based services as specified in Section 6.7.3.8
4. California Children Services (CCS) as specified in Section 6.7.3.2.
5. Mental health services as specified in Section 6.7.3.3.
6. Alcohol and drug treatment services as specified in Section 6.7.3.4.
7. Fabrication of optical lenses as specified in Section 6.7.3.6.
8. Direct observed treatment for tuberculosis as specified in Section
6.7.3.7.
9. Dental services as specified in Title 22, CCR, Section 51307.
10. Acupuncture services as specified in Title 22, CCR, Section 51308.5.
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Article II
11. Chiropractic services as specified in Title 22, CCR, Section 51308.
12. Prayer or spiritual healing as specified in Title 22, CCR, Section
51312.
13. Local Education Agency (LEA) assessment services as specified in Title
22, CCR, Section 51360(b)(l) provided to a Member who qualifies for
LEA services based on Title 22, CCR, Section 51190.1(a).
14. Any LEA services as specified in Title 22, CCR, Section 51360 provided
pursuant to an Individualized Education Plan (IEP) as set forth in
Education Code, Section 56340 et seq. or an Individualized Family
Service Plan (IFSP) as set forth in Government Code Section 95020.
15. Laboratory services provided under the State serum alphafetoprotein
testing program administered by the Genetic Disease Branch of DHS.
P. Credentialing means the recognition of professional or technical
competence. The process involved may include registration, certification,
licensure and professional association membership.
Q. DOC means the State Department of Corporations which is responsible for
administering the Xxxx-Xxxxx Act of 1975.
R. DMH means the Department of Mental Health, the State agency, in
consultation with the California Mental Health Directors Association
(CMHDA) and California Mental Health Planning Council, which sets policy
and administers for the delivery of community based public mental health
services statewide.
S. DHS means the Department of Health Services single State Department
responsible for administration of the Medi-Cal, CMSP, CCS, GHPP, CHDP, and
other health related programs.
T. DHHS means the Department of Health and Human Services, the federal agency
responsible for management of the Medicaid program.
U. Dietitian/Nutritionist means a person who is registered or eligible for
registration as a Registered Dietitian by the Commission on Dietetic
Registration (Business and Professions Code, Chapter 5.65, Sections 2585
and 2586).
V. Director means the Director of the State of California Department of Health
Services.
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W. Disproportionate Share Hospital (DSH) means a health Facility licensed
pursuant to Chapter 2, Division 2, Health and Safety Code, to provide acute
inpatient hospital services, which is eligible to receive payment
adjustments from the State pursuant to W&I Code, Section 14105.98.
X. Eligible Beneficiary means any Medi-Cal beneficiary who is residing in the
Contractor's Service Area with one of the following aid codes: Aid to
Families with Dependent Children - aid codes 30,32,33,35,38,39,3A,3C,40,
42,4C,54,59,3P,3R; Medically Needy Family - aid code 34; Public Assistance
Aged - aid codes 10,16,18; Medically Needy Aged - aid code 14; Public
Assistance Blind - aid codes 20,26,28,6A; Medically Needy Blind - aid code
24; Public Assistance Disabled - aid codes 36,60,66,68,6C; Medically Needy
Disabled - aid code 64; Medically Indigent Child - aid codes 03,04,4K,5K,
45,82; Medically Indigent Adult - aid code 86; and Refugees - aid codes
01,02, and 08, with the following exclusions:
1. Individuals who have been approved by the Medi-Cal Field Office or the
California Children Services Program for bone marrow, heart,
heart-lung, liver, lung, combined liver and kidney, or combined liver
and small bowel transplants.
2. Individuals who elect and are accepted to participate in the following
Medi-Cal waiver programs: In-Home Medical Care Waiver Program, the
Skilled Nursing Facility Waiver Program, the Model Waiver Program, the
Acquired Immune Deficiency (AIDS) and AIDS Related Conditions Waiver
Program, and the Multipurpose Senior Services Waiver Program.
3. Individuals determined by the Medi-Cal Field Office to be in need of
long term care and residing in a Skilled Nursing Facility (SNF) for 30
days past the month of admission.
Y. Emergency Conditions means those medical conditions requiring immediate
medical care to avoid disability or death.
Z. Emergency Services means those health services required for alleviation of
severe pain or immediate diagnosis and treatment of unforeseen medical
conditions, which if not immediately diagnosed and treated, could lead to
disability or death.
AA. Encounter means a single "face-to-face" visit or medically related service
rendered by (a) provider(s) in an Ambulatory Care setting to a Member
enrolled in the health plan during the date of service. It includes, but
not limited to, all services for which the Contractor incurred any
financial liability.
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BB. Enrollment means the process by which an Eligible Beneficiary becomes a
Member of the Contractor's plan.
CC. Facility means any premise that is:
1. Owned, leased, used or operated directly or indirectly by or for the
Contractor or its Affiliates for purposes related to this Contract or
2. Maintained by a provider to provide services on behalf of the
Contractor.
DD. Federal Financial Participation means federal expenditures provided to
match proper State expenditures made under approved State Medicaid plans.
EE. Federally Qualified HMO means a prepaid health delivery plan that has
fulfilled the requirements of the HMO Act, along with its amendments and
regulations, and has obtained the Federal Government's qualification status
under Section 1310(d) of the Public Health Service Act (42 USC S300e).
FF. Fee-For-Service (FFS) means a method of charging based upon billing for a
specific number of units of services rendered to an Eligible Beneficiary.
Fee-For-Service is the traditional method of reimbursement used by
Physicians and payment almost always occurs retrospectively (i.e., after
the service has been rendered).
GG. Fee-For-Service Mental Health Services (FFS/MC) means the mental health
services covered through Fee-For-Service Medi-Cal which include outpatient
services and acute care inpatient services. These services are provided
through Primary Care Physicians as well as psychiatrists and psychologists.
HH. Financial Security means cash or cash equivalents which are immediately
redeemable upon demand by DHS, in an amount determined by DHS, which shall
not be less than one full month's capitation. This is required when
prepayment of capitation is agreed upon by DHS and the Contractor.
II. Financial Statements means the Financial Statements as defined by Generally
Accepted Accounting Principles (GAAP) which includes a Balance Sheet,
Income Statement, Statement of Cash Flows, Statement of Equity and
accompanying footnotes. All documents are prepared in accordance with GAAP.
JJ. Fiscal Year (FY) means any 12-month period for which annual accounts are
kept. The State Fiscal Year is July 1 through June 30, the federal Fiscal
Year is October 1 through September 30.
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KK. Grievance means a complaint filed by either a Member or a provider.
LL. Health Maintenance Organization (HMO) means an organization that, through
a coordinated system of health care, provides or assures the delivery of an
agreed upon set of comprehensive health maintenance and treatment services
for an enrolled group of persons through a predetermined periodic fixed
prepayment.
MM. Indian Health Service (IHS) Facilities means Facilities operated with funds
from the IHS under the Indian Self-Determination Act and the Indian Health
Care Improvement Act, through which services are provided, directly or by
contract, to the eligible Indian population within a defined geographic
area.
NN. Intermediate Care Facility (ICF) means a Facility which is licensed as an
ICF by DHS or a hospital or Skilled Nursing Facility which meets the
standards specified in Title 22, CCR, Section 51212 and has been certified
by DHS for participation in the Medi-Cal program.
OO. Joint Commission On Accreditation of Hospitals (JCAHO) means the
composition of representatives of the American Hospital Association,
American Medical Association, American College of Physicians and American
College of Surgeons, JCAHO establishes guidelines for the operation of
hospitals and other health Facilities and accreditation programs.
PP. Xxxx-Xxxxx Health Care Service Plan Act of 1975 means the law which
regulates HMOs and is administrated by the Department of Corporations
(DOC), commencing with Section 1340, Health & Safety Code.
QQ. Local Authority means a health care organization in which local
stakeholders share governance responsibility for administrating Medi-Cal
managed care.
RR. Marketing means any activity conducted on behalf of the Contractor where
information regarding the services offered by the Contractor is
disseminated in order to persuade Eligible Beneficiaries to enroll.
Marketing also includes any similar activity to secure the endorsement of
any individual or organization on behalf of the Contractor.
SS. Marketing Organization means any subcontractor or entity who agrees to
provide Marketing services for the Contractor.
TT. Marketing Representative means a person who is engaged in Marketing
activities on behalf of the Contractor either through direct employment by
the Contractor or through a Marketing Organization.
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UU. Medi-Cal Eligibility Data System (MEDS) means the automated eligibility
information processing system operated by the State which provides on-line
access for recipient information, update of recipient eligibility data and
on-line printing of immediate need beneficiary identification cards. The
MEDS also produces Beneficiary Identification Cards (BIC) and maintains
data on federal SSI/SSP and Medicare buy-in beneficiaries.
VV. Medical Case Management Services means services provided by a Primary Care
Provider to ensure the coordination of Medically Necessary health care
services, assuring the provision of preventive services in accordance with
established standards and periodicity schedules and ensuring continuity of
care for Medi-Cal enrollees. It includes health risk assessment, treatment
planning, coordination, referral, follow-up, and monitoring of appropriate
services and resources required to meet an individual's health care needs.
WW. Medical Records means written documentary evidence of treatments rendered
to plan Members.
XX. Medically Necessary means reasonable and necessary services to protect
life, to prevent significant illness or significant disability, or to
alleviate severe pain through the diagnosis or treatment of disease,
illness, or injury.
YY. Member means any Eligible Beneficiary who has enrolled in the Contractor's
plan.
ZZ. Minor Consent Services means those treatment services of a sensitive nature
for which minors do not need parental consent to access. Such services
include pregnancy, abortion, mental health services.
A1. Newborn Child means a child born to a Member during her membership or the
month prior to her membership.
B1. Non-Emergency Medical Transportation means inclusion of services outlined
in Title 22, CCR, Sections 51231.1 and 51231.2 rendered by licensed
providers.
C1. Non-Medical Transportation means transportation of Members to medical
services by passenger car, taxicabs, or other forms of public or private
conveyances provided by persons not registered as Medi-Cal providers. Does
not include the transportation of sick, injured, invalid, convalescent,
infirm, or otherwise incapacitated Members by ambulances, litter vans, or
wheelchair vans licensed, operated and equipped in accordance with state
and local statutes, ordinances or regulations.
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D1. Non-Physician Medical Practitioners (Mid-Level Practitioner) means a nurse
practitioner, certified nurse midwife, or physician assistant authorized to
provide Primary Care under Physician supervision.
E1. Nurse means a person licensed by the California Board of Nursing as, at
least, a Registered Nurse (RN).
F1. Outpatient Care means treatment provided to an Member who is not confined
in a health care Facility. Outpatient care is associated with treatment in
a hospital that does not necessitate an overnight stay, e.g., emergency
treatment.
G1. Pediatric Subacute Care means health care services needed by a person under
21 years of age who uses a medical technology that compensates for the loss
of vital bodily function. Medical necessity criteria are described in the
Physician's Manual of Criteria for Medi-Cal Authorization.
H1. Physician means a person duly licensed as a Physician by the Medical Board
of California.
I1. Policy Letter means a document which has been dated, numbered and issued by
the Medi-Cal Managed Care Division. It clarifies regulatory or contractual
requirements.
J1. Prepaid Person means a person entitled to receive health care services from
the Contractor in consideration of a predetermined periodic, fixed
subscription premium, or capitation payment.
K1. Preventive Care means health care designed to prevent disease and /or its
consequences. There are three levels of Preventive Care; primary, such as
immunizations, aimed at preventing disease; secondary, such as disease
screening programs, aimed at early detection of disease; and tertiary, such
as physical therapy, aimed at restoring function after the disease has
occurred.
L1. Primary Care means a basic level of health care usually rendered in
ambulatory settings by general practitioners, family practitioners,
internists, obstetricians, pediatricians, and mid-level practitioners. This
type of care emphasizes caring for the Member's general health needs as
opposed to specialists focusing on specific needs.
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M1. Primary Care Physician means a Physician responsible for supervising,
coordinating, and providing initial and Primary Care to patients; for
initiating referrals for specialist care; and for maintaining the
continuity of patient care. A Primary Care Physician has focused the
delivery of medicine to general practice or is a board certified or board
eligible internist, pediatrician, obstetrician/gynecologist, or family
practitioner.
N1. Primary Care Provider means a person responsible for supervising,
coordinating, and providing initial and Primary Care to Members; for
initiating referrals and for maintaining the continuity of Member care. A
Primary Care Provider may be a Primary Care Physician or non-physician
medical practitioner.
O1. Prior Authorization means the process by which contractors approve, usually
in advance of the rendering, requested medical services. This is part of
the Utilization management system.
P1. Prior Authorization Request means a method by which practitioners seek
approval from Contractor to render medical services. The Contractor's
Utilization Review (UR) Coordinator is responsible for granting approval to
providing specific, non-emergency medical services in advance of rendering
such services.
Q1. Quality Assurance (QA) means a formal set of activities to assure the
quality of clinical and non-clinical services provided. Quality Assurance
includes quality assessment and Corrective Actions taken to remedy any
deficiencies identified through the assessment process. Comprehensive
Quality Assurance includes mechanisms to assess and assure the quality of
both health services and administrative and support services.
R1. Quality Improvement (QI) means the result of an effective QA program, which
objectively and systematically monitors and evaluates the quality and
appropriateness of care and services to Members through Quality of Care
studies and other health related activities.
S1. Quality Improvement Plan (QIP) means consisting of systematic activities to
monitor and evaluate the medical care delivered to Members according to the
standards set forth in regulations and Contract language. The plan must
have processes in place which measure the effectiveness of care, identify
problems, and implement improvement on a continuing basis.
T1. Quality of Care means the degree to which health services for individuals
and populations increase the likelihood of desired health outcomes and are
consistent with current professional knowledge.
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U1. Quality Indicators means the referral to measurable variables relating to a
specific clinic or health services delivery area which are reviewed over a
period of time to screen delivered health care and to monitor the process
or outcome of care delivered in that clinical area.
V1. Sensitive Services means those services related to:
1. Sexual Assault
2. Drug or alcohol abuse for children 12 years of age or older.
3. Pregnancy
4. Family Planning
5. Sexually transmitted diseases designated by the Director for children
12 years of age or older.
W1. Service Area means the geographic area comprised of those areas designated
by the U.S. Postal Service ZIP Codes that have been proposed by the
Contractor and approved in writing by DHS.
X1. Service Location means any location at which a Member obtains any health
care service provided by the Contractor under the terms of this Contract.
Y1. Service Site means the location designated by the Contractor at which
Members shall receive Primary Care Physician services.
Z1. Xxxxx-Xxxxx Medi-Cal Mental Health Services (SD/MC) means as defined in
Title 22, CCR, Section 51341, SD/MC Mental Health Services include: crisis
intervention, crisis sterilization, inpatient hospital services, crisis
residential treatment case management, adult residential treatment, day
treatment intensive, rehabilitation, outpatient therapy, medication and
support services.
A2. Xxxxx-Xxxxx Program means as defined in Title 22, CCR, Section 51341, the
program administered by the Department of Mental Health to provide
community mental health services and the program administered by the
Department of Alcohol and Drug Programs to provide drug and alcohol
treatment services.
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B2. Skilled Nursing Facility (SNF) means, as defined in Title 22, CCR, Section
51121(a), any institution, place, building, or agency which is licensed as
a Skilled Nursing Facility by DHS or is a distinct part or unit of a
hospital, meets the standard specified in Section 51215 of these
regulations (except that the distinct part of a hospital does not need to
be licensed as a Skilled Nursing Facility) and has been certified by DHS
for participation as a Skilled Nursing Facility in the Medi-Cal program.
Section 51121(b) further defines the term "Skilled Nursing Facility" as
including terms "skilled nursing home", "convalescent hospital", "nursing
home", or "nursing Facility".
C2. State means the State of California.
D2. Subacute Care means, as defined in Title 22, CCR, Section 51124.5, a level
of care needed by a patient who does not require hospital acute care but
who requires more intensive licensed skilled nursing care than is provided
to the majority of patients in a Skilled Nursing Facility (SNF).
E2. Subcontract means a written agreement entered into by the Contractor with
any of the following:
1. A provider of health care services who agrees to furnish Covered
Services to Members.
2. A Marketing Organization.
3. Any other organization or person(s) who agree(s) to perform any
administrative function or service for the Contractor specifically
related to fulfilling the Contractor's obligations to DHS under the
terms of this Contract.
F2. Sub-Subcontractor means party to an agreement with a subcontractor
descending from and subordinate to a Subcontract, which is entered into for
the purpose of providing any goods or services connected with the
obligations under this Contract.
G2. Supplemental Security Income (SSI) means the program authorized by Title
XVI of the Social Security Act for aged, blind, and disabled persons.
H2. Third Party Liability (TPL) means the responsibility of persons other than
the Contractor or the Member for payment of claims for injuries or trauma
sustained by Members. This may be contractual, a legal obligation or as a
result of or the fault or negligence of third parties (e.g., auto accidents
or other personal injury casualty claims or work compensation appeals). DHS
is responsible for follow up and collection of Third Party Liability
payments where it has paid for related care.
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I2. Urgent Care means services required to prevent serious deterioration of
health following the onset of an unforeseen condition or injury (i.e., sore
throats, fever, minor lacerations, and some broken bones).
J2. Utilization means the rate patterns of service usage or types of service
occurring within a specified time. Inpatient Utilization is generally
expressed in rates per unit of population-at-risk for a given period; e.g.,
the number of hospital admissions per 1,000 persons enrolled in an HMO/per
year.
K2. Utilization Review means the process of evaluating the necessity,
appropriateness, and efficiency of the use of medical services, procedures
and Facilities.
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ARTICLE III - GENERAL TERMS AND CONDITIONS
3.1 DELEGATION OF AUTHORITY
DHS intends to implement this Contract through a single administrator,
called the "Contracting Officer". The Contracting Officer will be appointed
by the Director of DHS. The Contracting Officer, on behalf of DHS, will
make all determinations and take all actions as are appropriate under this
Contract, subject to the limitations of applicable federal and State laws
and regulations. The Contracting Officer may delegate his/her authority to
act to an authorized representative through written notice to the
Contractor.
The Contractor will designate a single administrator, hereafter called the
"Contractor's Representative". The Contractor's Representative, on behalf
of the Contractor, will make all determinations and take all actions as are
appropriate to implement this Contract, subject to the limitations of the
Contract, federal and State laws and regulations. The Contractor's
Representative may delegate his/her authority to act to an authorized
representative through written notice to the Contracting Officer. The
Contractor's Representative will be empowered to legally bind the
Contractor to all agreements reached with DHS.
The Contractor's Representive will be designated in writing by the
Contractor. Such designation will be submitted to the Contracting Officer
in accordance with Section 3.3, Authority of the State.
3.2 GOVERNING AUTHORITIES
This Contract will be governed and construed in accordance with:
Chapter 7 and 8 (commencing with Section 14000), Part 3, Division 9, W&I
Code;
Division 3, Title 22, CCR;
Health and Safety Code Section 1340 et seq.
Title 10, CCR, Section 1300 et seq.
Title 42, Code of Federal Regulations (CFR);
Xxxxx 00, Xxxxxx Xxxxxx Code, Section 1396 et seq.;
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Title 45, CFR, Part 74;
Subchapter 13 (commencing with Section 6800), Chapter 4, Part 1, Title 17,
CCR, and;
All other applicable laws and regulations.
Any provision of this Contract which is in conflict with the above laws,
regulations and federal Medicaid statutes is hereby amended to conform to
the provisions of those laws and regulations. Such amendment of the
Contract will be effective on the effective date of the statutes or
regulations necessitating it, and will be binding on the parties even
though such amendment may not have been reduced to writing and formally
agreed upon and executed by the parties.
This amendment will constitute grounds for termination of this Contract in
accordance with the provisions of Section 3.17.1, Termination by the State,
and 3.17.2, Termination by the Contractor. The parties will be bound by the
terms of the amendment until the effective date of the termination.
3.3 AUTHORITY OF THE STATE
A. Sole authority to establish, define, or determine the reasonableness,
the necessity and level and scope of covered benefits under the
Medi-Cal Managed Care program administered in this Contract or
coverage for such benefits, or the eligibility of the beneficiaries or
providers to participate in the Medi-Cal Managed Care Program reside
with DHS.
B. Sole authority to establish or interpret policy and its application
related to the above areas will reside with DHS.
C. The Contractor may not make any limitations, exclusions, or changes in
benefits or benefit coverage; any changes in definition or
interpretation of benefits; or any changes in the administration of
the Contract related to the scope of benefits, allowable coverage for
those benefits, or eligibility of beneficiaries or providers to
participate in the program, without the express, written direction or
approval of the Contracting Officer.
3.4 FULFILLMENT OF OBLIGATIONS
No covenant, condition, duty, obligation, or undertaking continued or made
a part of this Contract will be waived except by written agreement of the
parties hereto, and forbearance or indulgence in any other form or manner
by either party in any regard
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whatsoever will not constitute a waiver of the covenant, condition, duty,
obligation, or undertaking to be kept, performed or discharged by the party
to which the same may apply; and, until performance or satisfaction of all
covenants, conditions, duties, obligations, and undertakings is complete,
the other party will have the right to invoke any remedy available under
this contract, or under law, notwithstanding such forbearance or
indulgence.
3.5 COMPLIANCE WITH PROTOCOLS
The Contractor will develop and comply with all protocols and procedures
within 30 days of their approval by DHS. All subsequent revisions thereof
will be approved by DHS and implemented by the Contractor within 30 days of
such approval. The Contractor will not implement protocols, procedures or
revisions thereof prior to approval by DHS.
3.6 EQUAL OPPORTUNITY EMPLOYER
The Contractor will, in all solicitations or advertisements for employees
placed by or on behalf of the Contractor, state that it is an equal
opportunity employer, and will send to each labor union or representative
of workers with which it has a collective bargaining agreement or other
contract or understanding, a notice to be provided by DHS, advising the
labor union or workers' representative of the Contract's commitments as an
equal opportunity employer and will post copies of the notice in
conspicuous places available to employees and applicants for employment.
3.7 NONDISCRIMINATION CLAUSE COMPLIANCE
A. During the performance of this Contract, Contractor and its
subcontractors will not unlawfully discriminate, harass, or allow
harassment, against any employee or applicant for employment because
of sex, race, color, ancestry, religious creed, national origin,
physical disability (including HIV and AIDS), mental disability,
medical condition (including Cancer), age (over 40), marital status,
and denial of family care leave. Contractors and subcontractors will
insure that the evaluation and treatment of their employees and
applicants for employment are free from discrimination and
harassment. Contractor and subcontractors will comply with the
provisions of the Fair Employment and Housing Act (Government Code,
Section 12900 et seq.) and the applicable regulations promulgated
thereunder (California Code of Regulations, Title 2, Section 7285.0
et seq.). The applicable regulations of the Fair Employment and
Housing Commission implementing Government Code, Section 12990
(a-f), set forth in Chapter 5 of Division 4 of Title 2 of the
California Code of Regulations are incorporated into this Contract
by reference and made a part
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hereof as if set forth in full. Contractor and its subcontractors
will give notice of their obligations under this clause to labor
organizations with which they have a collective bargaining or other
agreement.
B. The Contractor will include the nondiscrimination and compliance
provisions of this clause in all Subcontracts to perform work under
this Contract.
3.8 DISCRIMINATION PROHIBITION
The Contractor will not discriminate against Members or Eligible
Beneficiaries because of race, color, creed, religion, ancestry, marital
status, sexual orientation, national origin, age, sex, or physical or
mental handicap in accordance with Title VI of the Civil Rights Act of
1964, 42 USC Section 2000d, rules and regulations promulgated pursuant
thereto, or as otherwise provided by law or regulations. For the purpose of
this Contract discriminations on the grounds of race, color, creed,
religion, ancestry, age, sex, national origin, marital status, sexual
orientation, or physical or mental handicap include but are not limited to
the following: denying any Member any Covered Services or availability of a
Facility; providing to a Member any Covered Service which is different, or
is provided in a different manner or at a different time from that provided
to other Members under this Contract except where medically indicated;
subjecting a Member to segregation or separate treatment in any manner
related to the receipt of any Covered Service; restricting a Member in any
way in the enjoyment of any advantage or privilege enjoyed by others
receiving any Covered Service, treating a Member or Eligible Beneficiary
differently from others in determining whether he or she satisfies any
admission, Enrollment, quota, eligibility, membership, or other requirement
or condition which individuals must meet in order to be provided any
Covered Service; the assignment of times or places for the provision of
services on the basis of the race, color, creed, religion, age, sex,
national origin, ancestry, marital status, sexual orientation, or the
physical or mental handicap of the participants to be served. The
Contractor will take affirmative action to ensure that Members are provided
Covered Services without regard to race, color, creed, religion, sex,
national origin, ancestry, marital status, sexual orientation, or physical
or mental handicap, except where medically indicated. For the purposes of
this section, physical handicap includes the carrying of a gene which may,
under some circumstances, be associated with disability in that person's
offspring, but which causes no adverse effects on the carrier. Such genes
will include, but are not limited to, Tay-Sachs trait, sickle cell trait,
thalassemia trait, and X-linked hemophilia.
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3.9 DISCRIMINATION COMPLAINTS
The Contractor agrees that copies of all Grievances alleging discrimination
against Members or Eligible Beneficiaries because of race, color, creed,
sex, religion, age, national origin, ancestry, marital status, sexual
orientation, or physical or mental handicap will be forwarded to DHS for
review and appropriate action.
3.10 MEMBERSHIP DIVERSITY
The Contractor agrees to serve a population broadly representative of the
various age, social, and income groups within the Service Area, and that
less than 75 percent (75 %) of its Prepaid Person population is of
individuals receiving benefits under Title XVIII, Social Security Act, and
individuals receiving benefits under Title XIX, Social Security Act
(Section 1903(m), SSA).
DHS on request of the Contractor will apply to the Secretary, United States
Department of Health and Human Services (DHHS) for a waiver of the 75
percent (75%) requirement, based on good cause. If that waiver is granted,
then the 75 percent (75%) requirement under this Contract is waived as of
the effective date of that federal waiver and for the time period granted
by the waiver.
3.11 INSPECTION RIGHTS
The Contractor will allow DHS, DHHS, the Comptroller General of the United
States, Department of Justice, (DOJ), Bureau of Medi-Cal Fraud, Department
of Corporations (DOC) and other authorized state agencies, or their duly
authorized representatives, to inspect or otherwise evaluate the quality,
appropriateness, and timeliness of services performed under this Contract,
and to inspect, evaluate, and audit any and all books, records, and
Facilities maintained by the Contractor and subcontractors pertaining to
these services at any time during normal business hours. Books and records
include, but are not limited to, all physical records originated or
prepared pursuant to the performance under this Contract including working
papers, reports, financial records, and books of account, Medical Records,
prescription files, Subcontracts, and any other documentation pertaining to
medical and nonmedical services for Members. Upon request, at any time
during the period of this Contract, the Contractor will furnish any record,
or copy of it, to DHS or DHHS.
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3.12 NOTICES
All notices to be given under this Contract will be in writing and will be
deemed to have been given when mailed to DHS or the Contractor:
State Department of Health Services Xxxx Xxxxxx, X.X.
Medi-Cal Managed Care Division Chief Administrative Xxxxxxx
000 X Xxxxxx, Xxxx 000 Xxxxxx Medical Centers, Inc.
X.X. Xxx 000000 Xxx Xxxxxx Xxxxx
Xxxxxxxxxx, XX 00000-0000 Xxxx Xxxxx, XX 00000
Attn: Contracting Officer
3.13 CONTRACTOR'S NATIONAL LABOR RELATIONS BOARD (NLRB) DECLARATION
The Contractor, by signing this agreement, does swear under penalty of
perjury that, no more than one final unappealable finding of contempt of
court by a federal court has been issued against Contractor within the
immediately preceding two-year period because of the Contractor's failure
to comply with an order of a federal court which orders the Contractor to
comply with an order of the NLRB.
3.14 TERM
The Contract will become effective April 2, 1996 and will continue in full
force and effect through March 31, 2002 subject to the provisions of
Article V, Sections 5.2 and 5.10 because the State has currently
appropriated and available for encumbrance only funds to cover costs
through June 30, 1996.
The term of the Contract consists of the following three periods: 1) The
Implementation Period will extend from April 2, 1996; 2) The Operations
Period will extend from October 2, 1996, subject to the termination
provisions of Section 3.17, Termination and subject to the limitation
provisions of Article V, Payment Provisions Section 5.2; and 3) The
Turnover/Phaseout Period will extend from October 1, 2001 through March 31,
2002, subject to the provisions of Section 3.15, Contract Extension, in
which case the Turnover/Phaseout Period will apply to the six (6) month
period beginning the first day after the end of the Operations Period of
the extension.
The Operations Period will commence subject to DHS acceptance of the
Contractor's readiness to begin the Operations Period.
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3.15 CONTRACT EXTENSION
DHS will have the exclusive option to extend the term of the Contract
during the last twelve (12) months of the Contract, as determined by the
original termination date or by a new termination date if an extension
option has been exercised. DHS may invoke up to three (3) separate
extensions of one (1) year each. The Contractor will be given at least nine
(9) months prior written notice of DHS' decision on whether or not it will
exercise this option to extend the Contract.
The Contractor will notify DHS of its intent to accept or reject the
extension within five (5) State working days of the receipt of the notice
from DHS.
3.16 TURNOVER AND PHASEOUT REQUIREMENTS
DHS will withhold an amount equal to 10% or one million dollars
($1,000,000), whichever is greater unless provided otherwise by the
Financial Security agreement, from the capitation payment of the last month
of the Operations Period until all activities required during the Turnover
and Phaseout Period are completed.
If all Turnover and Phaseout activities are completed by the end of the
Turnover and Phaseout Period, the withhold will be paid to the Contractor.
If the Contractor fails to meet any requirement(s) by the end of the
Turnover and Phaseout Period, DHS will deduct the costs of the remaining
activities proportionately from the withhold amount and continue to
withhold payment until all activities are completed.
3.16.1 OBJECTIVES FOR TURNOVER AND PHASEOUT PERIOD
The objective of the Turnover Period is to ensure that, at the termination
of this Contract, the orderly transfer of necessary data and history
records is made from the Contractor to DHS or to a successor Contractor.
The orderly transfer is to ensure the continuity of access and Quality of
Care to Members.
The objective of the Phaseout Period is to ensure that, at the termination
of this Contract, the Contractor completes any and all of its remaining
contractual obligations under the Contract.
Given the uncertainties associated with the Turnover and Phaseout Periods
that will occur at the end of this Contract, the Contractor will be
flexible to changing requirements.
If DHS exercises its option(s) to extend this Contract, all Turnover and
Phaseout activities will be delayed a commensurate period of time.
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3.16.2 TURNOVER REQUIREMENTS
Prior to the termination or expiration of this Contract and upon request by
DHS, the Contractor will assist DHS in the orderly transfer of Member
medical care. In doing this, the Contractor will make available to DHS
copies of Medical Records, patient files, and any other pertinent
information, including information maintained by any subcontractor,
necessary for efficient case management of Members, as determined by the
Director. Costs of reproduction will be borne by DHS. In no circumstances
will a Medi-Cal Member be billed for this service.
3.16.3 PHASEOUT REQUIREMENTS
Phaseout for this Contract will consist of the processing, payment and
monetary reconciliation(s) necessary regarding claims for payment for
Covered Services.
Phaseout for the Contract will consist of the resolution of all financial
and reporting obligations of the Contractor. The Contractor will remain
liable for the processing and payment of invoices and other claims for
payment for Covered Services and other services provided to Members
pursuant to this Contract prior to the expiration or termination. The
Contractor will submit to DHS all reports required in Article VI, Scope of
Work, for the period from the last submitted report through the expiration
or termination date.
All data and information provided by the Contractor will be accompanied by
letter, signed by the responsible authority, certifying, under penalty of
perjury, to the accuracy and completeness of the materials supplied.
3.16.4 TURNOVER AND PHASEOUT PERIOD
Turnover and Phaseout Periods will occur during the same six (6) month time
period and this period will commence on the date the Operations Period of
the Contract or Contract extension ends. Turnover and Phaseout related
activities are non-payable items.
3.17 TERMINATION
3.17.1 TERMINATION - STATE OR DIRECTOR
DHS may terminate performance of work under this Contract in whole, or in
part, whenever for any reason DHS determines that the termination is in the
best interest of the State.
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Notification will be given at least nine (9) months prior to the effective
date of termination, except in cases where the Director determines the
health and welfare of Members is jeopardized by continuation of this
Contract, in which case the Contract will be immediately terminated.
Notification will state the effective date of, and the reason for, the
termination.
In addition to other grounds for termination, failure to comply with any of
the terms of this Contract will constitute cause for termination.
3.17.2 TERMINATION - CONTRACTOR
If mutual agreement between DHS and the Contractor cannot be attained on
capitation rates for rate years subsequent to September 30, 1997, the
Contractor will retain the right to terminate the Contract, no earlier than
September 30, 1998, by giving at least nine (9) months written notice to
DHS to that effect. The effective date of any termination under this
section will be September 30.
Grounds for contract termination by a Contractor are limited to its
unwillingness to accept the capitation rates determined by DHS, or if DHS
decides to negotiate rates, there is a failure to reach mutual agreement on
rates.
3.17.3 MANDATORY TERMINATION
DHS will terminate this Contract in the event that: (1) the Secretary,
DHHS, determines that the Contractor does not meet the requirements for
participation in the Medicaid program, Title XIX of the Social Security
Act, or (2) the Department of Corporations finds that the Contractor no
longer qualifies for licensure under the Xxxx-Xxxxx Health Care Service
Plan Act by giving written notice to the Contractor. Notification will be
given by DHS at least sixty (60) days prior to the effective date of
termination, except in cases where the Director determines the health and
welfare of Members is jeopardized by continuation of the Contract, in which
case the Contract will be immediately terminated. Notification will state
the effective date of, and the reason for, the termination.
Under these circumstances, termination of the Operations period will be
effective on the last day of the month in which the Secretary, DHHS, or DOC
makes such determination, provided that DHS provides the Contractor with at
least 60 days notice of termination. The termination of this Contract will
be effective on the last day of the second full month from the date of the
notice of termination. The Contractor agrees that 60 days notice is
reasonable. Termination under this section does not relieve the Contractor
of its obligations under the Turnover and Phaseout Requirements, Sections
3.16.2 and 3.16.3.
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3.17.4 TERMINATION OF OBLIGATIONS
All obligations to provide Covered Services under this Contract or Contract
extension will automatically terminate on the date the Operations Period
ends.
3.17.5 NOTICE TO MEMBERS OF TRANSFER OF CARE
No later than sixty (60) days prior to the termination or expiration of the
Contract, DHS will notify Members about their medical benefits and
available options.
3.18 SANCTIONS
In the event DHS finds Contractor non-compliant with the standards and
requirements prescribed in this Contract, DHS will have the power and
authority to impose sanctions provided in Welfare and Institutions Code,
Section 14304 and Title 22, CCR, Section 53350. In addition, DHS may
require the following:
The Contractor to ensure providers or subcontractors cease activities which
include, but are not limited to, referrals, assignment of beneficiaries,
and reporting, until new activities are approved by DHS and the Contractor
is again in compliance.
3.19 LIQUIDATED DAMAGES PROVISIONS
3.19.1 GENERAL
It is agreed by the State and Contractor that:
A. If Contractor does not provide or perform the requirements of
this Contract or applicable laws and regulations, damage to the
State will result;
B. Proving such damages will be costly, difficult, and
time-consuming;
C. Should the State choose to impose liquidated damages, the
Contractor will pay the State those damages for not providing or
performing the specified requirements;
D. Additional damages may occur in specified areas by prolonged
periods in which Contractor does not provide or perform
requirements;
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E. The damage figures listed below represent a good faith effort to
quantify the range of harm that could reasonably be anticipated
at the time of the making of the Contract;
F. DHS may, at its discretion, offset liquidated damages from
capitation payments owed to the Contractor;
G. Imposition of liquidated damages as specified in Sections 3.19.2,
3.19.3, and 3.19.4 will follow the administrative processes
described below;
H. DHS will provide the Contractor with written notice specifying
the Contractor requirement(s), contained in the Contract or as
required by federal and State law or regulation, not provided or
performed;
I. During the Implementation Period, the Contractor will submit or
complete the outstanding requirement(s) specified in the written
notice within five (5) State working days from the date of the
notice, unless, subject to the Contracting Officer's written
approval, the Contractor submits a written request for an
extension. The request must include the following: the
requirement(s) requiring an extension; the reason for the delay;
and the proposed date of the submission of the requirement;
J. During the Implementation Period, if the Contractor has not
performed or completed an Implementation Period requirement or
secured an extension for the submission of the outstanding
requirement, DHS may impose liquidated damages for the amount
specified in Section 3.19.2;
K. During the Operations Period, the Contractor will demonstrate the
provision or performance of the Contractor's requirement(s)
specified in the written notice within a thirty (30) calendar day
Corrective Action period from the date of the notice, unless a
request for an extension is submitted to the Contracting Officer,
subject to DHS' approval, within five (5) days from the end of
the Corrective Action period. If Contractor has not demonstrated
the provision or performance of the Contractor's requirement(s)
specified in the written notice during the Corrective Action
period, DHS may impose liquidated damages for each day the
specified Contractor's requirement is not performed or provided
for the amount specified in Section 3.19.3.
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L. During the Operations Period, if the Contractor has not performed
or provided the Contractor's requirement(s) specified in the
written notice or secured the written approval for an extension,
after thirty (30) days from the first day of the imposition of
liquidated damages, DHS will notify the Contractor in writing of
the increase of the liquidated damages to the amount specified in
Section 3.19.3.
Nothing in this provision will be construed as relieving the Contractor
from performing any other Contract duty not listed herein, nor is the
State's right to enforce or to seek other remedies for failure to perform
any other Contract duty hereby diminished.
3.19.2 LIQUIDATED DAMAGES FOR VIOLATION OF CONTRACT TERMS REGARDING THE
IMPLEMENTATION PERIOD
DHS may impose liquidated damages of $5,000 per requirement specified in
the written notice for each day of the delay in completion or submission of
Implementation Period requirements beyond the periods defined in the
Contract.
If DHS determines that a delay or other non-performance was caused in part
by the State, DHS will reduce the liquidated damages proportionately.
3.19.3 LIQUIDATED DAMAGES FOR VIOLATION OF CONTRACT TERMS OR REGULATIONS
REGARDING THE OPERATIONS PERIOD
DHS may impose liquidated damages of $1,000 per Contractor requirement not
performed or provided during the Operations Period. If after thirty (30)
days or such longer period as DHS may allow, the Contractor has not
demonstrated the provision or performance of the Contractor requirement
specified in the written notice, DHS may issue a written notice that the
liquidated damages will be increased to $2,000 per day per Contractor
requirement until the Contractor requirement is performed or provided.
If DHS determines that delay of the Contractor requirement was caused in
part by the State, DHS will reduce the liquidated damages proportionately.
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3.19.4 ANNUAL MEDICAL REVIEWS
DHS may impose liquidated damages of not less than $10,000 and not to
exceed $50,000 for each major deficiency determined during the annual
medical review. If, after notice, the Contractor does not correct the
deficiency to the satisfaction of DHS within thirty (30) days, or longer if
authorized by DHS in writing, DHS may impose an additional liquidated
damages of $5,000 per day per major deficiency that the major deficiency is
not corrected as determined by DHS medical review staff.
If DHS determines that non-performance of the requirement was caused in
part by the State, DHS will reduce the liquidated damages proportionately.
3.19.5 CONDITIONS FOR TERMINATION OF LIQUIDATED DAMAGES
Except as waived by the Contracting Officer, no liquidated damages imposed
on the Contractor will be terminated or suspended until the Contractor
issues a written notice of correction to the Contracting Officer
certifying, under penalty of perjury, the correction of condition(s) for
which liquidated damages were imposed. Liquidated damages will cease on the
day of the Contractor's certification only if subsequent verification of
the correction by DHS establishes that the correction has been made in the
manner and at the time certified to by the Contractor.
The Contracting Officer will determine whether the necessary level of
documentation has been submitted to verify corrections. The Contracting
Officer will be the sole judge of the sufficiency and accuracy of any
documentation. Corrections must be sustained for a reasonable period of at
least ninety (90) days from DHS acceptance; otherwise, liquidated damages
may be reimposed without a succeeding grace period within which to correct.
The Contractor's use of resources to correct deficiencies will not be
allowed to cause other contract compliance problems.
3.19.6 SEVERABILITY OF INDIVIDUAL LIQUIDATED DAMAGES CLAUSES
If any portion of these liquidated damages provisions is determined to be
unenforceable, the other portions will remain in full force and effect.
3.20 ASSIGNMENTS
The Contractor will not assign the Contract, in whole or in part, without
the prior written approval of DHS.
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3.21 DISPUTES AND APPEALS
This Disputes and Appeals section will be used by the Contractor as the
means of seeking resolution of disputes on contractual issues.
Filing a dispute will not preclude DHS from recouping the value of the
amount in dispute from the Contractor or from offsetting this amount from
subsequent capitation payment(s). If the amount to be recouped exceeds 25
percent of the capitation payment, amounts of up to 25 percent will be
withheld from successive capitation payments until the amount in dispute is
fully recouped. If a recoupment or offset is later found to be
inappropriate, DHS will repay the Contractor the full amount of recoupment
or offset, plus interest at the Pooled Money Investment Rate pursuant to
Government Code Section 16480 et seq.
3.21.1 DISPUTES RESOLUTION BY NEGOTIATION
DHS and Contractor agree to try to resolve all contractual issues by
negotiation and mutual agreement at the Contracting Officer level without
litigation. The parties recognize that the implementation of this policy
depends on open-mindedness, and the need for both sides to present adequate
supporting information on matters in question.
Before issuance of a Contracting Officer's decision, informal discussions
between the parties by individuals who have not participated substantially
in the matter in dispute will be considered by the parties in efforts to
reach mutual agreement.
3.21.2 NOTIFICATION OF DISPUTE
Within fifteen (15) days of the date the dispute concerning performance of
this Contract arises or otherwise becomes known to the Contractor, the
Contractor will notify the Contracting Officer in writing of the dispute,
describing the conduct (including actions, inactions, and written or oral
communications) which it is disputing.
The Contractor's notification will state, on the basis of the most accurate
information then available to the Contractor, the following:
A. That it is a dispute pursuant to this section.
B. The date, nature, and circumstances of the conduct which is subject of
the dispute.
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C. The names, phone numbers, function, and activity of each Contractor,
Subcontractor, DHS/State official or employee involved in or
knowledgeable about the conduct.
D. The identification of any documents and the substances of any oral
communications involved in the conduct. Copies of all identified
documents will be attached.
E. The reason why the Contractor is disputing the conduct.
F. The cost impact to the Contractor directly attributable to the alleged
conduct, if any.
G. The Contractor's desired remedy.
The required documentation, including cost impact data, will be carefully
prepared and submitted with substantiating documentation by the Contractor.
This documentation will serve as the basis for any subsequent appeal.
Following submission of the required notification, with supporting
documentation, the Contractor will diligently continue performance of this
Contract, including matters identified in the Notification of Disputes, to
the maximum extent possible.
3.21.3 CONTRACTING OFFICERS DECISION
Any disputes concerning performance of this Contract will be decided by the
Contracting Officer in a written decision stating the factual basis for the
decision. The Contracting Officer will serve a copy of the decision on the
Contractor. The decision of the Contracting Officer will be rendered within
thirty (30) days of receipt of a Notification of Dispute or any additional
substantiating documentation requested by the Contracting Officer, unless
the Contracting Officer provides a written explanation to the Contractor
why a longer period is necessary. The decision will be final and conclusive
unless within thirty (30) days from the date of service of that decision
the Contractor files with the Contracting Officer a written appeal
addressed to the Director, DHS, State of California.
The Contracting Officer's decision will:
A. Find in favor of the Contractor, in which case the Contracting Officer
may:
1. Countermand the earlier conduct which caused the Contractor to
file a dispute; or
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2. Reaffirm the conduct and, if there is a cost impact sufficient to
constitute a change in obligations pursuant to the payment
provisions contained in Article V, direct DHS to comply with that
section.
B. Deny the Contractor's dispute and, where necessary direct the manner
of future performance; or
C. Request additional substantiating documentation in the event the
information in the Contractor's notification is inadequate to permit a
decision to be made under A. or B. above, and will advise the
Contractor as to what additional information is required, and
establish how that information will be furnished. The Contractor will
have thirty (30) days to respond to the Contracting Officer's request
for further information. Upon receipt of this additional requested
information, the Contracting Officer will have thirty (30) days to
respond with a decision. Failure to supply additional information
required by the Contracting Officer within the time period specified
above will constitute waiver by the Contractor of all claims in
accordance with Section 3.21.5.
3.21.4 CONTRACTOR DUTY TO PERFORM
Pending final determination of any dispute hereunder, the Contractor will
proceed diligently with the performance of this Contract and in accordance
with the Contracting Officer's decision.
3.21.5 WAIVER OF CLAIMS
If the Contractor fails to submit a Notification of Dispute, supporting and
substantiating documentation, or any additionally required information in
the manner and within the time specified in the Disputes and Appeals
sections, that failure will constitute a waiver by the Contractor of all
claims arising out of that conduct, whether direct or consequential in
nature.
3.22 ENROLLMENT
The Contractor will accept as Members Medi-Cal beneficiaries in the
mandatory and voluntary aid categories as defined in Article II, Section X,
Eligible Beneficiaries, including beneficiaries in Aid Codes who elect to
enroll with the Contractor or are assigned to the Contractor.
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3.22.1 ENROLLMENT - GENERAL
Eligible Beneficiaries residing within the Service Area of the Contractor
may be enrolled at any time during the term of this Contract. Eligible
Beneficiaries will be accepted by the Contractor up to the limits imposed
in Section 3.22.2, Enrollment Totals, and without regard to physical or
mental condition, age, sex, race, religion, creed, color, national origin,
marital status, sexual orientation or ancestry.
3.22.2 ENROLLMENT TOTALS
* Enrollment under this contract in San Bernardino County will not
exceed 136,332.
* Enrollment under this contract in Riverside County will not exceed
83,038.
Total Enrollment under this Contract will not exceed 219,370 Members.
3.22.3 COVERAGE
Member coverage will begin at 12:01 a.m. on the first day of the calendar
month for which the Eligible Beneficiary's name is added to the approved
list of Members furnished by DHS to the Contractor. The term of membership
will continue indefinitely unless this Contract expires, is terminated, or
the Member is disenrolled under the conditions described in Section 3.22.5.
3.22.4 ENROLLMENT RESTRICTION
Enrollment may proceed to the plan's maximum total number of Members unless
restricted by DHS. Such restrictions will be defined in writing and the
Contractor notified at least 10 days prior to the start of the period of
restriction. Release of restrictions will be in writing and transmitted to
the Contractor at least 10 days prior to the date of the release.
3.22.5 DISENROLLMENT
Disenrollment will take place under the following conditions subject to
approval by DHS in accordance with the provisions of Title 22, CCR, Section
53440(b):
A. Disenrollment of a Member is mandatory when:
1. The Member requests Disenrollment
2. The Member's eligibility for Enrollment with the Contractor is
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terminated or eligibility for Medi-Cal is ended, including the
death of the Member.
3. Enrollment was in violation of Title 22, CCR, Sections 53400 or
53402, or requirements of this Contract regarding Marketing, and
DHS or Member requests Disenrollment.
4. Disenrollment is requested in accordance with Welfare and
Institutions Code Sections 14303.1 or 14303.2.
5. There is a change of a Member's place of residence to outside the
Contractor's Service Area.
B. Disenrollment is based on the circumstances described in Article VI,
Section 6.7.2, Excluded Services: Circumstances Under Which Member
Disenrolled.
Such Disenrollments will become effective on the first day of the
second month following authorization for Disenrollment, provided
Disenrollment was requested at least 30 days prior to that date.
C. The Contractor will have the right to recommend to DHS the
Disenrollment of any Member in the event of a breakdown in the
"doctor-patient relationship" which makes it impossible for the
Contractor's providers to render services adequately to a Member.
D. Except as provided in subsection B, Membership will cease at midnight
on the last day of the calendar month in which the Member's
Disenrollment request is approved by DHS. On the first day of the
month following the approval of the Disenrollment request, the
Contractor is relieved of all obligations to provide Covered Services
to the Member under the terms of this Contract. The Contractor agrees
in turn to return to DHS any capitation payment forwarded to the
Contractor for persons no longer enrolled under this Contract.
3.23 STANDARDS
Each provider who delivers Covered Services to Members will meet applicable
requirements established under Titles XVIII and XIX of the Social Security
Act, unless exempted from those provisions; applicable requirements of
Chapters 3 and 4, Subdivision 1, Division 3, Title 22, CCR; and the
standards expressed in this Contract. All providers of Covered Services
must be qualified in accordance with current applicable legal,
professional, and technical standards and appropriately
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licensed, certified or registered.
3.24 PHARMACEUTICAL SERVICES AND PRESCRIBED DRUGS
The Contractor will provide pharmaceutical services and prescribed drugs,
either directly or through Subcontracts, in accordance with all laws and
regulations regarding the provision of pharmaceutical services and
prescription drugs to Medi-Cal beneficiaries, including, but not limited
to, Title 22, CCR, Section 53214. As a minimum, such pharmaceutical
services and drugs will be available to Members during Service Site hours.
When in the course of treatment provided to a Member by a Contractor
provider under emergency circumstances requires the use of drugs, a
sufficient quantity of such drugs will be provided to the Member to last
until the Member can reasonably be expected to have a prescription filled.
3.25 FACILITIES
Facilities used by the Contractor for providing Covered Services will
comply with the provisions of Title 22, CCR, Section 53230.
3.26 LABORATORY CERTIFICATION
A. To ensure that each laboratory used to perform services under this
Contract or by Subcontract complies with federal and State law, each
location at which any test or examination on materials derived from
the human body for the purpose of providing information for the
diagnosis, prevention, treatment or assessment of any disease,
impairment, or health of a human being is performed shall have in
effect:
1. A current, unrevoked or unsuspended certificate, certificate for
provider-performed microscopy procedures, certificate of
accreditation, certificate of registration or certificate of
waiver issued under the requirements of 00 Xxxxxx Xxxxxx Code
Section 263a and the regulations adopted thereunder and found at
42 Code of Federal Regulations, Part 493; and, either
a. A current, unrevoked or unsuspended license or registration
issued under the requirements of Chapter 3 (commencing with
Section 1200) of Division 2 of the California Business and
Professions Code and the regulations adopted thereunder; or,
b. Be operated in conformity with Chapter 7 (commencing with
Section 1000) of Division 1 of the California Health and
Safety
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Code and the regulations adopted thereunder.
B. All places used to perform tests or examinations on human biological
specimens (materials derived from the human body) are, by definition,
"laboratories" under State and federal law.
C. Laboratories may exist, therefore, at Nurses' stations within
hospitals, clinics, Skilled Nursing Facilities, operating rooms,
surgical centers, rural health clinics, Physician offices, Xxxxxxx
Xxxxxxxxxx clinics, mobile labs, health fairs, and city, county or
State labs.
D. Any laboratory that does not comply with the appropriate federal and
State law is not eligible for participation in, or reimbursement from,
the Medicare, Medicaid, or Medi-Cal programs.
3.27 SUBCONTRACTS
The Contractor may elect to enter into Subcontracts with other entities in
order to fulfill the obligations of the Contract. In doing so, the
Contractor will meet the subcontracting requirements as stated in Title 22,
CCR, Section 53250 and this Contract.
3.27.1 XXXX-XXXXX AND REGULATIONS
All Subcontracts will be in writing, and will be entered into in accordance
with the requirements of the Xxxx-Xxxxx Health Care Services Plan Act of
1975, Health and Safety Code Section 1340 et seq.; Title 10, CCR, Section
1300 et seq.; W&I Code Section 14200 et seq.; Title 22, CCR, Section 53000
et seq.; and applicable federal and State laws and regulations.
3.27.2 SUBCONTRACT REQUIREMENTS
Each Subcontract will contain:
A. The subcontractor's agreement to make all of its books and records,
pertaining to the goods and services furnished under the terms of the
Subcontract, available for inspection, examination or copying:
1. By DHS, DHHS, DOJ, and DOC.
2. At all reasonable times at the subcontractor's place of business
or at such other mutually agreeable location in California.
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3. In a form maintained in accordance with the general standards
applicable to such book or record keeping.
4. For a term of at least five years from the close of DHS' fiscal
year in which the Subcontract was in effect.
5. Including all Encounter data for a period of at least five years.
B. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor from the Contractor.
C. Subcontractor's agreement to maintain and make available to DHS, upon
request, copies of all sub-subcontracts and to ensure that all
sub-subcontracts are in writing and require that the
Sub-subcontractor:
1. Make all applicable books and records available at all reasonable
times for inspection, examination, or copying by DHS, DHHS, DOJ
and DOC.
2. Retain such books and records for a term of at least five years
from the close of DHS' fiscal year in which the sub-subcontract
is in effect.
D. Subcontractor's agreement to assist the Contractor in the transfer of
care pursuant to Section 3.16.2, in the event of Contract termination.
E. Subcontractor's agreement to notify DHS in the event the agreement
with the Contractor is amended or terminated. Notice is considered
given when properly addressed and deposited in the United States
Postal Service as first-class registered mail, postage attached.
F. Subcontractor's agreement that assignment or delegation of the
Subcontract will be void unless prior written approval is obtained
from DHS.
G. Subcontractor's agreement to hold harmless both the State and plan
Members in the event the Contractor cannot or will not pay for
services performed by the subcontractor pursuant to the Subcontract.
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3.27.3 DEPARTMENTAL APPROVAL - NON-FEDERALLY QUALIFIED HMOs
Except as provided in Section 3.27.6, Federally Qualified Health Centers, a
provider or management Subcontract entered into by a Contractor which is
not a federally qualified HMO will become effective upon approval by DHS in
writing, or by operation of law where DHS has acknowledged receipt of the
proposed Subcontract, and has failed to approve or disapprove the proposed
Subcontract within 60 days of receipt.
Subcontract amendments will be submitted to DHS for prior approval at least
30 days before the effective date of any proposed changes governing
compensation, services, or term. Proposed changes which are neither
approved or disapproved by DHS, will become effective by operation of law
30 days after DHS has acknowledged receipt or upon the date specified in
the Subcontract amendment, whichever is later.
3.27.4 DEPARTMENTAL APPROVAL - FEDERALLY QUALIFIED HMOs
Except as provided in Section 3.27.6, Subcontracts entered into by a plan
which is a federally qualified HMO will be:
A. Exempt from prior approval by DHS.
B. Submitted to DHS upon request.
3.27.5 COMPENSATION
Contractor will not enter into any Subcontract if the compensation or other
consideration which the subcontractor will receive under the terms of the
Subcontract is determined by a percentage of the Contractor's payment from
DHS. This subsection will not be construed to prohibit Subcontracts in
which compensation or other consideration is determined on a capitation
basis.
3.27.6 FEDERALLY QUALIFIED HEALTH CENTERS
Contractor will not enter into a Subcontract with a Federally Qualified
Health Center unless DHS approves the provisions regarding rates, which
will be subject to the standard that they be reasonable, as determined by
DHS, in relation to the services to be provided. In Subcontracts where the
Federally Qualified Health Center has made the election to be reimbursed on
a reasonable cost basis by the State, provisions will be included that
require the subcontractor to keep a record of the number of visits by plan
Members separate from Fee-For-Service Medi-Cal beneficiaries, in addition
to any other data reporting requirements of the Subcontract.
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Subcontracts with FQHCs will also meet Contract requirements of Article VI,
Sections 6.6.19 and 6.6.20.
In Subcontracts where a negotiated capitation rate or Fee-For-Service
reimbursement rate is agreed to as total payment, a provision that the rate
constitutes total payment will be explicitly stated in the Subcontract.
3.27.7 PUBLIC RECORDS
Subcontracts entered into by the Contractor and all information received in
accordance with this subsection will be public records on file with DHS,
except as specifically exempted in statute. The names of the officers and
owners of the subcontractor, stockholders owning more than 10 percent of
the stock issued by the subcontractor and major creditors holding more than
5 percent of the debt of the subcontractor will be attached to the
Subcontract at the time the Subcontract is presented to DHS.
3.27.8 DISCLOSURES
Each Subcontract will contain at least the elements required by Section
3.27.2, Subcontract Requirements, and the following:
A. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor from the plan.
B. Specification of the services to be provided.
C. Specification that the Subcontract will be governed by and construed
in accordance with all laws, regulations, and contractual obligations
of the Contractor.
D. Specification that the Subcontract or Subcontract amendments will
become effective only as set forth in Sections 3.27.3 or 3.27.4.
E. Specification of the term of the Subcontract including the beginning
and ending dates as well as methods of extension, renegotiation and
termination.
F. Subcontractor's agreement to submit reports as required by the
Contractor.
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3.27.9 PAYMENT
Contractor will timely pay provider claims within thirty (30) working days
after receipt, unless the Contractor is a federally qualified health
maintenance organization, in which case the requirement is forty-five (45)
working days from receipt. Notice must be provided to providers in the case
of contested claims within thirty (30) working days after receipt, unless
the Contractor is a federally qualified health maintenance organization, in
which case the requirement is forty-five (45) working days from receipt.
Contractor will have sufficient claims processing/payment systems to timely
process and pay provider claims and to reasonably determine the status of
received claims and calculate provisions for Incurred But Not Reported
Claims.
3.28 CONFIDENTIALITY OF DATA
The Contractor will perform the following duties and responsibilities with
respect to confidentiality of information and data.
3.28.1 CONFIDENTIALITY OF INFORMATION
Notwithstanding any other provision of this Contract, names of persons
receiving public social services are confidential and are to be protected
from unauthorized disclosure in accordance with Title 42, CFR, Section
431.300 et seq., Section 14100.2, W&I Code, and regulations adopted
thereunder. For the purpose of this Contract, all information, records,
data, and data elements collected and maintained for the operation of the
Contract and pertaining to Members will be protected by the Contractor from
unauthorized disclosure.
The Contractor may release Medical Records in accordance with applicable
law pertaining to the release of this type of information.
3.28.2 CONTRACTOR'S DUTIES TO MAINTAIN CONFIDENTIALITY
With respect to any identifiable information concerning a Member under this
Contract that is obtained by the Contractor or its subcontractors, the
Contractor: (1) will not use any such information for any purpose other
than carrying out the express terms of this Contract, (2) will promptly
transmit to DHS all requests for disclosure of such information, except
requests for Medical Records in accordance with applicable law, (3) will
not disclose except as otherwise specifically permitted by this Contract,
any such information to any party other than DHS without DHS' prior written
authorization specifying that the information is releasable under Title 42,
CFR, Section 431.300 et seq., Section 14100.2, W&I Code, and regulations
adopted thereunder, and (4) will, at the expiration or termination of this
Contract, return all
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such information to DHS or maintain such information according to written
procedures sent to the Contractor by DHS for this purpose.
3.29 KEY PERSONNEL (DISCLOSURE FORM)
A. Contractor will file an annual statement with DHS disclosing any
purchases or leases of services, equipment, supplies, or real property
from an entity in which any of the following persons have a
substantial financial interest:
1. Any person also having a substantial financial interest in the
Contractor.
2. Any director, officer, partner, trustee, or employee of the
Contractor.
3. Any member of the immediate family of any person designated in 1
or 2 above.
B. Comply with federal regulations 42 CFR 455.104 (Disclosure by
providers and fiscal agents: Information on ownership and control), 42
CFR 455.105 (Disclosure by providers: Information related to business
transactions), and 42 CFR 455.106.
3.30 CONFLICT OF INTEREST - CURRENT AND FORMER STATE EMPLOYEES
Contractor will not utilize in the performance of this Contract any State
officer or employee in the State civil service or other appointed State
official unless the employment, activity, or enterprise is required as a
condition of the officer's or employee's regular state employment. Employee
in the State civil service is defined to be any person legally holding a
permanent or intermittent position in the State civil service.
3.31 RECORD KEEPING, AUDIT/INSPECTION OF RECORDS
The Contractor will maintain such books and records necessary to disclose
how the Contractor discharged its obligations under this Contract. These
books and records will disclose the quantity of Covered Services provided
under this contract, the quality of those services, the manner and amount
of payment made for those services, the persons eligible to receive Covered
Services, the manner in which the Contractor administered its daily
business, and the cost thereof.
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3.31.1 BOOKS AND RECORDS
These books and records will include, but are not limited to, all physical
records originated or prepared pursuant to the performance under this
Contract including working papers; reports submitted to DHS; financial
records; all Medical Records, medical charts and prescription files; and
other documentation pertaining to medical and non-medical services rendered
to Members.
3.31.2 RECORDS RETENTION
These books and records will be maintained for a minimum of five years from
the end of the Fiscal Year in which the Contract expires or is terminated,
or, in the event the Contractor has been duly notified that DHS, DHHS, DOJ,
or the Comptroller General of the United States, or their duly authorized
representatives, have commenced an audit or investigation of the Contract,
until such time as the matter under audit or investigation has been
resolved, whichever is later.
3.32 AMENDMENT OF CONTRACT
Should either party during the life of this Contract desire a change in
this Contract, that change will be proposed in writing to the other party.
The other party will acknowledge receipt of the proposal within 10 days of
receipt of the proposal. The party proposing any such change will have the
right to withdraw the proposal any time prior to acceptance or rejection by
the other party. Any proposal will set forth a detailed explanation of the
reason and basis for the proposed change, a complete statement of cost and
benefits of the proposed change and the text of the desired amendment to
this Contract which would provide for the change. If the proposal is
accepted, this Contract will be amended to provide for the change mutually
agreed to by the parties on the condition that the amendment is approved by
DHHS, and the State Department of Finance, if necessary.
3.33 CONTRACTOR CERTIFICATIONS
With respect to any report, invoice, record, papers, documents, books of
account, or other Contract required data submitted, pursuant to the
requirements of this Contract, the Contractor's Representative or his/her
designee will certify, under penalty of perjury, that the report, invoice,
record, papers, documents, books of account or other Contract required data
is current, accurate, complete and in full compliance with legal and
contractual requirements to the best of that individual's knowledge and
belief, unless the requirement for such certification is expressly waived
by DHS in writing.
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3.34 CHANGE REQUIREMENTS
3.34.1 GENERAL PROVISIONS
The parties recognize that during the life of this Contract, the Medi-Cal
Managed Care program will be a dynamic program requiring numerous changes
to its operations and that the scope and complexity of changes will vary
widely over the life of the Contract. The parties agree that the
development of a system which has the capability to implement such changes
in an orderly and timely manner is of considerable importance.
3.34.2 CONTRACTOR'S OBLIGATION TO IMPLEMENT
The Contractor will make changes mandated by DHS. In the case of mandated
changes in policy, regulations, statutes, or judicial interpretation, DHS
may direct the Contractor to immediately begin implementation of any change
by issuing a Change Order. If DHS issues a Change Order, the Contractor
will be obligated to implement the required changes while discussions
relevant to any capitation rate adjustment, if applicable, are taking
place.
DHS may, at any time, within the general scope of the Contract, by written
notice, issue Change Orders to the Contract. This process will make use of
the following documents:
Medi-Cal Managed Care Division (MMCD) Policy Letters - This document will
be utilized to notify the Contractor of clarifications made to the Medi-Cal
Managed Care Program. This document will include instructions to the
Contractor regarding implementation. This document will also be used to
initiate various ongoing changes required of the Contractor throughout the
Contract, the performance of which falls within the Contract's agreed upon
capitated rate.
Change Orders will be used when an Annual Capitation Rate, if applicable,
is adjusted (See Article V, Payment Provisions). Change Orders may also be
used to amend the Contractor's responsibilities.
3.35 MINORITY/WOMEN/DISABLED VETERAN BUSINESS ENTERPRISES (M/W/DVBE)
Contractor will comply with applicable requirements of California law
relating to Minority/Women/Disabled Veteran Business Enterprises (M/W/DVBE)
commencing at Section 10115 of the Public Contract Code.
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3.36 DRUG FREE WORKPLACE ACT OF 1990
Contractor will comply with applicable requirements of the Drug Free
Workplace Act of 1990 (Government Code Section 8355).
3.37 INDEMNIFICATION
3.37.1 INDEMNIFICATION BY CONTRACTOR
Contractor agrees to indemnify, defend, and save harmless the State, its
officers, agents, and employees:
A. From any and all claims and losses accruing or resulting to any and
all Contractors, Subcontractors, materialmen, laborers, and any other
person, firm, corporation, or other entity furnishing or supplying
work services, materials, or supplies in connection with the
performance of this Contract;
B. From any and all claims and losses accruing or resulting to any
person, firm, corporation, or other entity injured or damaged by the
Contractor, its officers, employees, or Subcontractors in the
performance of this Contract.
3.38 AMERICANS WITH DISABILITIES ACT OF 1990 REQUIREMENTS
The Contractor will comply with all applicable federal requirements in
Section 504 of the Rehabilitation Act of 1973 and the Americans with
Disabilities Act of 1990 (42 USC, Section 12100 et seq.), Title 45, Code of
Federal Regulations (CFR), Part 84 and Title 28, CFR, Part 36.
3.39 NEWBORN CHILD COVERAGE
The Contractor will provide Covered Services to a child born to a Member
for the month of birth and the following month. For a child born in the
month immediately preceding the mother's membership, the Contractor will
provide Covered Services to the child during the mother's first month of
Enrollment. No additional capitation payment will be made to the Contractor
by DHS.
3.40 RECOVERY FROM OTHER SOURCES OR PROVIDERS
Contractor will make reasonable efforts to recover the value of Covered
Services rendered to Members whenever the Members are covered for the same
services, either fully or partially, under any other State or federal
medical care program or under other contractual or legal entitlement
including, but not limited to, a private
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Article III
group or indemnification program, but excluding instances of the tort
liability of a third party. Contractor will coordinate benefits with other
programs or entitlement, recognizing the other coverage as primary and
Medi-Cal as the payor of last resort. Such monies recovered are retained by
the Contractor.
3.41 THIRD-PARTY TORT LIABILITY
Contractor will make no claim for recovery of the value of Covered Services
rendered to a Member when such recovery would result from an action
involving the tort liability of a third party or casualty liability
insurance including Workers' Compensation awards and uninsured motorists
coverage. The Contractor will identify and notify DHS of cases in which an
action by the Medi-Cal Member involving the tort or Workers' Compensation
liability of a third party could result in recovery by the Member of funds
to which DHS has lien rights under Article 3.5 (commencing with Section
14124.70), Part 3, Division 9, Welfare and Institutions Code. Such cases
will be referred to DHS within 10 days of discovery. To assist DHS in
exercising its responsibility for such recoveries, Contractor will meet the
following requirements:
A. If DHS requests payment information and/or copies of paid
invoices/claims for Covered Services to an individual Member,
Contractor will deliver the requested information within 10-30 days of
the request. The value of the Covered Services will be calculated as
the usual, customary and reasonable charge made to the general public
for similar services or the amount paid to subcontracted providers or
out of plan providers for similar services.
B. Information to be delivered will contain the following data items:
1. Member name.
2. Full 14 digit Medi-Cal number.
3. Social Security Number.
4. Date of birth.
5. Contractor name.
6. Provider name (if different from Contractor).
7. Dates of service.
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8. Diagnosis code and/or description of illness/injury.
9. Procedure code and/or description of services rendered.
10. Amount billed by a subcontractor or out of plan provider to
Contractor (if applicable).
11. Amount paid by other health insurance to Contractor or
subcontractor.
12. Amount and date paid by Contractor to subcontractor or out of
plan provider (if applicable).
13. Date of denial and reasons (if applicable).
C. Contractor will identify to DHS the name, address and telephone number
of the person responsible for receiving and complying with requests
for mandatory and/or optional at-risk service information.
D. If Contractor receives any requests by subpoena from attorneys,
insurers, or beneficiaries for copies of bills, Contractor will
provide DHS with a copy of any document released as a result of such
request, and will provide the name and address and telephone number of
the requesting party.
3.42 OBTAINING DHS APPROVAL
Contractor will obtain written approval from DHS prior to implementing or
using the following:
A. Providers of Covered Services, except for providers of seldom used or
unusual services as determined by DHS.
B. Facilities.
C. Subcontracts and sub-subcontracts with providers or for management
services if the Contractor is not a federally qualified HMO.
D. Marketing activities.
E. Marketing materials, promotional materials, and public information
releases relating to performance under this Contract, Member service
guides; Member newsletters; and provider claim forms unique to the
Contract.
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Article III
F. Member Grievance procedure.
G. Member Disenrollment procedure.
H. Enrollment, Disenrollment and Grievance forms.
Revisions to these items must be approved by DHS prior to taking effect.
3.43 PILOT PROJECTS
DHS, pursuant to W&I Code Section 14094.3(c)(2), may establish pilot
projects to test alternative managed care models tailored to the special
health care needs of children under the California Children Services (CCS)
Program. These pilot projects may affect the Contractor's obligations under
the Contract in the areas of Covered Services, eligible enrollees, and
administrative systems. These pilot projects will be implemented through
Contract amendment pursuant to Section 3.32 and, if necessary, Change Order
pursuant to Section 3.34. DHS will not require the Contractor to cover CCS
services under the capitation rate as part of a pilot project unless the
Contractor is a voluntary participant in the project.
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Article IV
ARTICLE IV - DUTIES OF THE STATE
In discharging its obligations under this Contract, the State will perform
the following duties:
4.1 PAYMENT FOR SERVICES
Pay the appropriate capitation payments set forth in Article V, Payment
Provisions, to the Contractor for each eligible Member under this Contract,
and ensure that such payments are reasonable and do not exceed the amount
set forth in 42 CFR, Section 447.361. Payments will be made monthly for the
duration of this Contract.
4.2 MEDICAL REVIEWS
Conduct medical reviews at least once every 12 months in accordance with
the provisions of Section 14456, Welfare and Institutions Code, and issue
medical review reports to the Contractor detailing findings,
recommendations, Corrective Action and liquidated damages, as appropriate.
4.3 FACILITY INSPECTIONS
Conduct random on-site inspections, at the discretion of DHS of health
Facilities and review and approve, in writing, the required Site Inspection
Forms prior to their use for providing services to Members under the terms
of this Contract. Inspections for continuing Facility adequacy will be
conducted periodically thereafter.
4.4 ENROLLMENT PROCESSING
Review applications for Enrollment submitted timely by the Enrollment
Contractor, and check the eligibility of applicants for services under this
Contract. For those applications for Enrollment received prior to the
specified deadlines, DHS will provide to the Contractor a list of Members
on a monthly basis, effective the first of the following month.
Those applications for Enrollment received after the specified submission
deadlines will become effective the first day of the second month following
the receipt of the late application.
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Article IV
4.5 DISENROLLMENT PROCESSING
Review and process requests for Disenrollment and notify the Contractor and
the Member of its decision.
4.6 TESTING AND CERTIFICATION OF MARKETING REPRESENTATIVES
Test all Contractor Marketing Representatives for knowledge of the program
prior to their engaging in Marketing or Medi-Cal Managed Care information
activities on behalf of the Contractor. Certify as qualified Marketing
Representatives, those persons demonstrating adequate knowledge of the
program, provided they are of good moral character.
4.7 APPROVAL PROCESS
Acknowledge in writing, within five working days of receipt, the receipt of
any material sent to DHS by the Contractor under the provisions of Article
III, Section 3.42, Obtaining Departmental Approval. Within 60 days of
receipt, approve in writing the use of such material or provide the
Contractor with a written explanation why its use is not approved.
4.8 PROGRAM INFORMATION
Provide the Contractor with complete and current information with respect
to pertinent policies, procedures, and guidelines affecting the operation
of this Contract.
4.9 SANCTIONS
Apply sanctions, in accordance with Title 22, CCR, Section 53350, to the
Contractor for violations of the terms of this Contract, applicable federal
and State laws and regulations.
4.10 CATASTROPHIC COVERAGE LIMITATION
Limit the Contractor's liability to provide or arrange and pay for care for
illness of, or injury to, Members which results from or is greatly
aggravated by, a catastrophic occurrence or disaster.
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4.11 RISK LIMITATION
Agree, that there will be no risk limitation and that Contractor will have
full financial liability to provide covered services to enrolled beneficiaries.
4.12 NOTICE OF TERMINATION OF CONTRACT
Notify Members of their health care benefits and options available upon
termination or expiration of this Contract.
4.13 ACCESS REQUIREMENTS AND STATE'S RIGHT TO MONITOR
The State will have the right to monitor all aspects of the Contractor's
operation for compliance with the provisions of this Contract and
applicable federal and State laws and regulations. Such monitoring
activities will include, but are not limited to, inspection and auditing of
Contractor, subcontractor, and provider Facilities, management systems and
procedures, and books and records as the Director deems appropriate, at any
time during the Contractor's or other Facility's normal business hours. The
monitoring activities will be either announced or unannounced.
To assure compliance with the Contract and for any other reasonable
purpose, the State and its authorized representatives and designees will
have the right to premises access, with or without notice to the
Contractor. This will include the MIS operations site or such other place
where duties under the Contract are being performed.
Staff designated by the State or DHS will have access to all security areas
and the Contractor will provide, and will require any and all of its
subcontractors to provide, reasonable facilities, cooperation and
assistance to State representative(s) in the performance of their duties.
Access will be undertaken in such a manner as to not unduly delay the work
of the Contractor and/or the subcontractor(s).
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ARTICLE V
ARTICLE V - PAYMENT PROVISIONS
5.0 PAYMENT PROVISIONS
5.1 CONTRACTOR RISK IN PROVIDING SERVICES
Contractor will assume the total risk of providing the Covered Services on
the basis of the periodic capitation payment for each Member, except as
otherwise allowed in this Contract. Any monies not expended by the
Contractor after having fulfilled obligations under this Contract will be
retained by the Contractor.
5.2 AMOUNTS PAYABLE
The maximum amount payable for the 1995-96 Fiscal Year ending June 30, 1996
will not exceed $32,080,630. Any requirement of performance by DHS and the
Contractor for the period of the Contract subsequent to June 30, 1996 will
be dependent upon the availability of future appropriations by the
Legislature for the purpose of this Contract. If funds become available for
purposes of this Contract from future appropriations by the Legislature,
the maximum amount payable under this Contract in the 1996-97 Fiscal Year
ending June 30, 1997 will not exceed $194,472,680. If funds become
available for purposes of this Contract from future appropriations by the
Legislature, the maximum amount payable under this Contract in the 1997-98
Fiscal Year ending June 30, 1998 will not exceed $194,472,680. If funds
become available for purposes of this Contract from future appropriations
by the Legislature, the maximum amount payable under this Contract in the
1998-99 Fiscal Year ending June 30, 1999 will not exceed $194,472,680. If
funds become available for purposes of this Contract from future
appropriations by the Legislature, the maximum amount payable under this
Contract in the 1999-2000 Fiscal Year ending June 30, 2000 will not exceed
$194,472,680. If funds become available for purposes of this Contract from
future appropriations by the Legislature, the maximum amount payable under
this Contract in the 2000-01 Fiscal Year ending June 30, 2001 will not
exceed $194,472,680. If funds become available for purposes of this
Contract from future appropriations by the Legislature, the maximum amount
payable under this Contract in the 2001-02 Fiscal Year ending June 30, 2002
will not exceed $145,854,520. The maximum amount payable under this
Contract will not exceed $1,150,298,550.
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ARTICLE V
5.3 CAPITATION RATES
DHS will remit to the Contractor a capitation payment each month for each
Medi-Cal Member that appears on the approved list of Members supplied to
the Contractor by DHS. The capitation rate shall be the amount specified in
this Article. The payment period for health care services will commence on
the first day of operations, as determined by DHS. Capitation payments will
be made in accordance with the following schedule of capitation payment
rates:
AID CODE CATEGORIES
Family: 01,02,08,30,32,33,34,35,38,39,3A,3C,3P,3R,40,42,4C,4K,54,59,5K;
Aged : 10,14,16,18; Disabled: 20,24,26,28,36,60,64,66,68,6A,6C;
Child : 03,04,45,82; Adult : 00
XXX XXXXXXXXXX XXXXXX 0/00 - 0/00 XXX XXXXXXXXXX XXXXXX 6/96 - 9/97
Family $ 70.01 Family $ 71.59
Child $ 67.91 Child $ 67.17
Aged $ 117.66 Aged $ 121.76
Disabled $ 177.15 Disabled $ 174.45
Adult $ 536.02 Adult $ 554.73
RIVERSIDE COUNTY 7/95 - 5/96 RIVERSIDE COUNTY 6/96 - 9/97
Family $ 74.70 Family $ 76.39
Child $ 68.51 Child $ 67.74
Aged $ 110.37 Aged $ 114.62
Disabled $ 181.61 Disabled $ 178.77
Adult $ 492.78 Adult $ 509.94
5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop loss
reinsurance provisions, on behalf of a Member for all Covered Services
required by such Member and for all Administrative Costs incurred by the
Contractor in providing or arranging for such services, but do not include
payment for the recoupment of current or previous losses incurred by the
Contractor. DHS is not responsible for making payments for recoupment of
losses. The basis for the determination of the capitation payment rates is
outlined in Attachment I (consisting of 20 pages).
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ARTICLE V
5.5 DETERMINATION OF RATES
DHS will determine the capitation rates for the initial period December 1,
1995, or the Contract effective date of operations if later, through
September 30, 1997. Subsequent to September 30, 1997 and through the
duration of the Contract, DHS will make an annual redetermination of rates
for each rate year defined as the 12 month period from October 1, through
September 30. DHS reserves the right to redetermine rates on an actuarial
basis or move to a negotiated rate for each rate year. All payments beyond
June 1996 and rate adjustments beyond September 1997 are subject to future
appropriations of funds by the Legislature and the Department of Finance
approval. Further, all payments are subject to the availability of Federal
congressional appropriation of funds.
If DHS redetermines rates on an actuarial basis, DHS will determine whether
the rates will be increased, decreased, or remain the same. If it is
determined by DHS that the Contractor's capitation rates will be increased
or decreased, that increase or decrease will be effectuated through a
Change Order to this Contract in accordance with the provisions of Article
III, Section 3.34, Change Requirements, subject to the following
provisions:
A. The Change Order will be effective as of October 1 of each year
covered by this Contract.
B. In the event there is a any delay in a determination to increase or
decrease capitation rates, so that a Change Order may not be
processed in time to permit payment of new rates commencing October 1,
the payment to the Contractor will continue at the rates then in
effect. Those continued payments will constitute interim payment
only. Upon final approval of the Change Order providing for the rate
change, DHS will make adjustments for those months for which interim
payment was made.
C. Notwithstanding paragraph B, payment of the new annual rates will
commence no later than December 1, provided that a Change Order
providing for the new annual rates has been issued by DHS. By
accepting payment of new annual rates prior to full approval by all
control agencies of the Change Order to this Contract implementing
such new rates, the Contractor stipulates to a confession of judgment
for any amounts received in excess of the final approved rate. If the
final approved rate differs from the rates agreed upon by the
Contractor and DHS:
1. Any underpayment by the State will be paid to the Contractor
within 30 days after final approval of the new rates.
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ARTICLE V
2. Any overpayment to the Contractor will be recaptured by the
State's withholding the amount due from the Contractor's next
capitation check.
If the amount to be withheld from that capitation check exceeds
25 percent of the capitation payment for that month, amounts up
to 25 percent will be withheld from successive capitation
payments until the overpayment is fully recovered by the State.
5.6 REDETERMINATION OF RATES - OBLIGATION CHANGES
The Capitation rates may be adjusted during the rate year to provide for a
change in obligations which results in an increase or decrease of more than
one percent of cost (as defined in Title 22, CCR, Section 53322) to the
Contractor. Any adjustments will be effectuated through a Change Order to
the Contract subject to the following provisions:
A. The Change Order will be effective as of the first day of the month in
which the change in obligations is effective, as determined by DHS.
B. In the event DHS is unable to process the Change Order in time to
permit payment of the adjusted rates as of the month in which the
change in obligations is effective, payment to Contractor will
continue at the rates then in effect. Continued payment will
constitute interim payment only. Upon final approval of the Change
Order providing for the change in obligations, DHS will make
adjustments for those months for which interim payment was made.
If mutual agreement between DHS and the Contractor cannot be attained on
capitation rates for rate years subsequent to September 30, 1997, the
Contractor will retain the right to terminate the Contract, but no earlier
than September 30, 1998. Notification of intent to terminate a Contract
will be in writing and provided to DHS at least nine months prior to the
effective date of termination. Contract termination due to an inability to
reach agreement upon capitation rates is limited to termination at the end
of each rate year, September 30th. Therefore, Contractor must provide
termination notification by December 31st of the prior year for an
effective termination date of September 30th. DHS will pay the capitation
rates last offered for that rate period until the Contract is terminated.
5.7 REINSURANCE
A. The Contractor may obtain reinsurance (stop loss coverage) for the
cost of providing Covered Services under this Contract. Reinsurance
will not limit
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ARTICLE V
the Contractor's liability below $5,000 per Member for any 12-month
period as specified by DHS. The Contractor may obtain reinsurance for
the total cost of services provided to Members by non-contractor
emergency service providers and for 90 percent of all costs exceeding
115 percent of its income during any Contractor fiscal year.
B. If Contractor selects State reinsurance, Contractor will submit a
reinsurance claim form along with copies of the actual claims upon
exceeding the reinsurance threshold. As part of the processing, actual
claims are priced to appropriate Medi-Cal rates and the appropriate
amount in excess of the reinsurance threshold is remitted to the
Contractor by DHS.
C. Claims submitted will not be paid by DHS unless received by DHS not
later than the last day of the sixth month following the end of the
twelve-month period in which they were incurred.
D. The time specified for submission of claims may be extended for a
period not to exceed one year upon a finding of "good cause" by the
Director in the following circumstances:
1. Where the claim involves health coverage, other than Medi-Cal,
and the delay is necessary to permit the Contractor to obtain
payment, partial payment, or proof of non-liability of that other
health coverage.
2. Where the claim submission was delayed due to eligibility
certification or determination by the State or county.
3. Where there was substantial interference with claim submission
due to damage to or destruction of the Contractor's (or
subcontractor's) business office or records by a natural
disaster, including fire, flood or earthquake or other similar
circumstances.
4. Where delay in claims submission was due to other circumstances
that are clearly beyond the control of the Contractor.
Circumstances that will not be considered beyond the control of
the Contractor include, but are not limited to:
a. Negligence or delay of the Contractor or Contractor's
employees, agents, and subcontractors.
b. Misunderstanding of or unfamiliarity with Medi-Cal
regulations, or the terms of this Contract.
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ARTICLE V
c. Illness, absence or other incapacity of a Contractor's
employee, agent, or subcontractor responsible for
preparation and submission of claims.
d. Delays caused by the United States Postal Service or any
private delivery service.
5.8 CATASTROPHIC COVERAGE LIMITATION
DHS may limit the Contractor's liability to provide or arrange and pay for
care for illness of, or injury to, Members which results from or is greatly
aggravated by, a catastrophic occurrence or disaster.
Contractor will return a prorated amount of the capitation payment
following the Director's invocation of the catastrophic coverage
limitation. The amount returned will be determined by dividing the total
capitation payment by the number of days in the month. The amount will be
returned to DHS for each day in the month after the Director has invoked
the catastrophic coverage limitation clause.
5.9 FINANCIAL SECURITY
If capitation is prepaid, Contractor will provide satisfactory evidence of
and maintain Financial Security in an amount equal to at least one month's
capitation payment, in a manner specified by DHS. The Financial Security
will remain in effect for at least 90 days following termination or
expiration of this Contract or until, in the judgment of DHS the
obligations set forth in this Contract are fulfilled.
5.10 LIMITATION TO FEDERAL FINANCIAL PARTICIPATION
Limitation to Federal Financial Participation is as follows:
A. It is mutually understood between the parties that this Contract may
have been written before ascertaining the availability of
congressional appropriation of funds, for the mutual benefit of both
parties in order to avoid program and fiscal delays which would occur
if the Contract were executed after that determination was made.
B. This Contract is valid and enforceable only if sufficient funds are
made available to the State by the United States government for each
Fiscal Year for the purpose of this program. In addition, this
Contract is subject to any additional restrictions, limitations or
conditions enacted by the Congress or any statute enacted by the
Congress which may affect the provisions, terms or
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funding of this Contract in any manner.
