Deficit. If the total actual cost of Pharmacy Shared Savings services is more than the total allocation to the Pharmacy Shared Savings Fund, then NA percent (NA) of the amount by which the actual costs exceed the total allocation shall be allocated to Group and shall be handled as follows: (i) the excess may be deducted from any other settlements or payments, except capitation and Professional Stop Loss Program payments made pursuant to Exhibit I, due to Group from Blue Shield, and, (ii) any remaining, amounts shall be carried forward into future Agreement years and shall be deducted from Pharmacy Shared Savings Payments to Group in future years. SUMMARIES & SETTLEMENTS: Blue Shield shall provide to Group, as further described in the Provider Manual, on a quarterly basis, a summary of the Pharmacy Shared savings expenses along with a comparison to the Pharmacy Shared Savings Funding and utilization data pertaining to the cost of prescriptions written on a physician specific basis. Blue Shield shall also provide to Group a Shared Savings Annual Settlement. Exhibit D-1 HMO IPA/Medical Group Agreement Shared Savings Fund Allocations for Professional Care IPA - 385U9 Effective Date: 01/01/2003 As of 01/01/2003, the effective net yield (which includes the deduction for Stop Loss, if applicable) for the following PMPMs are *** for the HMO Group, and *** for the HMO IFP, based on the 08/01/2002 membership. The actual allocation to Shared Saving Fund for each month will be calculated based on the actual member mix for each age/sex category. Members Other Than Blue Shield 65 Plus Members *Medicare Primary Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) F 0-1 $ *** $ *** F 2 - 6 $ *** $ *** F 7- 18 $ *** $ *** F 19-21 $ *** $ *** F 22 -24 $ *** $ *** F 25 - 29 $ *** $ *** F 30 - 34 $ *** $ *** F 35 - 39 $ *** $ *** F 40 - 44 $ *** $ *** F 45 - 49 $ *** $ *** F 50 - 54 $ *** $ *** F 55 - 59 $ *** $ *** F 60 - 64 $ *** $ *** F 65 + (NM) $ *** $ *** F 65 + (M*) $ *** $ *** M 0 - 1 $ *** $ *** M 2 - 6 $ *** $ *** M 7 - 18 $ *** $ *** M 19 - 21 $ *** $ *** M 22 - 24 $ *** $ *** M 25 - 29 $ *** $ *** M 30 - 34 $ *** $ *** M 35 - 39 $ *** $ *** M 40 - 44 $ *** $ *** M 45 - 49 $ *** $ *** M 50 - 54 $ *** $ *** M 55 - 59 $ *** $ *** M 60 - 64 $ *** $ *** M 65 + (NM) $ *** $ *** M 65 + (M)* $ *** $ *** HMO IPA/Medical Group Agreement SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: January 1, 2003 BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for a benefit that is designated as a Shared Savings Service in Exhibit B. HMO IPA/Medical Group Agreement PHARMACY SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for outpatient prescription drug services. Exhibit E HMO IPA/Medical Group Agreement BLUE SHIELD ALLOWABLE RATES PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: JANUARY 1, 2003 The following shall constitute Blue Shield Allowable Rates to be paid to Group or Group Providers for Reciprocity (Paragraph 2.10), Retroactive Deletions (Paragraph 6.3(b)), and Services Other Than Capitated Professional Services (Paragraph 7.2): The lesser of one-hundred percent (100%) of the Blue Shield PPO Physician Allowances in effect on the date of service, or the amount paid by the Group (or Group Provider) for the services, if any, (excluding Capitation payment), minus the Member’s/individual’s applicable copayment, coinsurance or deductible. Further detail regarding Blue Shield’s proprietary fee schedule is provided upon request. *** Exhibit F HMO IPA/Medical Group Agreement DELEGATION RESPONSIBILITIES PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: JANUARY 1.2003
Appears in 1 contract
Samples: Shared Savings Provider Agreement (Prospect Medical Holdings Inc)
