Exhibit 10.30
FIFTH AMENDMENT TO
MANAGED CARE ALLIANCE AGREEMENT
THIS AMENDMENT (the "Amendment") is entered into this 27th day of October, 2005
by and between CIGNA Health Corporation, for and on behalf of its CIGNA
Affiliates (individually and collectively, "CIGNA"), and Gentiva CareCentrix,
Inc. ("MCA").
WITNESSETH
WHEREAS, CIGNA and MCA entered into a Managed Care Alliance Agreement which
became effective January 1, 2004 (the "Agreement") whereby MCA agreed to provide
or arrange for the provision of certain home health care services to
Participants, as that term is defined in the Agreement;
WHEREAS, the parties wish to amend the Agreement to extend the term of the
Agreement and to exclude certain home medical equipment/durable medical
equipment from the Agreement, including but not limited to, home oxygen,
respiratory equipment and services and enteral nutrition, effective February 1,
2006;
NOW THEREFORE, CIGNA and MCA agree to amend the Agreement as follows:
1. The provisions in this Amendment shall be effective on February 1,
2006, unless otherwise provided below.
2. The definition for the term Covered Home Care Services is replaced in
its entirety with the following:
Covered Home Care Services means the Medically Necessary Home Health
Services, Home Infusion Therapy Services and select Home Medical
Equipment/Durable Medical Equipment provided to a Participant in
accordance with a Service Agreement. It also includes the following
services with respect to Participants receiving Covered Home Care
services:
(a) training and education;
(b) family orientation;
(c) family/caregiver training, if required; and
(d) instructional literature.
3. The definition for the term Home Care Services is replaced in its
entirety with the following:
Home Care Services means those Home Health Services, Home Infusion
Therapy Services, select Home Medical Equipment, as defined below,
appropriately and safely (see Exhibit IX Safe Home Care Admission
Criteria) provided in a Home Setting (except that Home Infusion
Therapy Services includes the administration of the first dose of home
infusion therapies in a controlled medical setting for the purpose of
managing potential acute anaphylactic reactions, and Home Medical
Equipment includes medical equipment used in the Home Setting, except
in preparation for hospital discharge), subject to the conditions and
limitations of this Agreement.
4. The definition for the term Home Medical Equipment (HME)/Durable
Medical Equipment (DME) is replaced in its entirety with the following
definition:
Home Medical Equipment (HME)/Durable Medical Equipment (DME) means
equipment that can stand repeated use, is primarily and customarily
used to serve a
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medical purpose, is generally not useful to a Participant in the
absence of an illness or injury and is one of the home medical
equipment/durable medical equipment services listed in the fee
schedules set forth in Exhibit A to the Program Attachments to the
Agreement. It is ordered or prescribed by a physician for a
Participant (including all services, training, supplies, maintenance
and repairs necessary for use of such equipment) including durable
medical equipment provided in accordance with Exhibit XIII (DME
Guidelines Grid).
5. The definition for the term Urgent Care is replaced in its entirety
with the following definition:
Urgent Care means services required, as directed by physician orders,
within 4 hours from receipt of a Complete Order (see EXHIBIT III).
Services which will be considered urgent for the purposes of this
agreement shall include the following: hydration therapy for pregnant
members with diagnosis of hyperemesis, hydration therapy for pediatric
members and infusion therapies with less than an every 12 hour dosing
schedule. Urgent care services also include same day discharges
requiring pain management. Urgent care services are not intended to
replace appropriate discharge planning when the Participant has been
in the facility for greater than 23 hours. Inappropriate utilization
of same day and urgent request for same day hospital discharge will be
monitored.
6. Section II.B.8. of the Agreement is replaced in its entirety with the
following provision:
For Home Medical Equipment, MCA agrees to a rental cap at purchase
price. Payor shall pay a fee equal to one (1) month's rental charge
every six (6) months to compensate for the cost of maintaining the
equipment. MCA or Represented Provider, as applicable, shall retain
title to the equipment. Payor may continue to rent the equipment until
the rental cap is met or purchase the piece of equipment with a
maximum of two (2) months rental payments applied to the purchase
price.
7. Section II.G.10. is deleted in its entirety.
8. Section III.C.2. entitled "Services Upon Termination" is replaced in
its entirety with the following:
Services Upon Termination or Amendment.
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a. Upon termination of this Agreement or upon an amendment to this
Agreement which results in the termination of the provision of any
services under this Agreement, MCA through its Represented Providers
shall continue to provide Covered Services for specific conditions for
which a Participant was under Represented Provider's care at the time
of such termination or amendment, as applicable, so long as the
Participant retains eligibility under a Service Agreement, until the
earlier of completion of such services, CIGNA's provision for the
assumption of such treatment by another provider, or the expiration of
*. MCA shall be compensated for Covered Services provided to any such
Participant in accordance with the compensation arrangements under
this Agreement until * following such amendment or termination, and
compensation thereafter for continued services authorized by CIGNA
shall be at the fee for service rates contained in the Agreement prior
to this Amendment. MCA and its Represented Providers have no
obligation under this Agreement to provide services to individuals who
cease to be Participants.
* Confidential treatment requested.
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b. Upon receipt of notice of termination of this Agreement or upon the
execution of an amendment to this Agreement which results in the
termination of the provision of any services under this Agreement (the
services affected by such termination or amendment shall be referred
to as the "Terminated Services"), MCA and its Represented Providers
shall cooperate as necessary to ensure a smooth transitioning of care
of the Terminated Services. MCA and CIGNA agree to evaluate all
requests for Terminated Services commencing 30 days prior to the
effective date of such termination or amendment to limit unnecessary
Participant transition of care during the period following the
effective date of such termination or amendment. Upon and following
the effective date of such termination or amendment, MCA shall refer
all requests for Terminated Services to a Participating Provider
designated by CIGNA.
9. Section II.B.9. of the HMO Program Attachment to the Managed Care
Alliance Agreement (Capitation) is deleted in its entirety.
10. Section II.B.9. of the Gatekeeper Program Attachment to the Managed
Care Alliance Agreement (Capitation) is deleted in its entirety.
11. Exhibit XIII. is replaced in its entirety with the attached Exhibit
XIII.
12. The Agreement is amended to add the following new provision to Section
II.B. entitled "Compensation and Billing":
Commencing February 1, 2007, utilization will be measured periodically
for all * issued to all Participants, both under this Agreement and by
other providers outside this Agreement. If the ratio of * units to *
units for * exceeds *, the * for * under this Agreement shall be
amended to bring the average cost * to below *. If MCA is unwilling to
amend the Agreement to reflect this revised rate, CIGNA shall have the
right to exclude * from this Agreement upon 90 days advance notice to
MCA.
13. The Agreement is amended to add the following new provision to Section
II.B. entitled "Compensation and Billing":
CIGNA may exclude * and * from this Agreement at any time on or after
February 1, 2007. CIGNA must provide MCA with 90 days advance notice
of its intent to exclude such services.
14. Effective upon execution of this Amendment, Section 8 in the Second
Amendment to the Agreement effective January 1, 2005 relating to * is
replaced in its entirety with the following provision:
CIGNA may exclude * from this Agreement at any time on or after
January 1, 2006. CIGNA must provide MCA with thirty (30) days advance
notice of its intent to exclude such services. Ninety (90) days
following such notice, the rates indicated in Section 2A(1) will apply
to any remaining existing patients and new patient referral to MCA
requested to be taken by CIGNA.
15. Effective upon execution of this Amendment, the parties agree to
continue to implement the leakage abatement program described in
Attachment A for Home Health Services, Home Infusion Therapy Services
and Home Medical Equipment/Durable Medical Equipment. Effective
February 1, 2006, the leakage program will continue for Home Health
Services, Home Infusion Therapy Services and the select Home Medical
Equipment/Durable Medical Equipment, included in Exhibit A to the
Program Attachments, for the remainder of the term of the Agreement.
* Confidential treatment requested.
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16. Effective February 1, 2006, Exhibit A HMO Program Attachment -
Capitation Schedule of Capitation Rates is hereby deleted and replaced
with a new Exhibit A HMO Program Attachment - Capitation Schedule of
Capitation Rates attached hereto.
17. Effective February 1, 2006, Exhibit A HMO Program Attachment - Fee for
Service Reimbursement For Other Services is hereby deleted and
replaced with a new Exhibit A HMO Program Attachment - Fee for Service
Reimbursement For Other Services attached hereto.
18. Effective February 1, 2006, Exhibit A PPO & Indemnity Program
Attachment - Fee for Service Reimbursement For Other Services is
hereby deleted and replaced with a new Exhibit A PPO & Indemnity
Program Attachment Reimbursement For Other Services attached hereto.
19. Effective February 1, 2006, Exhibit A Gatekeeper Program Attachment -
Capitation Schedule of Capitation Rates is hereby deleted and replaced
with a new Exhibit A Gatekeeper Program Attachment -Capitation
Schedule of Capitation Rates attached hereto.
20. Effective February 1, 2006, Exhibit A Gatekeeper Program Attachment -
Fee for Service Reimbursement For Other Services is hereby deleted and
replaced with a new Exhibit A Gatekeeper Program Attachment - Fee for
Service Reimbursement For Other Services attached hereto.