C. It is mutually agreed that if Congress does not appropriate sufficient
funds for the program, this Contract will be amended to reflect any
reduction in funds.
D. DHS has the option to terminate the Contract under the 60 day
termination clause or to amend the Contract to reflect any reduction
in funds.
5.11 RECOVERY OF CAPITATION PAYMENTS
DHS will have the right to recover amounts paid to the Contractor in the
following circumstances as specified:
A. DHS determines that a Member has either been improperly enrolled, or
should have been disenrolled with an effective date in a prior month.
DHS may recover the capitation payments made to the Contractor for the
Member and absolve the Contractor from all financial and other risk
for the provision of services to the Member under the terms of the
Contract for the month or months in question.
B. As a result of the Contractor's failure to perform contractual
responsibilities to comply with mandatory federal Medicaid
requirements, the Department of Health and Human Services (DHHS)
disallows Federal Financial Participation (FFP) for payments made by
DHS to the Contractor. DHS may recover the amounts disallowed by DHHS
by an offset to the capitation payment made to the Contractor. If
recovery of the full amount at one time imposes a financial hardship
on the Contractor, DHS at its discretion may grant a Contractor's
request to repay the recoverable amounts in monthly installments over
a period of consecutive months not to exceed six (6) months.
C. If DHS determines that any other erroneous or improper payment not
mentioned above has been made to the Contractor, DHS may recover the
amounts determined by an offset to the capitation payment made to the
Contractor. If recovery of the full amount at one time imposes a
financial hardship on the Contractor, DHS, at its discretion, may
grant a Contractor's request to repay the recoverable amounts in
monthly installments over a period of consecutive months not to exceed
six (6) months.
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ARTICLE VI - SCOPE OF WORK
6.0 ORGANIZATION
6.1 LEGAL CAPACITY
Contractor will maintain the legal capacity to contract with DHS and
maintain appropriate licensure as a health care service plan in accordance
with the Xxxx-Xxxxx Act.
6.2 ADMINISTRATION/STAFFING
6.2.1 CONTRACT PERFORMANCE
Contractor will maintain the organization and staffing, for implementing
and operating the Contract. Contractor will ensure the following:
A. The organization has an accountable governing body.
B. This Contract is a high priority and that the Contractor is committed
to supplying any necessary resources to assure full performance of the
Contract.
C. If the Contractor is a subsidiary organization, the attestation of the
parent organization that this Contract will be a high priority to the
parent organization, and that the parent organization is committed to
supplying any necessary resources to assure full performance of the
Contract.
6.2.2 MEDICAL DIRECTOR
Contractor will maintain a full time Physician as Medical Director who will
assume the following responsibilities:
A. Ensure that medical decisions are rendered by qualified medical
personnel, unhindered by fiscal or administrative management.
B. Ensure that medical care provided meets the standards for acceptable
medical care.
C. Ensure that medical protocols and rules of conduct for plan medical
personnel are followed.
D. Develop and implement medical policy.
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E. Resolve medically related Grievances.
F. Have a significant role in monitoring, investigating and hearing
Grievances.
G. Have a significant role in the Contractor's Quality Improvement
program.
6.2.3 MEDICAL DECISIONS
Contractor will ensure that medical decisions are not unduly influenced by
fiscal management.
6.2.4 MEDICAL DIRECTOR CHANGES
The Contractor will report to DHS any changes in the status of the Medical
Director within ten (10) days.
6.2.5 ADMINISTRATIVE DUTIES/RESPONSIBILITIES
The Contractor will maintain the organizational and administrative
capabilities to carry out its duties and responsibilities under the
Contract. This will include as a minimum the following:
A. Designated persons, qualified by training or experience, to be
responsible for the Medical Record service.
B. Member and Enrollment reporting systems as specified in Section 6.4,
Management and Information Systems and Section 6.9, Member Services/
Grievance Systems.
C. A Member Grievance procedure, as specified in Section 6.9, Member
Services/Grievance System.
D. Data reporting capabilities sufficient to provide necessary and timely
reports to DHS, as required by Section 6.4, Management Information
Systems.
E. Financial records and books of account maintained on the accrual
basis, in accordance with Generally Accepted Accounting Principles,
which fully disclose the disposition of all Medi-Cal program funds
received, as specified in Section 6.3, Financial Information.
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6.2.6 MEMBER REPRESENTATION
Contractor will ensure that Medi-Cal Members are represented and
participate in establishing the public policy of the plan, regarding the
plan's Medi-Cal programs.
6.3 FINANCIAL INFORMATION
6.3.1 FINANCIAL VIABILITY/STANDARDS COMPLIANCE
The Contractor will demonstrate financial viability/standards compliance to
DHS' satisfaction for each of the following elements:
A. Tangible Net Equity (TNE).
The Contractor at all times will be in compliance with the TNE
requirements in accordance with Title 10, CCR, Section 1300.76.
B. Administrative Costs.
Contractor's Administrative Costs will not exceed the guidelines as
established under Title 10, CCR, Section 1300.78.
C. Standards of Organization and Financial Soundness.
The Contractor will maintain reasonable standards of its organization
sufficient to conduct the proposed operations and that its financial
resources are sufficient for sound business operations in accordance
with Title 10, CCR, Sections 1300.67.3, 1300.75.1, 1300.76, 1300.76.3,
1300.77.1, 1300.77.2, 1300.77.3, 1300.77.4, 1300.78, and Title 22,
CCR, Sections 53200, 53251, and 53324.
D. Working Capital.
The Contractor will maintain a working capital ratio of at least 1:1.
6.3.2 FINANCIAL AUDIT/REPORTS
The Contractor will ensure that an annual audit is performed according to
Section 14459, W&I Code. Combined Financial Statements will be prepared to
show the financial position of the overall related health care delivery
system when delivery of care or other services is dependent upon
Affiliates. Financial Statements will be presented in a form that clearly
shows the financial position of the Contractor
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separately from the combined totals. Inter-entity transactions and profits
will eliminated if combined statements are prepared. The Contractor will
have separate certified Financial Statements prepared if an independent
accountant decides that preparation of combined statements is
inappropriate.
A. The independent accountant will state in writing reasons for not
preparing combined Financial Statements.
B. The Contractor will provide supplemental schedules that clearly
reflect all inter-entity transactions and eliminations necessary to
enable DHS to analyze the overall financial status of the entire
health care delivery system.
1. In addition to annual certified Financial Statements the
Contractor will complete the entire 1989 HMO Financial Report of
Affairs and Conditions Format, commonly known as the "Orange
Blank". The Certified Public Accountant's (CPA) audited Financial
Statements and the "Orange blank" report will be submitted to DHS
no later than ninety (90) calendar days after the close of the
Contractor's Fiscal Year.
2. On a quarterly basis the Contractor will submit to DHS forty-five
(45) calendar days after the end of each quarter under this
Contract financial reports required by Title 22, CCR, Section
53324(c). The required quarterly financial reports will be
prepared on the "Orange Blank" format and will include, at a
minimum, the following reports/schedules:
a. Jurat.
b. Report 1A and 1B: Balance Sheet.
c. Report 2: Statement of Revenue, Expenses, and Net Worth.
d. Statement of Cash Flow, prepared in accordance with
Financial Accounting Standards Board Statement Number 96
(This statement is prepared in lieu of Report #3: Statement
of Changes in Financial Position for Generally Accepted
Accounting Principles (GAAP) compliance.
e. Report 4: Enrollment and Utilization Table.
f. Schedule F: Unpaid Claims Analysis.
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g. Appropriate footnote disclosures in accordance with GAAP.
C. The Contractor will authorize the independent accountant to allow
representatives of DHS, upon written request, to inspect any and all
working papers related to the preparation of the audit report.
6.3.3 MONTHLY FINANCIAL STATEMENTS
The Contractor may be required to file monthly Financial Statements at DHS'
request. If the Contractor is required to file monthly Financial Statements
with DOC, they will file monthly Financial Statements with DHS.
6.3.4 COMPLIANCE WITH AUDIT REQUIREMENTS
The Contractor will cooperate with DHS' own independent audits annually or
as necessary for good cause, at the discretion of DHS. Such audits may be
waived upon submission of the financial audit for the same period conducted
by DOC pursuant to Section 1382 of the Health and Safety Code.
6.3.5 SUBMITTAL OF FINANCIAL INFORMATION
The Contractor will prepare financial information requested in accordance
with Generally Accepted Accounting Principles (GAAP) and where Financial
Statements/projections are requested these statements/projections should be
prepared on the 1989 HMO Reporting Format (commonly known as the "Orange
Blank"). Where appropriate, reference has been made to the Xxxx-Xxxxx
Health Care Service Plan Act of 1975 Rules, found under Title 10, CCR,
Section 1300.51 et. seq. Information submitted will be based on current
operations.
6.4 MANAGEMENT INFORMATION SYSTEM
6.4.1 MANAGEMENT INFORMATION SYSTEM (MIS) CAPABILITY
The Contractor will maintain an MIS that will provide support for all
functions of the plan's processes and procedures related to the flow and
use of data within the plan. The MIS must enable the Contractor to meet the
contractual requirements contained in this Article. It will have the
capability to capture and utilize various data elements to develop
information for plan administration.
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6.4.2 ENCOUNTER DATA SUBMITTAL
The Contractor will submit Encounter data to DHS on a monthly basis 90 days
following the end of the reporting month in which the Encounter occurred as
specified in the Managed Care Encounter Data Reporting Manual. Encounter
data will include the data elements as outlined in Attachment 9.4-B,
Managed Care Encounter Data Reporting Elements of the RFA.
6.4.3 ACCESS TO MIS
The Contractor will provide on-line read-only access to DHS to the
Contractor's MIS.
6.4.4 LATE REPORTS
The Contractor will ensure that, upon written notice by DHS of a late
report, that they will submit the report within five (5) working days from
the date of the post xxxx, or longer if allowed by DHS.
6.4.5 INACCURATE/INSUFFICIENT REPORTS
The Contractor will ensure that the reports submitted to DHS shall contain
complete and accurate information as outlined in Attachment 9.4-B of the
RFA.
Upon written notice by DHS that a report is insufficient or inaccurate, the
Contractor will ensure that a corrected report is submitted to DHS within
fifteen (15) days, or longer if allowed by DHS.
6.5 QUALITY IMPROVEMENT SYSTEM
6.5.1 GENERAL REQUIREMENT
The Contractor will monitor, evaluate, and take effective action to address
any needed improvements in the Quality of Care delivered by all
practitioners providing services on its behalf in all types of settings:
ambulatory, impatient or home setting. The Contractor will be accountable
for the quality of health care delivered whether it be preventive, primary,
specialty, emergency, or ancillary care services regardless of the number
of contracting and subcontracting layers between the Contractor and the
individual practitioner delivering care to the Member.
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6.5.1.1 WRITTEN DESCRIPTION
The Contractor will implement and maintain a written description of its QIP
which will include the following:
A. Organizational commitment to deliver quality health care services,
goals, and objectives including accreditation of its QIP program,
which are evaluated and updated annually and include a time table for
implementation and accomplishment.
B. Organizational chart showing the key persons, the committees and
bodies responsible for Quality Improvement, reporting relationships of
QIP committees within the Contractor's organization, and provisions
for support staff including reporting relationships.
C. Qualifications of staff responsible for Quality Improvement studies
and activities including appropriate education, experience and
training.
D. The QIP scope of review, which must include:
1. Quality of clinical care services including, but not limited to,
preventive services, prenatal care, and family planning services.
2. Quality of nonclinical services including, but not limited to,
availability, accessibility, coordination and continuity of care.
3. Representation of the entire range of care provided by the
Contractor including all demographic groups, care settings
(e.g. Emergency Services, inpatient, ambulatory, and home health
care) and types of services (e.g. preventive, primary, specialty
and ancillary).
E. A description of specific Quality of Care studies and other activities
to be undertaken over a prescribed period of time, the responsible
individuals, organizational resources utilized to accomplish them,
methodologies to be used, including but not limited to those that
address health outcomes, and mechanisms for tracking issues over time.
F. A description of a system for provider review of the QIP which at a
minimum demonstrates Physicians' and other professionals' involvement
and provisions for providing feedback to staff and providers regarding
performance and outcomes.
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G. A description of the annual QIP report will include a summary of all
QIP studies and other activities completed; trending of clinical and
service indicators and other performance data; areas of deficiency and
Corrective Actions undertaken; an evaluation of the overall
effectiveness of the QIP and evidence that activities have contributed
to significant improvements in care delivered to Members.
6.5.2 QIP ADMINISTRATIVE SERVICES
6.5.2.1 Accountability
The Contractor will maintain a system of accountability which includes the
participation of the Governing Body of the Contractor's organization, the
designation of a Quality Improvement Committee with oversight and
performance responsibility, the supervision of activities by the Medical
Director, the inclusion of contracted Physicians and other providers in the
process of QIP development and performance review.
6.5.2.2 GOVERNING BODY
The Contractor will implement and maintain policies that specify the
responsibilities of the Governing Body including at a minimum the
following:
A. Approves the overall QIP and the annual report of the QIP.
B. Appoints an accountable entity or entities within the Contractor's
organization to provide oversight of the QIP.
C. Routinely receives written progress reports from the QIP committee
describing actions taken, progress in meeting QIP objectives, and
improvements made.
D. Formally reviews, (at least annually), a written report on the QIP
which includes; studies undertaken, results, subsequent actions, and
aggregate data on Utilization and quality of services rendered; and
assess the QIP's continuity, effectiveness, and current acceptability.
E. Directs the operational QIP to be modified on an ongoing basis, and
tracks all review findings for follow-up.
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6.5.2.3 QUALITY IMPROVEMENT COMMITTEE
The Contractor will implement and maintain a Quality Improvement Committee
designated by, and accountable to the Governing Body. The role, structure,
function of this committee will be delineated. The committee will meet at
least quarterly but as frequently as necessary to demonstrate follow-up on
all findings and required actions. On a scheduled basis the activities,
findings, recommendations, and actions of the committee are reported to the
Governing Body in writing. The Contractor will ensure that minutes of
committee meetings are submitted to DHS quarterly for review.
Subcontractors, who are representative of the composition of the contracted
provider network, will actively participate in the Quality Improvement
Committee. The Contractor will maintain a process to ensure confidentiality
of QIP discussions as well as avoidance of conflict of interest on the part
of the reviewer.
6.5.2.4 MEDICAL DIRECTOR
The Contractor will ensure that the Medical Director will be directly
involved in the implementation of Quality Improvement activities.
6.5.2.5 PROVIDER PARTICIPATION
The Contractor will ensure that Physicians and other health care providers
will be involved as an integral part of the Quality Improvement program.
The Contractor will maintain and implement appropriate procedures to keep
providers informed of the written QIP, its activities and outcomes. The
Contractor will maintain employment agreements and provider contracts which
include a requirement securing cooperation with the QIP. The Contractor
will ensure that contracted hospitals and other subcontractors will allow
the Contractor access to the Medical Records of its Members.
6.5.2.6 DELEGATION OF QIP ACTIVITIES
The Contractor is accountable for Quality Improvement even when it
delegates Quality Improvement activities to its subcontractors. The
Contractor will maintain a system to ensure accountability of delegated QIP
activities including:
A. Maintenance of policies and procedures which describe delegated
activities, QIP authority, function, and responsibility, how each
subcontractor will be informed of its scope of QIP responsibilities,
and the subcontractor's accountability for delegated activities.
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B. Establish reporting standards to include findings and actions taken by
the subcontractor as a result of the QIP activities with the reporting
frequency to be at least quarterly.
C. Maintenance of written procedures and documentation of continuous
monitoring and evaluation of the delegated functions, evidence that
the actual Quality of Care being provided meets professionally
recognized standards.
D. Assurance and documentation that the subcontractor has the
administrative capacity, task experience, and budgetary resources to
fulfill its responsibilities.
E. The Contractor will approve the delegate's QIP, including its policies
and procedures which will meet standards set forth by the Contractor.
F. The Contractor will ensure that the actual Quality of Care being
provided is being continuously monitored and evaluated.
6.5.2.7 COORDINATION WITH OTHER MANAGEMENT ACTIVITIES
The Contractor will implement and maintain Quality Improvement channels and
facilitate coordination with other performance monitoring activities,
including risk management and resolution and monitoring of Member
complaints and Grievances. The Contractor's QIP will maintain linkages with
other management functions such as network changes, medical management
systems (i.e. pre-certification), practice feedback to Physicians, patient
education/health education, Member services, and human resources feedback.
6.5.3 SYSTEMATIC PROCESS OF QUALITY IMPROVEMENT
6.5.3.1 GENERAL REQUIREMENTS
The Contractor's QIP will objectively and systematically monitor and
evaluate the quality and appropriateness of care and services rendered on
an ongoing basis. The Contractor will conduct Quality of Care studies that
address the quality of clinical care as well as the quality of health
services delivery. The Contractor will ensure that the studies reflect the
population served in terms of age groups, disease categories and special
risk status. These studies will continuously monitor care against practice
guidelines or clinical standards and will use appropriate Quality
Indicators as measurable variables. The Contractor will ensure that data
collected will be analyzed by the appropriate health professionals, and
system issues will be addressed by multi-disciplinary teams. The Contractor
will undertake Corrective Actions whenever problems are identified. The
Contractor will maintain a system for tracking the issues
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over time to ensure that actions for improvement are effective.
6.5.3.2 QUALITY OF CARE STUDIES
The Contractor will perform eleven (11) focused studies on an ongoing basis
as listed below:
A. Clinical Areas
1. Pediatric preventive services: immunizations and health screens.
2. Obstetrical care.
3. Adult preventive services.
B. Health Services Delivery Areas
1. Access to care.
2. Utilization of services.
3. Coordination of care.
4. Continuity of care.
5. Health Education.
6. Emergency Services.
7. Member satisfaction surveys.
8. Family planning.
6.5.3.3 STANDARDS AND GUIDELINES
The Contractor will use the following standards and guidelines for
Preventive Care as designated by DHS. The Contractor will adopt these
standards and guidelines as a baseline for assessment against which care
actually delivered can be compared. For Quality of Care studies in the
health services delivery areas, the Contractor will use the specific
standards set forth in the pertinent subsections. The Contractor's Quality
of Care studies may include health services delivery issues other than the
eleven (11) priority areas identified. For other clinical or health
services delivery areas where
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DHS has not specified clinical standards or practice guidelines, the
Contractor will submit these standards or guidelines to DHS for approval
six weeks prior to conducting the studies.
A. Pediatric:
Periodic health screen schedule based on recommendations of the
American Academy of Pediatrics (AAP) as specified in Title 17, CCR,
Section 6800 et seq. Child Health and Disability Program (CHDP).
Immunization schedule based on recommendations of either the Advisory
Committee on Immunization Practices or the AAP will be acceptable.
B. Adult:
Guidelines based on the Report of the United States Preventive
Services Task Force.
C. Obstetric:
Minimum standards based on recommendations of the American College of
Obstetrics and Gynecology. Contractors are further required to provide
risk assessment and interventions consistent with Comprehensive
Perinatal Services Program (CPSP) requirements as specified in Title
22, CCR, Sections 51348 and 51348.1.
6.5.3.4 QUALITY INDICATORS
The Contractor will use the following Quality Indicators for the required
studies in preventive services indicated in Section 6.5.3.3.
A. Pediatric preventive services:
Medi-Cal children who had received the required number of
immunizations in the first two years of life.
B. Adult preventive services:
1. Medi-Cal women aged 52-64 who had at least one mammogram during
the past two years.
2. Medi-Cal women aged 21-64 who had at least one Pap smear during
the past 3 years.
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3. Medi-Cal Members between ages 20 and 64 screened for cholesterol
at least once in the past five years.
C. Pregnant Women
1. Medi-Cal pregnant Members who received adequate prenatal care
based on:
a. The month of pregnancy in which the beneficiary became a
Member of the health plan.
b. The month of pregnancy in which the initial comprehensive
medical/OB visit occurred for each pregnant Member.
c. The number of pregnancy related medical/OB visits during
pregnancy, exclusive of delivery for each pregnant woman.
d. The delivery date for each pregnant Member.
2. Outcomes:
a. Medi-Cal pregnant women who delivered live births (single or
multiple), or still born greater than 20 weeks gestation;
by age, race/ethnicity, and risk status (high risk vs.
others).
b. Live born infants greater than or equal to 20 weeks
gestation (linked to a Medi-Cal pregnant Member) who weighs:
1. Up to 1499 grams (VLBW).
2. 1500 - 2499 grams (LBW).
3. 2500 - 4000 grams
4. > 4000 grams
6.5.3.5 REPORTS
The Contractor will initiate all Quality of Care studies within six months
of operation and the progress and/or results of these Quality of Care
studies will be submitted to DHS contract managers six months after
initiation of the study (due fifteen (15) days after the end of the first
year of operation) and at least quarterly updates thereafter.
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Quarterly updates will be due fifteen (15) days after the end of the
quarter.
6.5.4 CREDENTIALING AND RECREDENTIALING
6.5.4.1 GENERAL REQUIREMENTS
The Contractor will develop, and maintain written policies and procedures
which include initial Credentialing, recredentialing, recertification, and
reappointment of practitioners. Contractor will ensure that policies and
procedures are reviewed and approved by the Governing Body, or its
designee. Contractor will ensure that the responsibility for
recommendations regarding Credentialing decisions will rest with a
Credentialing committee or other peer review body.
6.5.4.2 CREDENTIALING
Contractor will ensure that the initial Credentialing process obtains and
verifies the following information:
A. A current valid license, registration or certificate to practice, a
valid Drug Enforcement Agency registration number as applicable.
B. Graduation from a medical school, completion of a residency, Board
certified or Board eligible as applicable; education as required.
C. Clinical privileges in good standing at the hospital designated by the
practitioner as the primary admitting Facility (this requirement may
be waived for practices which do not have or do not need access to
hospitals), includes review of past history of curtailment or
suspension of medical staff privileges.
D. Work history.
E. Professional liability claims history.
F. Requested information from: National Practitioner Data Bank and the
Medical Board of California (MBC).
G. Any sanctions imposed by Medi-Cal, Medicaid and Medicare.
H. A signed statement by the practitioner at time of application
regarding any physical or mental health problems, any history of
chemical dependency/substance abuse, history of loss of license and/or
felony convictions, history of loss or limitation of privileges or
disciplinary actions.
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As part of the initial Credentialing procedure, the Contractor will conduct
site reviews of each potential Primary Care Physician's office.
6.5.4.3 RECREDENTIALING
The Contractor will develop and maintain policies and procedures
delineating the process for periodic reverification of clinical
credentials. The Contractor will ensure that recredentialing occurs at
least every two years. The Contractor will ensure that the process includes
a review of all areas reviewed for Credentialing, excluding previously
researched past history, a performance review which includes data from
Member complaints, results of quality reviews, Utilization management,
Member satisfaction surveys, and a site visit to Primary Care Physicians'
Facilities will also be included in the recredentialing process.
6.5.4.4 DELEGATED CREDENTIALING
The Contractor will ensure the qualifications of all network practitioners,
approve new providers and sites, and terminate or suspend individual
providers. The Contractor may delegate Credentialing and recredentialing
activities but will monitor the completion and effectiveness of the
delegated process, If the Contractor delegates Credentialing and
recredentialing activities, the Contractor will implement and maintain
policies and procedures which delineate the delegated activities and
responsibility for these activities.
6.5.4.5 DISCIPLINARY ACTIONS
The Contractor will implement and maintain a system for the reporting of
serious quality deficiencies which result in suspension or termination of a
practitioner to the appropriate authorities. The Contractor will implement
and maintain policies and procedures for disciplinary actions including,
reducing, suspending, or terminating a practitioner's privileges.
Contractor will implement and maintain a provider appeal process. The
Contractor will ensure that any providers impacted by adverse
determinations will be provided due process through the Contractor's
provider appeal process.
6.5.5 FACILITY REVIEW
6.5.5.1 GENERAL REQUIREMENT
The Contractor will conduct Facility reviews on all Primary Care Provider's
sites as part of the Credentialing procedures.
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6.5.5.2 REVIEW PROCEDURES
The Contractor will ensure that its Facility review procedures will be
submitted to DHS for approval prior to use and will comply with all of DHS
requirements which include the following categories:
A. Front office procedures including:
1. Telephone access, triage/advice.
2. Appointment scheduling.
3. Missed appointment and follow-up.
4. Referral appointment and follow-up.
5. Referral (consultation) reports, lab and X-ray follow-up.
B. Fire and disaster plan.
C. Infection control.
D. Handling of bio-hazardous wastes.
E. Health education.
F. Medical emergencies.
G. Pharmacy policies (including handling of sample drugs).
H. Medical Records storage and filing.
I. Medical Records documentation.
J. Grievances.
K. Laboratory services.
L. Radiological services.
M. Preventive services for children, adults and pregnant women.
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N. Facility access for physically disabled individuals.
O. Human sterilization consent procedures.
6.5.5.3 NUMBER OF SITES TO BE REVIEWED PRIOR TO OPERATIONS
The Contractor will ensure that Facility reviews are completed on at least
25 % of the total number of Primary Care sites or a minimum of 30 sites
prior to initiating plan operation or new site expansion. Contractors with
30 sites or less, will complete Facility reviews on all sites prior to
initiating operation. The Contractor with NCQA or JCAHO accreditation is
exempted from this requirement.
6.5.5.4 NUMBER OF SITES TO BE REVIEWED AFTER OPERATIONS BEGIN
The Contractor, regardless of NCQA or JCAHO accreditation, will complete
Facility reviews on all (100%) Primary Care sites within 6 months after
plan operation and will conduct ongoing Facility reviews as part of the
recredentialing process.
6.5.5.5 DHS FACILITY INSPECTIONS
Contractor will provide any necessary assistance to DHS in its conduct of
Facility inspections and medical reviews of the Quality of Care being
provided to Members. Contractor will ensure correction of deficiencies as
identified by those inspections and reviews according to the frames
delineated in the resulting reports.
6.5.5.6 CORRECTIVE ACTIONS
The Contractor will take Corrective Actions if a DHS inspection finds a
Primary Care site to be in substantial non-compliance. Contractor will
ensure that Primary Care sites with major, uncorrected deficiencies are not
allowed to begin operation.
6.5.5.7 CONTINUING OVERSIGHT
The Contractor will remain responsible for the oversight and monitoring of
delegated Facility review activities.
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6.5.6 MEMBERS RIGHTS AND RESPONSIBILITIES
6.5.6.1 GENERAL REQUIREMENT
The Contractor will develop, implement and maintain written policies that
address the Member's rights and responsibilities and will communicate these
to its Members and providers.
6.5.6.2 WRITTEN POLICY: MEMBER'S RIGHTS
The Contractor's written policy regarding Member rights will include the
Member's right to be treated with respect, to be provided with information
about the organization and its services, to be able to choose a Primary
Care Physician within the Contractor's network, to participate in decision
making regarding their own health care, to voice Grievances about the
organization or the care received, to formulate advance directives, to have
access to family planning services, FQHC, Indian Health, STD services and
Emergency Services outside the Contractor's network pursuant to the federal
law, the right to request a fair hearing, to have access to their Medical
Record, and to disenroll.
6.5.6.3 WRITTEN POLICY: MEMBER'S RESPONSIBILITY
The Contractor's written policy regarding Member responsibilities will
include providing accurate information to the professional staff, following
instructions, and cooperating with the providers.
6.5.6.4 MEMBER'S GRIEVANCE SYSTEM
The Contractor will implement and maintain procedures to monitor the
Members' Grievance system which includes:
A. Procedure to ensure timely resolution and feedback to complainant. The
Contractor will acknowledge receipt of the complaint within 5 days and
resolve the complaint within 30 days or document reasonable efforts to
resolve the complaint.
B. Procedure for systematic aggregation and analysis of the Grievance
data and use for Quality Improvement.
C. Procedure to ensure that the Grievance submitted is reported to an
appropriate level, i.e., medical issues versus health care delivery
issues.
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6.5.6.5 MEMBER'S RIGHT TO CONFIDENTIALITY
The Contractor will implement and maintain policies and procedures to
ensure the Members' right to confidentiality of medical information.
A. The Contractor will ensure that Facilities implement and maintain
procedures that guard against disclosure of confidential information
to unauthorized persons inside and outside the network.
B. Contractor will counsel Members on their right to confidentiality and
the Contractor will obtain Member's consent prior to release of
confidential information.
C. The Contractor will implement and maintain procedures to ensure the
Members' confidentiality when accessing Sensitive Services such as
family planning, STD, abortion and HIV testing.
6.5.6.6 MINOR'S RIGHTS AND SERVICES
The Contractor will implement and maintain policies and procedures on
providing treatment services to minors and their right to access Minor
Consent Services.
6.5.6.7 MEMBER SATISFACTION SURVEYS
The Contractor will conduct surveys of Member satisfaction with its
services, at least annually:
A. At a minimum, the surveys will include the following groups of
Members: Members filing Grievance/complaints, Members requesting
change of providers or Facilities, groups who speak a primary language
other than English meeting threshold levels, and Members requesting
Disenrollment from the Contractor.
B. The Contractor's Member survey will identify perceived problems in
quality, availability and accessibility of care as well as reasons for
Member's accessing care from an out-of-plan provider, e.g., family
planning services.
C. The Contractor will use the survey to identify sources of
dissatisfaction, outline action steps to follow up on the findings,
inform providers of the results, and reevaluate the effects of the
actions taken.
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6.5.7 AVAILABILITY AND ACCESSIBILITY
6.5.7.1 GENERAL REQUIREMENT
The Contractor will implement and maintain procedures for Members to obtain
appointments for routine care, Urgent Care, emergency care, prenatal care,
CHDP periodic health screens, adult initial health assessments, and
procedures for obtaining appointments with specialists.
6.5.7.2 EMERGENCY CARE
The Contractor will ensure that a Member with an Emergency Condition as
defined in Article II, Definitions, will be seen immediately and Emergency
Services will be available and accessible within the Service Xxxx 00 hours
a day. The Contractor will ensure adequate follow-up care for those Members
who require non-emergent care and who are denied services in the emergency
room.
6.5.7.3 URGENT CARE
The Contractor will ensure that a Member needing Urgent Care will be seen
within 48 hours upon request.
6.5.7.4 FIRST PRENATAL VISIT
The Contractor will ensure that the first prenatal visit for a pregnant
Member will be available within a week upon request.
6.5.7.5 WAITING TIMES
The Contractor will develop, implement, and maintain a procedure to monitor
waiting times in the providers' offices, telephone calls (to answer and
return), and in obtaining various types of appointments as indicated in
Section 6.5.7.1.
6.5.7.6 TELEPHONE PROCEDURES
The Contractor will maintain a procedure for triaging Members' telephone
calls and providing telephone medical advice.
6.5.7.7 AFTER HOURS CALLS
At a minimum, Contractor will ensure that a Physician or a Nurse under his
(her) supervision will be available for after-hours calls.
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6.5.7.8 SENSITIVE SERVICES
The Contractor will implement and maintain procedures to ensure ready
access to Sensitive Services for adult and adolescent Members. Adolescent
Members will be able to access Sensitive Services without parental consent
and through a provider other than the Primary Care Physician if so
requested. Adults will be able to access Sensitive Services in a timely
manner and without barriers such as Prior Authorization requirements.
6.5.7.9 ACCESS FOR DISABLED MEMBERS
The Contractor's Facilities will comply with the requirements of Title III
of the Americans with Disabilities Act of 1990, and will ensure access for
the disabled which includes, but is not limited to, ramps, elevators,
restrooms, designated parking spaces, and drinking water provision.
6.5.7.10 UNUSUAL SPECIALTY SERVICES
The Contractor will arrange for the provision of seldom used or unusual
specialty services from specialists outside the network when determined
Medically Necessary.
6.5.8 MEDICAL RECORDS
6.5.8.1 GENERAL REQUIREMENT
The Contractor will ensure that appropriate Medical Records for the Member
will be available to health care providers at each Encounter.
6.5.8.2 MEDICAL RECORDS PROCEDURES
The Contractor will implement and maintain the following:
A. Procedures for storage and filing of Medical Records
including: collection, processing, maintenance, storage,
retrieval identification, and distribution.
B. A written policy to ensure that Medical Records are
protected and confidential.
C. Written procedures for release of information and obtaining
consent for treatment.
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D. Policies and procedures to ensure maintenance of Medical
Records in a legible, current, detailed, organized and
comprehensive manner (records may be electronic or hard
copy).
6.5.8.3 ON-SITE MEDICAL RECORDS
The Contractor will ensure that an individual will be delegated the
responsibility of securing and maintaining Medical Records at each site.
6.5.8.4 MEMBER MEDICAL RECORD
The Contractor will ensure that a complete Medical Record will be
maintained for each Member in accordance with Title 22, CCR, Section 53284,
and it will reflect all aspects of patient care, including ancillary
services, and at a minimum will include:
A. Member identification on each page; personal/biographical data in the
record.
B. All entries dated and author identified; the entries will include at a
minimum, the subjective complaints, the objective findings, and the
plan for diagnosis and treatment.
C. The record will contain a problem list, a complete record of
immunizations and health maintenance or preventive services rendered.
D. Allergies and adverse reactions are prominently noted in the record.
E. All informed consent documentation, including the human sterilization
consent procedures required by Title 22, CCR, Sections 51305.1
through 51305.6, if applicable.
F. All emergency care provided (directly by the contracted provider or
through a emergency room) and the hospital discharge summaries for all
hospital admissions while the patient is enrolled.
G. All consultations, referrals, and specialists' reports, and all
pathology and laboratory reports. Any abnormal results will have an
explicit notation in the record.
H. For Medical Records of adults, documentation of whether the individual
has been informed and has executed an advanced directive such as a
Durable Power of Attorney for Health Care.
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I. Request or refusal of language/interpretation services.
J. Health education behavioral assessment and referrals to health
education services. For patients 12 years or older, a notation
concerning use of cigarettes, alcohol, and substance abuse, health
education or counseling and anticipatory guidance.
6.5.8.5 MEDICAL RECORDS REVIEW
The Contractor will implement and maintain a system to review records for
compliance with Medical Records standards, and institute a Corrective
Action when necessary. The Contractor will ensure that Medical Records will
be reviewed for:
A. Uniformity of forms.
B. Legibility (the record is legible to a person other than the
writer).
C. Completeness.
D. Quality and appropriateness of services provided.
E. Immunizations.
F. Preventive health screening.
6.5.9 UTILIZATION MANAGEMENT
6.5.9.1 GENERAL REQUIREMENT
The Contractor will develop, implement and maintain a Utilization
Management (UM) program which includes list of services that require Prior
Authorization, persons responsible for UM and their qualifications,
procedures to evaluate Medical Necessity, criteria used for approval,
referral and denial of services, information sources, and the process used
to review and approve the provision of medical services.
6.5.9.2 UNDER AND OVER-UTILIZATION
The Contractor will ensure that the UM program has mechanisms to detect
both under and over-utilization of services.
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6.5.9.3 PRE-AUTHORIZATION/REVIEW PROCEDURES
The Contractor will ensure that its pre-authorization and concurrent review
procedures will meet the following minimum requirements:
A. Review decisions are supervised by qualified medical
professionals and all denials will be reviewed by a qualified
Physician.
B. There is a set of written criteria or guidelines for Utilization
Review that is based on sound medical evidence, is updated
regularly and consistently applied.
C. Reasons for decisions are clearly documented.
D. There is a well-publicized appeals procedure for both providers
and patients.
E. Decisions and appeals are made in a timely manner.
6.5.9.4 EXCEPTIONS TO PRIOR AUTHORIZATION REQUIREMENT
The Contractor will ensure that Prior Authorization requirements are not
applied to Emergency Services, family planning services, preventive
services, sensitive and confidential services and basic prenatal care.
6.5.9.5 DELEGATING UM ACTIVITIES
Contractor will ensure that delegated UM activities to subcontractors are
approved and regularly evaluated. Contractor will ensure that this process
is documented.
6.5.10 CONTINUITY OF CARE AND CASE MANAGEMENT
6.5.10.1 MEDICAL CASE MANAGEMENT
The Contractor will provide basic medical case management to each Member.
6.5.10.2 INITIAL HEALTH ASSESSMENT
The Contractor will develop, implement, and maintain procedures for the
performance of initial health assessment for each Member within 120 days of
Enrollment.
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6.5.10.3 REFERRALS AND FOLLOW-UP CARE
The Contractor will develop, implement, and maintain an adequate system for
tracking all referrals and follow-up care.
6.5.10.4 COORDINATION OF CARE
The Contractor will maintain procedures for monitoring the coordination of
care provided to the Member, including but not limited to coordination of
discharge planning from inpatient Facilities, and coordination of all
Medically Necessary services both within and outside the Contractor's
provider network.
6.5.10.5 MISSED/BROKEN APPOINTMENTS
The Contractor will implement and maintain policies and procedures to
follow-up on missed/broken appointments.
6.5.10.6 CONTINUITY OF CARE
The Contractor will ensure continuity of care from the Ambulatory Care
setting to the inpatient care setting.
6.5.11 INPATIENT CARE
6.5.11.1 GENERAL REQUIREMENT
The Contractor will implement and maintain procedures to monitor Quality of
Care provided in an inpatient setting to its Members. If the Contractor
delegates the QI functions to hospitals, the Contractor will maintain
procedures to monitor the delegated function, including review of services
provided by its Physicians within the hospital.
6.5.12 INFECTION CONTROL
6.5.12.1 INFECTION CONTROL PLAN
The Contractor will implement and maintain an effective plan for the
surveillance, prevention and control of infection. The Contractor will
ensure that this plan will include the scope (both patient care and support
services) the persons responsible, the policies and procedures and
frequency of review (at least every 2 years), the role and responsibilities
of each service, the monitoring activities, and approval by the Governing
Body.
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6.5.12.2 INFECTION CONTROL POLICIES AND PROCEDURES
The Contractor will implement and maintain policies for prevention and
control of infection transmission in patients and personnel which include:
A. Application of universal precaution procedures.
B. The availability of adequate infection control devices and supplies in
the patient areas.
C. Infectious or biohazardous waste disposal procedures complying with
applicable State and federal regulations.
D. Isolation precautions and procedures.
E. Cleaning and sterilization methods, agents, and schedules; including
maintenance of autoclave, spore testing, storage of sterile packs,
etc.
F. Training and continuing education of all personnel.
6.5.12.3 REVIEW OF PATIENT INFECTIONS
The Contractor will ensure the review of patient infections that present
the potential for prevention or intervention to reduce the risk of future
occurrence.
6.5.12.4 REPORTING PROCEDURES
The Contractor will implement and maintain a procedure for reporting
infectious diseases to public health authorities as required by State law.
6.5.12.5 SUBCONTRACTS
The Contractor will ensure that its infection control policies are
communicated to its subcontractors and monitor its subcontractors for
compliance.
6.6 PROVIDER NETWORK AND GEOGRAPHIC ACCESS
6.6.1 TIME AND DISTANCE STANDARD
Contractor will maintain a network of Primary Care Physicians which are
located within thirty (30) minutes or ten (10) miles of a Member's
residence unless the Contractor has a DHS approved alternative time and
distance standard.
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6.6.2 NETWORK CAPACITY
The Contractor will maintain a provider network adequate to serve sixty
percent (60%) of the Eligible Beneficiaries in the proposed county and
provide the full scope of benefits. Contractor will increase the capacity
of the network as necessary to accommodate Enrollment growth beyond the
sixty percent (60%). However, after the first twelve months of operation,
if Enrollments do not achieve seventy-five (75%) of the required network
capacity, the Contractor's total network capacity requirement may be
renegotiated.
6.6.3 NETWORK COMPOSITION
The Contractor will maintain an adequate number of inpatient Facilities,
Service Locations, Service Sites, professional, allied, specialist and
supportive paramedical personnel within their network to provide Covered
Services to its Members.
6.6.4 ACCESS REQUIREMENTS
The Contractor will ensure Members access to all Medically Necessary
specialists through staffing, subcontracting, or referral. Contractor will
ensure adequate staff within the Service Area, including Physicians,
administrative and other support staff directly and/or through
Subcontracts, sufficient to assure that health services will be provided
consistent with all specified requirements.
6.6.5 SPECIALISTS
The Contractor will maintain adequate numbers and types of specialists
within their network to accommodate the need for specialty care. Contractor
will provide a recording/tracking mechanism for each authorized, denied, or
modified referral. In addition, the Contractor will offer second opinions
by Specialists to any Member upon request.
6.6.6 PROVIDER TO MEMBER RATIOS
The Contractor will ensure that networks will satisfy the following full
time equivalent provider to Member ratios:
A. Primary Care Physicians 1:2,000
B. Total Physicians 1:1,200
C. Non-Physician Medical Practitioner 1:1,000
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6.6.7 PHYSICIAN SUPERVISOR TO NON-PHYSICIAN MEDICAL PRACTITIONER
RATIOS
Contractor will ensure compliance with Title 22, CCR, Sections 51240 and
51241, and that full time equivalent Physician Supervisor to Non-Physician
Medical Practitioner ratios do not exceed the following:
A. Nurse Practitioners 1:4
B. Midwives 1:3
C. Physician Assistants 1:2
D. Four (4) Non-Physician Medical Practitioners in any combination that
does not include more than three nurse midwives or two physician
assistants and maintains the full time equivalence limits.
6.6.8 SUBCONTRACTS
The Contractor will execute Subcontracts pursuant to the requirements
contained in Article III, Section 3.27, Xxxxxxxxxxxx xxx Xxxxx 00, XXX,
Xxxxxxx 00000.
6.6.9 TRADITIONAL AND SAFETY-NET PROVIDERS PARTICIPATION
The Contractor will ensure the participation and broad representation of
traditional and safety-net providers within the county. Federally Qualified
Health Centers meet the definitions of both traditional and safety-net
providers.
6.6.10 TRADITIONAL AND SAFETY-NET PROVIDER CAPACITY
The Contractor will maintain the percentage of traditional and safety-net
provider capacity submitted and approved by DHS.
6.6.11 EXISTING PATIENT-PHYSICIAN RELATIONSHIPS
The Contractor will ensure that no traditional or safety-net provider, upon
entry into the Contractor's network, suffers any disruption of existing
patient-physician relationships, to the maximum extent possible. The
Contractor will ensure that Members may choose traditional and safety-net
providers as their Primary Care Physician. Contractor will submit a plan
that proportionately includes contracting traditional and safety-net
providers in the assignment process for Members who do not choose a Primary
Care Physician.
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6.6.12 MONTHLY REPORT
The Contractor will submit to DHS on a monthly basis, in a format specified
by DHS, a report summarizing changes in the provider network. The report
will identify provider deletions and additions and the resulting impact to:
1) geographic access for the Members; 2) cultural and linguistic services;
3) the targeted percentage of traditional and safety-net providers; 4) the
ethnic composition of providers; and 5) the number of Members assigned to
Primary Care Physicians and the percentage of Members assigned to
traditional and safety-net providers. The Contractor will submit the report
thirty (30) days following the end of the reporting month.
6.6.13 CONTRACT AND EMPLOYMENT TERMINATIONS
Contractor will also ensure that provider contract or employment
terminations do not adversely affect the ethnic composition of their
provider network.
6.6.14 UTILIZATION OF DSH HOSPITALS
The Contractor will increase Utilization of Disproportionate Share
Hospitals by Members to a level specified by DHS upon notification. DHS
will only impose this requirement if the Utilization of Disproportionate
Share Hospitals has decreased in such magnitude as to jeopardize
disproportionate status of hospitals in the county.
6.6.15 ADEQUATE FACILITIES AND PERSONNEL
Contractor will demonstrate the continuous availability and accessibility
of adequate numbers of institutional Facilities, Service Locations, Service
Sites, and professional, allied, and supportive paramedical personnel to
provide Covered Services including the provision of all medical care
necessary under emergency circumstances on a 24-hour-a-day, 7-day-a-week
basis. The Contractor will ensure that a plan Physician is available 24
hours a day for timely authorization of Medically Necessary care and to
coordinate transfer of stabilized Members in the emergency department, if
necessary. The Contractor will have as a minimum a designated Emergency
Services Facility, providing care on a 24-hour-a-day, 7-day-a-week basis.
This designated Emergency Services Facility will have one or more
Physicians and one Nurse on duty in the Facility at all times.
6.6.16 EMERGENCY SERVICE PROVIDERS
Contractor will pay for Emergency Services received by a Member from
non-Contractor providers. Payments to non-Contractor providers will be for
the treatment of the emergency medical condition including Medically
Necessary services
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rendered to a Member until the Member's condition has stabilized
sufficiently to permit discharge, or referral and transfer in accordance
with instructions from the Contractor. Emergency Services will not be
subject to Prior Authorization by the Contractor.
The Contractor will pay for those services provided by a non-Contractor
emergency department (ED) that are required to determine whether treatment
of the Member's condition qualifies as an Emergency Service. At a minimum,
the Contractor must reimburse the non-Contractor ED and, if applicable, its
affiliated providers for Physician services at the lowest level of
evaluation and management CPT (Physician's Current Procedural Terminology)
codes, unless a higher level is clearly supported by documentation, and for
the Facility fee and diagnostic services such as laboratory and radiology.
Payment by the Contractor for properly documented claims for services
rendered by a non-Contractor provider pursuant to this section will be made
in accordance with Article III, Section 3.27.9, and will not exceed the
lower of the following rates applicable at the time the services were
rendered by the provider:
A. The usual charges made to the general public by the provider.
B. The maximum Fee-For-Service rates for similar services under the
Medi-Cal Program.
Disputed claims may be submitted to DHS for resolution under the provisions
of Section 14454, W&I Code and Title 22, CCR, Sections 53620 through 53702.
The Contractor agrees to abide by the findings of DHS in such cases, to
promptly reimburse the non-Contractor provider within 30 days of the
effective date of a decision that the Contractor is liable for payment of a
claim and to provide proof of reimbursement in such form as the Director
may require. Failure to reimburse the non-Contractor provider and provide
proof of reimbursement to DHS within 30 days will result in liability
offsets in accordance with Title 22, CCR, Section 53702.
6.6.17 USERS MANUAL AND BULLETINS
Contractor will issue a Users Manual and Bulletins (updates) to the
providers of Medi-Cal services. The manual and bulletins shall serve as a
source of information to health care providers regarding Medi-Cal services,
policies and procedures, statutes, regulations, telephone access and
special requirements.
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6.6.18 PROVIDER TRAINING
Contractor will ensure that all providers receive training regarding the
Medi-Cal Managed Care program in order to operate in full compliance with
the Contract and all applicable Federal and State regulations. Contractor
will ensure that provider training relates to Medi-Cal Managed Care
services, policies, procedures and any modifications to existing services,
policies or procedures. Contractor will conduct training for all providers
within ten (10) days after the Contractor places a newly contracted
provider on active status. Contractor will ensure that ongoing training is
conducted when deemed necessary by either the Contractor or the State.
6.6.19 FQHC SERVICES
Contractor will meet federal requirements for access and reimbursement for
FQHC services, including those in 00 Xxxxxx Xxxxxx Code Section 1396 b(m)
and Medicaid Regional Memorandum 93-13. If FQHC services are not available
in the provider network of either Medi-Cal managed care contractor in the
county, the Contractor will reimburse FQHCs for services provided
out-of-plan to the Contractor's Members at the interim FQHC rate determined
by DHS.
For family planning and Emergency Services, the provisions of Sections
6.6.16 and 6.7.4.5 through 6.7.4.9 apply.
6.6.20 FQHC SUBCONTRACTS
Any Subcontract with an FQHC will specify reimbursement on the basis of
reasonable cost or at-risk capitation, and notwithstanding Article III,
Section 3.27.4, the Contractor will submit it to DHS for approval of the
reimbursement provision prior to implementation.
If the Subcontract reimbursement is based on reasonable cost, the
Contractor will demonstrate that the rate to be paid by the Contractor is a
reasonable equivalent to the interim FQHC rate determined by DHS. The
Subcontract will specify that the reimbursement from the Contractor does
not constitute payment in full to the FQHC and that the FQHC will be
entitled to cost reconciliation by DHS. The Subcontract will also require
the FQHC to keep a record of the number of visits by plan Members separate
from FFS Medi-Cal beneficiaries, in addition to any other data reporting
requirements. DHS will perform the reconciliation to determine the FQHC's
reasonable costs and will pay to or recover from the FQHC the difference
between the amount reimbursed by the Contractor and the FQHC's reasonable
costs.
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If the subcontract reimbursement is at-risk capitation, the Subcontract
must specify that the capitation is total payment. If reimbursement is
at-risk capitation, DHS will not perform the reconciliation and will not
pay the FQHC's reasonable costs.
6.6.21 INDIAN HEALTH SERVICES FACILITIES
The Contractor will reimburse out-of-plan Indian Health Service Facilities
for services provided to Members who are qualified to receive services from
an Indian Health Service Facility. The Contractor will reimburse the
out-of-plan Indian Health Service Facility at the approved Medi-Cal rate
for that Facility.
The requirements in Section 6.6.19 apply to any Indian Health Service
Facility which is also an FQHC.
6.6.22 VISION CARE SERVICES
Contractor will ensure a vision care services system, consistent with good
professional practice, which provides that a Member may be seen initially
by either of the following:
A. An optometrist or an ophthalmologist.
B. A Primary Care Physician before referral to an optometrist or an
ophthalmologist.
Contractor will provide ophthalmic lenses in accordance with Section
6.7.3.6.
6.6.23 SUBCONTRACTOR SERVICES
The Contractor will not prohibit any subcontractor from providing services
to Medi-Cal beneficiaries who are not Members of the Contractor's plan.
6.6.24 EMERGENCY DEPARTMENT PROTOCOLS
Contractor will develop and maintain protocols for communicating and
interacting with emergency departments. Protocols will be distributed to
all emergency departments in the contracted Service Area and will include
at a minimum the following:
A. Description of telephone access, triage and advice systems used by the
Contractor.
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B. A plan contact person responsible for coordinating services that can
be accessed 24 hours a day.
C. Process for rapid interfacing with emergency care systems.
D. Referral procedures (including after-hours instruction) which
emergency department personnel can provide to Medi-Cal Members who
present at the emergency department for non-emergency services.
E. Procedures for emergency departments to report system and/or protocol
failures and process for ensuring Corrective Action.
6.7 SCOPE OF SERVICES/MEDICAL STANDARDS/HEALTH EDUCATION
6.7.1 COVERED SERVICES
6.7.1.1 GENERAL REQUIREMENTS
The Contractor will provide or arrange for all Medically Necessary Covered
Services for Members. Covered Services are those services set forth in
Title 22, CCR, Chapter 3, Article 4, beginning with Section 51301 and Title
17, CCR, Division 1, Chapter 4, Subchapter 13, beginning with Section 6840,
unless otherwise specifically excluded under the terms of this Contract.
The Contractor will ensure that the medical necessity of Covered Services
is determined through Utilization control procedures established in
accordance with Sections 6.5.9.3 and 6.5.9.4, unless specific Utilization
control requirements are included as a term of the Contract under sections
applicable to specific services.
6.7.1.2 REFERRAL SERVICES
The Contractor will arrange for the timely referral and coordination of
those services to which the Contractor or subcontractor has religious or
ethical objections to perform or otherwise support and will demonstrate
ability to arrange, coordinate and ensure provision of services through
referrals at no additional expense to DHS.
6.7.2 EXCLUDED SERVICES: CIRCUMSTANCES UNDER WHICH MEMBER DISENROLLED
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6.7.2.1 MAJOR ORGAN TRANSPLANTS
Major organ transplant procedures are not covered under the Contract. These
procedures are bone marrow transplants, heart transplants, liver
transplants, lung transplants, heart/lung transplants, combined liver and
kidney transplants, combined liver and small bowel transplants.
When a Member is identified as a potential transplant candidate, the
Contractor will refer the Member to a Medi-Cal approved transplant center.
If the transplant center Physician considers the Member to be a suitable
candidate, the Contractor will submit a Prior Authorization Request to
either the Medi-Cal Field Office (for adults) or the California Children
Services Program (for children) for approval. The Contractor will initiate
Disenrollment of the Member when all of the following has occurred:
referral of the Member to the organ transplant Facility, the Facility's
evaluation concurred that the Member is a candidate for an organ transplant
and the transplant is authorized by either DHS' Medi-Cal Field Office (for
adults) or the California Children Services Program (for children).
Upon Disenrollment, the Contractor will ensure continuity of care by
transferring all of the Member's medical documentation to the transplant
Physician. The effective date of the Disenrollment will be retroactive to
the beginning of the month in which the transplant is approved. All
services provided during this month will be billed FFS.
If the Member is evaluated and determined not to be a candidate for a major
organ transplant or DHS denies authorization for a transplant, the Member
will not be disenrolled. The cost of the evaluation and responsibility for
the continuing treatment of the Member will remain with the Contractor.
6.7.2.2 WAIVER PROGRAMS
The Contractor will maintain systems for identifying and referring Members
to the appropriate waiver program. If the agency administering the waiver
program concurs with the Contractor's assessment of the Member and there is
available placement in the waiver program, the Contractor will initiate
Disenrollment for the Member. The Contractor will provide documentation to
ensure the Member's orderly transfer to the Medi-Cal Fee-For-Service
program. If the Member does not meet the criteria for the waiver program,
or if placement is not available, the Contractor will continue to case
manage and provide all Medically Necessary services to the Member.
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6.7.2.3 LONG TERM CARE (LTC)
Contractor will ensure that Members, other than Members requesting hospice
services, in need of nursing Facility services are placed in Facilities
providing the appropriate level of care commensurate with the Member's
medical needs. These Facilities include Skilled Nursing Facilities,
subacute Facilities, pediatric subacute Facilities, and Intermediate Care
Facilities. The Contractor will base decisions on the appropriate level of
care on the definitions set forth in Title 22, CCR, Sections 51118, 51120,
51120.5, 51121, 51124.5, and 51124.6 and the criteria for admission set
forth in Title 22, CCR, Sections 51335, 51335.5, 51335.6, and 51334 and
related sections of the Manual of Criteria for Medi-Cal Authorization
referenced in Title 22, CCR, 51003(e).
The Contractor will assess the projected length of stay of the Member upon
admission to an appropriate Facility. If the Member will require long term
care, care in the Facility for longer than the month of admission plus one
month, the Contractor will submit a Disenrollment request for the Member
to DHS for approval. The Contractor will provide all Medically Necessary
Covered Services to the Member until the Disenrollment is effective. An
approved Disenrollment request will become effective the first day of the
second month following the month of the Member's admission to the Facility,
provided the Contractor submitted the Disenrollment request at least 30
days prior to that date. If the Contractor submitted the Disenrollment
request less than 30 days prior to that date, Disenrollment will be
effective the first day of the month that begins at least 30 days after
submission of the Disenrollment request. Upon Disenrollment, the
Contractor will ensure the Member's orderly transfer from the Contractor to
the Medi-Cal Fee-For-Service program.
Admission to a nursing Facility of a Member who has elected hospice
services as described in Title 22, CCR, Section 51349, does not affect the
Member's eligibility for Enrollment under this Contract. Hospice services
are Covered Services under this Contract and are not long term care
services regardless of the Member's expected or actual length of stay in a
nursing Facility.
6.7.3 EXCLUDED SERVICES: CIRCUMSTANCES UNDER WHICH MEMBER ENROLLED WITH
SERVICE CARVE OUT
6.7.3.1 MISCELLANEOUS SERVICE CARVE OUTS
Acupuncture services, adult day health care services, chiropractic
services, and healing by prayer or spiritual means are not Covered Services
under this Contract. The Contractor may, upon request, refer Members to
these services.
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Local Education Agency (LEA) assessment services provided to any student
and any LEA services provided pursuant to an Individual Education Plan
(IEP) or Individual Family Service Plan (IFSP) are not covered under the
Contract.
6.7.3.2 CALIFORNIA CHILDREN SERVICES (CCS)
CCS services are not covered under this Contract. The Contractor will
identify children with CCS eligible conditions, arrange for their referral
to the local CCS office, and will continue to provide case management of
the children until eligibility is established with the CCS program. The
Contractor will provide Primary Care and other services unrelated to the
CCS eligible condition and will ensure the coordination of services between
its Primary Care Providers, the CCS specialty providers, and the local CCS
program.
6.7.3.3 MENTAL HEALTH
The following mental health services are excluded from the Contract: all of
SD/MC mental services (inpatient and outpatient); FFS/MC outpatient mental
health services provided by psychiatrists and psychologists; FFS/MC
inpatient mental health services. Effective June 1, 1996 all
psychotherapeutic drugs prescribed by psychiatrists will be excluded.
The Contractor will provide outpatient mental health services within the
Primary Care Physician's scope of practice. The Contractor will refer
Members who need specialty mental health services to the appropriate FFS/MC
mental health provider or to the appropriate SD/MC provider. The Contractor
will case manage the physical health of the Member and coordinate services
with the mental health provider of the Member. Effective June 1, 1996 the
Contractor will provide all psychotherapeutic drugs prescribed by its
primary care physicians, but will not longer be responsible for
psychotherapeutic drugs prescribed by psychiatrists.
6.7.3.4 ALCOHOL AND DRUG TREATMENT SERVICES
Alcohol and drug treatment services available under the Xxxxx-Xxxxx
Medi-Cal (SD/MC) program as defined in Title 22, CCR, Section 51341(a) and
(c) and outpatient heroin detoxification as defined in Title 22, CCR,
Section 51328 are excluded from this Contract.
The Contractor will arrange and coordinate Medically Necessary services,
including referral of Members requiring alcohol and drug treatment to SD/MC
alcohol and drug treatment programs including outpatient heroin
detoxification providers. The Contractor will assist Members in locating
available treatment Service Sites. To the
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extent that treatment slots are not available within the Contractor's
geographical Service Area, the Contractor is encouraged to pursue placement
outside the area.
6.7.3.5 DENTAL
Dental services are not covered under this Contract. The Contractor will
perform dental screening for all Members as part of the initial health
assessment and refer Members to Medi-Cal dental providers. The Contractor
will ensure referrals to dental providers.
6.7.3.6 VISION CARE - LENSES
The Contractor will order the fabrication of optical lenses for Members
from Prison Industry Authority (PIA) optical laboratories. DHS will
reimburse PIA for these lenses in accordance with the contract between DHS
and PIA. The Contractor will provide all other Covered Services described
in Title 22, CCR, Section 51317, including contact lenses and eyeglass
frames.
6.7.3.7 DIRECT OBSERVED THERAPY (DOT) FOR TREATMENT OF TUBERCULOSIS
DOT services are not covered under this Contract. DOT services are offered
by local health departments (LHDs). The Contractor will assess the risk of
noncompliance for each Member who needs to be placed on anti-TB drugs.
Members who are determined to be at risk will be referred to the LHD TB
Control Officer for DOT. The Contractor will follow up and coordinate
care with the LHD TB Control Officer.
The Contractor will refer the following groups of Members with active TB
for DOT: patients with demonstrated multiple drug resistance (defined as
resistance to Isoniazid and Rifampin), patients whose treatment has failed
or who have relapsed after completing a prior regimen, children and
adolescents, and individuals who have demonstrated noncompliance (those who
failed to keep office appointments).
The Contractor will assess the following groups of Members for potential
noncompliance and for consideration for DOT: substance abusers, persons
with mental illness, the elderly, persons with unmet housing needs, and
persons with language and/or cultural barriers.
6.7.3.8 DEPARTMENT OF DEVELOPMENTAL SERVICES ADMINISTERED MEDICAID
HOME AND COMMUNITY BASED SERVICES WAIVER
The HCBS waiver services are not covered under this Contract. The
Contractor will maintain systems for identifying developmentally disabled
Members who are at risk
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for institutional placement and refer these Members to the HCBS waiver
administered by DDS. If DDS concurs with the Contractor's assessment of the
Member and there is available placement in the waiver program, the Member
will receive waiver services while enrolled in the plan. The Contractor
will continue to provide all Primary Care and other Medically Necessary
Covered Services to a plan Member who is receiving HCBS waiver services. If
the Member does not meet the criteria for the waiver program, or if
placement is not available, the Contractor will continue to case manage and
provide all Medically Necessary Covered Services to the Member.
6.7.4 CAPITATED SERVICES: SERVICES WITH SPECIAL ARRANGEMENTS AND/OR
PAYMENT OF OUT-OF-PLAN PROVIDERS
6.7.4.1 SCHOOL LINKED CHDP SERVICES: COORDINATION OF CARE
The Contractor will maintain a "medical home" for the Members and ensure
the overall coordination of care and case management of Members who obtain
CHDP services through the local school districts or school sites.
6.7.4.2 SCHOOL LINKED CHDP SERVICES: COOPERATIVE ARRANGEMENTS
The Contractor will enter into one or a combination of the following
arrangements with the local school district or school sites:
A. Cooperative arrangements (e.g. Subcontracts) with school
districts or school sites to directly reimburse schools for
the provision of some or all of the CHDP services, including
guidelines for sharing of critical medical information. The
arrangements will also include guidelines specifying
coordination of services, reporting requirements, quality
standards, processes to ensure services are not duplicated,
and processes for notification to Member/student/parent on
where to receive initial and follow up services.
B. Cooperative arrangements whereby the Contractor agrees to
provide or contribute staff or resources to support the
provision of school linked CHDP services.
C. Referral protocols/guidelines between the Contractor and
the school sites to assure that Members who are identified
at school sites as being in need of CHDP services receive
those services from the Contractor within the required State
and federal time frames. This will include strategies for
the Contractor to follow up and document that services
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are provided to the Member.
D. Any innovative approach that the Contractor may develop to
assure access to CHDP services and coordination with and
support for school based health care services.
6.7.4.3 SCHOOL LINKED CHDP SERVICES: SUBCONTRACTS
The Contractor will ensure that the Subcontracts with the local school
districts or school sites meet the requirements of Article III, Section
3.27 and address the following: the population covered, beginning and end
dates of the agreement, services covered, practitioners covered, outreach,
information dissemination and educational responsibilities, Utilization
Review requirements, referral procedures, medical information flows,
patient information confidentiality, Quality Assurance interface, data
reporting requirements, Grievances and complaint procedures.
6.7.4.4 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
(EPSDT) SUPPLEMENTAL SERVICES, EXCLUDING CASE MANAGEMENT
SERVICES
For members under the age of 21 years, the Contractor will provide or
arrange and pay for EPSDT supplemental services as defined in Title 22,
CCR, Section 51184, excluding EPSDT case management services, except when
EPSDT supplemental services are provided as CCS services pursuant to
Section 6.7.3.2. The Contractor will determine the medical necessity of
EPSDT supplemental services using the criteria established in Title 22,
CCR, Section 51340.
For Members under the age of 21 years, who meet the medical necessity
criteria for EPSDT case management, pursuant to Title 22, CCR, Section
51340(f), the Contractor will refer the Member to a targeted case
management (TCM) provider under contract with a local government agency
pursuant to Welfare and Institutions Code Section 14132.44 or to entities
and organizations, including Regional Centers, that provide TCM services
pursuant to Welfare and Institutions Code Section 14132.48. If EPSDT case
management services are rendered by these referral providers, the
Contractor is not required to pay for the EPSDT case management services.
If EPSDT case management services are not available from these referral
providers, the Contractor will provide or arrange and pay for the EPSDT
case management services.
6.7.4.5 FAMILY PLANNING: GENERAL REQUIREMENT
The Contractor will provide the full array of family planning services
covered under the Contract without Prior Authorization. Medi-Cal Members
have the right to access
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family planning services through any family planning provider. The
Contractor will inform its Members in writing of their right to access any
qualified family planning provider without Prior Authorization as required
in Section 6.9.5(P), Membership Services Guide.
6.7.4.6 FAMILY PLANNING: INFORMED CONSENT
The Contractor will ensure that informed consent will be obtained from
Medi-Cal enrollees for all contraceptive methods, including sterilization,
consistent with requirements of Title 22, CCR, Sections 51305.1 and
51305.3.
6.7.4.7 FAMILY PLANNING: OUT-OF-NETWORK REIMBURSEMENT
The Contractor will reimburse out-of-network family planning providers for
the following services provided to Members of childbearing age to
temporarily or permanently prevent or delay pregnancy:
A. Health education and counseling necessary to make informed
choices and understand contraceptive methods.
B. Limited history and physical examination. Comprehensive physicals
are the responsibility of the Contractor.
C. Laboratory tests if medically indicated as part of decision
making process for choice of contraceptive methods. The
Contractor will not be required to reimburse out-of-plan
providers for pap smears if the Contractor has provided pap
smears to meet the U.S. Preventive Services Task Force
guidelines.
D. Diagnosis and treatment of STDs if medically indicated.
E. Screening testing and counseling of at risk individuals for HIV
and referral for treatment.
F. Follow-up care for complications associated with contraceptive
methods issued by the family planning provider.
G. Provision of contraceptive pills, devices, supplies.
H. Tubal ligation.
I. Vasectomies.
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J. Pregnancy testing and counseling.
6.7.4.8 FAMILY PLANNING: REIMBURSEMENT RATE
The Contractor will reimburse out-of-plan family planning providers at the
appropriate Medi-Cal FFS rate, unless otherwise negotiated.
6.7.4.9 SEXUALLY TRANSMITTED DISEASES (STDs)
The Contractor will provide access to STD services without Prior
Authorization to all Members both within and outside its provider network.
The reimbursement of out-of-plan STD services is limited to one office
visit per disease episode for the purposes of: (1) diagnosis and treatment
of vaginal discharge and urethral discharge, (2) those STDs that are
amenable to immediate diagnosis and treatment, and this includes syphilis,
gonorrhea, chlamydia, herpes simplex, chancroid, Trichomoniasis, human
papilloma virus, non-gonococcal urethritis, lymphogranuloma venereum and
granuloma inguinale and (3) evaluation and treatment of Pelvic Inflammatory
Disease (PID). The Contractor will provide follow-up care. The Contractor
will reimburse STD providers at the Medi-Cal Fee-For-Service (FFS) rate,
unless otherwise negotiated, and the Contractor will provide reimbursement
only if STD treatment providers provide treatment records or documentation
of the Member's refusal to release Medical Records to the Contractor along
with billing information.
6.7.4.10 EARLY INTERVENTION SERVICES
The Applicant will refer to the local Early Start program those children in
need of early intervention services, e.g. those with an established
condition leading to developmental delay, those in whom a significant
development delay is suspected, or those whose early health history places
them at risk for delay. The Contractor will also collaborate with the
regional center or local Early Start program to provide all Medically
Necessary diagnostic, preventive and treatment services.
6.7.4.11 SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES
The Contractor will provide all screening, preventive, and Medically
Necessary and therapeutic services covered by the Contract to Members with
developmental disabilities. The Contractor will coordinate all medical
services rendered to the Members, including the determination of medical
necessity. The Contractor will refer enrollees with developmental
disabilities to the regional centers for those nonmedical services such as
respite, out-of-home placement, supportive living, etc. for persons with
substantial disabilities if such services are needed.
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6.7.4.12 CONFIDENTIAL HIV TESTING
Members may access confidential HIV counseling and testing services through
the Contractor's provider network and through the out-of-network local
health department and family planning providers. The Contractor will
reimburse these providers at the Medi-Cal FFS rate, unless otherwise
negotiated, for HIV testing and counseling provided that out-of-network
local health departments and family planning providers make all reasonable
efforts, consistent with current laws and regulations, to report
confidential test results to the Contractor.
6.7.4.13 IMMUNIZATIONS
The Contractor will fully immunize its Members per DHS requirements. The
Contractor will, upon request, provide updated information on the status of
Members' immunizations and ensure reimbursement to LHDs for the
administration fee of immunizations given to Members. However, the
Contractor will not reimburse the LHD for an immunization provided to a
Member who was already up to date as required per DHS. The LHD will provide
immunization records when immunization services are billed to the
Contractor. Providers other than LHDs will not be reimbursed by the
Contractor unless they enter into an agreement with the Contractor.
6.7.4.14 NURSE MIDWIFE SERVICES
The Contractor will meet federal requirements for access and reimbursement
for Nurse Midwife services as defined in Title 22, CCR, Section 51345.
Federal guidelines are currently under development. If federal guidelines
require that Members have a right to go out-of-plan for Nurse Midwife
services, the Contractor will reimburse Nurse Midwives for services
provided out-of-plan to the Contractor's Members at the Medi-Cal
Fee-For-Service rate.
6.7.5 REQUIRED REFERRAL ARRANGEMENTS
6.7.5.1 WOMEN, INFANTS, AND CHILDREN (WIC) SUPPLEMENTAL FOOD
PROGRAM: GENERAL REQUIREMENT
The Contractor, as part of its initial assessment of Members, and as part
of the initial evaluation of newly pregnant women, will provide and
document the referral of pregnant, breastfeeding, or postpartum women or a
parent/guardian of a child under the age of five, as indicated, to the WIC
program as mandated by Xxxxx 00, XXX 431.635(c).
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6.7.5.2 WIC SUPPLEMENTAL FOOD PROGRAM: MEDICAL RECORDS
The Contractor will conduct the hemoglobin or hematocrit test and use the
CHDP program Form PM160 to document the laboratory values for eligible
children and/or a prescription pad written by a Physician to document
laboratory values for eligible women for referral to the WIC program. The
Contractor will document such referrals in the Members' Medical Records.
6.7.6 MEDICAL STANDARDS - CLINICAL PREVENTIVE SERVICES
6.7.6.1 INITIAL HEALTH ASSESSMENT
The Contractor will schedule and provide an initial health assessment
(complete history and physical examination) to each Member within 120 days
of the date of Enrollment, unless the Member's Primary Care Physician
determines that the Member's Medical Record contains complete and current
information consistent with the assessment requirements stated below. For
Members age 21 years and older, the assessment will follow the guidelines
required by Section 6.7.6.7. For Members under the age of 21 years, the
assessment will follow the requirements of Title 17, CCR, Sections 6846 and
6847. If the Member fails to keep the scheduled appointment, the Contractor
will recontact the Member in accordance with the procedures for follow up
on missed appointments established pursuant to Section 6.5.10.5.
6.7.6.2 CHILDREN
The Contractor will maintain and operate a system which ensures the
provision of CHDP services to Members under the age of 21 years in
accordance with the provisions of the Health and Safety Code, Section 320
et seq. and Title 17, CCR, Section 6840 through 6850. The system will
include the following components:
A. Initial health assessments as required by Section 6.7.6.1.
B. Notification, in writing, of the availability of health assessment
services, the times and places where these services are available, and
the method by which appointments for CHDP services may be made will be
provided upon Enrollment and annually thereafter. Notification may be
given to the parent(s) or guardian of the Member under the 21 years of
age, or to the Member directly if the Member is an emancipated minor.
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C. Where a request is made for CHDP services by the Member, the Member's
parent(s) or guardian or through a referral from the local CHDP
program, an appointment will be made for the Member to be examined
within two weeks of the request.
D. Members under the age of 21 years will be scheduled for periodic
health assessments in accordance with periodicity schedule recommended
by the American Academy of Pediatrics and the immunizations will be
provided following the recommendations of either the Advisory
Committee on Immunization Practices or the American Academy of
Pediatrics.
E. At each non-emergency Primary Care Encounter with Members under the
age of 21 years, the Member (if an emancipated minor) or the parent(s)
or guardian of the Member will be advised of the CHDP services
available from Contractor, if the Member has not received CHDP
services in accordance with the CHDP periodicity schedule.
Documentation will be entered in the Member's Medical Record which
will indicate the receipt of CHDP services in accordance with the CHDP
periodicity schedule or proof of voluntary refusal of these services
in the form of a signed statement by the Member (if an emancipated
minor) or the parent(s) or guardian of the Member. If the responsible
party refuses to sign this statement, the refusal will be noted in the
Member's Medical Record.
F. Written notification and explanation of the results of CHDP health
assessments will be supplied to the Member (if an emancipated minor)
or the parent(s) or guardian of the Member in a timely manner. Upon
request by the Member or the parent(s) or the guardian, the Contractor
will provide for additional discussion or consultation regarding the
results of the assessment if appropriate.
G. Diagnosis and treatment of any medical conditions identified through
any CHDP assessment will normally be initiated within sixty days of
the CHDP assessment appointment, consistent with the terms of the
Contract for the identified services or conditions. Justification for
delays beyond sixty days will be maintained in the Medical Record.
H. The Confidential Screening/Billing Report form, PM 160-PHP, will be
used to report all CHDP Encounters. The Contractor will submit
completed forms to DHS and to the local CHDP program within 30 days of
the end of each month for all Encounters during that month.
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I. The Contractor will coordinate its CHDP system with the Local CHDP
program as required by Section 6.7.8.1.
6.7.6.3 PREGNANT WOMEN: MINIMUM STANDARDS
The Contractor will follow the American College of Obstetrics and
Gynecologists (ACOG) standards (currently Seventh edition) as the minimum
standards for services provided to Medi-Cal pregnant women. Contractor will
develop and implement standardized risk assessment tools and risk
intervention protocols which are consistent with CPSP requirements set
forth in Title 22, CCR, Sections 51348 and 51348.1. Contractor will not
implement them until they are approved by DHS.
6.7.6.4 PREGNANT WOMEN: PROVIDER CREDENTIALING STANDARDS
The Contractor will apply its provider Credentialing standards to all
providers providing perinatal services. These Credentialing standards are
specified in the Contractor's Quality Improvement document which must be
approved by DHS. The Contractor's obstetrical providers are exempt from
the requirement of certification as a Medi-Cal comprehensive perinatal
services provider.
6.7.6.5 PREGNANT WOMEN: RISK ASSESSMENT
The Contractor will ensure that an obstetrical record and a comprehensive
initial risk assessment tool is completed on all pregnant women at the
initiation of pregnancy-related services. The risk assessment will include
medical/obstetrical risk assessment; nutritional assessment; psychosocial
assessment; and health education assessment. Evaluation of the patient's
risk status will be done at each trimester and at the postpartum visit.
All identified risk conditions will be followed up by interventions
designed to ameliorate or remedy the condition or problem in a prioritized
manner.
6.7.6.6 PREGNANT WOMEN: REFERRALS TO SPECIALISTS
The Contractor will implement and maintain policies and procedures for
appropriate referrals of high risk pregnancy women to specialists and have
procedures for genetic screening and referral, and for admission to the
appropriate hospitals for delivery.
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6.7.6.7 ADULTS
Contractor will implement and maintain The Guide to Clinical Preventive
Services, a report of the U.S. Preventive Service Task Force (USPSTF) as
the minimum acceptable standard for Adult Preventive Health Services. The
following are a core set of preventive services that will be provided to
all asymptomatic, healthy adult Members (age 21 and older): (This is not an
inclusive list of all appropriate preventive services. The presence of risk
factors in individual patients will affect the type and quantity of
preventive services that may be appropriate. A given patient may need
additional services or core services at more frequent intervals).
A. History and physical examination - an initial complete history and
physical examination will be performed on each adult Member within 120
days of Enrollment. Targeted history and physical examination focusing
on the needs and risk factors of each Member will be done every one to
three years for adults age 21 to 64 years; and annually for
individuals age 65 and older.
B. Blood pressure - persons who are normotensive will have blood pressure
measurements at least every 2 years.
C. Cholesterol - total cholesterol will be measured at least once every 5
years for adults age 20 and older.
D. Clinical breast examination - women over age 40 will have annual
clinical breast examination.
E. Mammogram - all women over age 50 will have a screening mammogram
every 1 to 2 years, concluding at age 75 unless pathology has been
demonstrated.
F. Pap Smear - beginning at the age of first sexual intercourse, pap
smears will be performed every one to three years, depending on the
presence or absence of risk factors.
G. Tuberculosis (Tb) screening - all adults will be screened for Tb risk
factors upon Enrollment and Mantoux skin test will be performed on all
persons at increased risk of developing Tb.
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6.7.6.8 TUBERCULOSIS (Tb)
Tb screening, diagnosis, treatment and follow-up are covered under the
Contract. The Contractor will provide Tb care and treatment in compliance
with the guidelines recommended by American Thoracic Society and the
Centers for Disease Control. Following the award, but prior to beginning
operation, DHS will evaluate the Contractor's capability to deliver Tb
care. If the Contractor is not capable of providing adequate Tb care, it
will subcontract for those services. The Contractor will coordinate with
LHDs in the provision of DOT, contact tracing, and other Tb services.
6.7.7 HEALTH EDUCATION
6.7.7.1 GENERAL REQUIREMENTS
The Contractor will implement and maintain a system for providing Member
health education services, clinical preventive services, health education
and promotion and patient education and counseling. The system will utilize
one to one and group interventions, written and audio-visual materials. The
Contractor will ensure that the services are provided directly by the
Contractor or through Subcontracts or formal agreements with other
providers specializing in health education services. The Contractor will
maintain a health education system which includes, at a minimum, the
following services:
A. Member Education
1. Use of Clinical Preventive Services.
2. Promote Appropriate Use of Managed Care Plan Services.
3. Availability of Local Social and Health Care Programs.
B. Clinical Preventive Services, Education and Counseling:
1. Nutrition
2. Tobacco Prevention and Cessation
3. HIV/STD Prevention
4. Family Planning
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5. Exercise
6. Dental
7. Perinatal
8. Age Specific Anticipatory Guidance - EPSDT
9. Injury Prevention
10. Immunizations
C. Patient Education and Clinical Counseling
1. Diabetes
2. Asthma
3. Hypertension
4. Substance Abuse
5. Tuberculosis
6. Inpatient - Condition Specific
7. Other Outpatient
6.7.7.2 HEALTH EDUCATOR
The Contractor will maintain administrative oversight of the program by a
qualified full time health educator with a masters degree in community or
public health education (MPH).
6.7.7.3 BEHAVIORAL ASSESSMENTS
The Contractor will ensure that individual health education behavioral
assessments are conducted on all Members within 120 days of Enrollment to
determine health practices, values, behaviors, knowledge, attitudes,
cultural practices, beliefs, literacy levels, or health education needs.
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6.7.7.4 HEALTH EDUCATION POLICIES AND PROCEDURES
The Contractor will develop, implement, and maintain standards, policies
and procedures and ensure provision of the following:
A. Member orientation, education regarding health promotion, personal
health behavior, and patient education and counseling.
B. Provider education on health education services.
C. Individual health education behavioral assessment, referral, and
follow-up.
6.7.7.5 HEALTH EDUCATION STANDARDS
The Contractor will develop and maintain health education services
standards, policies and procedures, and monitor provider performance to
ensure the standards for health education services are maintained and
include methods for formally communicating findings with providers.
6.7.7.6 HEALTH EDUCATION AND QIP
The Contractor will ensure coordination and integration of the health
education system with the Quality Improvement program.
6.7.7.7 GROUP NEEDS ASSESSMENT
The Contractor will conduct a group needs assessment of their Members to
determine health education needs including literacy level. The Contractor
will submit to DHS a report summarizing the methodology, findings, proposed
services, key activities, timeline for implementation and the responsible
individuals. The Contractor will complete the needs assessment within six
months after one year of operations under this Contract.
6.7.7.8 HEALTH EDUCATION WORKPLAN
If the Contractor does not comply with all of the requirements in Sections
6.7.7.1 through 6.7.7.9 upon implementation of die Contract, the Contractor
will comply with all of the requirements for the provision of health
education services except for the requirements in Section 6.7.7.6.
Contractor will submit for DHS' approval a proposed workplan for meeting
the full scope of requirements by the end of one year of operations under
this Contract. Contractor will include in the workplan a description of
the required activities, a timeline with milestones, and identify the
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responsible individuals and the individual with overall responsibility. The
Contractor will entitle the workplan "Health Education Services: Proposed
Activities".
6.7.7.9 HEALTH EDUCATION READING LEVEL
The Contractor will ensure that all plan materials used to communicate
covered benefits are written at the appropriate reading level, as
determined by the Contractor and approved by DHS.
6.7.8 LOCAL HEALTH DEPARTMENT COORDINATION
6.7.8.1 SUBCONTRACT
The Contractor will execute a Subcontract for the specified public health
services with the Local Health Department (LHD) in each county that is
covered by this Contract. The Subcontract will specify the scope and
responsibilities of both parties, billing and reimbursements, reporting
responsibilities, and Medical Record management to ensure coordinated
health care services. The Subcontract will meet the requirements contained
in Article III, Sections 3.27 through 3.27.8. The specified public health
services under the Subcontract are as follows:
A. Family Planning Services: as specified in Section 6.7.4.7
B. STD services diagnosis and treatment of disease episode of the
following STDs: syphilis, gonorrhea, chlamydia, herpes simplex,
chancroid, trichomoniasis, human papilloma virus, non-gonococcal
urethritis, lymphogranuloma venereum and granuloma inguinale.
C. Confidential HIV testing: as specified in Section 6.7.4.12
D. Immunizations: as specified in Section 6.7.4.13
E. California Children Services (CCS)
F. Maternal and Child Health (MCH)
G. Child Health and Disability Prevention (CHDP) Program
H. Tuberculosis Direct Observed Therapy
I. Women, Infants, and Children (WIC) Supplemental Food Program
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J. Population based Prevention Programs: collaborate in LHD community
based prevention programs
Services A-D require provisions for reimbursement. All services require
delineation of the roles and responsibilities of the Contractor and the
local program.
To the extent that Contractor does not meet this requirement on or before 4
months after award of this Contract, Contractor will submit documentation
substantiating reasonable efforts to enter into Subcontracts.
6.8 MARKETING AND ENROLLMENT
6.8.1 MARKETING REPRESENTATIVES
The Contractor will ensure, in addition to compliance with the requirements
of Title 22, CCR, Section 53400, that:
A. All Marketing Representatives including supervisors, have
satisfactorily completed the Contractor's Marketing orientation and
training program and the DHS Marketing Representative Certification
Examination prior to engaging in Marketing activities on behalf of the
Contractor.
B. A Marketing Representative will not provide Marketing services on
behalf of more than one Contractor.
C. Marketing Representatives do not engage in Marketing practices that
discriminate against an Eligible Beneficiary because of race, creed,
age, color, sex, religion, national origin, ancestry, marital
status, sexual orientation, physical or mental handicap, or health
status.
6.8.2 LIABILITY
The Contractor is responsible for all Marketing activity conducted on
behalf of the Contractor. Contractor will be held liable for any and all
violations by any Marketing Representatives.
6.8.3 CERTIFICATION OF MARKETING REPRESENTATIVES
The Contractor will ensure that any office staff of a provider whose
primary duties are Marketing, are certified as Marketing Representatives.
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6.8.4 ENROLLMENT PROGRAM
Contractor will cooperate and participate in the DHS Enrollment program and
will provide to DHS' Enrollment contractor Marketing materials, Evidence of
Coverage and disclosure forms, Member services guide, list of network
providers, linguistic and cultural capabilities of the Contractor and other
information deemed necessary by DHS to assist beneficiaries in making an
informed choice of health plan.
6.8.5 DISENROLLMENT FORMS
Contractor will ensure that Disenrollment forms are available at all
Primary Care sites and that staff at those locations are knowledgeable of
Enrollment and Disenrollment requirements.
6.8.6 MARKETING PLAN
Except for door to door Marketing which is prohibited, Contractors will
implement and maintain a Marketing plan in compliance with MCOB Letter
93-12.
6.8.7 DHS APPROVAL
Contractor will not conduct Marketing activities without written approval
of its Marketing plan from DHS.
6.9 MEMBER SERVICES/GRIEVANCE SYSTEM
6.9.1 SYSTEM CAPACITY
Contractor will maintain the capability to provide Member services to
Medi-Cal Members through sufficient assigned staff.
6.9.2 MEMBER SERVICES EMPLOYEE TRAINING
Contractor will ensure membership services staff are trained on all
contractually required membership service functions including, policies,
procedures, and scope of benefits.
6.9.3 DISCLOSURE FORMS
Contractor will provide to all Members Disclosure Forms and Evidence of
Coverage materials which constitute a fair disclosure of the provisions of
the covered health care services.
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6.9.4 MEMBER IDENTIFICATION CARD
Contractor will provide an identification card to each Member which
identifies the Member and authorizes the provision of Covered Services to
the Member. The card will specify that Emergency Services rendered to the
Member by non-Contracting providers are reimbursable by the Contractor
without Prior Authorization.
6.9.5 MEMBERSHIP SERVICES GUIDE
Contractor will develop and distribute a Membership Services Guide that
includes the following information:
A. The name, address and telephone number of the health plan.
B. A description of the full scope of Medi-Cal covered benefits and all
available services including health education, interpretive services,
and "carve out" services and an explanation of any service limitations
and exclusions from coverage.