Deficit. If the total actual cost of Pharmacy Shared Savings services is more than the total allocation to the Pharmacy Shared Savings Fund, then NA percent (NA) *** of the amount by which the actual costs exceed the total allocation, not to exceed *** of the total allocation to the Pharmacy Risk Fund for that Agreement Year, shall be allocated to Group and shall be handled as follows: (i) the excess may be deducted from any other settlements or payments, except capitation and Professional Stop Loss Program payments made pursuant to Exhibit I, due to Group from Blue Shield, and, (ii) any remaining, remaining amounts shall be carried forward into future Agreement years and shall be deducted from Pharmacy Shared Savings Payments to Group in future years. SUMMARIES & SETTLEMENTS: Blue Shield shall provide to Group, as further described in the Provider Manual, on a quarterly basis, a summary of the Pharmacy Shared savings expenses along with a comparison to the Pharmacy Shared Savings Funding and utilization data pertaining to the cost of prescriptions written on a physician specific basis. Blue Shield shall also provide to Group a Shared Savings Annual Settlement. Exhibit D-1 D- l HMO IPA/Medical Group Agreement Shared Savings Fund Allocations for Professional Care IPA - 385U9 SHARED SAVINGS FUND ALLOCATIONS Gateway Medical Group, Inc. Effective Date: 01/01/2003 January l, 2002-December 31, 2002 As of 01/01/200301/01/2002, the effective net yield (which includes the deduction for Stop Loss, if applicable) for the following PMPMs are is *** for the HMO Group, Group and *** for the HMO IFPIFP combined, based on the 08/01/2002 08/01/2001 membership. The actual allocation to Shared Saving Fund for each month will be calculated based on the actual member mix for each age/sex category. Members Other Than Blue Shield MEMBERS OTHER THAN BLUE SHIELD 65 Plus Members *Medicare Primary PLUS MEMBERS Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) F 0-0 - 1 $ *** $ *** F 2 - 6 $ *** $ *** F 7- 7 - 18 $ *** $ *** F 19-19 - 21 $ *** $ *** F 22 -24 $ - 24 *** $ *** F 25 - 29 $ *** $ *** F 30 - 34 $ *** $ *** F 35 - 39 $ *** $ *** F 40 - 44 $ *** $ *** F 45 - 49 $ *** $ *** F 50 - 54 $ *** $ *** F 55 - 59 $ *** $ *** F 60 - 64 $ *** $ *** F 65 + (NM) $ *** $ *** F 65 + (M*) $ )* *** $ *** *** *** M 0 - 1 $ *** $ *** M 2 - 6 $ *** $ *** M 7 - 18 $ *** $ *** M 19 - 21 $ *** $ *** M 22 - 24 $ *** $ *** M 25 - 29 $ *** $ *** M 30 - 34 $ *** $ *** M 35 - 39 $ *** $ *** M 40 - 44 $ *** $ *** M 45 - 49 $ *** $ *** M 50 - 54 $ *** $ *** M 55 - 59 $ *** $ *** M 60 - 64 $ *** $ *** M 65 + (NM) $ *** $ *** M 65 + (M)* $ *** $ *** * = Medicare Primary. *** Confidential Treatment Requested Effective Date: January 1, 2003-Decetnber 31, 2003, & thereafter until amended As of 01/01/2003 the effective net yield for the following PMPMs is *** for the HMO Group and IFP combined, based on the 08/01/2001 membership. The actual allocation to Shared Saving Fund for each month will be calculated based on the actual member mix for each age/sex category. MEMBERS OTHER THAN BLUE SHIELD 65 PLUS MEMBERS Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) F 0 - 1 *** *** F 2 - 6 *** *** F 7 - 18 *** *** F 19 - 21 *** *** F 22 - 24 *** *** F 25 - 29 *** *** F 30 - 34 *** *** F 35 - 39 *** *** F 40 - 44 *** *** F 45 - 49 *** *** F 50 - 54 *** *** F 55 - 59 *** *** F 60 - 64 *** *** F 65 + (NM) *** *** F 65 + (M)* *** *** *** *** M 0 - 1 *** *** M 2 - 6 *** *** M 7 - 18 *** *** M 19 - 21 *** *** M 22 - 24 *** *** M 25 - 29 *** *** M 30 - 34 *** *** M 35 - 39 *** *** M 40 - 44 *** *** M 45 - 49 *** *** M 50 - 54 *** *** M 55 - 59 *** *** M 60 - 64 *** *** M 65 + (NM) *** *** M 65 + (M)* *** *** * Medicare Primary. Exhibit D-2 HMO IPA/Medical Group Agreement SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Gateway Medical Group, Inc. Effective Date: January 1, 2003 2002-December 31, 2002 & thereafter until amended BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) *** of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) *** of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for a benefit that is designated as a Shared Savings Service in Exhibit B. HMO IPA/Medical Group Agreement PHARMACY SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Gateway Medical Group, Inc. Effective Date: January 1, 