21. Section III.B. entitled Term of the Agreement shall be replaced in its
entirety with the following provision:
This Agreement shall be in full force and effect for a three (3) year
period terminating on January 31, 2009. MCA shall present its proposal
to CIGNA for the * rates on or before *. If 1) MCA timely submits such
proposal; 2) the proposal includes a * that exceeds * per member per
month or an increase to the fee-for-service rates that exceeds the
permitted inflation ceiling as set forth in Exhibit A to the Program
Attachments; and 3) the parties are unable to reach agreement on the
*, either party may terminate this Agreement effective * by providing
written notice to the other party on or before *. If neither party
exercises such right to terminate this Agreement or if MCA fails to
timely submit its proposal for the * rates, then the existing rates
will remain in place and this Agreement shall automatically renew for
consecutive one year terms without any further action by either party,
unless either party elects not to renew this Agreement by providing at
least ninety (90) days advance written notice to the other party,
prior to the commencement of the next term.
Notwithstanding the expiration or non-renewal of this Agreement
pursuant to this Section B., this Agreement shall continue in effect
with respect to those Payors covered under Service Agreements in
effect as of the end of the term of this Agreement or the notice
period, as applicable, but not to exceed * from the effective date of
termination or expiration.
22. To the extent that the provisions in the Agreement, including any
prior amendments, conflict with the terms of this Amendment (including
the exhibits and schedules hereto), the terms in this Amendment shall
supersede and control. All other terms and conditions of the
Agreement, as previously amended, including the Program Attachments
and the Exhibits attached thereto, shall remain the same and in full
force and effect. Capitalized terms not defined herein but defined in
the Agreement shall have the same meaning as defined in the Agreement.
* Confidential treatment requested.
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IN WITNESS WHEREOF, CIGNA and MCA have caused their duly authorized
representatives to execute this Amendment as of the date first written above.
CIGNA HEALTH CORPORATION
By: _________________________________
Its: _________________________________
Dated: _________________________________
GENTIVA CARECENTRIX, INC.
By: _________________________________
Its: _________________________________
Dated: _________________________________
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EXHIBIT XIII.
DME GUIDELINES GRID
Durable Medical Equipment (DME) is defined as equipment that can stand repeated
use, is primarily and customarily used to serve a medical purpose, and is
generally not useful to a person in the absence of an illness or injury. DME
items have the following characteristics:
1. The equipment is prescribed by a physician;
2. The equipment meets the definition of DME;
3. The equipment is necessary and reasonable for the treatment of a patient's
illness or injury.
4. The equipment is manufactured primarily for use in the home environment but
is not limited to use in the home. Portable equipment for use outside the
home may be covered as an alternative to a stationery unit when the cost of
the portable unit is equal to or less than the stationery unit and the
member's medical condition supports the need for the equipment periodically
outside the home setting. Equipment intended for extended use in the home,
but which is appropriately delivered for use and education in an inpatient
environment for up to five days will be delivered to the member either in
the inpatient environment prior to discharge , or in the member's home
prior to an admission.
5. Institutional equipment requested by CIGNA to be provided by Gentiva in an
inpatient facility for use in the facility when the equipment is not part
of the discharge plan for use in the member's home, or when the member is
not a permanent resident of the facility, is not covered under the member's
DME benefit. Initial attempts should be made to have the facility provide
the equipment as part of their facility charges. When this cannot be
accomplished, Gentiva will contact contracted vendors to obtain the
requested equipment for CIGNA on a discount FFS basis. If the health plan
is not available to issue the FFS authorization (week-ends and after hours)
the request will be sent to the health plan and it is expected that a FFS
authorization number will be issued by the health plan. It should be noted
that Home Medical Equipment vendors do not have all institutional type
equipment in stock and there may be a need to special order the equipment
HOME: The home is defined as either the member's home; the home of a family
member or primary care giver within the national CIGNA/ Gentiva service area.
Member's who have been permanently admitted to an inpatient skilled nursing
facility or inpatient hospice and who have changed their home address to that of
the SNF or hospice will have the SNF or hospice defined as their home. DME
covered under cap in the home would be covered under cap in these facilities.
Products. A listing of the contracted items, or group of items, that are or may
be perceived as home medical equipment. This listing, while reasonably complete
is not intended to quantify the entire spectrum of products that may be
considered DME either now or in the future. Installation of equipment that
requires attachment to the structure of the home or making home modifications
(construction/renovation) is not the responsibility of GENTIVA Care Centrix.
Coverage Criteria. Conditions under which DME coverage is justified. These
guidelines are a combination of Medicare guidelines, CIGNA benefit
interpretations, and DME industry standards. Equipment noted as "not covered"
only refer to coverage under the DME capitation, but may be covered under other
benefit plans such as pharmacy, consumable medical supplies, external prosthetic
appliances or hospital benefits. Efforts should be made to provide "not covered"
items on a discount fee for service basis to assist in meeting CIGNA and
patient's needs. Items may have separate coverage guidelines noted for medicare
coverage issues and are identified by italics.
HCPC. Medicare HCFA Common Procedure Coding system. For reference only, note
that the existence of a Medicare code does not indicate coverage or
reimbursement acceptance.
Diagnosis. These are typical diagnosis indicated for each type of DME; this list
is a general guideline and is not exhaustive of all potential qualifying
diagnosis.
Site of Service, Training and Supplies. A listing of common industry practices
that are the minimal accepted levels noting how equipment is to be delivered to
the patient (or picked up), who is responsible for patient education and how it
is accomplished, and which accessories and supplies are included in the DME
benefit. Minimum standards will be adjusted on a state by state basis to meet
legal and regulatory requirements. Supplies listed as included reflect
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capitated coverage only, fee for service and Medicare will generally pay
additional charges for supplies used with CPM.
BRAND Supplied. When completed, it will list typical manufacturers and their
model numbers as specific examples of items provided for these product
descriptions, but are not considered inclusive of all products that could be
offered. If there is an established clinical need for a model number or product
other than those listed it will be considered under capitated coverage.
Rent/Purchase. Used internally at GENTIVA CareCentrix to determine the
appropriate time to make the financial decision when it is more cost effective
to purchase equipment versus ongoing rental. Patients' diagnosis, prognosis,
level of care and equipment maintenance needs will be the key factors. All
discount FFS equivalent rental amounts will be applied to the purchase price of
any purchased equipment.
Coverage Statements for General Categories. General policies for coverage of
items that may fall under multiple benefits are listed beginning on page 39, are
unique in their requirements, or are generally excluded from all coverage. Many
of these items can be purchased at local drug stores, hardware stores or retail
outlets.
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SITE OF SERVICE DEFINITIONS
Category I (product only) - Delivered to patients home by small package delivery
service (i.e. UPS or U.S. mail) is an acceptable site of service if:
Consumer agrees to small package delivery via telephone or in writing.
1. Meets patients or caregivers requirements for timeliness, same day delivery
may incur additional charges;
2. Is a purchase item only;
3. Requires minimal or no assembly;
4. Setup and training can be easily accomplished via written (or video)
instruction;
5. Is a supply reorder; and
6. Is easily transported and can sustain shipping and handling.
Category II (product and service, outpatient) - Items can be picked up at DME
provider or from PCP (consigned from contracted DME provider) location if:
1. It meets the patients or caregivers requirements for timeliness;
2. Requires specialized fitting and measurement that can be best accomplished
in a professional environment;
3. May be a stat or rush order;
4. Needs minimal patient or caregiver training (or training completed at
physicians office);
5. Requires a written physician order upon pickup;
6. Can easily be transported;
7. Includes all category I items.
Category III (product and service at patients home) - Delivered by DME company
employee (clinical staff if noted) to patients residence if:
1. Patient or caregiver training required;
2. Clinical assistance required;
3. Is too bulky for easy transport;
4. Is considered a hazardous material;
5. Is a stat or rush order (may apply to all categories)
6. Requires installation and setup;
7. Requires an environmental site inspection;
8. Includes category II items where customer pickup cannot be accomplished;
This option may include delivery to physician office or hospital.
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PRODUCTS COVERAGE CRITERIA HCPC EXAMPLE of SITE OF USUAL RENT-
DIAGNOSeS SERVICE, BRAND PURCHASE
TRAINING, SUPPLIED
SUPPLIES
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AMBULATORY EQUIPMENT
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o NOTE:
o More than one piece of ambulatory
equipment may be appropriate if member
is expected to improve during
rehabilitation or if the diagnosis
and/or prognosis indicates deterioration
in medical condition.
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DECUBITIS CARE EQUIPMENT
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WOUND Negative Pressure Wound Therapy or KCI
VACUUM Vacuum-Assisted Closure, including a
DEVICES FDA-approved pump (i.e., VAC(R), Kinetic Coverage
Concepts Inc., San Antonio, TX) and supplies, limited to
may be covered when the treating physician's the
request and supporting documentation following
establish the following: diagnoses:
Chronic Stage
o The ulcer, as described below, III or Stage IV
demonstrates a lack of pressure ulcers
improvement* despite: or,
1. Treatment with the following complete Chronic
wound therapy program: diabetic
neuropathic
o At least weekly visits with ulcers, or
written documentation in the
member's medical record of
evaluation and care by a Complications
licensed medical professional of a
and at least monthly surgically
documentation of the wound's created
measurements; AND wound (e.g.,
dehiscence) or a
o Application of moist topical traumatic wound
dressings; AND
o Serial sharp, chemical and/or
mechanical debridement of
necrotic tissue as
appropriate; AND
o Provision for adequate
nutritional status as
documented by a serum albumin
of >/= 3.0 g/dl during the month
prior to the use of negative
pressure wound therapy.