C. Procedures for obtaining Covered Services including the address and
telephone number of each Service Site (locations of hospitals, Primary
Care Physicians, optometrists, psychologists, pharmacies, Skilled
Nursing Facilities, Urgent Care Facilities). In the case of a medical
foundation or independent practice association, the address and
telephone number of each Physician provider.
1. The hours and days when each of these Facilities is open, the
services and benefits available, and the telephone number to call
after normal business hours.
D. Procedures for selecting or requesting a change in Primary Care
Physician, including requirements for change in PCP; reasons for which
a request may be denied; and reasons why a provider may request a
change.
E. The purpose and value of scheduling an initial health assessment
appointment.
F. The appropriate use of health care services in a managed care system.
G. The availability and procedures for obtaining after hours services
(24-hour basis) and care, including the appropriate provider locations
and telephone numbers.
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H. Procedure for obtaining emergency health care both within and outside
the Contractor's Service Area.
I. Process for referral to specialists.
J. Procedures for obtaining transportation services if offered by the
Contractor.
K. The causes for which a Member will lose entitlement to receive
services under this Contract. (See Article III, Section 3.27.5)
L. Procedures for filing a complaint/Grievance, including procedures for
appealing decisions regarding Member's coverage, benefits, or
relationship to the organization. Include the title, address, and
telephone number of the person responsible for processing and
resolving complaints/Grievances.
M. Procedures for Disenrollment, including an explanation of the Member's
right to disenroll without cause at any time.
N. Information on the Member's right to the Medi-Cal fair hearing process
regardless of whether or not a complaint/Grievance has been submitted
or if the complaint/Grievance has been resolved. The State Department
of Social Services' Public Inquiry and Response Unit toll free
telephone number (000) 000-0000.
O. Information on the availability of, and procedures for obtaining,
services at FQHCs and Indian Health Clinics.
P. Information on the Member's right to seek family planning services
from any qualified provider of family planning services such as the
following statement:
"Family planning services are provided to Members of child bearing
age to enable them to determine the number and spacing of children.
These services include all methods of birth control approved by the
Federal Food and Drug Administration. As a Member, you pick a doctor
who is located near you and will give you the services you need. Our
Primary Care Physicians and OB/GYN specialists are available for
family planning services. For family planning services, you may also
pick a doctor or clinic not connected with Xxxxxx Medical Centers
without having to get permission from Xxxxxx Medical Centers. Xxxxxx
Medical Centers will pay that doctor or clinic for the family planning
services you get".
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Q. DHS' Office of Family Planning's toll free telephone number
(0-000-000-0000) providing consultation and referral to family
planning clinics.
R. Any other information determined by DHS to be essential for the proper
receipt of Covered Services.
6.9.6 ENROLLEE INFORMATION
The Contractor will provide the following information to the Member or
Member's family unit either in the form of a cover letter or insert in the
above prescribed Membership Services Guide:
A. Each Member's effective date of Enrollment and term of Enrollment.
B. The name, telephone number, and Service Site address of the Primary
Care Physician chosen by or assigned to the Member.
6.9.7 DISTRIBUTION OF MEMBER SERVICES INFORMATION
The Contractor will distribute the Member identification card and
membership services guide to all Members, including family members, no
later than seven (7) days after the effective date of the Member's
Enrollment. The Contractor will revise this information, if necessary, and
distribute it annually to each Member or Member's family unit.
6.9.8 CHANGES IN AVAILABILITY OR LOCATION OF COVERED SERVICES
Contractor will ensure Medi-Cal Members are notified in writing of
any changes in the availability or location of Covered Services at least
thirty (30) days prior to the effective date of such changes, or within
fourteen (14) days prior to the change in cases of unforeseeable
circumstances. The notification must be approved by DHS prior to the
release.
6.9.9 PRIMARY CARE PHYSICIAN SELECTION
The Contractor will implement and maintain DHS approved procedures to
ensure that each Member is allowed to select or change a Primary Care
Physician from the Contractor's network of providers. The Contractor will
assist Members in making their selection within thirty (30) days of their
effective date of Enrollment. The Contractor will provide the Member
sufficient information (verbal and written) in the appropriate language
and reading level about the selection process and the available
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providers in the network to ensure their ability to make an informed
decision.
6.9.10 PRIMARY CARE PHYSICIAN ASSIGNMENT
If the Member does not select a Primary Care Physician within thirty (30)
days of the effective date of Enrollment, Contractor will complete the
assignment of the Member to a Primary Care Provider, notify the Member and
the assigned Primary Care Physician within forty (40) days from the
effective date of Enrollment. Contractor will ensure that adverse
selection does not occur during the assignment process of Members to
providers.
6.9.11 CONTINUITY OF CARE
The Contractor will ensure that Members with an established relationship
with a provider in the network, who have expressed a desire to continue
their patient/provider relationship, are assigned to their provider
without disruption in their care.
6.9.12 DISCLOSURE
The Contractor will disclose to affected Members any reasons for which
their selection or change in Primary Care Physician could not be made.
6.9.13 MEMBER COMPLAINT/GRIEVANCE SYSTEM
Contractor will implement and maintain a Member complaint/Grievance system
in accordance with Title 10, CCR, Section 1300.68, except subsection
1300.68(g), and Title 22, CCR, Sections 53200 and 53260.
A. Contractor will acknowledge receipt of a complaint within 5 days. The
written acknowledgement will also notify the complainant of a person
at the plan who may be contacted regarding the complaint. The
Contractor will resolve the complaint within 30 days.
6.9.14 DISENROLLMENTS
Contractor will implement and maintain procedures to ensure that requests
for Disenrollments made under the following circumstances are referred to
the county Enrollment Contractor immediately and are not processed through
the Grievance process:
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A. The Member's eligibility as a Medi-Cal beneficiary for Enrollment in
the plan is terminated.
B. The Enrollment is in violation of Sections 53400 or 53402.
C. The request for Disenrollment is pursuant to Section 53508.
D. Change of a Member's place of residence outside the plan's Service
Area.
6.9.15 DENIAL, DEFERRAL, OR MODIFICATION OF PRIOR AUTHORIZATION
REQUESTS
A. Contractor will notify Members of denial, deferral, or modification of
requests for Prior Authorization, in accordance with Title 22, CCR,
Sections 51014.1 and 53261 by providing written notification to
Members and/or their authorized representative, regarding any denial,
deferral or modification of a request for approval to provide a health
care service. This notification must be provided as specified in Title
22, CCR, Sections 51014.1 and 53261, when all of the following
conditions exists:
1. The request is made by a health care provider who has a formal
arrangement with the Contractor to provide services to
Medi-Cal Members.
2. The request is made by the provider through the formal Prior
Authorization procedures operated by the Contractor.
3. The service for which Prior Authorization is requested is a
Medi-Cal Covered Service for which the Contractor has
established a Prior Authorization requirement.
4. The Prior Authorization decision is being made at the ultimate
level of responsibility within the Contractor's organization
for approving, denying, deferring or modifying the service
requested but prior to the point at which the Member must
initiate the Contractor's complaint/Grievance procedure.
B. Contractor will provide for a written notification to the Member and
the Member's representative on a standardized form approved by DHS,
informing the Member of all the following:
1. The Member's right to, and method of obtaining, a fair hearing
to contest the denial, deferral or modification action.
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2. The Member's right to represent himself/herself at the fair
hearing or to be represented by legal counsel, friend or other
spokesperson.
3. The name and address of the Contractor and the State toll-free
telephone number for obtaining information on legal service
organizations for representation.
C. The notice to the Member may inform the Member that the Member may
file a complaint/Grievance concerning the Contractor's action using
the Contractor's complaint/Grievance process prior to or concurrent
with the initiation of the fair hearing process.
D. The Contractor will provide required notification to beneficiaries and
the representatives in accordance with the time frames set forth in
Title 22, CCR, Sections 51014.1 and 53261.
6.10 CULTURAL AND LINGUISTIC SERVICES REQUIREMENTS
6.10.1 CIVIL RIGHTS ACT OF 1964
The Contractor will ensure compliance with Title 6 of the Civil Rights
Act of 1964 (42 U.S.C. Section 2000d, 45 C.F.R. Part 80) which
prohibits recipients of federal financial assistance from
discriminating against persons based on race, color, or national
origin.
The Contractor will provide 24 hour access to interpreter services for
all Members at all provider sites within the Contractor's network
either through telephone language services or interpreters.
6.10.2 LINGUISTIC SERVICES
The Contractor will provide linguistic services to a population group
of mandatory Medi-Cal eligibles residing in the proposed Service Area
who indicate their primary language as other than English and who meet
a numeric threshold of 3,000, or a population group of mandatory
Medi-Cal eligibles residing in the proposed Service Area who indicate
their primary language as other than English and who meet the
concentration standards of 1,000 in a single ZIP code or 1,500 in two
contiguous ZIP codes.
The Contractor will provide the following services to those Member
groups at these key points of contact:
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A. Key Points of Contact
1. Medical: Advice and Urgent Care telephone, face to face
Encounters with providers.
2. Non-medical: membership services, orientations, and
appointments.
B. Types of Services
1. Interpreters.
2. Translated signage.
3. Translated written materials.
4. Referrals to culturally and linguistically appropriate
community services programs.
6.10.3 LINGUISTIC CAPABILITY OF EMPLOYEES
The Contractor will assess, identify and report the linguistic capability
of interpreters or bilingual employed and contracted staff (clinical and
non-clinical).
6.10.4 SUBCONTRACTS
The Contractor will document in the Subcontracts with Traditional and
Safety-Net providers the linguistic services to be provided and the
individuals who will provide the linguistic services to Members within the
proposed Service Area.
6.10.5 COMMUNITY ADVISORY COMMITTEE
Contractor will implement and maintain community linkages through the
formation of a Community Advisory Committee (CAC) with demonstrated
participation of consumers, community advocates, and Traditional and
Safety-Net providers. The Contractor will ensure that the committee
responsibilities include advisement on educational and operational issues
affecting groups who speak a primary language other than English and
cultural competency.
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6.10.6 CULTURAL AND LINGUISTIC SERVICES PLAN
Contractor will ensure that a group needs assessment is conducted to
identify the linguistic and cultural needs of the groups who speak a
primary language other than English. The findings of the assessment will
be submitted to DHS in the form of a plan entitled "Cultural and
Linguistic Services Plan" at the end of the first year of operations. In
the plan, the Contractor will summarize the methodology, findings, and
outline the proposed services to be implemented, the timeline for
implementation with milestones, and the responsible individual. The
Contractor will ensure implementation of the Cultural and Linguistic
Services Plan within six months after the beginning of year two of
operations. The Contractor will also identify the individual with overall
responsibility for the activities to be conducted under the plan. DHS
approval of the plan is required prior to its implementation.
6.10.7 IMPLEMENTATION PLAN
If a Contractor does not comply with all of the Cultural and Linguistic
Services requirements in Sections 6.10 through 6.10.9 upon implementation
of the Contract, the Contractor will comply with the threshold
requirements in Sections 6.10.1, 6.10.2, 6.10.2-A through 6.10.2-B(1),
6.10.2-B(4), 6.10.4 and 6.10.7 for the provision of oral interpretation
services to the groups who speak a primary language other than English
meeting the thresholds.
The Contractor will submit for DHS approval a proposed workplan for
meeting the full scope of requirements. In the workplan, the Contractor
will include a description of the required activities, a timeline with
milestones, and identify the individuals responsible for the activity. The
Contractor will identify the individual with overall responsibility and
ensure that the activities identified in the workplan approved by DHS will
be fully operational within six months of the beginning of year two of
operations under the Contract. The Contractor will entitle the workplan
"Cultural and Linguistic Services: Proposed Activities".
6.10.8 STANDARDS AND PERFORMANCE REQUIREMENTS
Contractor will develop and implement standards and performance
requirements for the provision of linguistic services, and will monitor
the performance of the individuals who provide linguistic services.
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6.10.9 INTERPRETER COORDINATION
Contractor will develop and implement standards for appointment scheduling
and a system for coordinating interpreters, to ensure continuity in the
assignment of interpreters to Members when follow-up care is required.
6.11 IMPLEMENTATION PLANS
6.11.1 TIME FRAMES
The Contractor will submit deliverables within the timeframes specified on
the Implementation Plan approved by DHS. Compliance with the schedule is
mandatory unless otherwise approved by DHS. (See Article III, Section
3.19, Liquidated Damages Provisions). Unless otherwise specified, all
completion dates listed for the deliverables are calculated from the
Contract effective date.
6.11.2 IMPLEMENTATION PLAN OVERSIGHT
The Contractor will identify a single individual to be responsible for
oversight of the Implementation Plan.
6.11.3 MONTHLY PROGRESS REPORTS
The Contractor will submit monthly written progress reports to DHS at the
request of DHS.
The progress reports will contain the following:
A. Any discrepancies with the Implementation Plan.
B. Activity number and name the Contractor assigns to each
deliverable/milestone.
C. Description of current activities that have taken place toward
achieving the deliverable/milestone.
D. Summary of activities yet to be accomplished toward completion of
the deliverable/milestone.
E. Due date in the Implementation Plan.
F. Current estimated due date.
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G. If the estimated due date in later than the Implementation Plan due
date, then:
1. Identify reasons why the activity is not on schedule, and
2. Identify actions the Contractor is taking to remedy the activity
and meet the due date.
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Xxxxxx Medical Centers Attachment I
95-23637
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Family
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.816 4.223 .370 2.232 .000 3.330
Age/sex Adjustment 1.026 .997 1.040 1.019 1.000 1.010
Aid Code Adjustment .989 .990 .985 .995 1.000 .976
Adjusted Units 3.872 4.168 .379 2.263 .000 3.283
Average Cost Per Unit 71.93 14.73 880.94 21.79 369.03 28.02
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 72.87 $ 14.73 $ 880.94 $ 21.79 $ 369.03 $ 28.02
Interest Adjustment .997 1.000 .994 .997 .997 .997
Contract Cost per Eligible $ 281.31 $ 61.39 $ 331.87 $ 49.16 $ .00 $ 91.71 $ 815.44
Benefit Adjustments
FY 94/95 1.003 .852 1.030 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 .975
Trend Adjustment 7/93 - 1/96 1.027 1.220 1.043 .945 1.000 1.317 *
Annual Cost Per Eligible $ 289.77 $ 46.20 $ 362.94 $ 46.60 $ .00 $ 119.42 $ 864.93
Mental Health Adjustment 1.4% .0% 6.6% 5.0% 1.5% 4.5%
Eyewear Adjustment 1.5%
Cost Excluding Mental Health $ 285.71 $ 46.20 $ 338.99 $ 44.27 $ .00 $ 112.34 $ 827.51
Preliminary Monthly Rate $ 68.96
Adj. for Fee-for-Service Limitation -2.0% $ -1.38
CHDP 2.43
Final Rate $ 70.01
1
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Child
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.791 3.907 .361 1.620 .000 1.882
Age/sex Adjustment 1.184 1.019 1.227 1.087 1.000 1.109
Aid Code Adjustment 1.011 .993 1.025 1.010 1.000 .998
Adjusted Units 4.538 3.953 .454 1.779 .000 2.083
Average Cost Per Unit 69.47 11.05 901.25 22.20 .00 40.13
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.37 $ 11.05 $ 901.25 $ 22.20 $ .00 $ 40.13
Interest Adjustment .996 .999 .990 .994 .998 .995
Contract Cost per Eligible $ 318.06 $ 43.64 $ 405.08 $ 39.26 $ .00 $ 83.17 $ 889.21
Benefit Adjustments
FY 94/95 1.003 .852 1.031 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/96 1.040 1.238 .853 .906 1.000 1.210
Annual Cost Per Eligible $ 331.77 $ 33.33 $ 362.66 $ 35.68 $ .00 $ 98.32 $ 861.76
Mental Health Adjustment 1.6% .0% 13.4% 2.9% 3.4% 3.6%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 326.46 $ 33.33 $ 314.06 $ 34.65 $ .00 $ 93.93 $ 802.43
Preliminary Monthly Rate $ 66.87
Adj. for Fee-for-Service Limitation -2.0% $ -1.34
CHDP 2.38
Final Rate $ 67.91
2
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Aged
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 4.280 19.624 1.476 1.310 2.880 14.314
Age/sex Adjustment .986 1.004 .995 .987 1.031 1.005
Aid Code Adjustment .936 1.021 .968 .931 1.007 1.016
Adjusted Units 3.950 20.116 1.422 1.204 2.990 14.616
Average Cost Per Unit 44.28 28.65 265.64 16.35 76.99 6.95
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 44.86 $ 28.65 $ 265.64 $ 16.35 $ 76.99 $ 6.95
Interest Adjustment .994 1.000 .990 .991 .998 .996
Contract Cost per Eligible $ 176.13 $ 576.32 $ 373.96 $ 19.51 $ 229.74 $ 101.17 $ 1,476.83
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.347 1.194 .925 1.091 1.054 1.404
Annual Cost Per Eligible $ 237.96 $ 424.47 $ 364.82 $ 21.35 $ 257.36 $ 142.18 $ 1,448.14
Mental Health Adjustment .3% .0% .7% .9% .4% .0%
Eyewear Adjustment 2.1%
Cost Excluding Mental Health $ 237.25 $ 424.47 $ 362.27 $ 21.16 $ 256.33 $ 139.19 $ 1,440.67
Preliminary Monthly Rate $ 120.06
Adj. for Fee-for-Service Limitation -2.0% $ -2.40
CHDP .00
Final Rate $ 117.66
3
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Disabled
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 7.452 23.494 1.498 4.212 1.440 28.577
Age/sex Adjustment 1.005 .979 .990 1.001 1.011 1.008
Aid Code Adjustment .994 1.003 .983 .993 .999 1.004
Adjusted Units 7.444 23.070 1.458 4.229 1.454 28.921
Average Cost Per Unit 43.31 32.19 511.29 18.05 108.27 10.65
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.87 $ 32.19 $ 511.29 $ 18.05 $ 108.27 $ 10.65
Interest Adjustment .995 .999 .991 .993 .999 .996
Contract Cost per Eligible $ 324.94 $ 741.88 $ 738.75 $ 75.80 $ 157.27 $ 306.78 $ 2,345.42
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.115 1.190 .986 1.047 .992 1.233
Annual Cost Per Eligible $ 363.40 $ 544.58 $ 768.21 $ 79.60 $ 165.82 $ 378.64 $ 2,300.25
Mental Health Adjustment 7.8% .0% 11.7% 2.4% 1.3% 1.4%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 335.05 $ 544.58 $ 678.33 $ 77.69 $ 163.66 $ 369.98 $ 2,169.29
Preliminary Monthly Rate $ 180.77
Adj. for Fee-for-Service Limitation -2.0% $ -3.62
CHDP .00
Final Rate $ 177.15
4
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Adult
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 22.752 5.069 3.590 4.465 .000 20.412
Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
Average Cost Per Unit 59.80 16.00 960.30 20.51 .00 43.66
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 60.58 $ 16.00 $ 960.30 $ 20.51 $ .00 $ 43.66
Interest Adjustment .996 .999 .995 .993 .996 .995
Contract Cost per Eligible $ 1,372.80 $ 81.02 $ 3,430.24 $ 90.94 $ .00 $ 886.73 $ 5,861.73
Benefit Adjustments
FY 94/95 1.003 .852 1.035 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.076 1.020 1.086 1.122 1.000 1.139
Annual Cost Per Eligible $ 1,481.56 $ 50.98 $ 3,925.30 $ 102.34 $ .00 $ 1,023.12 $ 6,583.03
Mental Health Adjustment .1% .0% .3% 1.1% .0% .1%
Eyewear Adjustment .4%
Cost Excluding Mental Health $ 1,480.08 $ 50.98 $ 3,913.25 $ 101.21 $ .00 $ 1,018.01 $ 6,563.53
Preliminary Monthly Rate $ 546.96
Adj. for Fee-for-Service Limitation -2.0% $ -10.94
CHDP .00
Final Rate $ 536.02
5
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Family
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.816 4.223 .370 2.232 .000 3.330
Age/sex Adjustment 1.026 .997 1.040 1.019 1.000 1.010
Aid Code Adjustment .989 .990 .985 .995 1.000 .976
Adjusted Units 3.872 4.168 .379 2.263 .000 3.283
Average Cost Per Unit 71.93 14.73 880.94 21.79 369.03 28.02
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 72.87 $ 14.73 $ 800.94 $ 21.79 $ 369.03 $ 28.02
Interest Adjustment .997 1.000 .994 .997 .997 .997
Contract Cost per Eligible $ 281.31 $ 61.39 $ 331.87 $ 49.16 $ .00 $ 91.71 $ 815.44
Benefit Adjustments
FY 94/95 1.003 .852 1.030 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/97 1.036 1.313 1.060 .925 1.000 1.454
Annual Cost Per Eligible $ 292.31 $ 49.72 $ 368.86 $ 45.61 $ .00 $ 131.84 $ 888.34
Mental Health Adjustment 1.4% 6.0% 6.6% 5.0% l.5% 4.5%
Eyewear Adjustment 1.5%
Cost Excluding Mental Health $ 288.22 $ 46.74 $ 344.52 $ 43.33 $ .00 $ 124.02 $ 846.83
Preliminary Monthly Rate $ 70.57
Adj. for Fee-for-Service Limitation -2.0% $ -1.41
CHDP 2.43
Final Rate $ 71.59
6
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Child
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.791 3.907 .361 1.620 .000 1.882
Age/sex Adjustment 1.184 1.019 1.227 1.087 1.000 1.109
Aid Code Adjustment 1.011 .993 1.025 1.010 1.000 .998
Adjusted Units 4.538 3.953 .454 1.779 .000 2.083
Average Cost Per Unit 69.47 11.05 901.25 22.20 .00 40.13
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.37 $ 11.05 $ 901.25 $ 22.20 $ .00 $ 40.13
Interest Adjustment .996 .999 .990 .994 .998 .995
Contract Cost per Eligible $ 318.06 $ 43.64 $ 405.08 $ 39.26 $ .00 $ 83.17 $ 889.21
Benefit Adjustments
FY 94/95 1.003 .852 1.031 1.003 1.042 1.001
FY 95/96 1.000 .724 1,018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/97 1.047 1.330 .807 .878 1.000 1.285
Annual Cost Per Eligible $ 334.01 $ 35.80 $ 343.10 $ 34.57 $ .00 $ 104.41 $ 851.89
Mental Health Adjustment 1.6% 4.6% 13.4% 2.9% 3.4% 3.6%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 328.67 $ 34.15 $ 297.12 $ 33.57 $ .00 $ 99.75 $ 793.26
Preliminary Monthly Rate $ 66.11
Adj. for Fee-for-Service Limitation -2.0% $ -1.32
CHDP 2.38
Final Rate $ 67.17
7
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Aged
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 4.280 19.624 1.476 1.310 2.880 14.314
Age/sex Adjustment .986 1.004 .995 .987 1.031 1.005
Aid Code Adjustment .936 1.021 .968 .931 1.007 1.016
Adjusted Units 3.950 20.116 1.422 1.204 2.990 14.616
Average Cost Per Unit 44.28 28.65 265.64 16.35 76.99 6.95
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 44.86 $ 28.65 $ 265.64 $ 16.35 $ 76.99 $ 6.95
Interest Adjustment .994 1.000 .990 .991 .998 .996
Contract Cost per Eligible $ 176.13 $ 576.32 $ 373.96 $ 19.51 $ 229.74 $ 101.17 $ 1,476.83
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/97 1.486 1.278 .896 1.127 1.075 1.565
Annual Cost Per Eligible $ 262.51 $ 454.33 $ 353.38 $ 22.05 $ 262.49 $ 158.49 $ 1,513.25
Mental Health Adjustment .3% 3.2% .7% .9% .4% .0%
Eyewear Adjustment 2.1%
Cost Excluding Mental Health $ 261.72 $ 439.79 $ 350.91 $ 21.85 $ 261.44 $ 155.16 $ 1,490.87
Preliminary Monthly Rate $ 124.24
Adj. for Fee-for-Service Limitation -2.0% $ -2.48
CHDP .00
Final Rate $ 121.76
8
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Disabled
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 7.452 23.494 1.498 4.212 1.440 28.577
Age/sex Adjustment 1.005 .979 .990 1.011 1.011 1.008
Aid Code Adjustment .994 1.003 .983 .993 .999 1.004
Adjusted Units 7.444 23.070 1.458 4.229 1.454 28.921
Average Cost Per Unit 43.31 32.19 511.29 18.05 108.27 10.65
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.87 $ 32.19 $ 511.29 $ 18.05 $ 108.27 $ 10.65
Interest Adjustment .995 .999 .991 .993 .999 .996
Contract Cost per Eligible $ 324.94 $ 741.88 $ 738.75 $ 75.80 $ 157.27 $ 306.78 $ 2,345.42
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/97 1.160 1.270 .981 1.065 .991 1.327
Annual Cost Per Eligible $ 378.06 $ 581.19 $ 764.32 $ 80.97 $ 165.65 $ 407.50 $ 2,377.69
Mental Health Adjustment 7.8% 18.8% 11.7% 2.4% 1.3% 1.4%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 348.57 $ 471.93 $ 674.89 $ 79.03 $ 163.50 $ 398.18 $ 2,136.10
Preliminary Monthly Rate $ 178.01
Adj. for Fee-for-Service Limitation -2.0% $ -3.56
CHDP .00
Final Rate $ 174.45
9
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: San Bernardino
Capitation Payable: End of Month
Aid Code: Adult
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 22.752 5.069 3.590 4.465 .000 20.412
Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
Average Cost Per Unit 59.80 16.00 960.30 20.51 .00 43.66
Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 60.58 $ 16.00 $ 960.30 $ 20.51 $ .00 $ 43.66
Interest Adjustment .996 .999 .995 .993 .996 .995
Contract Cost per Eligible $ 1,372.80 $ 81.02 $ 3,430.24 $ 90.94 $ .00 $ 886.73 $ 5,861.73
Benefit Adjustments
FY 94/95 1.003 .852 1.035 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/97 1.099 1.023 1.126 1.169 1.000 1.195
Annual Cost Per Eligible $ 1,513.23 $ 51.13 $ 4,069.59 $ 106.63 $ .00 $ 1,073.42 $ 6,814.00
Mental Health Adjustment .1% 2.2% .3% 1.1% .0% .1%
Eyewear Adjustment .4%
Cost Excluding Mental Health $ 1,511.72 $ 50.01 $ 4,057.38 $ 105.46 $ .00 $ 1,068.06 $ 6,792.63
Preliminary Monthly Rate $ 566.05
Adj. for Fee-for-Service Limitation -2.0% $ -11.32
CHDP .00
Final Rate $ 554.73
10
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: Riverside
Capitation Payable: End of Month
Aid Code: Family
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.816 4.223 .370 2.232 .000 3.330
Age/sex Adjustment 1.062 .994 1.094 1.032 1.000 1.021
Aid Code Adjustment 1.029 .998 1.098 1.042 1.000 1.020
Adjusted Units 4.170 4.189 .444 2.400 .000 3.468
Average Cost Per Unit 71.93 14.73 828.49 21.79 369.03 28.02
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.92 $ 14.73 $ 828.49 $ 21.79 $ 369.03 $ 28.02
Interest Adjustment .997 1.000 .994 .997 .997 .997
Contract Cost per Eligible $ 294.85 $ 61.70 $ 365.64 $ 52.14 $ .00 $ 96.88 $ 871.21
Benefit Adjustments
FY 94/95 1.003 .852 1.030 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/96 1.027 1.220 1.043 .945 1.000 1.317
Annual Cost Per Eligible $ 303.72 $ 46.43 $ 399.87 $ 49.42 $ .00 $ 126.15 $ 925.59
Mental Health Adjustment 1.4% .0% 6.6% 5.0% 1.5% 4.5%
Eyewear Adjustment 1.5%
Cost Excluding Mental Health $ 299.47 $ 46.43 $ 373.48 $ 46.95 $ .00 $ 118.67 $ 885.00
Preliminary Monthly Rate $ 73.75
Adj. for Fee-for-Service Limitation -2.0% $ -1.48
CHDP 2.43
Final Rate $ 74.70
11
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: Riverside
Capitation Payable: End of Month
Aid Code: Child
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.791 3.907 .361 1.620 .000 1.882
Age/sex Adjustment 1.193 .991 1.245 1.064 1.000 1.114
Aid Code Adjustment 1.020 1.035 1.048 1.013 1.000 1.025
Adjusted Units 4.613 4.007 .471 1.746 .000 2.149
Average Cost Per Unit 69.47 11.05 890.67 22.20 .00 40.13
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 68.50 $ 11.05 $ 890.67 $ 22.20 $ .00 $ 40.13
Interest Adjustment .996 .999 .990 .994 .998 .995
Contract Cost per Eligible $ 314.73 $ 44.23 $ 415.31 $ 38.53 $ .00 $ 85.81 $ 898.61
Benefit Adjustments
FY 94/95 1.003 .852 1.031 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/96 1.040 1.238 .853 .906 1.000 1.210
Annual Cost Per Eligible $ 328.30 $ 33.78 $ 371.82 $ 35.01 $ .00 $ 101.44 $ 870.35
Mental Health Adjustment 1.6% .0% 13.4% 2.9% 3.4% 3.6%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 323.05 $ 33.78 $ 322.00 $ 33.99 $ .00 $ 96.91 $ 809.73
Preliminary Monthly Rate $ 67.48
Adj. for Fee-for-Service Limitation -2.0% $ -1.35
CHDP 2.38
Final Rate $ 68.51
12
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: Riverside
Capitation Payable: End of Month
Aid Code: Aged
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 4.280 19.624 1.476 1.310 2.880 14.314
Age/sex Adjustment .991 1.002 1.000 .991 1.034 1.006
Aid Code Adjustment .941 1.015 .969 .932 1.004 1.003
Adjusted Onits 3.991 19.958 1.430 1.210 2.990 14.443
Average Cost Per Unit 44.28 28.65 205.53 16.35 76.99 6.95
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.66 $ 28.65 $ 205.53 $ 16.35 $ 76.99 $ 6.95
Interest Adjustment .994 1.000 .990 .991 .998 .996
Contract Cost per Eligible $ 173.20 $ 571.80 $ 290.97 $ 19.61 $ 229.74 $ 99.98 $ 1,385.30
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.347 1.194 .925 1.091 1.054 1.404
Annual Cost Per Eligible $ 234.00 $ 421.14 $ 283.86 $ 21.46 $ 257.36 $ 140.51 $ 1,358.33
Mental Health Adjustment .3% .0% .7% .9% .4% .0%
Eyewear Adjustment 2.1%
Cost Excluding Mental Health $ 233.30 $ 421.14 $ 281.87 $ 21.27 $ 256.33 $ 137.56 $ 1.351.47
Preliminary Monthly Rate $ 112.62
Adj. for Fee-for-Service Limitation -2.0% $ -2.25
CHDP .00
Final Rate $ 110.37
13
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: Riverside
Capitation Payable: End of Month
Aid Code: Disabled
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 7.452 23.494 1.498 4.212 1.440 28.577
Age/sex Adjustment 1.003 .992 .992 1.003 1.012 1.005
Aid Code Adjustment- 1.002 1.003 1.018 1.006 .997 1.005
Adjusted Units 7.489 23.376 1.513 4.250 1.453 28.863
Average Cost Per Unit 43.31 32.19 532.47 18.05 108.27 10.65
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 42.70 $ 32.19 $ 532.47 $ 18.05 $ 108.27 $ 10.65
Interest Adjustment .995 .999 .991 .993 .999 .996
Contract Cost per Eligible $ 318.18 $ 751.72 $ 798.38 $ 76.18 $ 157.16 $ 306.16 $ 2,407.78
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.115 1.190 .986 1.047 .992 1.233
Annual Cost Per Eligible $ 355.84 $ 551.80 $ 830.22 $ 80.00 $ 165.70 $ 377.87 $ 2,361.43
Mental Health Adjustment 7.8% .0% 11.7% 2.4% 1.3% 1.4%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 328.08 $ 551.80 $ 733.08 $ 78.08 $ 163.55 $ 369.23 $ 2,223.82
Preliminary Monthly Rate $ 185.32
Adj. for Fee-for-Service Limitation -2.0% $ -3.71
CHDP .00
Final Rate $ 181.61
14
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 7/95 - 5/96
County: Riverside
Capitation Payable: End of Month
Aid Code: Adult
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 22.752 5.069 3.590 4.465 .000 20.412
Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
Average Cost Per Unit 59.80 16.00 840.07 20.51 .00 43.66
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 58.96 $ 16.00 $ 840.07 $ 20.51 $ .00 $ 43.66
Interest Adjustment .996 .999 .995 .993 .996 .995
Contract Cost per Eligible $ 1,336.09 $ 81.02 $ 3,000.77 $ 90.94 $ .00 $ 886.73 $ 5,395.55
Benefit Adjustments
FY 94/95 1.003 .852 1.035 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/96 1.076 1.020 1.086 1.122 1.000 1.139
Annual Cost Per Eligible $ 1,441.95 $ 50.98 $ 3,433.61 $ 102.34 $ .00 $ 1,023.12 $ 6,052.00
Mental Health Adjustment .1% .0% .3% 1.1% .0% .1%
Eyewear Adjustment .4%
Cost Excluding Mental Health $ 1.440.51 $ 50.98 $ 3,423.31 $ 101.21 $ .00 $ 1,018.01 $ 6,034.02
Preliminary Monthly Rate $ 502.84
Adj. for Fee-for-Service Limitation -2.0% $ -10.06
CHDP .00
Final Rate $ 492.78
15
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: Riverside
Capitation Payable: End of Month
Aid Code: Family
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 8.816 4.223 .370 2.232 .000 3.330
Age/sex Adjustment 1.062 .994 1.094 1.032 1.000 1.021
Aid Code Adjustment 1.029 .998 1.098 1.042 1.000 1.020
Adjusted Units 4.170 4.189 .444 2.400 .000 3.468
Average Cost Per Unit 71.93 14.73 828.49 21.79 369.03 28.02
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.92 $ 14.73 $ 828.49 $ 21.79 $ 369.03 $ 28.02
Interest Adjustment .997 1.000 .994 .997 .997 .997
Contract Cost per Eligible $ 294.85 $ 61.70 $ 365.64 $ 52.14 $ .00 $ 96.88 $ 871.21
Benefit Adjustments
FY 94/95 1.003 .852 1.030 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/97 1.036 1.313 1.060 .925 1.000 1.454
Annual Cost Per Eligible $ 306.38 $ 49.97 $ 406.39 $ 48.37 $ .00 $ 139.27 $ 950.38
Mental Health Adjustment 1.4% 6.0% 6.5% 5.0% 1.5% 4.5%
Eyewear Adjustment 1.5%
Cost Excluding Mental Health $ 302.09 $ 46.97 $ 379.57 $ 45.95 $ .00 $ 131.01 $ 905.59
Preliminary Monthly Rate $ 75.47
Adj. for Fee-for-Service Limitation -2.0% $ -1.51
CHDP 2.43
Final Rate $ 76.39
16
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: Riverside
Capitation Payable: End of Month
Aid Code: Child
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 3.791 3.907 .361 1.620 .000 1.882
Age/sex Adjustment 1.193 .991 1.245 1.064 1.000 1.114
Aid Code Adjustment 1.020 1.035 1.048 1.013 1.000 1.025
Adjusted Units 4.613 4.007 .471 1.746 .000 2.149
Average Cost Per Unit 69.47 11.05 890.67 22.20 .00 40.13
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 68.50 $ 11.05 $ 890.67 $ 22.20 $ .00 $ 40.13
Interest Adjustment .996 .999 .990 .994 .998 .995
Contract Cost per Eligible $ 314.73 $ 44.23 $ 415.31 $ 38.53 $ .00 $ 85.81 $ 898.61
Benefit Adjustments
FY 94/95 1.003 .852 1.031 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 .976
Trend Adjustment 7/93 - 1/97 1.047 1.330 .807 .878 1.000 1.285
Annual Cost Per Eligible $ 330.51 $ 36.29 $ 351.76 $ 33.93 $ .00 $ 107.73 $ 860.22
Mental Health Adjustment 1.6% 4.6% 13.4% 2.9% 3.4% 3.6%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 325.22 $ 34.62 $ 304.62 $ 32.95 $ .00 $ 102.92 $ 800.33
Preliminary Monthly Rate $ 66.69
Adj. for Fee-for-Service Limitation -2.0% $ -1.33
CHDP 2.38
Final Rate $ 67.74
17
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: Riverside
Capitation Payable: End of Month
Aid Code: Aged
Phys Pharm HIP HOP LTC Other Total
Units per 1.000 eligibles 4.280 19.624 1.476 1.310 2.880 14.314
Age/sex Adjustment .991 1.002 1.000 .991 1.034 1.006
Aid Code Adjustment .941 1.015 .969 .932 1.004 1.003
Adjusted Units 3.991 19.958 1.430 1.210 2.990 14.443
Average Cost Per Unit 44.28 28.65 205.53 16.35 76.99 6.95
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.66 $ 28.65 $ 205.53 $ 16.35 $ 76.99 $ 6.95
Interest Adjustment .994 1.000 .990 .991 .998 .996
Contract Cost per Eligible $ 173.20 $ 571.80 $ 290.97 $ 19.61 $ 229.74 $ 99.98 $ 1,385.30
Benefit Adjustments
FT 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/97 1.486 1.278 .896 1.127 1.075 1.565
Annual Cost Per Eligible $ 258.15 $ 450.77 $ 274.96 $ 22.17 $ 262.49 $ 156.63 $ 1,425.17
Mental Health Adjustment .3% 3.2% .7% .9% .4% .0%
Eyewear Adjustment 2.1%
Cost Excluding Mental Health $ 257.38 $ 436.35 $ 273.04 $ 21.97 $ 261.44 $ 153.34 $ 1,403.52
Preliminary Monthly Rate $ 116.96
Adj. for Fee-for-Service Limitation -2.0% $ -2.34
CHDP .00
Final Rate $ 114.62
18
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: Riverside
Capitation Payable: End of Month
Aid Code: Disabled
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 7.452 23.494 1.498 4.212 1.440 28.577
Age/sex Adjustment 1.003 .992 .992 1.003 1.012 1.005
Aid Code Adjustment 1.002 1.003 1.018 1.006 .997 1.005
Adjusted Units 7.489 23.376 1.513 4.250 1.453 28.863
Average Cost Per Unit 43.31 32.19 532.47 18.05 108.27 10.65
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 42.70 $ 32.19 $ 532.47 $ 18.05 $ 108.27 $ 10.65
Interest Adjustment .995 .999 .991 .993 .999 .996
Contract Cost per Eligible $ 318.18 $ 751.72 $ 798.38 $ 76.18 $ 157.16 $ 306.16 $ 2,407.78
Benefit Adjustments
FY 94/95 1.003 .852 1.036 1.003 1.042 1.001
FY 95/96 1.000 .724 1.018 1.000 1.020 l.000
Trend Adjustment 7/93 - 1/97 1.160 1.270 .981 1.065 .991 1.327
Annual Cost Per Eligible $ 370.20 $ 588.90 $ 826.01 $ 81.38 $ 165.53 $ 406.68 $ 2.438.70
Mental Health Adjustment 7.8% 18.8% 11.7% 2.4% 1.3% 1.4%
Eyewear Adjustment .9%
Cost Excluding Mental Health $ 341.32 $ 478.19 $ 729.37 $ 79.43 $ 163.38 $ 397.38 $ 2,189.07
Preliminary Monthly Rate $ 182.42
Adj. for Fee-for-Service Limitation -2.0% $ -3.65
CHDP .00
Final Rate $ 178.77
19
Attachment I
Plan Name: Mainstream Base Period: CY '93
Plan Number: Rate Period: 6/96 - 9/97
County: Riverside
Capitation Payable: End of Month
Aid Code: Adult
Phys Pharm HIP HOP LTC Other Total
Units per 1,000 eligibles 22.752 $ 5.069 3.590 4.465 .000 20.412
Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
Average Cost Per unit 59.80 16.00 840.07 20.51 .00 43.66
Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 58.96 $ 16.00 $ 840.07 $ 20.51 $ .00 $ 43.66
Interest Adjustment .996 .999 .995 .993 .996 .995
Contract Cost per Eligible $ 1,336.09 $ 81.02 $ 3,000.77 $ 90.94 $ .00 $ 886.73 $ 5,395.55
Benefit Adjustments
FY 94/95 1.003 .852 1.035 1.003 1.042 1.013
FY 95/96 1.000 .724 1.018 1.000 1.020 1.000
Trend Adjustment 7/93 - 1/97 1.099 1.023 1.126 1.169 1.000 1.195
Annual Cost Per Eligible $ 1,472.77 $ 51.13 $ 3,560.08 $ 106.63 $ .00 $ 1,073.42 $ 6,264.03
Mental Health Adjustment .1% 2.2% .3% 1.1% .0% .1%
Eyewear Adjustment .4%
Cost Excluding Mental Health $ 1,471.30 $ 50.01 $ 3,549.40 $ 105.46 $ .00 $ 1,068.06 $ 6,244.23
Preliminary Monthly Rate $ 520.35
Adj. for Fee-for-Service Limitation -2.0% $ -10.41
CHDP .00
Final Rate $ 509.94
20
STATE OF CALIFORNIA
STANDARD AGREEMENT -- APPROVED BY THE CONTRACT NUMBER AM. NO.
STD.2(REV.5-91) ATTORNEY GENERAL 95-23637 01
TAXPAYER'S FEDERAL
EMPLOYER IDENTIFICATION NO.
00-0000000
THIS AGREEMENT, made and entered into this 30th day of May, 1997 in the State of
California, by and between State of California, through its duly elected or
appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
Xxxxxx Medical Centers, hereafter called the Contractor:
WTTNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter express does
hereby agree to furnish to the State services and materials as follows: (Set
forth service to be rendered by Contractor, amount to be paid Contractor, time
for performance or completion, and attach plans and specifications, if any.)
Amendment A01 to contract number 95-23637 between Xxxxxx Medical Centers
and the State of California; and
WHERE AS, the State of California and Xxxxxx Medical Centers, entered into
a contract to provide health care services to Medi-Cal beneficiaries dated
April 2, 1996; and
NOW THEREFORE, this contract is amended as follows:
[SEAL]
CONTINUED ON 1 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
-------------------------------------------------------------------------------------------------------------------------------
STATE OF CALIFORNIA CONTRACTOR
-------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (If other than an individual, state whether a corporation, partnership, etc.)
Department of Health Service Xxxxxx Medical Centers
-------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ Xxxxx Xxxxxx For /s/ Xxxx Xxxxxx For
-------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx J. Xxxxx Xxxxxx, M.D., President
-------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
-------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE Department of General
DOCUMENT Loc. Asst. Section 14157 W&I Code Health Care Deposit Services Use Only
$ -0- ----------------------------------------------------------------------
------------------------------ (OPTIONAL USE)
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ------------------------------------------------------------
$ 226,553,310 ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 162 1996 96/97
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------
$ 226,553,310 OBJECT OF EXPENDITURE (CODE AND TITLE) Exempt from PCC
Fed. Cat. No. 93778 4260-101-001 & 890 per W&I Code
---------------------------------------------------------------------------------------------------- Section 14087.4
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
----------------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ Xxxxxxx Xxxxxx 6/26/97
----------------------------------------------------------------------------------------------------
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD 2 (REV.5-01)(REVERSE)
1. The Contractor agrees to indemnify, defend and save harmless the
State, its officers, agents and employees from any and all claims and
losses accruing or resulting to any and all contractors,
subcontractors, materialmen, laborers and any other person, firm or
corporation furnishing or supplying work services, materials or
supplies in connection with the performance of this contract, and
from any and all claims and losses accruing or resulting to any
person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and
not as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment
of any consideration to Contractor should Contractor fail to perform
the covenants herein contained at the time and in the manner herein
provided. In the event of such termination the State may proceed with
the work in any manner deemed proper by the State. The cost to the
State shall be deducted from any sum due the Contractor under this
agreement, and the balance, if any, shall be paid the Contractor upon
demand.
4. Without the written consent of the State, this agreement is not
assignable by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be
valid unless made in writing and signed by the parties hereto, and no
oral understanding or agreement not incorporated herein, shall be
binding on any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be
in compensation for all of Contractor's expenses incurred in the
performance hereof, including travel and per diem, unless otherwise
expressly so provided.
Contract Amendment
The Department of Health Services ("DHS") and Xxxxxx Medical Centers
("Contractor") enter into this contract amendment as follows:
WHEREAS DHS and Contractor entered into contract number 95-23637 on April
2, 1996 (the "Contract"), identifying Contractor as the mainstream plan for the
Medi-Cal Two Plan Model Program in San Bernardino and Riverside counties, and
WHEREAS DHS and Contractor desire to modify certain rights and obligations
of the parties as they relate to termination of the Contract,
DHS and Contractor therefore mutually agree:
1. Section 3.17.6 is added to the Contract as though fully set forth therein:
(a) Notwithstanding any other provision of this Contract and except as
provided in subsection (b), this Contract shall terminate on November 30,
1997, unless Contractor can accept enrollment on December 1, 1997, with
coverage to be effective on December 1, 1997.
(b) The termination provisions of subsection (a) above, shall not apply if
Contractor is unable to accept enrollment on December 1, 1997, as a result
of (1) conditions, natural or otherwise, beyond the control of Contractor,
which substantially interfere with normal business operations, or (2)
legal, regulatory or other obstacles, unrelated to any act or omission of
Contractor, that prevent, postpone or suspend commencement of the Two Plan
Model Program in San Bernardino and Riverside counties.
(c) In the event of termination of the Contract pursuant to this section
3.17.6, Contractor waives any further notice and any administrative appeal
rights otherwise arising from or associated with termination of the
Contract pursuant to this section 3.17.6.
Department of Health Services Xxxxxx Medical Centers
(signature) (signature) /s/
__________________________________ _____________________________________
(printed name) (printed name) J. Xxxxx Xxxxxx MD
__________________________________ _____________________________________
(title) (title) President
__________________________________ _____________________________________
(date) (date) 6/9/97
__________________________________ _____________________________________
Xxxxxx Medical Centers 95-23637-A01
1. Article III, GENERAL TERMS AND CONDITIONS, is amended to add new Section
3.17.6, Termination-Other Conditions, as follows:
"3.17.6 Termination-Other Conditions
(a) Notwithstanding any other provision of this Contract and except as
provided in subsection (b), this Contract will terminate on November
30, 1997, unless Contractor can accept enrollment on December 1,
1997, with coverage to be effective on December 1, 1997.
(b) The termination provisions of subsection (a) above, shall not apply
if Contractor is unable to accept enrollment on December 1, 1997, as
a result of (1) conditions, natural or otherwise, beyond the control
of Contractor, which substantially interfere with normal business
operations, or (2) legal, regulatory or other obstacles, unrelated to
any act or omission of Contractor, that prevent, postpone or suspend
commencement of the Two Plan Model Program in San Bernardino and
Riverside counties.
(c) In the event of termination of the Contract pursuant to this section
3.17.6, Contractor waives any further notice and any administrative
appeal rights otherwise arising from or associated with termination
of the Contract pursuant to this section 3.17.6."
2. The effective date of this amendment is May 30, 1997.
3. All other rights, duties, obligations, and liabilities of the parties
otherwise remain unchanged.
STATE OF CALIFORNIA CONTRACT NUMBER AM. NO.
95-23637 02
STANDARD AGREEMENT -- APPROVED BY THE TAXPAYER'S FEDERAL
[STD. 2 (REV.5-91) ATTORNEY GENERAL EMPLOYER IDENTIFICATION
NUMBER
00-0000000
THIS AGREEMENT, made and entered into this 1st day of July, 1997, in the State
of California, by and between State of California, through its duly elected or
appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
Xxxxxx Medical Centers, Inc., hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the State services and materials as follows:
(Set forth service to be rendered by contractor, amount to be paid contractor,
time for performance or completion, and attach plans and specifications, if
any.)
Amendment A02 to contract number 95-23637 BETWEEN XXXXXX MEDICAL CENTERS, INC.
and the STATE OF CALIFORNIA; and
WHERE AS, the State of California and Xxxxxx Medical Centers, Inc., entered into
a contract to provide health care services to eligible Medi-Cal beneficiaries,
dated April 2, 1996; and
NOW THEREFORE, this Contract is amended as follows"
[SEAL]
CONTINUED ON 2 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
STATE OF CALIFORNIA CONTRACTOR
---------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (if other than an individual, state whether a corporation, partnership, etc.)
Department of Health Service Xxxxxx Medical Centers, Inc., A CA Corporation
---------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ Xxxxx Xxxxxx for /s/
---------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx J. Xxxxx Xxxxxx, M.D.
---------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
---------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE DEPARTMENT OF GENERAL
DOCUMENT Loc. Asst.Sect. 14157 W&I Code Health Care Deposit SERVICE USE ONLY
$ 194,472,680.00 ------------------------------------------------------------
------------------------------ (OPTIONAL USE) Exempt From PCC per
W&I Code Section 14087.4
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ------------------------------------------------------------
$ 226,553,310.00 ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 Subject to the Budget Act
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------
DATE OBJECT OF EXPENDITURE (CODE AND TITLE)
421,025,990 Fed.Cat.No.93778 4260-101-001 & 890
-------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
-------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ Xxxxxxx Xxxxxx 7.8.97
-------------------------------------------------------------------------------------------
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD.2 (REV. 5-01) (REVERSE)
1. The Contractor agrees to indemnify, defend and save harmless the
state, its officers, agents and employees from any and all claims and
losses accruing or resulting to any and all contractors,
subcontractors, materialmen, laborers and any other person, firm or
corporation furnishing or supplying work services, materials or
supplies in connection with the performance of this contract, and
from any and all claims and losses accruing or resulting to any
person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity
and not as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment
of any consideration to Contractor should Contractor fail to perform
the covenants herein contained at the time and in the manner herein
provided. In the event of such termination the State may proceed with
the work in any manner deemed proper by the State. The cost to the
State shall be deducted from any sum due the Contractor under this
agreement, and the balance, if any, shall be paid the Contractor upon
demand.
4. Without the written consent of the State, this agreement is not
assignable by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be
valid unless made in writing and signed by the parties hereto, and no
oral understanding or agreement not incorporated herein, shall be
binding on any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be
in compensation for all of Contractor's expenses incurred in the
performance hereof, including travel and per diem, unless otherwise
expressly so provided.
Xxxxxx Medical Centers, Inc. 00-00000-00
1, Article II, DEFINITIONS, Section O, Covered Services, is amended to add a
new subparagraph 16, to read:
"16. HTV and AIDS drugs listed in Attachment II (consisting of one page),
and HIV and AIDS drugs classified as Nucleoside Analogs, Protease
Inhibitors, and Non-Nucleoside Reverse Transcriptase Inhibitors,
approved by the federal Food and Drug Administration (FDA) after July
1, 1997."
2. Article V, PAYMENT PROVISIONS, Section 5.3, Capitation Rates, is amended to
read as follows:
"5.3 CAPITATION RATES
DHS will remit to the Contractor a capitation payment each month for
each Medi-Cal Member that appears on the approved list of Members
supplied to the Contractor by DHS. The capitation rate shall be the
amount specified in this Article. The payment period for health care
services will commence on the first day of operations, as determined
by DHS. Capitation payments will be made in accordance with the
following schedule of capitation payment rates:
Aid Code Categories
Family: 01, 02, 08, 30, 32, 33, 34, 35, 38, 39, 3A, 3C, 3P, 3R, 40,
42, 4C, 4K, 54, 59, 5K; Aged: 10, 14, 16, 18; Disabled: 20 24, 26, 28,
36, 60, 64, 66, 68, 6A, 6C; Child: 03, 04, 45, 82; Adult: 86
For the Period 0/00 - 0/00
Xxxxxxxxx Xxxxxx Xxx Xxxxxxxxxx Xxxxxx
Family $ 76.81 Family $ 72.12
Aged $ 123.58 Aged $ 130.50
Disabled $ 190.62 Disabled $ 186.32
Child $ 68.08 Child $ 67.51
Adult $ 496.01 Adult $ 538.82"
2
Xxxxxx Medical Centers, Inc. 00-00000-00
3. Article VI, SCOPE OF WORK, Section 6.5.7.8, Sensitive Services, is amended
to add a new paragraph, to read:
"The Contractor will develop, implement and maintain policies and
procedures for the treatment of HIV infection and AIDS. These policies and
procedures will be submitted to DHS no later than October 1, 1997. The
Contractor will submit any changes in these policies and procedures to DHS
at least 30 days prior to their implementation."
4. Article VI, SCOPE OF WORK, Section 6.7.3.3, Mental Health, is amended to
read:
"The following mental health services are excluded from the Contract: all
of SD/MC mental health services (inpatient and outpatient); FFS/MC
outpatient mental health services provided by psychiatrists and
psychologists; FFS/MC inpatient mental health services.
The Contractor will provide outpatient mental health services within the
Primary Care Physician's scope of practice. The Contractor will refer
Members who need specialty mental health services to the appropriate
FFS/MC mental health provider or to the appropriate SD/MC provider. The
Contractor will case manage the physical health of the Member and
coordinate services with the mental health referral provider. The
Contractor will ensure the provision of all psychotherapeutic drugs for
Members. Reimbursement to pharmacies for those psychotherapeutic drugs
listed in Attachment III (consisting of one page), and psychotherapeutic
drugs classified as Anti-Psychotics and approved by the FDA after July 1,
1997, will be made by DHS through the Medi-Cal FFS program, whether these
drugs are provided by a pharmacy contracting with the Contractor or by an
out-of-plan pharmacy provider. To qualify for reimbursement under this
provision, a pharmacy must be enrolled as a Medi-Cal provider in the
Medi-Cal FFS program."
5. The effective date of this amendment will be July 1, 1997.
6. All other rights, duties, obligations and liabilities of the parties hereto
otherwise remain unchanged.
Xxxxxx Medical Centers, Inc. 00-00000-00
ATTACHMENT II
EXCLUDED DRUGS FOR THE TREATMENT OF HIV AND AIDS
CRIXIVAN
EPIVIR
INVIRASE
NORVIR
VIRACEPT
VIRAMUNE
RESCRIPTOR
ZERIT
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
ATTACHMENT III
EXCLUDED PSYCHOTHERAPEUTIC DRUGS
GENERIC NAME
Benztropine Mesylate Biperiden HCL
Biperiden Lactate Procyclidine HCL
Trihexphenidyl HCL Amantadine HCL
Lithium Carbonate Lithium Citrate
Chloroprothixene Clozapine
Haloperidol Haloperidol Deconoate
Haloperidol Lactate Loxapine HCL
Loxapine Succinate Molindone HCL
Olanzapine Pimozide
Risperidone Thiothixene
Thiothixene HCL Chlorpromazine HCL
Fluphanazine Decanoate Fluphanazine Enanthate
Fluphanazine HCL Mesoridazine Besylate
Perphenazine Promazine HCL
Thioridazine HCL Trifluoperazine HCL
Triflupromazine HCL Isocarboxazid
Phenelzine Sulfate Tranylcypromine Sulfate
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 355 Base Period: CY '93
County Riverside Rate Period: 6/96 - 9/97
Aid Code Group Family
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 3.816 4.223 .370 2.232 .000 3.330
2. Aid Code Adjustment 1.029 .998 1.098 1.042 1.000 1.020
3. Age/sex Adjustment 1.062 .994 1.094 1.032 1.000 1.021
Adjusted Units 4.170 4.189 .444 2.400 .000 3.468
4. Average Cost Per Unit 71.93 14.73 828.49 21.79 369.03 28.02
5. Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.92 $ 14.73 $ 828.49 $ 21.79 $ 369.03 $ 28.02
6. Interest Adjustment .993 .996 .990 .993 .993 .993
Contract Cost per Eligible $ 293.67 $ 61.46 $ 364.17 $ 51.93 $ .00 $ 96.49 $ 867.72
7. Benefit Adjustments
FY 94/95 1.021 .926 1.002 1.002 1.042 1.025
FY 95/96 1.001 .850 1.000 1.000 .999 .991
8. Trend Adjustment 7/93-1/97 1.036 1.313 1.060 .925 1.000 1.454
Annual Cost Per Eligible $ 310.94 $ 63.52 $ 386.79 $ 48.13 $ .00 $ 142.51 $ 951.89
9. Mental Health Adjustment 1.4% .6% 6.6% 5.0% l.5% 4.5%
10. Lenses Adjustment 1.5%
Cost Excl. MH/Lenses $ 306.59 $ 63.14 $ 361.26 $ 45.72 $ .00 $ 134.06 $ 910.77
Preliminary Monthly Rate $ 75.90
11. Stop Loss Reinsurance - All
Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (1.52)
13. CHDP 2.43
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 76.81
1
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 355 Base Period: CY '93
County Riverside Rate Period: 6/96 - 9/97
Aid Code Group Aged
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 4. 280 19.624 1.476 1.310 2.880 14.314
2. Aid Code Adjustment .941 l.015 .969 .932 1.004 1.003
3. Age/sex Adjustment .991 1.002 1.000 .991 1.034 1.006
Adjusted Units 3.991 19.958 1.430 1.210 2.990 14.443
4. Average Cost Per Unit 44.28 28.65 205.53 16.35 76.99 6.95
5. Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.66 $ 28.65 $ 205.53 $ 16.35 $ 76.99 $ 6.95
6. Interest Adjustment .991 .996 .986 .988 .994 .992
Contract Cost per Eligible $ 172.68 $ 569.51 $ 289.79 $ 19.55 $ 228.82 $ 99.58 $ 1,379.93
7. Benefit Adjustments
FY 94/95 1.002 .926 1.008 1.002 1.042 1.000
FY 95/96 1.000 .850 l.000 1.000 .989 1.000
8. Trend Adjustment 7/93-1/97 1.486 1.278 .896 1.127 1.075 1.565
Annual Cost Per Eligible $ 257.12 $ 572.88 $ 261.73 $ 22.08 $ 253.49 $ 155.84 $ 1,523.14
9. Mental Health Adjustment .3% .5% .7% .9% .4% .0%
10. Lenses Adjustment 2.1%
Cost Excl. MH/Lenses $ 256.35 $ 570.02 $ 259.90 $ 21.88 $ 252.48 $ 152.57 $ 1,513.20
Preliminary Monthly Rate $ 126.10
11. Stop Loss Reinsurance - All
Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (2.52)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 123.58
2
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 355 Base Period: CY '93
County Riverside Rate Period: 6/96 - 9/97
Aid Code Group Disabled
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 7.452 23.494 1.498 4.212 1.440 28.577
2. Aid Code Adjustment 1.002 1.003 1.018 1.006 .997 l.005
3. Age/sex Adjustment 1.003 .992 .992 1.003 1.012 l.005
Adjusted Units 7.489 23.376 1.513 4.250 1.453 28.863
4. Average Cost Per Unit 43.31 32.19 532.47 18.O5 108.27 10.65
5. Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 42.70 $ 32.19 $ 532.47 $ 18.05 $ 108.27 $ 10.65
6. Interest Adjustment .992 .996 .998 .990 .995 .992
Contract Cost per Eligible $ 317.22 $ 749.46 $ 795.96 $ 75.95 $ 156.53 $ 304.93 $ 2,400.05
7. Benefit Adjustments
FY 94/95 1.002 .926 1.005 1.002 1.042 1.000
FY 95/96 1.000 .850 1.000 1.000 .989 1.000
8. Trend Adjustment 7/93-1/97 1.160 1.270 .981 1.065 .991 1.327
Annual Cost Per Eligible $ 368.71 $ 749.17 $ 784.74 $ 81.05 $ 159.86 $ 404.64 $ 2,548.17
9. Mental Health Adjustment 7.8% 10.7% 11.7% 2.4% 1.3% 1.4%
10. Lenses Adjustment .9%
Cost Excl. MH/Lenses $ 339.95 $ 669.01 $ 692.93 $ 79.10 $ 157.78 $ 395.38 $ 2,334.15
Preliminary Monthly Rate $ 194.51
11. Stop Loss Reinsurance - All
Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (3.89)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - capitation Payments at Beginning of Month $ 190.62
3
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 355 Base Period: CY '93
County Riverside Rate Period: 6/96 - 9/97
Aid Code Group Child
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 3.791 3.907 .361 1.620 .000 1.882
2. Aid Code Adjustment 1.020 1.035 1.048 1.013 1.000 1.025
3. Age/sex Adjustment 1.193 .992 1.245 1.064 1.000 1.114
Adjusted Units 4.613 4.007 .471 1.746 .000 2.149
4. Average Cost Per Unit 69.47 11.05 890.67 22.20 .00 40.13
5. Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 68.50 $ ll.05 $ 890.67 $ 22.20 $ .00 $ 40.13
6. Interest Adjustment .992 .995 .987 .990 .994 .992
Contract Cost per Eligible $ 313.46 $ 44.06 $ 414.05 $ 38.37 $ .00 $ 85.55 $ 895.49
7. Benefit Adjustments
FY 94/95 1.021 .926 1.002 1.002 1.042 1.019
FY 95/96 1.001 .850 1.000 1.000 .989 .991
8. Trend Adjustment 7/93-1/97 1.047 1.330 .807 .878 1.000 1.285
Annual Cost Per Eligible $ 336.42 $ 46.12 $ 334.81 $ 33.76 $ .00 $ 111.01 $ 861.12
9. Mental Health Adjustment 1.6% 1.1% 13.4% 2.9% 3.4% 3.6%
10. Lenses Adjustment .9%
Cost Excl. MH/Lenses $ 330.05 $ 45.61 $ 289.95 $ 32.78 $ .00 $ 106.05 $ 804.44
Preliminary Monthly Rate $ 67.04
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (1.34)
13. CHDP 2.38
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 68.08
4
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 355 Base Period: CY '93
County Riverside Rate Period: 6/96 - 9/97
Aid Code Group Adult
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 22.752 5.069 3.590 4.465 .000 20.412
2. Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
4. Average Cost Per Unit 59.80 16.00 840.07 20.51 .00 43.66
5. Area Adjustment .986 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 58.96 $ 16.00 $ 840.07 $ 20.51 $ .00 $ 43.66
6. Interest Adjustment .993 .996 .991 .989 .993 .991
Contract Cost per Eligible $ 1,332.07 $ 80.78 $ 2,988.71 $ 90.57 $ .00 $ 883.17 $ 5,375.30
7. Benefit Adjustments
FY 94/95 1.002 .926 1.008 1.002 1.042 1.006
PY 95/96 1.000 .850 1.000 1.000 .985 1.000
8. Trend Adjustment 7/93-1/97 1.099 1.023 1.126 1.169 1.000 1.195
Annual Cost Per Eligible $ 1,466.87 $ 65.04 $ 3,392.21 $ 106.09 $ .00 $ 1,061.72 $ 6,091.93
9. Mental Health Adjustment .1% .4% .3% 1.1% .0% .1%
10. Lenses Adjustment .4%
Cost Xxxx.XX/Xxxxxx $ 1,465.40 $ 64.78 $ 3,382.03 $ 104.92 $ .00 $ 1,056.42 $ 6,073.55
Preliminary Monthly Rate $ 506.13
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (10.12)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 496.01
5
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 356 Base Period: CY '93
County San Bernardino Rate Period: 6/96 - 9/97
Aid Code Group Family
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 3.816 4.223 .370 2.232 .000 3.330
2. Aid Code Adjustment .989 .990 .985 .995 1.000 .976
3. Age/sex Adjustment 1.026 .997 1.040 1.019 1.000 1.010
Adjusted Units 3.872 4.168 .379 2.263 .000 3.283
4. Average Cost Per Unit 71.93 14.73 880.94 21.79 369.03 28.02
5. Area Adjustment 1.013 1.000 1.000 1.000 l.000 1.000
Adjusted Cost $ 72.87 $ 14.73 $ 880.94 $ 21.79 $ 369.03 $ 28.02
6. Interest Adjustment .993 .996 .990 .993 .993 .993
Contract Cost per Eligible $ 280.18 $ 61.15 $ 330.54 $ 48.97 $ .00 $ 91.35 $ 812.19
7. Benefit Adjustments
FY 94/95 1.021 .926 1.002 1.002 1.042 1.025
FY 95/96 1.001 .850 1.000 1.000 .989 .991
8. Trend Adjustment 7/93-1/97 1.036 1.313 1.060 .926 1.000 1.454
Annual Cost Per Eligible $ 296.66 $ 63.20 $ 351.07 $ 45.39 $ .00 $ 134.92 $ 891.24
9. Mental Health Adjustment 1.4% .6% 6.6% 5.0% 1.5% 4.5%
10. Lenses Adjustment 1.5%
Cost Excl. MH/Lenses $ 292.51 $ 62.82 $ 327.90 $ 43.12 $ .00 $ 126.92 $ 853.27
Preliminary Monthly Rate $ 71.11
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (1.42)
13. CHDP 2.43
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 72.12
6
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 356 Base Period: CY '93
County San Bernardino Rate Period: 6/96 - 9/97
Aid Code Group Aged
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 4.280 19.624 1.476 1.310 2.880 14.314
2. Aid Code Adjustment .936 1.021 .968 .931 1.007 1.016
3. Age/sex Adjustment .986 1.004 .995 .987 1.031 l.005
Adjusted Units 3.950 20.116 1.422 1.204 2.990 14.616
4. Average Cost Per Unit 44.28 28.65 265.64 16.35 76.99 6.95
5. Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 44.86 $ 28.65 $ 265.64 $ 16.35 $ 76.99 $ 6.95
6. Interest Adjustment .991 .996 .986 .988 .994 .992
Contract Cost per Eligible $ 175.60 $ 574.02 $ 372.45 $ 19.45 $ 228.82 $ 100.77 $ 1,471.11
7. Benefit Adjustments
FY 94/95 1.002 .926 1.008 l.002 1.042 1.000
FY 95/96 1.000 .850 1.000 1.000 .989 1.000
8. Trend Adjustment 7/93-1/97 1.486 1.278 .896 1.127 1.075 1.565
Annual Cost Per Eligible $ 261.46 $ 577.41 $ 336.38 $ 21.96 $ 253.49 $ 157.71 $ 1,608.41
9. Mental Health Adjustment .3% .5% .7% .9% .4% .0%
10. Lenses Adjustment 2.1%
Cost Excl. MH/Lenses $ 260.68 $ 574.52 $ 334.03 $ 21.76 $ 252.48 $ 154.40 $ 1,597.87
Preliminary Monthly Rate $ 133.16
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (2.66)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 130.50
7
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 356 Base Period: CY '93
County San Bernardino Rate Period: 6/96 - 9/97
Aid Code Group Disabled
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 7.452 23.494 1.498 4.212 1.440 28.577
2. Aid Code Adjustment .994 1.003 .983 .993 .999 1.004
3. Age/sex Adjustment l.005 .979 .990 1.011 1.011 1.008
Adjusted Units 7.444 23.070 1.458 4.229 1.454 28.921
4. Average Cost Per Unit 43.31 32.19 511.29 18.05 108.27 10.65
5. Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 43.87 $ 32.19 $ 511.29 $ 18.05 $ 108.27 $ 10.65
6. Interest Adjustment .992 .996 .988 .990 .995 .992
Contract Cost per Eligible $ 323.96 $ 739.65 $ 736.52 $ 75.57 $ 156.64 $ 305.54 $ 2,337.88
7. Benefit Adjustments
FY 94/95 1.002 .926 l.005 1.002 1.042 1.000
FY 95/96 1.000 .850 1.000 1.000 .989 1.000
8. Trend Adjustment 7/93-1/97 1.160 1.270 .981 1.065 .991 1.327
Annual Cost Per Eligible $ 376.55 $ 739.37 $ 726.14 $ 80.64 $ 159.97 $ 405.45 $ 2,488.12
9. Mental Health Adjustment 7.8% 10.7% 11.7% 2.4% 1.3% 1.4%
10. Lenses Adjustment .9%
Cost Excl. MH/Lenses $ 347.18 $ 660.26 $ 641.18 $ 78.70 $ 157.89 $ 396.18 $ 2,281.39
Preliminary Monthly Rate $ 190.12
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (3.80)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 186.32
8
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 356 Base Period: CY '93
County San Bernardino Rate Period: 6/96 - 9/97
Aid Code Group Child
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 3.791 3.907 .361 l.620 .000 1.882
2. Aid Code Adjustment 1.011 .993 1.025 1.010 1.000 .998
3. Age/sex Adjustment 1.184 1.019 1.227 1.087 1.000 1.109
Adjusted Units 4.538 3.953 .454 1.779 .000 2.083
4. Average Cost Per Unit 69.47 11.05 901.25 22.20 .00 40.13
5. Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.37 $ 11.05 $ 901.25 $ 22.20 $ .00 $ 40.13
6. Interest Adjustment .992 .995 .987 .990 .994 .992
Contract Cost per Eligible $ 316.78 $ 43.46 $ 403.85 $ 39.10 $ .00 $ 82.92 $ 886.11
7. Benefit Adjustments
FY 94/95 1.021 .926 1.002 1.002 1.042 1.019
FY 95/96 1.001 .850 1.000 1.000 .989 .991
8. Trend Adjustment 7/93-1/97 1.047 1.330 .807 .878 1.000 1.285
Annual Cost Per Eligible $ 338.97 $ 45.50 $ 326.56 $ 34.40 $ .00 $ 107.60 $ 853.03
9. Mental Health Adjustment 1.6% 1.1% 13.4% 2.9% 3.4% 3.6%
10. Lenses Adjustment .9%
Cost Excl. MH/Lenses $ 333.55 $ 45.00 $ 282.80 $ 33.40 $ .00 $ 102.79 $ 797.54
Preliminary Monthly Rate $ 66.46
11. Stop Loss Reinsurance - All Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (1.33)
13. CHDP 2.38
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 67.51
9
XXXXXX MEDICAL CENTERS, INC. 00-00000-00
Plan Name Xxxxxx Medical Center Date: 6/24/1997
Plan Number 356 Base Period: CY '93
County San Bernardino Rate Period: 6/96 - 9/97
Aid Code Group Adult
Phys Pharm HIP HOP LTC Other Total
1. Base Units per Eligible 22.752 5.069 3.590 4.465 .000 20.412
2. Aid Code Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.752 5.069 3.590 4.465 .000 20.412
4. Average Cost Per Unit 59.80 16.00 960.30 20.51 .00 43.66
5. Area Adjustment 1.013 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 60.58 $ 16.00 $ 960.30 $ 20.51 $ .00 $ 43.66
6. Interest Adjustment .993 .996 .991 .989 .993 .991
Contract Cost per Eligible $ 1,368.67 $ 80.78 $ 3,416.45 $ 90.57 $ .00 $ 883.17 $ 5,839.64
7. Benefit Adjustments
FY 94/95 1.002 .926 1.008 1.002 1.042 1.006
FY 95/96 1.000 .850 1.000 1.000 .989 1.000
8. Trend Adjustment 7/93-1/97 1.099 1.023 1.126 1.169 1.000 1.195
Annual Cost per Eligible $ 1,507.18 $ 65.04 $ 3,877.70 $ 106.09 $ .00 $ 1,061.72 $ 6,617.73
9. Mental Health Adjustment .1% .4% .3% 1.1% .0% .1%
10. Lenses Adjustment .4%
Cost Excl. MH/Lenses $ 1,505.67 $ 64.78 $ 3.866.07 $ 104.92 $ .00 $ 1,056.42 $ 6,597.86
Preliminary Monthly Rate $ 549.82
11. Stop Loss Reinsurance - All
Services 0 .0% .00
12. Adjustment for FFS Limitation -2% (11.00)
13. CHDP .00
14. FQHC Incremental Amount .00
Final Monthly Rate - Capitation Payments at Beginning of Month $ 538.82
10
STATE OF CALIFORNIA CONTRACT NUMBER AM. NO.
95-23637 03
STANDARD AGREEMENT -- APPROVED BY THE TAXPAYER'S FEDERAL
(REV.5-91) ATTORNEY GENERAL EMPLOYER IDENTIFICATION NUMBER
00-0000000
THIS AGREEMENT, made and entered into this 1st day of October, 1998, in the
State of California, by and between State of California, through its duly
elected or appointed, qualified and acting
TITLE Of OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTORS NAME
Xxxxxx Medical Centers, Inc., hereafter called the Contractor
WITNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed does
hereby agree to furnish to the State services and materials as follows: (Set
forth service to be rendered by Contractor, amount to be paid Contractor time
for performance or completion, and attach plans and specifications, if any.)
Amendment A03 to Contract no. 95-23637 BETWEEN XXXXXX MEDICAL CENTERS,
INC., and the STATE OF CALIFORNIA,
WHEREAS, the State of California and Xxxxxx Medical Centers, Inc.,
entered into a contract to provide health care services to Medi-Cal
beneficiaries dated April 2, 1996; and
NOW THEREFORE, this Contract is amended as follows:
[SEAL]
CONTINUED ON 98 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitutes a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
================================================================================================================================
STATE OF CALIFORNIA CONTRACTOR
--------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (IF other than an individual, state whether a corporation, partnership, etc.)
Department of Health Services Xxxxxx Medical Centers, Inc.
--------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ Xxxxx Xxxxxx for /s/
--------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx J. Xxxxx Xxxxxx, M.D.
--------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
--------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE Department of General Services
DOCUMENT Loc. Asst.Section 14157 W&I Code Health Care Deposit Use Only
$ [187,972,680] 97/98 ------------------------------------------------------------
$ [114,472,680] 98/99 (OPTIONAL USE) Exempt From PCC per W&I Code
------------------------------ Section 14087.4
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ------------------------------------------------------------
$ 615,498,670 ITEM CHAPTER STATUTE FISCAL YEAR
282 1997 97/98
------------------------------ 0000-000-000 324 1998 98/99
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------
DATE OBJECT OF EXPENDITURE (CODE AND TITLE)
3,058,310 9912-705-95915
-------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
-------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ Xxxxxx Xxxxxxxx 11.19.98
-------------------------------------------------------------------------------------------
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91) (REVERSE)
1. The contractor agrees to indemnify, defend and save harmless the
State, its officers, agents and employees from any and are claims
and losses accruing or resulting to any and all contractors,
subcontractors, materialmen, laborers and any other person, firm
or corporation furnishing or supplying work services, materials
or supplies in connection with the performance of this contract,
and from any and all claims and losses accruing or resulting to
any person, firm or corporation who may be injured or damaged by
the Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in
the performance of the agreement, shall act in an independent
capacity and not as officers or employees or agents of State of
California.
3. The State may terminate this agreement and be relieved of the
payment of any consideration to Contractor should Contractor fail
to perform the covenants herein contained at the time and in the
manner herein provided. In the event of such termination the
State may proceed with the work in any manner deemed proper by
the State. The cost to the state shall be deducted from any sum
due the Contractor under this agreement, and the balance, if any,
shall be paid the Contractor upon demand.
4. Without the written consent of the State, this agreement is not
assignable by Contractor either in whole or in part.
5. Time is the essence of this agreement.
6. No alteration or variation of the terms of this contract shall be
valid unless made in writing and signed by the parties hereto,
and no oral understanding or agreement not incorporated herein,
shall be binding on any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein,
shall be in compensation for all of Contractor's expenses
incurred in the performance hereof, including travel and per
diem, unless otherwise expressly so provided.
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
TABLE OF CONTENTS
ARTICLE II DEFINITIONS Pg 2
ARTICLE III GENERAL TERMS AND CONDITIONS Pg 11
3.1 INTERPRETATION OF CONTRACT Pg 11
3.2 ENTIRE AGREEMENT Pg 11
3.4 CHANGES IN STATUTES OR REGULATIONS Pg 12
3.12 INSPECTION RIGHTS Pg 13
3.18.2 Termination-Contractor Pg 14
3.19 Sanctions Pg 15
3.20.1 General Pg 16
3.22.3 Contracting Officer's or Alternate Dispute Officer's Decision Pg 18
3.22.4 Appeal of Contracting Officer's or Alternate Dispute Officer's Decision Pg 19
3.22.5 Contractor Duty to Perform Pg 20
3.22.6 Waiver of Claims Pg 20
3.23.1 Enrollment-General Pg 20
3.23.3 Coverage Pg 21
3.23.5 Disenrollment Pg 21
3.26 FACILITIES Pg 24
3.28.1 Xxxx-Xxxxx and Regulations Pg 25
3.28.3 Departmental Approval-Non-Federally Qualified HMOs Pg 25
3.28.4 Departmental Approval-Federally Qualified HMOs Pg 26
3.28.6 Federally Qualified Health Centers/Rural Health Clinics Pg 26
3.28.8 Disclosures Pg 27
3.28.9 Payment Pg 27
3.28.10 Electronic Billing Capability Pg 28
3.28.11 Physician Incentive Plan Requirements Pg 29
3.33 AMENDMENT OF CONTRACT Pg 29
3.41 COST AVOIDANCE AND POST-PAYMENT RECOVERY OF OTHER Pg 30
HEALTH COVERAGE SOURCES
3.42 THIRD PARTY TORT LIABILITY/ESTATE RECOVERY Pg 32
3.43 OBTAINING DHS APPROVAL Pg 34
3.44 PILOT PROJECT Pg 35
3.45 RECORDS RELATED TO RECOVERY FOR TOBACCO RELATED Pg 35
ILLNESSES
3.45.1 Records Pg 35
3.45.2 Payment for Records Pg 36
3.46 FRAUD AND ABUSE REPORTING Pg 37
ARTICLE IV
4.3 FACILITY INSPECTIONS Pg 37
4.4 ENROLLMENT PROCESSING Pg 37
4.4.1 General Pg 37
4.4.2 Definition Pg 38
4.4 3 DHS Enrollment Obligations Pg 39
4.4.4 Disputes Concerning DHS Enrollment Obligations Pg 40
4.6 TESTING AND CERTIFICATION OF MARKETING REPRESENTATIVES Pg 42
4.7 APPROVAL PROCESS Pg 42
4.8 PROGRAM INFORMATION Pg 43
4.9 SANCTIONS Pg 43
1
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
ARTICLE V
5.2 AMOUNTS PAYABLE Pg 43
5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL Pg 45
5.5 DETERMINATION OF RATES Pg 46
5.6 REDETERMINATION OF RATES-OBLIGATION CHANGES Pg 48
5.9 FINANCIAL PERFORMANCE GUARANTEE Pg 49
5.11 RECOVERY OF CAPITATION PAYMENTS Pg 49
5.12 DATA REPORTING PERFORMANCE INCENTIVES Pg 50
5.12.1 Definitions Pg 50
5.12.2 Payment Provisions Pg 52
5.12.3 Performance Incentive Standards Pg 54
5.13 FQHC/RHC RISK CORRIDOR PAYMENTS Pg 61
5.14 PAYMENT OF AIDS BENEFICIARY RATES Pg 61
ARTICLE VI Scope of Work
6.3.1 Financial Viability/Standards Compliance Pg 63
6.3.2 Financial Audit/Reports Pg 64
6.3.6 Submittal of FQHC and RHC Payment Information Pg 66
6.3.7 Submittal of In-Patient Days Information Pg 66
6.4.1 Management Information System (MIS) Capability Pg 67
6.4.2 Encounter Data Submittal Pg 67
6.4.3 MIS/Data Correspondence Pg 68
6.4.4 Timely, Complete and Accurate Data Submission Pg 68
6.5.3.4 Quality Indicators Pg 68
6.5.5.2 Review Procedures Pg 69
6.5.5.3 Number of Sites to be Reviewed Prior to Operations Pg 69
6.5.5.5 Facility Inspections Pg 69
6.5.5.6 Corrective Actions Pg 70
6.5.10.7 Targeted Case Management Services Pg 71
6.6.6 Provider to Member Ratios Pg 71
6.6.8 Subcontracts Pg 71
6.6.13 Quarterly Report Pg 72
6.6.14 Contract and Employment Terminations Pg 72
6.6.15 Utilization of DSH Hospitals Pg 72
6.6.17 Emergency Service Providers Pg 73
6.6.20 FQHC Services Pg 75
6.6.21 FQHC and Rural Health Clinics (RHC) Contracts Pg 75
6.6.22 Indian Health Services Facilities Pg 76
6.7.1.1 General Requirements Pg 76
6.7.2.2 Waiver Programs Pg 77
6.7.3.1 Miscellaneous Service Carve Outs Pg 77
6.7.3.2 California Children Services (CCS) Pg 78
6.7.3.3 Mental Health Pg 80
6.7.3.5 Dental Pg 83
6.7.3.7 Directly Observed Therapy (DOT) for Treatment of Tuberculosis Pg 83
6.7.4.3 School Linked CHDP Services: Subcontracts Pg 84
6.7.4.4 Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental
Services, Including Case Management Services Pg 84
6.7.4.7 Family Planning: Out-of-Network Reimbursement Pg 85
6.7.4.8 Family Planning: Reimbursement Rate Pg 86
2
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
6.7.4.9 Sexually Transmitted Diseases (STDs) Pg 86
6.7.4.14 Nurse Midwife and Nurse Practitioner Services Pg 87
6.7.7.3 Individual Health Education Behavioral Assessments Pg 88
6.7.7.7 Group Needs Assessment Pg 88
6.7.9 LOCAL MENTAL HEALTH PLAN COORDINATION Pg 89
6.7.9.1 Memorandum of Understanding Pg 89
6.8.6 Marketing Plan Pg 91
6.9.3 Disclosure Forms Pg 91
6.9.5 Membership Services Guide Pg 91
6.9.9 Primary Care Physician Selection Pg 94
6.9.10 Primary Care Physician Assignment Pg 95
6.9.11 Continuity of Care Pg 95
6.9.13 Member Compliant/Grievance Systems Pg 95
6.9.15 Denial, Deferral, or Modification of Prior Authorization Requests Pg 96
6.10.6 Cultural and Linguistics Services Plan Pg 97
6.11.1 Time Frames Pg 98
3
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
1. Article II, DEFINITIONS, is amended by adding a new Section I, Catastrophic
Coverage Limitation, to read:
I. Catastrophic Coverage Limitation means the date beyond which
Contractor is not at risk, as determined by the Director, to provide
or make reimbursement for illness of or injury to beneficiaries which
results from or is greatly aggravated by a catastrophic occurrence or
disaster, including, but not limited to, an act of war, declared or
undeclared, and which occurs subsequent to enrollment.
2. Article II, DEFINITIONS, is amended by relettering old Sections I through
LL as new Sections J through MM.
3. Article II, DEFINITIONS, relettered Section P, Covered Services, is amended
to read:
P. Covered Services means Medical Case Management and those services set
forth in Title 22, CCR, Division 3, Subdivision 1, Chapter 3,
beginning with Section 51301, and Title 17, CCR, Chapter 4, Subchapter
13, Article 4, beginning with Section 6840. Covered Services do not
include:
1. Services for major organ transplants as specified in Section
6.7.2.1, Major Organ Transplants.
2. Long term care services as specified in Section 6.7.2.3, Long
Term Care, (LTC).
3. Home and community based services (HCBS) as specified in Sections
6.7.2.2, Waiver Programs, and 6.7.3.8, Department of
Developmental Services Administered Medicaid Home and Community
Based Services Waiver. HCBS do not include any service that is
available as an EPSDT service, including EPSDT supplemental
services, as described in Title 22, CCR, Sections 51184, 51340
and 51340.1. EPSDT supplemental services are covered under this
Contract, as specified in Article VI, Section 6.7.4.4, Early and
Periodic Screening, Diagnosis and Treatment (EPSDT) Supplemental
Services, Including Case Management Services.
4. California Children Services (CCS) as specified in Section
6.7.3.2, CCS Services.
5. Mental health services as specified in Section 6.7.3.3, Mental
Health.
2
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
6. Alcohol and drug treatment services and outpatient heroin
detoxification as specified in Section 6.7.3.4, Alcohol and Drug
Treatment Services.
7. Fabrication of optical lenses as specified in Section 6.7.3.6,
Vision Care - Lenses.
8. Directly observed therapy for tuberculosis as specified in
Section 6.7.3.7, Directly Observed Therapy (DOT) for Treatment of
Tuberculosis.
9. Dental services as specified in Title 22, CCR, Section 51307 and
EPSDT supplemental dental services as described in Title 22, CCR,
Section 51340.1(a). However, Contractor is responsible for all
Covered Services as specified in Article VI, Section 6.7.3.5,
Dental.
10. Acupuncture services as specified in Title 22, CCR, Section
51308.5.
11. Chiropractic services as specified in Title 22, CCR, Section
51308.
