Amendment No. 14 to Health Services Agreement between Texas HHSC and Amerigroup Texas, Inc. for CHIP

Contract Categories: Business Finance › Modification Agreements
Summary

This amendment updates the agreement between the Texas Health & Human Services Commission (HHSC) and Amerigroup Texas, Inc. to provide health services under the Children's Health Insurance Program (CHIP). It extends the contract term through August 31, 2006, clarifies payment terms, and sets premium rates for different age groups. The amendment also details requirements for data reporting, delivery supplemental payments, and cost-sharing for CHIP members. Both parties agree to these changes, which are effective September 1, 2005, unless otherwise specified.

Read More Arrow
EX-10.32.8 8 w17973exv10w32w8.txt EX-10.32.8 Exhibit 110.32.8 STATE OF TEXAS HHSC CONTRACT NO. 529-00-139-N COUNTY OF TRAVIS AMENDMENT 14 TO THE AGREEMENT BETWEEN THE HEALTH & HUMAN SERVICES COMMISSION AND AMERIGROUP TEXAS, INC. FOR HEALTH SERVICES TO THE CHILDREN'S HEALTH INSURANCE PROGRAM THIS CONTRACT AMENDMENT (the "Amendment") is entered into between the HEALTH & HUMAN SERVICES COMMISSION ("HHSC"), an administrative agency within the executive department of the State of Texas, and AMERIGROUP TEXAS, INC., ("CONTRACTOR"), a health maintenance organization organized under the laws of the State of Texas, possessing a certificate of authority issued by the Texas Department of Insurance to operate as a health maintenance organization, and having its principal office at 1200 E. COPELAND ROAD, SUITE 200, ARLINGTON, TEXAS. HHSC and CONTRACTOR may be referred to in this Amendment individually as a "Party" and collectively as the "Parties." The Parties hereby agree to amend their original contract, HHSC contract number 529-00-139 (the "Agreement"), as set forth in Article 2 of this Amendment. ARTICLE 1. PURPOSE. SECTION 1.01 AUTHORIZATION. This Amendment is executed by the Parties in accordance with Article 8 of the Agreement. SECTION 1.02 EFFECTIVE DATE OF CHANGES (a) General effective date of changes. Except as specified below, this Amendment is effective SEPTEMBER 1, 2005, and terminates on the Expiration Date of the Agreement, unless extended or terminated sooner by HHSC in accordance with the Agreement. ARTICLE 2. AMENDMENT TO THE OBLIGATIONS OF THE PARTIES. SECTION 2.01 CONFIRMATION OF TERM OF AGREEMENT AND EXPIRATION DATE. (a) In this Amendment, the Parties extend the term of the Agreement through August 31, 2006 (unless extended or terminated sooner by HHSC in accordance with the Agreement) and set forth the time and manner of premium payments for members covered by CONTRACTOR from September 1, 2005, through August 31, 2006. (b) The Parties hereby clarify and confirm that: (1) the term of the Agreement is through August 31, 2006, unless extended or terminated sooner by HHSC in accordance with the Agreement; and Page 1 of 8 (2) the definition of "Expiration Date" in Article 3 of the Agreement is revised to mean "August 31, 2006." SECTION 2.02 MODIFICATION TO ARTICLE 3, DEFINITIONS Article 3, Definitions, is modified by with the addition of a new definition as follows: ""AFFILIATE" means any individual or entity owning or holding more than a five percent (5%) interest in the CONTRACTOR or in which the CONTRACTOR holds more than a five percent (5%) interest; any parent entity; or subsidiary entity of the CONTRACTOR, regardless of the organizational structure of the entity." SECTION 2.03 MODIFICATION TO ARTICLE 10, TERMS AND CONDITIONS OF PAYMENT Section 10.01, Monthly Premium Payments, is modified with the addition of a new subsection (e) as follows: "SECTION 10.01 MONTHLY PREMIUM PAYMENTS. (e) CONTRACTOR will be required to provide in a timely manner financial and statistical information necessary in the capitation rate determination process. Encounter data provided by CONTRACTOR must conform to all HHSC requirements. Encounter data containing non-compliant information, including, but not limited to, inaccurate member identification numbers, inaccurate provider identification numbers, or diagnosis or procedure codes insufficient to adequately describe the