AND
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1. The member has one of the following:
a) Chronic Stage III or Stage IV
pressure ulcers; AND
o The ulcer has demonstrated a
lack of improvement* and
remains full thickness despite
consistent application of all
of the following for at least
the last two (2) continuous
months prior to initiating
vacuum-assisted wound closure:
o The member has been
appropriately turned and
positioned; AND
o The member has used an
appropriate pressure relief
device (e.g., low air loss
bed, alternating pressure
mattress) for pressure ulcers
on the posterior trunk or
pelvis; AND
o The member's moisture and
incontinence have been
appropriately maintained.
OR
a) Chronic diabetic neuropathic ulcers;
AND
o The ulcer has demonstrated a
lack of improvement* despite
the consistent application of
all of the following for at
least the last two (2)
continuous months prior to
initiating vacuum-assisted
wound closure:
o The member has been on a
comprehensive diabetic
management program; AND
o The member has had appropriate
foot care, including an
attempt to reduce pressure on
a foot ulcer; AND
o The member has been non-weight
bearing as appropriate.
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OR
a) Chronic venous stasis ulcers; AND
o The ulcer has demonstrated a
lack of improvement* despite
the consistent application of
all of the following for at
least the last two (2)
continuous months prior to
initiating vacuum-assisted
wound closure:
o Compression garments/dressings
have been consistently
applied; AND
o Leg elevation and ambulation
have been encouraged.
*Lack of improvement is defined as a
lack of progress in quantitative measurements
of wound characteristics including wound
length, and width (surface area), and depth
measurements measured in centimeters, and
amount of exudate (drainage), serially
observed and documented over a specific time
interval.
OR
o The member has complications of a
surgically created wound (e.g.,
dehiscence) or a traumatic wound (e.g.,
pre-operative flap or graft) where there
is documentation of the medical
necessity for accelerated formation of
granulation tissue which cannot be
achieved by other topical wound
treatments (e.g., the member has
comorbidities that will not allow for
healing times achievable with other
topical wound treatments).
Contraindications
According to the manufacturer, KCI USA Inc.,
contraindications to V.A.C.(R) use includes
any of the following:
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o The presence in the wound of necrotic
tissue with eschar, unless effective
debridement has occurred
o Untreated osteomyelitis within the
vicinity of the wound;
o Cancer present in the wound;
o The presence of a fistula to an organ or
body cavity within the vicinity of the wound.
It should be used cautiously in patients with
active bleeding, difficult wound hemostasis,
and patients who
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DIABETIC CARE
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INJECTORS, May be covered as an alternative to an
NEEDLELESS insulin pump in children under age 16 who
require three or more insulin injections to
maintain a normal blood sugar.
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Diabetic Needles, lancets, alcohol wipes, insulin etc
supplies. are covered under the member's pharmacy plan
and not supplied through Gentiva.
Medically necessary diabetic shoes may be
covered under the member's orthotic coverage.
Check plan language and refer to local
orthotic vendor.
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EXTERNAL Covered if prescribed by a physician and; E0784 Same as above Category III, Minimed Purchase
AMBULATORY o the patient is injecting insulin three delivery Disetronics only.,
INFUSION times daily and has experienced should be
PUMP FOR difficulty in controlling blood sugar coordinated
INSULIN levels on less than three insulin with PCP to
injections every day.. The member does handle
not need to attempt a fourth injection training.
prior to coverage, Supplies
included.
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CPM
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CONTINUOUS Covered: E0935 Total knee Category III, Therakinetics Rental
PASSIVE o For patients who have TKR or ACL repair replacement delivery and Xxxxxx only
MOTION and and total duration only up to 3 ACL repair training Stryker
EXERCISE weeks. performed
(CPM) KNEE by patient
o The 3 week limit may be repeated if a service
second surgery is required. CPM is also technician.
covered for members requiring joint CPM softgoods
manipulation after a surgical procedure (fleece)
as a method to prevent further adhesions included.
or repeat surgery.
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CPM, HAND, Not Covered
WRIST, ANKLE
& SHOULDER
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STIMULATORS
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BONE GROWTH o Covered for a long bone fracture that E0747 Nonunion of Category III EBI
will not be healed in 120 days, long
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STIMULATOR & o Covered for healing of post-operative E0748 bone fractures Orthologic
ULTRASOUND spinal fusion in patients at risk for longer than Bio electron
failure to heal due to cigarette/ 120 days. Exogen
tobacco abuse. No trial period is
required for patients with an identified Spinal fusion
risk factor. in members who
smoke tobacco.,
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HEAT, LIGHT & COLD THERAPY
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WHIRLPOOLS Portable whirlpools are covered in the E1300 Wounds of an
home only when required as part of a home E1310 extremity
physicial therapy program for wound care & requiring home
debridement of a wound on an extremity. debridement
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MISCELLANEOUS
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CONSUMABLE Not covered under the DME benefit, these are A codes
SUPPLIES nonreusable for single patient use;
o these may be supplied by Gentiva upon
request under a fee for service
arrangement or as part of a home health
visit by a nurse.
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Sterile Sterile saline and water in quantities of
Saline or >60cc used for irrigation is considered a
sterile legend item and should be obtained through
water for the pharmacy benefit.
irrigation.
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EQUIPMENT Repairs are covered to make the equipment E1350 Category II, if
REPAIRS serviceable unless caused by abuse or patient is
improper use of equipment. ambulatory and
equipment is
o Equipment under manufacturer warranty category I or II
may have to be sent to manufacturer for then every effort
repair or replacement. Repair cost should be made for
limited to replacement value of equipment to be
equipment. Items such as compressors, brought to
tires, upholstery, will be provider location
repaired/replaced no more frequently for repair.
than the expected life of the particular
component and is subject to any DME plan
maximums.
o Adjustments for growth or changes
in condition are covered within
plan benefit limits , Standard
loaner equipment will be provided
when a members equipment needs to
be sent out for repair; or repair
is delayed waiting for parts or
service.
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EXHIBIT A
LEAKAGE ABATEMENT PROGRAM
Leakage Abatement
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Steps: Who What
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1 Identify CIGNA Generate a report of DME claims paid directly to
providers rather than to / through CareCentrix
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2 Analyze CareCentrix Create a "working report" of target providers and cases
Finance needing recovery and redirection
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3 Communicate CareCentrix Fax explanation letter to each target provider with case
Provider specifics and instructions
Relations
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Mail refund check (made out to CIGNA) to CareCentrix NCC
4 Refund Provider along with revised claim addressed to CareCentrix and
any documentation
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5 Re-adjudicate CareCentrix Adjudicate claims received with refund (from step 4
National Claim above) to re-pay provider as per provider contract
Center (NCC)
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Steps: When Open Questions / Comments
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1 Identify Monthly Future reports will provide member
liability detail (per Xxx)
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2 Analyze Monthly Format and exact timing t.b.d.?
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3 Communicate Monthly CareCentrix to draft letter and
instructions
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As soon as
possible Consider special address or fax
4 Refund following number?
appropriate
communication
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Create intake and/or authorizations
5 Re-adjudicate As received as necessary. Forward documents to
NBC for imaging / reference
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6 Forward CareCentrix National Forward refund check from provider to CIGNA for
Claim Center (NCC) adjustment to member account
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Forward refund check with Special Handle instructions to
7 Forward CIGNA Electronic Mailroom (EMR) for coding and scanning of
check and documentation.
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EMR forwards scanned check to Bank Of America for
8 Forward EMR deposit.
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Post refund and reverse original (direct) claims and
9 Post CIGNA issue corrected EOBs to member
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10 Notification CIGNA Once refund is posted, CIGNA notifies Gentiva that
refund is complete
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11 Re-invoice CareCentrix National Invoice CIGNA for claim(s) involved
Billing Center (NBC)
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12 Re-payment CIGNA Pay CareCentrix for claim(s) per contracted rates and
issue new EOB(s) to CareCenrix and member
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Address to: CIGNA COR Unit, Attn:
6 Forward As received Xxxxxx Xxxxx, 00 Xxxxxx Xx.,
Xxxxxxx, XX 00000
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Address to: CIGNA Healthcare, Attn:
Xxxx Xxxxxx Personal and
7 Forward As received Confidential, 000 Xxxxxxx Xxx.,
Xxxxxxxx, XX 00000
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Both EMR and Bank send CIGNA a file
once completed in their area. Once
8 Forward As received files are received, CIGNA posts
refund to account.
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Any additional notice or explanation
to member from CIGNA (and/or
9 Post As received trainning scripts for Member
Services)?
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10 Notification As Posted
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Within week
11 Re-invoice following Procedures / protocols regarding any
re-adjudication CIGNA pre-authorization requirements?
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Special appeal process if
differences result? Also, how to
12 Re-payment Within 30 days handle changes in benefit or
eligibility subsequent to original
payment?