12. Prayer or spiritual healing as specified in Title 22, CCR,
Section 51312.
13. Local Education Agency (LEA) assessment services as specified in
Title 22, CCR, Section 51360(b)(1) provided to a Member who
qualifies for LEA services based on Title 22, CCR, Section
51190.1(a).
14. Any LEA services as specified in Title 22, CCR, Section 51360
provided pursuant to an Individualized Education Plan (IEP) as
set forth in Education Code, Section 56340 et seq. or an
Individualized Family Service Plan (IFSP) as set forth in
Government Code Section 95020, or LEA services provided under an
Individualized Health and Support Plan (IHSP), as described in
Title 22, CCR, Section 51360.
15. Laboratory services provided under the State serum
alphafetoprotein- testing program administered by the Genetic
Disease Branch of DHS.
16. Adult Day Health Care.
17. Targeted case management services as specified in Title 22, CCR,
Sections 51185(h) and 51351, and as described in Article VI,
Section 6.5.10.7, Targeted Case Management Services.
3
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
18. Childhood lead poisoning case management provided by County
health departments.
19. HIV and AIDS drugs listed in Attachment II (consisting of one
page), and HIV and AIDS drugs classified as Nucleoside Analogs,
Protease Inhibitors, and Non-Nucleoside Reverse Transcriptase
Inhibitors, approved by the federal Food and Drug Administration
(FDA) after July 1, 1997.
4. Article II, DEFINITIONS, relettered Section Y, Eligible Beneficiary, is
amended to read:
Y. Eligible Beneficiary means any Medi-Cal beneficiary who is residing in
Contractor's Service Area with one of the following aid codes:
CalWORKS/Public Assistance Family - aid codes 30, 32, 3G, 33, 3H, 35,
38, 39, 3A, 3C, 40, 00, 00, 00, 0X, 0X, 0X, 0X, 0X; 0X, 0X, 0X;
Medically Needy Family - aid code 34; Public Assistance Aged - aid
codes 10, 16, 18; Medically Needy Aged - aid code 14; Public
Assistance Blind - aid codes 20, 26, 28, 6A; Medically Needy Blind -
aid code 24; Public Assistance Disabled - aid codes 36, 60, 66, 68,
6C, 6N, 6P, 6R; Medically Needy Disabled - aid code 64; Medically
Indigent Child - aid codes 03, 04, 45, 4C, 4K, 5K, 82; Medically
Indigent Adult - aid code 86; and Refugees - aid codes 01, 0A, 02, and
08, with the following exclusions:
1. Individuals who have been approved by the Medi-Cal Field Office
or the California Children Services Program for bone marrow,
heart, heart-lung, liver, lung, combined liver and kidney, or
combined liver and small bowel transplants.
2. Individuals who elect and are accepted to participate in the
following Medi-Cal waiver programs: In-Home Medical Care Waiver
Program, the Skilled Nursing Facility Waiver Program, the Model
Waiver Program, the Acquired Immune Deficiency (AIDS) and AIDS
Related Conditions Waiver Program, and the Multipurpose Senior
Services Waiver Program.
3. Individuals determined by the Medi-Cal Field Office to be in need
of long term care and residing in a Skilled Nursing Facility
(SNF) for 30 days past the month of admission.
4
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
4. Individuals who have commercial or Medicare HMO coverage, unless
the Medicare HMO is a provider under this Contract and DHS has
agreed, as a term of the HMO's Contract, that these individuals
may be enrolled, and DHS and the Medicare HMO have negotiated an
appropriate rate for these individuals. Individuals with Medicare
fee-for-service coverage are not excluded from enrolling under
this Contract.
5. Article II, DEFINITIONS, relettered Section Z, Emergency Conditions, is
amended to read:
Z. Emergency Medical Condition means a medical condition which is
manifested by acute symptoms of sufficient severity (including severe
pain), such that a prudent lay person, who possesses an average
knowledge of health and medicine, could reasonably expect the absence
of immediate medical attention to result in:
1. placing the health of the individual (or, in the case of a
pregnant woman, the health of the woman or her unborn child) in
serious jeopardy,
2. serious impairment to bodily function, or
3. serious dysfunction of any bodily organ or part.
6. Article II, DEFINITIONS, relettered Section AA, Emergency Services, is
amended to read:
AA. Emergency Services means those health services needed to evaluate or
stabilize an Emergency Medical Condition.
7. Article II, DEFINITIONS, relettered Section HH, Fee-For-Service Mental
Health Services (FFS/MC), is amended to read:
HH. Fee-For-Service Medi-Cal Mental Health Services (FFS/MC) means the
mental health services covered through Fee-For-Service Medi-Cal which
include outpatient services and acute care inpatient services. These
services are provided through Primary Care Physicians as well as
psychiatrists and psychologists.
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8. Article II, DEFINITIONS, relettered Section II, Financial Security, is
amended to read:
II. Financial Performance Guarantee means cash or cash equivalents which
are immediately redeemable upon demand by DHS, in an amount determined
by DHS, which shall not be less than one full month's capitation.
9. Article II, DEFINITIONS, is amended by adding a new Section NN, Health Plan
Employer Data and Information Set, to read:
NN. Health Plan Employer Data and Information Set (HEDIS) means the set of
standardized performance measures developed by the National Committee
for Quality Assurance (NCQA), a not-for-profit organization. HEDIS is
designed to ensure that the public has the information it needs to
reliably compare the performance of managed health care plans.
10. Article II, DEFINITIONS, is amended by relettering old Sections MM through
K2 as new Sections OO through M2.
11. Article II, DEFINITIONS, relettered Section QQ, Joint Commission on
Accreditation of Hospitals (JCAHCO), is amended to read:
QQ. Joint Commission on the Accreditation of Health Care Organizations
(JCAHCO) means the organization composed of representatives of the
American Hospital Association, the American Medical Association, the
American College of Physicians, the American College of Surgeons, and
the American Dental Association. JCAHCO provides health care
accreditation and related services that support performance
improvement in health care organizations.
12. Article II, DEFINITIONS, relettered Section B1, Minor Consent Services, is
amended to read:
B1. Minor Consent Services means those Covered Services of a sensitive
nature which minors do not need parental consent to access related to:
1. Sexual assault, including rape.
2. Drug or alcohol abuse for children 12 years of age or older.
3. Pregnancy.
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4. Family planning.
5. Sexually transmitted diseases (STDs), designated by the Director,
in children 12 years of age or older.
6. Outpatient mental health care for children 12 years of age or
older who are mature enough to participate intelligently and
where either (1) there is a danger of serious physical or mental
harm to the minor or others or (2) the children are the alleged
victims of incest or child abuse.
State law provides minors the right to obtain an abortion without
parental consent.
13. Article II, DEFINITIONS, relettered Section P1, Primary Care Provider, is
amended to read:
P1. Primary Care Provider means a person responsible for supervising,
coordinating, and providing initial and Primary Care to Members; for
initiating referrals and for maintaining the continuity of Member
care. A Primary Care Provider may be a Primary Care Physician or
Non-Physician Medical Practitioner.
14. Article II, DEFINITIONS, relettered Section X1, Sensitive Services, is
amended to read:
X1. Sensitive Services means those services related to:
1. Family planning.
2. Sexually transmitted diseases (STDs).
3. Abortion.
4. HIV testing.
15. Article II, DEFINITIONS, relettered Section B2, Xxxxx-Xxxxx Medi-Cal Mental
Health Services (SD/MC), is amended to read:
B2. Xxxxx-Xxxxx Medi-Cal Mental Health Services (SD/MC) means those
services defined in Title 22, CCR, Section 51341. SD/MC Mental Health
Services include: crisis intervention, crisis stabilization, inpatient
hospital services, crisis residential treatment case management, adult
residential treatment, day treatment intensive, rehabilitation,
outpatient therapy, medication and support services.
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16. Article II, DEFINITIONS, relettered Section J2, Third Party Liability
(TPL), is amended to read:
J2. Third Party Tort Liability (TPTL) means the responsibility of an
individual or entity other than Contractor or the Member for the
payment of claims for injuries or trauma sustained by a Member. This
responsibility may be contractual, a legal obligation, or as a result
of, or the fault or negligence of, third parties (e.g., auto accidents
or other personal injury casualty claims or Workers' Compensation
appeals).
17. Article II, DEFINITIONS, is amended by adding a new subsection N2 to read:
N2. Physician Incentive Plan means any compensation arrangement between
Contractor and a Physician or a Physician group that may directly or
indirectly have the effect of reducing or limiting services provided
to Members under this Contract.
18. Article II, DEFINITIONS, is amended by adding a new subsection O2 to read:
O2. Rural Health Clinic (RHC) means an entity defined in Title 22, CCR,
Section 51115.5.
19. Article II, DEFINITIONS, is amended by adding a new subsection P2 to read:
P2. Beneficiary Assignment means the act of DHS or DHS' enrollment
contractor of notifying a beneficiary in writing of the health plan in
which the beneficiary shall be enrolled if the beneficiary fails to
timely choose a health plan. If, at any time, the beneficiary notifies
DHS or DHS' enrollment contractor of the beneficiaries health plan
choice, such choice shall override the beneficiary assignment and be
effective as provided in Article III, Section 3.23.3, Coverage.
20. Article II, DEFINITIONS, is amended by adding a new subsection Q2 to read:
Q2. AIDS Beneficiary means a Member for whom a Diagnosis of Acquired
Immunodeficiency Syndrome (AIDS) has been made by a treating
Physician.
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21. Article II, DEFINITIONS, is amended by adding a new subsection R2 to read:
R2. Diagnosis of AIDS means a clinical diagnosis of AIDS that meets the
most recent communicable disease surveillance case definition of AIDS
established by the federal Centers for Disease Control and Prevention
(CDC), United States Department of Health and Human Services and
published in the Morbidity and Mortality Weekly Report (MMWR) or its
supplements, in effect for the month in which the clinical diagnosis
is made.
22. Article II, DEFINITIONS, is amended by adding a new subsection S2 to read:
S2. Other Healthcare Coverage Sources (OHCS) means the responsibility of
an individual or entity, other than Contractor or the Member, for the
payment of the reasonable value of all or part of the healthcare
benefits provided to a Member. Such OHCS may originate under any other
State, federal, or local medical care program or under other
contractual or legal entitlement, including, but not limited to, a
private group or indemnification program. This responsibility may
result from a health insurance policy or other contractual agreement
or legal obligation, excluding tort liability.
23. Article II, DEFINITIONS, is amended by adding a new subsection T2 to read:
T2. Cost Avoid means Contractor requires a provider to xxxx all liable
third parties and receive payment or proof of denial of coverage from
such third parties prior to Contractor paying the provider for the
services rendered.
24. Article II, DEFINITIONS, is amended by adding a new subsection U2 to read:
U2. Post-Payment Recovery means Contractor pays the provider for the
services rendered and then uses all reasonable efforts to recover the
cost of the services from all liable third parties.
25. Article II, DEFINITIONS, is amended by adding a new subsection V2 to read:
V2. Word Usage. Unless the context of this Contract clearly requires
otherwise, (a) the plural and singular numbers shall each be deemed to
include the other; (b) the masculine, feminine, and neuter genders
shall each be deemed to include the others; (c) "shall," "will,"
"must," or "agrees" are mandatory, and "may" is permissive; (d) "or"
is not exclusive; and (e) "includes" and "including" are not limiting.
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26. Article II, DEFINITIONS, is amended by adding a new section W2 to read:
W2. Specialty Mental Health Provider means a person or entity who is
licensed, certified or otherwise recognized or authorized under State
law governing the healing arts to provide Specialty Mental Health
Services and who meets the standards for participation in the Medi-Cal
program. Specialty Mental Health Providers include clinics, hospital
outpatient departments, certified residential treatment facilities,
skilled nursing facilities, psychiatric health facilities, hospitals,
and licensed mental health professionals, including psychiatrists,
psychologists, licensed clinical social workers, marriage, family and
child counselors, and registered nurses authorized to provide
Specialty Mental Health Services.
27. Article II, DEFINITIONS, is amended by adding a new section X2 to read:
X2. Specialty Mental Health Service means:
1. Rehabilitative services, which includes mental health services,
medication support services, day treatment intensive, day
rehabilitation, crisis intervention, crisis stabilization, adult
residential treatment services, crisis residential services, and
psychiatric health facility services;
2. Psychiatric inpatient hospital services;
3. Targeted Case Management;
4. Psychiatrist services;
5. Psychologist services; and
6. EPSDT supplemental specialty mental health services.
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28. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding new
Sections 3.1 and 3.2 to read:
3.1 INTERPRETATION OF CONTRACT
If it is necessary to interpret this Contract, all applicable laws may be
used as aids in interpreting the Contract. However, the parties agree that
any such applicable laws shall not be interpreted to create contractual
obligations upon DHS or Contractor, unless such applicable laws are
expressly incorporated into this Contract in some section other than this
Section 3.1, Interpretation of Contract. Except for Section 3.19, Sanctions
and Section 3.20, Liquidated Damages Provision, the parties agree that any
remedies for DHS' or Contractor's non-compliance with laws not expressly
incorporated into this Contract, or any covenants implied to be part of
this Contract, shall not include money damages, but may include equitable
remedies such as injunctive relief or specific performance. In the event
any provision of this Contract is held invalid by a court, the remainder of
this Contract shall not be affected. This Contract is the product of mutual
negotiation, and if any ambiguities should arise in the interpretation of
this Contract, both parties shall be deemed authors of this Contract.
3.2 ENTIRE AGREEMENT
This written Contract and any amendments shall constitute the entire
agreement between the parties. No oral representations shall be binding on
either party unless such representations are reduced to writing and made an
amendment to the Contract.
29. Article III, GENERAL TERMS AND CONDITIONS, is amended by renumbering old
Section 3.1, Delegation of Authority, as Section 3.3 and amending paragraph
three to read:
Contractor's Representative shall be designated in writing by Contractor.
Such designation shall be submitted to the Contracting Officer in
accordance with Section 3.5, Authority of the State.
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30. Article III, GENERAL TERMS AND CONDITIONS, is amended by deleting old
Section 3.2, Governing Authorities, and replacing it with a new Section
3.4, Changes in Statutes or Regulations, to read:
3.4 CHANGES IN STATUTES OR REGULATIONS
The parties recognize that during the life of this Contract, the Medi-Cal
Managed Care Program shall be a dynamic program requiring numerous changes
to its operations and
that the scope and complexity of these changes shall vary widely over the
life of the Contract. The parties agree that the development of a system
that has the capability to implement such changes in an orderly and timely
manner is of considerable importance.
Any provision of this Contract which is in conflict with current or future
applicable federal or State laws or regulations is hereby amended to
conform to the provisions of those laws and regulations. Such amendment of
the Contract shall be effective on the effective date of the statutes or
regulations necessitating it, and shall be binding on the parties even
though such amendment may not have been reduced to writing and formally
agreed upon and executed by the parties.
Such amendment shall constitute grounds for termination of this Contract in
accordance with the procedures and provisions of Section 3.18.2,
Termination - Contractor. The parties shall be bound by the terms of the
amendment until the effective date of the termination.
31. Article III, GENERAL TERMS AND CONDITIONS, is amended by renumbering old
Sections 3.3 through 3.9, as Sections 3.5 through 3.11.
32. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.7,
Compliance with Protocols, sentence one, is amended to read:
Contractor shall develop the protocols and procedures specified in this
Contract and shall comply with them within 30 days of their approval by
DHS.
33. Article III, GENERAL TERMS AND CONDITIONS, is amended by deleting old
Section 3.10, Membership Diversity.
34. Article III, GENERAL TERMS AND CONDITIONS, is amended by renumbering old
Sections 3.11 through 3.43 as Sections 3.12 through 3.44.
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35. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.12,
Inspection Rights, is amended to read:
3.12 INSPECTION RIGHTS
Through the end of the records retention period specified in Section
3.32.2, Records Retention, Contractor shall allow DHS, DHHS, the
Comptroller General of the United States, Department of Justice (DOJ)
Bureau of Medi-Cal Fraud, Department of Corporations (DOC), and other
authorized State agencies, or their duly authorized representatives,
including DHS' external quality review organization contractor, to inspect,
monitor or otherwise evaluate the quality, appropriateness, and timeliness
of services performed under this Contract, and to inspect, evaluate, and
audit any and all books, records, and Facilities maintained by Contractor
and subcontractors pertaining to these services at any time during normal
business hours.
Books and records include, but are not limited to, all physical records
originated or prepared pursuant to the performance under this Contract,
including working papers, reports, financial records, and books of account,
Medical Records, prescription files, laboratory results, Subcontracts,
information systems and procedures, and any other documentation pertaining
to medical and non-medical services rendered to Members. Upon request,
through the end of the records retention period specified in Section
3.32.2, Records Retention, Contractor shall furnish any record, or copy of
it, to DHS or any other entity listed in this section, at Contractor's sole
expense.
36. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.15, Term,
paragraph two, is amended to read:
The term of the Contract consists of the following three periods: 1) The
Implementation Period shall extend from March 1, 1996 to June 1,1996; 2)
The Operations Period shall extend from June 1, 1996 to March 1,2001,
subject to the termination provisions of Sections 3.18, Termination, and
3.19, Sanctions, and subject to the limitation provisions of Article V,
Payment Provisions, Section 5.2, Amounts Payable; and 3) The
Turnover/Phaseout Period shall extend for six (6) months from the end of
the Operations Period, subject to the provisions of Section 3.16, Contract
Extension, in which case the Turnover/Phaseout Period shall apply to the
six (6) month period beginning the first day after the end of the
Operations Period, as extended.
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37. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.17,
Turnover and Phaseout Requirements, paragraph one, is amended to read:
DHS shall retain an amount equal to 10% or one million dollars
($1,000,000), whichever is greater unless provided otherwise by the
Financial Performance Guarantee, from the capitation payment of the last
month of the Operations Period until all activities required during the
Turnover and Phaseout Period are fully completed to the satisfaction of
DHS, in it sole discretion.
38. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.18.1,
Termination - State or Director, paragraph two, is amended to read:
Notification shall be given at least nine (9) months prior to the effective
date of termination, except in cases where the Director determines the
health and welfare of Members is jeopardized by continuation of this
Contract, in which case the Contract shall be immediately terminated.
Notification shall state the effective date of, and the reason for the
termination. DHS and Contractor may negotiate an earlier termination date.
39. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.18.2,
Termination - Contractor, is amended to read:
3.18.2 TERMINATION - CONTRACTOR
If mutual agreement between DHS and Contractor cannot be attained on
capitation rates for rate years subsequent to September 30,1997, Contractor
shall retain the right to terminate the Contract, no earlier than September
30,1998, by giving at least nine (9) months written notice to DHS to that
effect. The effective date of any termination under this section shall be
September 30.
Grounds under which Contractor may terminate this Contract are limited to:
(1) Unwillingness to accept the capitation rates determined by DHS, or if
DHS decides to negotiate rates, failure to reach mutual agreement on rates;
or (2) When a change in contractual obligations is created by a State or
federal change in the Medi-Cal program, or a lawsuit, that substantially
alters the financial assumptions and conditions under which Contractor
entered into this Contract, such that Contractor can demonstrate to the
satisfaction of DHS that it cannot remain financially solvent through the
term of the Contract.
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If Contractor invokes ground number 2, Contractor shall submit a detailed
written financial analysis to DHS supporting its conclusions that it cannot
remain financially solvent. At the request of DHS, Contractor shall submit
or otherwise make conveniently available to DHS, all of Contractor's
financial work papers, financial reports, financial books and other
records, bank statements, computer records, and any other information
required by DHS to evaluate Contractor's financial analysis.
Based on the above two grounds, Contractor may terminate the Contract, no
earlier than September 30, 1998, by giving at least nine (9) months written
notice to DHS to that effect. The effective date of any termination under
this section shall be September 30.
DHS and Contractor may negotiate an earlier termination date if Contractor
can demonstrate to the satisfaction of DHS that it cannot remain
financially solvent until the termination date that would otherwise be
established under this section. Termination under these circumstances shall
not relieve Contractor from performing the Turnover and Phaseout
activities, as described in Section 3.17.
40. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.18.3,
Mandatory Termination, paragraph 2, is amended to read:
Under these circumstances, termination of the Contract shall be effective
on the last day of the month in which the Secretary, DHHS, or DOC makes
such determination, provided that DHS provides Contractor with at least 60
days notice of termination. The termination of this Contract shall be
effective on the last day of the second full month from the date of the
notice of termination. Contractor agrees that 60 days notice is reasonable.
Termination under this section does not relieve Contractor of its
obligations under the Turnover and Phaseout Requirements, Sections 3.17
through 3.17.4, except that these requirements may be performed after
Contract termination.
41. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.19,
Sanctions, is amended to read:
3.19 SANCTIONS
In the event DHS finds Contractor non-compliant with any provisions of this
Contract, applicable statutes or regulations, or for good cause shown, DHS
may impose sanctions provided in Welfare and Institutions Code, Section
14304 and Title 22, CCR, Section 53872. Good cause includes, but is not
limited to, three repeated and uncorrected findings of serious deficiencies
that have the potential to endanger patient care identified in the medical
audits conducted by DHS.
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If required by DHS, Contractor shall ensure subcontractors cease specified
activities which may include, but are not limited to, referrals, assignment
of beneficiaries, and reporting, until DHS determines that Contractor is
again in compliance.
42. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.20.1,
General, is amended to read:
3.20.1 GENERAL
It is agreed by the State and Contractor that:
A. If Contractor does not provide or perform the requirements of this
Contract or applicable laws and regulations, damage to the State shall
result;
B. Proving such damages shall be costly, difficult, and time-consuming;
C. Should the State choose to impose liquidated damages, Contractor shall
pay the State those damages for not providing or performing the
specified requirements;
D. Additional damages may occur in specified areas by prolonged periods
in which Contractor does not provide or perform requirements;
E. The damage figures listed below represent a good faith effort to
quantify the range of harm that could reasonably be anticipated at the
time of the making of the Contract;
F. DHS may, at its discretion, offset liquidated damages from capitation
payments owed to Contractor;
G. Imposition of liquidated damages as specified in Sections 3.20.2,
Liquidated Damages for Violation of Contract Terms Regarding the
Implementation Period, 3.20.3, Liquidated Damages for Violation of
Contract Terms or Regulations Regarding the Operations Period, and
3.20.4, Annual Medical Reviews, shall follow the administrative
processes described below;
H. DHS shall provide Contractor with written notice specifying Contractor
requirement(s), contained in the Contract or as required by federal
and State law or regulation, not provided or performed;
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I. During the Implementation Period, Contractor shall submit or complete
the outstanding requirement(s) specified in the written notice within
five (5) State working days from the date of the notice, unless,
subject to the Contracting Officer's written approval, Contractor
submits a written request for an extension. The request must include
the following: the requirement(s) requiring an extension; the reason
for the delay; and the proposed date of the submission of the
requirement.
J. During the Implementation Period, if Contractor has not performed or
completed an Implementation Period requirement or secured an extension
for the submission of the outstanding requirement, DHS may impose
liquidated damages for the amount specified in Section 3.20.2,
Liquidated Damages for Violation of Contract Terms Regarding the
Implementation Period.
K. During the Operations Period, Contractor shall demonstrate the
provision or performance of Contractor's requirement(s) specified in
the written notice within a thirty (30) calendar day Corrective
Action period from the date of the notice, unless within five (5) days
from the end of the Corrective Action period a request for an
extension is submitted to the Contracting Officer. If Contractor has
not demonstrated the provision or performance of Contractor's
requirement(s) specified in the written notice by the end of the
Corrective Action period, DHS may impose liquidated damages for each
day the specified Contractor's requirement is not performed or
provided for, in the amount specified in Section 3.20.3, Liquidated
Damages for Violation of Contract Terms or Regulations Regarding the
Operations Period.
L. During the Operations Period, if Contractor has not performed or
provided Contractor's requirement(s) specified in the written notice
or secured the written approval for an extension, after thirty (30)
days from the first day of the imposition of liquidated damages, DHS
shall notify Contractor in writing of the increase of the liquidated
damages to the amount specified in Section 3.20.3, Liquidated Damages
for Violation of Contract Terms or Regulations Regarding the
Operations Period.
Nothing in this provision shall be construed as relieving Contractor from
performing any other Contract duty not listed herein, nor is the State's
right to enforce or to seek other remedies for failure to perform any other
Contract duty hereby diminished.
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43. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.20.4,
Annual Medical Reviews, paragraph one, sentence two, is amended to read:
If, after notice, Contractor does not correct the deficiency to the
satisfaction of DHS within thirty (30) days, or longer if authorized by DHS
in writing, DHS may impose an additional liquidated damages of $5,000 per
day per major uncorrected deficiency as determined by DHS medical review
staff.
44. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.22.3,
Contracting Officer's Decision, is amended to read:
3.22.3 CONTRACTING OFFICER'S OR ALTERNATE DISPUTE OFFICER'S DECISION
Pursuant to a request by Contractor, the Contracting Officer may provide
for a dispute to be decided by an alternate dispute officer designated by
DHS, who is not the Contracting Officer and is not directly involved in the
Medi-Cal Managed Care Program. Any disputes concerning performance of this
Contract shall be decided by the Contracting Officer or the alternate
dispute officer in a written decision stating the factual basis for the
decision. Within thirty (30) days of receipt of a Notification of Dispute,
the Contracting Officer or the alternate dispute officer shall either
render a decision or shall request from Contractor, which in the opinion of
the Contracting Officer or alternate dispute officer is sufficient to allow
the rendering of a decision. Within thirty (30) days of receipt of the
additional substantiating documentation requested, a decision shall be
rendered. A copy of the decision shall be served on Contractor.
The Contracting Officer's or alternate dispute officer's decision shall:
A. Find in favor of Contractor, in which case the Contracting Officer or
alternate dispute officer may:
1. Countermand the earlier conduct which caused Contractor to file a
dispute; or
2. Reaffirm the conduct and, if there is a cost impact sufficient to
constitute a change in obligations pursuant to the payment
provisions contained in Article V, direct DHS to comply with that
section.
B. Deny Contractor's dispute and, where necessary, direct the manner of
future performance; or
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C. Request additional substantiating documentation in the event the
information in Contractor's notification is inadequate to permit a
decision to be made under A. or B. above, and shall advise Contractor
as to what additional information is required, and establish how that
information shall be furnished. Contractor shall have thirty (30) days
to respond to the Contracting Officer's or alternate dispute officer's
request for further information. Upon receipt of this additional
requested information, the Contracting Officer or alternate dispute
officer shall have thirty (30) days to respond with a decision.
Failure to supply additional information required by the Contracting
Officer or alternate dispute officer within the time period specified
above shall constitute waiver by Contractor of all claims in
accordance with Section 3.22.6, Waiver of Claims.
45. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
Section 3.22.4, to read:
3.22.4 APPEAL OF CONTRACTING OFFICER'S OR ALTERNATE DISPUTE OFFICER'S
DECISION
Contractor shall have thirty (30) calendar days following the receipt of
the decision to file an appeal of the decision to the Director. All appeals
shall be governed by Health and Safety Code Section 100171, except for
those provisions of Section 100171(d)(1) relating to accusations,
statements of issues, statement to respondent, and notice of defense. All
appeals shall be in writing and shall be filed with DHS' Office of
Administrative Hearings and Appeals. An appeal shall be deemed filed on the
date it is received by the Office of Administrative Hearings and Appeals.
An appeal shall specifically set forth each issue in dispute, and include
Contractor's contentions as to those issues. However, Contractor's appeal
shall be limited to those issues raised in its Notice of Dispute filed
pursuant to Section 3.22.2, Notification of Dispute. Failure to timely
appeal the decision shall constitute a waiver by Contractor of all claims
arising out of that conduct, in accordance with Section 3.22.6, Waiver of
Claims. Contractor shall exhaust all procedures provided for in Section
3.22, Disputes and Appeals, prior to initiating any other action to enforce
this Contract.
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46. Article III, GENERAL TERMS AND CONDITIONS, old Section 3.21.4, Contractor
Duty to Perform, is amended to read:
3.22.5 CONTRACTOR DUTY TO PERFORM
Pending final determination of any dispute hereunder, Contractor shall
proceed diligently with the performance of this Contract and in accordance
with the Contracting Officer's or alternate dispute officer's decision.
If, pursuant to an appeal under Section 3.22.4, Appeal of Contracting
Officer's or Alternate Dispute Officer's Decision, the Contracting
Officer's or alternate dispute officer's decision is reversed, the effect
of the decision pursuant to Section 3.22.4 shall be retroactive to the date
of the Contracting Officer's or alternate dispute officer's decision, and
Contractor shall promptly receive any benefits of such decision. DHS shall
not pay any interest on any amounts paid pursuant to a Contracting
Officer's or alternate dispute officer's decision or any appeal of such
decision.
47. Article III, GENERAL TERMS AND CONDITIONS, old Section 3.21.5, Waiver of
Claims, is amended to read:
3.22.6 WAIVER OF CLAIMS
If Contractor fails to submit a Notification of Dispute, supporting and
substantiating documentation, any additionally required information, or an
appeal of the Contracting Officer's or alternate dispute officer's
decision, in the manner and within the time specified in the Disputes and
Appeals sections, that failure shall constitute a waiver by Contractor of
all claims arising out of that conduct, whether direct or consequential in
nature.
48. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.23.1,
Enrollment - General, is amended to read:
3.23.1 ENROLLMENT - GENERAL
Eligible Beneficiaries residing within the Service Area of Contractor may
be enrolled at any time during the term of this Contract. Eligible
Beneficiaries shall be accepted by Contractor up to the limits imposed in
Section 3.23.2, Enrollment Totals, and without regard to physical or mental
condition, age, sex, race, religion, creed, color, national origin, marital
status, sexual orientation or ancestry.
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49. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.23.3,
Coverage, is amended to read:
3.23.3 COVERAGE
Member coverage shall begin at 12:01 a.m. on the first day of the calendar
month for which the Eligible Beneficiary's name is added to the approved
list of Members furnished by DHS to Contractor. The term of membership
shall continue indefinitely unless this Contract expires, is terminated, or
the Member is disenrolled under the conditions described in Section 3.23.5,
Disenrollment.
50. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.23.5,
Disenrollment, is amended to read:
3.23.5 DISENROLLMENT
The enrollment contractor shall process a Member Disenrollment under the
following conditions, subject to approval by DHS, in accordance with the
provisions of Title 22, CCR, Section 53891:
A. Disenrollment of a Member is mandatory when:
1. The Member requests Disenrollment, subject to any lock-in
restrictions on Disenrollment under the federal lock-in option,
if applicable.
2. The Member's eligibility for Enrollment with Contractor is
terminated or eligibility for Medi-Cal is ended, including the
death of the Member.
3. Enrollment was in violation of Title 22, CCR, Section 53891
(a)(2), or requirements of this Contract regarding Marketing, and
DHS or Member requests Disenrollment.
4. Disenrollment is requested in accordance with Welfare and
Institutions Code, Sections 14303.1 or 14303.2.
5. There is a change of a Member's place of residence to outside
Contractor's Service Area.
6. It is determined that the Member is enrolled as a commercial or
Medicare member of an HMO other than Contractor.
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7. Disenrollment is based on the circumstances described in Article
VI, Section 6.7.2, Excluded Services: Circumstances Under Which
Member Disenrolled.
Such Disenrollment shall become effective on the first day of the
second month following receipt by DHS of all documentation necessary,
as determined by DHS, to process the Disenrollment, provided
Disenrollment was requested at least 30 days prior to that date,
except for Disenrollments pursuant to Article VI, Section 6.7.2.1,
Major Organ Transplants, for which Disenrollment shall be effective
the beginning of the month in which the transplant is approved.
B. Contractor shall recommend to DHS the Disenrollment of any Member in
the event of a breakdown in the "Contractor/Member relationship" which
makes it impossible for Contractor's providers to render services
adequately to a Member. Except in cases of violent behavior or fraud,
Contractor shall make significant efforts to resolve the problem with
the Member through avenues such as reassignment of Primary Care
Physician, education, or referral to services (such as mental health
or substance abuse programs), before requesting a Contractor-initiated
Disenrollment. In cases of Contractor-initiated Disenrollment of a
Member, Contractor must submit to DHS a written request with
supporting documentation for Disenrollment based on the breakdown of
the "Contractor/Member relationship." Contractor-initiated
disenrollments must be prior approved by DHS and shall be considered
only under the following circumstances:
1. Member is repeatedly verbally abusive to Contractor providers,
ancillary or administrative staff, subcontractor staff, or to
other plan Members.
2. Member physically assaults a Contractor provider or staff person,
subcontractor staff person, or other Member, or threatens another
individual with a weapon on Contractor premises. In this
instance, Contractor or subcontractor shall file a police report
and file charges against the Member.
3. Member is disruptive to Contractor operations, in general.
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4. Member habitually uses providers not affiliated with Contractor
for non-Emergency Services without required authorizations
(causing Contractor to be subjected to repeated provider demands
for payment for those services or other demonstrable degradation
in Contractor's relations with community providers).
5. Member has allowed the fraudulent use of Medi-Cal coverage under
the plan, which includes allowing others to use the Member's plan
membership card to receive services from Contractor.
C. A Member's failure to follow prescribed treatment (including failure
to keep established medical appointments) shall not, in and of itself,
be good cause for the approval by DHS of a Contractor-initiated
Disenrollment request unless Contractor can demonstrate to DHS that,
as a result of the failure, Contractor is exposed to a substantially
greater and unforeseeable risk than that otherwise contemplated under
the Contract and rate-setting assumptions.
D. The problem resolution attempted prior to a Contractor-initiated
Disenrollment described in subsection B, must be documented by
Contractor. A formal procedure for Contractor-initiated Disenrollments
shall be established by Contractor and approved by DHS. As part of the
procedure, the Member shall be notified in writing by Contractor of
the intent to disenroll the Member for cause and allowed a period of
no less that twenty (20) days to respond to the proposed action.
1. Contractor must submit a written request for Disenrollment and
the documentation supporting the request to DHS for approval. The
supporting documentation must establish the pattern of behavior
and Contractor's efforts to resolve the problem. DHS shall review
the request and render a decision in writing within ten(10)
State working days of receipt of a Contractor request and
necessary documentation. If the Contractor-initiated request for
Disenrollment is approved by DHS, DHS shall submit the
Disenrollment request to the enrollment contractor for
processing. Contractor shall be notified by DHS of the decision,
and if the request is granted, shall be notified by the
enrollment contractor of the effective date of the Disenrollment.
Contractor shall notify the Member of the Disenrollment for cause
if DHS grants the Contractor-initiated request for Disenrollment.
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2. Contractor shall continue to provide Covered Services to the
Member until the effective date of the Disenrollment.
E. Except as provided in subsection A.7, Membership shall cease no later
than midnight on the last day of the second calendar month after the
Member's Disenrollment request and all required supporting
documentation are received by DHS. On the first day after membership
ceases, Contractor is relieved of all obligations to provide Covered
Services to the Member under the terms of this Contract. Contractor
agrees in turn to return to DHS any capitation payment forwarded to
Contractor for persons no longer enrolled under this Contract.
F. Contractor shall implement and maintain procedures to ensure that all
Members requesting Disenrollment or information regarding the
Disenrollment process are immediately referred to the enrollment
contractor.
51. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.25,
Pharmaceutical Services and Prescribed Drugs, sentence one, is amended to
read:
Contractor shall provide pharmaceutical services and prescribed drugs,
either directly or through Subcontracts, in accordance with all laws and
regulations regarding the provision of pharmaceutical services and
prescription drugs to Medi-Cal beneficiaries, including, but not limited
to, Title 22, CCR, Section 53854.
52. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.26,
Facilities, is amended to read:
3.26 FACILITIES
Facilities used by Contractor for providing Covered Services shall comply
with the provisions of Title 22, CCR, Section 53856.
53. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28,
Subcontracts, sentence two, is amended to read:
In doing so, Contractor shall meet the subcontracting requirements as
stated in Title 22, CCR, Section 53867 and this Contract.
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54. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.1,
Xxxx-Xxxxx and Regulations, is amended to read:
3.28.1 XXXX-XXXXX AND REGULATIONS
All Subcontracts shall be in writing, and shall be entered into in
accordance with the requirements of the Xxxx-Xxxxx Health Care Services
Plan Act of 1975, Health and Safety Code Section 1340 et seq.; Title 10,
CCR, Section 1300 et seq.; W&I Code Section 14200 et seq.; Title 22, CCR,
Section 53800 et seq.; and applicable federal and State laws and
regulations.
55. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.2,
Subcontract Requirements, Subsection D, is amended to read:
D. Subcontractor's agreement to assist Contractor in the transfer of care
pursuant to Section 3.17.2, Turnover Requirements, in the event of
Contract termination.
56. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
subsection H, to renumbered Section 3.28.2, Subcontract Requirements, to
read:
H. Subcontractor's agreement to timely gather, preserve and provide to
DHS, any records in the Subcontractor's possession, in accordance with
Section 3.45, Records Related to Recovery for Tobacco Related
Illnesses.
57. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.3,
Departmental Approval - Non-Federally Qualified HMOs, is amended to read:
3.28.3 DEPARTMENTAL APPROVAL - NON-FEDERALLY QUALIFIED HMOS
Except as provided in Section 3.28.6, Federally Qualified Health
Centers/Rural Health Clinics, a provider or management Subcontract entered
into by a Contractor which is not a federally qualified HMO shall become
effective upon approval by DHS in writing, or by operation of law where DHS
has acknowledged receipt of the proposed Subcontract, and has failed to
approve or disapprove the proposed Subcontract within sixty (60) days of
receipt. Within five (5) State working days of receipt, DHS shall
acknowledge in writing the receipt of any material sent to DHS by
Contractor for approval.
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Subcontract amendments shall be submitted to DHS for prior approval at
least thirty (30) days before the effective date of any proposed changes
governing compensation, services, or term. Proposed changes which are
neither approved or disapproved by DHS, shall become effective by operation
of law 30 days after DHS has acknowledged receipt or upon the date
specified in the Subcontract amendment, whichever is later.
58. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.4,
Departmental Approval - Federally Qualified HMOs, is amended to read:
3.28.4 DEPARTMENTAL APPROVAL - FEDERALLY QUALIFIED HMOS
Except as provided in Section 3.28.6, Federally Qualified Health Centers/
Rural Health Clinics, Subcontracts entered into by a plan which is a
federally qualified HMO shall be:
A. Exempt from prior approval by DHS.
B. Submitted to DHS upon request.
59. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.6,
Federally Qualified Health Centers, is amended to read:
3.28.6 FEDERALLY QUALIFIED HEALTH CENTERS/RURAL HEALTH CLINICS
Contractor shall not enter into a Subcontract with a Federally Qualified
Health Center (FQHC) or a Rural Health Clinic (RHC) unless DHS approves the
provisions regarding rates, which shall be subject to the standard that
they be reasonable, as determined by DHS, in relation to the services to be
provided in accordance with Article VI, Section 6.6.21, FQHC and RHC
Contracts. In Subcontracts where the FQHC or RHC has made the election to
be reimbursed on a reasonable cost basis by the State, provisions shall be
included that require the subcontractor to keep a record of the number of
visits by plan Members separate from Fee-For-Service Medi-Cal
beneficiaries, in addition to any other data reporting requirements of the
Subcontract.
Subcontracts with FQHCs shall also meet Contract requirements of Article
VI, Sections 6.6.20, FQHC Services, and 6.6.21, FQHC and RHC Contracts.
Subcontracts with RHCs shall also meet Contract requirements of Article VI,
Section 6.6.21.
In Subcontracts where a negotiated reimbursement rate is agreed to as total
payment, a provision that such rate constitutes total payment shall be
included in the Subcontract.
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60. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.8,
Disclosures, is amended to read:
3.28.8 DISCLOSURES
Each Subcontract shall contain at least the elements required by Section
3.28.2, Subcontract Requirements, and the following:
A. Full disclosure of the method and amount of compensation or other
consideration to be received by the subcontractor from the plan.
B. Specification of the services to be provided by the subcontractor.
C. Specification that the Subcontract shall be governed by and construed
in accordance with the contractual obligations of Contractor.
D. Specification that the Subcontract or Subcontract amendments shall
become effective only as set forth in Sections 3.28.3, Departmental
Approval - Non-Federally Qualified HMOs, or 3.28.4, Departmental
Approval - Federally Qualified HMOs.
E. Specification of the term of the Subcontract including the beginning
and ending dates as well as methods of extension, renegotiation and
termination.
F. Subcontractor's agreement to submit reports as required by Contractor.
61. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.28.9,
Payment, is amended to read:
3.28.9 PAYMENT
Contractor shall pay all claims submitted by subcontracting providers in
accordance with this section, unless the subcontracting provider and
Contractor have agreed in writing to an alternate payment schedule.
A. Contractor shall comply with Section 1932(f), Title XIX, Social
Security Act (42 U.S.C. Section 1396u-2(f)), and Health and Safety
Code, Section 1371, subject to the following:
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1. Contractor shall pay or deny 90% of claims for payment submitted
by providers for which no further written documentation or
substantiation is required within 30 calendar days of receipt by
Contractor. Written notice must be given to providers of
contested claims within thirty (30) calendar days after receipt
of the claim by Contractor. Such notice shall state the reason(s)
for contesting the claim. Contractor agrees that failure to
provide timely notification to a provider of a contested claim
means that the claim is not being contested and is subject to the
requirements for paying uncontested claims.
2. Contractor shall ensure that 100% of claims for payment submitted
by providers for which no further written documentation or
substantiation is required are paid or denied within forty-five
(45) State working days after receipt.
B. Contractor shall maintain procedures for prepayment and postpayment
claims review, including review of data related to provider, Member
and Covered Services for which payment is claimed.
C. Contractor shall maintain sufficient claims
processing/tracking/payment systems capability to: comply with
applicable state and federal law, regulations and Contract
requirements, determine the status of received claims, and calculate
the estimate for incurred and unreported claims, as specified by Title
10, CCR, Sections 1300.77.1 and 1300.77.2.
62. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
Section 3.28.10 to read:
3.28.10 ELECTRONIC BILLING CAPABILITY
No later than April 1, 1999, Contractor shall submit to DHS a written
report detailing Contractor's actual or planned capability to accept
provider claims electronically. The report shall describe Contractor's
electronic capability for accepting claims from the following types of
providers:
A. Pharmacy;
B. Hospital;
C. Physician, including Emergency room Physician; and
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D. Allied health providers.
The report shall include a timetable for implementation of the
necessary electronic capability for each type of provider claim that
Contractor plans to install. For each type of provider claim that
Contractor has no plans to accept electronically, the report shall
include a supporting statement, which shall include a cost-benefit
analysis, any infrastructure limitations, and any other circumstances
that could preclude acceptance of those claims electronically. DHS
shall submit any questions regarding Contractor's report within sixty
(60) days of DHS' receipt of the report. Contractor shall respond to
any questions from DHS within 60 (sixty) days after Contractor's
receipt of the questions.
63. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
Section 3.28.11 to read:
3.28.11 PHYSICIAN INCENTIVE PLAN REQUIREMENTS
Contractor may implement and maintain a Physician Incentive Plan only if:
A. No specific payment is made directly or indirectly under the incentive
plan to a Physician or Physician group as an inducement to reduce or
limit Medically Necessary Covered Services provided to an individual
Member; and
B. The stop-loss protection (reinsurance), beneficiary survey, and
disclosure requirements of 42 CFR 417.479 are met by Contractor.
64. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.33,
Amendment of Contract, is amended to read:
3.33 AMENDMENT OF CONTRACT
Should either party during the life of this Contract desire a change in
this Contract, that change shall be proposed in writing to the other party.
The other party shall acknowledge receipt of the proposal within 10 days of
receipt of the proposal. The party proposing any such change shall have the
right to withdraw the proposal any time prior to acceptance or rejection by
the other party. Any proposal shall set forth an explanation of the reason
and basis for the proposed change and the text of the desired amendment to
this Contract which would provide for the change. If the proposal is
accepted, this Contract shall be amended to provide for the change mutually
agreed to by the parties on the condition that the amendment is approved by
DHHS, and the State Department of Finance, if necessary.
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65. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.41,
Recovery From Other Sources or Providers, is amended to read:
3.41 COST AVOIDANCE AND POST-PAYMENT RECOVERY OF OTHER HEALTH COVERAGE
SOURCES
A. Contractor shall Cost Avoid or make a Post-Payment Recovery for the
reasonable value of services paid for by Contractor and rendered to a
Member whenever a Member's OHCS covers the same services, either fully
or partially. However, in no event shall Contractor Cost Avoid or seek
Post-Payment Recovery for the reasonable value of services from a TPTL
action or make a claim against the estates of deceased Members.
B. All monies recovered by Contractor are retained by Contractor.
C. Contractor shall coordinate benefits with other coverage programs or
entitlements, recognizing the OHCS as primary and the Medi-Cal program
as the payor of last resort.
D. Cost Avoidance
1. If Contractor reimburses the provider on a fee-for-service basis,
Contractor shall not pay claims for services provided to a Member
whose Medi-Cal eligibility record indicates third party coverage,
designated by a Other Health Coverage (OHC) code or Medicare
coverage, without proof that the provider has first exhausted all
sources of other payments. Contractor shall have written
procedures implementing this requirement. Contractor shall submit
these procedures to DHS for review and comment.
2. Proof of third party billing is not required prior to payment for
services provided to Members with OHC codes A, M, X, Y, or Z.
E. Post-Payment Recovery
1. If Contractor reimburses the provider on a fee-for-service basis,
Contractor shall pay the provider's claim and then seek to
recover the cost of the claim by billing the liable third
parties:
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a. For services provided to Members with OHC codes A, M, X, Y,
or Z;
b. For services defined by DHS as prenatal or preventive
pediatric services; or
c. In child-support enforcement cases, identifiable by
Contractor. If Contractor does not have access to sufficient
information to determine whether or not the OHC coverage is
the result of a child support enforcement case, Contractor
shall follow the procedures for Cost Avoidance.
2. In instances where Contractor does not reimburse the provider on
a fee-for-service basis, Contractor shall pay for services
provided to a Member whose eligibility record indicates third
party coverage, designated by a OHC code or Medicare coverage,
and then shall xxxx the liable third parties for the cost of
actual services rendered.
3. Contractor shall also xxxx the liable third parties for the cost
of services provided to Members who are retroactively identified
by Contractor or DHS as having OHC.
4. Contractor shall have written procedures implementing the above
requirements. Contractor shall submit these procedures to DHS for
review and comment.
F. Contractor shall initiate a Disenrollment for all Members whose
eligibility record indicates OHC codes K, C, P, or F, within three (3)
State working days after Contractor becomes aware of the OHC code.
Until the Member is disenrolled, Contractor shall Cost Avoid or seek
Post-Payment Recovery as specified in subsections D and E above.
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G. Reporting Requirements
1. Contractor shall submit monthly reports to DHS, in a format
prescribed by DHS, displaying claims counts and dollar amounts of
costs avoided and the amount of Post-Payment Recoveries, by aid
category, as well as the amount of outstanding recovery claims
(accounts receivable) by age of account. The report shall display
separate claim counts and dollar amounts for Medicare Part A and
Part B. Reports shall be sent to the Department of Health
Services, Third Party Liability Branch, Cost Avoidance Unit,
X.X. Xxx 0000, Xxxxxxxxxx, XX 00000-0000.
2. When Contractor identifies OHC unknown to DHS, Contractor shall
report this information to DHS within ten (10) days of discovery
in automated format as prescribed by DHS. This information shall
be sent to the Department of Health Services, Third Party
Liability Branch, Health Identification Unit, X.X. Xxx 0000,
Xxxxxxxxxx, XX 00000-0000.
3. Contractor shall demonstrate to DHS that where Contractor does
not Cost Avoid or perform Post-Payment Recovery, that the
aggregate cost of this activity exceeds the total revenues
Contractor projects it would receive from such activity.
66. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.42, Third
Party Tort Liability, is amended to read:
3.42 THIRD PARTY TORT LIABILITY/ESTATE RECOVERY
Contractor shall identify and notify DHS' Third Party Liability Branch of
all instances or cases in which Contractor believes that an action by the
Medi-Cal Member involving the tort or Workers' Compensation liability of a
third party or estate recovery could result in recovery by the Member of
funds to which DHS has lien rights under Article 3.5 (commencing with
Section 14124.70), Part 3, Division 9, Welfare and Institutions Code.
Contractor shall make no claim for recovery of the value of Covered
Services rendered to a Member in such cases or instances and shall refer
all such cases or instances to DHS' Third Party Liability Branch within ten
(10) days of discovery. To assist DHS in exercising its responsibility for
such recoveries, Contractor shall meet the following requirements:
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A. If DHS requests service information and/or copies of paid
invoices/claims for Covered Services to an individual Member,
Contractor shall deliver the requested information within thirty (30)
days of the request. Service information includes subcontractor and
out-of-plan provider data. The value of the Covered Services shall be
calculated as the usual, customary and reasonable charge made to the
general public for similar services or the amount paid to
subcontracted providers or out-of-plan providers for similar services.
B. Information to be delivered shall contain the following data items:
1. Member name.
2. Full 14-digit Medi-Cal number.
3. Social Security Number.
4. Date of birth.
5. Contractor name.
6. Provider name (if different from Contractor).
7. Dates of service.
8. Diagnosis code and description of illness/injury.
9. Procedure code and/or description of services rendered.
10. Amount billed by a subcontractor or out-of-plan provider to
Contractor (if applicable).
11. Amount paid by other health insurance to Contractor or
subcontractor (if applicable).
12. Amounts and dates of claims paid by Contractor to subcontractor
or out-of-plan provider (if applicable).
13. Date of denial and reasons for denial of claims (if applicable).
14. Date of death (if applicable).
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C. Contractor shall identify to DHS' Third Party Liability Branch the
name, address and telephone number of the person responsible for
receiving and complying with requests for mandatory and/or optional
at-risk service information.
D. If Contractor receives any requests from attorneys, insurers, or
beneficiaries for copies of bills, Contractor shall provide DHS' Third
Party Liability Branch with a copy of any document released as a
result of such request, and shall provide the name and address and
telephone number of the requesting party.
E. Information submitted to DHS under this section shall be sent to
Department of Health Services, Third Party Liability Branch, Recovery
Section, X.X. Xxx 0000, Xxxxxxxxxx, XX 00000-0000.
67. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.43,
Obtaining DHS Approval, is amended to read:
3.43 OBTAINING DHS APPROVAL
Contractor shall obtain written approval from DHS, as provided in Section
4.7, Approval Process, prior to implementing or using any of the following,
including revisions to any of the items listed:
A. Providers of Covered Services, except for providers of seldom used or
unusual services as determined by DHS.
B. Facilities.
C. Marketing activities.
D. Marketing materials, promotional materials, and public information
releases relating to performance under this Contract, Member service
guides; Member newsletters; and provider claim forms unique to the
Contract.
E. Member Grievance procedure.
F. Member Disenrollment procedure.
G. Grievance forms.
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H. Any other protocol, policy or procedure otherwise requiring approval
under this Contract.
68. Article III, GENERAL TERMS AND CONDITIONS, renumbered Section 3.44, Pilot
Projects, is amended to read:
3.44 PILOT PROJECTS
DHS, pursuant to W&I Code Section 14094.3(c)(2), may establish pilot
projects to test alternative managed care models tailored to the special
health care needs of children under the California Children Services (CCS)
Program. These pilot projects may affect Contractor's obligations under the
Contract in the areas of Covered Services, eligible enrollees, and
administrative systems. These pilot projects shall be implemented through
Contract amendment pursuant to Section 3.33, Amendment of Contract, and, if
necessary, Change Order pursuant to Section 3.35, Change Requirements. DHS
shall not require Contractor to cover CCS services under the capitation
rate as part of a pilot project unless Contractor is a voluntary
participant in the project.
69. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
Section 3.45, to read:
3.45 RECORDS RELATED TO RECOVERY FOR TOBACCO RELATED ILLNESSES
3.45.1 RECORDS
DHS has filed a lawsuit for the recovery of medical expenses paid for the
treatment of tobacco related illnesses, (People of the State of California
ex rel. Xxxxxx X. Xxxxxxx, Attorney General of the State of California; S.
Xxxxxxxx Xxxxxx, Director of Health Services of the State of California v.
Xxxxxx Xxxxxx, Inc.; X.X. Xxxxxxxx Tobacco Company; Xxxxx & Xxxxxxxxxx
Tobacco Corporation; B.A.T. Industries P.L.C.; Lorillard Tobacco Company,
Inc.; American Tobacco Company, Inc.; United States Tobacco Company; Hill &
Xxxxxxxx, Inc.; The Council for Tobacco Research-U.S.A., Inc.; Tobacco
Institute, Inc.; Smokeless Tobacco Council, Inc. and Does 1 through 200,
inclusive) (hereafter the "Tobacco Lawsuit"). Upon request by DHS,
Contractor shall timely gather, preserve and provide to DHS, in the form
and manner specified by DHS, any information specified by DHS, subject to
any lawful privileges, in Contractor's or its subcontractors' possession,
relating to the Tobacco Lawsuit. (If Contractor asserts that any requested
documents are covered by a privilege, Contractor shall: 1) identify such
privileged documents with sufficient particularity to reasonably identify
the document
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while retaining the privilege; and 2) state the privilege being claimed
that supports withholding production of the document.) Such request
shall include, but is not limited to, a response to a request for
documents submitted by any defendant in the Tobacco Lawsuit. Contractor
acknowledges that time may be of the essence in responding to some
requests. Contractor shall use all reasonable efforts to immediately
notify DHS of any subpoenas, document production requests, or requests
for records, received by Contractor or its subcontractors related to
tobacco related illnesses or the incidence of disease associated with
the use of tobacco products.
3.45.2 PAYMENT FOR RECORDS
In addition to the payments provided for in Article V, DHS agrees to pay
Contractor for complying with Section 3.45.1, Records, above, as
follows:
A. DHS shall reimburse Contractor amounts paid by Contractor to third
parties for services necessary to comply with Section 3.45.1. Any
third party assisting Contractor with compliance with Section
3.45.1 shall comply with all applicable confidentiality
requirements. Amounts paid by Contractor to any third party for
assisting Contractor in complying with Section 3.45.1 shall not
exceed normal and customary charges for similar services and such
charges and supporting documentation shall be subject to review by
DHS.
B. If Contractor uses existing personnel and resources to comply with
Section 3.45.1, DHS shall reimburse Contractor as specified below.
Contractor shall maintain and provide to DHS time reports
supporting the time spent by each employee as a condition of
reimbursement. Reimbursement claims and supporting documentation
shall be subject to review by DHS.
1. Compensation and payroll taxes and benefits, on a prorated
basis, for the employees' time devoted directly to compiling
information pursuant to Section 3.45.1.
2. Costs for copies of all documentation submitted to DHS
pursuant to Section 3.45.1, subject to a maximum
reimbursement of ten (10) cents per copied page.
C. Contractor shall submit to DHS all information needed by DHS to
determine reimbursement to Contractor under this section,
including, but not limited to, copies of invoices from third
parties and payroll records.
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70. Article III, GENERAL TERMS AND CONDITIONS, is amended by adding a new
Section 3.46 to read:
3.46 FRAUD AND ABUSE REPORTING
Contractor shall report to the Contracting Officer all cases of
suspected fraud and/or abuse, as defined in 42 Code of Federal
Regulations, Section 455.2, where there is reason to believe that an
incident of fraud and/or abuse has occurred, by subcontractors, Members,
providers, or employees within ten (10) State working days of the date
when Contractor first becomes aware of or is on notice of such activity.
Contractor shall establish policies and procedures for identifying,
investigating and taking appropriate corrective action against fraud
and/or abuse in the provision of health care services under the Medi-Cal
program. Contractor shall notify DHS prior to conducting any
investigations, based upon Contractor's finding that there is reason to
believe that an incident of fraud and/or abuse has occurred, and, upon
the request of DHS, consult with DHS prior to conducting such
investigations. Without waiving any privileges of Contractor, Contractor
shall report investigation results within ten (10) State working days
of conclusion of any fraud and/or abuse investigation.
71. Article IV, DUTIES OF THE STATE, Section 4.3, Facility Inspections, is
amended to read:
4.3 FACILITY INSPECTIONS
Conduct unannounced validation reviews on a number of Contractor's
Primary Care sites, selected at DHS' discretion, to verify compliance of
these sites with DHS requirements.
72. Article IV, DUTIES OF THE STATE, Section 4.4, Enrollment Processing, is
amended to read:
4.4 ENROLLMENT PROCESSING
4.4.1 GENERAL
The parties to this Contract agree that the primary purpose of DHS'
Medi-Cal managed care system is to improve quality and access to care
for Medi-Cal beneficiaries. The parties acknowledge that the Medi-Cal
eligibility process and the managed care enrollment system are dynamic
and complex programs. The parties also acknowledge that it is
impractical to ensure that every beneficiary eligible for enrollment in
the Contractor's plan will be enrolled in a timely manner. Furthermore,
the parties recognize
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that for a variety of reasons some Eligible Beneficiaries will not be
enrolled in Contractor's plan and will receive Covered Services in the
Medi-Cal Fee-for-Service system. These reasons include, but are not
limited to, the exclusion of some beneficiaries from participating in
Medi-Cal managed care, the time it takes to enroll beneficiaries,
changes in laws and policies, the loss and subsequent regaining of
eligibility by beneficiaries, retroactive periods of eligibility for
some beneficiaries, and the lack of a current valid address for some
beneficiaries. The parties desire to work together in a cooperative
manner so that Eligible Beneficiaries who choose to or should be
assigned to Contractor's plan are enrolled in Contractor's plan pursuant
to the requirements of Section 4.4. The parties agree that to accomplish
this goal it is necessary to be reasonably flexible with regard to the
enrollment process.
4.4.2 DEFINITIONS
For purposes of Section 4.4, Enrollment Processing, the following
definitions shall apply:
A. Fully Converted County means a county in which the following
circumstances - exist, except for those Medi-Cal beneficiaries
covered by Title 22, CCR, Section 53887,:
1. Eligible Beneficiaries who meet the mandatory enrollment
criteria contained in Tide 22, CCR, Section 53845(a) may no
longer choose to receive Covered Services on a
Fee-for-Service basis; and
2. All new Eligible Beneficiaries who meet the mandatory
enrollment criteria contained in Title 22, CCR, Section
53845(a) must now choose a managed care plan or they will be
assigned to a managed care plan; and
3. All Eligible Beneficiaries listed in MEDS as meeting the
mandatory enrollment criteria contained in Title 22, CCR,
Section 53845(a) on the last date that both 1. and 2. above
occur:
(i) have been notified of the requirement to choose a
managed care plan and informed that if they fail to
choose a plan they will be assigned to a managed
care plan; and
(ii) those beneficiaries still eligible for Medi-Cal and
enrollment into a managed care plan at the time
their plan enrollment is processed in MEDS have been
enrolled into a managed care plan.
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B. Mandatory Plan Beneficiary means:
1. A new Eligible Beneficiary who meets the mandatory
enrollment criteria contained in Title 22, CCR, Section
53845(a) both at the time her/his plan enrollment is
processed by the DHS Enrollment Contractor and by MEDS; or
2. An Eligible Beneficiary previously receiving Covered
Services in a county without mandatory managed care
enrollment who now resides in a county where mandatory
enrollment is in effect and who meets the mandatory
enrollment criteria contained in Title 22, CCR, Section
53845(a); or
3. An Eligible Beneficiary meeting the criteria of Title 22,
CCR, Section 53845(b) prior to October 1, 1998, and who
subsequently meets the criteria of Title 22, CCR, Section
53845(a).
C. Mandatory Plan Beneficiary shall not include any Eligible
Beneficiary who:
(i) is eligible to receive Covered Services on a
Fee-for-Service basis because her/his MEDS
eligibility for managed care plan enrollment is
interrupted due to aid code, ZIP code or county code
changes; or
(ii) becomes eligible for enrollment in a managed care
plan on a retroactive basis.
4.4.3 DHS ENROLLMENT OBLIGATIONS
A. DHS shall receive applications for enrollment from its enrollment
contractor and shall verify the current eligibility of applicants
for enrollment in Contractor's plan under this Contract. If the
Contractor has the capacity to accept new enrollees, DHS or its
enrollment contractor shall enroll or assign eligible applicants in
Contractor's plan when selected by the applicant or when the
applicant fails to timely select a plan. Of those to be enrolled or
assigned in Contractor's plan, DHS will ensure that in a Fully
Converted County a Mandatory Plan Beneficiary will receive an
effective date of plan enrollment that is no later than 90 days
from the date that MEDS lists such an individual as meeting the
enrollment criteria contained in Title 22, CCR, Section 53845(a),
if all changes to MEDS have been made to allow for the enrollment
of the individual and all changes necessary to this Contract to
accommodate such enrollment, including, but not limited to rate
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changes and aid code changes, have been executed. DHS will use due
diligence in making any changes to MEDS and to this Contract. DHS
will provide Contractor a list of Members on a monthly basis.
B. DHS or its enrollment contractor shall assign Eligible
Beneficiaries meeting the enrollment criteria contained in Title
22, CCR, Section 53845(a) to plans in accordance with Title 22,
CCR, Section 53884.
C. Notwithstanding any other provision in this Contract, A. and B.
above shall not apply to:
1. Eligible Beneficiaries previously eligible to receive
Medi-Cal services from a Prepaid Health Plan or Primary Care
Case Management plan and such plan's contract with DHS
expires, terminates, or is assigned or transferred to
Contractor;
2. Members who are enrolled into another managed care plan on
account of assignment, assumption, termination, or
expiration of this Contract;
3. Eligible Beneficiaries covered by a new mandatory aid code,
added to this Contract after October 1, 1998;
4. Eligible Beneficiaries meeting the criteria of Title 22,
CCR, Section 53845(b) prior to October 1, 1998, who
subsequently meet the criteria of Title 22, CCR 53845(a) due
solely to DHS designating a prior voluntary aid code as a
new mandatory aid code;
5. Eligible Beneficiaries residing in a County that is not a
Fully Converted County; or
6. Eligible Beneficiaries without a current valid deliverable
address or with an address designated as a County post
office box for homeless beneficiaries.
4.4.4 DISPUTES CONCERNING DHS ENROLLMENT OBLIGATIONS
A. Pursuant to the requirements and procedures contained in Section
3.20, Disputes and Appeals, Contractor shall notify DHS of DHS'
noncompliance with Section 4.4, Enrollment Processing.
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B. DHS shall have 120 days from the date of DHS' receipt of
Contractor's notice (the "Cure Period") to cure any noncompliance
with Section 4.4, Enrollment Processing, identified in Contractor's
notice, without incurring any financial liability to Contractor.
For purposes of this section, DHS shall be deemed to have cured any
noncompliance with Section 4.4, Enrollment Processing, identified
in Contractor's notice if within the Cure Period any of the
following occurs:
1. Mandatory Plan Beneficiaries receive an effective date of
plan enrollment that is within the Cure Period, or
2. DHS corrects enrollment that failed to comply with Section
4.4, Enrollment Processing, by redirecting enrollment from
one Contractor to another within the Cure Period in order to
comply with Section 4.4, Enrollment Processing, or
3. Within the Cure Period, DHS changes the distribution of
beneficiary Assignment (subject to the requirements of Title
22, CCR, Section 53884(b)(l) through (b)(4)), to the maximum
extent new beneficiaries are available to be assigned, to
make up the number of incorrectly assigned beneficiaries as
soon as possible.
C. If it is necessary to redirect enrollment or change the
distribution of beneficiary Assignment due to noncompliance with
Section 4.4, Enrollment Processing, and such change varies from the
requirements of Title 22, CCR, Section 53884(b)(5) or (b)(6),
Contractor agrees it will neither seek legal nor equitable relief
for such variance or the results of such variance if DHS resumes
assignment consistent with Sections 53884 (b)(5) or (b)(6) after
correcting a noncompliance with Section 4.4, Enrollment Processing.
D. Notwithstanding Section 3.1 or any other provision of this
Contract, if DHS fails to cure a noncompliance with Section 4.4,
Enrollment Processing, within the Cure Period, DHS will be
financially liable for such noncompliance as follows:
DHS will be financially liable for Contractor's demonstrated actual
reasonable losses as a result of the noncompliance, beginning with
DHS' first failure to comply with its enrollment obligation set
forth herein. DHS' financial liability shall not exceed 15 percent
of Contractor's monthly capitation payment calculated as if
noncompliance with Section 4.4 did not occur, for each month in
which DHS has not cured noncompliance pursuant to subparagraph
4.4.4.B, beginning with DHS' first failure to comply with its
enrollment obligation set forth herein.
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E. Notwithstanding Section 4.4.4.D above, DHS shall not be financially
liable to Contractor for any noncompliance with Section 4.4,
Enrollment Processing, in an affected county (on a county-by-county
basis) if Contractor's loss of Mandatory Plan Beneficiaries, in a
month in which any noncompliance occurs, is less than five percent
of Contractor's total Members in that affected county in the month
in which the noncompliance occurs. The parties acknowledge that the
above-referenced five-percent threshold shall apply on a
county-by-county basis, not in the aggregate.
73. Article IV, DUTIES OF THE STATE, Section 4.6, Testing and Certification
of Marketing Representatives, is amended to read:
4.6 TESTING AND CERTIFICATION OF MARKETING
REPRESENTATIVES
Test all Contractor Marketing Representatives for knowledge of the
program prior to their engaging in Marketing or Medi-Cal Managed Care
information activities on behalf of Contractor. Certify as qualified
Marketing Representatives, those persons demonstrating adequate
knowledge of the program, provided they are of good moral character.
Contractor may be permitted, subject to approval and oversight by DHS,
to perform such testing on behalf of DHS, provided that Contractor has
never been sanctioned for Marketing violations or abuses. With respect
to evidence of good moral character, Contractor shall be permitted to
rely on the Marketing Representative's written statements. DHS reserves
the right to rescind approval for Contractor testing at any time.
74. Article IV, DUTIES OF THE STATE, Section 4.7, Approval Process, is
amended to read:
4.7 APPROVAL PROCESS
A. Within five (5) State working days of receipt, DHS shall
acknowledge in writing the receipt of any material sent to DHS by
Contractor pursuant to Article III, Section 3.3, Obtaining DHS
Approval.
B. Within sixty (60) days of receipt, DHS shall make all reasonable
efforts to approve in writing the use of such material provided to
DHS pursuant to Article III, Section 3.43, Obtaining DHS Approval,
provide Contractor with a written explanation why its use is not
approved, or provide a written estimated date of completion of DHS'
review process. If DHS does not complete its review of submitted
material within sixty (60) days of receipt, or within the estimated
date
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of completion of DHS review, Contractor may elect to implement or
use the material at Contractor's sole risk and subject to possible
subsequent disapproval by DHS. This subsection shall not be
construed to imply DHS approval of any material that has not
received written DHS approval. This subsection shall not apply to
Subcontracts or sub-subcontracts subject to DHS approval in
accordance with Section 3.28.3, Departmental Approval -
Non-Federally Qualified HMOs, or Section 3.28.4, Departmental
Approval - Federally Qualified HMOs.
75. Article IV, DUTIES OF THE STATE, Section 4.8, Program Information, is
amended to read:
4.8 PROGRAM INFORMATION
Provide Contractor with complete and current information with respect to
pertinent policies, procedures, and guidelines affecting the operation
of this Contract, within thirty (30) days of receipt of Contractor's
written request for information, to the extent that the information is
readily available. If the requested information is not available, DHS
shall notify Contractor within thirty (30) days, in writing, of the
reason for the delay and when Contractor may expect the information.
76. Article IV, DUTIES OF THE STATE, Section 4.9, Sanctions, is amended to
read:
4.9 SANCTIONS
Apply sanctions, in accordance with Welfare and Institutions Code,
Section 14304, and Title 22, CCR, Section 53872, to Contractor for
violations of the terms of this Contract, applicable federal and State
laws and regulations.
77. Article V, PAYMENT PROVISIONS, Section 5.2, Amounts Payable, is amended
to read:
5.2 AMOUNTS PAYABLE
The maximum amount payable for the 1995-96 Fiscal Year ending June 30,
1996 will not exceed $32,080,630; the maximum amount payable for the
1996-97 Fiscal Year ending June 30, 1997 will not exceed $194,472,680;
the maximum amount payable for the 1997-98 Fiscal Year ending June 30,
1998 will not exceed $6,500,000; the maximum amount payable for the
1998-99 Fiscal Year ending June 30, 1999 will not exceed $80,000,000.
Any requirement for performance by DHS and the Contractor for the period
of the Contract subsequent to June 30, 1999, will be dependent upon the
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availability of future appropriations by the Legislature for the purpose
of this Contract. If funds become available for purposes of this
Contract from future appropriations by the Legislature, the maximum
amount payable for the 1999-2000 Fiscal Year ending June 30, 2000 will
not exceed $107,000,000; the maximum amount payable for the 2000-2001
Fiscal Year ending June 30, 2001 will not exceed $107,000,000; the
maximum amount payable for the 2001-2002 Fiscal Year ending June 30,
2002 will not exceed $80,000,000. The maximum amount payable under this
Contract will not exceed $607,053,310.
78. Article V, PAYMENT PROVISIONS, Section 5.3, Capitation Rates, is amended
to read:
DHS shall remit to Contractor a capitation payment each month for each
Medi-Cal Member that appears on the approved list of Members supplied to
Contractor by DHS. The capitation rate shall be the amount specified in
this Article. The payment period for health care services shall commence
on the first day of operations, as determined by DHS. Capitation
payments shall be made in accordance with the following schedule of
capitation payment rates:
AID CODE CATEGORIES
Family: 01, 02, 08, 30, 32, 33, 34, 35, 38, 39, 3A, 3C, 3P, 3R, 40, 42,
4C, 4K, 54, 59, 5K; Aged: 10, 14, 16, 18; Disabled: 20, 24, 26, 28, 36,
60, 64, 66, 68, 6A, 6C; Child 03, 04, 45, 82; Adult 86
SAN BERNARDINO COUNTY 7/95 - 5/96 SAN BERNARDINO COUNTY 6/96 - 9/97
Family $ 70.01 Family $ 71.59
Child $ 67.91 Child $ 67.17
Aged $ 117.66 Aged $ 121.76
Disabled $ 177.15 Disabled $ 174.45
Adult $ 536.02 Adult $ 554.73
RIVERSIDE COUNTY 7/95-5/96 RIVERSIDE COUNTY 6/96 - 9/97
Family $ 74.70 Family $ 76.39
Child $ 68.51 Child $ 67.74
Aged $ 110.37 Aged $ 114.62
Disabled $ 181.61 Disabled $ 178.77
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Adult $ 492.78 Adult $ 509.94
AID CODE CATAGORIES
Family: 01, OA, 02, 08, 30, 32, 3G, 33, 3H, 34, 35, 38, 39, 3A, 3C, 3N,
3U, 3P, 3R, 40, 42, 54, 59, 7X; CalWORKS: 3E, 3L, 3M; Aged: 10, 14, 16,
18; Disabled: 20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6N, 6P, 6R;
Child: 03, 04, 45, 4C, 4K, 5K, 82; Adult: 86
For the Period 10/97 - 09/30/98
RIVERSIDE COUNTY SAN BERNARDINO
Family $ 75.91 Family $ 74.04
Aged $ 162.29 Aged $ 167.25
Disabled $ 204.96 Disabled $ 217.87
Child $ 79.33 Child $ 79.42
Adult $ 515.67 Adult $ 531.42
AIDS Beneficiary Rate $ 1021.49 Aids $ 1072.78
In the future, DHS expects to activate aid codes 3N, 3U, 7X, 3E, 3L, 3M,
6N, 6P, and 6R, listed above by aid code rate category. If DHS activates
these new aid codes, Contractor agrees to accept Eligible Beneficiaries
with these aid codes as Members and to provide Covered Services to these
Members at the monthly capitation rate specified for each rate category
in this section.
79. Article V, PAYMENT PROVISIONS, Section 5.4, Capitation Rates Constitute
Payment In Full, is amended to read:
5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop
loss reinsurance provisions, on behalf of a Member for all Covered
Services required by such Member and for all Administrative Costs
incurred by Contractor in providing or arranging for such services, and
subject to adjustments for federally qualified health centers in
accordance with Section 5.13, but do not include payment for the
recoupment of current or previous losses incurred by Contractor. DHS is
not responsible for making payment for recoupment of losses. The
actuarial basis for the determination of the capitation payment rates is
outlined in Attachment 1 (consisting of twelve (12) pages).
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80. Article V, PAYMENT PROVISIONS, Section 5.5, Determination of Rates, is
amended to read:
5.5 DETERMINATION OF RATES
DHS shall determine the capitation rates for the initial period December
1, 1995, or the Contract effective date of operations if later, through
September 30, 1997. Subsequent to September 30, 1997 and through the
duration of the Contract, DHS shall make an annual redetermination of
rates for each rate year defined as the 12-month period from October 1,
through September 30. DHS reserves the right to redetermine rates on an
actuarial basis or move to a negotiated rate for each rate year. All
payments beyond June 1996 and rate adjustments beyond September 1997 are
subject to future appropriations of funds by the Legislature and the
Department of Finance approval. Further, all payments are subject to
Xxxxx 00, XXX 447.361 and the availability of Federal congressional
appropriation of funds.
If DHS redetermines rates on an actuarial basis, DHS shall determine
whether the rates shall be increased, decreased, or remain the same. If
it is determined by DHS that Contractor's capitation rates shall be
increased or decreased, that increase or decrease shall be effectuated
through a Change Order to this Contract in accordance with the
provisions of Article III, Section 3.35, Change Requirements, subject to
the following provisions:
A. The Change Order shall be effective as of October 1 of each year
covered by this Contract.
B. In the event there is any delay in a determination to increase or
decrease capitation rates, so that a Change Order may not be
processed in time to permit payment of new rates commencing October
1, the payment to Contractor shall continue at the rates then in
effect. Those continued payments shall constitute interim payment
only. Upon final approval of the Change Order providing for the
rate change, DHS shall make adjustments for those months for which
interim payment was made.
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C. Notwithstanding paragraph B, payment of the new annual rates shall
commence no later than December 1, provided that a Change Order
providing for the new annual rates has been issued by DHS. By
accepting payment of new annual rates prior to full approval by all
control agencies of the Change Order to this Contract implementing
such new rates, Contractor stipulates to a confession of judgment
for any amounts received in excess of the final approved rate. If
the final approved rate differs from the rates agreed upon by
Contractor and DHS:
1. Any underpayment by the State shall be paid to Contractor
within 30 days after final approval of the new rates.
2. Any overpayment to Contractor shall be recaptured by the
State's withholding the amount due from Contractor's next
capitation check.
If the amount to be withheld from that capitation check
exceeds 25 percent of the capitation payment for that month,
amounts up to 25 percent shall be withheld from successive
capitation payments until the overpayment is fully recovered
by the State.
D. If mutual agreement between DHS and Contractor cannot be
attained on capitation rates for rate years subsequent to
September 30, 1997 (resulting from a rate change pursuant to
Section 5.5 or 5.6), Contractor shall retain the right to
terminate the Contract, but no earlier than September 30,
1998. Notification of intent to terminate a Contract shall
be in writing and provided to DHS at least nine (9) months
prior to the effective date of termination, subject to any
earlier termination date negotiated in accordance with
Article III, Section 3.18.2, Termination - Contractor. DHS
shall pay the capitation rates last offered for that rate
period until the Contract is terminated.
E. DHS shall make every effort to notify and consult with
Contractor regarding proposed redetermination of rates
pursuant to this section or Section 5.6 at the earliest
possible time prior to implementation of the new rate.
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81. Article V, PAYMENT PROVISIONS, Section 5.6, Redetermination of Rates -
Obligation Changes, is amended to read:
5.6 REDETERMINATION OF RATES - OBLIGATION CHANGES
The Capitation rates may be adjusted during the rate year to provide for
a change in obligations which results in an increase or decrease of more
than one percent of cost (as defined in Title 22, CCR, Section 53869) to
Contractor. Any adjustments shall be effectuated through a Change Order
to the Contract subject to the following provisions:
A. The Change Order shall be effective as of the first day of the
month in which the change in obligations is effective, as
determined by DHS.
B. In the event DHS is unable to process the Change Order in time to
permit payment of the adjusted rates as of the month in which the
change in obligations is effective, payment to Contractor shall
continue at the rates then in effect. Continued payment shall
constitute interim payment only. Upon final approval of the Change
Order providing for the change in obligations, DHS shall make
adjustments for those months for which interim payment was made.
C. DHS and Contractor may negotiate an earlier termination date,
pursuant to Article III, Section 3.18.2, Termination - Contractor,
if a change in contractual obligations is created by a State or
federal change in the Medi-Cal program, or a lawsuit, that
substantially alters the financial assumptions and conditions under
which Contractor entered into this Contract, such that Contractor
can demonstrate to the satisfaction of DHS that it cannot remain
financially solvent until the termination date that would otherwise
be established under this section.
82. Article V, PAYMENT PROVISIONS, Section 5.7, Reinsurance, subsection (A),
sentence one, is amended to read:
Contractor may obtain reinsurance (stop loss coverage) through DHS or
other insurers or may self-insure upon approval by DHS to ensure
maintenance of adequate capital by Contractor, for the cost of providing
Covered Services under this Contract.
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83. Article V, PAYMENT PROVISIONS, Section 5.9, Financial Security, is
amended to read:
5.9 FINANCIAL PERFORMANCE GUARANTEE
Contractor shall provide satisfactory evidence of and maintain Financial
Performance Guarantee in an amount equal to at least one month's
capitation payment, in a manner specified by DHS. At Contractor's
request and with DHS approval, Contractor may establish a phase-in
schedule to accumulate the required Financial Performance Guarantee.
Contractor may elect to satisfy the Financial Performance Guarantee
requirement by receiving payment on a post payment basis. The Financial
Performance Guarantee shall remain in effect for a period not exceeding
90 days following termination or expiration of this Contract, unless DHS
has a financial claim against Contractor.
84. Article V, PAYMENT PROVISIONS, Section 5.11, Recovery of Capitation
Payments, is amended to read:
5.11 RECOVERY OF CAPITATION PAYMENTS
DHS shall have the right to recover amounts paid to Contractor in the
following circumstances as specified:
A. DHS determines that a Member has either been improperly enrolled,
due to ineligibility of the Member to enroll in Contractor's plan,
residence outside of Contractor's Service Area, or pursuant to
Title 22, Section 53891(a)(2), or should have been disenrolled with
an effective date in a prior month. DHS may recover or, upon
request by Contractor, DHS shall recover the capitation payments
made to Contractor for the Member and absolve Contractor from all
financial and other risk for the provision of services to the
Member under the terms of the Contract for the month or months in
question. In such event, Contractor shall have the authority to
recover any payments made to providers for Covered Services
rendered for the month or months in question. Contractor shall
inform providers that claims for services provided to Members
during the month or months in question shall be paid by DHS' fiscal
intermediary, if the Member is determined eligible for the Medi-Cal
program.
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Upon request by Contractor, DHS may allow Contractor to retain the
capitation payments made for Members that are eligible to enroll in
Contractor's plan, but should have been retroactively disenrolled
pursuant to Article VI, Section 6.7.2, Excluded Services:
Circumstances Under Which Member Disenrolled, or under other
circumstances as approved by DHS. If Contractor retains the
capitation payments, Contractor shall provide or arrange and pay
for all Medically Necessary Covered Services for the Member, until
the Member is disenrolled on a nonretroactive basis pursuant to
Article III, Section 3.23.5, Disenrollment.
B. As a result of Contractor's failure to perform contractual
responsibilities to comply with federal Medicaid requirements, the
Department of Health and Human Services (DHHS) disallows Federal
Financial Participation (FFP) for payments made by DHS to
Contractor. DHS may recover the amounts disallowed by DHHS by an
offset to the capitation payments made to Contractor. If recovery
of the full amount at one time imposes a financial hardship on
Contractor, DHS at its discretion may grant a Contractor's request
to repay the recoverable amounts in monthly installments over a
period of consecutive months not to exceed six (6) months.
C. If DHS determines that any other erroneous or improper payment not
mentioned above has been made to Contractor, DHS may recover the
amounts determined by an offset to the capitation payments made to
Contractor. If recovery of the full amount at one time imposes a
financial hardship on Contractor, DHS, at its discretion, may grant
a Contractor's request to repay the recoverable amounts in monthly
installments over a period of consecutive months not to exceed six
(6) months. At least thirty (30) days prior to seeking any such
recovery, DHS shall notify Contractor to explain the improper or
erroneous nature of the payment and to describe the recovery
process.
85. Article V, PAYMENT PROVISIONS is amended by adding a new section 5.12 to
read:
5.12 DATA REPORTING PERFORMANCE INCENTIVES
5.12.1 DEFINITIONS
For purposes of Section 5.12 Data Reporting Performance
Incentives, the following definitions shall apply:
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A. Financial Performance Incentive means the funds retained by DHS and
paid to the Contractor upon Contractor's achieving the data
reporting performance incentive standards contained in Section
5.12.3, Performance Incentive Standards.
B. Reporting Year means the twelve-month period beginning July 1, 1998
and ending June 30, 1999, and each subsequent twelve-month period
beginning July 1 and ending June 30.
C. Services Reporting Period means the period during which Contractor
provides the services counted to determine Contractor's compliance
with the Children Served and Outpatient and Emergency Department
Services standards, contained in Section 5.12.3, Performance
Incentive Standards. The first Services Reporting Period shall
consist of the first three months of the Reporting Year; the second
Services Reporting Period shall consist of the first six months of
the Reporting Year; the third Services Reporting Period shall
consist of the first nine months of the Reporting Year, and the
fourth Services Reporting Period shall consist of the entire 12
months of the Reporting Year.
D. Timeliness Reporting Period means the period during which
Contractor reports data counted to determine Contractor's
compliance with the Timeliness of Data Reporting Standards,
contained in Section 5.12.3, Performance Incentive Standards. The
first Timeliness Reporting Period shall consist of the first three
months of the Reporting Year; the second timeliness Reporting
Period shall consist of the first six months of the Reporting
Years; the third Timeliness Reporting Period shall consist of the
first nine months of the Reporting Year; and the fourth Timeliness
Reporting Period shall consist of the entire 12 months of the
Reporting Year.
E. Claim Run-Out Period means the period beginning on the first day of
each Services Reporting Period of Timeliness Reporting Period and
ending ninety (90) days after the last day of each Services
Reporting Period or Timeliness Reporting Period.
F. Data Processing Period means the period beginning on the first day
of each Services Reporting Period of Timeliness Reporting Period
and ending ninety (90) days after the last day of each Claim
Run-Out Period.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
G. Evaluation Period means the ninety (90) day period beginning on the
day after the last day of each Data Processing Period.
H. PM-160 Information Only Data means Child Health and Disability
Prevention (CHDP) Encounter information contained on the
Confidential Screening/Billing Report form used by the Contractor
to report all CHDP Encounters to DHS and to the local CHDP program.
I. Encounter Record means an individual data entry, which follows the
format code contained in the Managed Care Data Element Dictionary,
reported to DHS for services provided to a Member during an
Encounter.
5.12.2 PAYMENT PROVISIONS
For purposes of this Section 5.12, Data Reporting Performance
Incentives, the following payment provisions shall apply:
A. Commencing with the monthly capitation payment for services
provided by Contractor to Members during the month of April 1999,
and for each subsequent monthly capitation payment, DHS shall
retain and reserve one percent (1%) of each capitation payment for
each county services by Contractor; however, in no event shall more
than $100,000 per month be retained by DHS for a Contractor serving
more than 150,000 Members. The retained funds reserved by DHS shall
be allocated to each performance incentive standard as specified in
Section 5.12.3, Performance Incentive Standards.
B. DHS shall pay Contractor the reserved Financial Performance
Incentive funds allocated to each performance incentive standard,
as provided in Section 5.12.3, Performance Incentive Standards,
upon Contractor's achieving the standard, in a county serviced by
Contractor under this Contract. If Contractor is providing services
in multiple counties under this Contract, a Financial Performance
Incentive payment shall only be paid for the county or counties in
which Contractor achieves the specific performance incentive
standard. If Contractor achieves a performance incentive standard
in one county, this shall not affect the payment or nonpayment to
Contractor for the same performance incentive standard in another
county served under this Contract.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
C. The funds available to each Financial Performance Incentive payment
shall be the sum of all funds reserved by DHS for each performance
incentive standard, as provided in Section 5.12.3, Performance
Incentive Standards, for the Services Reporting Period or the
Timeliness Reporting period under review, less any funds already
paid to Contractor for achieving the standard in a previous
Services Reporting Period or Timeliness Reporting Period in the
same reporting year.