2002-December 31, 2002 & thereafter until amended BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) *** of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) *** of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for outpatient prescription drug services. Exhibit E HMO IPA/Medical Group Agreement BLUE SHIELD ALLOWABLE RATES PROFESSIONAL CARE IPA MEDICAL GROUP Gateway Medical Group, Inc. Effective Date: JANUARY January 1, 2003 2002 The following shall constitute Blue Shield Allowable Rates to be paid to Group or Group Providers for Reciprocity (Paragraph 2.10), Retroactive Deletions (Paragraph 6.3(b)), and Services Other Than Capitated Professional Services (Paragraph 7.2): The lesser of one-hundred percent (100%) *** of the Blue Shield PPO Physician Allowances in effect on the date of service, or the amount paid by the Group (or Group Provider) for the services, if any, (excluding Capitation payment), minus the Member’s/individual’s applicable copayment, coinsurance or deductible. Further detail regarding Blue Shield’s proprietary fee schedule is provided upon request. *** Exhibit F HMO IPA/Medical Group Agreement DELEGATION RESPONSIBILITIES PROFESSIONAL CARE IPA MEDICAL GROUP Gateway Medical Group, Inc. Effective Date: JANUARY 1.2003January 1, 2002
Appears in 1 contract
Deficit. If the total actual cost of Pharmacy Shared Savings services is more than the total allocation to the Pharmacy Shared Savings Fund, then NA percent (NA) of the amount by which the actual costs exceed the total allocation shall be allocated to Group and shall be handled as follows: (i) the excess may be deducted from any other settlements or payments, except capitation and Professional Stop Loss Program payments made pursuant to Exhibit I, due to Group from Blue Shield, and, (ii) any remaining, remaining amounts shall be carried forward into future Agreement years and shall be deducted from Pharmacy Shared Savings Payments to Group in future years. SUMMARIES & SETTLEMENTS: Blue Shield shall provide to Group, as further described in the Provider Manual, on a quarterly basis, a summary of the Pharmacy Shared savings expenses along with a comparison to the Pharmacy Shared Savings Funding and utilization data pertaining to the cost of prescriptions written on a physician specific basis. Blue Shield shall also provide to Group a Shared Savings Annual Settlement. Exhibit D-1 HMO IPA/Medical Group Agreement Shared Savings Fund Allocations Allocation for Professional Care IPA - 385U9 NorthWest Orange County Medical Group Effective Date: 01/01/2003 02/01/03 As of 01/01/200302/01/2003, the effective net yield (which includes the deduction for Stop Loss, if applicable) for the following PMPMs are *** for the HMO GroupGroup *** for the HMO IFP, and *** for the HMO IFP, PERS based on the 08/01/2002 07/01/2002 membership. The actual allocation to Shared Saving Fund for each month will be calculated based on the actual member mix for each age/sex category. Members Other Than Blue Shield 65 Plus Members *Medicare Primary Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) PERS (non-POS) F 0-0 - 1 $ *** $ *** *** F 2 - 6 $ *** $ *** *** F 7- 7 - 18 $ *** $ *** *** F 19-19 - 21 $ *** $ *** *** F 22 -24 $ - 24 *** $ *** *** F 25 - 29 $ *** $ *** *** F 30 - 34 $ *** $ *** *** F 35 - 39 $ *** $ *** *** F 40 - 44 $ *** $ *** *** F 45 - 49 $ *** $ *** *** F 50 - 54 $ *** $ *** *** F 55 - 59 $ *** $ *** *** F 60 - 64 $ *** $ *** *** F 65 + (NM) $ *** $ *** *** F 65 + (M*) $ )* *** $ *** *** *** *** *** M 0 - 1 $ *** $ *** *** M 2 - 6 $ *** $ *** *** M 7 - 18 $ *** $ *** *** M 19 - 21 $ *** $ *** *** M 22 - 24 $ *** $ *** *** M 25 - 29 $ *** $ *** *** M 30 - 34 $ *** $ *** *** M 35 - 39 $ *** $ *** *** M 40 - 44 $ *** $ *** *** M 45 - 49 $ *** $ *** *** M 50 - 54 $ *** $ *** *** M 55 - 59 $ *** $ *** *** M 60 - 64 $ *** $ *** *** M 65 + (NM) $ *** $ *** *** M 65 + (M)* $ *** $ *** *** * = Medicare Primary *** All references to the shared savings fund allocation have been deleteted. HMO IPA/Medical