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13 Settlement CareCentrix National Calculate appropriate adjustment to member liability and
Billing Center (NBC) xxxx member and/or provider accordingly
-------------------------------------------------------------------------------------------------------------
Monitor compliance and results and readdress with
14 Follow-up CareCentrix non-compliant providers (if any)
-------------------------------------------------------------------------------------------------------------
----------------------------------------------------------------------------------------
As new EOBs Predetermine and script most likely
13 Settlement received from scenarios (e.g. change from 30% out
CIGNA of network, to 20% in network)
----------------------------------------------------------------------------------------
Intent is to not only redirect past
claims, but reduce / avoid future
14 Follow-up Monthly leakage as well. Tracking tool(s)
and department t.b.d.?
----------------------------------------------------------------------------------------
EXHIBIT A
HMO PROGRAM ATTACHMENT - CAPITATION
SCHEDULE OF CAPITATION RATES
CAPITATION RATES EFFECTIVE 2/1/06 - 1/31/07
These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in HMO Programs. An "HMO Program" means a
non-governmental, fully insured HMO or Point of Service product that is
underwritten based on a community rating methodology (i.e. community rating,
community rating by class, adjusted community rating by class).
----------------------------------------------------------------------------------------------------
Gentiva Homehealth
Infusion and
DME/HME Capitation
Rate PMPM
----------------------------------------------------------------------------------------------------
All Commercial HMO Capitated Affiliates *
----------------------------------------------------------------------------------------------------
Capitation Rate Compensation Terms
----------------------------------
The following rates are established for the provision of Home Care Services
rendered to Program Participants covered under the HMO and Gatekeeper plans:
February 1, 2006 - January 31, 2007 $* per member per month
February 1, 2007 - January 31, 2008 $* per member per month
February 1, 2008 - January 31, 2009 $* per member per month
The capitation rate listed above for each twelve month period is allocated
between HMO and Gatekeeper Program participants in accordance with established
business practices. On or about December 1 of each year, the parties shall
reconcile the allocation and settle any payment difference no later than
December 31 of each calendar year.
If an outlier calculation for * demonstrates a patient per thousand (PPK)
increase in excess of *, (* ppk), then MCA reserves the right to propose an *
pmpm outlier adjustment no later than September 1. CIGNA may elect to accept the
proposed adjustment or * and * from this agreement.
* Confidential treatment requested.
EXHIBIT A
HMO PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
---------------------------------------------------------------------------------------------------------------
STATE RATE AREA RATE DESIGNATION
---------------------------------------------------------------------------------------------------------------
Alabama * *
---------------------------------------------------------------------------------------------------------------
Alaska * *
---------------------------------------------------------------------------------------------------------------
Arizona * *
---------------------------------------------------------------------------------------------------------------
Arkansas * *
---------------------------------------------------------------------------------------------------------------
California * *
---------------------------------------------------------------------------------------------------------------
Colorado * *
---------------------------------------------------------------------------------------------------------------
Connecticut * *
---------------------------------------------------------------------------------------------------------------
Delaware * *
---------------------------------------------------------------------------------------------------------------
District of Columbia * *
---------------------------------------------------------------------------------------------------------------
Florida * *
---------------------------------------------------------------------------------------------------------------
Georgia * *
---------------------------------------------------------------------------------------------------------------
Hawaii * *
---------------------------------------------------------------------------------------------------------------
Idaho * *
---------------------------------------------------------------------------------------------------------------
Illinois * *
---------------------------------------------------------------------------------------------------------------
Indiana * *
---------------------------------------------------------------------------------------------------------------
Iowa * *
---------------------------------------------------------------------------------------------------------------
Kansas * *
---------------------------------------------------------------------------------------------------------------
Kentucky * *
---------------------------------------------------------------------------------------------------------------
Louisiana * *
---------------------------------------------------------------------------------------------------------------
Maine * *
---------------------------------------------------------------------------------------------------------------
Maryland * *
---------------------------------------------------------------------------------------------------------------
Massachusetts * *
---------------------------------------------------------------------------------------------------------------
Michigan * *
---------------------------------------------------------------------------------------------------------------
Minnesota * *
---------------------------------------------------------------------------------------------------------------
Mississippi * *
---------------------------------------------------------------------------------------------------------------
Missouri * *
---------------------------------------------------------------------------------------------------------------
Montana * *
---------------------------------------------------------------------------------------------------------------
Nebraska * *
---------------------------------------------------------------------------------------------------------------
Nevada * *
---------------------------------------------------------------------------------------------------------------
New Hampshire * *
---------------------------------------------------------------------------------------------------------------
New Jersey * *
---------------------------------------------------------------------------------------------------------------
New Mexico * *
---------------------------------------------------------------------------------------------------------------
New York * *
---------------------------------------------------------------------------------------------------------------
North Carolina * *
---------------------------------------------------------------------------------------------------------------
North Dakota * *
---------------------------------------------------------------------------------------------------------------
Ohio * *
---------------------------------------------------------------------------------------------------------------
Oklahoma * *
---------------------------------------------------------------------------------------------------------------
Oregon * *
---------------------------------------------------------------------------------------------------------------
Pennsylvania * *
---------------------------------------------------------------------------------------------------------------
Rhode Island * *
---------------------------------------------------------------------------------------------------------------
South Carolina * *
---------------------------------------------------------------------------------------------------------------
South Dakota * *
---------------------------------------------------------------------------------------------------------------
Tennessee * *
---------------------------------------------------------------------------------------------------------------
Texas * *
---------------------------------------------------------------------------------------------------------------
Utah * *
---------------------------------------------------------------------------------------------------------------
Vermont * *
---------------------------------------------------------------------------------------------------------------
Virginia * *
---------------------------------------------------------------------------------------------------------------
Washington * *
---------------------------------------------------------------------------------------------------------------
West Virginia * *
---------------------------------------------------------------------------------------------------------------
Wisconsin * *
---------------------------------------------------------------------------------------------------------------
Wyoming * *
---------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31, 2007
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have both Visit and Hourly rates.
Notes 1, 2, 3, 4, 5 and 6 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
------------------------------------------------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
HOME HEALTH AIDE * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
LVN/LPN - HIGH TECH * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH INFUSION * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH OTHER * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have Visit only rates.
Notes 1, 3, 4, 5, 7 and 8 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
------------------------------------------------------------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
DIETITIAN * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
MATERNAL CHILD HEALTH * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHLEBOTOMIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PSYCHIATRIC NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
REHABILITATION NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RESPIRATORY THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
SPEECH THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service has Hourly only rates.
-------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
------------------------------------------------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service is priced on a Per Diem basis.
-------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Per Diem Per Diem Per Diem
------------------------------------------------------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
------------------------------------------------------------------------------------------------------------------------------------
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment.
Use requires special coordination.
9. There shall be a ceiling for annual inflation increases in Home Health
Services of *.
* Confidential treatment requested.
HOME INFUSION RATES
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31, 2007
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies
-------------------------------------------------------------------------------------------------------------------
Primary or Primary or Primary or
Multiple Therapy Multiple Therapy Multiple Therapy
Per Diem Dispensing Fee Drug Discount off AWP
-------------------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
-------------------------------------------------------------------------------------------------------------------
Biological Response Modifiers * *
-------------------------------------------------------------------------------------------------------------------
Cardiac (Inotropic) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chelation Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chemotherapy * *
-------------------------------------------------------------------------------------------------------------------
Enteral Therapy * *
-------------------------------------------------------------------------------------------------------------------
Enzyme Therapy * *
-------------------------------------------------------------------------------------------------------------------
Growth Hormone * *
-------------------------------------------------------------------------------------------------------------------
IV Immune Globulin * *
-------------------------------------------------------------------------------------------------------------------
Other Injectable Therapies * *
-------------------------------------------------------------------------------------------------------------------
Other Infusion Therapies * *
-------------------------------------------------------------------------------------------------------------------
Pain Management Therapy * *
-------------------------------------------------------------------------------------------------------------------
Steroid Therapy * *
-------------------------------------------------------------------------------------------------------------------
Thrombolytic (Anticoagulation) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Synagis * *
-------------------------------------------------------------------------------------------------------------------
Remodulin Therapy * *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP, and there IS a price difference between
primary and multiple anti-infective therapies
-------------------------------------------------------------------------------------------------------------------
Per Diem Drug Discount Off AWP
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Multiple Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rate EXCLUDES drugs. Drugs are
priced per vial, and there is NO price difference between primary and multiple
anti-infective therapies
--------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem Cost of Drug
-------------------------------------------------------------------------------------------------------------------
Flolan Therapy *
-------------------------------------------------------------------------------------------------------------------
Flolan 0.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan 1.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan diluent vial *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rates INCLUDE drugs, and there is NO
price difference between primary and multiple therapies
--------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem
-------------------------------------------------------------------------------------------------------------------
Enteral Therapy *
-------------------------------------------------------------------------------------------------------------------
Hydration Therapy *
-------------------------------------------------------------------------------------------------------------------
Total Parenteral Nutrition *
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will apply.
7. There shall be a ceiling for annual inflation increases in Home Infusion
Therapy of*.
8. There shall be a ceiling for annual inflation increases in Medications
under *.