D. All Financial Performance incentive calculations for the percent of
compliance with the standards described in Section 5.12.3,
Financial Performance Standards, achieved by Contractor shall be
rounded to the nearest whole number according to the following: all
percentages shall be carried out to two (2) decimal places and
those ending with 0.49 or less shall be rounded down to the next
lower whole number, and all percentages ending with 0.50 or more
shall be rounded up to the next higher whole number.
E. DHS shall notify Contractor of the results of its determination of
Contractor's compliance with each performance incentive standard
not later than ten (10) working days after the end of the
Evaluation Period for the Services Reporting Period or Timeliness
Reporting Period under review. The Financial Performance Incentive
payment shall be included in Contractor's monthly capitation
payment, no later than the second month after the last day of the
Evaluation Period.
F. Payments to Contractor for achieving a performance incentive
standard shall be subject to verification reviews, including but
not limited to review of Member medical records, by DHS. If, based
upon such review, Contractor did not achieve compliance with a
performance incentive standard, DHS shall recover any Financial
Performance Incentive payments made to Contractor for achieving the
standard. Contract shall timely and fully cooperate with DHS, and
required timely and full cooperation of all entities subcontracting
with Contractor, in the conduct of verification reviews and the
furnishing of all records and information requested by DHS to
complete the reviews. Contractor shall not be compensated,
including but not limited to compensation for copies of
information, for cooperating in such reviews. Contractor's failure
to cooperate in verification reviews, as determined by DHS in its
sole discretion, shall be grounds for DHS' recovery of any payments
made for achieving a performance incentive standard.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
G. If DHS fails to determine Contractor's compliance with a
performance incentive standard and mail notification to Contractor
of the results of such determination within ten (10) working days
after the end of the Evaluation Period for the Services Reporting
Period or Timeliness reporting Period under review, DHS shall pay
Contractor the Financial Performance Incentive allocated to the
standard for which DHS failed to timely determine compliance. Such
payment shall be included in Contractor's monthly capitation
payment, no later than the second month after the last day of the
Evaluation Period.
H. Contractor may dispute any determination of compliance with
performance incentive standards made by DHS under Section 5.12,
Data Reporting Performance Incentives, by filing a notice of
dispute pursuant to Section 3.xx, Disputes and Appeals. Contractor
shall comply with all provisions of Section 3.xx, Dispute and
Appeals, in disputing any determination of compliance with
performance incentive standards made by DHS pursuant to Section
5.12, Data Reporting Performance Incentives. Contract shall exhaust
all procedures provided for in Section 3.xx, Dispute and Appeals,
prior to initiating any other action to enforce Section 5.12 Data
Reporting Performance Incentives.
I. DHS shall pay interest to Contractor for funds reserved from or
subsequently paid to Contractor, under Section 5.12, Data Reporting
Performance Incentives.
5.12.3 PERFORMANCE INCENTIVE STANDARDS
Contractor shall be eligible for payment of Financial Performance Incentive
payments as set forth in Section 5.12, Data Reporting Performance Incentives,
upon compliance with the following standards:
A. Children Served
1. PM-160 Information Only Data submitted by Contractor, that meets
the requirements in paragraph 3 below, shall demonstrate compliance
with the applicable county rte specified in Table 1 below, for the
applicable Services Reporting Period. Contractor's failure to
achieve the required standard for any Services Reporting Period,
shall not prevent Contractor from receiving payment of the
Financial Performance Incentive payment for such Services Reporting
Period, if in a subsequent Services Reporting Period, within the
same Reporting
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
Year, Contractor achieves the standard required for the subsequent
Services Reporting Period.
Table 1: Required % of Member Children Served to Qualify for Incentive Payments
County By End of Reporting Period 1 By End of Reporting Period 2 By End of Reporting Period 3
==============================================================================================================
Alameda ****8% ****16% ****24%
--------------------------------------------------------------------------------------------------------------
Contra Costa ****7 ****14 ****21
--------------------------------------------------------------------------------------------------------------
Fresno ****8 ****16 ****24
--------------------------------------------------------------------------------------------------------------
Xxxx ****8 ****16 ****24
--------------------------------------------------------------------------------------------------------------
Los Angeles ****8 ****16 ****24
--------------------------------------------------------------------------------------------------------------
Riverside ****6 ****12 ****18
--------------------------------------------------------------------------------------------------------------
San Bernardino ****7 ****14 ****21
--------------------------------------------------------------------------------------------------------------
San Francisco ****7 ****14 ****21
--------------------------------------------------------------------------------------------------------------
San Xxxxxxx ****8 ****16 ****24
--------------------------------------------------------------------------------------------------------------
Santa Xxxxx ****7 ****14 ****21
--------------------------------------------------------------------------------------------------------------
Stanislaus ****6 ****12 ****18
--------------------------------------------------------------------------------------------------------------
Tulare ****6 ****12 ****18
========================================================================================================------
==============================================
County By End of Reporting Period 4
----------------------------------------------
Alameda ****32%
----------------------------------------------
Contra Costa ****28
----------------------------------------------
Fresno ****31
----------------------------------------------
Xxxx ****30
----------------------------------------------
Los Angeles ****30
----------------------------------------------
Riverside ****24
----------------------------------------------
San Bernardino ****27
----------------------------------------------
San Francisco ****26
----------------------------------------------
San Xxxxxxx ****30
----------------------------------------------
Santa Xxxxx ****29
----------------------------------------------
Stanislaus ****25
----------------------------------------------
Tulare ****23
============================================--
----------
**** - Greater than or Equal to
2. Compliance with the Children Services standard shall be based on
the unduplicated count of Member children, who were enrolled in
Contractor's plan for at least one month during the Services
Reporting Period and who were at least four (4) months of age, but
less than six (6) years of age during the month in which a reported
pediatric preventive service encounter occurred. Information may be
reported in hard copy or via computer media claiming, to the extent
such arrangements are available to Contractor. This shall not be
construed as creating any obligation on DHS to make available to
Contractor or condition Contractor performance under this section
on the availability of computer medial claiming submission.
3. DHS' determination as to whether Contractor has achieved the
performance incentive standard for Children Served shall be based
solely on evaluation of PM-160 Information Only Data:
a. Documenting CHDP services rendered to Members with a date of
service during the Services Reporting Period;
b. Submitted to DHS by Contractor no later than the last day of
the Claims Run-Out Period for the Services Reporting Period
under review; and
c. Accepted by DHS' fiscal intermediary for processing.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
4. PM-160 Information Only Data submitted by Contractor during a Claim
Run-Out Period that is rejected by DHS' fiscal intermediary shall
not be included in DHS' evaluation for the purposes of this section
unless it is resubmitted by Contractor and meets the requirements
in paragraph 3 above. However, solely for purposes of evaluation
contractor's eligibility to receive Financial Performance Incentive
payments, PM-160 Information Only Data resubmitted after the end of
the Claims Run-Out Period and accepted for processing by DHS'
fiscal intermediary shall be included in DHS' evaluation for
subsequent Services Reporting Periods within the same Reporting
Year if such data is received by DHS no later than the last day of
the Claims Run-Out Period for the last Services Reporting Period of
the Reporting Year. The provisions of subsection 5.12.3.A.4 apply
only to evaluating Contractor's compliance with the performance
incentive standards and do not relieve Contractor of the obligation
to report CHDP Encounters in compliance with Article VI, Section
6.7.6.2, Children, nor shall this section be construed to limit
DHS' right to imposed all appropriate sanctions for Contractor's
failure to comply with Article VI, Section 6.7.6.2, Children.
5. Thirty-five percent (35%) of the funds reserved by DHS each month,
for each county in which contractor provides services under this
Contract, shall be allocated to the Children Served performance
incentive standard.
6. DHS shall pay Contractor for achieving the performance incentive
standard for Children Serviced based upon the graduated payment
schedule shown in Table 2 below. Each Financial Performance
Incentive payment shall be the sum of all funds reserved by DHS for
the Children Serviced standard for the Services Reporting Period
under review, minus any funds already paid to Contractor for
compliance with the Children Served standard in a previous Services
Reporting Period in the same Reporting Year, multiplied by the
amount of Financial Incentive Payment shown in Table 2 that was
achieved by Contractor for the Children Served performance
incentive standard.
Table 2: PM-160 Payment Criteria for Children Served and
Outpatient and Emergency Department Services Performance Incentive Standards
=========================================================================================
% of Compliance Standard Achieved Amount of Financial Incentive Payment
-----------------------------------------------------------------------------------------
100% 100% of funds reserved for the relevant standard
-----------------------------------------------------------------------------------------
76-99% 75% of funds reserved for the relevant standard
-----------------------------------------------------------------------------------------
51-75% 50% of funds reserved for the relevant standard
-----------------------------------------------------------------------------------------
26-50% 25% of funds reserved for the relevant standard
-----------------------------------------------------------------------------------------
0-25% 0% of funds reserved for the relevant standard
=========================================================================================
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B. Outpatient and Emergency Department Service Encounters
1. For each county in which Contractor operates under this Contract,
Contractor shall demonstrate compliance with the applicable
utilization rate per 1,000 Members specified in Table 3 below, for
each Services Reporting Period, and based upon Contractor's length
of operations. Contractor's failure to achieve the required
standard for any Services Reporting Period, shall not prevent
Contractor from receiving payment of the Financial Performance
Incentive for such Services Reporting Period, if in a subsequent
Services Reporting Period, within the same Reporting Year,
Contractor achieves the standard required for the subsequent
Services Reporting Period.
Table 3: Utilization Rate Per 1,000 Members
================================================================================================================================
Length of Operations Under Two-Plan Model Contract Outpatient and Emergency Department Utilization Rate Per 1,000
Members Required to Qualify for Financial Incentive Payment (based
on an annualized rate of 2,760 encounters per 1,000 members)
--------------------------------------------------------------------------
Services Reporting Period
--------------------------------------------------------------------------------------------------------------------------------
1 2 3 4
--------------------------------------------------------------------------------------------------------------------------------
Less than 12 months ****207/1,000 ****414/1,000 ****621/1,000 ****828/1,000
--------------------------------------------------------------------------------------------------------------------------------
More than 12 months, but less than 24 months ****345/1,000 ****690/1,000 ****1,035/1,000 ****1,380/1,000
--------------------------------------------------------------------------------------------------------------------------------
More than 24 months ****455/1,000 ****910/1,000 ****1,365/1,000 ****1,822/1,000
================================================================================================================================
----------
**** - Greater than or equal to
2. Contractor's length of operations under this Section 5.12, Data
Reporting Performance Incentives, shall be determined based upon
the amount of time Contractor has been providing Covered Services
under this Contract as of the last day of each Services Reporting
Period. However, if Contractor's length of operations category
changes after the last day of the ninth month of the Reporting
Year, DHS shall use the Contractor's previous length of operations
category to evaluate Contractor's compliance with the Outpatient
and Emergency Department Services standard for the entire Reporting
Year.
3. Compliance with the Outpatient and Emergency Department Service
Encounters standard shall be based on the outpatient and emergency
department services Encounters, exclusive of PM-160 Information
Only Data, reported by Contractor to DHS as provided to Members in
each county in which the Contractor operations with a data of
service during the Services Reporting Period. Contractor
performance shall be determined using an unduplicated count of
Members, who were enrolled in Contractor's plan in each county for
at least one month during the Services Reporting Period under
review.
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4. DHS' determination as to whether Contractor has met the standard
for Outpatient and Emergency Department Service Encounters shall be
based solely on evaluation of the Encounter data, exclusive of
PM-160 Information Only Data, for outpatient and emergency
department services, as described in HEDIS 3.0, Ambulatory Care,
rendered to Members with a data of service during the Services
Reporting Period under review, and that Contractor has submitted to
DHS no later than the last day of the Claim Run-Out Period for the
Services Reporting Period under review and has been accepted for
processing by DHS' fiscal intermediary. Encounter data submitted by
Contractor during a Claim Run-Out Period that is rejected by DHS'
fiscal intermediary shall not be included in DHS' evaluation for
the purposes of this section unless it is resubmitted no later than
the last day of the Claim Run-Out Period and accepted for
processing by DHS' fiscal intermediary. However, solely for the
purposes of evaluating Contractor's eligibility to receive
financial Performance Incentive payments, non-PM 160 Encounter data
submitted or resubmitted after the end of the claims Run-Out Period
and accepted for processing DHS' fiscal intermediary shall be
included in DHS' evaluation for subsequent Services Reporting
Periods within the same Reporting Year if such data is received by
DHS no later than the last day of the claim Run-Out Period for the
last Services Reporting Period of the reporting Year. The
provisions of this subsection 5.12.3.B.4 apply only to evaluating
Contractor's compliance with the Outpatient and Emergency
Department Services Encounters performance incentive standard and
do not relieve Contractor of the obligation to report Encounter
data in compliance with Article VI, Section 6.4, Management
Information System.
5. Thirty-five percent (35%) of the total funds reserved by DHS for
each month shall be allocated to the Outpatient and Emergency
Department Service Encounters performance incentive standard.
6. DHS shall pay Contractor for achieving the performance incentive
standard for Outpatient and Emergency Department Service Encounters
according to the graduated payment schedule provided in Table 2 of
Section 5.12.3, Performance Incentive Standards, paragraph A.5.
Each Financial Performance Incentive payment shall be the sum of
all funds reserved by DHS for the Outpatient and Emergency
Department Encounter standard for the Services Reporting Period
under review, less any funds already paid to Contractor for
compliance with the Outpatient and Emergency Department Service
Encounter standard in a previous Services Reporting Period in the
same Reporting Year, multiplied by the amount of Financial
Incentive Payment shown in able 3 that was achieved by Contractor
for the Outpatient and Emergency Department Service Encounter
performance incentive standard.
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C. Timeliness of Data Reporting
1. Timeliness of PM-160 Information Only Data Reporting: To receive a
Financial Performance Incentive payment for Timeliness of PM-160
Information Only Data reporting, for any Timeliness Reporting
Period, Contractor shall meet or exceed:
a. Seventy-five period (75%) of the applicable standard for
Children Served for the Timeliness Reporting Period under
review, and
b. Seventy-five percent (75%) of all PM-160 Information Only
Data submitted by Contractor during the Timeliness Reporting
Period under review, shall be submitted within thirty (30)
days of the end of the month in which the PM-160 Encounter
occurred, in accordance with Article VI, Section 6.7.6.2,
Children, subsection H, and accepted for processing by DHS'
fiscal intermediary no later than the last day of the
Timeliness Reporting Period. PM-160 Information Only Data
originally submitted during the Timeliness Reporting
Period under review, but rejected for processing by DHS'
fiscal intermediary, resubmitted after the Timeliness
Reporting Period under review and accepted by DHS' fiscal
intermediary no later than the last day of the subsequent
Timeliness Reporting Period shall be included in DHS'
evaluation for the subsequent Timeliness Reporting Period.
Notwithstanding the above, only PM-160 Information Only Data
received by DHS and accepted for processing by DHS' fiscal
intermediary no later than June 30 of the Reporting Year
under review shall be considered for Contractor's compliance
with the Timeliness of PM-160 Information Only Data
Reporting standard for that Reporting Year.
2. Timeliness of Encounter Data Reporting: To receive a Financial
Performance Incentive payment for timeliness of Encounter data
reporting, for any Timeliness Reporting Period, Contractor shall
meet or exceed:
a. Seventy-five percent (75%) of the applicable standard for
Outpatient and Emergency Department Service Encounters for
the Timeliness Reporting Period under review; and
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
b. Seventy percent (70%) of all Encounter Records submitted by
Contractor during the Timeliness Reporting Period under
review, shall be submitted within ninety (90) days of the
end of the month in which the Encounter occurred, and
accepted for processing by DHS' fiscal intermediary and DHS
no later than the last day of the Timeliness Reporting
Period. Encounter Records originally submitted to DHS during
the Timeliness Reporting Period under review, but rejected
for processing by DHS' fiscal intermediary or DHS,
resubmitted after the Timeliness Reporting Period under
review and accepted for processing by DHS' fiscal
intermediary and DHS no later than the last day of the
subsequent Timeliness Reporting Period shall be included
in DHS' evaluation for the subsequent Timeliness Reporting
Period. Notwithstanding the above, only Encounter Records
received by DHS and accepted for processing by DHS' fiscal
intermediary and DHS no later than June 30 of the Reporting
Year under review shall be considered for Contractor's
compliance with the Timeliness of Encounter Data Reporting
standard for that Reporting Year.
3. Fifteen percent (15%) of the total funds reserved by DHS for each
month shall be allocated to the Timeliness of PM-160 Information
Only Data Reporting standard, and fifteen percent (15%) of the
total funds reserved by DHS for each month shall be allocated to
the Timeliness of Encounter Data reporting standard.
4. Each Financial Performance Incentive payment shall be the sum of
all funds reserved by DHS for the Timeliness of PM-160 Information
Only Data Reporting standard for the Timeliness Reporting Period
under review, less any funds already paid to Contractor for
compliance with such Timeliness standard in a previous Timeliness
Reporting Period in the same Reporting Year.
5. Each Financial Performance Incentive payment shall be the sum of
all funds reserved by DHS for the Timeliness of Encounter Data
Reporting standard for the Timeliness Reporting Period under
review, less any funds already paid to Contractor for compliance
with such Timeliness standard in a previous Timeliness Reporting
Period in the same Reporting Year.
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86. Article V, PAYMENT PROVISIONS is amended by adding a new Section 5.13,
FQHC/RHC Risk Corridor Payments, to read:
5.13 FQHC/RHC RISK CORRIDOR PAYMENTS
Beginning October 1, 1997 and through September 30, 2000, provided that
Contractor annually submits, within four months after the last day of
each fiscal year, required expenditure data to DHS in the form and
manner specified by DHS, DHS shall perform reconciliations to determine
the variance between the funds that have been paid to Contractor in its
capitation rates to reflect the dollar value of FQHC and RHC interim
rate payments made to these entities in the Medi-Cal FFS program and the
amount that Contractor has paid to subcontracting FQHCs and RHCs.
For each annual reconciliation, if, pursuant to subcontracts with FQHCs
and RHCs that have been reviewed and approved in writing by DHS,
Contractor has paid subcontracting FQHCs and RHCs in the aggregate an
amount greater than 110 percent of the dollar value of FQHC and RHC
interim rate payments included in Contractor's capitation rates, DHS
shall pay Contractor the amount in excess of 110 percent.
For each annual reconciliation, if, pursuant to subcontracts with FQHCs
and RHCs that have been reviewed and approved in writing by DHS,
Contractor has paid subcontracting FQHCs and RHCs in the aggregate an
amount less than 90 percent of the dollar value of FQHC and RHC interim
rate payments included in Contractor's capitation rates, Contractor
shall refund the amount below 90 percent to DHS. DHS may recover amounts
owed by Contractor pursuant to this section through an offset to the
capitation payments made to Contractor, pursuant to Section 5.11(C),
Recovery of Capitation Payments.
All reconciliations shall be subject to an annual reconciliation audit
at which time payments to or recoupments from Contractor shall be
finalized.
87. Article V, PAYMENT PROVISIONS, is amended by adding a new Section 5.14,
Payment of AIDS Beneficiary Rates, to read:
5.14 PAYMENT OF AIDS BENEFICIARY RATES
Subject to Contractor's compliance with the requirements contained in
subsection A below, Contractor shall be eligible to receive compensation
at the AIDS Beneficiary Rate (ABR) for AIDS Beneficiaries. Compensation
to Contractor at the ABR for each AIDS Beneficiary shall consist of
payment at the ABR less the capitation rate initially paid for the AIDS
beneficiary.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
A. Compensation at the ABR shall be subject to the conditions listed
below. Contractor's failure to comply with any of the conditions
listed below for any request for compensation at the ABR on behalf
of an individual AIDS Beneficiary for a specific month of
Enrollment shall result in DHS' denial of Contractor's claim for
compensation at the ABR for that individual AIDS Beneficiary for
that specific month of Enrollment. Contractor may submit a
corrected claim, within the timeframes specified in paragraph 4
below, that complies with all the conditions listed below and DHS
shall reimburse Contractor at the ABR.
1. The ABR shall be in lieu of any other compensation for an
AIDS Beneficiary in any month.
2. For AIDS Beneficiaries, Contractor shall be eligible to
receive compensation at the ABR commencing in the month in
which a Diagnosis of AIDS is made and recorded, dated and
signed by the treating physician in the AIDS Beneficiary's
Medical Record.
3. Contractor shall submit an invoice to DHS by the 25th day of
each month for claims for compensation at the ABR for AIDS
Beneficiaries. The invoice shall include the following:
a. A list of all AIDS Beneficiaries identified by
Medi-Cal numbers only for whom Contractor is
claiming compensation at the ABR Member names shall
not be used.
b. The month(s) and year(s) for which compensation at
the ABR is being claimed for each AIDS Beneficiary
listed, sorted by month and year of service.
c. The capitation rate initially paid for the AIDS
Beneficiary for each month being claimed by
Contractor, the ABR being claimed, and the
difference between the ABR and the capitation rate
initially paid for the AIDS Beneficiary.
d. The total amount being claimed on the invoice.
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4. Invoices, containing originally submitted claims or
corrected claims, for compensation at the ABR for any month
of eligibility during the rate year beginning October 1,
1997 and ending September 30, 1998, or any rate year
thereafter beginning October 1 and ending September 30, must
be submitted by Contractor to DHS no later than six (6)
months following the end of the subject rate year.
B. Contractor shall confirm Medi-Cal eligibility of AIDS Beneficiaries
prior to submission of the monthly invoice to DHS. DHS may verify
the Medi-Cal eligibility of each Member for whom the ABR is claimed
and adjust the invoiced amounts to reflect any capitation payments
which have been previously made to Contractor for each Member prior
to submission of the invoice required under subsection A(3).
C. If DHS determines that a Member for whom compensation has been paid
at the ABR did not meet the definition of an AIDS Beneficiary, in a
month for which the ABR was paid, DHS shall recover any amount
improperly paid, by an offset to Contractor's capitation payment,
in accordance with Section 5.11(C), Recovery of Capitation
Payments. DHS shall give Contractor thirty (30) days prior written
notice of any such offset.
88. Article VI, SCOPE OF WORK, Section 6.2.5, Administrative
Duties/Responsibilities, subsection (B), is amended to read:
B. Member and Enrollment reporting systems as specified in Section
6.4, Management Information Systems (MIS), and Section 6.9, Member
Services/Grievance Systems.
89. Article VI, SCOPE OF WORK, Section 6.3.1, Financial Viability/Standards
Compliance, is amended to read:
6.3.1 FINANCIAL VIABILITY/STANDARDS COMPLIANCE
Contractor shall demonstrate financial viability/standards compliance to
DHS' satisfaction for each of the following elements:
A. Tangible Net Equity (TNE).
Contractor at all times shall be in compliance with the TNE
requirements in accordance with Title 10, CCR, Section 1300.76.
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XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
B. Administrative Costs.
Contractor's Administrative Costs shall not exceed the guidelines
as established under Title 10, CCR, Section 1300.78.
C. Standards of Organization and Financial Soundness.
Contractor shall maintain an organizational structure sufficient to
conduct the proposed operations and ensure that its financial
resources are sufficient for sound business operations in
accordance with Title 10, CCR, Sections 1300.67.3, 1300.75.1,
1300.76, 1300.76.3, 1300.77.1, 1300.77.2, 1300.77.3, 1300.77.4,
1300.78, and Title 22, CCR, Sections 53851, 53863, and 53864.
D. Working capital and current ratio of one of the following:
1. Contractor shall maintain a working capital ratio of at
least 1:1; or
2. Contractor shall demonstrate to DHS that Contractor is now
meeting financial obligations on a timely basis and has been
doing so for at least the preceding two years; or
3. Contractor shall provide evidence that sufficient noncurrent
assets, which are readily convertible to cash, are available
to achieve an equivalent working capital ratio of 1:1, if
the noncurrent assets are considered current.
90. Article VI, SCOPE OF WORK, Section 6.3.2, Financial Audit/Reports, is
amended to read:
6.3.2 FINANCIAL AUDIT/REPORTS
Contractor shall ensure that an annual audit is performed according to
Section 14459, W&I Code. Combined Financial Statements shall be prepared
to show the financial position of the overall related health care
delivery system when delivery of care or other services is dependent
upon Affiliates. Financial Statements shall be presented in a form that
clearly shows the financial position of Contractor separately from the
combined totals. Inter-entity transactions and profits shall be
eliminated if combined statements are prepared. Contractor shall have
separate certified Financial Statements prepared if an independent
accountant decides that preparation of combined statements is
inappropriate.
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A. The independent accountant shall state in writing reasons for not
preparing combined Financial Statements.
B. Contractor shall provide supplemental schedules that clearly
reflect all inter-entity transactions and eliminations necessary to
enable DHS to analyze the overall financial status of the entire
health care delivery system.
1. In addition to annual certified Financial Statements
Contractor shall complete the entire 1989 HMO Financial
Report of Affairs and Conditions Format, commonly known as
the "Orange Blank". The Certified Public Accountant's (CPA)
audited Financial Statements and the "Orange Blank" report
shall be submitted to DHS no later than 120 calendar days
after the close of Contractor's Fiscal Year.
2. Contractor shall submit to DHS within forty-five (45)
calendar days after the close of Contractor's fiscal quarter
financial reports required by Title 22, CCR, Section
53862(b)(l). The required quarterly financial reports shall
be prepared on the "Orange Blank" format and shall include,
at a minimum, the following reports/schedules:
a. Jurat.
b. Report 1A and 1B: Balance Sheet.
c. Report 2: Statement of Revenue, Expenses, and Net
Worth.
d. Statement of Cash Flow, prepared in accordance with
Financial Accounting Standards Board Statement
Number 95 (This statement is prepared in lieu of
Report #3: Statement of Changes in Financial
Position for Generally Accepted Accounting
Principles (GAAP) compliance.)
e. Report 4: Enrollment and Utilization Table.
f. Schedule F: Unpaid Claims Analysis.
g. Appropriate footnote disclosures in accordance with
GAAP.
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C. Contractor shall authorize the independent accountant to
allow representatives of DHS, upon written request, to
inspect any and all working papers related to the
preparation of the audit report.
D. Contractor shall submit to DHS all financial reports
relevant to Affiliates as specified in Title 22, CCR,
Section 53862(c)(4).
E. Contractor shall submit to DHS copies of any financial
reports submitted to other public or private organizations
as specified in Title 22, CCR, Section 53862(c)(5).
91. Article VI, SCOPE OF WORK, is amended by adding a new Section 6.3.6,
Submittal of FQHC and RHC Payment Information, to read:
6.3.6 SUBMITTAL OF FQHC AND RHC PAYMENT INFORMATION
Effective with the October 1997 month of service, Contractor shall keep
a record of the number of visits by plan Members to each FQHC and RHC
contracting with Contractor and related payment information, and shall
submit this information to DHS in the frequency, format, and manner
specified by DHS. This requirement shall remain in effect through the
September 1999 month of service.
92. Article VI, SCOPE OF WORK, is amended by adding a new Section 6.3.7,
Submittal of Inpatient Days Information, to read:
6.3.7 SUBMITTAL OF INPATIENT DAYS INFORMATION
Upon DHS' written request, Contractor shall report inpatient days to DHS
as required by W&I Code, Section 14105.985(b)(2) for the time period and
in the form and manner specified in DHS' request, within thirty (30)
days of receipt of the request. Contractor shall submit additional
reports to DHS, as requested, for the administration of the
Disproportionate Share Hospital program.
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93. Article VI, SCOPE OF WORK, Section 6.4, Management Information System,
is amended to read:
6.4.1 MANAGEMENT INFORMATION SYSTEM (MIS) CAPABILITY
Contractor shall have and maintain an MIS that provides, at a minimum:
A. All Medi-Cal eligibility data,
B. Members enrolled in Contractor's plan,
C. Provider claims status and payment data,
D. Encounter-level health care services delivery data,
E. Provider network information, and
F. Financial information as specified in Section 6.2.5(E),
Administrative Duties/Responsibilities.
6.4.2 ENCOUNTER DATA SUBMITTAL
Contractor shall implement policies and procedures for ensuring the
complete, accurate, and timely submission of Encounter-level data for
all services for which Contractor has incurred any financial liability,
whether directly or through Subcontracts or other arrangements. As a
condition of payment, Contractor may require subcontractors and
out-of-plan providers to provide Encounter-level data to Contractor that
meets the same standards required for Contractor to comply with this
section. Contractor shall submit
Encounter-level data to DHS on a monthly basis, no later than ninety
(90) days following the end of the reporting month in which the
Encounter occurred, in the form and manner specified in DHS' most recent
Managed Care Data Element Dictionary. Encounter-level data received and
processed by Contractor too late to be submitted timely, shall be
submitted to DHS with the next monthly submission. Encounter-level data
shall include data elements specified in DHS' most recent Managed Care
Data Element Dictionary.
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6.4.3 MIS/DATA CORRESPONDENCE
Contractor shall ensure, that upon written notice by DHS of any problems
related to the submittal of data or any changes or clarifications
related to Contractor's MIS system, that Contractor shall submit to DHS
a Corrective Action Plan with measurable benchmarks within thirty (30)
calendar days from the date of the postmark of DHS' written notice to
Contractor. Within thirty (30) days of DHS' receipt of Contractor's
Corrective Action Plan, DHS shall approve the Corrective Action Plan or
request revisions. Within fifteen (15) days after receipt of a request
for revisions to the Corrective Action Plan, Contractor shall submit a
revised Corrective Action Plan for DHS approval.
6.4.4 TIMELY, COMPLETE AND ACCURATE DATA SUBMISSION
Contractor shall ensure that the Encounter-level data submitted to DHS
are complete, accurate, and timely and in compliance with the
requirements of DHS' most recent Managed Care Data Element Dictionary.
Upon written notice by DHS that Encounter-level data is insufficient or
inaccurate, Contractor shall ensure that corrected data is resubmitted
within fifteen (15) days of receipt of DHS' notice. Upon Contractor's
written request, DHS may provide a written extension of the time to
resubmit corrected Encounter-level data.
94. Article VI, SCOPE OF WORK, Section 6.5.3.3, Standards and Guidelines,
subsection A, is amended to read:
A. Pediatric:
Periodic health screen schedule based on the most recent
recommendations of the American Academy of Pediatrics (AAP).
Immunization schedule based on recommendations of either the
Advisory Committee on Immunization Practices or the AAP shall be
acceptable.
95. Article VI, SCOPE OF WORK, Section 6.5.3.4, Quality Indicators, is
amended to read:
6.5.3.4 QUALITY INDICATORS
To the extent feasible and appropriate, Contractor shall use the most
recent HEDIS indicators for the required Quality of Care studies
indicated in Section 6.5.3.2, Quality of Care Studies. The HEDIS
indicators selected for use by Contractor shall be approved by DHS.
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96. Article VI, SCOPE OF WORK, Section 6.5.5.2, Facility Review Procedures,
subsection O, is amended to read:
6.5.5.2 REVIEW PROCEDURES
O. Informed consent procedures.
97. Article VI, SCOPE OF WORK, Section 6.5.5.3, Number of Sites to be
Reviewed Prior to Operations, is amended to read:
6.5.5.3 NUMBER OF SITES TO BE REVIEWED PRIOR TO OPERATIONS
Contractor shall ensure that Facility reviews are completed on thirty
(30) sites or a five (5) percent sample of the total number of Primary
Care sites, whichever is less, prior to initiating plan operation or new
site expansion. Contractors with 30 sites or less, or who are expanding
by 30 sites or less, shall complete Facility reviews on all sites prior
to initiating operation. A Contractor with NCQA accreditation is
exempted from this requirement.
Contractor shall submit the results of pre-operational and expansion
site reviews to DHS at least six (6) weeks prior to plan or site
operation. For pre-operational site reviews, Contractor shall submit the
Primary Care Facility Identification form, the facility checklist, and
any corrective actions and follow-up. For expansion site reviews,
Contractor shall submit an aggregate report of the review results
without the Primary Care Facility Identification form or facility
checklist.
98. Article VI, SCOPE OF WORK, Section 6.5.5.5, DHS Facility Inspections, is
amended to read:
6.5.5.5 FACILITY INSPECTIONS
Contractor shall provide any necessary assistance to DHS in its conduct
of Facility inspections and medical reviews of the Quality of Care being
provided to Members. Contractor shall ensure correction of deficiencies
as identified by those inspections and reviews according to the
timeframes delineated by DHS in the resulting reports.
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99. Article VI, SCOPE OF WORK, Section 6.5.5.6, Corrective Actions, is
amended to read:
6.5.5.6 CORRECTIVE ACTIONS
Contractor shall ensure that Primary Care sites with major, uncorrected
deficiencies are not allowed to begin operation. In the event a Primary
Care site develops such deficiencies subsequent to the commencement of
operations, Contractor shall require such site to cease providing
services to Members; provided that such site may not be required to
cease providing services in the event DHS and Contractor agree to a plan
of corrective action to be implemented by the site, and such plan is
being implemented to the satisfaction of DHS.
100. Article VI, SCOPE OF WORK, Section 6.5.6.5, Member's Right to
Confidentiality, subsection (B), is amended to read:
B. Contractor shall counsel Members on their right to confidentiality
and Contractor shall obtain Member's consent prior to release of
confidential information, unless such consent is not required
pursuant to Title 22, CCR, Section 51009.
101. Article VI, SCOPE OF WORK, Section 6.5.7.8, Sensitive Services,
paragraph one, is amended to read:
Contractor shall implement and maintain procedures to ensure
confidentiality and ready access to Sensitive Services for all Members,
including minors. Members shall be able to access Sensitive Services in
a timely manner and without barriers such as Prior Authorization
requirements. Access to abortion services for Members who are minors
shall be subject to applicable state and federal law.
102. Article VI, SCOPE OF WORK, Section 6.5.8.4, Member Medical Record,
sentence one, is amended to read:
Contractor shall ensure that a complete Medical Record shall be
maintained for each Member in accordance with Title 22, CCR, Section
53861, and it shall reflect all aspects of patient care, including
ancillary services, and at a minimum shall include:
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103. Article VI, SCOPE OF WORK, is amended by adding a new Section 6.5.10.7,
Targeted Case Management Services, to read as follows:
6.5.10.7 TARGETED CASE MANAGEMENT SERVICES
If a Member is receiving targeted case management services as defined in
Title 22, CCR, Section 51185(h) and as specified in Title 22, CCR,
Section 51351, Contractor shall be responsible for coordinating the
Member's health care with the targeted case management provider and for
determining the medical necessity of diagnostic and treatment services
recommended by the targeted case management provider that are Covered
Services under the Contract.
104. Article VI, SCOPE OF WORK, Section 6.6.6, Provider to Member Ratios, is
amended to read:
6.6.6 PROVIDER TO MEMBER RATIOS
A. Contractor shall ensure that networks continuously satisfy the
following full time equivalent provider to Member ratios:
1. Primary Care Physicians 1:2,000
2. Total Physicians 1:1,200
B. If Non-Physician Medical Practitioners are included in Contractor's
provider network, each individual Non-Physician Medical
Practitioner shall not exceed a full-time equivalent
provider/patient caseload of one provider per 1,000 patients.
105. Article VI, SCOPE OF WORK, Section 6.6.7, Physician Supervisor to
Non-Physician Medical Practitioner Ratios, subsection (D), is amended to
read:
D. Four (4) Non-Physician Medical Practitioners in any combination
that does not include more than three nurse midwives or two
physician assistants.
106. Article VI, SCOPE OF WORK, Section 6.6.8, Subcontracts, is amended to
read:
6.6.8 SUBCONTRACTS
Contractor shall execute Subcontracts pursuant to the requirements
contained in Article III, Section 3.28, Subcontracts and Title 22, CCR,
Section 53867.
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107. Article VI, SCOPE OF WORK, Section 6.6.13, Monthly Report, is amended to
read:
6.6.13 QUARTERLY REPORT
Contractor shall submit to DHS on a quarterly basis, in a format
specified by DHS, a report summarizing changes in the provider network.
The report shall identify provider deletions and additions and the
resulting impact to: 1) geographic access for the Members; 2) cultural
and linguistic services; 3) the targeted percentage of traditional and
safety-net providers; 4) the ethnic composition of providers; and 5) the
number of Members assigned to Primary Care Physicians and the percentage
of Members assigned to traditional and safety-net providers. Contractor
shall submit the report thirty (30) days following the end of the
reporting quarter.
108. Article VI, SCOPE OF WORK, Section 6.6.14, Contract and Employment
Terminations, is amended to read:
6.6.14 CONTRACT AND EMPLOYMENT TERMINATIONS
Contractor shall ensure that the composition of Contractor's provider
network meets the ethnic, cultural, and linguistic needs of Contractor's
Members on a continuous basis.
109. Article VI, SCOPE OF WORK, Section 6.6.15, Utilization of DSH Hospitals,
is amended to read:
6.6.15 UTILIZATION OF DSH HOSPITALS
Contractor shall increase Utilization of Disproportionate Share
Hospitals (DSH) by Members to a level specified by DHS upon
notification. DHS shall only impose this requirement if the Utilization
of DSH has decreased in such magnitude as to jeopardize DSH supplemental
payments in the county.
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110. Article VI, SCOPE OF WORK, Section 6.6.17, Emergency Service Providers,
is amended to read:
6.6.17 EMERGENCY SERVICE PROVIDERS
A. Contractor shall pay for Emergency Services received by a Member
from non-Contractor providers. Payments to non-Contractor
providers shall be for the treatment of the Emergency Medical
Condition including Medically Necessary services rendered to a
Member until the Member's condition has stabilized sufficiently to
permit discharge, or referral and transfer in accordance with
instructions from Contractor. Emergency Services shall not be
subject to Prior Authorization by Contractor.
B. Contractor shall pay for those services provided by a
non-Contractor emergency department (ED) that are required to
determine whether treatment of the Member's condition qualifies as
an Emergency Service, including, at a minimum, a medical screening
examination to determine the presence or absence of an Emergency
Medical Condition. At a minimum, Contractor must reimburse the
non-Contractor ED and, if applicable, its affiliated providers for
Physician services at the lowest level of evaluation and management
CPT (Physician's Current Procedural Terminology) codes, unless a
higher level is clearly supported by documentation, and for the
Facility fee and diagnostic services such as laboratory and
radiology.
C. Payment by Contractor, or by a subcontractor who is at risk for
out-of-plan Emergency Services, for properly documented claims for
services rendered by a non-Contractor provider pursuant to this
section shall be made in accordance with Article III, Section
3.28.9, Payment, and shall not exceed the lower of the following
rates applicable at the time the services were rendered by the
provider:
1. The usual charges made to the general public by the
provider.
2. The maximum Fee-For-Service rates for similar services under
the Medi-Cal program.
3. The rate agreed to by Contractor and the provider.
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D. For inpatient services, reimbursement by Contractor, or by a
subcontractor that is at risk for out-of-plan Emergency Services,
to an out-of-plan Emergency Services provider shall be the lower of
the following rates applicable to the provider at the time the
services were rendered by the provider:
1. For a provider not contracting with the State under the
Selected Provider Contracting Program, the lower of:
a. The Medi-Cal Fee-For-Service rate that would be
received by the provider if the service were
provided for a beneficiary under the Medi-Cal
Fee-For-Service program; or
b. The inpatient rate negotiated by Contractor or
subcontractor with the provider.
2. For a provider contracting with the State under the Selected
Provider Contracting Program, the lower of:
a. The average California Medical Assistance Commission
(CMAC) rate for the geographic region, referred to
as Standard Consolidated Statistical Area, in which
the provider is located, for the last year reported,
as published in the most recent CMAC Annual Report
to the Legislature; or
b. The inpatient rate negotiated by Contractor or
subcontractor with the provider.
E. Disputed Emergency Services claims may be submitted to DHS for
resolution under the provisions of Section 14454, W&I Code and
Title 22, CCR, Section 53875. Contractor agrees to abide by the
findings of DHS in such cases, to promptly reimburse the
non-Contractor provider within 30 days of the effective date of a
decision that Contractor is liable for payment of a claim and to
provide proof of reimbursement in such form as the Director may
require. Failure to reimburse the non-Contractor provider and
provide proof of reimbursement to DHS within 30 days shall result
in liability offsets in accordance with Title 22, CCR, Section
53875.
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111. Article VI, SCOPE OF WORK, Section 6.6.20, FQHC Services, paragraph one,
is amended to read as follows:
6.6.20 FQHC SERVICES
Contractor shall meet federal requirements for access and reimbursement
for FQHC services, including those in 00 Xxxxxx Xxxxxx Code Section 1396
b(m) and Medicaid Regional Memorandum 93-13. If FQHC services are not
available in the provider network of either Medi-Cal managed care
contractor in the county, Contractor shall reimburse FQHCs for services
provided out-of-plan to Contractor's Members at the interim FQHC rate
determined by DHS. If FQHC services are not available in Contractor's
provider network, but are available within DHS' time and distance
standards for access to Primary Care for Contractor's Members in the
other Medi-Cal managed care contractor's provider network in the county,
Contractor shall not be obligated to reimburse FQHCs for services
provided out-of-plan to Members (unless authorized by Contractor).
112. Article VI, SCOPE OF WORK, Section 6.6.21, FQHC Subcontracts is amended
to read:
6.6.21 FQHC AND RURAL HEALTH CLINICS (RHC) CONTRACTS
A. Notwithstanding Article III, Section 3.28.4, Department Approval -
Federally Qualified HMOs, Contractor shall not enter into any
contract with an FQHC or RHC for provision of Covered Services to
Members without prior written approval by DHS. All contracts with
FQHCs or RHCs shall provide reimbursement to the FQHC or RHC on the
basis of each center's or clinic's Medi-Cal interim per visit rate,
applicable on the date the reimbursable services were provided, as
established by DHS, unless:
1. DHS has approved in writing an alternate reimbursement
methodology; or
2. The FQHC or RHC agrees to be reimbursed on an at-risk basis
and such agreement is contained in the contract with the
center or clinic. In contracts where a negotiated rate is
agreed to as total payment, the contract shall state that
such payment constitutes total payment to the entity.
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B. To the extent that Indian Health Service facilities qualify as
FQHCs or RHCs, the same reimbursement requirements shall apply to
contracts with Indian Health Service facilities.
113. Article VI, SCOPE OF WORK, Section 6.6.22, Indian Health Service
Facilities, is amended to read:
6.6.22 INDIAN HEALTH SERVICES FACILITIES
Contractor shall reimburse out-of-plan Indian Health Service Facilities
for services provided to Members who are qualified to receive services
from an Indian Health Service Facility. Contractor shall reimburse the
out-of-plan Indian Health Service Facility at the approved Medi-Cal rate
for that Facility.
The contract requirements in Section 6.6.21, FQHC and Rural Health
Clinic Contracts, shall apply to any Indian Health Service Facility
which is also an FQHC or RHC.
114. Article VI, SCOPE OF WORK, Section 6.7.1.1, General Requirements, is
amended to read:
6.7.1.1 GENERAL REQUIREMENTS
Contractor shall provide or arrange for all Medically Necessary Covered
Services for Members. Covered Services are those services set forth in
Title 22, CCR, Chapter 3, Article 4, beginning with Section 51301, and
Title 17, CCR, Division 1, Chapter 4, Subchapter 13, beginning with
Section 6840, unless otherwise specifically excluded under the terms of
this Contract. Contractor shall ensure that the medical necessity of
Covered Services is determined through Utilization control procedures
established in accordance with Sections 6.5.9.3,
Pre-Authorization/Review Procedures, and 6.5.9.4, Exceptions to Prior
Authorization Requirement, unless specific Utilization control
requirements are included as terms of the Contract under sections
applicable to specific services. However, no Utilization control
procedure, or any other policy or procedure used by Contractor, shall
limit services Contractor is required to provide under this Contract.
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115. Article VI, SCOPE OF SERVICES, Section 6.7.2.2, Waiver Programs, is
amended to read:
6.7.2.2 WAIVER PROGRAMS
Contractor shall maintain systems for identifying and referring Members
to the appropriate waiver program, including the In-Home Medical Care
Waiver Program, the Skilled Nursing Facility Waiver Program, the Model
Waiver Program, the Acquired Immune Deficiency (AIDS) and AIDS Related
Conditions Waiver Program, and the Multipurpose Senior Services Waiver
Program. If the agency administering the waiver program concurs with
Contractor's assessment of the Member and there is available placement
in the waiver program, Contractor shall initiate Disenrollment for the
Member. Contractor shall provide documentation to ensure the Member's
orderly transfer to the Medi-Cal Fee-For-Service program. If the Member
does not meet the criteria for the waiver program, or if placement is
not available, Contractor shall continue to case manage and provide all
Medically Necessary Covered Sservices to the Member.
116. Article VI, SCOPE OF WORK, Section 6.7.3.1, Miscellaneous Service Carve
Outs, is amended to read:
6.7.3.1 MISCELLANEOUS SERVICE CARVE OUTS
Acupuncture services, adult day health care services, chiropractic
services, and healing by prayer or spiritual means are not Covered
Services under this Contract. Contractor may, upon request, refer
Members to these services.
Local Education Agency (LEA) assessment services provided to any student
and any LEA services provided pursuant to an Individual Education Plan
(IEP) or Individual Family Service Plan (IFSP) or Individualized Health
and Support Plan (IHSP) are not covered under the Contract.
Childhood lead poisoning case management is not a Covered Service under
this Contract. Laboratories subcontracting with Contractor shall refer
Members with elevated blood lead levels to the Childhood Lead Poisoning
Prevention Branch of DHS which, in turn, shall provide this information
to the Local Health Department. The Local Health Department shall
coordinate case information and care with the Primary Care Physician.
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117. Article VI, SCOPE OF WORK, Section 6.7.3.2, CCS Services, is amended to
read:
6.7.3.2 CALIFORNIA CHILDREN SERVICES (CCS)
A. Contractor shall develop and implement written policies and
procedures for identifying and referring children with CCS-eligible
conditions to the local CCS program. The policies and procedures
shall include, but not be limited to:
1. Policies and operational controls that assure that
Contractor's providers perform appropriate baseline health
assessments and diagnostic evaluations that provide
sufficient clinical detail to establish, or raise a
reasonable suspicion, that a Member child has a CCS-eligible
medical condition;
2. Procedures for assuring that Contracting Providers are
informed about CCS-paneled providers and CCS-approved
hospitals within Contractor's network; and
3. Procedures for initial referrals of Member children with
CCS-eligible conditions to the local CCS program by
telephone, same-day mail or FAX, if available. The initial
referral shall be followed by submission of supporting
medical documentation sufficient to allow for eligibility
determination by the local CCS program.
4. Procedures that provide for continuity of care between
Contractor's providers and CCS providers for Member children
determined eligible for the CCS program.
B. Contractor shall consult and coordinate CCS referral activities
with the local CCS program in accordance with the agreement reached
under a Memorandum of Agreement (MOA) between Contractor and LHD
for coordination of CCS services.
C. Contractor shall continue to provide all Medically Necessary
Covered Services and case management services for Member children
referred to CCS until eligibility for the CCS program is
established. Eligibility for the CCS program includes confirmation
by the local CCS program of a Member child's CCS-eligible condition
and agreement by the local CCS program to assume case management
responsibilities for the Member child.
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D. Once eligibility for the CCS program is established for a Member
child:
1. Contractor shall continue to provide Primary Care and other
Medically Necessary Covered Services unrelated to the
CCS-eligible condition and will ensure the coordination of
services between its Primary Care providers, the CCS
specialty providers, and the local CCS program.
2. The CCS program shall authorize Medi-Cal payments to
Contractor network physicians who currently are members of
the CCS panel and to other providers who provided
CCS-covered services to the Member child during the
CCS-eligibility determination period and are determined to
meet the CCS standards in accordance with subsection E.
Authorization for payment shall be retroactive to the date
the CCS program was informed about the Member child through
an initial referral by Contractor or a Contractor network
physician, via telephone, FAX, or mail. In an emergency
admission, Contractor or Contractor network physician shall
be allowed until the next business day to inform the CCS
program about the Member child. Authorization shall be
issued upon confirmation of panel status or completion of
the process described in subsection E. Payment shall be
dependent on the submittal of appropriately completed and
timely claims to the local CCS program, which authorizes
care. Claims authorized by the local CCS program shall be
forwarded to the Medi-Cal Fee-For-Service program fiscal
intermediary for payment.
E A board-certified physician who is a member of Contractor's
provider network shall be determined to meet the CCS standards for
participation as a CCS provider and shall be added to the CCS panel
when all the following conditions are met:
1. The physician has successfully met Contractor's
Credentialing standards;
2. The physician meets the CCS certification standards in
accordance with Title 22, CCR, Sections 42320, 42321, 42336;
3. Contractor has submitted to the CCS program either a
completed provider Credentialing application form used by
Contractor or the information continued in lines one through
five of the CCS Panel Application Form, extracted from
Contractor's provider Credentialing application form for the
physician;
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4. Contractor has submitted to the CCS program a signed and
dated CCS Panel Application Form with the Medi-Cal provider
number for the physician.
For a physician who is board-eligible at the time of completion of
Contractor's Credentialing application, Contractor must submit a
completed provider Credentialing application form and a signed and dated
CCS Panel Application Form, including the provider's Medi-Cal number.
The application of such a physician to the CCS panel will be retroactive
to the extent necessary to enable the physician to receive payment for
services on or after the date the CCS program was informed about the
Member child, as provided in subsection D.2.
118. Article VI, SCOPE OF WORK, Section 6.7.3.3, Mental Health, is amended to
read:
6.7.3.3 MENTAL HEALTH
All Specialty Mental Health Services (inpatient and outpatient) are
excluded from the Contract.
A. Contractor shall provide outpatient mental health services within
the Primary Care Physician's scope of practice. Contractor shall
provide assistance to Members needing Specialty Mental Health
Services by referring such Members, whose mental health diagnosis
is covered by the local Medi-Cal mental health plan or whose
diagnosis is uncertain, to the local Medi-Cal mental health plan,
if operational. If the Medi-Cal mental health plan is not
operational or if the Member's diagnosis is not covered by the
local Medi-Cal mental health plan, Contractor shall refer such
Members to an appropriate fee-for-service Medi-Cal mental health
provider accepting Medi-Cal patients, if known to the Contractor,
or shall refer such Members to the County Mental Health Department,
or other community resources that may be able to assist the Member
to locate mental health services, including the local CHDP program,
regional centers for the developmentally disabled, and provider
referral services.
B. Contractor shall provide Medical Case Management and cover and pay
for all Medically Necessary Covered Services for the Member,
including the services listed below, and coordinate services with
the Specialty Mental Health Provider.
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1. Emergency room professional services as described in Title
22, CCR, Section 53855, except psychiatrists, psychologists,
licensed clinical social workers, marriage, family and child
counselors, or other Specialty Mental Health Providers;
2. Facility charges for emergency room visits which do not
result in a psychiatric admission;
3. All laboratory, radiological and radioisotope services when
these services are necessary for the diagnosis, monitoring,
or treatment of a Member's mental health condition.
4. Emergency medical transportation services necessary to
provide access to all Medi-Cal covered services, including
emergency mental health services, as described in Title 22,
CCR, Section 51323.
5. All non-emergency medical transportation services, as
provided for in Title 22, CCR, Section 51323, required by
Members to access Medi-Cal covered mental health services,
subject to a written prescription by a Medi-Cal Specialty
Mental Health Provider, except when the transportation is
required to transfer the Member from one facility to
another, for the purpose of reducing the local Medi-Cal
mental health plan's cost of providing services.
6. Medically Necessary Covered Services for Members admitted to
a psychiatric inpatient hospital, including the initial
health history and physical assessment required upon
admission and any consultations related to Medically
Necessary Covered Services. However, notwithstanding this
requirement, Contractor shall not be responsible for room
and board charges for psychiatric inpatient hospital stays
by Members.
7. All Medically Necessary Medi-Cal covered psychotherapeutic
drugs for Members not otherwise excluded under this
Contract.
a. This includes reimbursement for covered
psychotherapeutic drugs prescribed by out-of-plan
psychiatrists for Members.
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b. If Contractor requires that covered prescriptions
written by out-of-plan psychiatrists be filled by
pharmacies in Contractor's provider network,
Contractor shall ensure that drugs prescribed by
out-of-plan psychiatrists are no less accessible to
Members than drugs prescribed by network providers.
c. Reimbursement to pharmacies for those
psychotherapeutic drugs listed in Attachment III
(consisting of one page), and psychotherapeutic
drugs classified as Anti-Psychotics and approved by
the FDA after July 1, 1997, shall be made by DHS
through the Medi-Cal FFS program, whether these
drugs are provided by a pharmacy contracting with
Contractor or by an out-of-plan pharmacy provider.
To qualify for reimbursement under this provision, a
pharmacy must be enrolled as a Medi-Cal provider in
the Medi-Cal FFS program.
8. Paragraphs 3,5, and 6 shall not be construed to preclude
Contractor from: a) requiring that Covered Services be
provided through Contractor's provider network or b)
applying Utilization controls for these services, including
Prior Authorization, consistent with Contractor's obligation
to provide Covered Services under this Contract.
C. Contractor shall execute a Memorandum of Understanding (MOU), in
accordance with Section 6.7.9, Local Mental Health Plan
Coordination, for coordination of Specialty Mental Health Services
with the local Medi-Cal mental health plan in each county that is
covered by this Contract.
D. Disputes between Contractor and the local Medi-Cal mental health
plan regarding this section shall be resolved pursuant to Title 9,
CCR, Section 1850.505. Any decision rendered by DHS and the
California Department of Mental Health regarding a dispute between
Contractor and the local Medi-Cal mental health plan concerning
provision of mental health services or Covered Services required
under this Contract shall not be subject to the Disputes and
Appeals procedures specified in Article III, Section 3.22.
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119. Article VI, SCOPE OF WORK, Section 6.7.3.4, Alcohol and Drug Treatment
Services, sentence one, is amended to read:
Alcohol and drug treatment services available under the Xxxxx-Xxxxx Drug
Medi-Cal program as defined in Title 22, CCR, Section 51341.1 and
outpatient heroin detoxification as defined in Title 22, CCR, Section
51328 are excluded from this Contract.
120. Article VI, SCOPE OF WORK, Section 6.7.3.5, Dental, is amended to read:
6.7.3.5 DENTAL
Dental services are not covered under this Contract. Contractor shall
perform dental screening for all Members as a part of the initial health
assessment and refer Members to Medi-Cal dental providers. Dental
screenings for Members under twenty-one (21) years of age shall be
performed in accordance with the most recent recommendations of the
American Academy of Pediatrics, as part of the initial health
assessment. Contractor shall ensure referrals to dental providers.
Services related to dental services that are covered medical services
and are not provided by dentists or dental anesthetists, are the
responsibility of Contractor. Covered medical services include:
prescription drugs, laboratory services, pre-admission physical
examinations required for admission to a facility, anesthesia services,
out-patient surgical center services and in-patient hospitalization
services required for a dental procedure. Contractor may require Prior
Authorization for medical services required in support of dental
procedures.
Contractor shall develop referral and Prior Authorization policies and
procedures to implement the above requirements. Contractor shall submit
these policies and procedures to DHS for review and approval.
121. Article VI, SCOPE OF WORK, Section 6.7.3.7, Direct Observed Therapy
(DOT) for Treatment of Tuberculosis, section title only, is amended to
read:
6.7.3.7 DIRECTLY OBSERVED THERAPY (DOT) FOR TREATMENT OF
TUBERCULOSIS
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122. Article VI, SCOPE OF WORK, Section 6.7.4.3, School Linked CHDP Services:
Subcontracts, is amended to read:
6.7.4.3 SCHOOL LINKED CHDP SERVICES: SUBCONTRACTS
Contractor shall ensure that the Subcontracts with the local school
districts or school sites meet the requirements of Article III, Section
3.28, Subcontracts, and address the following: the population covered,
beginning and end dates of the agreement, services covered,
practitioners covered, outreach, information dissemination and
educational responsibilities, Utilization Review requirements, referral
procedures, medical information flows, patient information
confidentiality, Quality Assurance interface, data reporting
requirements, Grievances and complaint procedures.
123. Article VI, SCOPE OF WORK, Section 6.7.4.4, Early and Periodic
Screening, Diagnosis and Treatment (EPSDT) Supplemental Services,
Excluding Case Management Services, is amended to read:
6.7.4.4 EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT
(EPSDT) SUPPLEMENTAL SERVICES, INCLUDING CASE MANAGEMENT
SERVICES
For Members under the age of 21 years, Contractor shall provide or
arrange and pay for EPSDT supplemental services as defined in Title 22,
CCR, Section 51184, except when EPSDT supplemental services are provided
as CCS services pursuant to Section 6.7.3.2, CCS Services, or as mental
health services pursuant to Section 6.7.3.3, Mental Health. Contractor
shall determine the medical necessity of EPSDT supplemental services
using the criteria established in Title 22, CCR, Sections 51340 and
51340.1.
For Members under the age of 21 years, who meet the medical necessity
criteria for EPSDT case management, pursuant to Title 22, CCR, Section
51340(f), Contractor shall refer the Member to a targeted case
management (TCM) provider under contract with a local government agency
pursuant to Welfare and Institutions Code Section 14132.44 or to
entities and organizations, including Regional Centers, that provide TCM
services pursuant to Welfare and Institutions Code Section 14132.48. If
EPSDT case management services are rendered by these referral providers,
Contractor is not required to pay for the EPSDT case management
services. If EPSDT case management services are not available from these
referral providers, Contractor shall provide or arrange and pay for the
EPSDT case management services.
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124. Article VI, SCOPE OF WORK, Section 6.7.4.7, Family Planning:
Out-of-Network Reimbursement, is amended to read:
6.7.4.7 FAMILY PLANNING: OUT-OF-NETWORK REIMBURSEMENT
Contractor shall reimburse out-of-network family planning providers for
the following services provided to Members of childbearing age to
temporarily or permanently prevent or delay pregnancy:
A. Health education and counseling necessary to make informed choices
and understand contraceptive methods.
B. Limited history and physical examination.
C. Laboratory tests if medically indicated as part of decision making
process for choice of contraceptive methods. Contractor shall not
be required to reimburse out-of-plan providers for pap smears if
Contractor has provided pap smears to meet the U.S. Preventive
Services Task Force guidelines.
D. Diagnosis and treatment of STD disease episode, as defined by DHS
for each STD, if medically indicated.
E. Screening, testing and counseling of at risk individuals for HIV
and referral for treatment.
F. Follow-up care for complications associated with contraceptive
methods provided or prescribed by the family planning provider.
G. Provision of contraceptive pills, devices, supplies.
H. Tubal ligation.
I. Vasectomies.
J. Pregnancy testing and counseling.
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125. Article VI, SCOPE OF WORK, Section 6.7.4.8, Family Planning:
Reimbursement Rate, is amended to read:
6.7.4.8 FAMILY PLANNING: REIMBURSEMENT RATE
Contractor shall reimburse out-of-plan family planning providers at
the appropriate Medi-Cal FFS rate, unless otherwise negotiated with
the out-of-plan family planning provider.
126. Article VI, SCOPE OF WORK, Section 6.7.4.9, Sexually Transmitted
Diseases (STDs), is amended to read:
6.7.4.9 SEXUALLY TRANSMITTED DISEASES (STDS)
Contractor shall provide access to STD services without Prior
Authorization to all Members both within and outside its provider
network. Members may access out-of-plan STD services through local
health department (LHD) clinics, family planning clinics, or- through
other community STD service providers. LHD and family planning
providers shall be reimbursed for STD services pursuant to Sections
6.7.8.1, Subcontract, and 6.7.4.7, Family Planning: Out-Of-Network
Reimbursement. For community providers other than LHD and family
planning providers, the reimbursement of out-of-plan STD services is
limited to one office visit per disease episode for the purposes of:
(1) diagnosis and treatment of vaginal discharge and urethral
discharge, (2) those STDs that are amenable to immediate diagnosis and
treatment, and this includes syphilis, gonorrhea, chlamydia, herpes
simplex, chancroid, Trichomoniasis, human papilloma virus, non-
gonococcal urethritis, lymphogranuloma venereum and granuloma
inguinale and (3) evaluation and treatment of Pelvic Inflammatory
Disease (PID). Contractor shall provide follow-up care. Contractor
shall reimburse STD providers at the Medi-Cal Fee-For-Service (FFS)
rate, unless otherwise negotiated, and Contractor shall provide
reimbursement only if STD treatment providers provide treatment
records or documentation of the Member's refusal to release Medical
Records to Contractor along with billing information.
127. Article VI, SCOPE OF WORK, Section 6.7.4.10, Early Intervention
Services, sentence one, is amended to read:
Contractor shall refer to the local Early Start program those children
in need of early intervention services, e.g., those with an
established condition leading to developmental delay, those in whom a
significant developmental delay is suspected, or those whose early
health history places them at risk for delay.
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128. Article VI, SCOPE OF WORK, Section 6.7.4.14, Nurse Midwife Services,
is amended to read:
6.7.4.14 NURSE MIDWIFE AND NURSE PRACTITIONER SERVICES
Contractor shall meet federal requirements for access and
reimbursement for Certified Nurse Midwife (CNM) services as defined in
Title 22, CCR, Section 51345 and Certified Nurse Practitioner (CNP)
services as defined in Title 22, CCR, Section 51345.1. If Members do
not have access to CNM or CNP services within the provider network of
either Medi-Cal managed care contractor in the county, Contractor
shall inform Members that they have a right to obtain out-of-plan CNM
or CNP services, and Contractor shall reimburse CNMs or CNPs for
services provided out-of-plan to Members at the applicable Medi-Cal
Fee-For-Service rates. If CNM services are unavailable in Contractor's
provider network, but are available within DHS' time and distance
standards for access to Primary Care in the other Medi-Cal managed
care contractor's provider network in the county, Contractor shall not
be obligated to reimburse CNMs for services provided out-of-plan to
Members (unless authorized by Contractor). (This provision shall apply
equally to CNP services.)
Notwithstanding the above paragraph, for Emergency Services and family
planning, the provisions of Sections 6.6.16, Emergency Service
Providers, 6.7.4.5, Family Planning: General Requirement, and 6.7.4.8,
Family Planning: Reimbursement Rate, shall apply.
129. Article VI, SCOPE OF WORK, Section 6.7.6.1, Initial Health Assessment,
sentence three, is amended to read:
For Members under the age of 21 years, the assessment shall follow the
applicable requirements of Health and Safety Code, Section 124025, et
seq., and Title 17, Sections 6840 through 6850, except that Contractor
shall follow the most recent periodicity schedule recommended by the
American Academy of Pediatrics.
130. Article VI, SCOPE OF WORK, Section 6.7.6.2, Children, paragraph one,
is amended to read:
Contractor shall maintain and operate a system which ensures the
provision of CHDP services to Members under the age of 21 years in
accordance with the applicable provisions of the Health and Safety
Code, Section 124025, et seq., and Title 17, CCR, Sections 6840
through 6850. The system shall include the following components:
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131. Article VI, SCOPE OF WORK, Section 6.7.6.3, Pregnant Women: Minimum
Standards, sentence two, is amended to read:
Contractor shall develop and implement standardized risk assessment
tools which are consistent with Comprehensive Perinatal Services
Program (CPSP) requirements set forth in Title 22, CCR, Sections 51348
and 51348.1.
132. Article VI, SCOPE OF WORK, Section 6.7.7.3, Behavioral Assessments, is
amended to read:
6.7.7.3 INDIVIDUAL HEALTH EDUCATION BEHAVIORAL ASSESSMENTS
Contractor shall ensure that individual health education behavioral
assessments are conducted on all Members within 120 days of Enrollment
to determine health practices, values, behaviors, knowledge,
attitudes, cultural practices, beliefs, literacy levels, and health
education needs. Upon Contractor's written request, DHS may, at its
discretion, delay Contractor implementation of this requirement. DHS
shall approve any such request in writing. DHS may terminate any
approved delay in implementation thirty (30) days after DHS' notice to
Contractor of intent to terminate.
133. Article VI, SCOPE OF WORK, Section 6.7.7.7, Group Needs Assessment, is
amended to read:
6.7.7.7 GROUP NEEDS ASSESSMENT
Contractor shall conduct a group needs assessment of its Members to
determine health education needs, including literacy level. Contractor
shall submit to DHS a report summarizing the methodology, findings,
proposed services, key activities, timeline for implementation, and
the responsible individuals. Contractor shall complete the needs
assessment and submit the report to DHS between twelve (12) and
eighteen (18) months after the commencement of operations under this
Contract.
134. Article VI, SCOPE OF WORK, Section 6.7.8.1, Subcontract, paragraph 1,
is amended to read:
Contractor shall execute a Subcontract for the specified public health
services with the Local Health Department (LHD) in each county that is
covered by this Contract. The Subcontract shall specify the scope and
responsibilities of both parties, billing and reimbursements,
reporting responsibilities, and Medical Record management to ensure
coordinated health care services. The Subcontract shall meet the
requirements contained
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in Article III, Sections 3.28, Subcontracts, through 3.28.8,
Disclosures. The specified public health services under the
Subcontract are as follows:
135. Article VI, SCOPE OF WORK, Section 6.7.8.1, Subcontracts, subsection
(B), is amended to read:
B. STD services for the disease episode, as defined by DHS for each
STD, including diagnosis and treatment of the following STDs:
syphilis, gonorrhea, chlamydia, herpes simplex, chancroid,
trichomoniasis, human papilloma virus, non-gonococcal urethritis,
lymphogranuloma venereum and granuloma inguinale.
136. Article VI, SCOPE OF WORK, Section 6.7.8.1, Subcontracts, subsection
(H), is amended to read:
H. Tuberculosis Directly Observed Therapy
137. Article VI, SCOPE OF WORK, is amended by adding a new Section 6.7.9 to
read:
6.7.9. LOCAL MENTAL HEALTH PLAN COORDINATION
6.7.9.1 MEMORANDUM OF UNDERSTANDING
A. Contractor shall negotiate in good faith and execute a Memorandum
of Understanding (MOU) with the local mental health plan (MHP).
The MOU shall specify, consistent with this Contract, the
respective responsibilities of Contractor and the MHP in
delivering Medically Necessary Covered Services and Specialty
Mental Health Services to Members. The MOU shall address:
1. Protocols and procedures for referrals between Contractor
and the MHP;
2. Protocols for the delivery of Specialty Mental Health
Services, including the MHP's provision of clinical
consultation to Contractor for Members being treated by
Contractor for mental illness;
3. Protocols for the delivery of mental health services within
the Primary Care Physician's scope of practice;
4. Protocols and procedures for the exchange of Medical Records
information, including procedures for maintaining the
confidentiality of Medical Records;
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5. Procedures for the delivery of Medically Necessary Covered
Services to Members who require Specialty Mental Health
Services, including:
a. Pharmaceutical services and prescription drugs;
b. Laboratory, radiological and radioisotope services;
c. Emergency room facility charges and professional
services;
d. Emergency and non-emergency medical transportation;
e. Home health services;
f. Medically Necessary Covered Services to Members who are
patients in psychiatric inpatient hospitals.
6. Procedures for transfers between inpatient psychiatric
services and inpatient medical services to address changes
in a Member's medical or mental health condition.
7. Procedures to resolve disputes between Contractor and the
MHP.
B. To the extent Contractor does not execute an MOU within four (4)
months after implementation of the Medi-Cal Specialty Mental
Health Services Consolidation program in the area being served by
this Contract, Contractor shall submit documentation
substantiating its good faith efforts to enter into an MOU. Until
such time as an MOU is executed, Contractor shall submit monthly
reports to DHS documenting its continuing good faith efforts to
execute an MOU and the justifications why such an MOU has not
been executed.
138. Article VI, SCOPE OF WORK, Section 6.8.1, Marketing Representatives,
paragraph one, sentence one, is amended to read:
Contractor shall ensure, in addition to compliance with the
requirements of Title 22, CCR, Section 53880, that:
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139. Article VI, SCOPE OF WORK, Section 6.8.6, Marketing Plan, is amended
to read:
6.8.6 MARKETING PLAN
Contractor shall implement and maintain a Marketing plan approved by
DHS. Door to door Marketing is prohibited.
140. Article VI, SCOPE OF WORK, Section 6.9.3, Disclosure Forms, is amended
to read:
6.9.3 DISCLOSURE FORMS
Contractor shall provide to all Members the Evidence of Coverage and
Disclosure Form materials which constitute a fair disclosure of the
provisions of the covered health care services.
141. Article VI, SCOPE OF WORK, Section 6.9.5, Membership Services Guide,
is amended to read:
6.9.5 MEMBERSHIP SERVICES GUIDE
Contractor shall develop and distribute a Membership Services Guide
that includes the following information:
A. The name, address and telephone number of the health plan.
B. A description of the full scope of Medi-Cal covered benefits and
all available services including health education, interpretive
services, and "carve out" services and an explanation of any
service limitations and exclusions from coverage or charges for
services.
C. Procedures for obtaining Covered Services including the address
and telephone number of each Service Site (locations of
hospitals, Primary Care Physicians, optometrists, psychologists,
pharmacies, Skilled Nursing Facilities, Urgent Care Facilities).
In the case of a medical foundation or independent practice
association, the address and telephone number of each Physician
provider.
1. The hours and days when each of these Facilities is open,
the services and benefits available, and the telephone
number to call after normal business hours.
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D. Procedures for selecting or requesting a change in Primary Care
Physician, including requirements for a change in PCP; reasons
for which a request may be denied; and reasons why a provider may
request a change.
E. The purpose and value of scheduling an initial health assessment
appointment.
F. The appropriate use of health care services in a managed care
system.
G. The availability and procedures for obtaining after hours
services (24-hour basis) and care, including the appropriate
provider locations and telephone numbers.
H. Procedure for obtaining emergency health care both within and
outside Contractor's Service Area.
I. Process for referral to specialists.
J. Procedures for obtaining any non-medical transportation services
offered by Contractor and through the local CHDP programs, and
how to obtain such services.
K. The causes for which a Member shall lose entitlement to receive
services under this Contract. (See Article III, Section 3.23.5,
Disenrollment)
L. Procedures for filing a complaint/Grievance, including procedures
for appealing decisions regarding Member's coverage, benefits, or
relationship to the organization. Include the title, address, and
telephone number of the person responsible for processing and
resolving complaints/Grievances.
M. Procedures for Disenrollment, including an explanation of the
Member's right to disenroll without cause at any time, subject to
any restricted disenrollment period.
N. Information on the Member's right to the Medi-Cal fair hearing
process, regardless of whether or not a complaint/Grievance has
been submitted or if the complaint/Grievance has been resolved,
pursuant to Title 22, CCR, Section 53452, when a health care
service requested by the Member or provider has been denied,
deferred or modified. The State Department of Social Services'
Public Inquiry and Response Unit toll free telephone number (800)
952-5253.
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O. Information on the availability of, and procedures for obtaining,
services at FQHCs and Indian Health Clinics.
P. Information on the Member's right to seek family planning
services from any qualified provider of family planning services
under the Medi-Cal program, including providers outside
Contractor's provider network, and a description of those
services, such as the following statement:
" Family planning services are provided to Members of child
bearing age to enable them to determine the number and spacing of
children. These services include all methods of birth control
approved by the Federal Food and Drug Administration. As a
Member, you pick a doctor who is located near you and will give
you the services you need. Our Primary Care Physicians and OB/GYN
specialists are available for family planning services. For
family planning services, you may also pick a doctor or clinic
not connected with Xxxxxx Medical Centers, Inc. without having to
get permission from Xxxxxx Medical Centers, Inc. Xxxxxx Medical
Centers, Inc. shall pay that doctor or clinic for the family
planning services you get".
Q. DHS' Office of Family Planning's toll free telephone number
(0-000-000-0000) providing consultation and referral to family
planning clinics.
R. Any other information determined by DHS to be essential for the
proper receipt of Covered Services.
S. Information on the availability of, and procedures for obtaining,
Certified Nurse Midwife and Certified Nurse Practitioner
services, pursuant to Section 6.7.4.14, Nurse Midwife and Nurse
Practitioner Services.
T. Information on the availability of transitional Medi-Cal
eligibility and how the Member may apply for this program.
Contractor shall include this information with all Membership
Service Guides sent to Members after the date such information is
furnished to Contractor by DHS.
U. Information on how to access State resources for investigation
and resolution of Member complaints, including the DHS Medi-Cal
Managed Care Ombudsman toll-free telephone number
(0-000-000-0000) and the DOC HMO Consumer Service toll-free
telephone number (0-000-000-0000).
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V. Information concerning the provision and availability of services
covered under the CCS program from providers outside Contractor's
provider network and how to access these services.
W. An explanation of the expedited disenrollment process for
children receiving services under the Xxxxxx Care or Adoption
Assistance Programs; Members with special health care needs,
including, but not limited to major organ transplants; and
Members already enrolled in another Medi-Cal, Medicare or
commercial managed care plan.
X. Information on how to obtain Minor Consent Services through
Contractor's plan, and an explanation of those services.
Y. A brief explanation on how to use the fee-for-service system when
Medi-Cal covered services are excluded or limited under this
Contract and how to obtain additional information.
Z. An explanation of an American Indian Member's right to access
Indian Health Service facilities and to disenroll from
Contractor's plan at any time, without cause.
AA. Subsections S through Z above, except subsection T, shall be
included in Contractor's Membership Services Guide by April
1,1999, or upon the next reprinting of Contractor's Membership
Services Guide, whichever is sooner.
142. Article VI SCOPE OF WORK, Section 6.9.9, Primary Care Physician
Selection, is amended to read:
6.9.9 PRIMARY CARE PHYSICIAN SELECTION
Contractor shall implement and maintain DHS approved procedures to
ensure that each new Member has an appropriate and available Primary
Care Physician. Contractor shall provide each new Member an
opportunity to select a Primary Care Physician within the first thirty
(30) days of Enrollment. If Contractor's provider network includes
nurse practitioners or certified nurse midwives, the Member may select
a nurse practitioner or certified nurse midwife within thirty (30)
days of enrollment to provide Primary Care services. Contractor shall
ensure that Members are allowed to change a Primary Care Physician,
nurse practitioner or certified nurse midwife, upon request, by
selecting a different Primary Care Provider from Contractor's network
of providers. Contractor shall
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provide the Member sufficient information (verbal and written) in the
appropriate language and reading level about the selection process and
the available providers in the network, including certified nurse
midwives and certified nurse practitioners, to ensure their ability to
make an informed decision.
143. Article VI, SCOPE OF WORK, Section 6.9.10, Primary Care Physician
Assignment, is amended to read:
6.9.10 PRIMARY CARE PHYSICIAN ASSIGNMENT
If the Member does not select a Primary Care Physician, nurse
practitioner, or certified nurse midwife within thirty (30) days of
the effective date of Enrollment, Contractor shall assign that Member
to a Primary Care Physician and notify the Member and the assigned
Primary Care Physician no later than forty (40) days after the
Member's Enrollment. In all cases where a nurse practitioner or a
certified nurse midwife is a Member's selected Primary Care Provider,
Contractor shall assure that an individual Primary Care Physician is
responsible for the overall coordination of the Member's health care,
consistent with applicable State and federal laws and regulations.
Contractor shall ensure that adverse selection does not occur during
the assignment process of Members to providers.
144. Article VI, SCOPE OF WORK, Section 6.9.11, Continuity of Care, is
amended to read:
6.9.11 CONTINUITY OF CARE
Contractor shall ensure that Members with an established relationship
with a provider in Contractor's network, who have expressed a desire
to continue their patient/provider relationship, are assigned to that
provider without disruption in their care.
145. Article VI, SCOPE OF WORK, Section 6.9.13, Member Complaint/Grievance
System, is amended to read:
6.9.13 MEMBER COMPLAINT/GRIEVANCE SYSTEM
Contractor shall implement and maintain a Member complaint/Grievance
system in accordance with Title 10, CCR, Section 1300.68, except
subsection 1300.68(g), and Title 22, CCR, Section 53858.
A. Contractor shall acknowledge receipt of a complaint within 5
days. The written acknowledgement shall also notify the
complainant of a person at the plan who may be contacted
regarding the complaint.
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B. Contractor shall resolve the complaint within 30 days of receipt
or document reasonable efforts to resolve the complaint within
thirty (30) days of receipt.
146. Article VI, SCOPE OF WORK, Section 6.9.14, Disenrollments, is deleted.
147. Article VI, SCOPE OF WORK, Section 6.9.15, Denial, Deferral, or
Modification of Prior Authorization Requests, is renumbered and
amended to read:
6.9.15 DENIAL, DEFERRAL, OR MODIFICATION OF PRIOR AUTHORIZATION
REQUESTS
A. Contractor shall notify Members of denial, deferral, or
modification of requests for Prior Authorization, in accordance
with Title 22, CCR, Sections 51014.1 and 53894 by providing
written notification to Members and/or their authorized
representative, regarding any denial, deferral or modification of
a request for approval to provide a health care service. This
notification must be provided as specified in Title 22, CCR,
Sections 51014.1, 51014.2, and 53894.
B. Contractor shall provide for a written notification to the Member
and the Member's representative on a standardized form approved
by DHS, informing the Member of all the following:
1. The Member's right to, and method of obtaining, a fair
hearing to contest the denial, deferral or modification
action.
2. The Member's right to represent himself/herself at the fair
hearing or to be represented by legal counsel, friend or
other spokesperson.
3. The name and address of Contractor and the State toll-free
telephone number for obtaining information on legal service
organizations for representation.
C. The notice to the Member may inform the Member that the Member
may file a complaint/Grievance concerning Contractor's action
using Contractor's complaint/Grievance process prior to or
concurrent with the initiation of the fair hearing process.
D. Contractor shall provide required notification to beneficiaries
and the representatives in accordance with the time frames set
forth in Title 22, CCR, Sections 51014.1 and 53894.
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148. Article VI, SCOPE OF WORK, Section 6.10.2, Linguistic Services,
subsection (B), paragraph (3), is amended to read:
3. Translated written materials, including the Membership Services
Guide, enrollee information, welcome packets, and marketing
information.
149. Article VI, SCOPE OF WORK, Section 6.10.6, Cultural and Linguistics
Services Plan, is amended to read:
6.10.6 CULTURAL AND LINGUISTICS SERVICES PLAN
Contractor shall ensure that a group needs assessment of Members is
completed between twelve (12) and eighteen (18) months after the
commencement of operations under this Contract. This group needs
assessment shall be conducted in conjunction with the health education
group needs assessment, described in Section 6.7.7.7, Group Needs
Assessment, and shall include identification of linguistic and
cultural needs of the groups which speak a primary language other than
English.
The findings of the assessment shall be submitted to DHS in the form
of a plan entitled "Cultural and Linguistic Services Plan" between
twelve (12) and eighteen (18) months after commencement of operations
under this Contract. In the plan, Contractor shall summarize the
methodology, and findings of the group needs assessment of cultural
and linguistic needs of non-English-speaking groups, and outline the
proposed services to be implemented to address the findings of
cultural and linguistic needs of non-English-speaking Members, the
timeline for implementation with milestones, and the responsible
individual.
Contractor shall ensure implementation of the Cultural and Linguistic
Services Plan between twelve (12) and eighteen (18) months after the
commencement of operations under this Contract. Contractor shall also
identify the individual with overall responsibility for the activities
to be conducted under the plan. DHS approval of the plan is required
prior to its implementation.
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150. Article VI, SCOPE OF WORK, Section 6.11.1, Time Frames, is amended to
read:
6.11.1 TIME FRAMES
Contractor shall submit deliverables within the timeframes specified
on the Implementation Plan approved by DHS. Compliance with the
schedule is mandatory unless otherwise approved in writing by DHS.
(See Article III, Section 3.18, Liquidated Damages Provisions). Unless
otherwise specified, all completion dates listed for the deliverables
are calculated from the Contract effective date.
151. Attachment 1 is amended by adding the following language to the
capitation rate sheets:
The State is entering into this capitated Contract as an alternative
means of paying for medical care for members of the eligible Medi-Cal
population. The traditional payment method, called Fee-For-Service,
requires Medi-Cal beneficiaries to find an authorized Medi-Cal
provider when they are in need of health care. The State reimburses
these Medi-Cal providers for services rendered, according to an
established schedule of fees. Under this capitated Contract, the
State pays Contractor a monthly fee for each Medi-Cal beneficiary
enrolled in its prepaid health plan, and Contractor is then
responsible for providing all medically necessary health care services
to the beneficiary as required by the Contract.
The rate development process for this Contract consists of two
separate calculations. First, a Fee-For-Service equivalent (FFSE) is
determined for the entire group of Medi-Cal eligibles. Second, rates
are calculated for each Contract by beneficiary aid code using
historical Medi-Cal managed care data. The name given this latter
method is an experienced based methodology. Both the FFSE and
experience based methodologies use factors which directly influence
the cost of providing health care to Medi-Cal beneficiaries. These
factors are age, sex, geographic area with price indices, Medi-Cal aid
code, and eligibility for Medicare. The rate methodologies also employ
adjustments for changes that are likely to occur during the term of
the Contract. These adjustments include fee, benefit, or policy
changes to reflect changes to the Medi-Cal program that are mandated
each year by the State Legislature and the use of a trend factor to
project costs to the term of the Contract.
Actuaries employed by the Department of Health Services conduct the
rate development process for this Contract. This attachment presents
the methodology and calculation of the capitation rates for this
Contract.
98
XXXXXX MEDICAL CENTERS, INC. 95-23637-A03
152. The effective date of the following amendments shall be the date of
approval by the Department of Finance of this amendment package: 28,
41, 56, 59, 62, 64, 66, 67, 69, 70, 72, 75, 89, 90, 91, 106, 113, 116,
117, 119, 122, 127, 131, 136, 138, 140, 141, 147.
153. The effective date of the following amendments is January 1, 1999: 61,
65, 84, 92, 109.
154. The effective date of the all other amendments in this package shall
be October 1, 1997.
155. The effective date of the rate adjustment shall be October 1,1997.
156. All rights, duties, obligations and liabilities of the parties hereto
otherwise remain unchanged.