Group Agreement Shared Savings Fund Allocation for NorthWest Orange County Medical Group Effective Date: 02-01-04 As of 02/01/2004, the effective net yield (which includes the deduction for Stop Loss, if applicable) for the following PMPMs are *** for the HMO Group, *** for the HMO IFP, and *** for the HMO PERS based on the 07/01/2002 membership. The actual allocation to Shared Saving Fund for each month will be calculated based on the actual member mix for each age/sex category. Members Other Than Blue Shield 65 Plus Members Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) PERS (non-POS) F 0 - 1 *** *** *** F 2 - 6 *** *** *** F 7 - 18 *** *** *** F 19 - 21 *** *** *** F 22 - 24 *** *** *** F 25 - 29 *** *** *** F 30 - 34 *** *** *** F 35 - 39 *** *** *** F 40 - 44 *** *** *** F 45 - 49 *** *** *** F 50 - 54 *** *** *** F 55 - 59 *** *** *** F 60 - 64 *** *** *** F 65 + (NM) *** *** *** F 65 + (M)* *** *** *** *** *** *** M 0 - 1 *** *** *** M 2 - 6 *** *** *** M 7 - 18 *** *** *** M 19 - 21 *** *** *** M 22 - 24 *** *** *** M 25 - 29 *** *** *** M 30 - 34 *** *** *** M 35 - 39 *** *** *** M 40 - 44 *** *** *** M 45 - 49 *** *** *** M 50 - 54 *** *** *** M 55 - 59 *** *** *** M 60 - 64 *** *** *** M 65 + (NM) *** *** *** M 65 + (M)* *** *** *** * = Medicare Primary *** All references to the shared savings fund allocation have been deleteted. EXHIBIT D-2 HMO IPA/Medical Group Agreement SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA NORTHWEST ORANGE COUNTY MEDICAL GROUP Effective DateEFFECTIVE DATE: January FEBRUARY 1, 2003 BLUE SHIELD 65 PLUS MEMBERS NA percent ( (NA %) of the Monthly CMS Capitation received by Blue Shield from CMS and NA percent ( NA %) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for a benefit that is designated as a Shared Savings Service in Exhibit B. *** Confidential Treatment requested HMO IPA/Medical Group Agreement PHARMACY SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA NORTHWEST ORANGE COUNTY MEDICAL GROUP Effective Date: NA BLUE SHIELD 65 PLUS MEMBERS NA percent ( %(NA%) of the Monthly CMS Capitation received by Blue Shield from CMS and NA percent ( %(NA%) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for outpatient prescription drug services. *** Confidential Treatment requested Exhibit E HMO IPA/Medical Group Agreement BLUE SHIELD ALLOWABLE RATES PROFESSIONAL CARE IPA NORTHWEST ORANGE COUNTY MEDICAL GROUP Effective Date: JANUARY February 1, 2003 The following shall constitute Blue Shield Allowable Rates to be paid to Group or Group Providers for Reciprocity (Paragraph 2.10), Retroactive Deletions (Paragraph 6.3(b)), and Services Other Than Capitated Professional Services (Paragraph 7.2): The lesser of one-one hundred percent (100%) of the Blue Shield PPO Physician Allowances in effect on the date of service, or the amount paid by the Group (or Group Provider) for the services, if any, (excluding Capitation payment), minus the Member’s/individual’s applicable copayment, coinsurance or deductible. Further detail regarding Blue Shield’s proprietary fee schedule is provided upon request. *** Exhibit F HMO IPA/Medical Group Agreement DELEGATION RESPONSIBILITIES PROFESSIONAL CARE IPA NORTHWEST ORANGE COUNTY MEDICAL GROUP Effective Date: JANUARY 1.2003February 1, 2003
Appears in 1 contract
Samples: Savings Provider Agreement (Prospect Medical Holdings Inc)
Deficit. If the total actual cost of Pharmacy Shared Savings services is more than the total allocation to the Pharmacy Shared Savings Fund, then NA fifty percent (NA50%) of the amount by which the actual costs exceed the total allocation allocation, not to exceed five percent (5%) of the HMO Capitation Fees, shall be allocated to Group and shall be handled as follows: (i) the excess may be deducted from any other settlements or payments, except capitation and Professional Stop Loss Program payments made pursuant to Exhibit IH, due to Group from Blue Shield, and, (ii) any remaining, remaining amounts shall be carried forward into future Agreement years and