9. All Medications are subject to MAC pricing, where applicable.
-------------------------------------------------------------------------------------------------------------------
The following are for the stated item ONLY. Unless otherwise noted, nursing, supplies, etc. are NOT included.
-------------------------------------------------------------------------------------------------------------------
Blood Transfusion per Unit (Tubing, Filters) *
-------------------------------------------------------------------------------------------------------------------
Catheter Care Per Diem *
-------------------------------------------------------------------------------------------------------------------
Midline Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
PICC Line Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
Blood Product *
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-------------------------------------------------------------------------------------------------------------------
Novoseven 1200MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
-------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
-------------------------------------------------------------------------------------------------------------------
Alphanine *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Other)
-------------------------------------------------------------------------------------------------------------------
Konyne - 80 *
-------------------------------------------------------------------------------------------------------------------
Proplex T *
-------------------------------------------------------------------------------------------------------------------
Bebulin *
-------------------------------------------------------------------------------------------------------------------
Profilnine SD *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Anti-Inhibitor Complex
-------------------------------------------------------------------------------------------------------------------
Autoplex-T *
-------------------------------------------------------------------------------------------------------------------
Feiba-VH *
-------------------------------------------------------------------------------------------------------------------
Hyate-C *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
HEMOSTATIC AGENTS
-------------------------------------------------------------------------------------------------------------------
DDAVP - 10ml vial *
-------------------------------------------------------------------------------------------------------------------
Stimate - 2.5xx xxxx *
-------------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-------------------------------------------------------------------------------------------------------------------
Novoseven 1200MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
-------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
-------------------------------------------------------------------------------------------------------------------
Alphanine *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Other)
-------------------------------------------------------------------------------------------------------------------
Konyne - 80 *
-------------------------------------------------------------------------------------------------------------------
Proplex T *
-------------------------------------------------------------------------------------------------------------------
Bebulin *
-------------------------------------------------------------------------------------------------------------------
Profilnine SD *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Anti-Inhibitor Complex
-------------------------------------------------------------------------------------------------------------------
Autoplex-T *
-------------------------------------------------------------------------------------------------------------------
Feiba-VH *
-------------------------------------------------------------------------------------------------------------------
Hyate-C *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
HEMOSTATIC AGENTS
-------------------------------------------------------------------------------------------------------------------
DDAVP - 10ml vial *
-------------------------------------------------------------------------------------------------------------------
Stimate - 2.5xx xxxx *
-------------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
------------------------------------------------------------------------------------------------------------------------------------
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31, 2009
------------------------------------------------------------------------------------------------------------------------------------
CAT TYPE HCPCS CHC CareCentrix DESCRIPTION PURCHASE RENTAL DAILY
CODE CODE Code PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
HME A4230 A4230 Infusion set for external insulin pump, non-needle *
cannula Type
------------------------------------------------------------------------------------------------------------------------------------
HME A4231 A4231 Infusion set for external insulin pump, needle type *
------------------------------------------------------------------------------------------------------------------------------------
HME A4232 A4232 Reservoir/Syringe with needle for external insulin pump *
------------------------------------------------------------------------------------------------------------------------------------
HME A4632 A4632 Replacement battery for external insulin pump, any *
type, each
------------------------------------------------------------------------------------------------------------------------------------
HME A5119 A5119 Skin Barrier, wipes, box per 50 *
------------------------------------------------------------------------------------------------------------------------------------
HME A6257 A6257 Transparent film/ dressing *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, *
SPINAL APPLICATIONS
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOFIX
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOLOGIC
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
------------------------------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances:
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 2731 SHIPPING AND HANDLING FEES *
------------------------------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment:
------------------------------------------------------------------------------------------------------------------------------------
RESP EQUIP E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF *
SKILL OF A TECH
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
------------------------------------------------------------------------------------------------------------------------------------
NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception
supplies will be billed at *.
3. If item is rented, rates include repair and maintenance costs.
* Confidential treatment requested.
EXHIBIT A
PPO & INDEMNITY PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
---------------------------------------------------------------------------------------------------------------
STATE RATE AREA RATE DESIGNATION
---------------------------------------------------------------------------------------------------------------
Alabama * *
---------------------------------------------------------------------------------------------------------------
Alaska * *
---------------------------------------------------------------------------------------------------------------
Arizona * *
---------------------------------------------------------------------------------------------------------------
Arkansas * *
---------------------------------------------------------------------------------------------------------------
California * *
---------------------------------------------------------------------------------------------------------------
Colorado * *
---------------------------------------------------------------------------------------------------------------
Connecticut * *
---------------------------------------------------------------------------------------------------------------
Delaware * *
---------------------------------------------------------------------------------------------------------------
District of Columbia * *
---------------------------------------------------------------------------------------------------------------
Florida * *
---------------------------------------------------------------------------------------------------------------
Georgia * *
---------------------------------------------------------------------------------------------------------------
Hawaii * *
---------------------------------------------------------------------------------------------------------------
Idaho * *
---------------------------------------------------------------------------------------------------------------
Illinois * *
---------------------------------------------------------------------------------------------------------------
Indiana * *
---------------------------------------------------------------------------------------------------------------
Iowa * *
---------------------------------------------------------------------------------------------------------------
Kansas * *
---------------------------------------------------------------------------------------------------------------
Kentucky * *
---------------------------------------------------------------------------------------------------------------
Louisiana * *
---------------------------------------------------------------------------------------------------------------
Maine * *
---------------------------------------------------------------------------------------------------------------
Maryland * *
---------------------------------------------------------------------------------------------------------------
Massachusetts * *
---------------------------------------------------------------------------------------------------------------
Michigan * *
---------------------------------------------------------------------------------------------------------------
Minnesota * *
---------------------------------------------------------------------------------------------------------------
Mississippi * *
---------------------------------------------------------------------------------------------------------------
Missouri * *
---------------------------------------------------------------------------------------------------------------
Montana * *
---------------------------------------------------------------------------------------------------------------
Nebraska * *
---------------------------------------------------------------------------------------------------------------
Nevada * *
---------------------------------------------------------------------------------------------------------------
New Hampshire * *
---------------------------------------------------------------------------------------------------------------
New Jersey * *
---------------------------------------------------------------------------------------------------------------
New Mexico * *
---------------------------------------------------------------------------------------------------------------
New York * *
---------------------------------------------------------------------------------------------------------------
North Carolina * *
---------------------------------------------------------------------------------------------------------------
North Dakota * *
---------------------------------------------------------------------------------------------------------------
Ohio * *
---------------------------------------------------------------------------------------------------------------
Oklahoma * *
---------------------------------------------------------------------------------------------------------------
Oregon * *
---------------------------------------------------------------------------------------------------------------
Pennsylvania * *
---------------------------------------------------------------------------------------------------------------
Rhode Island * *
---------------------------------------------------------------------------------------------------------------
South Carolina * *
---------------------------------------------------------------------------------------------------------------
South Dakota * *
---------------------------------------------------------------------------------------------------------------
Tennessee * *
---------------------------------------------------------------------------------------------------------------
Texas * *
---------------------------------------------------------------------------------------------------------------
Utah * *
---------------------------------------------------------------------------------------------------------------
Vermont * *
---------------------------------------------------------------------------------------------------------------
Virginia * *
---------------------------------------------------------------------------------------------------------------
Washington * *
---------------------------------------------------------------------------------------------------------------
West Virginia * *
---------------------------------------------------------------------------------------------------------------
Wisconsin * *
---------------------------------------------------------------------------------------------------------------
Wyoming * *
---------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have both Visit and Hourly rates.
-------------------------------------------------------------------------------
Notes 1, 2, 3, 4, 5 and 6 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
------------------------------------------------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
HOME HEALTH AIDE * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
LVN/LPN - HIGH TECH * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC LVN/LPN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH INFUSION * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH OTHER * * * * * *
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have Visit only rates.
Notes 1, 3, 4, 5, 7 and 8 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
-------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
DIETITIAN * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
MATERNAL CHILD HEALTH * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHLEBOTOMIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
PSYCHIATRIC NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
REHABILITATION NURSE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RESPIRATORY THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
SPEECH THERAPIST * N/A * N/A * N/A
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service has Hourly only rates.
-------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
------------------------------------------------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
------------------------------------------------------------------------------------------------------------------------------------
------------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service is priced on a Per Diem basis.
-------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
-------------------------------------------------------------------------------
Per Diem Per Diem Per Diem
------------------------------------------------------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
------------------------------------------------------------------------------------------------------------------------------------
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume
specialty certification which is not readily available in the home care
environment. Use requires special coordination.
9. There shall be a ceiling for annual inflation increases in Home Health
Services of*.
* Confidential treatment requested.