99
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: Family
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 4.127 4.686 0.263 2.139 0.002 3.495 0.120
2. Eligibility Adjustment 1.014 0.998 1.045 1.026 1.000 0.995 1.000
3. Age/sex Adjustment 1.028 0.987 1.045 1.012 1.000 1.006 1.000
Adjusted Units 4.302 4.616 0.287 2.221 0.002 3.498 0.120
4. Average Cost Per Unit $ 67.40 $ 16.48 940.29 $ 17.95 $ 115.00 $ 22.23 $ 64.52 $ 1,243.87
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.64 $ 16.48 $ 940.29 $ 17.95 $ 115.00 $ 22.23 $ 64.52 $ 1,247.11
6. Contract Adjustments
a.Mental Health 0.978 0.995 1.000 0.955 0.994 0.919 0.949
b.Long Term Care 1.000 1.000 1.000 1.000 0.335 1.000 1.000
c.Procedure Adjs. 0.999 1.000 1.000 1.000 1.000 0.913 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 295.43 $ 75.31 $ 268.51 $ 37.88 $ 0.08 $ 64.92 $ 7.31 $ 749.44
8. Legislative Adjustment 1.026 1.052 0.993 1.004 1.038 1.027 1.027
9. Trend Adjustments
a.Cost per Unit 1.036 1.146 1.048 0.967 1.123 1.046 1.000
b.Units per Eligible 0.950 1.100 0.998 1.045 1.000 1.050 1.000
Projected Cost per Eligible $ 298.32 $ 99.87 $ 278.87 $ 38.43 $ 0.09 $ 73.23 $ 7.51 $ 796.32
Preliminary Monthly Rate $ 66.36
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 4.60
12. 0.00
13. Fee-for-Service Adjustment 6.6% 4.69
14. FQHC County Cost Differential 0.26
Capitation Rate $ 75.91
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: Aged
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 3.770 19.658 0.982 2.464 0.554 13.308 0.120
2. Eligibility Adjustment 0.960 1.017 0.959 0.979 1.002 1.021 1.000
3. Age/sex Adjustment 0.989 1.002 1.005 0.990 1.043 1.008 1.000
Adjusted Units 3.579 20.032 0.946 2.388 0.579 13.696 0.120
4. Average Cost Per Unit $ 47.81 $ 30.45 889.66 $ 10.85 $ 69.41 $ 5.85 $ 43.50 $ 1,097.53
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 50.10 $ 30.45 $ 889.66 $ 10.85 $ 69.41 $ 5.85 $ 43.50 $ 1,099.82
6. Contract Adjustments
a.Mental Health 0.991 0.996 1.000 0.986 0.996 0.958 0.989
b.Long Term Care 1.000 1.000 1.000 1.000 0.196 1.000 1.000
c.Procedure Adjs. 0.990 1.000 1.000 1.000 1.000 0.799 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 175.04 $ 604.50 $ 837.41 $ 25.42 $ 7.81 $ 61.02 $ 5.14 $ 1,716.34
8. Legislative Adjustment 1.004 1.033 0.907 0.917 1.038 1.001 1.001
9. Trend Adjustments
a.Cost per Unit 0.865 1.105 1.079 1.036 1.034 1.049 1.000
b.Units per Eligible 0.950 1.050 1.050 1.100 1.000 1.045 1.000
Projected Cost per Eligible $ 144.41 $ 724.52 $ 860.51 $ 26.56 $ 8.38 $ 66.96 $ 5.15 $ 1,836.49
Preliminary Monthly Rate $ 153.04
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 9.18
14. FQHC County Cost Differential 0.07
Capitation Rate $ 162.29
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: Disabled
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 6.559 24.089 1.155 4.742 0.176 20.858 0.240
2. Eligibility Adjustment 0.996 1.005 1.000 0.999 0.996 1.007 1.000
3. Age/sex Adjustment 0.995 0.989 0.985 0.999 1.009 0.996 1.000
Adjusted Units 6.500 23.943 1.138 4.733 0.177 20.920 0.240
4. Average Cost Per Unit $ 45.69 $ 35.66 867.73 $ 13.05 $ 100.13 $ 9.33 $ 72.26 $ 1,143.85
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 47.88 $ 35.66 $ 867.73 $ 13.05 $ 100.13 $ 9.33 $ 72.26 $ 1,146.04
6. Contract Adjustments
a.Mental Health 0.894 0.882 1.000 0.972 0.994 0.949 0.909
b.Long Term Care 1.000 1.000 1.000 1.000 0.099 1.000 1.000
c.Procedure Adjs. 0.998 0.997 1.000 1.000 1.000 0.918 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 276.29 $ 747.04 $ 982.54 $ 59.74 $ 1.74 $ 169.19 $ 15.69 $ 2,252.23
8. Legislative Adjustment 1.010 1.034 0.908 0.918 1.039 1.007 1.007
9. Trend Adjustments
a.Cost per Unit 0.954 1.161 1.032 0.977 1.042 1.032 1.000
b.Units per Eligible 0.950 1.050 0.950 1.050 1.000 0.998 1.000
Projected Cost per Eligible $ 252.91 $ 941.64 $ 874.66 $ 56.26 $ 1.88 $ 175.47 $ 15.80 $ 2,318.62
Preliminary Monthly Rate $ 193.22
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 11.59
14. FQHC County Cost Differential 0.15
Capitation Rate $ 204.96
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: Child
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 3.962 3.669 0.332 1.521 0.000 2.012 0.120
2. Eligibility Adjustment 1.005 1.017 1.021 1.020 1.000 1.077 1.000
3. Age/sex Adjustment 1.201 0.992 1.294 1.101 1.000 1.112 1.000
Adjusted Units 4.782 3.702 0.439 1.708 0.000 2.410 0.120
4. Average Cost Per Unit $ 65.30 $ 11.46 965.53 $ 17.74 $ 0.00 $ 24.55 $ 60.59 $ 1,145.17
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 68.43 $ 11.46 $ 965.53 $ 17.74 $ 0.00 $ 24.55 $ 60.59 $ 1,148.30
6. Contract Adjustments
a.Mental Health 0.976 0.989 1.000 0.974 0.993 0.911 0.982
b.Long Term Care 1.000 1.000 1.000 1.000 0.140 1.000 1.000
c.Procedure Adjs. 0.999 1.000 1.000 1.000 1.000 0.917 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 317.46 $ 41.75 $ 421.75 $ 29.36 $ 0.00 $ 49.18 $ 7.10 $ 866.60
8. Legislative Adjustment 1.026 1.052 0.993 1.004 1.038 1.023 1.023
9. Trend Adjustments
a.Cost per Unit 0.967 1.085 1.024 0.933 1.178 1.091 1.000
b.Units per Eligible 0.950 1.050 0.950 1.045 1.000 1.100 1.000
Projected Cost per Eligible $ 299.22 $ 50.04 $ 407.41 $ 28.74 $ 0.00 $ 60.38 $ 7.26 $ 853.05
Preliminary Monthly Rate $ 71.09
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 3.46
12. 0.00
13. Fee-for-Service Adjustment 6.0% 4.47
14. FQHC County Cost Differential 0.31
Capitation Rate $ 79.33
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: Adult
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 21.372 5.536 3.082 4.726 0.000 12.855 0.240
2. Eligibility Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 21.372 5.536 3.082 4.726 0.000 12.855 0.240
4. Average Cost Per Unit $ 100.08 $ 16.10 998.85 $ 15.92 $ 0.00 $ 37.45 $ 54.29 $ 1,222.69
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 104.88 $ 16.10 $ 998.85 $ 15.92 $ 0.00 $ 37.45 $ 54.29 $ 1,227.49
6. Contract Adjustments
a.Mental Health 0.999 0.999 1.000 0.991 1.000 0.997 0.996
b.Long Term Care 1.000 1.000 1.000 1.000 1.000 1.000 1.000
c.Procedure Adjs. 1.000 1.000 1.000 1.000 1.000 0.867 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 2,228.06 $ 88.60 $ 3,063.06 $ 74.19 $ 0.00 $ 414.06 $ 12.91 $ 5,880.88
8. Legislative Adjustment 1.022 1.052 0.993 1.004 1.038 1.023 1.023
9. Trend Adjustments
a.Cost per Unit 0.961 1.162 1.023 0.886 1.015 1.096 1.000
b.Units per Eligible 0.950 0.998 1.000 1.155 1.000 0.950 1.000
Projected Cost per Eligible $ 2,078.86 $ 108.09 $ 3,111.58 $ 76.22 $ 0.00 $ 441.03 $ 13.21 $ 5,828.99
Preliminary Monthly Rate $ 485.75
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 29.15
14. FQHC County Cost Differential 0.77
Capitation Rate $ 515.67
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 355
Plan Type: Commercial Plan Base Period: FY 95/96
County: Riverside
Aid Code Grouping: AIDS
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 22.646 65.596 3.118 7.972 0.000 39.287 0.360
2. Eligibility Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.646 65.596 3.118 7.972 0.000 39.287 0.360
4. Average Cost Per Unit $ 31.10 $ 92.80 867.73 $ 19.90 $ 0.00 $ 50.87 $ 72.26 $ 1,134.66
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 32.59 $ 92.80 $ 867.73 $ 19.90 $ 0.00 $ 50.87 $ 72.26 $ 1,136.15
6. Contract Adjustments
a.Mental Health 0.934 0.990 1.000 0.993 1.000 0.988 0.959
b.Long Term Care 1.000 1.000 1.000 1.000 0.456 1.000 1.000
c.Procedure Adjs. 1.000 0.819 1.000 1.000 1.000 0.592 1.000
d.Viral Testing 1.000 1.082 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 685.88 $ 5,313.67 $ 2,692.05 $ 156.74 $ 0.00 $ 1,163.09 $ 24.82 $ 10,036.25
8. Legislative Adjustment 1.004 1.073 0.993 1.004 1.038 1.001 1.001
9. Trend Adjustments
a.Cost per Unit 0.954 1.161 1.032 0.977 1.042 1.032 1.000
b.Units per Eligible 0.903 1.045 0.950 0.950 1.000 1.045 1.000
Projected Cost per Eligible $ 593.22 $ 6,917.40 $ 2,620.81 $ 146.06 $ 0.00 $ 1,255.58 $ 24.84 $ 11,557.91
Preliminary Monthly Rate $ 963.16
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 57.79
14. FQHC County Cost Differential 0.54
Capitation Rate $ 1,021.49
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: Family
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 4.127 4.686 0.263 2.139 0.002 3.495 0.120
2. Eligibility Adjustment 0.987 0.994 0.967 0.985 1.000 0.982 1.000
3. Age/sex Adjustment 1.016 0.995 1.026 1.010 1.000 1.005 1.000
Adjusted Units 4.139 4.635 0.261 2.128 0.002 3.449 0.120
4. Average Cost Per Unit $ 67.40 $ 16.48 1,023.54 $ 17.95 $ 115.00 $ 22.23 $ 64.52 $ 1,327.12
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 70.64 $ 16.48 $ 1,023.54 $ 17.95 $ 115.00 $ 22.23 $ 64.52 $ 1,330.36
6. Contract Adjustments
a.Mental Health 0.978 0.995 1.000 0.955 0.994 0.919 0.949
b.Long Term Care 1.000 1.000 1.000 1.000 0.335 1.000 1.000
c.Procedure Adjs. 0.999 1.000 1.000 1.000 1.000 0.913 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 284.23 $ 75.62 $ 265.81 $ 36.30 $ 0.08 $ 64.01 $ 7.31 $ 733.36
8. Legislative Adjustment 1.026 1.052 0.993 1.004 1.038 1.027 1.027
9. Trend Adjustments
a.Cost per Unit 1.036 1.146 1.048 0.967 1.123 1.046 1.000
b.Units per Eligible 0.950 1.100 0.998 1.045 1.000 1.050 1.000
Projected Cost per Eligible $ 287.01 $ 100.28 $ 276.07 $ 36.83 $ 0.09 $ 72.20 $ 7.51 $ 779.99
Preliminary Monthly Rate $ 65.00
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 4.60
12. 0.00
13. Fee-for-Service Adjustment 6.0% 4.18
14. FQHC County Cost Differential 0.26
Capitation Rate $ 74.04
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: Aged
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 3.770 19.658 0.982 2.464 0.554 13.308 0.120
2. Eligibility Adjustment 0.969 1.014 0.965 0.985 1.000 1.015 1.000
3. Age/sex Adjustment 0.987 1.002 0.995 0.990 1.032 1.005 1.000
Adjusted Units 3.606 19.973 0.943 2.403 0.572 13.575 0.120
4. Average Cost Per Unit $ 47.81 $ 30.45 952.39 $ 10.85 $ 69.41 $ 5.85 $ 43.50 $ 1,160.26
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 50.10 $ 30.45 $ 952.39 $ 10.85 $ 69.41 $ 5.85 $ 43.50 $ 1,162.55
6. Contract Adjustments
a.Mental Health 0.991 0.996 1.000 0.986 0.996 0.958 0.989
b.Long Term Care 1.000 1.000 1.000 1.000 0.196 1.000 1.000
c.Procedure Adjs. 0.990 1.000 1.000 1.000 1.000 0.799 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 176.36 $ 602.72 $ 893.61 $ 25.58 $ 7.71 $ 60.48 $ 5.14 $ 1,771.60
8. Legislative Adjustment 1.004 1.033 0.907 0.917 1.038 1.001 1.001
9. Trend Adjustments
a.Cost per Unit 0.865 1.105 1.079 1.036 1.034 1.049 1.000
b.Units per Eligible 0.950 1.050 1.050 1.100 1.000 1.045 1.000
Projected Cost per Eligible $ 145.50 $ 722.38 $ 918.26 $ 26.73 $ 8.28 $ 66.36 $ 5.15 $ 1,892.66
Preliminary Monthly Rate $ 157.72
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 9.46
14. FQHC County Cost Differential 0.07
Capitation Rate $ 167.25
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: Disabled
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 6.679 24.089 1.155 4.742 0.176 20.858 0.120
2. Eligibility Adjustment 0.995 1.001 0.976 0.991 0.999 0.996 1.000
3. Age/sex Adjustment 0.998 0.976 0.981 1.006 1.003 0.993 1.000
Adjusted Units 6.632 23.534 1.106 4.728 0.176 20.629 0.120
4. Average Cost Per Unit $ 45.69 $ 35.66 1,064.73 $ 13.05 $ 100.13 $ 9.33 $ 72.26 $ 1,340.85
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 47.88 $ 35.66 $ 1,064.73 $ 13.05 $ 100.13 $ 9.33 $ 72.26 $ 1,343.04
6. Contract Adjustments
a.Mental Health 0.894 0.882 1.000 0.972 0.994 0.949 0.909
b.Long Term Care 1.000 1.000 1.000 1.000 0.099 1.000 1.000
c.Procedure Adjs. 0.998 0.997 1.000 1.000 1.000 0.918 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 281.90 $ 734.28 $ 1,171.70 $ 59.67 $ 1.73 $ 166.84 $ 7.84 $ 2,423.96
8. Legislative Adjustment 1.010 1.034 0.908 0.918 1.039 1.007 1.007
9. Trend Adjustments
a.Cost per Unit 0.954 1.161 1.032 0.977 1.042 1.032 1.000
b.Units per Eligible 0.950 1.050 0.950 1.050 1.000 0.998 1.000
Projected Cost per Eligible $ 258.04 $ 925.56 $ 1,043.05 $ 56.19 $ 1.87 $ 173.04 $ 7.89 $ 2,465.64
Preliminary Monthly Rate $ 205.47
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 12.33
14. FQHC County Cost Differential 0.07
Capitation Rate $ 217.87
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: Child
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 3.962 3.669 0.332 1.521 0.000 2.012 0.120
2. Eligibility Adjustment 1.019 1.003 1.034 1.026 1.000 1.021 1.000
3. Age/sex Adjustment 1.168 1.009 1.237 1.095 1.000 1.072 1.000
Adjusted Units 4.716 3.713 0.425 1.709 0.000 2.202 0.120
4. Average Cost Per Unit $ 65.30 $ 11.46 1,022.12 $ 17.74 $ 0.00 $ 24.55 $ 60.59 $ 1,201.76
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 68.43 $ 11.46 $ 1,022.12 $ 17.74 $ 0.00 $ 24.55 $ 60.59 $ 1,204.89
6. Contract Adjustments
a.Mental Health 0.976 0.989 1.000 0.974 0.993 0.911 0.982
b.Long Term Care 1.000 1.000 1.000 1.000 0.140 1.000 1.000
c.Procedure Adjs. 0.999 1.000 1.000 1.000 1.000 0.917 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 313.08 $ 41.87 $ 432.23 $ 29.38 $ 0.00 $ 44.93 $ 7.10 $ 868.59
8. Legislative Adjustment 1.026 1.052 0.993 1.004 1.038 1.023 1.023
9. Trend Adjustments
a.Cost per Unit 0.967 1.085 1.024 0.933 1.178 1.091 1.000
b.Units per Eligible 0.950 1.050 0.950 1.045 1.000 1.100 1.000
Projected Cost per Eligible $ 295.09 $ 50.18 $ 417.53 $ 28.76 $ 0.00 $ 55.16 $ 7.26 $ 853.98
Preliminary Monthly Rate $ 71.17
10. Stop Loss Reinsurance $ 0 0.0% 00.00
11. CHDP 3.46
12. 0.00
13. Fee-for-Service Adjustment 6.0% 4.48
14. FQHC County Cost Differential 0.31
Capitation Rate $ 79.42
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: Adult
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 21.492 5.536 3.082 4.726 0.000 12.855 0.120
2. Eligibility Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 21.492 5.536 3.082 4.726 0.000 12.855 0.120
4. Average Cost Per Unit $ 100.08 $ 16.10 1,055.89 $ 15.92 $ 0.00 $ 37.45 $ 54.29 $ 1,279.73
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 104.88 $ 16.10 $ 1,055.89 $ 15.92 $ 0.00 $ 37.45 $ 54.29 $ 1,284.53
6. Contract Adjustments
a.Mental Health 0.999 0.999 1.000 0.991 1.000 0.997 0.996
b.Long Term Care 1.000 1.000 1.000 1.000 1.000 1.000 1.000
c.Procedure Adjs. 1.000 1.000 1.000 1.000 1.000 0.867 1.000
d. 1.000 1.000 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 2,240.57 $ 88.60 $ 3,237.98 $ 74.19 $ 0.00 $ 414.06 $ 6.46 $ 6,061.86
8. Legislative Adjustment 1.022 1.052 0.993 1.004 1.038 1.023 1.023
9. Trend Adjustments
a.Cost per Unit 0.961 1.162 1.023 0.886 1.015 1.096 1.000
b.Units per Eligible 0.950 0.998 1.000 1.155 1.000 0.950 1.000
Projected Cost per Eligible $ 2,090.53 $ 108.09 $ 3,289.27 $ 76.22 $ 0.00 $ 441.03 $ 6.61 $ 6,011.75
Preliminary Monthly Rate $ 500.98
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 30.06
14. FQHC County Cost Differential 0.38
Capitation Rate $ 531.42
Plan Name: Xxxxxx Medical Center Date: 12-Aug-98
Plan Number: 356
Plan Type: Commercial Plan Base Period: FY 95/96
County: San Bernardino
Aid Code Grouping: AIDS
The Rate Period is October 1, 1997 to September 30, 1998
Capitation Payments at the Beginning of the Month
Stop Loss Reinsurance has not been elected
CCS indicated claims are not covered
Eye appliances are provided by PIA
The plan is not responsible for Mental Health services
The plan is responsible for Long Term Care Services in the month of admission
and the next month only
The plan provides CHDP Services
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other FQHC Total
1. Base Units per Eligible 22.886 65.596 3.118 7.972 0.000 39.287 0.120
2. Eligibility Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Age/sex Adjustment 1.000 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Units 22.886 65.596 3.118 7.972 0.000 39.287 0.120
4. Average Cost Per Unit $ 31.10 $ 92.80 1,064.73 $ 19.90 $ 0.00 $ 50.87 $ 72.26 $ 1,331.66
5. Area Adjustment 1.048 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Cost $ 32.59 $ 92.80 $ 1,064.73 $ 19.90 $ 0.00 $ 50.87 $ 72.26 $ 1,333.15
6. Contract Adjustments
a.Mental Health 0.934 0.990 1.000 0.993 1.000 0.988 0.959
b.Long Term Care 1.000 1.000 1.000 1.000 0.456 1.000 1.000
c.Procedure Adjs. 1.000 0.819 1.000 1.000 1.000 0.592 1.000
d.Viral Testing 1.000 1.082 1.000 1.000 1.000 1.000 1.000
7. Interest Adjustment 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Contract Cost per Eligible $ 693.15 $ 5,313.67 $ 3,303.23 $ 156.74 $ 0.00 $ 1,163.09 $ 8.27 $ 10,638.15
8. Legislative Adjustment 1.004 1.073 0.993 1.004 1.038 1.001 1.001
9. Trend Adjustments
a.Cost per Unit 0.954 1.161 1.032 0.977 1.042 1.032 1.000
b.Units per Eligible 0.903 1.045 0.950 0.950 1.000 1.045 1.000
Projected Cost per Eligible $ 599.51 $ 6,917.40 $ 3,215.82 $ 146.06 $ 0.00 $ 1,255.58 $ 8.28 $ 12,142.65
Preliminary Monthly Rate $ 1,011.89
10. Stop Loss Reinsurance $ 0 0.0% 0.00
11. CHDP 0.00
12. 0.00
13. Fee-for-Service Adjustment 6.0% 60.71
14. FQHC County Cost Differential 0.18
Capitation Rate $ 1,072.78
STATE OF CALIFORNIA CONTRACT NUMBER AM. NO.
95-23637 04
STANDARD AGREEMENT -- APPROVED BY THE TAXPAYER'S FEDERAL ID NO.
STD. 2(REV 5-91) ATTORNEY GENERAL 00-0000000
THIS AGREEMENT, made and entered into this 15th day of August, 1999 in the
State of California, by and between State of California, through its duly
elected or appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
MOLINA, hereafter called the Contractor.
WTTNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed,
Does hereby agree to furnish to the State services and materials as follows:
(Set forth services to be rendered by Contractor, amount to be paid Contractor,
Time for performance or completion, and attach plans and specifications, if
any.)
ARTICLE I - PREAMBLE
Amendment A04 to Contract No.95-23637 BETWEEN XXXXXX MEDICAL CENTERS, INC., AND
THE STATE OF CALIFORNIA;
WHEREAS, the State of California and Xxxxxx Medical Centers, Inc., entered into
a contract to provide health care services to Medi-Cal beneficiaries dated April
2, 1996; and
NOW THEREFORE, this Contract is amended as follows:
CONTINUED ON 1 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
====================================================================================================================================
STATE OF CALIFORNIA CONTRACTOR
------------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (if other than an individual, state whether a corporation, partnership, etc.)
Department of Health Services Molina
------------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ Xxxxx Xxxxxx for /s/
------------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME OF AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx XXXXX XXXXXX CHIEF Xxxxxx Xxxxxxxxx, President
CONTRACT MANAGEMENT UNIT
------------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
------------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE Department of General
DOCUMENT Loc.Asst.Section 14157, W&I Code Health Care Deposit Services Use Only
$ 0 ----------------------------------------------------------------------------------------
------------------------------ (OPTIONAL USE)
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ----------------------------------------------------------------------------------------
$ 420,053,310 ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 50 1999 99/00 Exempt From PCC per
TOTAL AMOUNT ENCUMBERED TO ---------------------------------------------------------------W&I Code Section
DATE OBJECT OF EXPENDITURE (CODE AND TITLE)
$ 420,053,310 0000-000-00000 14087.4
-----------------------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. I.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
-----------------------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ Xxxxxx Xxxxxxxx 08/30/99
===========================================================================================================
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91)(REVERSE)
1. The contractor agrees to indemnify, defend and save harmless the State, its
officers, agents and employees from any and all claims and losses accruing
or resulting to any and all contractors, subcontractors, materialmen,
laborers and any other person, firm or corporation furnishing or supplying
work services, materials or supplies in connection with the performance of
this contract, and from any and all claims and losses accruing or resulting
to any person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and not
as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment of
any consideration to Contractor should Contractor fail to perform the
covenants herein contained at the time and in the manner herein provided.
In the event of such termination, the State may proceed with the work in
any manner deemed proper by the State. The cost to the state shall be
deducted from any sum due the Contractor under this agreement, and the
balance, if any, shall be paid the Contractor upon demand.
4. Without the written consent of the State, this agreement is not assignable
by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid
unless made in writing and signed by the parties hereto, and no oral
understanding or agreement not incorporated herein, shall be binding on any
of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in
compensation for all of Contractor's expenses incurred in the performance
hereof, including travel and per diem, unless otherwise expressly so
provided.
MOLINA 95-23637-A04
1. ARTICLE III - GENERAL TERMS AND CONDITIONS, Section 3.15 Term, paragraph
two, is amended to read:
3.15 TERM
The term of the Contract consists of the following three periods: 1) The
Implementation Period shall extend from March 1,1996 to June 1,1996; 2) The
Operations Period shall extend from June 1,1996 to March 1,2002, subject to
the termination provisions of Sections 3.18, Termination and 3.19,
Sanctions, and subject to the limitation provisions of Article V, Payment
Provisions, Section 5.2, Amounts Payable; and 3) The Turnover/Phaseout
Period shall extend for six (6) months from the end of the Operations
Period, subject to the provisions of Section 3.16, Contract Extension, in
which case the Turnover/Phaseout shall apply to the six (6) month period
beginning the first day after the end of the Operations Period, as
extended.
2. The Contractor name, Xxxxxx Medical Centers, Inc., has been changed to
Molina. Therefore, all references in this Contract to Xxxxxx Medical
Centers, Inc shall be retitled as Molina.
3. The effective date of this Amendment shall be August 15,1999.
4. All rights, obligations, duties and Liabilities of the parties hereto
otherwise remain unchanged.
2
CONTRACT NUMBER AM. NO.
95-23637 05
STANDARD AGREEMENT -- APPROVED BY THE TAXPAYER'S FEDERAL ID NUMBER
STD. 2(REV.5-91) ATTORNEY GENERAL 00-0000000
THIS AGREEMENT, made and entered into this 1 day of September, 2000 in the
State of California, by and between State of California, through its duly
elected or appointed, qualified and acting
TITLE Of OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
Molina, hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed does
hereby agree to furnish to the State services and materials as follows: (Set
forth services to be rendered by Contractor, amount to be paid Contractor, time
for performance or completion, and attach plans and specifications, if any.)
AMENDMENT A-05 TO CONTRACT NUMBER 95-23637 BETWEEN MOLINA AND THE STATE OF
CALIFORNIA; AND
WHEREAS, the State of California and Molina entered into a Contract to provide
health care services to Medi-Cal beneficiaries dated April 1, 1996, and;
NOW THEREFORE, this Contract is amended as follows:
CONTINUED ON 7 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
================================================================================================================================
STATE OF CALIFORNIA CONTRACTOR
--------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (if other than an individual, state whether a corporation, partnership,
Department of Health Services etc.)
Molina
-------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ Xxxxxx Xxxxxx Roh for /s/
-------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME OF AND TITLE OF PERSON SIGNING
Xxxxxx Xxxxxxxxx Xxxxxx Xxxxxx Roh, Chief Xxxxxx Xxxxxxxxx, President
CMU PRoduction
-------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx, Xxxx Xxxxx, XX 00000
-------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE
DOCUMENT Loc.Asst.Section 14157 W&I Health Care Deposit
$ -0- ------------------------------------------------------------
------------------------------ (OPTIONAL USE)
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ------------------------------------------------------------
$ 527,053,310 ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 51 2000 00/01 Exempt From PCC per
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------ W&I Code Section
DATE OBJECT OF EXPENDITURE (CODE AND TITLE) 14087.4
$ 527,053,310 0000-000-00000
----------------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
----------------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ 11-14-00
====================================================================================================
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91)(REVERSE)
1. The Contractor agrees to indemnify, defend and save harmless the State, its
officers, agents and employees from any and all claims and losses accruing
or resulting to any and all contractors, subcontractors, materialmen,
laborers and any other person, firm or corporation furnishing or supplying
work services, materials or supplies in connection with the performance of
this contract, and from any and all claims and losses accruing or resulting
to any person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and not
as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment of
any consideration to Contractor should Contractor fail to perform the
covenants herein contained at the time and in the manner herein provided.
In the event of such termination, the State may proceed with the work in
any manner deemed proper by the State. The cost to the State shall be
deducted from any sum due the Contractor under this agreement, and the
balance, if any, shall be paid the Contractor upon demand.
4. Without the written consent of the State, this agreement is not assignable
by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid
unless made in writing and signed by the parties hereto, and no oral
understanding or agreement not incorporated herein, shall be binding on any
of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in
compensation for all of Contractor's expenses incurred in the performance
hereof, including travel and per diem, unless otherwise expressly so
provided.
Molina. 95-23637-A05
TABLE OF CONTENTS
ARTICLE II DEFINITIONS Pg 2
ARTICLE III GENERAL TERMS AND CONDITIONS Pg 11
3.12 Inspection Rights Pg 2
3.18.3 Mandatory Termination Pg 3
3.28.2 Subcontract Requirements Pg 3
ARTICLE VI SCOPE OF WORK
6.3.3 Monthly Financial Statement Pg 5
6.3.4 Compliance with Audit Requirements Pg 5
6.9.5 Membership Services Guide Pg 5
1
Molina. 95-23637 A-05
1. ARTICLE II, DEFINITIONS, SECTION Q, DMHC IS AMENDED TO READ:
Q. DMHC means the State Department of Managed Health Care, which is
responsible for administering the Xxxx-Xxxxx Act of 1975.
2. ARTICLE II, DEFINITIONS, SECTION PP, DMHC IS AMENDED TO READ:
PP. Xxxx-Xxxxx Health Care Service Plan Act of 1975 means the law,
which regulates HMOs and is administrated by the Department of
Managed Health Care (DMHC), commencing with Section 1340, Health
and Safety Code.
3. ARTICLE III, GENERAL TERMS AND CONDITIONS, SECTION 3.11 INSPECTION RIGHTS,
IS AMENDED TO READ:
3.11 INSPECTION RIGHTS
Through the end of the records retention period specified in
Section 3.32.2, Records Retention, Contractor shall allow DHS,
DHHS, the Comptroller General of the United States, Department of
Justice (DOJ), Bureau of Medi-Cal Fraud, Department of Managed
Health Care (DMHC), and other authorized State agencies, or their
duly authorized representative, including DHS' external quality
review organization contractor, to inspect, monitor or otherwise
evaluate the quality, appropriateness, and timeliness of services
performed under this Contract, and to inspect, evaluate, and
audit any and all books, records, and Facilities maintained by
Contractor and subcontractors pertaining to these services at any
time during normal business hours.
Books and records include, but are not limited to, all physical
records originated or prepared pursuant to the performance under
this Contract, including working papers, reports, financial
records, and books of account, Medical Records, prescription
files, laboratory results, Subcontracts, information systems and
procedures, and any other documentation pertaining to medical and
non-medical services rendered to Members. Upon request, through
the end of the records retention period specified in Section
3.32.2, Records Retention, Contractor shall furnish any record,
or copy of it, to DHS or any other entity in this section, at
Contractor's sole expense.
2
Molina. 95-23637-A05
4. ARTICLE III, GENERAL TERMS AND CONDITIONS, SECTION 3.18.3, MANDATORY
TERMINATION, IS AMENDED TO READ:
3.18.3 MANDATORY TERMINATION
DHS will terminate this Contract in the event that: (1) the
Secretary, DHHS, determines that the Contractor does not meet the
requirements for participation in the Medicaid program, Title XIX
of the Social Security Act, or (2) the Department of Managed
Health Care finds that the Contractor no longer qualifies for
licensure under the Xxxx-Xxxxx Health Care Service Plan Act by
giving written notice to the Contractor. Notification will be
given by DHS at least sixty (60) days prior to the effective date
of termination, except in cases where the Director determines the
health and welfare of Members is jeopardized by continuation of
the Contract, in which case the Contract will be immediately
terminated. Notification will state the effective date of, and
the reason for, the termination.
Under these circumstances, termination of the Contract will be
effective on the last day of the month in which the Secretary,
DHHS, or the DMHC makes such determination, provided that DHS
provides the Contractor with at least 60 days notice of
termination. The termination of this Contract will be effective
on the last day of the second full month from the date of the
notice of termination. Contractor agrees that 60 days notice is
reasonable. Termination under this section does not relieve the
Contractor of its obligations under the Turnover and Phaseout
Requirements, Section 3.17 through 3.17.4, except that these
requirements may be performed after Contract termination.
5. ARTICLE III, GENERAL TERMS AND CONDITIONS, SECTION 3.27.2, SUBCONTRACT
REQUIREMENTS, IS AMENDED TO READ:
3.27.2 SUBCONTRACT REQUIREMENTS
Each Subcontract will contain:
A. The subcontractor's agreement to make all of its books and
records, pertaining to the goods and services furnished
under the terms of the Subcontract, available for
inspection, examination or copying:
1. By DHS, DHHS, DOJ, DMHC
2. At all reasonable times at the subcontractor's place of
business or at such other mutually agreeable location
in California.
3
Molina. 95-23637 A-05
3. In a form maintained in accordance with the general
standards applicable to such book or record keeping
4. For a term of at least five years from the close of DHS
fiscal year in which the Subcontract was in effect.
5. Including all Encounter data for a period of at least
five years.
B. Full disclosure of the method and amount of compensation or
other consideration to be received by the subcontractor from
the Contractor.
C. Subcontractor's agreement to maintain and make available to
DHS, upon request, copies of all sub-subcontracts and to
ensure that all sub-subcontracts are in writing and require
that the sub-contractor:
1. Make all applicable books and records available at all
reasonable times for inspection, examination, or
copying by DHS, DHHS, DOJ and DMHC.
2. Retain such books and records for a term of at least
five years from the close of DHS' fiscal year in which
the sub-contract is in effect.
D. Subcontractor's agreement to assist Contractor in the
transfer of care pursuant to Section 3.17.2, Turnover
Requirements, in the event of Contract termination.
E. Subcontractor's agreement to notify DHS in the event the
agreement with the Contractor is amended or terminated.
Notice is considered given when properly addressed and
deposited in the United States Postal Service as first class
registered mail, postage attached.
F. Subcontractor's agreement that assignment or delegation of
the Subcontract will be void unless prior written approval
is obtained from DHS.
G. Subcontractor's agreement to hold harmless both the State
and plan Members in the event the Contractor cannot or will
not pay for services performed by the subcontractor pursuant
to the Subcontract.
H. Subcontractor's agreement to provide Contractor with
Encounter level data in the manner consistent with DHS
requirements.
4
Molina. 95-23637 A-05
I. Subcontracts with safety-net providers will include
Contractor and subcontractor's agreement to notify DHS upon
termination of the subcontract.
J. Subcontractor's agreement to timely gather, preserve and
provide to DHS, any records in the Subcontractor's
possession, in accordance with Section 3.45, Records Related
to Recovery for Tobacco Related Illnesses.
6. ARTICLE VI, SCOPE OF WORK, SECTION 6.3.3, MONTHLY FINANCIAL STATEMENT, IS
AMENDED TO READ:
6.3.3 MONTHLY FINANCIAL STATEMENT
The Contractor may be required to file monthly Financial
Statements at DHS' request. If the Contractor is required to file
monthly Financial Statements with DMHC, they will file monthly
Financial Statements with DHS.
7. ARTICLE VI, SCOPE OF WORK, SECTION 6.3.4, COMPLIANCE WITH AUDIT
REQUIREMENTS, IS AMENDED TO READ:
6.3.4 COMPLIANCE WITH AUDIT REQUIREMENTS
The Contractor will cooperate with DHS' own independent audits
annually or as necessary for good cause, at the discretion of
DHS. Such audits may be waived upon submission of the financial
audit for the same period conducted by DMHC pursuant to Section
1382 of the Health and Safety Code.
8. ARTICLE VI, SCOPE OF WORK, SECTION 6.9.5, MEMBERSHIP SERVICES GUIDE, IS
AMENDED TO READ:
6.9.5 MEMBERSHIP SERVICES GUIDE
Contractor shall develop and distribute a Membership Services
Guide that includes the following information:
A. The name address and telephone number of the health plan.
B. A description of the full scope of Medi-Cal covered benefits
and all available services including health education,
interpretive services, and "carve out" services and an
explanation of any service limitations and exclusions from
coverage or charges for services.
5
Molina. 95-23637 A-05
C. Procedures for obtaining Covered Services including the
address and telephone number of each Service Site (locations
of hospital, Primary Care Physicians, optometrists,
psychologists, pharmacies, Skilled Nursing Facilities,
Urgent Care Facilities). In the case of a medical foundation
or independent practice association, the address and
telephone number of each Physician provider.
1. The hours and days when each of these facilities is
open, the services and benefits available, and the
telephone number to call after normal business hours.
D. Procedures for selecting or requesting a change in Primary
Care Physician, including requirements for a change in PCP,
reasons for which a request may be denied, and reasons why a
provider may request a change.
E. The purpose and value of scheduling an initial health
assessment appointment.
F. The appropriate use of health care services in a managed
care system.
G. The availability and procedures for obtaining after hours
services (24 hour basis) and care, including the appropriate
provider locations and telephone numbers.
H. Procedure for obtaining emergency health care both within
and outside Contractor's Service Area.
I. Process for referral to specialists.
J. Procedures for obtaining any non-medical transportation
services offered by Contractor and through the local CHDP
programs, and how to obtain such services.
K. The causes for which a Member shall lose entitlement re
receive services under this Contract.
L. Procedures for filing a complaint/Grievance, including
procedures for appealing decisions regarding Members'
coverage, benefits, or relationship to the organization.
Include the title, address, and telephone number of the
person responsible for processing and resolving
complaints/Grievances.
6
Molina. 95-23637 A-05
M. Procedures for Disenrollment, including an explanation of
the Member's right to disenroll without cause at any time,
subject to any restricted disenrollment period.
N. Information on the Member's right to the Medi-Cal fair
hearing process regardless of whether or not a
complaint/Grievance has been submitted or if the
complaint/Grievance has been resolved, pursuant to Title 22,
CCR, Section 53452, when a health care service requested by
the Member or provider has been denied, deferred or
modified. The State Department of Social Services' Public
Inquiry and Response Unit toll free telephone number (800)
952-5253.
O. Information on the availability of, and procedures for
obtaining, services at FQHCs and Indian Health Clinics.
P. Information on the Member's right to seek family planning
services from any qualified provider of family planning
services, under the Medi-Cal program, including providers
outside Contractor's provider network, and a description of
those services, such as the following statement:
"Family planning services are provided to Members of child
bearing age to enable them to determine the number and
spacing of children. These services include all methods of
birth control approved by the Federal Food and Drug
Administration. As a Member, you pick a doctor who is
located near you and will give you the services you need.
Our Primary Care Physicians and OB/GYN specialists are
available for family planning services. For family planning
services, you may also pick a doctor or clinic not connected
with Molina without having to get permission from Molina.
Molina shall pay that doctor or clinic for the family
planning services you get."
Q. The DHS' Office of Family Planning's toll free telephone
number (0-000-000-0000) providing consultation and referral
to family planning clinics.
R. Any other information determined by the DHS to be essential
for the proper receipt of Covered Services.
S. Information on the availability of, and procedures for
obtaining, Certified Nurse Midwife and Certified Nurse
Practitioner services, pursuant to Section 6.7.4.14, Nurse
Midwife and Nurse Practitioner Services.
7
Molina. 95-23637 A-05
T. Information on the availability of transitional Medi-Cal
eligibility and how the Member may apply for this program.
Contractor shall include this information with all
membership Services Guides sent to Members after the date
such information is furnished to Contractor by DHS.
U. Information on how to access State resources for
investigation and resolution of Member complaints, including
the DHS Medi-Cal Managed Care Ombudsman and toll-free
telephone number (0-000-000-0000) and the DMHC HMO Consumer
Service toll-free telephone Number (0-000-000-0000).
V. Information concerning the provision and availability of
services covered under the CCS program from providers
outside Contractor's provider network and how to access
these services.
W. An explanation of the expedited disenrollment process for
children receiving services under the Xxxxxx Care or
Adoption Assistance Programs; Members with special health
care needs, including, but not limited to major organ
transplants; and Members already enrolled in another
Medi-Cal, Medicare or commercial managed care plan.
X. Information how to obtain Minor Consent Services through
Contractor's plan, and an explanation of those services.
Y. A brief explanation on how to use the fee-for-service system
when Medi-Cal covered services are excluded or limited under
this Contract and how to obtain additional information.
Z. An explanation of an American Indian Member's right to
access Indian Health Service Facilities and to disenroll
from Contractor's plan at any time, without cause.
AA. Subsections S through Z above, except subsections T, shall
be included in Contractor's Membership Services Guide by
April 1, 1999, or upon the next reprinting of Contractor's
Membership Services Guide, whichever is sooner.
9. The effective date of this Amendment is September 1, 2000.
10. All rights duties, liabilities, and obligations of the parties hereto
otherwise remain unchanged.
8
STATE OF CALIFORNIA CONTRACT NUMBER AM. NO.
95-23637 6
STANDARD AGREEMENT -- APPROVED BY THE TAXPAYER'S FEDERAL ID NUMBER
STD. 2(REV.5-91) ATTORNEY GENERAL 00-0000000
THIS AGREEMENT, made and entered into this 1st day of July, 2001 in the
State of California, by and between State of California, through its duly
elected or appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services,
hereafter called the State, and
CONTRACTOR'S NAME
Xxxxxx Healthcare of California dba: Molina, hereafter called the Contractor:
WITNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed does
hereby agree to furnish to the State services and materials as follows: (Set
forth services to be rendered by Contractor, amount to be paid contractor. time
for performance or completion, and attach plans and specifications, if any.)
AMENDMENT A-6 TO CONTRACT XX.00-00000 XXXXXXX XXXXXX XXXXXXXXXX XX XXXXXXXXXX,
dba: MOLINA AND THE STATE OF CALIFORNIA; AND
WHEREAS, the State of California and Xxxxxx Healthcare of California, dba:
Molina entered into a Contract to provide health care services to Medi-Cal
beneficiaries dated April 2, 1996, and;
NOW THEREFORE, this Contract is amended as follows:
CONTINUED ON 5 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
The provisions on the reverse side hereof constitute a part of this agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
===============================================================================================================================
STATE OF CALIFORNIA CONTRACTOR
-------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (If other than an individual, state whether a corporation, partnership,
etc.)
Department of Health Services Xxxxxx Healthcare of California, dba: Molina
-------------------------------------------------------------------------------------------------------------------------------
BY (AUTHORIZED SIGNATURE) BY (AUTHORIZED SIGNATURE)
/s/ for /s/
-------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME OF AND TITLE OF PERSON SIGNING
Xxxxxx Xxxxxxxxx Xxxxxx Xxxxxx Roh, Chief J. Xxxxx Xxxxxx, CEO
CMU Production
-------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx Xxxxx, Xxxx Xxxxx, XX 00000
-------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE
DOCUMENT Loc.Asst.Section 14157 W&I Health Care Deposit
$ -0- ------------------------------------------------------------
------------------------------ (OPTIONAL USE)
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT ------------------------------------------------------------
$ 527,053,310 ITEM CHAPTER STATUTE FISCAL YEAR
------------------------------ 0000-000-000 52 2000 00/01 Exempt From PCC per
TOTAL AMOUNT ENCUMBERED TO ------------------------------------------------------------ W&I Code Section
DATE OBJECT OF EXPENDITURE (CODE AND TITLE)
$ 527,053,310 0000-000-00000 14087.4
----------------------------------------------------------------------------------------------------------
I hereby certify upon my own personal T.B.A. NO. B.R. NO.
knowledge that budgeted funds are
available for the period and purpose
of the expenditure stated above.
----------------------------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
/s/ 5/24/01
==========================================================================================================
[ ] CONTRACTOR [ ] STATE AGENCY [ ] DEPT. OF GEN. SER. [ ] CONTROLLER [ ]
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91) (REVERSE)
1. The contractor agrees to indemnify, defend and save harmless the State, its
officers, agents and employees from any and all claims and losses accruing
or resulting to any and all contractors, subcontractors, materialmen,
laborers and any other person, firm or corporation furnishing or supplying
work services, materials or supplies in connection with the performance of
this contract, and from any and all claims and losses accruing or resulting
to any person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and not
as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment of
any consideration to Contractor should Contractor fail to perform the
covenants herein contained at the time and in the manner herein provided.
In the event of such termination the State may proceed with the work in
any manner deemed proper by the State. The cost to the state shall be
deducted from any sum due the Contractor under this agreement, and the
balance, if any, shall be paid the Contractor upon demand.
4. Without the written consent of the State, this agreement is not assignable
by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be valid
unless made in writing and signed by the parties hereto, and no oral
understanding or agreement not incorporated herein, shall be binding on any
of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in
compensation for all of Contractor's expenses incurred in the performance
hereof, including travel and per diem, unless otherwise expressly so
provided.
XXXXXX HEALTHCARE XX XXXXXXXXXX 00-00000 A-06
DBA: MOLINA
1. ARTICLE II - DEFINITIONS, SECTION Y, ELIGIBLE BENEFICIARY IS AMENDED TO
READ:
"Y. Eligible Beneficiary means any Medi-Cal beneficiary who is
residing in Contractor's Service Area with one of the following
aid codes: Family: 01,OA, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40,
42, 47, 54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 0X, 0X,
0X, 0X, 0X, 0X, 0X; Aged: 1H, 10, 14, 16, 18; Disabled: 20, 24,
26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R; Child: 03,
04, 4A, 4C, 4K, 5K, 45, 0X, 0X, 0X, 00; Adult: 86; with the
following exclusions:
1. Individuals who have been approved by the Medi-Cal Field
Office or the California Children Services Program for bone
marrow, heart, heart-lung, liver, lung, combined liver, and
kidney, or combined liver and small bowel transplants.
2. Individuals who elect and are accepted to participate in the
following Medi-Cal waiver programs: In-Home Medical Care
Waiver Program, the Skilled Nursing Facility Waiver Program,
the Model Waiver Program, the Acquired Immune Deficiency
(AIDS) and AIDS Related Conditions Waiver Program, and the
Multipurpose Senior Services Waiver Program.
3. Individuals determined by the Medi-Cal Field Office to be in
need of long term care and residing in a Skilled Nursing
Facility (SNF) for 30 days past the month of admission.
4. Individuals who have commercial or Medicare HMO coverage,
unless the Medicare HMO is a provider under this Contract
and DHS has agreed, as a term of the HMO's Contract, that
these individuals may be enrolled, and DHS and the Medicare
HMO have negotiated an appropriate rate for these
individuals. Individuals with Medicare fee-for-service
coverage are not excluded from enrolling under this
Contract."
2. ARTICLE III ~ GENERAL TERMS AND CONDITIONS, SECTION 3.49, PROHIBITED USE OF
STATE FUNDS FOR UNION ORGANIZING IS BEING ADDED TO YOUR CONTRACT TO READ:
"3.49 Prohibited Use of State Funds for Union Organizing
Contractor by signing this agreement hereby acknowledges the
applicability of Government Code Section 16645 through Section
16649 to this agreement.
0
XXXXXX XXXXXXXXXX XX XXXXXXXXXX 00-00000 A-06
DBA: MOLINA
1. Contractor will not assist, promote, or deter union
organizing by employees performing work on a state service
contract, including a public works contract.
2. No state funds received under this agreement will be used to
assist, promote, or deter union organizing.
3. Contractor will not, for any business conducted under this
agreement, use any state property to hold meetings with
employees or supervisors, if the purpose of such meetings is
to assist, promote or deter union organizing, unless the
state property is equally available to the general public
for holding meetings.
4. If Contractor incurs costs, or makes expenditures to assist,
promote or deter union organizing, Contractor will maintain
records sufficient to show that no reimbursement from state
funds has been sought for these costs, and that Contractor
shall provide those records to the Attorney General upon
request."
3. ARTICLE III -- GENERAL TERMS AND CONDITIONS, SECTION 3.50, DEBARMENT AND
SUSPENSION CERTIFICATION, IS BEING ADDED TO YOUR CONTRACT TO READ:
"3.50 Debarment and Suspension Certifications
By signing this agreement, the Contractor/Grantee agrees to comply
with the applicable federal suspension and debarment regulations, and
certifies the following:
A. The Contractor/Grantee certifies to the best of its knowledge and
belief, that it and its principals:
1. Are not presently debarred, suspended, proposed for
debarment, declared ineligible, or voluntarily excluded from
participation in a federally sponsored project by any
federal department or agency;
2. Have not within a three-year period preceding this agreement
been convicted of or had a civil judgement rendered against
them for commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or
performing a public (Federal, State or local) transaction or
contract under public transaction; violation of Federal or
State antitrust statutes or commission of embezzlement,
theft, forgery, bribery, falsification or destruction of
records, making false statements, or receiving stolen
property;
3
XXXXXX HEALTHCARE XX XXXXXXXXXX 00-00000 A-06
DBA: MOLINA
3. Are not presently indicted for or otherwise criminally or
civilly charged by a governmental entity (Federal, State or
Local) with commission of any of the offenses enumerated in
the foregoing paragraph of this certification; and
4. Have not within a three-year period preceding this agreement
had one or more public transactions (Federal, State or
local) terminated for cause or default.
5. Contractor/Grantee shall not knowingly enter into any lower
tier covered transaction with a person or firm that is
proposed for debarment under federal regulations, debarred,
suspended, declared ineligible, or voluntarily excluded from
participation in such transactions, unless authorized by the
State. The Contractor/Grantee may rely on the certification
of a prospective participant in a lower tier covered
transaction unless it knows that the certification is
erroneous. The Contractor/Grantee may, but is not required
to, check the Procurement and Nonprocurement List issued by
U.S. General Service Administration at the following
Internet site: xxxx://xxxx.xxxxx.xxx/.
6. Contractor/Grantee will include a clause entitled,
"Debarment and Suspension Certification" that essentially
sets forth the provisions herein, in all lower tier covered
transactions and in all solicitations for lower tier covered
transactions.
B. If the Contractor/Grantee is unable to certify to any of the
statements in this certification, the Contractor/Grantee shall
submit an explanation to the DHS program funding this agreement.
C. The terms and definitions herein have the meanings set out in the
Definitions and Coverage sections of the rules implementing
Federal Executive Order 12549.
D. If the Contractor/Grantee knowingly violates this certification,
in addition to other remedies available to the Federal
Government, DHS may terminate this agreement for cause or
default."
4
XXXXXX HEALTHCARE XX XXXXXXXXXX 00-00000 A-06
DBA: MOLINA
4. ARTICLE V - PAYMENT PROVISIONS, SECTION 5.3, CAPITATION RATES, IS AMENDED
TO READ:
"5.3 Capitation Rates
DHS shall remit to Contractor a capitation payment each month for each
Medi-Cal Member that appears on the approved list of Members supplied
to Contractor by DHS. The capitation rate shall be the amount
specified in this Article. The payment period for health care services
shall commence on the first day of operations, as determined by DHS.
Capitation payments shall be made in accordance with the following
schedule of capitation payment rates:
FOR THE PERIOD OF 10/01/00 - 9/30/01 RIVERSIDE
------------------------------------------------------------------------------
GROUPS AID CODES RATES
------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, $ 86.14
38, 39, 40, 42, 47, 54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U, 4F, 4G, 5X, 7X, 8P
------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $223.64
6A, 6C, 6H, 6N, 6P, 6R
------------------------------------------------------------------------------
Aged 1H, 10, 14, 16, 18 $160.60
------------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, 7A, $ 89.04
7J, 8R, 82
------------------------------------------------------------------------------
Adult 86 $843.25
------------------------------------------------------------------------------
Aids Beneficiary $847.95
------------------------------------------------------------------------------
FOR THE PERIOD OF 10/01/00 - 9/30/01 SAN BERNARDINO
------------------------------------------------------------------------------
GROUPS AID CODES RATES
------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, $ 82.56
38, 39, 40, 42, 47, 54, 59, 72, 3A,
3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P,
3R, 3U, 4F, 4G, 5X, 7X, 8P
------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $223.41
6A, 6C, 6H, 6N, 6P, 6R
------------------------------------------------------------------------------
Aged 1H, 10, 14, 16, 18 $151.60
------------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, 7A, $ 93.48
7J, 8R, 82
------------------------------------------------------------------------------
Adult 86 $922.71
------------------------------------------------------------------------------
Aids Beneficiary $891.15
------------------------------------------------------------------------------
5
XXXXXX HEALTHCARE XX XXXXXXXXXX 00-00000 A-06
DBA: MOLINA
If DHS creates a new aid code that is split or derived from an
existing aid code covered under this Contract, and the aid code has a
neutral revenue effect for the Contractor, then the split aid code
will automatically be included in the same aid code category as is the
original aid code covered under this Contract. Contractor agrees to
continue providing covered services to the Members at the monthly
capitation rate specified for the original aid code. DHS shall confirm
all aid code splits, and the rates of payment for such new aid codes,
in writing to Contractor as soon as practicable after such aid code
splits occur.
5. The effective date of this Amendment is July 1, 2001.
6. The effective date of 1H and 6H is May 1, 2001
7. All rights duties, liabilities, and obligations of the parties hereto
otherwise remain unchanged.
6
Enclosure I
The purpose of this enclosure to Xxxxxx Healthcare of California, dba Molina,
amendment 6, Contract Number 95-23637 is to provide you the Contractor with an
explanation for the amendment.
This amendment adds an Aid Code 7J to your existing contract, which is result of
recent legislation that allows certain categories of Children under the age of
19, to have their eligibility continued for one more year. This aid code was
added to the child category with no increase in rate.
This amendment adds Aid Code 1H to the Aged category and 6H to the Disabled
category.
This amendment also adds two (2) new Sections to your existing Contract.
The first is Section 3.47, Prohibition of the use of State funds for Union
Organizing. This section is mandated by Legislative Xxxx AB1839 and must be
included in all contracts, which are initiated by the State. This section
prohibits the use of state funds to assist, promote, or deter union organizing
by employees performing work on a state contract or use state property to hold
meetings if the purpose of the meeting is to assist, promote or deter union
organizing.
The second is Section 3.48, Debarment and Suspension. This section requires
language of a certification by contractor that contractor principals are not
presently debarred, suspended, proposed for debarment, declared ineligible, or
voluntarily excluded from participation in a federally qualified project by any
federal department or agency. Have not within the last three years been
convicted or had civil judgement rendered against them. This section is required
by federal law and must be included in any state contract receiving federal
funding of $50,000 dollars or more.
STATE OF CALIFORNIA
APPROVED BY THE ----------------------------------
STANDARD AGREEMENT -- ATTORNEY GENERAL CONTRACT NUMBER AM. NO.
STD. 2 (REV. 5-91) 95-23637 7
----------------------------------
TAXPAYER'S FEDERAL ID. NUMBER
00-0000000
----------------------------------
THIS AGREEMENT, made and entered into this 1st day of June, 2001 in the
State of California, by and between State of California, through its duly
elected or appointed, qualified and acting
TITLE OF OFFICER ACTING FOR STATE AGENCY
Chief, Program Support Branch Department of Health Services, hereafter
called the State, and
CONTRACTOR'S NAME
Xxxxxx Healthcare of California dba Molina, hereafter called the Contractor.
WITNESSETH: That the Contractor for and in consideration of the covenants,
conditions, agreements, and stipulations of the State hereinafter expressed,
does hereby agree to furnish to the State services and materials as follows:
(Set forth services to be rendered by Contractor, amount to be paid Contractor,
time for performance or completion, and attach plans and specifications, if
any.)
Amendment A07 to Contract No. 95-23637 BETWEEN XXXXXX HEALTHCARE OF CALIFORNIA
dba MOLINA AND THE STATE OF CALIFORNIA;
WHEREAS, the State of California and Xxxxxx Healthcare of California dba Molina
entered into this Contract to provide healthcare services to Medi-Cal
beneficiaries, under the provisions of Welfare and Institution Code Section
14087.4, dated Ap 1, 1996, and subsquently amended;
NOW THEREFORE, this Contract is amended as follows:
CONTINUED ON 1 SHEETS, EACH BEARING NAME OF CONTRACTOR AND CONTRACT NUMBER.
================================================================================
The provisions on the reverse side hereof constitute a part of this
agreement.
IN WITNESS WHEREOF, this agreement has been executed by the parties hereto, upon
the date first above written.
================================================================================
====================================================================================================================================
STATE OF CALIFORNIA CONTRACTOR
------------------------------------------------------------------------------------------------------------------------------------
AGENCY CONTRACTOR (if other than an individual, state whether a corporation, partnership.
etc.)
Department of Health Services Xxxxxx Healthcare of California dba Molina
------------------------------------------------------------------------------------------------------------------------------------
BY Xxxxxx Xxxxxx Roh For BY
------------------------------------------------------------------------------------------------------------------------------------
PRINTED NAME OF PERSON SIGNING PRINTED NAME OF AND TITLE OF PERSON SIGNING
Xxxxxx Xxxxxxxxx Xxxxxx Xxxxxx Roh. Chief Xxxxxx X. Xxxxxxxxx, Ph.D
CMU Production
------------------------------------------------------------------------------------------------------------------------------------
TITLE ADDRESS
Chief, Program Support Branch Xxx Xxxxxx Xxxxx Xxxxx, Xxxx Xxxxx, XX 00000
------------------------------------------------------------------------------------------------------------------------------------
AMOUNT ENCUMBERED BY THIS PROGRAM/CATEGORY (CODE AND TITLE) FUND TITLE Department of General
DOCUMENT Loc.Asst.Section 14157 W&I Code Health CareDeposit Services Use Only
-------------------------------------------------------
$ 27,000,000 (OPTIONAL USE)
--------------------------------
PRIOR AMOUNT ENCUMBERED FOR
THIS CONTRACT
=======================================================
ITEM CHAPTER STATUTE FISCAL YEAR Exempt per W&I Code 14087.4
$ 607,053,310 4260-601-912 106 2001 2001/2002
---------------------------------------------------------------------------------------
TOTAL AMOUNT ENCUMBERED FOR OBJECT OF EXPENDITURE (CODE AND TITLE)
DATE
$ 634,053,310 9912-705-95915
---------------------------------------------------------------------------------------
I hereby certify upon my own personal knowledge T.B.A. NO. X.X.XX.
that budgeted funds are available for the period
and purpose of the expenditure stated above.
---------------------------------------------------------------------------------------
SIGNATURE OF ACCOUNTING OFFICER DATE
11/7/01
=======================================================================================
[ ] CONTRACTOR [ ] STATE AGENCY [ ]DEPT. OF GEN.SER. [ ] CONTROLLER [ ]
STATE OF CALFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91) (REVERSE)
1. The contractor agrees to indemnify, defend and save harmless the State, its
officers, agents and employees from any and all claims and losses accruing
or resulting to any and all contractors, subcontractors materialmen,
laborers and any other person, firm or corporation furnishing or supplying
work services materials or supplies in connection with the performance of
this contract, and from any and all claims and losses accruing or resulting
to any person, firm or corporation who may be injured or damaged by the
Contractor in the performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and not
as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment of
any consideration to Contractor, should Contractor fail to perform the
covenants herein contained at the time and in the manner herein provided.
In the event of such termination, the State may proceed with the work in
any manner deemed proper by the State. The cost to the state shall be
deducted from any sum due the Contractor under this agreement, and the
balance, if any, shall be paid the Contractor upon demand.
4. Without the written consent of the State, this agreement is not assignable
by Contractor either in whole or in part.
5. Time is the essence of this agreement.
6. No alteration or variation of the terms of this contract shall be valid
unless made in writing and signed the parties hereto, and no oral
understanding or agreement not incorporated herein, shall be binding on any
of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be in
compensation for all of Contractor's expenses incurred in the performance
hereof, including travel and per diem, unless otherwise expressly so
provided.
XXXXXX HEALTHCARE OF CALIFORNIA 95-23637-A07
DBA MOLINA
1. ARTICLE III, GENERAL TERMS AND CONDITIONS, Section 3.14, Term, paragraph 1
is amended to read:
3.14 TERM
This Contract will become effective April 2, 1996 and will continue in
full force and effect through March 31, 2003, subject to the
provisions of Article V, Sections 5.2 and 5.10 because the State has
currently appropriated and available for encumbrance only funds to
cover costs through June 30, 2001.
All other provisions of this Section remain unchanged.
2. ARTICLE V, PAYMENT PROVISIONS, Section 5.2, Amounts Payable, is amended to
read:
5.2 AMOUNTS PAYABLE
The maximum amount payable for the 1995-96 Fiscal Year ending June 30,
1996 will not exceed $32,080,630; the maximum amount payable for the
Fiscal Year 1996-97 Fiscal Year ending June 30, 1997 will not exceed
$194,472,680; the maximum amount payable for the 1997-98 Fiscal Year
ending June 30,1998 will not exceed $6,500,000; the maximum amount
payable for the 1998-99 Fiscal Year ending June 30,1999 will not
exceed $80,000,000; the maximum amount payable for the 1999-2000
Fiscal Year ending June 30, 2000 will not exceed $107,000,000; the
maximum amount payable for the 2000-2001 Fiscal Year ending June 30,
2001 will not exceed $107,000,000. Any requirement for performance by
DHS and Contractor for the period of the Contract subsequent to June
30, 2001, will be dependent upon the availability of future
appropriations by the Legislature for the purpose of this Contract. If
funds become available for purposes of this Contract from future
appropriations by the Legislature, the maximum amount payable for the
2001-2002 Fiscal Year ending June 30, 2002 will not exceed
$107,000,000; the maximum amount payable for the 2002-2003 Fiscal Year
ending June 30, 2003 will not exceed $80,000,000. The maximum amount
payable for this Contract will not exceed $714,053,310.
3. The effective date of this Amendment is June 1, 2001.
4. All rights, duties, liabilities and obligations of the parties hereto
otherwise remain unchanged.
2
Enclosure 1
The purpose of this enclosure to Xxxxxx'x amendment 07 to Contract
Number 96-23637 is to provide you the Contractor with an explanation
for the amendment.
This amendment extends the term of your contract to March 31, 2003.
This amendment also changes the amounts payable under your contract to
add additional dollars into the 2001-2002 Fiscal Year, and for the
additional 2002- 2003 Fiscal Year, to allow payment for that fiscal
year, as a result of the increase in the term of the contract.
STATE Of CALIFORNIA
STANDARD AGREEMENT AMENDMENT
STD. 213 A (NEW 02/98)
AGREEMENT NUMBER AMENDMENT NUMBER
95-23637 8
This Agreement is entered into between the State Agency and Contractor
named below:
---------------------------------------------------------------------------
STATE AGENCY'S NAME
California Department of Health Services
----------------------------------------------------------------------------
CONTRACTOR'S NAME
Xxxxxx Healthcare of California, dba: Molina
--------------------------------------------------------------------------------
2. The term of this
Agreement is 4-2-96 through 3-31-02
--------------------------------------------------------------------------------
3. The maximum amount $714,053,310
of this Agreement is: Seven hundred and fourteen million, fifth-three
thousand, three hundred ten
--------------------------------------------------------------------------------
4. The parties mutually agree to this amendment as follows. All actions noted
below are by this reference made a part of the Agreement and incorporated
herein:
--------------------------------------------------------------------------------
5. Article II - Definitions, Section Y, Eligible Beneficiary, is amended to
add two new Aid Codes: 4M to category Family and 6V to category Disabled,
to read as in page 2 of this amendment.
--------------------------------------------------------------------------------
6. Article V - Payment Provision, Section 5.3, Capitation Rates, is amended to
add two new Aid Codes: 4M to category Family and 6V to category Disabled,
to read as in page 3 of this amendment.
All other terms and conditions shall remain the same.
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
--------------------------------------------------------------------------------
CONTRACTOR CALIFORNIA
--------------------------------------------------------- Department of General
CONTRACTOR'S NAME (If other than an individual, state Services
whether a corporation, partnership, etc.) Use Only
Xxxxxx Healthcare of California, dba: Molina
---------------------------------------------------------
BY (Authorized Signature) DATE SIGNED (Do not type)
/s/
---------------------------------------------------------
PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx X. Xxxxxxxxx
---------------------------------------------------------
ADDRESS
Xxx Xxxxxx Xxxxx Xxxxx, Xxxx Xxxxx, XX 00000
---------------------------------------------------------
STATE OF CALIFORNIA
---------------------------------------------------------
AGENCY NAME
California Department of Health Services
---------------------------------------------------------
BY (Authorized Signature) for DATE SIGNED (Do not type)
/s/ Xxxxxx Xxxxxx Roh for 04/05/02
---------------------------------------------------------
PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx Xxxxxxxxx, Chief, Program Support Branch
---------------------------------------------------------
ADDRESS
0000 0xx. Xxxxxx, Xx. 455, X.X. Xxx 000000, Xxxxxxxxxx, X Exempt per: 14087.4
CA 94234-7320
================================================================================
STATE OF CALIFORNIA
STANDARD AGREEMENT
STD. 2 (REV. 5-91) (REVERSE)
1. The Contractor agrees to indemnify, defend and save harmless the
State, its officers, agents and emp1oyees from any and all claims and
losses accruing or resulting to any and all contractors,
subcontractors, materialmen, laborers and any other person, firm or
corporation furnishing or supplying work services materials or
supplies in connection with the performance of this contract, and from
any and all claims losses accruing or resulting to any person, firm or
corporation who may be injured or damaged by Contractor in the
performance of this contract.
2. The Contractor, and the agents and employees of Contractor, in the
performance of the agreement, shall act in an independent capacity and
not as officers or employees or agents of State of California.
3. The State may terminate this agreement and be relieved of the payment
of any consideration to Contractor should Contractor fail to perform
the covenants herein contained at the time and in the manner herein
provided. In the event of such termination the State may proceed with
the work in any manner deemed proper by the State. The cost to the
State shall be deducted from any sum due the Contractor under this
agreement, and the balance, if any, shall be paid the Contractor upon
demand.
4. Without the written consent of the State, this agreement is not
assignable by Contractor either in whole or in part.
5. Time is of the essence in this agreement.
6. No alteration or variation of the terms of this contract shall be
valid unless made in writing and signed by the parties hereto, and no
oral understanding or agreement not incorporated herein, shall be
binding on any of the parties hereto.
7. The consideration to be paid Contractor, as provided herein, shall be
in compensation for all of Contractor's expenses incurred in the
performance hereof, including travel and per diem, unless otherwise
expressly so provided.
XXXXXX HEALTHCARE OF CALIFORNIA,
DBA: MOLINA
95-23637 A-08
1. Article II - Definitions, Section Y, Eligible Beneficiary, is amended to
read:
"Y. Eligible Beneficiary means any Medical beneficiary who is residing in
Contractor's Service Area with one of the following aid codes: Family
- aid codes 01, 0A, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 0X, 0X, 0X, 0X, 0X,
0X, 0X, 0X; Aged - aid codes 10, 14, 16, 18, 1H; Disabled - aid codes
20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R, 6V; Child
- aid codes 03, 04, 45, 82, 4A, 4C, 4K, 5K, 7A, 7J, 8R; Adult- aid
code 86 with the following exclusions:
1. Individuals who have been approved by the Medi-Cal Field Office
or the California Children Services Program for bone marrow,
heart, heart-lung, liver, lung, combined liver, and kidney, or
combined liver and small bowel transplants.
2. Individuals who elect and are accepted to participate in the
following Medi-Cal waiver programs: In-Home Medical Care Waiver
Program, the Skilled Nursing Facility Waiver Program, the Model
Waiver Program, the Acquired Immune Deficiency (AIDS) and AIDS
Related Conditions Waiver Program, and the Multipurpose Senior
Services Waiver Program.
3. Individuals determined by the Medi-Cal Field Office to be in need
of long term care and residing in a Skilled Nursing Facility
(SNF) for 30 days past the month of admission.
4. Individuals who have commercial or Medicare HMO coverage, unless
the Medicare HMO is a provider under this Contract and DHS has
agreed, as a term of the HMO's Contract, that these individuals
may be enrolled, and DHS and the Medicare HMO have negotiated an
appropriate rate for these individuals. Individuals with Medicare
fee-for-service coverage are not excluded from enrolling under
this Contract."
2
XXXXXX HEALTHCARE OF CALIFORNIA,
DBA: MOLINA
95-23637 A-08
2. Article V - Payment Provision, Section 5.3, Capitation Rates, is amended to
read:
"5.3 Capitation Rates
DHS shall remit to Contractor a capitation payment each month for each
Medi-Cal Member that appears on the approved list of Members supplied
to Contractor by DHS. The capitation rate shall be the amount
specified in this Article. The payment period for health care services
shall commence on the first day of operations, as determined by DHS.
Capitation payments shall be made in accordance with the following
schedule of capitation payment rates:
For the period 10/01/00 - 9/30/01 Riverside
----------------------------------------------------------------------
Groups Aid Codes Rate
----------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, $ 86.14
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 4M, 5X, 7X, 8P
----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, $ 223.64
66, 68, 6A, 6C, 6N, 6P, 6R,
6V, 6H
----------------------------------------------------------------------
Aged 10,14,16,18, 1H $ 160.60
----------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 89.04
82, 7A, 7J, 8R
----------------------------------------------------------------------
Adult 86 $ 843.25
----------------------------------------------------------------------
Aids $ 847.95
Beneficiary
----------------------------------------------------------------------
3
XXXXXX HEALTHCARE OF CALIFORNIA,
DBA: MOLINA
95-23637 A-08
For the period 10/01/00 - 9/30/01 San Bernardino
----------------------------------------------------------------------
Groups Aid Codes Rate
----------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 33, $ 82.56
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R,
3U, 4F, 4G, 4M, 5X, 7X, 8P
----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, $ 223.41
66, 68, 6A, 6C, 6N, 6P, 6R,
6V, 6H
----------------------------------------------------------------------
Aged 10, 14, 16, 18, 1H $ 151.60
----------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 93.48
82, 7A, 7J, 8R
----------------------------------------------------------------------
Adult 86 $ 922.71
----------------------------------------------------------------------
Aids $ 891.15
Beneficiary
----------------------------------------------------------------------
If DHS creates a new aid code that is split or derived from an
existing aid code covered under this Contract, and the aid code has a
neutral revenue effect for the Contractor, then the split aid code
will automatically be included in the same aid code category as is the
original aid code covered under this Contract. Contractor agrees to
continue providing covered service to the Members at the monthly
capitation rate specified for the original aid code. DHS shall confirm
all aid code splits, and the rates of payment for such new aid codes,
in writing to Contractor as soon as practicable after such aid code
splits occur."
3. The effective date of this amendment is September 1, 2001.
4
STATE OF CALIFORNIA
STANDARD AGREEMENT AMENDMENT
TO [ILLEGIBLE] A (REV [ILLEGIBLE])
[X] CHECK HERE IF ADDITIONAL PAGES ARE ATTACHED 1 Pages AGREEMENT NUMBER AMENDMENT NUMBER
- 95-23637 9
=============================================================================================
1. This Agreement is entered into between the State Agency and Contractor
named below:
--------------------------------------------------------------------------------
STATE AGENCY'S NAME
California Department of Health Services
--------------------------------------------------------------------------------
CONTRACTOR'S NAME
Xxxxxx Healthcare of California, dba: Molina
--------------------------------------------------------------------------------
2. The term of this
Agreement is 4-2-96 through 3-31-04
--------------------------------------------------------------------------------
3. The maximum amount $794,653,310
of this Agreement is: Seven hundred ninety-four million, six hundred
fifty-three thousand, three hundred ten
--------------------------------------------------------------------------------
4. The parties mutually agree to this amendment as follows. All actions noted
below are by this reference made a part of the Agreement and incorporated
herein:
I. The effective date of this Amendment is September 1, 2002.
II. The purpose of this amendment is to extend the term of the contract
for one-year, adjust the encumbrance accordingly, add language, and
update the list of drugs carved-out.
III. Article III - GENERAL TERMS AND CONDITIONS, Section 3.14, Term is
amended to extend the term.
IV. Article V - PAYMENT PROVISIONS, Section 5.2 Amounts Payable, is
amended to adjust the encumbrance.
V. Article VI - SCOPE OF WORK, Section 6.6.23, Subcontractor Services to
Non-Plan Medi-Cal Beneficiaries, is amended to address subcontractors
are not prohibited from Xxxx-Xxxxx licensed health services plans.
VI. Attachments II and III, Excluded Drugs, is amended to add
Psychotherapeutic and HIV & AIDS drugs.
All other terms and conditions shall remain the same.
IN WITNESS WHEREOF, this Agreement has been executed by the parties hereto.
-------------------------------------------------------------------------------------------------------------------------
CONTRACTOR CONTRACTOR
-------------------------------------------------------------------------------- Department of General Services
CONTRACTOR'S NAME (if other than an individual, state whether a corporation, Use Only
partnership, etc.)
Xxxxxx Healthcare of California, dba: Molina
--------------------------------------------------------------------------------
BY (Authorized Signature) DATE SIGNED (Do not type)
/s/ 8/2/02
--------------------------------------------------------------------------------
PRINTED NAME AND TITLE OF PERSON SIGNING
Xxxxxx Xxxxxxxxx, President/CEO
--------------------------------------------------------------------------------
ADDRESS
Xxx Xxxxxx Xxxxx Xx., Xxxx Xxxxx, XX 00000
--------------------------------------------------------------------------------
STATE OF CALIFORNIA
--------------------------------------------------------------------------------
AGENCY NAME
California Department of Health Services
--------------------------------------------------------------------------------
BY (Authorized Signature) DATE SIGNED (Do not type)
/s/ XXXXXX XXXXXX ROH for 09/06/02
--------------------------------------------------------------------------------
PRINTED NAME AND TITLE OF PERSON SIGNING Xxxxxx Xxxxxx Roh, Chief X Exempt per W&I Code 14087.4
Xxxxxx Xxxxxxxxx, Chief, Program Support Branch CMU Production
--------------------------------------------------------------------------------
ADDRESS
[ILLEGIBLE] 3rd. Street, Rm. 455, X.X. Xxx 000000, Xxxxxxxxxx, XX 00000-0000
========================================================================================================================
Xxxxxx Healthcare of California,
dba: Molina
95-23637 A-9
1. Article III - GENERAL TERMS AND CONDITIONS, Section 3.14, Term, is amended
to read:
"3.14 Term
This Contract will become effective October 1, 1996, and will
continue in full force and effect through March 31, 2004, subject
to the provision of Article V, Section 5.2 and 5.10, because the State
has currently appropriated and available for encumbrance only funs to
cover cost through June 30, 2002."
2. Article V - PAYMENT PROVISIONS, Section 5.2 Amounts Payable, is amended to
read:
"5.2 Amounts Payable
The maximum amount payable for the 1995-96 Fiscal Year ending June 30,
1996, will not exceed $32,080,630; the maximum amount payable for the
1996-97 Fiscal Year ending June 30, 1997, will not exceed
$194,472,680; the maximum amount payable for the 1997-98 Fiscal Year
ending June 30, 1998, will not exceed $6,500,000; the maximum amount
payable for the 1998-99 Fiscal Year ending June 30, 1999, will not
exceed $80,000,000; the maximum amount payable for the 1999-00 Fiscal
Year ending June 30, 2000, will not exceed $107,000,000; the maximum
amount payable for the 2000-01 Fiscal Year ending June 30, 2001, will
not exceed $107,000,000; the maximum amount payable for the 2001-02
Fiscal Year ending June 30, 2002, will not exceed $107,000,000. Any
requirement for performance by DHS and Contractor for the period of
the Contract subsequent to June 30, 2002 will be dependent upon the
purposes of this Contract. If funds become available for purposes of
this Contract for future appropriations by the Legislature, the
maximum amount payable for the 2002-03 Fiscal Year ending June 30,
2003, will not exceed $90,200,000; the maximum amount payable for the
2003-04 Fiscal Year ending June 30, 2004, will not exceed $70,400,000.
The maximum amount payable for this Contract will not exceed
$794,653,310."
2
Xxxxxx Healthcare of California,
dba: Molina
95-23637 A-9
3. Article VI - SCOPE OF WORK, Section 6.6.23, Subcontractor Services to
Non-Plan Medi-Cal Beneficiaries, is amended to read:
"6.6.23 Subcontractor Services to Non-Plan Medi-Cal Beneficiaries
The Contractor will not prohibit any subcontractor from providing
services to Medi-Cal beneficiaries who are not Members of Contractor's
plan. Exclusivity requirements are not prohibited for subcontracting
Xxxx-Xxxxx Licensed health services plans."
Xxxxxx Healthcare of California,
dba: Molina
95-23627 A-9
Under Article II, DEFINITIONS, Section P, Covered Services, Subparagraph 19,
Attachment II, is amended to read:
ATTACHMENT II
EXCLUDED DRUGS FOR THE TREATMENT OF HIV AND AIDS
Generic Name
------------
Abacavir Sulfate
Abacavir Sulfate/Lamivudine/Zidovudine
Amprenavir
Indinavir Sulfate
Efavirenz
Lamivudine
Saquinavir
Lopinavir/Ritonavir
Ritonavir
Delavirdine Mesyiate
Saquinavir Mesyiate
Tenofovir Disoproxil Fumarate
Nelfinavir Mesyiate
Nevirapine
Stavudine
Zidovudine/Lamivudine
Xxxxxx Healthcare of California,
dba: Molina
95-23627 A-9
Under Article VI, SCOPE OF WORK, Section 6.7.3.3, Mental Health, Attachment III,
is amended to read:
ATTACHMENT III
EXCLUDED PSYCHOTHERAPEUTIC DRUGS
Generic Name
------------
Amantadine HCL
Benztropine Mesylate
Biperiden HCL
Biperiden Lactate
Chlorpromazine HCL
Chlorprothixene
Clozapine
Fluphanazine Decanoate
Fluphanazine Enanthate
Fluphanazine HCL
Haloperidol
Haloperidol Deconoate
Haloperiodol Lactate
Isocarboxazid
Lithium Carbonate
Lithium Citrate
Lozapine HCL
Loxapine Succinate
Mesoridazine Besylate
Molindone HCL
Olanzapine
Perphenazine
Phenelzine Sulfate
Pimozide
Procyclidine HCL
Promazine HCL
Quetiapine
Risperidone
Thioridazine HCL
Thiothixene
Thiothixene HCL
Tranylcypromine Sulfate
Trifluoperazine HCL
Triflupromazine HCL
Trihexphenidyl HCL
Ziprasidone
[LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES]
May 7, 1999 [SEAL]
Xxxx Xxxxxx, M.D.
Xxxxxx Medical Centers, Inc.
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxx:
In accordance with Article V, Section 5.5 of your Contract, the
enclosed Change Order transmits Xxxxxx Medical Centers, Inc., annual
capitation rates for the period October 1, 1998 to September 30,1999. The
new rates will appear in your capitation rate beginning June 1999. A check
for the difference between the old Contract rates and the new Contract
rates, for the period October 1, 1998 until the new rates are reflected in
your capitation payments will be mailed in approximately six (6) to eight
(8) weeks.
If you have any questions, please contact you contract manager.
Sincerely,
/s/ [illegible] for
------------------------------
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER NUMBER C1 to CONTRACT No. 95-23637: ADJUSTING THE ANNUAL
CAPITATION RATE FOR THE PERIOD OCTOBER 1,1998 TO SEPTEMBER 30, 1999, BY
CHANGING CONTRACT SECTIONS 5.3 CAPITATION RATES AND 5.4 CAPITATION RATES
CONSTITUTE PAYMENT IN FULL. Issued May 7, 1999.
1. 5.3 CAPITATION RATES
RIVERSIDE COUNTY
FOR THE PERIOD 07/01/95 - 05/31/96
------------------------------------------------------------------------
GROUP AID CODES RATE
------------------------------------------------------------------------
Family 01, 02, 08, 30, 32, 33, 35, 38, 39, $ 74.70
3A, 3C, 3P, 3R, 40, 42, 4C, 4K, 54,
59, 5K
------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 181.61
68, 6A, 6C.
------------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 110.37
------------------------------------------------------------------------
Child 03, 04, 45, 82 $ 68.51
------------------------------------------------------------------------
Adult 86 $ 492.78
------------------------------------------------------------------------
RIVERSIDE COUNTY
FOR THE PERIOD 06/01/96 - 09/30/97
------------------------------------------------------------------------
GROUP AID CODES RATE
------------------------------------------------------------------------
Family 01, 02, 08, 30, 32, 33, 34, 35, 38, 39, $ 76.39
3A, 3C, 3P, 3R, 40, 42, 4C, 4K, 54,
59, 5K
------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $ 178.77
6A, 6C,
------------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 114.62
------------------------------------------------------------------------
Child 03, 04, 45, 82 $ 67.74
------------------------------------------------------------------------
Adult 86 $ 509.94
------------------------------------------------------------------------
1 of 4
CHANGE ORDER C1
TO XXXXXXXX XX. 00-00000
XXX XXXXXXXXXX XXXXXX
FOR THE PERIOD 07/01/95 - 05/31/96
----------------------------------------------------------------------
GROUP AID CODES RATE
----------------------------------------------------------------------
Family 01, 02, 08, 30, 32, 33, 34, 35, 38, $ 70.01
39, 3A, 3C, 3P, 3R, 40, 42, 4C, 4K,
54, 59, 5K
----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $ 177.15
6A, 6C.
----------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 117.66
----------------------------------------------------------------------
Child 03, 04, 45, 82 $ 67.91
----------------------------------------------------------------------
Adult 86 $ 536.02
----------------------------------------------------------------------
SAN BERNARDINO COUNTY
FOR THE PERIOD 06/01/96 - 09/30/97
----------------------------------------------------------------------
GROUP AID CODES RATE
----------------------------------------------------------------------
Family 01, 02, 08, 30, 32, 33, 34, 35, 38, $ 71.59
39, 3A, 3C, 3P, 3R, 40, 42, 4C, 4K,
54, 59, 5K
----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $ 174.45
6A, 6C.
----------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 121.76
----------------------------------------------------------------------
Child 03, 04, 45, 82 $ 67.17
----------------------------------------------------------------------
Adult 86 $ 554.73
----------------------------------------------------------------------
RIVERSIDE COUNTY
FOR THE PERIOD 10/01/97 - 09/30/98
----------------------------------------------------------------------
GROUP AID CODES RATE
----------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 3G, 33, 3H, $ 75.91
34, 35, 38, 39, 3A, 3C, 3N, 3P, 3R,
3U, 3R, 40, 42, 54, 59, 7X;
CalWORKS: 3E, 3L, 3M
----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 204.96
68, 6A, 6C, 6N, 6P, 6R
----------------------------------------------------------------------
Aged 10, 14, 16, 18. $ 162.29
----------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 79.33
----------------------------------------------------------------------
Adult 86 $ 515.67
----------------------------------------------------------------------
AIDS Beneficiary Rate $ 1021.49
----------------------------------------------------------------------
2 of 4
CHANGE ORDER C1
TO XXXXXXXX XX. 00-00000
XXX XXXXXXXXXX XXXXXX
For the Period 10/01/97 - 09/30/98
GROUP AID CODES RATE
-----------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 3G, 33, 3H, $ 74.04
34, 35, 38, 39, 3A, 3C, 3N, 3P, 3R,
3U, 3R, 40, 42, 54, 59, 7X;
CalWORKS: 3E, 3L, 3M
-----------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $ 217.87
6A, 6C, 6N, 6P, 6R
-----------------------------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 167.25
-----------------------------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 79.42
-----------------------------------------------------------------------------------------
Adult 86 $ 531.42
-----------------------------------------------------------------------------------------
AIDS Beneficiary Rate $ 1072.78
-----------------------------------------------------------------------------------------
RIVERSIDE COUNTY
For the Period 10/01/98 - 09/30/99
GROUP AID CODES RATE
-----------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 3G, 33, 3H, $ 78.73
34, 35, 38, 39, 3A, 3C, 3N, 3P, 3R,
3U, 3R, 40, 54, 59, 7X;
CalWORKS: 3E, 3L, 3M
-----------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66,68, $ 222.61
6A, 6C, 6N, 6P, 6R
-----------------------------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 160.47
-----------------------------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 93.09
-----------------------------------------------------------------------------------------
Adult 86 $ 706.77
-----------------------------------------------------------------------------------------
AIDS Beneficiary Rate $ 962.42
-----------------------------------------------------------------------------------------
SAN BERNARDINO COUNTY
For the Period 10/01/98 - 09/30/99
GROUP AID CODES RATE
-----------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 3G, 33, 3H, $ 80.48
34, 35, 38, 39, 3A, 3C, 3N, 3P, 3R,
3U, 3R, 40, 54, 59, 7X:
CalWORKS: 3E, 3L, 3M
-----------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, $ 233.49
6A, 6C, 6N, 6P, 6R
-----------------------------------------------------------------------------------------
Aged 10, 14, 16, 18, $ 163.77
-----------------------------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 106.43
-----------------------------------------------------------------------------------------
Adult 86 $ 790.89
-----------------------------------------------------------------------------------------
AIDS Beneficiary Rate $ 995.00
-----------------------------------------------------------------------------------------
3 of 4
CHANGE ORDER C1
TO CONTRACT NO. 95-23637
In the future, DHS may be splitting existing aid codes into new aid codes.
The new split aid codes will be in the same aid code group category as the
original aid code. If DHS establishes new aid codes by splitting existing
aid codes, Contractor agrees to accept Eligible Beneficiaries with these
new aid codes as Members and to provide covered services to these Members
at the monthly capitation rate specified for the original aid code. The
Department shall confirm all aid code splits, and the rates of payment for
such new aid codes, in writing to Contractors as soon as practicable after
such aid code splits occur.
All other terms, conditions, and provisions contained in Section 5.3 remain
unchanged.
3. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL.
The actuarial basis for the determination of the capitation payment rates is
outlined in Attachment 1 (consisting of 12 pages).
All other terms, conditions, and provisions contained in Section 5.4 remain
unchanged.