shall be deducted from Pharmacy any Shared Savings Payments payments to Group in future years. SUMMARIES & SETTLEMENTS: Blue Shield shall provide to GroupGroup a Shared Savings Program quarterly Report and a Shared Savings Annual Settlement, as further described in the Provider Manual, on a quarterly basis, a summary of the Pharmacy Shared savings expenses along with a comparison to the Pharmacy Shared Savings Funding and utilization data pertaining to the cost of prescriptions written on a physician specific basis. Blue Shield shall also provide to Group a Shared Savings Annual Settlement. Exhibit D-1 EXHIBIT H-1 HMO IPA/Medical Group Agreement MEDICAL GROUP AGREEMENT Shared Savings Fund Allocations Allocation for Professional Care IPA - 385U9 NorthWest Orange County Medical Group Effective Date: 01/01/2003 01/01/03 As of 01/01/2003, the effective net yield (which includes the deduction for Stop Loss, if applicable) for the following PMPMs are *** for the HMO Group, and *** for the HMO IFP, and *** for the HMO PERS based on the 08/01/2002 07/01/2002 membership. The actual allocation to Shared Saving Fund fund for each month will be calculated based on the actual member mix for each age/sex category. Members Other Than Blue Shield 65 Plus Members *Medicare Primary Age & Sex Categories and Shared Savings Allocations Category Shared Savings Allocation (PMPM) Sex Age Group (non-POS) IFP (non-POS) PERS (non-POS) F 0-0 - 1 $ *** $ *** *** F 2 - 6 $ *** $ *** *** F 7- 7 - 18 $ *** $ *** *** F 19-19 - 21 $ *** $ *** *** F 22 -24 $ - 24 *** $ *** *** F 25 - 29 $ *** $ *** *** F 30 - 34 $ *** $ *** *** F 35 - 39 $ *** $ *** *** F 40 - 44 $ *** $ *** *** F 45 - 49 $ *** $ *** *** F 50 - 54 $ *** $ *** *** F 55 - 59 $ *** $ *** *** F 60 - 64 $ *** $ *** *** F 65 + (NM) $ *** $ *** *** F 65 + (M*) $ * *** $ *** *** M 0 - 1 $ *** $ *** *** M 2 - 6 $ *** $ *** *** M 7 - 18 $ *** $ *** *** M 19 - 21 $ *** $ *** *** M 22 - 24 $ *** $ *** *** M 25 - 29 $ *** $ *** *** M 30 - 34 $ *** $ *** *** M 35 - 39 $ *** $ *** *** M 40 - 44 $ *** $ *** *** M 45 - 49 $ *** $ *** *** M 50 - 54 $ *** $ *** *** M 55 - 59 $ *** $ *** *** M 60 - 64 $ *** $ *** *** M 65 + (NM) $ *** $ *** *** M 65 + (M)) * $ *** $ *** HMO IPA/Medical Group Agreement SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: January 1, 2003 BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for a benefit that is designated as a Shared Savings Service in Exhibit B. HMO IPA/Medical Group Agreement PHARMACY SHARED SAVINGS FUND ALLOCATIONS PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: BLUE SHIELD 65 PLUS MEMBERS NA percent ( %) of the Monthly CMS Capitation received by Blue Shield from CMS and percent ( %) of the monthly premium received by Blue Shield from the Member or from an Employer Group which Blue Shield determines, according to its actuarial standards and methodology, to be for outpatient prescription drug services. Exhibit E HMO IPA/Medical Group Agreement BLUE SHIELD ALLOWABLE RATES PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: JANUARY 1, 2003 The following shall constitute Blue Shield Allowable Rates to be paid to Group or Group Providers for Reciprocity (Paragraph 2.10), Retroactive Deletions (Paragraph 6.3(b)), and Services Other Than Capitated Professional Services (Paragraph 7.2): The lesser of one-hundred percent (100%) of the Blue Shield PPO Physician Allowances in effect on the date of service, or the amount paid by the Group (or Group Provider) for the services, if any, (excluding Capitation payment), minus the Member’s/individual’s applicable copayment, coinsurance or deductible. Further detail regarding Blue Shield’s proprietary fee schedule is provided upon request. *** Exhibit F HMO IPA/Medical Group Agreement DELEGATION RESPONSIBILITIES PROFESSIONAL CARE IPA MEDICAL GROUP Effective Date: JANUARY 1.2003* - Medicare Primary *** All references to the Shared Saving Fund Allocation have been deleted.
Appears in 1 contract
Samples: Service Ipa Agreement (Prospect Medical Holdings Inc)