HOME INFUSION RATES
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
-------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP (if applicable), and there is NO price
difference between primary and multiple therapies
-------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Primary or Primary or Primary or
Multiple Therapy Multiple Therapy Multiple Therapy
Per Diem Dispensing Fee Drug Discount off AWP
-------------------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
-------------------------------------------------------------------------------------------------------------------
Biological Response Modifiers * *
-------------------------------------------------------------------------------------------------------------------
Cardiac (Inotropic) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chelation Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chemotherapy * *
-------------------------------------------------------------------------------------------------------------------
Enteral Therapy * *
-------------------------------------------------------------------------------------------------------------------
Enzyme Therapy * *
-------------------------------------------------------------------------------------------------------------------
Growth Hormone * *
-------------------------------------------------------------------------------------------------------------------
IV Immune Globulin * *
-------------------------------------------------------------------------------------------------------------------
Other Injectable Therapies * *
-------------------------------------------------------------------------------------------------------------------
Other Infusion Therapies * *
-------------------------------------------------------------------------------------------------------------------
Pain Management Therapy * *
-------------------------------------------------------------------------------------------------------------------
Steroid Therapy * *
-------------------------------------------------------------------------------------------------------------------
Thrombolytic (Anticoagulation) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Synagis * *
-------------------------------------------------------------------------------------------------------------------
Remodulin Therapy * *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are
priced as a percentage discount off AWP, and there IS a price difference between
primary and multiple anti-infective therapies
--------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Per Diem Drug Discount Off AWP
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Multiple Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rate EXCLUDES drugs. Drugs are
priced per vial, and there is NO price difference between primary and multiple
anti-infective therapies
--------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem Cost of Drug
-------------------------------------------------------------------------------------------------------------------
Flolan Therapy *
-------------------------------------------------------------------------------------------------------------------
Flolan 0.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan 1.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan diluent vial *
-------------------------------------------------------------------------------------------------------------------
--------------------------------------------------------------------------------
The following Home Infusion Therapy service rates INCLUDE drugs, and there is NO
price difference between primary and multiple therapies
--------------------------------------------------------------------------------
----------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem
----------------------------------------------------------------------------------------------------------
Enteral Therapy *
----------------------------------------------------------------------------------------------------------
Hydration Therapy *
----------------------------------------------------------------------------------------------------------
Total Parenteral Nutrition *
----------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will apply.
7. There shall be a ceiling for annual inflation increases in Home Infusion
Therapy of *.
8. There shall be a ceiling for annual inflation increases in Medications
under *.
9. All Medications are subject to MAC pricing, where applicable
* Confidential treatment requested.
-------------------------------------------------------------------------------------------------------------------
The following are for the stated item ONLY. Unless otherwise noted, nursing, supplies, etc. are NOT included.
-------------------------------------------------------------------------------------------------------------------
Blood Transfusion per Unit (Tubing, Filters) *
-------------------------------------------------------------------------------------------------------------------
Catheter Care Per Diem *
-------------------------------------------------------------------------------------------------------------------
Midline Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
PICC Line Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
Blood Product *
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-------------------------------------------------------------------------------------------------------------------
Novoseven 1200MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
-------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
-------------------------------------------------------------------------------------------------------------------
Alphanine *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Other)
-------------------------------------------------------------------------------------------------------------------
Konyne - 80 *
-------------------------------------------------------------------------------------------------------------------
Proplex T *
-------------------------------------------------------------------------------------------------------------------
Bebulin *
-------------------------------------------------------------------------------------------------------------------
Profilnine SD *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Anti-Inhibitor Complex
-------------------------------------------------------------------------------------------------------------------
Autoplex-T *
-------------------------------------------------------------------------------------------------------------------
Feiba-VH *
-------------------------------------------------------------------------------------------------------------------
Hyate-C *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
HEMOSTATIC AGENTS
-------------------------------------------------------------------------------------------------------------------
DDAVP - 10ml vial *
-------------------------------------------------------------------------------------------------------------------
Stimate - 2.5xx xxxx *
-------------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-------------------------------------------------------------------------------------------------------------------
Novoseven 1200MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
-------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
-------------------------------------------------------------------------------------------------------------------
Alphanine *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Other)
-------------------------------------------------------------------------------------------------------------------
Konyne - 80 *
-------------------------------------------------------------------------------------------------------------------
Proplex T *
-------------------------------------------------------------------------------------------------------------------
Bebulin *
-------------------------------------------------------------------------------------------------------------------
Profilnine SD *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Anti-Inhibitor Complex
-------------------------------------------------------------------------------------------------------------------
Autoplex-T *
-------------------------------------------------------------------------------------------------------------------
Feiba-VH *
-------------------------------------------------------------------------------------------------------------------
Hyate-C *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
HEMOSTATIC AGENTS
-------------------------------------------------------------------------------------------------------------------
DDAVP - 10ml vial *
-------------------------------------------------------------------------------------------------------------------
Stimate - 2.5xx xxxx *
-------------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit;
24-hour on-call clinical support; home infusion monitoring system; product
delivery nationwide; patient training, education, and evaluation
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2009
------------------------------------------------------------------------------------------------------------------------------------
CAT TYPE HCPCS CHC CareCentrix DESCRIPTION PURCHASE RENTAL DAILY
CODE CODE Code PRICE PRICE PRICE
------------------------------------------------------------------------------------------------------------------------------------
HME A4230 A4230 Infusion set for external insulin pump, non-needle *
cannula Type
------------------------------------------------------------------------------------------------------------------------------------
HME A4231 A4231 Infusion set for external insulin pump, needle type *
------------------------------------------------------------------------------------------------------------------------------------
HME A4232 A4232 Reservoir/Syringe with needle for external insulin pump *
------------------------------------------------------------------------------------------------------------------------------------
HME A4632 A4632 Replacement battery for external insulin pump, any type, *
each
------------------------------------------------------------------------------------------------------------------------------------
HME A5119 A5119 Skin Barrier, wipes, box per 50 *
------------------------------------------------------------------------------------------------------------------------------------
HME A6257 A6257 Transparent film/ dressing *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
------------------------------------------------------------------------------------------------------------------------------------
HME INSULPP E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
------------------------------------------------------------------------------------------------------------------------------------
HME OTHER E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL *
APPLICATIONS
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOFIX
------------------------------------------------------------------------------------------------------------------------------------
HME STIM_BO E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOLOGIC
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
------------------------------------------------------------------------------------------------------------------------------------
HME WDSUCT K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
------------------------------------------------------------------------------------------------------------------------------------
The following may be charged under extraordinary circumstances:
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 2731 SHIPPING AND HANDLING FEES *
------------------------------------------------------------------------------------------------------------------------------------
The following may be charged if over and above routine on rental equipment:
------------------------------------------------------------------------------------------------------------------------------------
RESP EQUIP E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF *
A TECH
------------------------------------------------------------------------------------------------------------------------------------
HME SUP E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
------------------------------------------------------------------------------------------------------------------------------------
NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception
supplies will be billed at *.
3. If item is rented, rates include repair and maintenance costs.
* Confidential treatment requested.
EXHIBIT A
GATEKEEPER PROGRAM ATTACHMENT - CAPITATION
SCHEDULE OF CAPITATION RATES
CAPITATION RATES EFFECTIVE 2/1/06 - 1/31/07
These are the capitation rates that apply to services rendered to Patient Panel
Participants enrolled in Gatekeeper Programs. An "Gatekeeper Program" means (i)
a product that includes fully insured Standard HMO, Point of Service, or
Gatekkeper PPO benefits and which is underwritten by a licensed insurance
company based on an experience rating methodology, or (ii) a self funded product
which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This
definition includes, but is not limited to, Participants covered under Flexcare
plans insured/administered by Connecticut Life Insurance Company.
----------------------------------------------------------------------------------------------------------
Gentiva
Homehealth
Infusion and
DME/HME
Capitation
Rate PMPM
----------------------------------------------------------------------------------------------------------
All Commercial HMO Capitated Affiliates *
----------------------------------------------------------------------------------------------------------
Capitation Rate Compensation Terms
The following rates are established for the provision of Home Care Services
rendered to Program Participants covered under the HMO and Gatekeeper plans:
February 1, 2006 - January 31, 2007 $*per member per month
February 1, 2007 - January 31, 2008 $* per member per month
February 1, 2008 - January 31, 2009 $* per member per month
The capitation rate listed above will be allocated between HMO and Gatekeeper
Program participants in accordance with established business practices. On or
about December 1 of each year, the parties shall reconcile the allocation and
settle any payment difference no later than December 31 of each calendar year.
If an outlier calculation for * demonstrates a patient per thousand (PPK)
increase in excess of *, (* ppk), then MCA reserves the right to propose an *
pmpm outlier adjustment. CIGNA may elect to accept this adjustment or * from
this agreement.
* Confidential treatment requested.