4 of 4
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Family
CI for 95-23637
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 864.71 $ 16.16 $ 812.04
2. Units per Eligible 4.014 4.683 0.373 2.146 0.004
3. Addt'l Capitation Amts. $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00
Cost per Elig. per Mo. $ 23.60 $ 7.81 $ 31.50 2.90 $ 0.27
Adjustments
a. Demographics 1.004 0.976 1.023 1.002 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 23.97 $ 7.52 $ 31.04 $ 2.76 $ 0.27
3. Legislative Adjs. 1.053 1.053 0.998 1.023 1.141
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 23.98 $ 8.71 $ 34.15 $ 2.68 $ 0.32
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 78.73 $ 78.41
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1. Average Cost Per Unit $ 20.09 $ 68.39 $ 24.41
2. Units per Eligible 3.532 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 5.91 $ 0.96 $ 0.34 $ 73.29
Adjustments
a. Demographics 0.985 0.994 0.994
b. Area 1.000 1.000 1.000
c. Coverages 0.833 0.935 0.935
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 4.82 $ 0.89 $ 0.31 $ 71.58
3. Legislative Adjs. 1.046 1 027 1.027
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 5.03 $ 0.91 $ 0.32 $ 76.10
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 5.06
7. Fee-for-Service Adj. 3.0% (2.43)
Capitation Rate With FQHC Increment
Page 1 of 12
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Aged
CI for 95-23637
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
-----------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-----------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-----------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-----------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-----------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-----------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-----------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-----------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 287.24 $ 10.02 $ 77.33
2. Units per Eligible 4.472 21.914 1.265 3.306 2.016
3. Addt'l Capitation Amts. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 19.51 $ 59.73 $ 37.69 $ 2.78 $ 12.99
Adjustments
a. Demographics 0.955 1.019 0.957 0.970 1.039
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 18.97 $ 60.32 $ 35.78 $ 2.65 $ 13.39
3. Legislative Adjs. 0.939 1.049 0.926 0.931 1.140
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000
b. Units per Eligible 1.100 1.155 1.100 1.100 1.000
Projected Cost per Eligible $ 21.55 $ 80.39 $ 40.09 $ 2.85 $ 15.26
5 Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee for Service Adj.
Capitation Rate With FQHC Increment $ 160.47 $ 160.47
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 6.41 $ 28.59 $ 0.00
2. Units per Eligible 12.862 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 6.87 $ 0.31 $ 0.00 $ 139.88
Adjustments
a. Demographics 1,025 0.970 0.970
b. Area 1.000 1.000 1.000
c. Coverages 0.791 0.603 0.603
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 5.54 $ 0.18 $ 0.00 $ 136.83
3. Legislative 0.927 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.000
Projected Cost per Eligible $ 5.12 $ 0.17 $ 0.00 $ 165.43
5 Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7. Fee for Service Adj. -3.0% (4.96)
Capitation Rate With FQHC Increment
Page 2 of 12
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Disabled
CI for 95-23637
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
----------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
----------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
----------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
----------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
----------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
----------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
----------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
----------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
----------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
----------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
----------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
----------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
----------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
----------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
----------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 485.15 $ 12.37 $ 139.87
2. Units per Eligible 6.873 26.861 1.556 5.050 0.459
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 29.54 $ 88.96 $ 72.80 $ 5.23 $ 5.35
Adjustments
a. Demographics 0.983 0.989 0.981 0.998 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.12 $ 76.60 $ 65.37 $ 5.05 $ 5.30
3. Legislative Adjs. 0.941 1.043 0.919 0.931 1.130
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 28.07 $ 106.34 $ 66.23 $ 4.91 $ 6.26
5 Stop Loss Reins. Amount $ 0 Rate
6 CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 222.61 $ 222.61
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1. Average Cost Per Unit $ 10.16 $ 66.52 $ 0.00
2. Units per Eligible 21.959 0.216 0.216
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 18.59 $ 1.20 $ 0.00 $ 221.67
Adjustments
a. Demographics 1.015 0.987 0.987
b. Area 1.000 1.000 1.000
c. Coverages 0.878 0.863 0.883
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 16.48 $ 1.02 $ 0.00 $ 196.94
3. Legislative Adjs. 0.923 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 16.73 $ 0.95 $ 0.00 $ 229.49
5 Stop Loss 0.0% Premium 0.00
6 CHDP 0.00
7. Fee for Service Adj. -3.0% (6.88)
Capitation Rate With FQHC Increment
Page 3 of 12
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Child
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
-------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-------------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Hearth Pharmacy Costs NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 889.41 $ 16.21 $ 469.38
2. Units per Eligible 3.999 3.411 0.465 1.516 0.007
3. Addt'l Capitation Amts. $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.70 $ 3.91 $ 37.36 $ 2.05 $ 0.27
Adjustments
a. Demographics 1.181 1.019 1.321 1.114 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.10 $ 3.90 $ 46.75 $ 2.21 $ 0.27
3. Legislative Adjs. 1.076 1.047 0.999 1.024 1.134
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 27.70 $ 4.49 $ 51.49 $ 2.15 $ 0.32
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 93.09 $ 92.75
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 20.69 $ 68.39 $ 24.41
2. Units per Eligible 1.958 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 3.38 $ 0.96 $ 0.34 $ 70.97
Adjustments
a. Demographics 1.165 1.003 1.003
b. Area 1.000 1.000 1.000
c. Coverages 0.815 0.970 0.970
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 3.19 $ 0.93 $ 0.33 $ 84.68
3. Legislative Adjs. 1.090 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 3.47 $ 0.96 $ 0.34 $ 90.92
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP $ 5.04
7. Fee-for-Service Adj. -3.0% (2.87)
Capitation Rate With FQHC Increment
Page 4 of 12
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Adult
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 964.66 $ 15.76 $ 812.04
2. Units per Eligible 21.383 5.818 5.446 4.679 0.000
3. Addt'l Capitation Amts. $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00
Cost per Elig. per Mo. $ 161.60 $ 8.36 $ 473.41 $ 6.23 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 167.54 $ 8.31 $ 470.57 $ 6.13 $ 0.00
3 Legislative Adjs. 1.029 1.054 1.000 1.022 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 163.78 $ 9.63 $ 518.60 $ 5.95 $ 0.00
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 706.77 $ 705.26
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 36.13 $ 68.39 $ 24.41
2. Units per Eligible 10.172 0.735 0.735
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 30.63 $ 4.19 $ 1.50 $ 685.92
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.809 0.995 0.995
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 24.66 $ 4.15 $ 1.49 $ 682.85
3 Legislative Adjs. 1.004 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 24.70 $ 4.21 $ 1.51 $ 728.58
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. -3.0% (21.81)
Capitation Rate With FQHC Increment
Page 5 of 12
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: AIDS
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1 Average Cost Per Unit $ 32.67 $ 126.04 $ 485.15 $ 13.79 $ 139.87
2. Units per Eligible 26.305 74.792 3.169 9.882 0.000
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 74.57 $ 785.68 $ 138.01 $ 11.38 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.04 $ 506.56 $ 131.42 $ 11.23 $ 0.00
3. Legislative Adjs. 0.963 1.006 0.977 0.982 1.186
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 75.25 $ 678.28 $ 141.56 $ 11.52 $ 0.00
5 Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 962.42 $ 962.42
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1 Average Cost Per Unit $ 42.30 $ 66.52 $ 0.00
2. Units per Eligible 36.392 0.628 0.628
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 128.28 $ 3.46 $ 0.00 $ 1,141.38
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.599 0.951 0.951
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 76.46 $ 3.29 $ 0.00 $ 800.00
3. Legislative Adjs. 0.979 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 82.34 $ 3.24 $ 0.00 $ 992.19
5 Stop Loss Reins. 0.0% Premium 0.00
6. CHdP 0.00
7. Fee-for-Service Adj. -3.0% 29.77
Capitation Rate With FQHC Increment
Page 6 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Family
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 978.02 $ 16.16 $ 812.04
2. Units per Eligible 4.050 4.683 0.373 2.146 0.004
3. Addt'l Capitation Amts. $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00
Cost per Elig. per Mo. $ 23.81 $ 7.81 $ 35.02 $ 2.90 $ 0.27
Adjustments
a. Demographics 0.997 0.993 0.977 0.987 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 24.02 $ 7.65 $ 32.95 $ 2.72 $ 0.27
3. Legislative Adjs. 1.053 1.053 0.998 1.023 1.141
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 24.03 $ 8.86 $ 36.25 $ 2.64 $ 0.32
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 80.48 $ 80.41
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1. Average Cost Per Unit $ 20.09 $ 68.10 $ 7.33
2. Units per Eligible 3.532 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 5.91 $ 0.75 $ 0.08 $ 76.55
Adjustments
a. Demographics 0.985 0.992 0.992
b. Area 1.000 1.000 1.000
c. Coverages 0.833 0.935 0.935
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 4.82 $ 0.69 $ 0.07 $ 73.19
3. Legislative Adjs. 1.046 1.027 1.027
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 5.03 $ 0.71 $ 0.07 $ 77.91
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 5.06
7. Fee-for-Service Adj. -3.0% (2.49)
Capitation Rate With FQHC
Increment
Page 7 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Aged
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
-------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 316.16 $ 10.02 $ 77.33
2. Units per Eligible 4.580 21.914 1.265 3.306 2.016
3. Addt'l Capitation Amts. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 19.95 $ 59.73 $ 40.74 $ 2.78 $ 12.99
Adjustments
a. Demographics 0.963 1.014 0.962 0.975 1.027
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 19.56 $ 60.02 $ 38.88 $ 2.66 $ 13.23
3. Legislative Adjs. 0.939 1 049 0.926 0.931 1.140
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000
b. Units per Eligible 1.100 1.155 1.100 1.100 1 000
Projected Cost per $ 22.22 $ 79.99 $ 43.56 $ 2.86 $ 15.08
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 163.77 $ 163.77
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1. Average Cost Per Unit $ 6.41 $ 50.63 $ 0.00
2. Units per Eligible 12.862 0.024 0.024
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 6.87 $ 0.10 $ 0.00 $ 143.16
Adjustments
a. Demographics 1.013 0.979 0.979
b. Area 1.000 1.000 1.000
c. Coverages 0.791 0.603 0.603
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 5.48 $ 0.06 $ 0.00 $ 139.89
3. Legislative Adjs. 0.927 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1. 050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.000
Projected Cost per $ 5.07 $ 0.06 $ 0.00 $ 168.84
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj.
Capitation Rate With FQHC -3.0% (5.07)
Increment
Page 8 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Disabled
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
-----------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Eyewear NOT Covered by (he Plan
-----------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-----------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-----------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-----------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-----------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-----------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-----------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 611.26 $ 12.37 $ 139.87
2. Units per Eligible 6.969 26.861 1.556 5.050 0.459
3. Addl'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 29.91 $ 88.96 $ 89.15 $ 5.23 $ 5.35
Adjustments
a. Demographics 0.980 0.973 0.961 0.998 0.996
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.38 $ 75.36 $ 78.43 $ 5.05 $ 5.28
3. Legislative Adjs. 0.941 1.043 0.919 0.931 1.130
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 28.34 $ 104.62 $ 79.47 $ 4.91 $ 6.23
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7.Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 233.49 $ 233.49
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 10.16 $ 69.96 $ 0.00
2. Units per Eligible 21.959 0.120 0.120
3. Addl't Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 18.59 $ 0.70 $ 0.00 $ 237.89
Adjustments
a. Demographics 1.006 0.989 0.989
b. Area 1.000 1.000 1.000
c. Coverages 0.878 0.863 0.863
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 16.34 $ 0.59 $ 0.00 $ 208.43
3. Legislative Adjs. 0.923 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 16.59 $ 0.55 $ 0.00 $ 240.71
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7.Fee-for-Service Adj. -3.0% (7.22)
Capitation Rate With FQHC
Increment
Page 9 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Child
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 1,120.53 $ 16.21 $ 469.38
2. Units per Eligible 4.035 3.411 0.465 1.518 0.007
3. Addt'l Capitation Amts. $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.90 $ 3.91 $ 46.32 $ 2.05 $ 0.27
Adjustments
a. Demographics 1.212 1.021 1.342 1.157 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 28.05 $ 3.91 $ 58.88 $ 2.30 $ 0.27
3 Legislative Adjs 1.076 1.047 0.999 1.024 1.134
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 28.67 $ 4.50 $ 64.85 $ 2.24 $ 0.32
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7.Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 106.43 $ 106.35
/Without
FQHC
Rate Calculation Other FFSE Increment Total
1. Average Cost Per Unit $ 20.69 $ 68.10 $ 7.33
2. Units per Eligible 1.958 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 3.38 $ 0.75 $ 0.08 $ 79.68
Adjustments
a. Demographics 1.080 1.084 1.084
b. Area 1.000 1.000 1.000
c. Coverages 0.815 0.970 0.970
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 2.96 $ 0.78 $ 0.08 $ 97.23
3 Legislative Adjs 1.090 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 3.22 $ 0.80 $ 0.08 $ 104.68
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 5.04
7.Fee-for-Service Adj. -3.0% (3.29)
Capitation Rate With FQHC
Increment
Page 10 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Adult
CI for 95-23637
The Rate Period is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 1,140.81 $ 15.76 $ 812.04
2. Units per Eligible 21.541 5.818 5.446 4.679 0.000
3. Addt'l Capitation Amts. $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00
Cost per Elig. per Mo. $ 162.79 $ 8.36 $ 553.36 $ 6.23 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 168.77 $ 8.31 $ 550.04 $ 6.13 $ 0.00
3. Legislative Adjs. 1.029 1.054 1.000 1.022 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 164.98 $ 9.63 $ 606.42 $ 5.95 $ 0.00
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7.Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 790.89 $ 790.53
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 36.13 $ 68.10 $ 7.33
2. Units per Eligible 10.172 0.577 0.577
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 30.63 $ 3.28 $ 0.35 $ 765.00
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.809 0.995 0.995
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 24.66 $ 3.25 $ 0.35 $ 761.51
3. Legislative Adjs. 1.004 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 24.70 $ 3.30 $ 0.36 $ 815.34
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7.Fee-for-Service Adj. -3.0% (24.45)
Capitation Rate With FQHC
Increment
Page 11 of 12
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: AIDS
CI for 95-23637
The Rate Period Is October 1,1998 to September 30, 1999 Capitation Payments at the Beginning of the Month Attachment 1
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Ajphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Hospital Hospital Long Term
Rate Calculation Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 611.26 $ 13.79 $ 139.87
2. Units per Eligible 26.584 74.792 3.169 9.882 0.000
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Elig. per Mo. $ 75.33 $ 785.66 $ 171.31 $ 11.38 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1 043 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.77 $ 506.56 $ 163.12 $ 11.23 $ 0.00
3. Legislative Adjs. 0.963 1.006 0.977 0.982 1.186
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 76.03 $ 678.28 $ 175.70 $ 11.52 $ 0.00
5. Stop Loss Reins. Amount $ 0 Rate
6. CHDP
7.Fee-for-Service Adj.
Capitation Rate With FQHC
Increment $ 995.00 $ 995.00
/Without
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 42.30 $ 69.96 $ 0.00
2. Units per Eligible 36.392 0.349 0.349
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 128.28 $ 2.04 $ 0.00 $ 1.174.00
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.599 0.951 0.951
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 76.46 $ 1.93 $ 0.00 $ 831.07
3. Legislative Adjs. 0.979 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 82.34 $ 1.90 $ 0.00 $ 1.025.77
5. Stop Loss Reins. 0.0% Premium 0.00
6. CHDP 0.00
7.Fee-for-Service Adj. 3.0 (30.77)
Capitation Rate With FQHC Increment
Page 12 of 12
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
June 1, 1999
Xxxx Xxxxxx, M.D.
Xxxxxx Medical Centers, Inc.
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxx :
In accordance with Article III, Section 3.34.2 of your Contract, the
enclosed Change Order authorizes the coverage of aid codes 7A, 47, and 72
and transmits Xxxxxx Medical Center, Inc., capitation rates for these aid
codes for the period April 1, 1999, to September 30, 1999. The new rates
will be effective April 1, 1999.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
--------------------------------
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER NUMBER C2 to CONTRACT No. 95-23637 ADDING AID CODES 7A,
47, AND 72 AND CAPITATION RATES FOR THE PERIOD APRIL 1, 1999 TO
SEPTEMBER 30, 1999, BY ADDING ADDITIONAL LANGUAGE TO ARTICLE II,
SECTION Y, ELIGIBLE BENEFICIARY AND ARTICLE V, SECTIONS 5.3 CAPITATION
RATES; AND 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL, Issued May
21, 1999.
1. Article II, Section Y, Eligible Beneficiary, following the words
"Medically Indigent Adult - aid code 86", the following words are
added "Percent of Poverty - aid codes 7A, 47, and 72."
All other terms, conditions, and provisions contained in Article II,
Section Y remain unchanged.
2. 5.3 CAPITATION RATES
FOR THE PERIOD 04/01/99 - 09/30/99
GROUP AID CODES RATE
----------------------------------------------------------------
Percent of Poverty 7A $ 54.11
----------------------------------------------------------------
Percent of Poverty 47/72 $ 60.05
----------------------------------------------------------------
In the future, DHS may be splitting existing aid codes into new aid
codes. The new split aid codes will be in the same aid code group
category as the original aid code. If DHS establishes new aid codes by
splitting existing aid codes, Contractor agrees to accept Eligible
Beneficiaries with these new aid codes as Members and to provide
covered services to these Members at the monthly capitation rate
specified for the original aid code group category. The Department
shall confirm all aid code splits, and the rates of payment for such
new aid codes, in writing to Contractor as soon as practicable after
such aid code splits occur.
All other terms, conditions, and provisions contained in Section 5.3
remain unchanged.
3. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL.
The actuarial basis for the determination of the capitation payment
rates for Aid Codes 7A, 47, and 72 is outlined in Attachment 1
(consisting of 2 pages).
4. All other terms, conditions, and provisions contained in Section 5.4
remain unchanged.
Id Group Poverty - 7A Base: Statewide Family Age Adjusted
Base Period: FY 96/97
Payments at End of Month
Services==> Hospital Hospital Nursing
Physician Pharmacy Inpatient Outpatient Facility Other
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995
Contract Cost FY 96/97 $ 10.32 $ 6.73 $ 13.50 $ 3.74 $ 0.24 $ 7.36
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000
Projeced Cost 10/98-9/99 $ 10.77 $ 6.69 $ 14.73 $ 3.70 $ 0.28 $ 12.23
8. CHDP
9. Administrative Allowance 1.6%
Fee-for-Service Equivalent Cost
Fee-for-Service Adj. 94%
Capitation Rate with FQHC increment
Capitation Rate without FQHC increment
Services==> FQHC
FFSE Increment Total
1. Base Cost $ 2,98 $ 1.21 $ 47.42
2. Age/Sex Adjustments 1.000 1.000
3. Eligibility Adjustments 1.000 1.000
4. Coverage Adjustments 0.991 0.991
5. Interest Offset 0.998 0.998
Contract Cost FY 96/97 $ 2.94 $ 1.20 $ 46.03
6. Legislative Adjustments 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.071 1.071
b. utilization 1.265 1.265
Projeced Cost 10/98-9/99 $ 4.08 $ 1.66 $ 54.14
8. CHDP $ 2.54
9. Administrative Allowance $ 0.88
Fee-for-Service Equivalent Cost $ 57.56
Fee-for-Service Adj. (3.45)
Capitation Rate with FQHC increment $ 54.11
Capitation Rate without FQHC increment $ 52.55
1 of 2
Id Group Poverty - 47/72
Base: Statewide
Base Period: FY 96/97
Payments at End of Month
Hospital Hospital Nursing
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995
Contract Cost FY 96/97 $ 10.57 $ 7.25 $ 20.32 $ 5.09 $ 0.14 $ 2.59
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150
7. Trend Adjustments
a. Cost per Unit 1.000 1.306 1.055 0.970 1.000 1.445
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000
Project Cost 10/98-9/99 $ 11.04 $ 7.21 $ 22.17 $ 5.04 $ 0.16 $ 4.30
8. CHDP
9. Administrative Allowance 1.6%
Fee-for-Service Equivalent Cost
Fee-for-Service Adj. 94%
Capitation Rate with FQHC increment
Capitation Rate without FQHC increment
Payments at End of Month
FQHC
Services==> FFSE Increment Total
1. Base Cost $ 5.42 $ 2.21 $ 54.45
2. Age/Sex Adjustments 1.000 1.000
3. Eligibility Adjustments 1.000 1.000
4. Coverage Adjustments 0.991 0.991
5. Interest Offset 0.998 0.998
Contract Cost FY 96/97 $ 5.36 $ 2.18 $ 53.50
6. Legislative Adjustments 1024
7. Trend Adjustments
a. Cost per Unit 1.071 1.071
b. Utilization 1.265 1.265
Project Cost 10/98-9/99 $ 7.44 $ 3.02 $ 60.38
8. CHDP $ 2.54
9. Administrative Allowance $ 0.96
Fee-for-Service Equivalent Cost $ 63.88
Fee-for-Service Adj. (3.83)
Capitation Rate with FQHC increment $ 60.05
Capitation Rate without FQHC increment $ 57.21
2 of 2
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
July 1, 1999
Xxxx Xxxxxx, M.D.
Xxxxxx Medical Centers, Inc.
One Golden Share
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxx:
In accordance with Article III, Section 3.34.2 of your Contract, the
enclosed Change Order authorizes the change in rates for FQHC and RHC
subcontracts and transmits Xxxxxx Medical Centers, Inc. rates for the period
July 1, 1999 through September 30, 1999. This Change Order also changes contract
Sections 3.27.6, Federally Qualified Health Centers/Rural Health Clinics; 5.3
Capitation Rates; 5.4 Capitation Rates Constitute Payment in Full; 5.13 FQHC and
RHC Risk Corridor Payments; 6.3.6 Submittal of FQHC and RHC payment information
and 6.6.21 FQHC and RHC Contracts. The new rates will appear in your capitation
rate beginning July 1, 1999.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER NUMBER C3 TO CONTRACT NO. 95-23637 BY CHANGING CONTRACT SECTIONS
3.27.6 FEDERALLY QUALIFIED HEALTH CENTERS/RURAL HEALTH CLINICS; 5.3 CAPITATION
RATES; 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL; 5.13 FQHC/RHC RISK
CORRIDOR PAYMENTS; 6.3.6 SUBMITTAL OF FQHC AND RHC PAYMENT INFORMATION AND
6.6.21 FQHC AND RURAL HEALTH CLINIC (RHC) CONTRACTS. Issued July 1,1999.
1. 3.27.6 FEDERALLY QUALIFIED HEALTH CENTERS/RURAL HEALTH CLINICS
A. Contractor shall not enter into a Subcontract with a Federally
Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) unless
DHS approves the provisions regarding rates, which shall be subject to
the standard that they be reasonable, as determined by DHS, in
relation to the services to be provided, in accordance with Article
VI, Section 6.6.21 FQHC and RHC Contracts. In Subcontracts where the
FQHC or RHC has made the election to be reimbursed on a reasonable
cost basis by the State, provisions shall be included that require the
subcontractor to keep a record of the number of visits by plan Members
separate from Fee-For-Service Medi-Cal beneficiaries, in addition to
any other data reporting requirements of the Subcontract. The
provisions of this section shall end June 30, 1999.
B. The provisions of this section shall apply beginning July 1, 1999.
Contractor shall submit to DHS, within 30 days of a request and in the
form and manner specified by DHS, for each of Contractor's FQHC and
RHC Subcontracts the services provided and the reimbursement level and
amount. Further, Contractor shall certify to DHS that pursuant to
Welfare and Institutions Code, Section 14087.325(b) and (d), as
amended by Chapter 894/Statutes of 1998, that FQHC and RHC Subcontract
terms and conditions are the same as offered to other Subcontractors
providing similar scope of service and that reimbursement is not less
than the level and amount of payment that Contractor makes for the
same scope of services furnished by a provider that is not a FQHC or
RHC. Effective July 1, 1999, Contractor shall not be required to pay
FQHCs and RHCs at the Medi-Cal interim per visit rate described in
Section 6.6.22. Rather, Contractor shall be required to pay its FQHC
and RHC Subcontractors reimbursement that is
1 of 4
CHANGE ORDER C3
CONTRACT NO. 95-23637
not less than the level and amount of payment that Contractor makes
for the same scope of services furnished by a provider that is not a
FQHC or RHC. Effective July 1, 1999, Contractor capitation rates will
be reduced to reflect the removal of the requirement to pay FQHCs and
RHCs the Medi-Cal interim per visit rate. DHS reserves the right to
review and audit Contractor's FQHC and RHC reimbursement at its
discretion to ensure compliance with the state and federal law and
shall approve all FQHC and RHC Subcontracts consistent with the
provisions of Welfare and Institutions Code, Section 14087.325(h).
C. Subcontracts with FQHCs shall also meet Contract requirements of
Article VI, Sections 6.6.20, FQHC services and 6.6.21, FQHC and Rural
Health Clinic Subcontracts. Subcontracts with RHCs shall also meet
Contract requirements of Article VI, Section 6.6.21
D. In Subcontracts where a negotiated reimbursement rate is agreed to as
total payment, a provision that such rate constitutes total payment
shall be included in the Subcontract.
2. 5.3 CAPITATION RATES
FOR THE PERIOD 7/1/99 - 9/30/99 RIVERSIDE COUNTY
---------------------------------------------------------------------------
GROUPS AID CODES RATE
---------------------------------------------------------------------------
Fami1y 00, 0X, 00, 00, 00, 00, 0X, 00, $ 78.41
3H, 34, 35, 38, 39, 3A, 3C,
3N, 3P, 3R, 3U, 3R, 40, 54,
59, 7X; CalWORKS: 3E, 3L,
3M
---------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 222.61
68, 6A, 6C, 6N, 6P, 6R
---------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 160.47
---------------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 92.75
---------------------------------------------------------------------------
Adult 86 $ 705.26
---------------------------------------------------------------------------
AIDS Beneficiary $ 962.42
---------------------------------------------------------------------------
Percent of Poverty 7A $ 52.55
---------------------------------------------------------------------------
Percent of Poverty 47.72 $ 57.21
---------------------------------------------------------------------------
2 of 4
Change order c3
contract no. 95-23637
For the period 7/1/99 - 9/30/99 SAN BERNARDINO COUNTY
---------------------------------------------------------------------------
GROUPS AID CODES RATE
---------------------------------------------------------------------------
Family 00, 0X, 00, 00, 00, 00, 0X, 00, $ 80.41
3H, 34, 35, 38, 39, 3A, 3C,
3N, 3P, 3R, 3U, 40, 54, 59,
7X; Cal WORKS: 3E, 3L, 3M
---------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 233.49
68, 6A, 6C, 6N, 6P, 6R
---------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 163.77
---------------------------------------------------------------------------
Child 03, 04, 45, 4C, 4K, 5K, 82 $ 106.35
---------------------------------------------------------------------------
Adult 86 $ 790.53
---------------------------------------------------------------------------
AIDS Beneficiary $ 995.00
---------------------------------------------------------------------------
Percent of Poverty 7A $ 52.55
---------------------------------------------------------------------------
Percent of Poverty 47,72 $ 57.21
---------------------------------------------------------------------------
3. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
The actuarial basis for the determination of the capitation payment rates
is outlined in Attachment 1 (consisting of 16 pages).
All other terms, conditions, and provisions contained in Section 5.4 remain
unchanged.
4. 5.13 FQHC/RHC RISK CORRIDOR PAYMENTS
For service periods beginning October 1, 1997 and through June 30, 1999
provided that Contractor has submitted expenditure data to DHS in the form
and manner specified by DHS, DHS shall perform reconciliations to determine
the variance between the contractor's actual FQHC/RHC expenses and the
amount they were paid through capitation rates for FQHC/RHC services.
For each annual reconciliation, if, pursuant to subcontracts with FQHCs and
RHCs that have been reviewed and approved in writing by DHS, Contractor has
paid subcontracting FQHCs and RHCs in the aggregate interim rate payments
an amount greater than 110 percent of the dollar value of FQHC and RHC
interim rate payments included in Contractor's capitation rates, DHS shall
pay Contractor the amount in excess of 110 percent.
For each annual reconciliation, if, pursuant to subcontracts with FQHCs and
RHCs that have been reviewed and approved in writing by DHS, Contractor has
paid subcontracting FQHCs and RHCs in the aggregate an amount less than 90
percent of the dollar value of FQHC and RHC interim rate payments included
in Contractor's capitation rates,
3 of 4
CHANGE ORDER C3
CONTRACT NO. 95-23637
Contractor shall refund the amount below 90 percent to DHS. DHS may recover
amounts owed by Contractor pursuant to this section through an offset to
the capitation payments made to Contractor, pursuant to Section 5.11(C),
Recovery of Capitation Payments.
All reconciliations shall be subject to an annual reconciliation audit at
which time payments to or recoupments from Contractor shall be finalized.
5. 6.3.6 SUBMITTAL OF FQHC AND RHC PAYMENT INFORMATION
Effective with the October 1997 month of service, Contractor shall keep a
record of the number of visits by plan Members to each FQHC and RHC
contracting with Contractor and related payment information, and shall
submit this information to DHS in the frequency, format, and manner
specified by DHS. This requirement shall remain in effect for service
periods through the June 30, 1999.
6. 6.6.21 FQHC AND RURAL HEALTH CLINIC (RHC) CONTRACTS
A. This requirement shall remain in effect for service periods through
June 30, 1999. Notwithstanding Article III, Section 3.26.4,
Departmental Approval - Federally Qualified HMOs, Contractor shall not
enter into any contract with an FQHC or RHC for provision of Covered
Services to Members without prior approval by DHS. All contracts with
FQHCs or RHCs shall provide reimbursement to the FQHC or RHC on the
basis of each center's or clinic's Medi-Cal interim per visit rate,
applicable on the date the reimbursable services were provided, as
established by DHS, unless:
1. DHS has approved in writing an alternate reimbursement
methodology; or
2. The FQHC or RHC agrees to be reimbursed on an at-risk basis and
such agreement is contained in the contract with the center or
clinic. In contracts where the negotiated rate is agreed to as
total payment, the contract shall state that such payment
constitutes total payment to the entity.
B. To the extent that Indian Health Service facilities qualify as FQHCs
or RHCs, the same reimbursement requirements shall apply to contracts
with Indian Health Service facilities.
7. All other terms, conditions, and provisions contained in Section 5.4 remain
unchanged.
4 of 4
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Family
The Rate Period is October 1, 1998 to September 30,1999
Capitation Payments at the Beginning of the Month C3 to Contract 95-23637
Attachment 1
Page 1 of 16
Coverages
-----------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-----------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-----------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-----------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-----------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-----------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-----------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-----------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-----------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
-----------------------------------------------------------------------------
Rate Calculation
Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 864.71 $ 16.16 $ 812.04 $ 20.09
2. Units per Eligible 4.014 4.683 0.373 2.146 0.004 3.532
3. Addt'l Capitation Amts. $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 23.60 $ 7.81 $ 31.50 $ 2.90 $ 0.27 $ 5.91
Adjustments
a. Demographics 1.004 0.976 1.023 1.002 1.000 0.985
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.833
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 23.97 $ 7.52 $ 31.04 $ 2.76 $ 0.27 $ 4.82
3. Legislative Adjs. 1.053 1.053 0.998 1.023 1.141 1.046
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 23.98 $ 8.71 $ 34.15 $ 2.68 $ 0.32 $ 5.03
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate with FQHC
Increment $ 78.73 / Without $ 78.41
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.39 $ 24.41
2. Units per Eligible 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.96 $ 0.34 $ 73.29
Adjustments
a. Demographics 0.994 0.994
b. Area 1.000 1.000
c. Coverages 0.935 0.935
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.89 $ 0.31 $ 71.58
3. Legislative Adjs. 1.027 1.027
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.91 $ 0.32 $ 76.10
5. Stop Loss Reins Premium 0.00
6. CHDP 5.06
7. Fee-for-Service Adj. (2.43)
Capitation Rate with FQHC
Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 C3 to Contract
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Aged Attachment 1
Page 2 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 287.24 $ 10.02 $ 77.33 $ 6.41
2. Units per Eligible 4.472 21.914 1.265 3.306 2.016 12.862
3. Addt'l Capitation Amts. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00 $ 0.00
Cost per Ellg. per Mo. $ 19.51 $ 59.73 $ 37.69 $ 2.78 $ 12.99 $ 6.87
Adjustments
a. Demographics 0.955 1.019 0.957 0.970 1.039 1.025
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.791
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 18.97 $ 60.32 $ 35.78 $ 2.65 $ 13.39 $ 5.54
3. Legislative Adjs. 0.939 1.049 0.926 0.931 1.140 0.927
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000 1.050
b. Units per Eligible 1.100 1.155 1.100 1.100 1.000 0.950
Projected Cost per Eligible $ 21.55 $ 80.39 $ 40.09 $ 2.85 $ 15.26 $ 5.12
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC Increment $ 160.47 / Without $ 160.47
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 28.59 $ 0.00
2. Units per Eligible 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.31 $ 0.00 $ 139.88
Adjustments
a. Demographics 0.970 0.970
b. Area 1.000 1.000
c. Coverages 0.603 0.603
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.18 $ 0.00 $ 136.83
3. Legislative Adjs. 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.17 $ 0.00 $ 165.43
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (4.96)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 C3 to Contract
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Disabled Attachment 1
Page 3 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 485.15 $ 12.37 $ 139.87 $ 10.16
2. Units per Eligible 6.873 26.861 1.556 5.050 0.459 21.959
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 29.54 $ 88.96 $ 72.80 $ 5.23 $ 5.35 $ 18.59
Adjustments
a. Demographics 0.983 0.989 0.981 0.998 1 000 1.015
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.878
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.12 $ 76.60 $ 65.37 $ 5.05 $ 5.30 $ 16.48
3. Legislative Adjs. 0.941 1.043 0.919 0.931 1.130 0.923
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000
Projected Cost per Eligible $ 28.07 $ 106.34 $ 66.23 $ 4.91 $ 6.26 $ 16.73
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC Increment $ 222.61 / Without $ 222.61
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 66.52 $ 0.00
2. Units per Eligible 0.216 0.216
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 1.20 $ 0.00 $ 221.67
Adjustments
a. Demographics 0.987 0.987
b. Area 1.000 1.000
c. Coverages 0.863 0.863
d. Interest 0.995 0.995
Adjusted Base Cost $ 1.02 $ 0.00 $ 196.94
3. Legislative Adjs. 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.95 $ 0.00 $ 229.49
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (6.88)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 C3 to Contract
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Child Attachment 1
Page 4 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Oulpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing MOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 889.41 $ 16.21 $ 469.38 $ 20.69
2. Units per Eligible 3.999 3.411 0.465 1.516 0.007 1.958
3. Addt'l Capitation Amts. $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.70 $ 3.91 $ 37.36 $ 2.05 $ 0.27 $ 3.38
Adjustments
a. Demographics 1.181 1.019 1.321 1.114 1.000 1.165
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.815
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.10 $ 3.90 $ 46.75 $ 2.21 $ 0.27 $ 3.19
3. Legislative Adjs. 1.076 1.047 0.999 1.024 1.134 1.090
4. Trend Adjustments
a. Cost per Unit 1 000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 27.70 $ 4.49 $ 51.49 $ 2.15 $ 0.32 $ 3.47
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC Increment $93.09 / Without $ 92.75
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.39 $ 24.41
2. Units per Eligible 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Etlg. per Mo. $ 0.96 $ 0.34 $ 70.97
Adjustments
a. Demographics 1.003 1.003
b. Area 1.000 1.000
c. Coverages 0.970 0.970
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.93 $ 0.33 $ 84.68
3. Legislative Adjs. 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.96 $ 0.34 $ 90.92
5. Stop Loss Reins. Premium 0.00
6. CHDP 5.04
7. Fee-for-Service Adj. (2.87)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 C3 to Contract
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Adult Attachment 1
Page 5 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Oulpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Oulpatient Care Other
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 964.66 $ 15.76 $ 812.04 $ 36.13
2. Units per Eligible 21.383 5.818 5.446 4.679 0.000 10.172
3. Addt'l Capitation Amts. $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 161.60 $ 8.36 $ 473.41 $ 6.23 $ 0.00 $ 30.63
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1 000
b. Area 1.043 1.000 1.000 1.000 1 000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.809
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 167.54 $ 8.31 $ 470.57 $ 6.13 $ 0.00 $ 24.66
3. Legislative Adjs. 1.029 1.054 1.000 1.022 1.102 1.004
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 163.78 $ 9.63 $ 518.80 $ 5.95 $ 0.00 $ 24.70
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC Increment $ 706.77 / Without $ 705.26
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.39 $ 24.41
2. Units per Eligible 0.735 0.735
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 4.19 $ 1.50 $ 685.92
Adjustments
a. Demographics 1.000 1.000
b. Area 1.000 1.000
c. Coverages 0.995 0.995
d. Interest 0.995 0.995
Adjusted Base Cost $ 4.15 $ 1.49 $ 682.85
3. Legislative Adjs. 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 4.21 $ 1.51 $ 728.58
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (21.81)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 C3 to Contract
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: AIDS Attachment 1
Page 6 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpaitient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 485.15 $ 13.79 $ 139.87 $ 42.30
2. Units per Eligible 26.305 74.792 3.169 9.882 0.000 36.392
3. Addt'l Capitation Arms. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 74.57 $ 785.66 $ 138.01 $ 11.38 $ 0.00 $ 128.28
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1 043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.599
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.04 $ 506.56 $ 131.42 $ 11.23 $ 0.00 $ 76.46
3. Legislative Adjs. 0.963 1.006 0.977 0.982 1.186 0.979
4. Trend Adjustments
a. Cost par Unit 1.000 1.100 1.050 1.000 1.100 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000
Projected Cost per Eligible $ 75.25 $ 678.28 $ 141.56 $ 11.52 $ 0.00 $ 82.34
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC Increment $ 962.42 / Without $ 962.42
Rule Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 66.52 $ 0.00
2. Units per Eligible 0.628 0.628
3. Addt'l Capitation Arms. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 3.48 $ 0.00 $ 1.141.38
Adjustments
a. Demographics 1.000 1.000
b. Area 1.000 1.000
c. Coverages 0.951 0.951
d. Interest 0.995 0.995
Adjusted Base Cost $ 3.29 $ 0.00 $ 800.00
3. Legislative Adjs. 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 3.24 $ 0.00 $ 992.19
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment 29.77
Aid Group Poverty - 7A Base: Statewide Family Age Adjusted
Base Period : FY 96/97
Payments at End of Month
Hospital Hospital Nursing FQHC
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Total
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.98 $ 1.21 $47.42
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.998
Contract Cost FY 96/97 $ 10.32 $ 6.73 $ 13.50 $ 3.74 $ 0.24 $ 7.36 $ 2.94 $ 1.20 $46.03
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 10.77 $ 6.69 $ 14.73 $ 3.70 $ 0.28 $ 12.23 $ 4.08 $ 1.66 $54.14
8. CHDP $ 2.54
9. Adiministrative Allowance 1.5% $ 0.88
Fee-for-Service Equivalent Cost $57.56
Fee-for-Services Adj. 94% (3.45)
Capitation Rate with FQHC increment $54.11
Capitation Rate without FQHC increment $52.55
C3 to Contract 95-23637
Attachment 1
Page 7 of 16
Aid Group Poverty - 47/72 Base: Statewide
Base Period: FY 96/97
Payments at End of Month
Hospital Hospital Nursing FQHC
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Totals
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $ 2.21 $ 54.45
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.998
Contract Cost FY 96/97 $ 10.57 $ 7.25 $ 20.32 $ 5.09 $ 0.14 $ 2.59 $ 5.36 $ 2.18 $ 53.50
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 11.04 $ 7.21 $ 22.17 $ 5.04 $ 0.16 $ 4.30 $ 7.44 $ 3.02 $ 60.38
8. CHDP $ 2.54
9. Administrative Allowance 1.6% $ 0.96
Fee-for-Service Equivalent
Cost $ 63.88
Fee-for-Service Adj. 94% (3.83)
Capitation Rate with FQHC
increment $ 60.05
Capitation Rate without
FQHC increment $ 57.21
C3 to Contract 95-23637
Attachment 1
Page 8 of 16
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99 C3 to Contract
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Family Attachment 1
Page 9 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plun
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care alter month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 978.02 $ 16.16 $ 812.04 $ 20.09
2. Units per Eligible 4.050 4.683 0.373 2.146 0.004 3.532
3. Addt'l Capitation Amts. $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 23.81 $ 7.81 $ 35.02 $ 2.90 $ 0.27 $ 5.91
Adjustments
a. Demographics 0.997 0.993 0.977 0.987 1.000 0.985
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.833
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 24.02 $ 7.65 $ 32.95 $ 2.72 $ 0.27 $ 4.82
3. Legislative Adjs. 1.053 1.053 0.998 1.023 1.141 1.046
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 24.03 $ 8.86 $ 36.25 $ 2.64 $ 0.32 $ 5.03
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 80.48 / Without $ 80.41
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.10 $ 7.33
2. Units per Eligible 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.75 $ 0.08 $ 76.55
Adjustments
a. Demographics 0.992 0.992
b. Area 1.000 1.000
c. Coverages 0.935 0.935
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.69 $ 0.07 $ 73.19
3. Legislative Adj. 1.027 1.027
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.71 $ 0.07 $ 77.91
5. Stop Loss Reins. Premium 0.00
6. CHDP 5.06
7. Fee-for-Service Adj. (2.49)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99 C3 to Contract
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Disabled Attachment 1
Page 10 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 611.26 $ 12.37 $ 139.87 $ 10.16
2. Units per Eligible 6.969 26.861 1.556 5.050 0.459 21.959
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 29.91 $ 88.96 $ 89.15 $ 5.23 $ 5.35 $ 18.59
Adjustments
a. Demographics 0.980 0.973 0.961 0.998 0.996 1.006
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.878
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.38 $ 75.36 $ 78.43 $ 5.05 $ 5.28 $ 16.34
3. Legislative Adjs. 0.941 1.043 0.919 0.931 1.130 0.923
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000
Projected Cost per Eligible $ 28.34 $ 104.62 $ 79.47 $ 4.91 $ 6.23 $ 16.59
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 233.49 / Without $ 233.49
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 69.96 $ 0.00
2. Units per Eligible 0.120 0.120
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.70 $ 0.00 $ 237.89
Adjustments
a. Demographics 0.989 0.989
b. Area 1.000 1.000
c. Coverages 0.863 0.863
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.59 $ 0.00 $ 208.43
3. Legislative Adjs. 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.55 $ 0.00 $ 240.71
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (7.22)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Aged
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
C3 to Contract 95-23637
Attachment 1
Page 11 of 16
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C3 to Contract
95-23637
Attachment 1
Page 11 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 316.16 $ 10.02 $ 77.33 $ 6.41
2. Units per Eligible 4.580 21.914 1.265 3.306 2.016 12.862
3. Addt'l Capitation Amts. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 19.95 $ 59.73 $ 40.74 $ 2.78 $ 12.99 $ 6.87
Adjustments
a. Demographics 0.963 1.014 0.962 0.975 1.027 1.013
b. Area 1.043 1 000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.791
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 19.56 $ 60.02 $ 38.88 $ 2.66 $ 13.23 $ 5.48
3. Legislative Adjs. 0.939 1.049 0.926 0.931 1.140 0.927
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000 1.050
b. Units per Eligble 1.100 1.155 1.100 1.100 1.000 0.950
Projected Cost per Eligible $ 22.22 $ 79.99 $ 43.56 $ 2.86 $ 15.08 $ 5.07
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 163.77 / Without $ 163.77
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 50.63 $ 0.00
2. Units per Eligible 0.024 0.024
3. Addt'l Capitation Amis. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.10 $ 0.00 $ 143.16
Adjustments
a. Demographics 0.979 0.979
b. Area 1.000 1.000
c. Coverages 0.603 0.603
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.06 $ 0.00 $ 139.89
3. Legislative Adjs. 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.06 $ 0.00 $ 168.84
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (5.07)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99 C3 to Contract
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Child Attachment 1
Page 12 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care alter month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 1,120.53 $ 16.21 $ 469.38 $ 20.69
2. Units per Eligible 4.035 3.411 0.465 1.516 0.007 1.958
3. Addt'l Capitation Amts. $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.90 $ 3.91 $ 46.32 $ 2.05 $ 0.27 $ 3.38
Adjustments
a. Demographics 1.212 1.021 1.342 1.157 1.000 1.080
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.815
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 28.05 $ 3.91 $ 58.88 $ 2.30 $ 0.27 $ 2.96
3. Legislative Adjs. 1.076 1.047 0.999 1.024 1.134 1.090
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 28.67 $ 4.50 $ 64.85 $ 2.24 $ 0.32 $ 3.22
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 106.43 / Without $ 106.35
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.10 $ 7.33
2. Units per Eligible 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.75 $ 0.08 $ 79.66
Adjustments
a. Demographics 1.084 1.084
b. Area 1.000 1.000
c. Coverages 0.970 0.970
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.78 $ 0.08 $ 97.23
3. Legislative Adjs. 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.80 $ 0.08 $ 104.88
5. Stop Loss Reins. Premium 0.00
6. CHDP 5.04
7. Fee-for-Service Adj. (3.29)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99 C3 to Contract
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: Adult Attachment 1
Page 13 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 1,140.81 $ 15.76 $ 812.04 $ 36.13
2. Units per Eligible 21.541 5.818 5.446 4.679 0.000 10.172
3. Addt'l Capitation Amts. $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 162.79 $ 8.36 $ 553.36 $ 6.23 $ 0.00 $ 30.63
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.809
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 168.77 $ 8.31 $ 550.04 $ 6.13 $ 0.00 $ 24.66
3. Legislative Adjs. 1.029 1.054 1.000 1.022 1.102 1.004
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligble 0.950 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 164.98 $ 9.63 $ 606.42 $ 5.95 $ 0.00 $ 24.70
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 790.89 / Without $ 790.53
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.10 $ 7.33
2. Units per Eligible 0.577 0.577
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 3.28 $ 0.35 $ 765.00
Adjustments
a. Demographics 1.000 1.000
b. Area 1.000 1.000
c. Coverages 0.995 0.995
d. Interest 0.995 0.995
Adjusted Base Cost $ 3.25 $ 0.35 $ 761.51
3. Legislative Adjs. 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligble 1.000 1.000
Projected Cost per Eligible $ 3.30 $ 0.36 $ 815.34
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (24.45)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 356 Date: 04-May-99 C3 to Contract
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97 95-23637
Aid Code Grouping: AIDS Attachment 1
Page 14 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 611.26 $ 13.79 $ 139.87 $ 42.30
2. Units per Eligible 26.584 74.792 3.169 9.882 0.000 36.392
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 75.33 $ 785.66 $ 171.31 $ 11.38 $ 0.00 $ 128.28
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.599
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.77 $ 506.56 $ 163.12 $ 11.23 $ 0.00 $ 76.46
3. Legislative Adjs. 0.963 1.006 0.977 0.982 1.186 0.979
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100
b. Units per Eligble 1.100 1.210 1.050 1.045 0.950 1.000
Projected Cost per Eligible $ 76.03 $ 678.28 $ 175.70 $ 11.52 $ 0.00 $ 82.34
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 995.00 / Without $ 995.00
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 69.96 $ 0.00
2. Units per Eligible 0.349 0.349
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 2.04 $ 0.00 $ 1,174.00
Adjustments
a. Demographics 1.000 1.000
b. Area 1.000 1.000
c. Coverages 0.951 0.951
d. Interest 0.995 0.995
Adjusted Base Cost $ 1.93 $ 0.00 $ 831.07
3. Legislative Adjs. 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 1.90 $ 0.00 $ 1,025.77
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (30.77)
Capitation Rate With FQHC Increment
Aid Group Poverty - 7A Base: Statewide Family Age Adjusted
Base Period : FY 96/97
Payments at End of Month
Hospital Hospital Nursing FQHC
Services ==>> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Total
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.98 $ 1.21 $ 47.42
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.998
Contract Cost FY 96/97 $ 10.32 $ 6.73 $ 13.50 $ 3.74 $ 0.24 $ 7.36 $ 2.94 $ 1.20 $ 46.03
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.0OO 1.265 1.265
Projected Cost 10/98-9/99 $ 10.77 $ 6.69 $ 14.73 $ 3.70 $ 0.28 $ 12.23 $ 4.08 $ 1.66 $ 54.14
8. CHDP $ 2.54
9. Adiministrative Allowance 1.6% $ 0.88
Fee-for-Service Equivalent Cost $ 57.56
Fee-for-Service Adj. 94% (3.45)
Capition Rate with FQHC increment $ 54.11
Capition Rate without FQHC increment $ 52.55
C3 to Contract 95-23637
Attachment 1
Page 15 of 16
Aid Group Poverty - 47/72 Base: Statewide Family Age Adjusted
Base Period : FY 96/97
Payments at End of Month
Hospital Hospital Nursing FQHC
Services ==>> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Total
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $ 2.21 $ 54.45
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.998
Contract Cost FY 96/97 $ 10.57 $ 7.25 $ 20.32 $ 5.09 $ 0.14 $ 2.59 $ 5.36 $ 2.18 $ 53.50
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.0OO 1.265 1.265
Projected Cost 10/98-9/99 $ 11.04 $ 7.21 $ 22.17 $ 5.04 $ 0.16 $ 4.30 $ 7.44 $ 3.02 $ 60.38
8. CHDP $ 12.54
9. Adiministrative Allowance 1.5% $ 0.96
Fee-for-Service Equivalent Cost $ 63.88
Fee-for-Service Adj. 94% (3.83)
Capition Rate with FQHC increment $ 60.05
Capition Rate without FQHC increment $ 57.21
C3 to Contract 95-23637
Attachment 1
Page 16 of 16
[LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X. X. Xxx 000000
Xxxxxxxxxx, XX 00000-0000
(000) 000-0000
December 23, 1999
Xxxxxx Xxxxxxxxx, President
Xxxxxx Medical Centers
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
The enclosed Change Order No. C4 to Contract No. 95-23637 adds Section
3.47 to Article III of your Contract, relating to Year 2000 compliance
requirements. The text of the Change Order contains the State
Department of General Services Year 2000 warranty language. The Change
Order will be effective immediately. Alternative text is not
permitted.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
-------------------
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X. X. Xxx 000000
Xxxxxxxxxx. XX 00000-0000
(000) 000-0000
CHANGE ORDER No. C4 to CONTRACT No. 95-23637: AMEND ARTICLE III,
GENERAL TERMS AND CONDITIONS BY ADDING SECTION 3.47, YEAR 2000
COMPLIANCE REQUIREMENTS. Issued December 17, 1999.
3.47 YEAR 2000 COMPLIANCE REQUIREMENTS
The Contractor warrants and represents that the goods or
services sold, leased, or licensed to the State of California,
its agencies, or its political subdivisions, pursuant to this
contract are "Year 2000 compliant." For purposes of this
contract, a good or service is Year 2000 compliant If it will
continue to fully function before, at, and after the Year 2000
without interruption and if applicable, with full ability to
accurately and unambiguously process, display, compare,
calculate, manipulate, and otherwise utilize date information.
This warranty and representation supersedes all warranty
disclaimers and all limitations on liability provided by or
through the Contractor.
[GRAPHIC APPEARS HERE]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X.X. Xxx 00000
Xxxxxxxxxx, XX 00000-0000
(000) 000-0000
February 7, 2000
[SEAL]
Xxxxxx Xxxxxxxxx
Xxxxxx Medical Centers, Inc.
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Mr., Xxxxxxxxx:
On July 1, 1999, the Department of Health Services (Department) sent
you Change Order No. 03 to Contract No. 95-23637. After further
analysis, the Department determined that Change Order No. 03 did not
completely express its intent regarding Federally Qualified Health
Centers (FQHCs) and Rural Health Centers (RHCs). In addition, this
Change Order adds several new aid codes that became effective during
1999. These aid codes are split aid codes from existing aid codes you
are already capitated for, including 5X split from 59, 8R split from
7A, and 8P spirt from 72. Therefore, the Department is sending you
this enclosed Change Order (No. 05) to replace and supersede Change
Order No. 03.
In accordance with Article III, Section 3.34.2 of your Contract, the
enclosed Change Order authorizes the change in rates for FQHC and RHC
subcontracts and transmits (Xxxxxx Medical Centers, Inc.) rates for
the period July 1, 1999 through September 30, 1 999. This Change
Order also changes Contract Sections 3.28.6 Federally Qualified Health
Centers/Rural Health Clinics; 5.3 Capitation Rates; 5.4 Capitation
Rates Constitute Payment in Full; 5.13 FQHC and RHC Risk Corridor
Payments; 6.3,6 Submittal of FQHC and RHC Payment Information and
6.6.21 FQHC and RHC Contracts. These rates appeared in your capitation
rates beginning July 1, 1999.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
-------------------
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X. X. Xxx 000000
Xxxxxxxxxx, XX 00000-0000
(000)000-0000
CHANGE ORDER NUMBER C5 TO CONTRACT NO.95-23637: CHANGING CONTRACT
SECTIONS 3.28.6 FEDERALLY QUALIFIED HEALTH CENTERS/RURAL HEALTH
CLINICS; 5.3 CAPITATION RATES; 5.4 CAPITATION RATES CONSTITUTE PAYMENT
IN FULL; 5.13 FQHC/RHC RISK CORRIDOR PAYMENTS; 6.3.6 SUBMITTAL OF FQHC
AND RHC PAYMENT INFORMATION AND 6.6.21 FQHC AND RURAL HEALTH CLINIC
(RHC) CONTRACTS TO READ AS STATED BELOW. This Change Order is effective
July 1,1999.
1. 3.28.6 FEDERALLY QUALIFIED HEALTH CENTERS/RURAL HEALTH
CLINICS
A. For service periods from the effective date of this contract
through June 30,1999, Contractor shall not enter into a
Subcontract with a Federally Qualified Health Center (FQHC)
or a Rural Health Clinic (RHC) unless DHS approves the
provisions regarding rates, which shall be subject to the
standard that they be reasonable, as determined by DHS, in
relation to the services to be provided in accordance with
Article VI, Section 6.6.21, FQHC and RHC Contracts. In
Subcontracts where the FQHC or RHC has made the election to
be reimbursed on a reasonable cost basis by the State,
provisions shall be included that require the subcontractor
to keep a record of the number of visits by plan Members
separate from Fee-For-Service Medi-Cal beneficiaries, in
addition to any other data reporting requirements of the
Subcontract
B. For service periods beginning July 1,1999, Contractor shall
submit to DHS, within 30 days of a request and in the form
and manner specified by DHS, the services provided and the
reimbursement level and amount for each of Contractor's FQHC
and RHC Subcontracts. For service periods beginning July
1,1999, Contractor shall certify in writing to DHS within 30
days of DHS's written request, that pursuant to Welfare and
Institutions Code, Section 14087.325(b) and (d), as amended
by Chapter 894/Statutes of 1998, FQHC and RHC Subcontract
terms and conditions are the same as offered to other
Subcontractors providing a similar scope of service and that
reimbursement is not less than the level and amount of
payment that Contractor makes for the same scope of services
furnished by a provider that is not a FQHC or RHC. For FQHC
or RHC services provided on or after July 1,1999, Contractor
is not required to pay FQHCs and RHCs the Medi-Cal interim
per visit rate described in Section 6.6.21. At its
discretion, DHS reserves the right to review and audit
Contractor's FQHC and RHC reimbursement to ensure compliance
with state and federal law and shall approve all FQHC and
RHC Subcontracts consistent with the provisions of Welfare
and Institutions Code Section 14087.325(h).
1 of 5
C. Subcontracts with FQHCs shall also meet Contract
requirements of Article VI, Sections 6.6.20, FQHC Services,
and 6.6.21, FQHC and Rural Health Clinic Contracts.
Subcontracts with RHCs shall also meet Contract requirements
of Article VI, Section 6.6.21.
D. In Subcontracts where a negotiated reimbursement rate is
agreed to as total payment, a provision that such rate
constitutes total payment shall be included in the
Subcontract
2. 5.3 CAPITATION RATES
For the period 7/1/99-9/30/99 Riverside County
----------------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------------------------------------------------
Family 01, OA, 02, 08, $ 78.41
30, 32, 33, 34, 35, 38, 39, 40,
42, 54, 59, 3A, 3C, 3E, 3G, 3H, 3L
3M, 3N, 3P, 3R, 3U, 5X, 7X,
----------------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 222.61
60, 64, 66, 68,
6A, 6C, 6N, 6P,
6R
----------------------------------------------------------------------------------------------------------
Aged 10,14,16,18 $ 160.47
----------------------------------------------------------------------------------------------------------
Child 03,04,4C,4K, $ 92.75
5K, 45, 82
----------------------------------------------------------------------------------------------------------
Adult 86 $ 705.26
----------------------------------------------------------------------------------------------------------
AIDS Beneficiary . $ 962.42
----------------------------------------------------------------------------------------------------------
Percent of Poverty 7A, 8R $ 52.55
----------------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, 8P $ 57.21
----------------------------------------------------------------------------------------------------------
2 of 5
For the period 7/1/99 -9/30/99 San Bernardino County
---------------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
---------------------------------------------------------------------------------------------------------
Family 01,OA,02,08, $ 80.41
30, 32, 33, 34, 35, 38, 39, 40,
42, 54, 59, 3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R, 3U, 5X, 7X,
---------------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 233.49
60, 64, 66, 68,
6A, 6C, 6N, 6P,
6R
---------------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 163.77
---------------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 106.35
5K, 45, 82
---------------------------------------------------------------------------------------------------------
Adult 86 $ 790.53
---------------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 995.00
---------------------------------------------------------------------------------------------------------
Percent of Poverty 7A, 8R $ 52.55
---------------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, 8P $ 57.21
---------------------------------------------------------------------------------------------------------
All other terms, conditions, and provisions contained in Section 5.3 remain
unchanged.
3. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop
loss reinsurance provisions, on behalf of a Member for all Covered
Services required by such Member and for all Administrative Costs
incurred by the Contractor in providing or arranging for such
services, and subject to adjustments for federally qualified health
centers in accordance with Section 5.13, but do not include payment
for the recoupment of current or previous losses incurred by
Contractor. DHS is not responsible for making payments for recoupment
of losses. The actuarial basis for the determination of the capitation
payment rates is outlined in Attachment 1 (consisting of 16 pages).
4. 5.13 FQHC/RHC RISK CORRIDOR PAYMENTS
For FQHCs/RHCs service periods beginning October 1,1997, and
continuing through June 30,1999, provided that Contractor has
submitted expenditure data to DHS in the form and manner specified by
DHS, DHS shall perform reconciliations to determine the variance
between the funds that have been paid to the Contractor in its
capitation rates to reflect the dollar value of FQHC/RHC interim rate
payments made to these entities in the
3 of 5
Medi-Cal fee-for-service program, and the amount that the Contractor
has paid to subcontracting FQHCs/RHCs.
For the initial reconciliation and for each reconciliation thereafter,
if, pursuant to subcontracts with FQHCs and RHCs that have been
reviewed and approved by DHS, Contractor has paid subcontracting FQHCs
and RHCs in the aggregate an amount greater than 110 percent of the
dollar value of FQHC and RHC interim rate payments included in
Contractor's capitation rates, DHS shall pay Contractor the amount in
excess of 110 percent.
For the initial reconciliation and for each reconciliation thereafter,
if, pursuant to subcontracts with FQHCs and RHCs that have been
reviewed and approved by DHS, Contractor has paid subcontracting FQHCs
and RHCs in the aggregate an amount less than 90 percent of the dollar
value of FQHC and RHC interim rate payments included in Contractor's
capitation rates, Contractor shall refund the amount below 90 percent
to DHS. DHS may recover amounts owed by Contractor pursuant to this
section through an offset to the capitation payments made to
Contractor, pursuant to Section 5.11(C), Recovery of Capitation
Payments.
All reconciliations shall be subject to an annual reconciliation audit
at which time payments to or recoupment from Contractor shall be
finalized.
5. 6.3.6 SUBMITTAL OF FQHC AND RHC PAYMENT INFORMATION
Effective with the October 1997 month of service. Contractor shall
keep a record of the number of visits by plan Members to each FQHC and
RHC contracting with Contractor and related payment information, and
shall submit this information to DHS in the frequency, format, and
manner specified by DHS. -This requirement shall remain in effect for
service periods through the September 2000 month of service.
6. 6.6.21 FQHO AND RURAL HEALTH CLINIC (RHC) CONTRACTS
A. For service periods beginning October 1,1997, and continuing
through June 30,1999, notwithstanding Article III, Section
3.26.4, Departmental Approval - Federally Qualified HMOs,
Contractor shall not enter into any contract with an FQHC or
RHC for provision of Covered Services to Members without prior
written approval by DHS. All contracts with FQHCs or RHCs shall
provide reimbursement to the FQHC or RHC on the basis of each
center's or clinic's Medi-Cal interim per visit rate,
applicable on the date the reimbursable services were provided,
as established by DHS, unless:
1. DHS has approved in writing an alternate reimbursement
methodology, or
4 of 5
2. The FQHC or RHC agrees to be reimbursed on an at-risk basis
and such agreement is contained in the contract with the
center or clinic. In contracts where a negotiated rate is
agreed to as total payment, the contract shall state that
such payment' constitutes total payment to the entity.
B. To the extent that Indian Health Service facilities qualify as
FQHCs or RHCs, the same reimbursement requirements shall apply
to contracts with Indian Health Service facilities.
5 of 5
C5 to Contract 95-23637
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99 Attachment 1
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97 Page 1 of 16
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Deloxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 864.71 $ 16.16 $ 812.04 $ 20.09
2. Units per Eligible 4.014 4.683 0.373 2.146 0.004 3.532
3. Addt'l Capitation Amts. $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 23.60 $ 7.81 $ 31.50 $ 2.90 $ 0.27 $ 5.91
Adjustments
a. Demographics 1.004 0.976 1.023 1.002 1.000 0.085
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.833
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 23.97 $ 7.52 $ 31.04 $ 2.76 $ 0.27 $ 4.82
3. Legislative Adjs. 1.053 1.053 0.998 1.023 1.141 1.046
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950
b. Units per Eligible 0.050 1.000 1.050 0.950 1.050 1.050
Projected Cost per Eligible $ 23.98 $ 8.71 $ 34.15 $ 2.68 $ 0.32 $ 5.03
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 78.73 / Without $ 78.41
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 68.39 $ 24.41
2. Units per Eligible 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.96 $ 0.34 $ 73.29
Adjustments
a. Demographics 0.994 0.994
b. Area 1.000 1.000
c. Coverages 0.935 0.935
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.89 $ 0.31 $ 71.58
3. Legislative Adjs. 1.027 1.027
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.91 $ 0.32 $ 76.10
5. Stop Loss Reins. Premium 0.00
6. CHDP 5.06
7. Fee-for-Service Adj. (2.43)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Disabled
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
C5 to Contract 95-23637
Attachment 1
Page 2 of 16
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewcar NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 485.15 $ 12.37 $ 139.87 $ 10.16
2. Units per Eligible 6.873 26.861 1.556 5.050 0.459 21.959
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 29.54 $ 88.96 $ 72.80 $ 5.23 $ 5.35 $ 18.59
Adjustments
a. Demographics 0.983 0.989 0.981 0.998 1.000 1.015
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.878
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.12 $ 76.60 $ 65.37 $ 5.05 $ 5.30 $ 16.48
3. Legislative Adjs. 0.941 1.043 0.919 0.931 1.130 0.923
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000
Projected Cost per Eligible $ 28.07 $ 106.34 $ 66.23 $ 4.91 $ 6.26 $ 16.73
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 222.61 / Without $ 222.61
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 66.52 $ 0.00
2. Units per Eligible 0.216 0.216
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 1.20 $ 0.00 $ 221.67
Adjustments
a. Demographics 0.987 0.987
b. Area 1.000 1.000
c. Coverages 0.863 0.863
d. Interest 0.995 0.995
Adjusted Base Cost $ 1.02 $ 0.00 $ 196.94
3. Legislative Adjs. 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligble 1.000 1.000
Projected Cost per Eligible $ 0.95 $ 0.00 $ 229.49
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (8.88)
Capitation Rate With FQHC Increment
C5 to Contract 95-23637
Attachment 1
Page 3 of 16
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 04-May-99
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Aged
The Rate Period is October 1, 1998 to September 30, 1999 Capitation Payments at the Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafelo Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care alter month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 287.24 $ 10.02 $ 77.33 $ 6.41
2. Units per Eligible 4.472 21.014 1.265 3.306 2.016 12.862
3. Addt'l Capitation Amts. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 19.51 $ 59.73 $ 37.69 $ 2.78 $ 12.99 $ 6.87
Adjustments
a. Demographics 0.955 1.019 0.957 0.970 1.039 1.025
b. Area 1.043 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.791
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 18.97 $ 60.32 $ 35.78 $ 2.65 $ 13.39 $ 5.54
3. Legislative Adjs. 0.939 1.049 0.926 0.931 1.140 0.927
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000 1.050
b. Units per Eligible 1.100 1.155 1.100 1.100 1.000 0.950
Projected Cost per Eligible $ 21.55 $ 80.39 $ 40.09 $ 2.85 $ 15.28 $ 5.12
5. Stop Loss Reins. Amount $ 0 Rate 0.0%
6. CHDP
7. Fee-for-Service Adj. -3.0%
Capitation Rate With FQHC
Increment $ 160.47 / Without $ 160.47
Rate Calculation FQHC
FFSE Increment Total
1. Average Cost Per Unit $ 28.59 $ 0.00
2. Units per Eligible 0.132 0.132
3. Addt'l Capitation Amts. $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 0.31 $ 0.00 $ 139.88
Adjustments
a. Demographics 0.970 0.970
b. Area 1.000 1.000
c. Coverages 0.603 0.603
d. Interest 0.995 0.995
Adjusted Base Cost $ 0.18 $ 0.00 $ 136.83
3. Legislative Adjs. 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1.000 1.000
b. Units per Eligible 1.000 1.000
Projected Cost per Eligible $ 0.17 $ 0.00 $ 165.43
5. Stop Loss Reins. Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. (4.96)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 355 Date: 04-May-00
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Child
The Rale Period is October 1,1998 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 4 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 889.41 $ 16.21 $ 469.38
2. Units per Eligible 3.999 3.411 0.465 1.516 0.007
3. Addt'l Capitation Amts. $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.70 $ 3.91 $ 37.86 $ 2.05 $ 0.27
Adjustments
a. Demographics 1.181 1.019 1.321 1.114 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.10 $ 3.90 $ 46.75 $ 2.21 $ 0.27
3. Legislative Adjs. 1.076 1.047 0.999 1.024 1.134
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 27.70 $ 4.49 $ 51.49 $ 2.15 $ 0.32
5. Stop Loss Reins Amount $ 0
6. CHDP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 93.09 / Without $ 92.75
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 20.69 $ 68.39 $ 24.41
2. Units per Eligible 1.958 0.168 0.168
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 3.38 $ 0.96 $ 0.34 $ 70.97
Adjustments
a. Demographics 1.165 1.003 1.003
b. Area 1.000 1.000 1.000
c. Coverages 0.815 0.970 0.970
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 3.19 $ 0.93 $ 0.33 $ 84.68
3. Legislative Adjs. 1.090 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 3.47 $ 0.96 $ 0.34 $ 90.92
5. Stop Loss Reins. Rate 0.0% Premium 0.00
6. CHDP 5.04
7. Fee-for-Service Adj. -3.0% (2.87)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 355 Date: 04-May-00
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Adult
The Rate Period is October 1,1998 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 5 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 964.66 $ 15.76 $ 812.04
2. Units per Eligible 21.383 5.818 5.446 4.679 0.000
3. Addt'l Capitation Amts. $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00
Cost per Elig. per Mo. $ 161.60 $ 8.36 $ 473.41 $ 6.23 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 167.54 $ 8.31 $ 470.57 $ 6.13 $ 0.00
3. Legislative Adjs. 1.029 1.054 1.000 1.022 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 163.76 $ 9.63 $ 518.80 $ 5.95 $ 0.00
5. Stop Loss Reins Amount $ 0
6. CHDP
7. Fee-for-Service Adj.
Capitation Rale With FQHC Increment $ 706.77 / Without $ 705.26
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 36.13 $ 66.39 $ 24.41
2. Units per Eligible 10.172 0.735 0.735
3. Addt'l Capitation Amts. $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 30.63 $ 4.19 $ 1.50 $ 685.92
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.809 0.995 0.995
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 24.66 $ 4.15 $ 1.49 $ 682.85
3. Legislative Adjs 1.004 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 24.70 $ 4.21 $ 1.51 $ 728.58
5. Stop Loss Reins Rate 0.0% Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. -3.0% (21.81)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 355 Date: 04-May-OO
County: Riverside Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: AIDS
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 6 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 485.15 $ 13.79 $ 139.87
2. Units per Eligible 26.305 74.792 3.169 9.882 0.000
3. Addt'l Capitation Amts $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Ellg. per Mo $ 74.57 $ 785.66 $ 138.01 $ 11.38 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.04 $ 506.56 $ 131.42 $ 11.23 $ 0.00
3. Legislative Adjs 0.963 1.006 0.977 0.982 1.186
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 75.25 $ 678.28 $ 141.56 $ 11.52 $ 0.00
5. Slop Loss Reins Amount $ 0
6. CHDP
7. Fee-for-Service Adj.
Capitation Rale With FQHC Increment $ 962.42 / Without $ 962.42
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 42.30 $ 66.52 $ 0.00
2. Units per Eligible 36.392 0.628 0.628
3. Addt'l Capitation Amts $ 0.00 $ 0.00 $ 0.00
Cost per Ellg. per Mo $ 128.28 $ 3.48 $ 0.00 $ 1.141.30
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.599 0.951 0.951
d. Interest 0.995 0.995 0.995
Adjusted Base Cost $ 76.46 $ 3.29 $ 0.00 $ 800.00
3. Legislative Adjs 0.979 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 82.34 $ 3.24 $ 0.00 $ 992.19
5. Slop Loss Reins Rate 0,0% Premium 0.00
6. CHDP 0.04
7. Fee-for-Service Adj. -3.0% (29.77)
Capitation Rale With FQHC Increment
Aid Group Poverty-7A Base: Statewide Family Age Adjusted
Base Period: FY 96/97
Payments at Beginning of Month
Hospital Hospital Nursing FQHC
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Totals
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.98 $ 1.21 $ 47.42
2. Age/5ex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.990 0.996 0.987 0.989 0.993 0.990 0.994 0.994
Contract Cost FY 96/37 $ 10.27 $ 6.69 $ 13.45 $ 3.73 $ 0.24 $ 7.32 $ 2.93 $ 1.20 $ 45.83
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 10.72 $ 6.65 $ 14.68 $ 3.69 $ 0.28 $ 12.16 $ 4.06 $ 1.66 $ 53.90
8.CHDP $ 2.54
9. Administrative Allowance 1.6% $ 0.88
Fee-for-Service Equivalent Cost $ 57.32
Fee-for-Service Adj. 94% (3.44)
Capitation Rate with FQHC Increment $ 53.88
Capitation Rate without FQHC Increment $ 52.32
C5 to Contract 95-23637
Attachment 1
Page 7 of 16
Aid Group Poverty-47/72 Base: Statewide
Base Period: FY 96/97
Payments at Beginning of Month
Hospital Hospital Nursing FQHC
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Totals
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $ 2.21 $ 54.45
2. Age/5ex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1,000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.990 0.996 0.987. 0.989 0.993 0.990 0.994 0.994
Contract Cost FY 96/37 $ 10.52 $ 7.22 $ 20.24 $ 5.07 $ 0.14 $ 2.57 $ 5.34 $ 2.18 $ 53.28
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 10.98 $ 7.18 $ 22.08 $ 5.02 $ 0.16 $ 4.27 $ 7.41 $ 3.02 $ 60.12
8.CHOP $ 2.54
9. Administrative Allowance 1.6% $ 0.95
Fee-for-Service Equivalent Cost $ 63.61
Fee-for-Service Adj. 94% (3.82)
Capitation Rate with FQHC Increment $ 59.79
Capitation Rate without FQHC Increment $ 56.95
C5 to Contract 95-23637
Attachment 1
Page 8 of 16
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Family
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 9 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 978.02 $ 16.16 $ 812.04
2. Units per Eligible 4.050 4.683 0.373 2.146 0.004
3. Add'l Capitation Amis $ 0.37 $0.05 $ 4.62 $ 0.01 $ 0.00
Cost per Ellg. per Mo $ 23.81 $ 7.81 $ 35.02 $ 2.90 $ 0.27
Adjustments
a. Demographics 0.997 0.993 0.977 0.987 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 24.14 $ 7.69 $ 33.12 $ 2.74 $ 0.27
3. Legislative Adjs, 1.053 1.053 0.998 1.023 1.141
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 24.15 $ 8.91 $ 36.44 $ 2.66 $ 0.32
5. Slop Loss Reins Amount $ 0
6. CHOP
7. Fee-for-Sarvice Adj.
Capitation Rate With FQHC Increment $ 80.89 /Without $80.82
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 20.09 $ 68.10 $ 7.33
2. Units per Eligible 3.532 0.132 0.132
3. Add'l Capitation Amis $ 0.00 $ 0.00 $ 0.00
Cost per Ellg. per Mo $5.91 $ 0.75 $ 0.08 $ 76.55
Adjustments
a. Demographics 0.985 0.992 0.992
b. Area 1.000 1.000 1.000
c. Coverages 0.833 0.935 0.935
d. Interest 1.000 1.000 1.000
Adjusted Base Cost $ 4.85 $ 0.70 $ 0.07 $ 73.58
3. Legislative Adjs, 1.046 1.027 1.027
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 5.06 $ 0.72 $ 0.07 $ 78.33
5. Slop Loss Reins Rate 0,0% Premium 0.00
6. CHOP 5.06
7. Fee-for-Sarvice Adj. -3.0% (2.50)
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Disabled
The Rate Period Is October 1,1998 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 10 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 611.26 $ 12.37 $ 139.87
2. Units per Eligible 6.969 26.661 1.556 5.050 0.459
3. Addt'l Capitation Amts $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Ellg. per Mo $ 29.91 $ 88.45 $ 89.15 $ 5.23 $ 5.35
Adjustments
a. Demographics 0.980 0.973 0.961 0.998 0.996
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 27.51 $ 75.74 $ 78.82 $ 5.08 $ 5.30
3. Legislative Adjs 0.941 1.043 0.919 0.931 1.130
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 28.48 $ 105.14 $ 79.86 $ 4.94 $ 6.26
5. Slop Loss Reins Amount $ 0
6. CHDP
7. Fee-for-Service Adj.
Capitation Rale With FQHC Increment $ 234.65 / Without $ 234.65
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 10.16 $ 69.96 $ 0.00
2. Units per Eligible 21.959 0.120 0.120
3. Addt'l Capitation Amts $ 0.00 $ 0.00 $ 0.00
Cost per Ellg. per Mo $ 18.59 $ 0.70 0.00 $ 237.89
Adjustments
a. Demographics 1.006 0.989 0.989
b. Area 1.000 1.000 1.000
c. Coverages 0.878 0.863 0.863
d. Interest 1.000 1.000 1.000
Adjusted Base Cost $ 16.42 $ 0.60 $ 0.00 $ 209.47
3. Legislative Adjs 0.923 0.932 0.932
4. Trend Adjustments
a. Cost per Unit 1.100 1.000 1,000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 16.67 $ 0.56 $ 0.00 $ 241.91
5. Slop Loss Reins Rate 0.0% Premium 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. -3.0% (7.26)
Capitation Rale With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Aged
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 11 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 316.16 $ 10.02 $ 77.33
2. Units per Eligible 4.580 21.914 1.265 3.306 2.016
3. Add'l Capitation Amts $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00
Cost per Ellg. per Mo $ 19.95 $ 59.73 $ 40.74 $ 2.78 $ 12.99
Adjustments
a. Demographics 0.963 1.014 0.962 0.975 1.027
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 19.66 $ 60.32 $ 39.07 $ 2.67 $ 13.30
3. Legislative Adjs 0.939 1.049 0.926 0.931 1.140
4. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000
b. Units per Eligible 1.100 1.155 1.100 1.100 1.000
Projected Cost per Eligible $ 22.34 $ 80.39 $ 43.78 $ 2.87 $ 15.16
5. Stop Loss Reins Amount $ 0
6. CHOP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 164.60 /Without $ 164.60
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 6.41 $ 50.63 $ 0.00
2. Units per Eligible 12.862 0.024 0.024
3. Add'l Capitation Amts $ 0.00 $ 0.00 $ 0.00
Cost per Ellg. per Mo $ 6.87 $ 0.10 $ 0.00 $ 143.16
Adjustments
a. Demographics 1.013 0.979 0.979
b. Area 1.000 1.000 1.000
c. Coverages 0.791 0.603 0.603
d. Interest 1.000 1.000 1.000
Adjusted Base Cost $ 5.50 $ 0.06 $ 0.00 $ 140.58
3. Legislative Adjs 0.927 0.926 0.926
4. Trend Adjustments
a. Cost per Unit 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.000
Projected Cost per Eligible $ 5.09 $ 0.06 $ 0.00 $ 169.69
5. Stop Loss Reins Rate 0.0% Premium 0.00
6. CHOP 0.00
7. Fee-for-Service Adj. -3.0% (5.09)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Child
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 12 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 1,120.53 $ 16.21 $ 469.38
2. Units per Eligible 4.035 3.411 0.465 1.516 0.007
3. Add'l Capitation Amts $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00
Cost par Ellg. per Mo $ 22.90 $ 3.91 $ 46.32 $ 2.05 $ 0.27
Adjustments
a. Demographics 1.212 1.021 1.342 1.157 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 28.20 $ 3.93 $ 59.18 $ 2.31 $ 0.27
3. Legislative Adjs 1.076 1.047 0.999 1.024 1.134
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 28.83 $ 4.53 $ 65.18 $ 2.25 $ 0.32
5. Stop Loss Reins Amount $ 0 Rate
6. CHOP
7. Fee-for-Service AdJ.
Capitation Rate With FQHC Increment $ 106.97 /Without $ 106.89
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 20.69 $ 68.10 $ 7.33
2. Units per Eligible 1.958 0.132 0.132
3. Add'l Capitation Amts $ 0.00 $ 0.00 $ 0.00
Cost par Ellg. per Mo $ 3.38 $ 0.75 $ 0.08 $ 79.66
Adjustments
a. Demographics 1.080 1.084 1.084
b. Area 1.000 1.000 1.000
c. Coverages 0.815 0.970 0.970
d. Interest 1.000 1.000 1.000
Adjusted Base Cost $ 2.98 $ 0.79 $ 0.08 $ 97.74
3. Legislative Adjs 1.090 1.031 1.031
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 3.24 $ 0.81 $ 0.08 $ 105.24
5. Stop Loss Reins Premium 0.00
6. CHDP 5.04
7. Fee-for-Service AdJ. -3.0% (3.31)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Adult
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 13 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 1,140.81 $ 15.76 $ 812.04
2. Units per Eligible 21.541 5.818 5.446 4.679 0.000
3. Add'l Capitation Amts $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00
Cost per Ellg. per Mo $ 162.79 $ 6.36 $ 553.36 $ 6.23 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 169.62 $ 8.35 $ 552.81 $ 6.16 $ 0.00
3. Legislative Adjs 1.029 1.054 1.000 1.022 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 165.81 $ 9.68 $ 609.47 $ 5.98 $ 0.00
5. Stop Loss Reins Amount $ 0
6. CHOP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 794.86 /Without $ 794.50
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 36.13 $ 68.10 $ 7.33
2. Units per Eligible 10.172 0.577 0.577
3. Add'l Capitation Amts $ 0.00 $ 0.00 $ 0.00
Cost par Ellg. per Mo $ 30.63 $ 3.28 $ 0.35 $ 765.00
Adjustments
a. Demographics . 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.809 0.995 .0.995
d. Interest 1.000 1.000 1.000
Adjusted Base Cost $ 24.78 $ 3.26 $ 0.35 $ 765.33
3. Legislative Adjs 1.004 1.015 1.015
4. Trend Adjustments
a. Cost per Unit 0.950 1.000 1.000
b. Units per Eligible 1.050 1.000 1.000
Projected Cost per Eligible $ 24.82 $ 3.31 $ 0.36 $ 819.43
5. Stop Loss Reins 0.0% Premium 0.00
6. CHOP 0.00
7. Fee-for-Service Adj. -3.0% (24.57)
Capitation Rate With FQHC Increment
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Dec-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: AIDS
The Rate Period Is October 1,1998 Capitation Payments at the
to September 3D, 1999 Beginning of the Month
Coverages
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered-by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C5 to Contract 95-23637
Attachment 1
Page 14 of 16
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 611.26 $ 13.79 $ 139.87
2. Units per Eligible 26.584 74.792 3.169 9.882 0.000
3. Add'l Capitation Amis $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00
Cost per Elig. per Mo $ 75.33 $ 785.66 $ 171.31 $ 11.38 $ 0.00
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998
d. Interest 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 72.13 $ 509.11 $ 163.94 $ 11.29 $ 0.00
3. Legislative Adjs 0.963 1.006 0.977 0.982 1.186
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1,100
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950
Projected Cost per Eligible $ 76.41 $ 681.69 $ 176.59 $ 11.59 $ 0.00
5. Stop Loss Reins
6. CHOP
7. Fee-for-Service Adj.
Capitation Rate With FQHC Increment $ 1,000.01/Without $ 1,000.01
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 42.30 $ 69.96 $ 0.00
2. Units per Eligible 36.392 0.349 0.349
3. Add'l Capitation Amis $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo $ 128.28 $ 2.04 $ 0.00 $ 1,174.00
Adjustments
a. Demographics 1.000 1.000 1.000
b. Area 1.000 1.000 1.000
c. Coverages 0.599 0.951 0.951
d. Interest 1.000 1.000 1,000
Adjusted Base Cost $ 76.84 $ 1.94 $ 0.00 $ 835.25
3. Legislative Adjs 0.979 0.984 0.984
4. Trend Adjustments
a. Cost per Unit 1.100 1,000
1.000
b. Units per Eligible 1.000 1.000 1.000
Projected Cost per Eligible $ 82.75 $ 1.91 $ 0.00 $ 1,030.94
5. Stop Loss Reins 0.0% 0.00
6. CHOP 0.00
7. Fee-for-Service Adj. Rate -3.0% Premium (30.93)
Capitation Rate With FQHC Increment
Aid Group Poverty-47/72 Base: Statewide
Base Period: FY 96/97
Payments at Beginning of Month
Services ==>
Hospital Hospital Nursing FQHC
physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Totals
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.96 $ 1.21 $ 47.42
2. Age/5ex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.998
Contract Cost FY 96/37 $ 10.32 $ 6.73 $ 13.50 $ 3.74 $ 0.24 $ 7.36 $ 2.94 $ 1.20 $ 46.03
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 10.77 $ 6.69 $ 14.73 $ 3.70 $ 0.28 $ 12.23 $ 4.08 $ 1.66 $ 54.14
8.CHOP $ 2.54
9. Administrative Allowance 1.5% $ 0.88
Fee-for-Service Equivalent Cost $ 57.56
Fee-for-Service Adj. 94% (3.45)
Capitation Rate with FQHC Increment $ 54.11
Capitation Rate without FQHC Increment $ 52.55
C5 to Contract 95-23637
Attachment 1
Page 15 of 16
Aid Group Poverty-47/72 Base: Statewide
Base Period: FY 96/97
Payments at Beginning of Month
Services ==>
Hospital Hospital Nursing FQHC
physician Pharmacy Inpatient Outpatient Facility Other FFSE Increment Totals
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $ 2.21 $ 54.45
2. Age/5ex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991 0.991
5. Interest Offset 0.995 1.001 0.991 0.993 0.998 0.995 0.998 0.994
Contract Cost FY 96/37 $ 10.57 $ 7.25 $ 20.32 $ 5.09 $ 0.14 $ 2.59 $ 5.36 $ 2.18 $ 53.50
6. Legislative Adjustments 1.044 0.740 0.985 1.021 1.061 1.150 1.024 1.024
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265 1.265
Projected Cost 10/98-9/99 $ 11.04 $ 7.21 $ 22.17 $ 5.04 $ 0.16 $ 4.30 $ 7.44 $ 3.02 $ 60.38
8.CHOP $ 2.54
9. Administrative Allowance 1.5% $ 0.96
Fee-for-Service Equivalent Cost $ 63.88
Fee-for-Service Adj. 94% (3.83)
Capitation Rate with FQHC Increment $ 60.05
Capitation Rate without FQHC Increment $ 57.21
C5 to Contract 95-23637
Attachment 1
Page 16 of 16
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY XXXX XXXXX, Governor
================================================================================
[SEAL OF DEPARTMENT OF HEALTH SERVICES]
[SEAL]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X. X. Xxx 000000
Xxxxxxxxxx, XX 00000-0000
(000)000-0000
February 8, 2000
Xx. Xxxxxx Xxxxxxxxx, President
Molina
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
In accordance with Article V, Section 5.5 of your Contract, the
enclosed Change Order No. 06 transmits ( Xxxxxx'x ) annual capitation
rates for the period October 1, 1999 to September 30, 2000.