EXHIBIT A
GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE
REIMBURSEMENT FOR OTHER SERVICES
RATE AREA DESIGNATIONS:
---------------------------------------------------------------------------------------------------------------
STATE RATE AREA RATE DESIGNATION
---------------------------------------------------------------------------------------------------------------
Alabama * *
---------------------------------------------------------------------------------------------------------------
Alaska * *
---------------------------------------------------------------------------------------------------------------
Arizona * *
---------------------------------------------------------------------------------------------------------------
Arkansas * *
---------------------------------------------------------------------------------------------------------------
California * *
---------------------------------------------------------------------------------------------------------------
Colorado * *
---------------------------------------------------------------------------------------------------------------
Connecticut * *
---------------------------------------------------------------------------------------------------------------
Delaware * *
---------------------------------------------------------------------------------------------------------------
District of Columbia * *
---------------------------------------------------------------------------------------------------------------
Florida * *
---------------------------------------------------------------------------------------------------------------
Georgia * *
---------------------------------------------------------------------------------------------------------------
Hawaii * *
---------------------------------------------------------------------------------------------------------------
Idaho * *
---------------------------------------------------------------------------------------------------------------
Illinois * *
---------------------------------------------------------------------------------------------------------------
Indiana * *
---------------------------------------------------------------------------------------------------------------
Iowa * *
---------------------------------------------------------------------------------------------------------------
Kansas * *
---------------------------------------------------------------------------------------------------------------
Kentucky * *
---------------------------------------------------------------------------------------------------------------
Louisiana * *
---------------------------------------------------------------------------------------------------------------
Maine * *
---------------------------------------------------------------------------------------------------------------
Maryland * *
---------------------------------------------------------------------------------------------------------------
Massachusetts * *
---------------------------------------------------------------------------------------------------------------
Michigan * *
---------------------------------------------------------------------------------------------------------------
Minnesota * *
---------------------------------------------------------------------------------------------------------------
Mississippi * *
---------------------------------------------------------------------------------------------------------------
Missouri * *
---------------------------------------------------------------------------------------------------------------
Montana * *
---------------------------------------------------------------------------------------------------------------
Nebraska * *
---------------------------------------------------------------------------------------------------------------
Nevada * *
---------------------------------------------------------------------------------------------------------------
New Hampshire * *
---------------------------------------------------------------------------------------------------------------
New Jersey * *
---------------------------------------------------------------------------------------------------------------
New Mexico * *
---------------------------------------------------------------------------------------------------------------
New York * *
---------------------------------------------------------------------------------------------------------------
North Carolina * *
---------------------------------------------------------------------------------------------------------------
North Dakota * *
---------------------------------------------------------------------------------------------------------------
Ohio * *
---------------------------------------------------------------------------------------------------------------
Oklahoma * *
---------------------------------------------------------------------------------------------------------------
Oregon * *
---------------------------------------------------------------------------------------------------------------
Pennsylvania * *
---------------------------------------------------------------------------------------------------------------
Rhode Island * *
---------------------------------------------------------------------------------------------------------------
South Carolina * *
---------------------------------------------------------------------------------------------------------------
South Dakota * *
---------------------------------------------------------------------------------------------------------------
Tennessee * *
---------------------------------------------------------------------------------------------------------------
Texas * *
---------------------------------------------------------------------------------------------------------------
Utah * *
---------------------------------------------------------------------------------------------------------------
Vermont * *
---------------------------------------------------------------------------------------------------------------
Virginia * *
---------------------------------------------------------------------------------------------------------------
Washington * *
---------------------------------------------------------------------------------------------------------------
West Virginia * *
---------------------------------------------------------------------------------------------------------------
Wisconsin * *
---------------------------------------------------------------------------------------------------------------
Wyoming * *
---------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
-----------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have both Visit and Hourly rates.
------------------------------------------------------------------------------
Notes 1, 2, 3, 4, 5 and 6 apply Xxxx 0 Xxxx 0 Xxxx 0
------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
-----------------------------------------------------------------------------------------------------------------------------------
CERTIFIED NURSES AIDE * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
HOME HEALTH AIDE * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
LVN/LPN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
LVN/LPN - HIGH TECH * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH LVN/LPN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC HIGH TECH RN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC LVN/LPN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
PEDIATRIC RN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
RN * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH INFUSION * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
RN HIGH TECH OTHER * * * * * *
-----------------------------------------------------------------------------------------------------------------------------------
-----------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Services have Visit only rates.
------------------------------------------------------------------------------
Notes 1, 3, 4, 5, 7 and 8 apply Xxxx 0 Xxxx 0 Xxxx 0
------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
-----------------------------------------------------------------------------------------------------------------------------------
DIABETIC NURSE * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
DIETITIAN * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
ENTEROSTOMAL THERAPIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
MATERNAL CHILD HEALTH * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
MEDICAL SOCIAL WORKER * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
OCCUPATIONAL THERAPIST ASSISTANT * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
PHLEBOTOMIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
PHOTOTHERAPY PACKAGE SERVICE * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
PHYSICAL THERAPIST ASSISTANT * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
PSYCHIATRIC NURSE * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
REHABILITATION NURSE * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
RESPIRATORY THERAPIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
RN ASSESSMENT, INITIAL * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
RN SKILLED NURSING VISIT-EXTENSIVE * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
SPEECH THERAPIST * N/A * N/A * N/A
-----------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service has Hourly only rates.
------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
------------------------------------------------------------------------------
Visit Hour Visit Hour Visit Hour
-----------------------------------------------------------------------------------------------------------------------------------
HOMEMAKER N/A * N/A * N/A *
-----------------------------------------------------------------------------------------------------------------------------------
The following Traditional Home Health Service is priced on a Per Diem basis.
------------------------------------------------------------------------------
Notes 3, 4 and 5 apply Xxxx 0 Xxxx 0 Xxxx 0
------------------------------------------------------------------------------
Per Diem Per Diem Per Diem
-----------------------------------------------------------------------------------------------------------------------------------
COMPANION/LIVE IN * * *
-----------------------------------------------------------------------------------------------------------------------------------
NOTES:
1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL
CHILD HEALTH VISITS, which have no maximum duration).
2. Hourly rate for visits exceeding two (2) hours in duration, starting with
hour 3.
3. CIGNA does not reimburse for travel time, weekend, holiday or evening
differentials.
4. Above prices have no exclusions.
5. All services not listed above will be billed at * until rates are mutually
established and become part of the fee schedule.
6. RN High Tech Infusion visit and hourly utilization/costs to be reported
with HIT.
7. Respiratory Therapist visit utilization/costs to be reported with HME/RT.
8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty
certification which is not readily available in the home care environment.
Use requires special coordination.
9. There shall be a ceiling for annual inflation increases in Home Health
Services of*.
* Confidential treatment requested.
HOME INFUSION RATES
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
-------------------------------------------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP
(if applicable), and there is NO price difference between primary and multiple therapies
-------------------------------------------------------------------------------------------------------------------
Primary or Primary or Primary or
Multiple Therapy Multiple Therapy Multiple Therapy
Per Diem Dispensing Fee Drug Discount off AWP
-------------------------------------------------------------------------------------------------------------------
Ancillary Drugs * *
-------------------------------------------------------------------------------------------------------------------
Biological Response Modifiers * *
-------------------------------------------------------------------------------------------------------------------
Cardiac (Inotropic) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chelation Therapy * *
-------------------------------------------------------------------------------------------------------------------
Chemotherapy * *
-------------------------------------------------------------------------------------------------------------------
Enteral Therapy * *
-------------------------------------------------------------------------------------------------------------------
Enzyme Therapy * *
-------------------------------------------------------------------------------------------------------------------
Growth Hormone * *
-------------------------------------------------------------------------------------------------------------------
IV Immune Globulin * *
-------------------------------------------------------------------------------------------------------------------
Other Injectable Therapies * *
-------------------------------------------------------------------------------------------------------------------
Other Infusion Therapies * *
-------------------------------------------------------------------------------------------------------------------
Pain Management Therapy * *
-------------------------------------------------------------------------------------------------------------------
Steroid Therapy * *
-------------------------------------------------------------------------------------------------------------------
Thrombolytic (Anticoagulation) Therapy * *
-------------------------------------------------------------------------------------------------------------------
Synagis * *
-------------------------------------------------------------------------------------------------------------------
Remodulin Therapy * *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP,
and there IS a price difference between primary and multiple anti-infective therapies
-------------------------------------------------------------------------------------------------------------------
Per Diem Drug Discount Off AWP
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Primary Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
Anti-Infectives - Multiple Anti-Infective * *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
The following Home Infusion Therapy service rate EXCLUDES drugs. Drugs are priced per vial, and there is NO price
difference between primary and multiple anti-infective therapies
-------------------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem Cost of Drug
-------------------------------------------------------------------------------------------------------------------
Flolan Therapy *
-------------------------------------------------------------------------------------------------------------------
Flolan 0.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan 1.5 mg vial *
-------------------------------------------------------------------------------------------------------------------
Flolan diluent vial *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
The following Home Infusion Therapy service rates INCLUDE drugs, and there is NO price difference between primary
and multiple therapies
-------------------------------------------------------------------------------------------------------------------
Primary or
Multiple Therapy
Per Diem
-------------------------------------------------------------------------------------------------------------------
Enteral Therapy *
-------------------------------------------------------------------------------------------------------------------
Hydration Therapy *
-------------------------------------------------------------------------------------------------------------------
Total Parenteral Nutrition *
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES
NOTES:
1. Per Diems EXCLUDING drugs include all costs related to the therapy except
the cost of drugs, including but not limited to facility overhead,
supplies, delivery, professional labor including compounding and
monitoring, all nursing required, maintenance of specialized catheters,
equipment/patient supplies, disposables, pumps, general and administrative
expenses, etc.
2. Per Diems INCLUDING drugs include ALL costs - including but not limited to
cost of drugs, facility overhead, supplies, delivery, professional labor
including compounding and monitoring, all nursing required, maintenance of
specialized catheters, equipment/patient supplies, disposables, pumps,
general and administrative expenses, etc.
3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the
home infusion provider.
4. "PER DIEM" costs are the same for primary or multiple treatments for all
drug categories, except ANTI-INFECTIVES.
5. The per diem rate shall only be charged for those days the Participant
receives medication.
6. For home infusion pharmaceuticals not listed on fee schedule, * will apply.
7. There shall be a ceiling for annual inflation increases in Home Infusion
Therapy of *.
8. There shall be a ceiling for annual inflation increases in Medications
under *.
9. All Medications are subject to MAC pricing, where applicable
-------------------------------------------------------------------------------------------------------------------
The following are for the stated item ONLY. Unless otherwise noted, nursing, supplies, etc. are NOT included.
-------------------------------------------------------------------------------------------------------------------
Blood Transfusion per Unit (Tubing, Filters) *
-------------------------------------------------------------------------------------------------------------------
Catheter Care Per Diem *
-------------------------------------------------------------------------------------------------------------------
Midline Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
PICC Line Insertion (Catheter & Supplies) *
-------------------------------------------------------------------------------------------------------------------
Blood Product *
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-----------------------------------------------------------------
Novoseven 1200MCG Vial *
-----------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
-------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
-------------------------------------------------------------------------------------------------------------------
Alphanine *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Other)
-------------------------------------------------------------------------------------------------------------------
Konyne - 80 *
-------------------------------------------------------------------------------------------------------------------
Proplex T *
-------------------------------------------------------------------------------------------------------------------
Bebulin *
-------------------------------------------------------------------------------------------------------------------
Profilnine SD *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Anti-Inhibitor Complex
-------------------------------------------------------------------------------------------------------------------
Autoplex-T *
-------------------------------------------------------------------------------------------------------------------
Feiba-VH *
-------------------------------------------------------------------------------------------------------------------
Hyate-C *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
HEMOSTATIC AGENTS
-------------------------------------------------------------------------------------------------------------------
DDAVP - 10ml vial *
-------------------------------------------------------------------------------------------------------------------
Stimate - 2.5xx xxxx *
-------------------------------------------------------------------------------------------------------------------
Above rates include all necessary ancillary supplies and waste disposal unit; 24-hour on-call clinical support;
home infusion monitoring system; product delivery nationwide; patient training, education, and evaluation
-------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
-------------------------------------------------------------------------------------------------------------------
Factor Concentrates
-------------------------------------------------------------------------------------------------------------------
Vial price Unit Price
-------------------------------------------------------------------------------------------------------------------
Factor VII
-------------------------------------------------------------------------------------------------------------------
Novoseven 1200MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven 4800MCG Vial *
-------------------------------------------------------------------------------------------------------------------
Novoseven in 1200MCG or 4800MCG QTY *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Recombinant)
-------------------------------------------------------------------------------------------------------------------
Recombinate *
-------------------------------------------------------------------------------------------------------------------
Kogenate or Helixate *
-------------------------------------------------------------------------------------------------------------------
Bioclate *
-------------------------------------------------------------------------------------------------------------------
Helixate FS *
-------------------------------------------------------------------------------------------------------------------
Kogenate FS *
------------------------------------------------------------------------------------------------------------------
Refacto *
-------------------------------------------------------------------------------------------------------------------
Advate *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Monoclonal)
-------------------------------------------------------------------------------------------------------------------
Hemofil-M or A. R. C. Method M *
-------------------------------------------------------------------------------------------------------------------
Monoclate P *
-------------------------------------------------------------------------------------------------------------------
Monarc-M *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor VIII (Other)
-------------------------------------------------------------------------------------------------------------------
Koate *
-------------------------------------------------------------------------------------------------------------------
Humate *
-------------------------------------------------------------------------------------------------------------------
Alphanate SDHT *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Recombinant)
-------------------------------------------------------------------------------------------------------------------
BeneFix *
-------------------------------------------------------------------------------------------------------------------
-------------------------------------------------------------------------------------------------------------------
Factor IX (Monoclonal/High Purity)
-------------------------------------------------------------------------------------------------------------------
Mononine *
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Alphanine *
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Factor IX (Other)
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Konyne - 80 *
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Proplex T *
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Bebulin *
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Profilnine SD *
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Anti-Inhibitor Complex
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Autoplex-T *
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Feiba-VH *
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Hyate-C *
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HEMOSTATIC AGENTS
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DDAVP - 10ml vial *
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Stimate - 2.5xx xxxx *
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Above rates include all necessary ancillary supplies and waste disposal unit; 24-hour on-call clinical support;
home infusion monitoring system; product delivery nationwide; patient training, education, and evaluation
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* Confidential treatment requested.
DME / HME RESPIRATORY RATES:
RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2009
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CAT TYPE HCPCS CHC CareCentrix DESCRIPTION PURCHASE RENTAL DAILY
CODE CODE Code PRICE PRICE PRICE
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HME A4230 A4230 Infusion set for external insulin pump, non-needle *
cannula Type
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HME A4231 A4231 Infusion set for external insulin pump, needle type *
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HME A4232 A4232 Reservoir/Syringe with needle for external insulin pump *
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HME A4632 A4632 Replacement battery for external insulin pump, any type, *
each
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HME A5119 A5119 Skin Barrier, wipes, box per 50 *
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HME A6257 A6257 Transparent film/ dressing *
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HME INSULPP E0784 E0784 2158 PUMP (E0784), EXT AMBULATORY INFUSION, MINIMED, INSULIN *
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HME INSULPP E0784 E0784 6771 PUMP (E0784), INSULIN EXT INFUSION DISETRONICS OR OTHER *
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HME INSULPP E0784 E0784 7704 PUMP, EXT INFUSION, XXXX DIABECARE, INSULIN (E0784) *
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HME INSULPP E0784 E0784 7731 PUMP, EXT INFUSION, ANIMAS, INSULIN (E0784) *
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HME INSULPP E0784 E0784 7773 PUMP (E0784), EXT AMBULATORY INFUSION, DELTEC, INSULIN *
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HME OTHER E0746 DM570 2109 ELECTROMYOGRAPHY (EMG) (E0746), BIOFEEDBACK DEVICE * *
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HME OTHER E0935 E0935 2125 PASSIVE MOTION (E0935) EXERCISE DEVICE *
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HME OTHER E0935 E0935 2857 PASSIVE MOTION (E0935) EXERCISE DEVICE, HAND *
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HME OTHER E0935 E0935 2858 PASSIVE MOTION (E0935) EXERCISE DEVICE, SHOULDER *
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HME OTHER E0935 E0935 2859 PASSIVE MOTION (E0935) EXERCISE DEVICE, ANKLE *
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HME OTHER E0935 E0935 2860 PASSIVE MOTION (E0935) EXERCISE DEVICE, ELBOW *
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HME OTHER E0935 E0935 2861 PASSIVE MOTION (E0935) EXERCISE DEVICE, WRIST *
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HME OTHER E1300 DM570 2062 WHIRLPOOL (E1300), PORT (OVERTUB TYPE) *
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HME OTHER E1310 DM570 2061 WHIRLPOOL (E1399), NON-PORT (BUILT-IN TYPE) *
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HME OTHER E1399 E1399 2327 DURABLE MEDICAL EQUIP (E1399), MISCELLANEOUS *
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HME STIM_BO E0747 DM570 6875 STIMULATOR, OSTEOGENIC, ULTRASOUND *
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HME STIM_BO E0747 DM570 8386 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, EBI *
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HME STIM_BO E0747 DM570 8387 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOFIX *
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HME STIM_BO E0747 DM570 8388 STIMULATOR (E0747), OSTEOGENIC, NON-INVASIVE, ORTHOLOGIC *
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HME STIM_BO E0748 DM570 2124 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL *
APPLICATIONS
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HME STIM_BO E0748 DM570 8389 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, EBI *
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HME STIM_BO E0748 DM570 8390 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOFIX
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HME STIM_BO E0748 DM570 8391 STIMULATOR (E0748), OSTEOGENIC NON-INVASIVE, SPINAL, *
ORTHOLOGIC
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HME WDSUCT K0538 DM570 6873 WOUND SUCTION DEVICE (K0538) *
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HME WDSUCT K0539 DM570 7914 DRESSING SET, FOR WOUND SUCTION DEVICE (K0539) *
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HME WDSUCT K0540 DM570 7915 CANISTER SET, FOR WOUND SUCTION DEVICE (K0540) *
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The following may be charged under extraordinary circumstances:
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HME SUP E1399 E1399 4551 LABOR/SERVICE/SHIPPING CHARGES *
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HME SUP E1399 E1399 2731 SHIPPING AND HANDLING FEES *
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The following may be charged if over and above routine on rental equipment:
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RESP EQUIP E1350 E1350 2382 REPAIR OR NON-ROUTINE (E1350) SERVICE REQUIRING SKILL OF *
A TECH
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HME SUP E1399 E1399 4552 MISCELLANEOUS SUPPLIES * *
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NOTES:
1. Whether rental or purchase, rates include all shipping, labor and set-up.
2. If item is rented, rates include all supplies to enable the equipment to
function effectively with the exception Suction and CPM. Such exception
supplies will be billed at *.
3. If item is rented, rates include repair and maintenance costs.
* Confidential treatment requested.