This Change Order also includes a rate change for the two-month period
of August 1999 through September 1999, to include the provider rate
increases established in the Budget Act of 1999/2000, which were
effective August 1, 1999.
The retropayment between the old rates and the new 1999/2000 rates for
the period October 1, 1999 through February 2000 and the provider rate
increases for the period August 1999 through September 1999 will appear
in your capitation check for February 2000. The March capitation check
will reflect the 1999/2000 rates.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY XXXX XXXXX, Governor
================================================================================
[SEAL OF DEPARTMENT OF HEALTH SERVICES]
[SEAL]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X. X. Xxx 000000
Xxxxxxxxxx, XX 00000-0000
(000)000-0000
CHANGE ORDER C06 TO CONTRACT NO.95-23637: ADJUSTING THE ANNUAL CAPITATION RATE
FOR PROVIDER RATE INCREASES DURING THE TWO MONTH PERIOD OF AUGUST 1, 1999
THROUGH SEPTEMBER 30, 1999; AND THE ANNUAL CAPITATION RATES FOR THE PERIOD
OCTOBER 1,1999 TO SEPTEMBER 30, 2000, BY CHANGING CONTRACT SECTIONS; 5.3
CAPITATION RATES; AND 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL. This
Change Order is effective February 1, 2000.
1. 5.3 CAPITATION RATES
For the Period 8-1-99 to 9-30-99 San Bernardino County
---------------------------------------------------------------------------
GROUPS AID CODES RATE
---------------------------------------------------------------------------
Family 01, OA. 02, 08, 30, 81.00
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 5X.7X
---------------------------------------------------------------------------
Disabled 20,24, 26, 28, 36, 234.98
60, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
---------------------------------------------------------------------------
Aged 10, 14. 16. 18 165.06
---------------------------------------------------------------------------
Child 03, 04, 4C, 4K, 5K, 107.27
45,82
---------------------------------------------------------------------------
Adult 86 796.46
---------------------------------------------------------------------------
AIDS Beneficiary 996.35
---------------------------------------------------------------------------
Percent of Poverty 7A 52.87
---------------------------------------------------------------------------
Percent of Poverty 47,72 57.53
---------------------------------------------------------------------------
1
For the Period 8-1-99 to 9-30-99 Riverside County
----------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------
Family 01, OA, 02, 08, 30, 78.99
32, 33, 34, 35, 38, 39, 40,
42, 54, 59, 3A, 3C, 3E, 0X,
0X, 0X, 0X, 0X, 0X, 0X, 0X,
XX,0X
----------------------------------------------------------------
Disabled 20,24, 26, 28, 36, 224.00
60, 64, 66; 00, 0X,
0X, 0X, 0X. 6R
----------------------------------------------------------------
Aged 10, 14, 16, 18 161.75
----------------------------------------------------------------
Child 03, 04, 4C, 4K, 5K, 93.54
45,82
----------------------------------------------------------------
Adult 86 710.61
----------------------------------------------------------------
AIDS Beneficiary 963.67
----------------------------------------------------------------
Percent of Poverty 7A 52.87
----------------------------------------------------------------
Percent of Poverty 47,72 57.53
----------------------------------------------------------------
For the period 10-1-99 to 9-30-2000 San Bernardino County
----------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------
Family 01. OA. 02, 08, 30, 84.07
32, 33, 34, 35, 38, 39, 40,
42, 54, 59, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 5X, 7A, 7X
----------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 198.68
60, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
----------------------------------------------------------------
Aged 10, 14, 16, 18 145.52
----------------------------------------------------------------
Child 03, 04, 4A, AC, 4K, 8582
5K, 45, 47, 72, 82,
8R.8P
----------------------------------------------------------------
Adult 86 914.05
----------------------------------------------------------------
AIDS Beneficiary 763.69
----------------------------------------------------------------
2
Riverside County
For the period 10-1-99 to 9-30-2QQQ
----------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 79.61
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 4F, 4G, 5X, 7A,
7X
----------------------------------------------------------------
Disabled 20, 24. 26, 28, 36, 201.02
GO, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
----------------------------------------------------------------
Aged 10, 14, 16, 18 143.42
----------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 101.31
5K, 45, 47, 72, 82,
8R.8P
----------------------------------------------------------------
Adult 86 838.60
----------------------------------------------------------------
AIDS Beneficiary 722.10
----------------------------------------------------------------
. Aid codes 4A, 4F, 4G, 8R, & 8P will be effective February 1, 2000.
. All other terms, conditions, and provisions contained in Section 5.3
remain unchanged.
2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop loss
reinsurance provisions, on behalf of a Member for all Covered Services
required by such Member and for all Administrative Costs incurred by the
Contractor in providing or arranging for such services, and subject to
adjustments for federally qualified health centers in accordance with
Section 14087.325 of the W&.I Code, but do not include payment for the
recoupment of current or previous losses incurred by Contractor. DHS is not
responsible for making payments for recoupment of losses. The actuarial
basis for the determination of the capitation payment rates is outlined in
Attachment 1 (consisting of 28 pages).
All other terms, conditions, and provisions contained in Section 5.4 remain
unchanged.
3
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 01-Nov-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Ald Code Grouping: Family
Adjusted Rate is Effective August 1, Capitation Payments at the
1999 to September 30. 1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
-------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
-------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
-------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
-------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
-------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
-------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
-------------------------------------------------------------------------------
Alphateto Protein Testing NOT Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
-------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
-------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract 95-23637
Attachment 1
Page 1 of 28
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care
1. Average Cost Per Unit $ 69.46 $ 19.88 $ 978.02 $ 16.16 $ 812.04
2. Units per Eligible 4.050 4.683 0.373 2.146 0.004
3. Addt'l Capitation Amis $ 0.37 $ 0.05 $ 4.62 $ 0.01 $ 0.00
Cost per Elig. per Mo $ 23.81 $ 7.81 $ 35.02 $ 2.90 $ 0.27
4. Adjustments
a. Demographics 0.997 0.993 0.977 0.987 1.000
b. Area 1.043 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 24.02 $ 7.65 $ 32.95 $ 2.72 $ 0.27
5. Legislative Adjs 1.061 1.053 1.006 1.031
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050
Projected Cost per Eligible $ 24.21 $ 8.86 $ 36.55 $ 2.66 $ 0.34
7. Stop Loss Reins. Amount $ 0
8. CHOP
9. Fee-for-Service Adj.
Capitation Rate
Rate Calculation FQHC
Other FFSE Increment Total
1. Average Cost Per Unit $ 20.09 $ 68.10
2. Units per Eligible 3.532 0.132
3. Addt'l Capitation Amis $ 0.00 $ 0.00
Cost per Elig. per Mo $ 5.91 $ 0.75 $ 76.47
4. Adjustments
a. Demographics 0.985 0.992
b. Area 1.000 1.000
c. Coverages 0.833 0.935
d. Interest 0.995 0.995
Adjusted Base Cost $ 4.82 $ 0.69 $ 73.12
5. Legislative Adjs 1.061 1.041
6. Trend Adjustments
a. Cost per Unit 0.950 1.000
b. Units per Eligible 1.050 1.000
Projected Cost per Eligible $ 5.10 $ 0.72 $ 78.44
7. Stop Loss Reins. Rate 0.0% 0.00 $ 78.44
8. CHOP 0.00
9. Fee-for-Service Adj. 5.06
Capitation Rate -3.0% (2.50)
$ 81.00
Department of Health Services. Rate Development Branch
Plan Name: Xxxxxx Medical Center Plant #: 356 Date: 16-NOV-99
County: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Aged
Adjusted Rate is Effective August Capitation Payments at the
1,1999 to September 30, 1999 Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 2 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 316.16 $ 10.02 $ 77.33 $ 6.41 $ 50.63
2. Units per Eligible 4.580 21.914 1.265 3.306 2.016 12.862 0.024
3. Addt'l Capitation Amis. $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 19.95 $ 59.73 $ 40.74 $ 2.78 $ 12.99 $ 6.87 $ 0.10 $ 143.18
4. Adjustments
a. Demographics 0.963 1.014 0.962 0.975 1.027 1.013 0.979
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.791 0.603
d. Interest 0.995 O.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 19.56 $ 60.02 $ 38.88 $ 2.66 $ 13.23 $ 5.48 $ 0.06 $ 139.89
5. Legislative Adjs. 0.947 1.049 0.933 0.939 1.194 0.941 0.939
6. Trend Adjustments
a.Cost per Unit 1.100 1.100 1.100 1.050 1.000 1.050 1.000
b.Units per Eligible 1.100 1.155 1.100 1.100 1.000 0.950 1.000
Projected Cost per Eligible $ 22.41 $ 79.99 $ 43.89 $ 2.88 $ 15.80 $ 5.14 $ 0.06 $ 170.17
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
8. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (5.11)
Capitation Rate $ 165.06
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Disabled
Adjusted Rate is Effective August 1, 1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Cam NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 3 of 28
Rate Calculation
Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 611.26 $ 12.37 $ 139.87 $ 10.16 $ 69.96
2. Units per Eligible 6.969 26.861 1.556 5.050 0.459 21.959 0.120
3. Addt'l Capitation Amts $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $0.00 $ 0.00
Cost per Elig. per Mo. $ 29.91 $ 88.96 $ 89.15 $ 5.23 $ 5.35 $ 18.59 $ 0.70 $ 237.89
4. Adjustments
a. Demographics 0.980 0.973 0.961 0.998 0.996 1.006 0.989
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.878 0.863
d. Interest 0.995 0.995 0,995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.38 $ 75.36 $ 78.43 $ 5.05 $ 5.28 $ 16.34 $ 0.59 $ 208.43
5. Legislative Adjs. 0.949 1.043 0.927 0.939 1.184 0.937 0.945
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100 1.000
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000 1.000
Projected Cost per Eligible $ 28.58 $ 104.62 $ 80.16 $ 4.96 $ 6.53 $ 16.84 $ 0.56 $ 242.25
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (7.27)
Capitation Rate $ 234.98
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Child
Adjusted Rate is Effective August 1, 1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 4 of. 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 1,120.53 $ 16.21 $ 469.38 $ 20.69 $ 68.10
2. Units per Eligible 4.036 3.411 0.465 1.516 0.007 1.958 0.132
3. Addt'l Capitation Amts $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.90 $ 3.91 $ 46.32 $ 2.05 $ 0.27 $ 3.38 $ 0.75 $ 79.58
4. Adjustments
a. Demographics 1.212 1.021 1.342 1.157 1.000 1.080 1.084
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.815 0.970
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 28.05 $ 3.91 $ 58.88 $ 2.30 $ 0.27 $ 2.96 $ 0.78 $ 97.15
5. Legislative Adjs. 1.084 1.047 1.009 1.031 1.188 1.104 1.044
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950 1.000
b. Units per Eligible 0,950 1.000 1.050 0.950 1.050 1.050 1.000
Projected Cost per Eligible $ 28.89 $ 4.50 $ 65.50 $ 2.25 $ 0.34 $ 3.26 $ 0.81 $ 105.55
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 5.04
9. Fee-for-Service Adj. -3.0% (3.32)
Capitation Rate $ 107.27
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Adult
Adjusted Rate is Effective August 1,1999 Capitation Payments at the
to September 30,1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract :No. 95-23637
Page 5 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 1,140.81 $ 15.76 $ 812.04 $ 36.13 $ 68.10
2. Units per Eligible 21.541 5.818 5.446 4.679 0.000 10.172 0.577
3. Addt'l Capitation Amts $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 162.79 $ 8.36 $ 553.36 $ 6.23 $ 0.00 $ 30.63 $ 3.28 $ 764.65
4. Adjustments
a. Demographics 1.000 1.000 0.XXX 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 0.XXX 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 O.809 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 168.77 $ 8.31 $ 550.04 $ 6.13 $ 0.00 $ 24.66 $ 3.25 $ 761.16
5. Legislative Adjs. 1.038 1.054 1.007 1.031 1.154 1.018 1.029
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050 1.000
Projected Cost per Eligible $ 166.42 $ 9.63 $ 610.66 $ 6.00 $ 0.00 $ 25.04 $ 3.34 $ 821.09
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (24.63)
Capitation Rate $ 796.46
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan#: 356 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: AIDS
Adjusted Rate is Effective August 1,1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 6 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 611.26 $ 13.79 $ 139.87 $ 42.30 $ 69.96
2. Units per Eligible 26.584 74.792 3.169 9.882 0.000 36.392 0.349
3. Addt'l Capitation Amts $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 75.33 $ 785.66 $ 171.31 $ 11.38 $ 0.00 $ 128.28 $ 2.04 $ 1,174.00
4. Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000 1,000
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.599 0.951
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.77 $ 506.56 $ 163.12 $ 11.23 $ 0.00 $ 76.46 $ 1.93 $ 831.07
5. Legislative Adjs. 0.969 1.006 0.980 0.984 1.242 0.983 0.988
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100 1.000
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000 1.000
Projected Cost per Eligible $ 76.50 $ 678.28 $ 176.24 $ 11.55 $ 0.00 $ 82.68 $ 1.91 $ 1,027.16
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (30.81)
Capitation Rate $ 996.35
Department of Health Services, Rate Development Branch
C6 to Contract No.95-2367
Page 7 of 28
Aid Group: Poverty-47/72 Base: Statewide
Rate Period: August 1999 to September Base Period: FY 96/97
Hospital Hospital Nursing
Services ==> Physician Pharmacy Inpatient Outpatient Facility Other FQHC Totals
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $52.24
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 0.XXX 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991
5. Interest Offset 0.990 0.996 0.987 0.989 0.993 0.990 0.994
Contract Cost FY 96/97 $ 10.52 $ 7.22 $ 20.24 $ 5.07 $ 0.14 $ 2.57 $ 5.34 $51.10
6. Legislative Adjustments 1.054 0.740 0.997 1.031 1.111 1.167 1.038
7. Trend Adjustments
a. Cost Per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265
Projected Cost 10/98-9/99 $ 11.09 $ 7.18 $ 22.35 $ 5.07 $ 0.17 $ 4.33 $ 7.51 $57.70
8. CHDP $ 2.54
9. Administrative Allowance 1.6% $ 0.96
Fee-for-Service Equivalent Cost $61.20
Adjustment to Fee-for Service 94% $(3.67)
Capitation Rate (payments at beginning of month) $57.53
01/21/2000-Department of Health Services, Rate Development Branch
C6 to Contract No. 95-23637
Page 8 of 28
Aid Group: Poverty - 7 A Base: Statewide Family Age Adjusted
Rate Period : August 1999 to September Base Period: FY 96/97'
Hospital Hospital Nursing
Services==> Physician Pharmacy Inpatient Outpatient Facility Other FQHC Totals
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.98 $46.21
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1,000 1.000 1.000
3. Eligibility Adjustments 1,000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991
5. Interest Offset 0.99O 0.996 0.987 0.989 0.993 0.990 0.994
Contract Cost FY 96/97 $ 10.27 $ 6.69 $ 13.45 $ 3.73 $ 0.24 $ 7.32 $ 2.93 $44.63
6. Legislative Adjustments 1.054 0.740 0.997 1.031 1.111 1.167 1.038
7. Trend Adjustments
a. Cost Per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265
Projected Cost 10/98-9/99 $ 10.82 $ 6.65 $ 14.85 $ 3.73 $ 0.30 $ 12.34 $ 4.12 $52.81
8. CHDP $ 2.54
1.6% $ 0.89
9. Administrative Allowance
Fee-for-Service Equivalent Cost $56.24
Adjustment to Fee-for Service 94% $(3.37)
Capitation Rate (payments at beginning of month) $52.87
01 /21 /2000 - Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 16-Nov-99
County: Riverside Plan Type: Commercial Plan Base Period: Fy 96/97
Aid Code Grouping Family
Adjusted Rate is Effective August 1, 1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AiDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to 'Contract No. 95-23637
Page 9 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 69.46 $ 19.86 $ 864.71 $ 16.16 $ 812.04 $ 20.09 $ 68.39
2. Units per Eligible 4.014 4.683 0.373 2.146 0.004 3.532 0.168
3. Addt'l Capitation Amts $ 0.37 $ 0.05 $ 4.62 $ 0.00 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 23.60 $ 7.81 $ 31.50 $ 2.90 $ 0.27 $ 5.91 $ 0.96 $ 72.95
4. Adjustments
a. Demographics 1.004 0.976 1.023 1.002 1.000 0.985 0.994
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.833 0.935
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 23.97 $ 7.52 $ 31.04 $ 2.76 $ 0.27 $ 4.82 $ 0.89 $ 71.27
5. Legislative Adjs. 1.061 1.053 1.006 1.031 1.195 1.061 1.041
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950 1.000
b. Units per Eligible 0.950 1.210 1.050 0.950 0.050 1.050 1.000
Projected Cost per Eligible $ 24.16 $ 8.71 $ 34.43 $ 2.70 $ 0.34 $ 5.10 $ 0.93 $ 76.37
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (2.44)
Capitation Rate $ 78.99
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 16-Nov-99
County: Riverside Plan Type: Commercial Plan Base Period: Fy 96/97
Aid Code Grouping: Aged
Adjusted Rate is Effective August 1,1999 Capitation Payments at the
to September 30,1999 Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Menial Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 10 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 48.90 $ 32.71 $ 287.24 $ 10.02 $ 77.33 $ 6.41 $ 28.59
2. Units per Eligible 4.472 21.914 1.265 3.306 2.016 12.862 0.132
3. Addt'l Capitation Amts $ 1.29 $ 0.00 $ 7.41 $ 0.02 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 19.51 $ 59.73 $ 37.69 $ 2.78 $ 12.99 $ 6.87 $ 0.31 $ 139.88
4. Adjustments
a. Demographics 0.955 1.019 0.957 0.970 1.039 1.025 0.970
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.791 0.603
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 18.97 $ 60.32 $ 35.78 $ 2.65 $ 13.39 $ 5.54 $ 0.18 $ 136.83
5. Legislative Adjs. 0.947 1.049 0.933 0.939 1.194 0.941 0.939
6. Trend Adjustments
a. Cost per Unit 1.100 1.100 1.100 1.050 1.000 1.050 1.000
b. Units per Eligible 1.100 1.155 1.100 1.100 0.050 0.950 1.000
Projected Cost per Eligible $ 21.74 $ 80.39 $ 40.39 $ 2.87 $ 15.99 $ 5.20 $ 0.17 $ 166.75
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj. -3.0% (5.00)
Capitation Rate $ 161.75
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan #: 355 Date: 16-Nov-99
County: Riverside Plan Type: Commercial Plan Base Period: Fy 96/97
Aid Code Grouping: Disabled
Adjusted Rate is Effective August 1, 1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 11 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 46.41 $ 39.70 $ 485.15 $ 12.37 $ 139.87 $ 10.16 $ 66.52
2. Units per Eligible 6.873 26.861 1.556 5.050 0.459 21.959 0.216
3. Addt'l Capitation Amts $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 29.54 $ 88.96 $ 72.80 $ 5.23 $ 5.35 $ 18.59 $ 1.20 $ 221.67
4. Adjustments
a. Demographics 0.983 0.989 0.981 0.998 1.000 1.015 0.987
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.878 0.863
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.12 $ 76.60 $ 65.37 $ 5.05 $ 5.30 $ 16.48 $ 1.02 $ 196.94
5. Legislative Adjs. 0.949 1.043 0.927 0.939 1.184 0.937 0.945
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100 1.000
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000 1.000
Projected Cost per Eligible $ 28.31 $ 106.34 $ 66.81 $ 4.96 $ 6.56 $ 16.99 $ 0.96 $ 230.93
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 0.00
9. Fee-for-Service Adj -3.0% (6.93)
Capitation Rate $ 224.00
Plan Name: Xxxxxx Medical Center Plan#: 355 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Child
Adjusted Rate is Effective August 1,1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by [ha Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 12 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 67.42 $ 13.64 $ 889.41 $ 16.21 $ 469.38 $ 20.69 $ 68.39
2. Units per Eligible 3.999 3.411 0.465 1.516 0.007 1.958 0.168
3. Addt'l Capitation Amts $ 0.23 $ 0.03 $ 2.90 $ 0.00 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 22.70 $ 3.91 $ 37.36 $ 2.05 $ 0.27 $ 3.38 $ 0.96 $ 70.63
4. Adjustments
a. Demographics 1.181 1.019 1.321 1.114 1.000 1.165 1.003
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.815 0.970
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 27.10 $ 3.90 $ 46.75 $ 2.21 $ 0.27 $ 3.19 $ 0.93 $ 84.35
5. Legislative Adjs. 1.084 1.047 1.009 1.031 1.188 1.104 1.044
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050 1.000
Projected Cost per Eligible $ 27.91 $ 4.49 $ 52.01 $ 2.16 $ 0.34 $ 3.51 $ 0.97 $ 91.39
7. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHOP 5.04
9. Fee-for-Service Adj. -3.0% (2.89)
Capitation Rate $ 93.54
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan#: 355 Date: 16-Nov-99
Country: San Bernardino Plan Type: Commercial Plan Base Period: FY 96/97
Aid Code Grouping: Adult
Adjusted Rate is Effective August 1,1999 Capitation Payments at the
to September 30, 1999 Beginning of the Month
Coverages
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Menial Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by [ha Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
C6 to Contract No. 95-23637
Page 13 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 90.48 $ 17.11 $ 964.66 $ 15.76 $ 812.04 $ 36.13 $ 68.39
2. Units per Eligible 21.383 5.818 5.446 4.679 0.000 10.172 0.735
3. Addt'l Capitation Amts $ 0.37 $ 0.06 $ 35.62 $ 0.08 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 161.60 $ 8.36 $ 473.41 $ 6.23 $ 0.00 $ 30.63 $ 4.19 $ 684.42
4. Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.809 0.995
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 167.54 $ 8.31 $ 470.57 $ 6.13 $ 0.00 $ 24.66 $ 4.15 $ 681.36
5. Legislative Adjs. 1.038 1.054 1.007 1.031 1.154 1.018 1.029
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.000 0.950 1.000
b. Units per Eligible 0.950 1.000 1.050 0.950 1.050 1.050 1.000
Project Cost per Eligible $ 165.21 $ 9.63 $ 522.44 $ 6.00 $ 0.00 $ 25.04 $ 4.27 $ 732.59
7. Stop Loss Reins. Amount $0 Rate 0.0% 0.00
8. CHDP 0.00
9. Fee-for-Service Adj. -3.0% (21.98)
Capitation Rate $ 710.61
Department of Health Services, Rate Development Branch
Plan Name: Xxxxxx Medical Center Plan #: 355
County: Riverside Plan Type: Commercial Plan
Ald Code Grouping: AIDS
Date: 16-Nov-99
Base Period: FY 96/97
Adjusted Rate is Effective August 1,1999 to September 30,1999
Capitation Payments at the Beginning of the Month
Coverages
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care alter month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
C6 to Contract No.95-23637
Page 14 of 28
Rate Calculation Hospital Hospital Long Term FQHC
Physician Pharmacy Inpatient Outpatient Care Other FFSE Total
1. Average Cost Per Unit $ 32.67 $ 126.04 $ 485.15 $ 13.79 $ 139.87 $ 42.30 $ 66.52
2. Units per Eligible 26.305 74.792 3.169 9.882 0.000 36.392 0.628
3. Addt'l Capitation Amts. $ 2.96 $ 0.09 $ 9.89 $ 0.02 $ 0.00 $ 0.00 $ 0.00
Cost per Elig. per Mo. $ 74.57 $ 785.66 $ 138.01 $ 11.38 $ 0.00 $ 128.28 $ 3.48 $ 1,141.38
4. Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.043 1.000 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.599 0.951
d. Interest 0.995 0.995 0.995 0.995 0.995 0.995 0.995
Adjusted Base Cost $ 71.04 $ 506.56 $ 131.42 $ 11.23 $ 0.00 $ 76.46 $ 3.29 $ 800.00
5. Legislative Adjs. 0.969 1.006 0.980 0.984 1.242 0.983 0.988
6. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.050 1.000 1.100 1.100 1.000
b. Units per Eligible 1.100 1.210 1.050 1.045 0.950 1.000 1.000
Projected Cost per Eligible $ 75.72 $ 678.28 $ 141.99 $ 11.55 $ 0.00 $ 82.68 $ 3.25 $ 993.47
7. Stop Loss Reins. Amount 50 Rate 0.0% 0.00
8. CHDP 0.00
9. Fee-for-Service Adj. -3.0% (29.80)
Capitation Rate $ 963.67
Department of Health Services, Rate Development Branch
C6 to Contract No.95-23637
Page 15 of 28
Aid Group: Poverty-47/72
Rate Period: August 1999 to September Base: Statewide
Base Period: FY 96/97
Hospital Hospital Nursing
Services===> Physician Pharmacy Inpatient Outpatient Facility Other FQHC Total
1. Base Cost $ 10.66 $ 7.27 $ 20.52 $ 5.31 $ 0.14 $ 2.92 $ 5.42 $ 52.24
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991
5. Interest Offset 0.990 0.996 0.987 0.989 0.993 0.990 0.994
Contract Cost FY 96/97 $ 10.52 $ 7.22 $ 20.24 $ 5.07 $ 0.14 $ 2.57 $ 5.34 $ 51.10
6. Legislative Adjustments 1.054 0.740 0.997 1.031 1.111 1.167 1.038
7. Trend Adjustments
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265
Projected Cost 10/98-9/99 $ 11.09 $ 7.18 $ 22.35 $ 5.07 $ 0.17 $ 4.33 $ 7.51 $ 57.70
8. CHDP $ 2.54
9. Administrative Allowance 1.6% $ 0.96
Fee-for-Service Equivalent Cost $ 61.20
Adjustment to Fee-for Service 94% $ (3.67)
Capitation Rate (payments at
beginning of month) $ 57.53
01/21/2000 - Department of Health Services, Rate Development Branch
C6 to Contract No.95-23637
Page 16 of 28
Aid Group: Poverty-7A Base: Statewide Family Age Adjusted
Rate Period: August 1999 to September Base Period: FY 96/97
Hospital Hospital Nursing
Services===> Physician Pharmacy Inpatient Outpatient Facility Other FQHC Total
1. Base Cost $ 10.40 $ 6.74 $ 13.64 $ 3.91 $ 0.24 $ 8.30 $ 2.98 $ 46.21
2. Age/Sex Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000
3. Eligibility Adjustments 1.000 1.000 1.000 1.000 1.000 1.000 1.000
4. Coverage Adjustments 0.997 0.997 0.999 0.964 1.000 0.891 0.991
5. Interest Offset 0.990 0.996 0.987 0.989 0.993 0.990 0.994
Contract Cost FY 96/97 $ 10.27 $ 6.69 $ 13.45 $3.73 $ 0.24 $ 7.32 $ 2.93 $ 44.63
6. Legislative Adjustments 1.054 0.740 0.997 1.031 1.111 1.167 1.038
7. Trend Adjustment
a. Cost per Unit 1.000 1.308 1.055 0.970 1.000 1.445 1.071
b. Utilization 1.000 1.027 1.050 1.000 1.107 1.000 1.265
Projected Cost 10/98-9/99 $ 10.82 $ 6.65 $ 14.85 $ 3.73 $ 0.30 $ 12.34 $ 4.12 $ 52.81
8. CHDP $ 2.54
9. Administrative Allowance 1.6% $ 0.89
Fee-for-Service Equivalent Cost $ 56.24
Adjustment to Fee-for Service 94% $ (3.37)
Capitation Rate (payment at
beginning of month) $ 52.87
C6 to Contract No.95-23637
Page 17 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Family Plan Type: 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1, 1999 to September 30,2000 Capitation Payments
at the End of the Month
Coverage Adjustments
----------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
----------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
----------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
----------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
----------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
----------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
----------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
----------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
----------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
----------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
----------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
----------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
----------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
----------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
----------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 978.02 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 24.78 $ 4.43 $ 0.17 $ 4.70 $ 73.64
Adjustments
a. Demographics 0.829 0.863 0.714 0.835 1.000 0.871
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 26.80 $ 5.71 $ 17.13 $ 3.54 $ 0.17 $ 3.55 $ 56.90
3. Legislative Adjs. 1.139 0.975 1.012 1.034 1.159 1.065
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.100 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 30.53 $ 6.11 $ 18.12 $ 3.66 $ 0.20 $ 4.16 $ 62.78
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.88
7. Fee-for-Service Adj. 26.1% 16.41
Capitation Rate $ 84.07
C6 to Contract No.95-23637
Page 18 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Aged Plan Type : 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1, 1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 316.16 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 21.58 $ 3.80 $ 15.50 $ 23.14 $ 133.61
Adjustments
a. Demographics 0.964 1.019 0.964 0.983 1.034 1.022
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 14.76 $ 54.92 $ 20.74 $ 3.68 $ 15.98 $ 18.47 $ 128.55
3. Legislative Adjs. 0.952 0.920 0.940 1.035 1.159 0.932
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.950 1.045 0.950 1.100
Projected Cost per Eligible $ 14.75 $ 55.47 $ 20.37 $ 3.98 $ 17.59 $ 18.94 $ 131.10
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 14.42
Capitation Rate $ 145.52
C6 to Contract No.95-23637
Page 19 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Disabled Plan Type: 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1, 1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 611.26 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 51.50 $ 9.17 $ 6.96 $ 37.67 $ 220.32
Adjustments
a. Demographics 0.942 0.851 0.850 1.019 0.995 1.023
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 19.69 $ 68.49 $ 40.27 $ 9.09 $ 6.89 $ 33.80 $ 178.23
3. Legislative Adjs. 0.969 0.920 0.933 1.035 1.159 0.956
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 20.03 $ 69.17 $ 37.32 $ 8.94 $ 7.99 $ 35.54 $ 178.99
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 19.69
Capitation Rate $ 198.68
C6 to Contract No.95-23637
Page 20 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Child Plan Type: 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverages Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 1,120.53 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 40.71 $ 4.36 $ 0.22 $ 5.68 $ 80.73
Adjustments
a. Demographics 0.927 0.989 0.778 0.935 1.000 0.946
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 23.02 $ 4.35 $ 30.15 $ 3.97 $ 0.22 $ 4.74 $ 66.45
3. Legislative Adjs. 1.155 1.055 1.019 1.034 1.159 1.069
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 26.59 $ 5.04 $ 32.11 $ 4.10 $ 0.25 $ 5.57 $ 73.66
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.06
7. Fee-for-Service Adj. 11.0% 8.10
Capitation Rate $ 85.82
C6 to Contract No.95-23637
Page 21 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Adult Plan Type : 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1, 1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 1,140.81 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 417.06 $ 29.03 $ 0.00 $ 21.78 $ 778.24
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 305.43 $ 7.12 $ 416.64 $ 28.71 $ 0.00 $ 19.32 $ 777.22
3. Legislative Adjs. 1.059 0.945 1.011 1.034 1.159 1.071
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 323.45 $ 7.39 $ 440.18 $ 29.69 $ 0.00 $ 22.76 $ 823.47
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 90.58
Capitation Rate $ 914.05
C6 to Contract No.95-23637
Page 22 of 28
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: AIDS Plan Type: 356
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 611.26 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 194.74 $ 42.17 $ 8.55 $ 91.66 $ 954.16
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.642
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 58.37 $ 358.97 $ 186.37 $ 41.83 $ 8.53 $ 58.85 $ 712.92
3. Legislative Adjs. 0.982 0.843 0.981 1.009 1.159 0.989
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 60.19 $ 332.21 $ 181.60 $ 40.10 $ 9.89 $ 64.02 $ 688.01
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 75.68
Capitation Rate $ 763.69
C6 to Contract No.95-23637
Page 23 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Family Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 864.71 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 21.91 $ 4.43 $ 0.17 $ 4.70 $ 70.77
Adjustments
a. Demographics 0.883 0.8750 0.853 0.903 1.000 0.866
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 28.55 $ 5.79 $ 18.09 $ 3.82 $ 0.17 $ 3.53 $ 59.95
3. Legislative Adjs. 1.139 0.975 1.012 1.034 1.159 1.065
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 32.52 $ 6.20 $ 19.13 $ 3.95 $ 0.20 $ 4.14 $ 66.14
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.88
7. Fee-for-Service Adj. 13.0% 8.59
Capitation Rate $ 79.61
C6 to Contract No.95-23637
Page 24 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Aged Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 287.24 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 19.60 $ 3.80 $ 15.50 $ 23.14 $ 131.63
Adjustments
a. Demographics 0.953 1.025 0.958 0.968 1.035 1.021
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 14.59 $ 55.24 $ 18.72 $ 3.63 $ 15.99 $ 18.45 $ 126.62
3. Legislative Adjs. 0.952 0.920 0.940 1.035 1.159 0.932
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.950 1.045 0.950 1.100
Projected Cost per Eligible $ 14.58 $ 55.79 $ 18.39 $ 3.93 $ 17.61 $ 18.91 $ 129.21
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 14.21
Capitation Rate $ 143.42
C6 to Contract No.95-23637
Page 25 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Disabled Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000 \
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 485.15 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 40.87 $ 9.17 $ 6.96 $ 37.67 $ 209.69
Adjustments
a. Demographics 1.027 0.895 0.946 1.076 0.937 1.053
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 21.47 $ 72.03 $ 35.57 $ 9.60 $ 6.49 $ 34.79 $ 179.95
3. Legislative Adjs. 0.969 0.920 0.933 1.035 1.159 0.956
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 21.84 $ 72.75 $ 32.96 $ 9.44 $ 7.52 $ 36.59 $ 181.10
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 19.92
Capitation Rate $ 201.02
C6 to Contract No.95-23637
Page 26 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Child Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 889.41 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 32.32 $ 4.36 $ 0.22 $ 5.68 $ 72.34
Adjustments
a. Demographics 1.156 1.020 1.155 1.139 0.XXX 1.048
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 28.71 $ 4.49 $ 35.54 $ 4.83 $ 0.22 $ 5.25 $ 79.04
3. Legislative Adjs. 1.155 1.055 1.019 1.034 1.159 1.069
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 33.16 $ 5.20 $ 37.84 $ 4.99 $ 0.25 $ 6.17 $ 87.61
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.06
7. Fee-for-Service Adj. 11% 9.64
Capitation Rate $ 101.31
C6 to Contract No.95-23637
Page 27 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Adult Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 964.66 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 352.66 $ 29.03 $ 0.00 $ 21.78 $ 713.84
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 305.43 $ 7.12 $ 352.31 $ 28.71 $ 0.00 $ 19.32 $ 712.89
3. Legislative Adjs. 1.059 0.945 1.011 1.034 1.159 1.071
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 323.45 $ 7.39 $ 372.21 $ 29.69 $ 0.00 $ 22.76 $ 755.50
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 83.10
Capitation Rate $ 838.60
C6 to Contract No.95-23637
Page 28 of 28
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: AIDS Plan Type: 355
Date: 01-Dec-99
Base Period: FY 96/97
The Rate Period is October 1,1999 to September 30,2000
Capitation Payments at the End of the Month
Coverage Adjustments
---------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
---------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
---------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
---------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
---------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
---------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
---------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
---------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
---------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
---------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
---------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
---------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
---------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 485.15 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 154.56 $ 42.17 $ 8.55 $ 91.66 $ 913.98
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.642
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 58.37 $ 358.97 $ 147.91 $ 41.83 $ 8.53 $ 58.85 $ 674.46
3. Legislative Adjs. 0.982 0.843 0.981 1.009 1.159 0.989
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 60.19 $ 332.21 $ 144.13 $ 40.10 $ 9.89 $ 64.02 $ 650.54
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 71.56
Capitation Rate $ 722.10
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
DEPARTMENT OF HEALTH SERVICES
000/000 X Xxxxxx
X.X. Xxx 000000
Xxxxxxxxxx, XX 00000-0000
(000)000-0000
[SEAL]
Xxxxx 0, 0000
Xxxxxx Xxxxxxxxx
Xxxxxx
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
Change Order Number C7 to Contract No.95-23637 is being provided to rectify
the capitation payment schedule from prepaid to postpaid in accordance with
Article V, Section 5.3, Capitation Rates and Section 5.4 Capitation Rates
Constitute Payment in Full, of your Contract for the periods February 1,
1998 through September 30, 1998; October 1, 1998 through June 30, 1999
(Includes FQHC); July 1, 1999 through July 31, 1999 (excludes FQHC); and
August 1, 1999 through September 30, 1999. Corresponding postpaid rate
sheets are attached. This Change Order is effective March 1, 2000.
The retropayment for the above mentioned periods will be processed and
payment should be mailed within three (3) to six (6) weeks from the date of
this letter.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosures
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
1. 5.3 CAPITATION RATES
DHS will remit to the Contractor a capitation payment each month for each
Medi-Cal Member that appears on the approved list of Members supplied to the
Contractor by DHS. The capitation rate shall be the amount specified in this
Article. The payment period for health care services will commence on the first
day of operations, as determined by DHS. Capitation payments will be made in
accordance with the following schedule of capitation payment rates:
FOR THE PERIOD 2/1/98 - 9/30/98 RIVERSIDE COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, $ 76.14
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 205.99
60, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 163.11
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, 5K, $ 79.71
45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 518.25
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 1,026.62
-------------------------------------------------------------------------------------------------
1 of 5
FOR THE PERIOD 2/1/98 - 9/30/98 SAN BERNARDINO COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, $ 74.39
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 218.97
6O, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 168.09
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 79.79
5K, 45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 534.10
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 1,078.17
-------------------------------------------------------------------------------------------------
FOR THE PERIOD 10/1/98 - 6/30/99 RIVERSIDE COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, $ 79.13
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 223.73
60, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 161.27
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, 5K, $ 93.51
45,82
-------------------------------------------------------------------------------------------------
Adult 86 $ 710.32
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 967.27
-------------------------------------------------------------------------------------------------
Percent of Poverty 7A, $ 54.11
-------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, $ 60.05
-------------------------------------------------------------------------------------------------
2 of 5
FOR THE PERIOD 10/1/98 - 6/30/99 SAN BERNARDINO COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, OA, 02, 08, 30, $ 80.89
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 234.65
60, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 164.60
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 106.97
5K, 45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 794.86
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 1,000.01
-------------------------------------------------------------------------------------------------
Percent of Poverty 7A, $ 54.11
-------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, $ 60.05
-------------------------------------------------------------------------------------------------
FOR THE PERIOD 7/1/99 - 7/31/99 RIVERSIDE COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, $ 78.80
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 223.73
6O, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 161.27
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 93.17
5K, 45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 708.81
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 967.27
-------------------------------------------------------------------------------------------------
Percent of Poverty 7A, $ 52.55
-------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, $ 57.21
-------------------------------------------------------------------------------------------------
3 of 5
FOR THE PERIOD 7/1/99 - 7/31/99 SAN BERNARDINO COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, $ 80.82
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 234.65
6O, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 164.60
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 106.89
5K, 45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 794.50
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 1,000.01
-------------------------------------------------------------------------------------------------
Percent of Poverty 7A, $ 52.55
-------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, $ 57.21
-------------------------------------------------------------------------------------------------
FOR THE PERIOD 8/1/99 - 9/30/99 RIVERSIDE COUNTY
-------------------------------------------------------------------------------------------------
GROUPS AID CODES RATE
-------------------------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, $ 79.37
32, 33, 34, 35, 38,
39, 40, 42, 54, 59,
3A, 3C, 3E, 3G, 3H,
3L, 3M, 3N, 3P, 3R,
3U, 5X, 7X,
-------------------------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 225.12
6O, 64, 66, 68, 6A,
6C, 6N, 6P, 6R
-------------------------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 162.55
-------------------------------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 93.95
5K, 45, 82
-------------------------------------------------------------------------------------------------
Adult 86 $ 714.18
-------------------------------------------------------------------------------------------------
AIDS Beneficiary $ 968.53
-------------------------------------------------------------------------------------------------
Percent of Poverty 7A, $ 53.10
-------------------------------------------------------------------------------------------------
Percent of Poverty 47, 72, $ 57.78
-------------------------------------------------------------------------------------------------
4 of 5
For the Period 8/1/99 - 9/30/99 San Bernardino County
--------------------------------------------------------------------------
GROUPS AID CODES RATE
--------------------------------------------------------------------------
Family 01, 0A, 02, 08, $ 81.39
30, 32, 33, 34, 35,
38, 39, 40, 42, 54,
59, 3A, 3C, 3E,
3G, 3H, 3L, 3M,
3N, 3P, 3R, 3U,
5X, 7X,
--------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, $ 236.15
60, 64, 66, 68,
6A, 6C, 6N, 6P,
6R
--------------------------------------------------------------------------
Aged 10,14,16,18 $ 165.90
--------------------------------------------------------------------------
Child 03, 04, 4C, 4K, $ 107.81
5K, 45, 82
--------------------------------------------------------------------------
Adult 86 $ 800.46
--------------------------------------------------------------------------
AIDS Beneficiary $ 1,001.35
--------------------------------------------------------------------------
Percent of Poverty 7A, $ 53.10
--------------------------------------------------------------------------
Percent of Poverty 47,72, $ 57.78
--------------------------------------------------------------------------
All other terms, conditions, and provisions contained in Section 5.3
remain unchanged.
2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop
loss reinsurance provisions, on behalf of a Member for all Covered
Services required by such Member and for all Administrative Costs
incurred by the Contractor in providing or arranging for such services,
and subject to adjustments for federally qualified health centers in
accordance with Section 5.13, but do not include payment for the
recoupment of current or previous losses incurred by Contractor. DHS is
not responsible for making payments for recoupment of losses. The
actuarial basis for the determination of the capitation payment rates
is outlined in Attachment 1 (consisting of 60 pages).
5 of 5
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
[SEAL]
[SEAL]
November 20, 2000
Xx. Xxxxxx Xxxxxxxxx
President
Xxxxxx Healthcare of California
Dba Molina
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
In accordance with Article V, Section 5.5 of your Contract, the
enclosed Change Order No. 08 transmits (Xxxxxx'x) annual capitation
rates for the Period beginning October 1,2000 to September 30, 2001.
The retropayment between the old rates and the new 2000/2001 rates
for the period beginning October 1, 2000 will be processed in
approximately four to six weeks.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
----------------------
Xxxxxxx X. Xxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosure
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER C08 TO CONTRACT NO.95-23637; ADJUSTING THE ANNUAL
CAPITATION RATE FOR PROVIDER RATE INCREASES FOR THE PERIOD OCTOBER
1, 2000 TO SEPTEMBER 30, 2001, BY CHANGING CONTRACT SECTIONS; 5.3
CAPITATION RATES; AND 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN
FULL. This Change Order is effective November 1, 2000.
1. 5.3 CAPITATION RATES
For the period October 1, 2000 to
September 30,2001 Riverside County
-----------------------------------------------------------------------------
GROUPS AID CODES RATE
-----------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, $ 86.14
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 5X, 7X, 8P
-----------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, $ 223.64
66, 68, 6A, 6C, 6N, 6P, 6R
-----------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 160.60
-----------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 89.04
82, 7A, 8R
-----------------------------------------------------------------------------
Adult 86 $ 843.25
-----------------------------------------------------------------------------
AIDS Beneficiary $ 847.95
-----------------------------------------------------------------------------
For the period October 1, 2000 to
September 30,2001 San Bernardino County
----------------------------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, $ 82.56
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 5X, 7X, 8P
----------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, $ 223.41
66, 68, 6A, 6C, 6N, 6P, 6R
----------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 151.60
----------------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 93.28
82, 7A, 8R
----------------------------------------------------------------------------------
Adult 86 $ 922.71
----------------------------------------------------------------------------------
AIDS Beneficiary $ 891.15
----------------------------------------------------------------------------------
2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop
loss reinsurance provisions, on behalf of a Member for all Covered
Services required by such Member and for all administrative costs
incurred by the Contractor in providing or arranging for such services,
and subject to adjustments for federally qualified health centers in
accordance with Section 14087.325 of the W&I Code, but do not include
payment for recoupment of current or previous losses incurred by
Contractor. DHS is not responsible for making payments for recoupment
of losses. The actuarial basis for the determination of the capitation
payment rates is outlined in Attachment 1 (consisting of 12 pages).
3. All other terms, conditions, and provisions contained in Sections 5.3
and 5.4 remain unchanged.
2
Contract #95-23637 C-8
Attachment 1
Page 1 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Family Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 864.71 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 21.91 $ 4.43 $ 0.17 $ 4.70 $ 70.77
3. Adjustments
a.Demographics 0.933 0.927 0.903 0.933 1.000 0.938
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 26.93 $ 6.13 $ 19.15 $ 3.95 $ 0.17 $ 3.83 $ 60.16
4. Legislative Adjs. 1.261 0.895 1.016 1.065 1.375 1.086
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 33.96 $ 6.76 $ 20.73 $ 4.21 $ 0.23 $ 4.77 $ 70.66
6. Adjustment to No Loss 0.00
7. CHDP 4.88
8. Adjustment to Fee-For-Service 15.0% 10.60
Capitation Rate $ 86.14
Value of Provider Rate Increase $ 4.44
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 2 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Disabled Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 485.15 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 40.87 $ 9.17 $ 6.96 $ 37.67 $ 209.69
3. Adjustments
a.Demographics 0.990 0.881 0.935 1.064 0.954 1.046
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 18.48 $ 70.91 $ 35.16 $ 9.49 $ 6.61 $ 34.56 $ 175.21
4. Legislative Adjs. 1.151 0.925 0.952 1.057 1.379 0.991
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 22.82 $ 80.77 $ 33.15 $ 9.31 $ 9.12 $ 39.30 $ 194.47
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 29.17
Capitation Rate $ 223.64
Value of Provider Rate Increase $ 4.65
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 3 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Aged Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 287.24 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 19.60 $ 3.80 $ 15.50 $ 23.14 $ 131.63
3. Adjustments
a.Demographics 1.007 1.014 1.005 1.001 0.975 1.011
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 13.76 $ 54.65 $ 19.64 $ 3.75 $ 15.07 $ 18.27 $ 125.14
4. Legislative Adjs. 0.993 0.911 0.960 1.052 1.368 0.966
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.929 1.066 0.929 1.148
Projected Cost per Eligible $ 14.66 $ 61.31 $ 20.09 $ 4.20 $ 19.14 $ 20.25 $ 139.65
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 20.95
Capitation Rate $ 160.60
Value of Provider Rate Increase $ 0.84
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 4 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Child Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 889.41 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 32.32 $ 4.36 $ 0.22 $ 5.68 $ 72.34
3. Adjustments
a.Demographics 1.020 1.029 0.953 1.033 1.000 0.988
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 22.61 $ 4.53 $ 29.32 $ 4.38 $ 0.22 $ 4.95 $ 66.01
4. Legislative Adjs. 1.144 0.907 1.019 1.055 1.359 1.089
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 25.87 $ 5.06 $ 31.84 $ 4.62 $ 0.30 $ 6.19 $ 73.88
6. Adjustment to No Loss 0.00
7. CHDP 4.08
8. Adjustment to Fee-For-Service 15.0% 11.08
Capitation Rate $ 89.04
Value of Provider Rate Increase $ 0.71
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 5 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Adult Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 964.66 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 352.66 $ 29.03 $ 0.00 $ 21.78 $ 713.84
3. Adjustments
a.Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 272.64 $ 7.12 $ 352.31 $ 28.71 $ 0.00 $ 19.32 $ 680.10
4. Legislative Adjs. 1.075 0.900 1.008 1.062 1.213 1.053
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 293.09 $ 7.89 $ 378.44 $ 30.49 $ 0.00 $ 23.35 $ 733.26
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 109.99
Capitation Rate $ 843.25
Value of Provider Rate Increase $ 3.39
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 6 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: AIDS Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 485.15 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 154.56 $ 42.17 $ 8.55 $ 91.66 $ 913.98
3. Adjustments
a.Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.918 0.663 0.957 0.992 0.998 0.970
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 52.11 $ 367.28 $ 147.91 $ 41.83 $ 8.53 $ 88.91 $ 706.57
4. Legislative Adjs. 1.098 0.836 0.986 1.015 1.453 0.996
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 61.39 $ 378.09 $ 144.43 $ 39.43 $ 12.39 $ 101.62 $ 737.35
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 110.60
Capitation Rate $ 847.95
Value of Provider Rate Increase $ 7.25
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 7 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Family Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
----------------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 978.02 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 24.78 $ 4.43 $ 0.17 $ 4.70 $ 73.64
3. Adjustments
a. Demographics 0.870 0.911 0.786 0.871 1.000 0.918
b. Area 0.900 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 25.11 $ 6.03 $ 18.85 $ 3.69 $ 0.17 $ 3.75 $ 57.60
4. Legislative Adjs. 1.261 0.895 1.016 1.065 1.375 1.086
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 31.66 $ 6.65 $ 20.41 $ 3.93 $ 0.23 $ 4.67 $ 67.55
6. Adjustment to No Loss 0.00
7. CHDP 4.88
8. Adjustment to Fee-For-Service 15.0% 10.13
Capitation Rate $ 82.56
Value of Provider Rate Increase $ 4.15
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 8 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Disabled Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 611.26 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 51.50 $ 9.17 $ 6.96 $ 37.67 $ 220.32
3. Adjustments
a.Demographics 0.927 0.841 0.865 1.023 0.991 1.031
b.Area 0.900 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 17.30 $ 67.69 $ 40.98 $ 9.13 $ 6.86 $ 34.06 $ 176.02
4. Legislative Adjs. 1.151 0.925 0.952 1.057 1.379 0.991
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 21.37 $ 77.10 $ 38.64 $ 8.96 $ 9.46 $ 38.74 $ 194.27
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 29.14
Capitation Rate $ 223.41
Value of Provider Rate Increase $ 4.42
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 9 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Aged Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 316.16 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 21.58 $ 3.80 $ 15.50 $ 23.14 $ 133.61
3. Adjustments
a. Demographics 1.014 1.009 0.894 1.039 0.650 0.962
b. Area 0.900 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 13.86 $ 54.38 $ 19.23 $ 3.89 $ 10.04 $ 17.39 $ 118.79
4. Legislative Adjs. 0.993 0.911 0.960 1.052 1.368 0.966
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.929 1.066 0.929 1.148
Projected Cost per Eligible $ 14.77 $ 61.00 $ 19.67 $ 4.36 $ 12.75 $ 19.28 $ 131.83
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 19.77
Capitation Rate $ 151.60
Value of Provider Rate Increase $ 0.81
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 10 of 12
Date: 14-Nov-00
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Child Plan Type: Commercial Plan
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 1,120.53 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 40.71 $ 4.36 $ 0.22 $ 5.68 $ 80.73
3. Adjustments
a. Demographics 0.986 1.016 0.877 0.987 1.000 0.976
b. Area 0.900 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 21.86 $ 4.47 $ 33.99 $ 4.19 $ 0.22 $ 4.89 $ 69.62
4. Legislative Adjs. 1.144 0.907 1.019 1.055 1.359 1.089
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 25.01 $ 4.99 $ 36.91 $ 4.42 $ 0.30 $ 6.11 $ 77.74
6. Adjustment to No Loss 0.00
7. CHDP 4.08
8. Adjustment to Fee-For-Service 15.0% 11.66
Capitation Rate $ 93.48
Value of Provider Rate Increase $ 0.69
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 11 of 12
Date: 14-Nov-00
Plan Name: Xxxxxx Medical Center
County: San Bernadino Plan #: 356
Aid Code Grouping: Adult Plan Type: Commercial Plan
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 1,140.81 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 417.06 $ 29.03 $ 0.00 $ 21.78 $ 778.24
3. Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 0.900 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 272.64 $ 7.12 $ 416.64 $ 28.71 $ 0.00 $ 19.32 $ 744.43
4. Legislative Adjs. 1.075 0.900 1.008 1.062 1.213 1.053
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 1.073 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 293.09 $ 7.89 $ 447.54 $ 30.49 $ 0.00 $ 23.35 $ 802.36
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 120.35
Capitation Rate $ 922.71
Value of Provider Rate Increase $ 3.39
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-8
Attachment 1
Page 12 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: AIDS Plan Type: Commercial Plan
Date: 14-Nov-00
The Rate Period is October 1, 2000 Capitation Payments at the
to September 30, 2001 End of the Month
Coverages (C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
----------------------------------------------------------------------------------------------------------
GHPP C In Home Waiver N
----------------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
----------------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
----------------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screening N
----------------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
----------------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
----------------------------------------------------------------------------------------------------------
Psychiatrist N Injections N
----------------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
----------------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
----------------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
----------------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
----------------------------------------------------------------------------------------------------------
PIA Lenses N CHDP C
----------------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 611.26 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 194.74 $ 42.17 $ 8.55 $ 91.66 $ 954.16
3. Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 0.900 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.663 0.957 0.992 0.998 0.970
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 52.11 $ 367.28 $ 186.37 $ 41.83 $ 8.53 $ 88.91 $ 745.03
4. Legislative Adjs. 1.098 0.836 0.986 1.015 1.453 0.996
5. Trend Adjustments
a. Cost per Unit 1.000 1.148 1.148 1.000 1.000 1.000
b. Units per Eligible 1.073 1.073 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 61.39 $ 378.09 $ 181.99 $ 39.43 $ 12.39 $ 101.62 $ 774.91
6. Adjustment to No Loss 0.00
7. CHDP 0.00
8. Adjustment to Fee-For-Service 15.0% 116.24
Capitation Rate $ 891.15
Value of Provider Rate Increase $ 7.26
Prepared by Department of Health Services, Rate Development Branch
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
[SEAL]
[SEAL]
January 9, 2001
Xx. Xxxxxx Xxxxxxxxx
President
Xxxxxx Healthcare of California
Dba Molina
Xxx Xxxxxx Xxxxx
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
In accordance with Article V, Section 5.5 of your Contract, the
enclosed Change Order No. 09 transmits (Xxxxxx'x) annual capitation
rates for the Period August 1, 2000 to September 30, 2000.
The retropayment between the old rates and the new rates for the
period August 1, 2000 through September 30, 2000 will be processed
in approximately four to six weeks.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
------------------------
Xxxxxxx X. Xxxxxxxx
Acting Chief
Medi-Cal Managed Care Division
Enclosure
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER C09 TO CONTRACT NO.95-23637; ADJUSTING THE ANNUAL
CAPITATION RATE FOR PROVIDER RATE INCREASES FOR THE PERIOD AUGUST 1,
2000 TO SEPTEMBER 30, 2000, BY CHANGING CONTRACT SECTIONS; 5.3
CAPITATION RATES; AND 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN
FULL. This Change Order is effective January 1, 2001.
1. 5.3 CAPITATION RATES
For the period August 1, 2000 to September 30,2000 Riverside County
-----------------------------------------------------------------------------
GROUPS AID CODES RATE
-----------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, $ 84.28
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 5X, 7X, 8P
-----------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64 $ 205.86
66, 68, 6A, 6C, 6N, 6P, 6R
-----------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 144.20
-----------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 102.15
82, 7A, 8R
-----------------------------------------------------------------------------
Adult 86 $ 841.84
-----------------------------------------------------------------------------
AIDS Beneficiary $ 729.33
-----------------------------------------------------------------------------
For the period August 1, 2000 to September 30,2001 San Bernardino County
----------------------------------------------------------------------------------
GROUPS AID CODES RATE
----------------------------------------------------------------------------------
Family 01, 0A, 02, 08, 30, 32, 33, $ 88.96
34, 35, 38, 39, 40, 42, 47,
54, 59, 72, 3A, 3C, 3E, 3G,
3H, 3L, 3M, 3N, 3P, 3R, 3U,
4F, 4G, 5X, 7X, 8P
----------------------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, $ 203.17
66, 68, 6A, 6C, 6N, 6P, 6R
----------------------------------------------------------------------------------
Aged 10, 14, 16, 18 $ 146.29
----------------------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, $ 86.53
82, 7A, 8R
----------------------------------------------------------------------------------
Adult 86 $ 917.28
----------------------------------------------------------------------------------
AIDS Beneficiary $ 770.92
----------------------------------------------------------------------------------
2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS, are
prospective rates and constitute payment in full, subject to any stop
loss reinsurance provisions, on behalf of a Member for all Covered
Services required by such Member and for all administrative costs
incurred by the Contractor in providing or arranging for such services,
and subject to adjustments for federally qualified health centers in
accordance with Section 14087.325 of the W&I Code, but do not include
payment for recoupment of current or previous losses incurred by
Contractor. DHS is not responsible for making payments for recoupment
of losses. The actuarial basis for the determination of the capitation
payment rates is outlined in Attachment 1 (consisting of 12 pages).
3. All other terms, conditions, and provisions contained in Sections 5.3
and 5.4 remain unchanged.
Contract #95-23637 C-9
Attachment
Page 1 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Family Plan Type: 355
Date: 03-Nov-00
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 864.71 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 21.91 $ 4.43 $ 0.17 $ 4.70 $ 70.77
Adjustments
a. Demographics 0.883 0.875 0.853 0.903 1.000 0.866
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 28.55 $ 5.79 $ 18.09 $ 3.82 $ 0.17 $ 3.53 $ 59.95
3. Legislative Adjs. 1.280 0.975 1.012 1.034 1.159 1.094
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 36.54 $ 6.20 $ 19.13 $ 3.95 $ 0.20 $ 4.25 $ 70.27
5. Stop Loss Rein. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.88
7. Fee-for-Service Adj. 13.0% 9.13
Capitation Rate $ 84.28
Value of Provider Rate Increase $ 4.67
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 2 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan # : Commercial Plan
Aid Code Grouping: Disabled Plan Type: 355
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 485.15 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 40.87 $ 9.17 $ 6.96 $ 37.67 $ 209.69
Adjustments
a. Demographics 1.027 0.895 0.946 1.076 0.937 1.053
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 21.47 $ 72.03 $ 35.57 $ 9.60 $ 6.49 $ 34.79 $ 179.95
3. Legislative Adjs. 1.123 0.920 0.933 1.035 1.159 0.979
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 25.32 $ 72.75 $ 32.96 $ 9.44 $ 7.52 $ 37.47 185.46
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 20.40
Capitation Rate 205.86
Value of Provider Rate Increase 4.84
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 3 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Aged Plan Type: 355
Date: 03-Nov-00
Base Period: 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 287.24 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 19.60 $ 3.80 $ 15.50 $ 23.14 $ 131.63
Adjustments
a. Demographics 0.953 1.025 0.958 0.968 1.035 1.021
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 14.59 $ 55.24 $ 18.72 $ 3.63 $ 15.99 $ 18.45 $ 126.62
3. Legislative Adjs. 0.968 0.920 0.940 1.035 1.159 0.954
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.950 1.045 0.950 1.100
Projected Cost per Eligible $ 14.83 $ 55.79 $ 18.39 $ 3.93 $ 17.61 $ 19.36 129.91
5. Stop Loss Rein. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 14.29
Capitation Rate 144.20
Value of Provider Rate Increase 0.78
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 4 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Child Plan Type: 355
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 889.41 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 32.32 $ 4.36 $ 0.22 $ 5.68 $ 72.34
Adjustments
a. Demographics 1.156 1.020 1.155 1.139 1.000 1.048
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 28.71 $ 4.49 $ 35.54 $ 4.83 $ 0.22 $ 5.25 $ 79.04
3. Legislative Adjs. 1.175 1.055 1.019 1.034 1.159 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 33.73 $ 5.20 $ 37.84 $ 4.99 $ 0.25 $ 6.36 88.37
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.06
7. Fee-for-Service Adj. 11.0% 9.72
Capitation Rate 102.15
Value of Provider Rate Increase 0.84
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 5 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: Adult Plan Type: 355
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 964.66 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 352.66 $ 29.03 $ 0.00 $ 21.78 $ 713.84
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 305.43 $ 7.12 $ 352.31 $ 28.71 $ 0.00 $ 19.32 $ 712.89
3. Legislative Adjs. 1.067 0.945 1.011 1.034 1.159 1.093
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 325.89 $ 7.39 $ 372.21 $ 29.69 $ 0.00 $ 23.23 758.41
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 83.43
Capitation Rate 841.84
Value of Provider Rate Increase 3.24
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 6 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: Commercial Plan
Aid Code Grouping: AIDS Plan Type: 355
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 485.15 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 154.56 $ 42.17 $ 8.55 $ 91.66 $ 913.98
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.642
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 58.37 $ 358.97 $ 147.91 $ 41.83 $ 8.53 $ 58.85 $ 674.46
3. Legislative Adjs. 1.082 0.843 0.981 1.009 1.159 0.995
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 66.31 $ 332.21 $ 144.13 $ 40.10 $ 9.89 $ 64.41 657.05
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 72.28
Capitation Rate 729.33
Value of Provider Rate Increase 7.23
Prepared by Department of Health Services, Rate Development Branch
Contract #95-23637 C-9
Attachment 1
Page 7 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernadino Plan #: Commercial Plan
Aid Code Grouping: Family Plan Type: 356
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 978.02 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 24.78 $ 4.43 $ 0.17 $ 4.70 $ 73.64
Adjustments
a. Demographics 0.829 0.863 0.714 0.835 1.000 0.871
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 26.80 $ 5.71 $ 17.13 $ 3.54 $ 0.17 $ 3.55 $ 56.90
3. Legislative Adjs. 1.280 0.975 1.012 1.034 1.159 1.094
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 34.30 $ 6.11 $ 18.12 $ 3.66 $ 0.20 $ 4.27 66.66
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.88
7. Fee-for-Service Adj. 26.1% 17.42
Capitation Rate 88.96
Value of Provider Rate Increase 4.89
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-9
Attachment
Page 8 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Disabled Plan Type: 356
Date: 03-Nov-00
Base Period : FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 611.26 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 51.50 $ 9.17 $ 6.96 $ 37.67 $ 220.32
Adjustments
a. Demographics 0.942 0.851 0.850 1.019 0.995 1.023
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 19.69 $ 68.49 $ 40.27 $ 9.09 $ 6.89 $ 33.80 $ 178.23
3. Legislative Adjs 1.123 0.920 0.933 1.035 1.159 0.979
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 23.22 $ 69.17 $ 37.32 $ 8.94 $ 7.99 $ 36.40 183.04
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 20.13
Capitation Rate 203.17
Value of Provider Rate Increase 4.49
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-9
Attachment
Page 9 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Aged Plan Type: 356
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 316.16 $ 11.67 $ 117.26 $ 6.49
2. Units per Eligible 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 21.58 $ 3.60 $ 15.50 $ 23.14 $ 133.61
Adjustments
a. Demographics 0.964 1.019 0.964 0.963 1.034 1.022
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 14.76 $ 54.92 $ 20.74 $ 3.68 $ 15.98 $ 18.47 $ 128.55
3. Legislative Adjs 0.968 0.920 0.940 1.035 1.159 0.954
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.950 1.045 0.950 1.100
Projected Cost per Eligible $ 15.00 $ 55.47 $ 20.37 $ 3.98 $ 17.59 $ 19.38 131.79
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 14.50
Capitation Rate 146.29
Value of Provider Rate Increase 0.77
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-9
Attachment
Page 10 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Child Plan Type: 356
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 1,120.53 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible. 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo $ 25.29 $ 4.47 $ 40.71 $ 4.36 $ 0.22 $ 5.68 $ 80.73
Adjustments
a. Demographics 0.927 0.989 0.788 0.935 1.000 0.946
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 23.02 $ 4.35 $ 30.15 $ 3.97 $ 0.22 $ 4.74 $ 66.45
3. Legislative Adjs. 1.175 1.055 1.019 1.034 1.159 1.102
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 27.05 $ 5.04 $ 32.11 $ 4.10 $ 0.25 $ 5.75 74.30
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 4.06
7. Fee-for-Service Adj. 11.0% 8.17
Capitation Rate 86.53
Value of Provider Rate Increase 0.71
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-9
Attachment
Page 11 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: Adult Plan Type: 356
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 1,140.81 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 417.06 $ 29.03 $ 0.00 $ 21.78 $ 778.24
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 305.43 $ 7.12 $ 416.64 $ 28.71 $ 0.00 $ 19.32 $ 777.22
3. Legislative Adjs. 1.067 0.945 1.011 1.034 1.159 1.093
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.000 1.000 1.000 1.000
b. Units per Eligible 1.000 0.998 1.045 1.000 1.000 1.100
Projected Cost per Eligible $ 325.89 $ 7.39 $ 440.18 $ 29.69 $ 0.00 $ 23.23 826.38
5. Stop Loss Rein Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 90.90
Capitation Rate 917.28
Value of Provider Rate Increase 3.23
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-9
Attachment
Page 12 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: Commercial Plan
Aid Code Grouping: AIDS Plan Type: 356
Date: 03-Nov-00
Base Period: FY 96/97
The Rate Period is August 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverage Adjustments
--------------------------------------------------------------------------------
CCS Indicated Claims NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Outpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Pharmacy Costs NOT Covered by the Plan
--------------------------------------------------------------------------------
Mental Health Hospital Inpatient Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Eyewear NOT Covered by the Plan
--------------------------------------------------------------------------------
Heroin Detoxification NOT Covered by the Plan
--------------------------------------------------------------------------------
AIDS Waiver Services NOT Covered by the Plan
--------------------------------------------------------------------------------
Adult Day Health Care NOT Covered by the Plan
--------------------------------------------------------------------------------
Chiropractor/Acupuncture NOT Covered by the Plan
--------------------------------------------------------------------------------
Local Education Authority NOT Covered by the Plan
--------------------------------------------------------------------------------
Alphafeto Protein Testing NOT Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care for month of entry plus one Covered by the Plan
--------------------------------------------------------------------------------
Long Term Care after month of entry plus one NOT Covered by the Plan
--------------------------------------------------------------------------------
Special AIDS drugs NOT Covered by the Plan
--------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 611.26 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 194.74 $ 42.17 $ 8.55 $ 91.66 $ 954.16
Adjustments
a. Demographics 1.000 1.000 1.000 1.000 1.000 1.000
b. Area 1.008 1.000 1.000 1.000 1.000 1.000
c. Coverages 0.918 0.648 0.957 0.992 0.998 0.642
d. Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 58.37 $ 358.97 $ 186.37 $ 41.83 $ 8.53 $ 58.85 $ 712.92
3. Legislative Adjs 1.082 0.843 0.981 1.009 1.159 0.995
4. Trend Adjustments
a. Cost per Unit 1.000 1.100 1.100 1.000 1.000 1.000
b. Units per Eligible 1.050 0.998 0.903 0.950 1.000 1.100
Projected Cost per Eligible $ 66.31 $ 332.21 $ 181.60 $ 40.10 $ 9.89 $ 64.41 694.52
5. Stop Loss Reins. Amount $ 0 Rate 0.0% 0.00
6. CHDP 0.00
7. Fee-for-Service Adj. 11.0% 76.40
Capitation Rate 770.92
Value of Provider Rate Increase 7.23
Prepared by Department of Health Services, Rate Development Branch
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
October 30, 2001
Xx. Xxxxxx Xxxxxxxxx
CEO
Xxxxxx Healthcare of California
dba: Molina
Xxx Xxxxxx Xxxxx Xx.
Xxxx Xxxxx, XX 00000
Dear Xx. Xxxxxxxxx:
In accordance with Article V, Section 5.5 of your Contract, the
enclosed Change Order No. 10 transmits (Xxxxxx Health Care of
California dba: Molina) annual capitation rates for the period
beginning October 1, 2001 to September 30, 2002.
The retropayment, between the old rates and the new 2001/2002 rates
for the period beginning October 1, 2001, will be processed in
approximately four to six weeks.
If you have any questions, please contact your contract manager.
Sincerely,
/s/
-------------------
Xxxxx Xxxx, Chief
Medi-Cal Managed Care Division
Enclosure
[LETTER HEAD OF DEPARTMENT OF HEALTH SERVICES]
CHANGE ORDER NUMBER C10 TO CONTRACT NO.95-23637: ADJUSTING THE
ANNUAL CAPITATION RATE FOR PROVIDER RATE INCREASES FOR THE PERIOD
OCTOBER 1, 2001 TO SEPTEMBER 30, 2002, BY CHANGING CONTRACT
SECTIONS; 5.3 CAPITATION RATES; AND 5.4 CAPITATION RATES CONSTITUTE
PAYMENT IN FULL. This Change Order is effective October 1, 2001.
1. 5.3 CAPITATION RATES
DHS shall remit to Contractor a capitation payment each month
for each Medi-Cal Member that appears on the approved list of
Members supplied to Contractor by DHS. The capitation rate
shall be the amount specified in this Article. The payment
period for health care services shall commence on the first
day of operations, as determined by DHS. Capitation payments
shall be made in accordance with the following schedule of
capitation payment rates:
-----------------------------------------------------------------------
For the period 10/01/01 - 9/30/02 San Bernardino
-----------------------------------------------------------------------
Groups Aid Codes Rate
-----------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 33, 34, $ 87.86
35, 38, 39, 40, 42, 47, 54, 59,
72, 3A, 3C, 3E, 3G, 3H, 3L,
3M, 3N, 3P, 3R, 3U, 4F, 4G,
5X, 7X, 8P
-----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 235.58
68, 6A, 6C, 6H, 6N, 6P, 6R
-----------------------------------------------------------------------
Aged 1H, 10, 14, 16, 18 $ 172.72
-----------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, $ 104.73
7A, 7J, 8R
-----------------------------------------------------------------------
Adult 86 $ 925.69
-----------------------------------------------------------------------
Aids $ 922.10
Beneficiary
-----------------------------------------------------------------------
-----------------------------------------------------------------------
For the period 10/01/01 - 9/30/02 Riverside
-----------------------------------------------------------------------
Groups Aid Codes Rate
-----------------------------------------------------------------------
Family 01, OA, 02, 08, 30, 32, 33,34, $ 86.87
35,38, 39,40,42,47,54,59,
72, 3A, 3C, 3E, 3G, 3H, 3L,
3M, 3N, 3P, 3R, 3U, 4F, 4G,
5X, 7X, 8P
-----------------------------------------------------------------------
Disabled 20, 24, 26, 28, 36, 60, 64, 66, $ 233.86
68,6A,6C, 6H,6N,6P, 6R
-----------------------------------------------------------------------
Aged 1H, 10, 14, 16, 18 $ 170.89
-----------------------------------------------------------------------
Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, $ 97.58
7A, 7J, 8R
-----------------------------------------------------------------------
Adult 86 $ 844.46
-----------------------------------------------------------------------
Aids $ 878.16
Beneficiary
-----------------------------------------------------------------------
If DHS creates a new aid code that is split or derived from
an existing aid code covered under this Contract, and the aid
code has a neutral revenue effect for the Contractor, then
the split aid code will automatically be included in the same
aid code category as is the original aid code covered under
this Contract. Contractor agrees to continue providing
covered services to the Members at the monthly capitation
rate specified for the original aid code. DHS shall confirm
all aid code splits, and the rates of payment for such new
aid codes, in writing to Contractor as soon as practicable
after such aid code splits occur.
2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL
Capitation rates for each rate period, as calculated by DHS,
are prospective rates and constitute payment in full, subject
to any stop loss reinsurance provisions, on behalf of a
Member for all Covered Services required by such Member and
for all administrative Costs incurred by the Contractor in
providing or arranging for such services, and subject to
adjustments for federally qualified health centers in
accordance with Section 14087.325 of the W&I Code, but do not
include payment for recoupment of current or previous losses
incurred by Contractor. DHS is not responsible for making
payments for recoupment of losses. The actuarial basis for
the determination of the capitation payment rates is outlined
in Attachment 1 (consisting of 12 pages).
3. All other terms, conditions, and provisions contained in Sections 5.3 and
5.4 remain unchanged.
2
#95-23637 C-10
Attachment 1
Page 1 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Family Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 978.02 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible/year 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 24.78 $ 4.43 $ 0.17 $ 4.70 $ 73.64
3. Adjustments
a.Age/Sex 0.916 0.943 0.875 0.919 1.000 0.955
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 26.88 $ 6.24 $ 20.99 $ 3.89 $ 0.17 $ 3.90 $ 62.07
4. Legislative Adjustments 1.221 0.869 1.029 1.054 1.436 1.079
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 32.82 $ 8.08 $ 23.95 $ 4.10 $ 0.24 $ 4.83 $ 74.02
6. CHDP 4.88
7. Adjustment to Pool 12.1% 8.96
Capitation Rate $ 87.86
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 2 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Disabled Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 611.26 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible/year 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 51.50 $ 9.17 $ 6.96 $ 37.67 $ 220.32
3. Adjustments
a.Age/Sex 0.929 0.838 0.895 1.038 0.977 1.048
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 17.63 $ 67.44 $ 42.41 $ 9.26 $ 6.77 $ 34.62 $ 178.13
4. Legislative Adjustments 1.099 0.888 0.965 1.048 1.442 0.987
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 1.000
b.Units per Eligible 1.073 1.180 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 20.79 $ 89.18 $ 42.17 $ 9.02 $ 9.76 $ 39.23 $ 210.15
6. CHDP 0.00
7. Adjustment to Pool 12.1% 25.43
Capitation Rate $ 235.58
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 3 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Aged Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2000 Capitation Payments at
to September 30, 2000 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 316.16 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible/year 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 21.58 $ 3.80 $ 15.50 $ 23.14 $ 133.61
3. Adjustments
a.Age/Sex 0.995 1.007 1.003 0.992 1.021 1.005
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 13.83 $ 54.27 $ 21.58 $ 3.72 $ 15.78 $ 18.16 $ 127.34
4. Legislative Adjustments 0.984 0.879 0.969 1.046 1.433 0.963
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 1.000
b.Units per Eligible 1.073 1.180 0.929 1.066 0.929 1.148
Projected Cost per Eligible $ 14.60 $ 71.04 $ 23.20 $ 4.15 $ 21.01 $ 20.08 $ 154.08
6. CHDP 0.00
7. Adjustment to Pool 12.1% 18.64
Capitation Rate $ 172.72
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 4 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Child Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 1,120.53 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible/year 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 40.71 $ 4.36 $ 0.22 $ 5.68 $ 80.73
3. Adjustments
a.Age/Sex 1.062 1.056 1.029 1.067 1.000 0.997
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 23.94 $ 4.64 $ 39.88 $ 4.53 $ 0.22 $ 4.99 $ 78.20
4. Legislative Adjustments 1.116 0.875 1.035 1.049 1.424 1.082
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 $ 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 26.72 $ 6.05 $ 45.76 $ 4.75 $ 0.31 $ 6.20 $ 89.79
6. CHDP 4.08
7. Adjustment to Pool 12.1% 10.86
Capitation Rate $ 104.73
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 5 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: Adult Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 1,140.81 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible/year 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 417.06 $ 29.03 $ 0.00 $ 21.78 $ 778.24
3. Adjustments
a.Age/Sex 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 277.19 $ 7.12 $ 416.64 $ 28.71 $ 0.00 $ 19.32 $ 748.98
4. Legislative Adjustments 1.060 0.872 1.016 1.053 1.242 1.045
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 $ 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 293.82 $ 9.25 $ 469.29 $ 30.23 $ 0.00 $ 23.18 $ 825.77
6. CHDP 0.00
7. Adjustment to Pool 12.1% 99.92
Capitation Rate $ 925.69
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 6 of 12
Plan Name: Xxxxxx Medical Center
County: San Bernardino Plan #: 356
Aid Code Grouping: AIDS Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 611.26 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible/year 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 194.74 $ 42.17 $ 8.55 $ 91.66 $ 954.16
3. Adjustments
a.Age/Sex 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.918 0.663 0.957 0.992 0.998 0.642
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 52.98 $ 367.28 $ 186.37 $ 41.83 $ 8.53 $ 58.85 $ 715.84
4. Legislative Adjustments 1.070 0.826 0.989 1.013 1.529 1.001
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 $ 1.000
b.Units per Eligible 1.073 1.180 0.863 1.929 1.000 1.148
Projected Cost per Eligible $ 60.83 $ 451.77 $ 189.93 $ 39.37 $ 13.04 $ 67.63 $ 822.57
6. CHDP 0.00
7. Adjustment to Pool 12.1% 99.53
Capitation Rate $ 922.10
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 7 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Family Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 66.25 $ 23.82 $ 864.71 $ 20.37 $ 229.41 $ 8.79
2. Units per Eligible/year 5.957 3.361 0.304 2.609 0.009 6.410
Cost per Elig. per Mo. $ 32.89 $ 6.67 $ 21.91 $ 4.43 $ 0.17 $ 4.70 $ 70.77
3. Adjustments
a.Age/Sex 0.939 0.949 0.911 0.942 1.000 0.966
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.975 0.992 0.968 0.956 0.995 0.868
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 27.55 $ 6.28 $ 19.32 $ 3.99 $ 0.17 $ 3.94 $ 61.25
4. Legislative Adjustments 1.221 0.869 1.029 1.054 1.436 1.079
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 $ 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 33.64 $ 8.13 $ 22.04 $ 4.21 $ 0.24 $ 4.88 $ 73.14
6. CHDP 4.88
7. Adjustment to Pool 12.1% 8.85
Capitation Rate $ 86.87
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 8 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Disabled Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 20.15 $ 50.42 $ 485.15 $ 18.26 $ 184.85 $ 7.07
2. Units per Eligible/year 13.720 21.892 1.011 6.029 0.452 63.930
Cost per Elig. per Mo. $ 23.04 $ 91.98 $ 40.87 $ 9.17 $ 6.96 $ 37.67 $ 209.69
3. Adjustments
a.Age/Sex 0.981 0.869 0.938 1.074 0.949 1.077
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.900 0.875 0.920 0.973 0.995 0.877
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 18.61 $ 69.94 $ 35.27 $ 9.58 $ 6.57 $ 35.58 $ 175.55
4. Legislative Adjustments 1.099 0.888 0.965 1.048 1.442 0.987
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 $ 1.000
b.Units per Eligible 1.073 1.180 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 21.95 $ 92.49 $ 35.07 $ 9.33 $ 9.47 $ 40.31 $ 208.62
6. CHDP 0.00
7. Adjustment to Pool 12.1% 25.24
Capitation Rate $ 233.86
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 9 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Aged Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 16.06 $ 38.28 $ 287.24 $ 11.67 $ 177.26 $ 6.49
2. Units per Eligible/year 11.563 16.963 0.819 3.904 1.049 42.784
Cost per Elig. per Mo. $ 15.48 $ 54.11 $ 19.60 $ 3.80 $ 15.50 $ 23.14 $ 131.63
3. Adjustments
a.Age/Sex 0.993 1.008 1.012 0.993 1.029 1.007
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.981 0.996 0.997 0.986 0.997 0.781
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 13.87 $ 54.32 $ 19.78 $ 3.72 $ 15.90 $ 18.20 $ 125.79
4. Legislative Adjustments 0.984 0.879 0.969 1.046 1.433 0.963
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 $ 1.000
b.Units per Eligible 1.073 1.180 0.929 1.066 0.929 1.148
Projected Cost per Eligible $ 14.64 $ 71.10 $ 21.26 $ 4.15 $ 21.17 $ 20.12 $ 152.44
6. CHDP 0.00
7. Adjustment to Pool 12.1% 18.45
Capitation Rate $ 170.89
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 10 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Child Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 58.40 $ 17.50 $ 889.41 $ 18.79 $ 140.26 $ 6.45
2. Units per Eligible/year 5.196 3.068 0.436 2.787 0.019 10.564
Cost per Elig. per Mo. $ 25.29 $ 4.47 $ 32.32 $ 4.36 $ 0.22 $ 5.68 $ 72.34
3. Adjustments
a.Age/Sex 1.090 1.071 1.089 1.100 1.000 0.994
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.974 0.984 0.952 0.973 0.996 0.882
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 24.57 $ 4.71 $ 33.51 $ 4.67 $ 0.22 $ 4.98 $ 72.65
4. Legislative Adjustments 1.116 0.875 1.035 1.049 1.424 1.082
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 $ 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 27.42 $ 6.14 $ 38.45 $ 4.90 $ 0.31 $ 6.19 $ 83.41
6. CHDP 4.08
7. Adjustment to Pool 12.1% 10.09
Capitation Rate $ 97.58
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 11 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: Aged Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 164.23 $ 19.84 $ 964.66 $ 19.73 $ 0.00 $ 30.86
2. Units per Eligible/year 22.157 4.314 4.387 17.657 0.000 8.468
Cost per Elig. per Mo. $ 303.24 $ 7.13 $ 352.66 $ 29.03 $ 0.00 $ 21.78 $ 713.84
3. Adjustments
a.Age/Sex 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.999 0.999 0.999 0.989 1.000 0.887
d.Interest 1.000 1.000 1.000 1.000 1.000 1.000
Adjusted Base Cost $ 277.19 $ 7.12 $ 352.31 $ 28.71 $ 0.00 $ 19.32 $ 684.65
4. Legislative Adjustments 1.060 0.872 1.016 1.053 1.242 1.045
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.040 1.000 1.000 $ 1.000
b.Units per Eligible 1.000 1.180 1.066 1.000 1.000 1.148
Projected Cost per Eligible $ 293.82 $ 9.25 $ 396.83 $ 30.23 $ 0.00 $ 23.18 $ 753.31
6. CHDP 0.00
7. Adjustment to Pool 12.1% 91.15
Capitation Rate $ 844.46
Prepared by Department of Health Services, Rate Development Branch
#95-23637 C-10
Attachment 1
Page 12 of 12
Plan Name: Xxxxxx Medical Center
County: Riverside Plan #: 355
Aid Code Grouping: AIDS Plan Type: Commercial Plan
Date: 11-Oct-01
The Rate Period is October 1, 2001 Capitation Payments at
to September 30, 2002 the End of the Month
Coverages ( C = Covered by Plan, N = NOT Covered by Plan)
------------------------------------------------------------------------------------------------
CCS Indicated Claims N AIDS Waiver N
------------------------------------------------------------------------------------------------
GHPP N In Home Waiver N
------------------------------------------------------------------------------------------------
Hemodialysis C Model NF Waiver N
------------------------------------------------------------------------------------------------
Major Organ Transplants N Adult Day Health Care N
------------------------------------------------------------------------------------------------
Out-of-State C Newborn Hearing Screens N
------------------------------------------------------------------------------------------------
Chiropractor N Psychiatric Drugs N
------------------------------------------------------------------------------------------------
Local Education Authority N AIDS Drugs N
------------------------------------------------------------------------------------------------
Psychiatrist N Injections C
------------------------------------------------------------------------------------------------
Acupuncturist N MH - Hospital Inpatient N
------------------------------------------------------------------------------------------------
Alphafeto Protein Testing N MH - Outpatient Services N
------------------------------------------------------------------------------------------------
Heroin Detoxification N Long Term Care for month of entry plus one C
------------------------------------------------------------------------------------------------
Direct Observed Therapy N Long Term Care after month of entry plus one N
------------------------------------------------------------------------------------------------
Lenses for eyewear N CHDP C
------------------------------------------------------------------------------------------------
Rate Calculation Hospital Hospital Long Term
Physician Pharmacy Inpatient Outpatient Care Other Total
1. Average Cost Per Unit $ 25.87 $ 141.75 $ 485.15 $ 17.75 $ 228.06 $ 14.00
2. Units per Eligible/year 29.254 46.897 3.823 28.506 0.450 78.563
Cost per Elig. per Mo. $ 63.07 $ 553.97 $ 154.56 $ 42.17 $ 8.55 $ 91.66 $ 913.98
3. Adjustments
a.Age/Sex 1.000 1.000 1.000 1.000 1.000 1.000
b.Area 0.915 1.000 1.000 1.000 1.000 1.000
c.Coverages 0.918 0.663 0.957 0.992 0.998 0.642
d.Interest 1.000 1.000 1.000 1.000 1.000 $ 1.000
Adjusted Base Cost $ 52.98 $ 367.28 $ 147.91 $ 41.83 $ 8.53 $ 58.85 $ 677.38
4. Legislative Adjustments 1.070 0.826 0.989 1.013 1.529 1.001
5. Trend Adjustments
a.Cost per Unit 1.000 1.262 1.194 1.000 1.000 $ 1.000
b.Units per Eligible 1.073 1.180 0.863 0.929 1.000 1.148
Projected Cost per Eligible $ 60.83 $ 451.77 $ 150.73 $ 39.37 $ 13.04 $ 67.63 $ 783.37
6. CHDP 0.00
7. Adjustment to Pool 12.1% 94.79
Capitation Rate $ 878.16