diagnosis or medical procedure performed, will not be considered in the CONTRACTOR'S experience for rate-setting purposes. Information or data, including complete and accurate encounter data, as requested by HHSC for rate-setting purposes, must be provided by CONTRACTOR to HHSC: (1) within thirty (30) days of receipt of the letter from HHSC requesting the information or data; and (2) no later than March 31st of each year. SECTION 2.04 MODIFICATION TO ARTICLE 10, TERMS AND CONDITIONS OF PAYMENT Section 10.02. Time and manner of premium payment, is modified with the addition of a new subsection (f), as follows: "SECTION 10.02 TIME AND MANNER OF PREMIUM PAYMENT. (f) For the period beginning September 1, 2005, and ending August 31, 2006, CONTRACTOR will be entitled to a payment in accordance with this subsection (f). CONTRACTOR will be paid based on per member/per month premiums and new and current enrollment figures (including disenrollment adjustments to previous monthly enrollment totals). The Administrative Services Contractor will convey premiums payable information to CONTRACTOR for data reconciliation and to the Management Services Contractor. CONTRACTOR must reconcile the data and report any errors to the Management Services Contractor by the cut-off date of the next month. The Management Services Contractor will pay CONTRACTOR by the first business day following the 14th day of each month. Page 2 of 8 CONTRACTOR must accept payment for premiums by direct deposit into CONTRACTOR'S account. For the period beginning September 1, 2005, and ending August 31, 2006, the premium rates are:
CSA# Under Age 1 Ages 1-5 Ages 6-14 Ages 15-18 - ---- ----------- -------- --------- ---------- CSA2 $378.14 $78.52 $52.11 $101.71 CSA6 $308.48 $64.04 $42.51 $ 83.64
CONTRACTOR does not bill HHSC, the Administrative Services Contractor, other state agencies, or institutions for the monthly premium payment." SECTION 2.05 MODIFICATION TO ARTICLE 10, TERMS AND CONDITIONS OF PAYMENT Section 10.03, Delivery Supplement Payment, is modified as follows: "SECTION 10.03 DELIVERY SUPPLEMENTAL PAYMENT (DSP). HHSC shall pay to CONTRACTOR a one-time-per-pregnancy Delivery Supplemental Payment (DSP) in the amount of $3,000.00 for each live or still-birth delivery. The one-time payment is made regardless of whether there is a single birth or multiple births at the time of delivery. For purposes of this section, a "delivery" is the birth of a live-born infant, regardless of the duration of the pregnancy, or a stillborn (fetal death) infant of 22 weeks or more gestation. CONTRACTOR should make its best effort to report all deliveries to the Administrative Services Contractor within 10 days of the delivery and no later than 45 days from the date of delivery. No DSP will be made for deliveries that are not reported by CONTRACTOR to the Administrative Services Contractor within 120 days from the receipt of claim, or within 60 days from the date of discharge from the hospital for the stay related to the delivery, whichever is later. CONTRACTOR must also submit a monthly DSP report to HHSC that includes the data elements specified by HHSC. The report to HHSC must be submitted in the format specified by HHSC in Appendix E.8 to this Agreement. The report must include only unduplicated deliveries. The report must include only deliveries for which CONTRACTOR has made a payment for the delivery, to either a hospital or other provider. No DSP will be made for deliveries which are not reported by CONTRACTOR to HHSC within 120 days after the date of delivery, or within 60 days from the date of discharge from the hospital for the stay related to the delivery, whichever is later. CONTRACTOR must maintain complete claims and adjudication disposition documentation, including paid and denied amounts for each delivery. CONTRACTOR must submit the documentation to HHSC within five (5) days from the date of a HHSC request for documentation. HHSC reserves the right to audit the claims submitted for DSP to ensure the accuracy of those claims. The DSP will be paid to Page 3 of 8 CONTRACTOR as part of the monthly premium payment after receiving an accurate report from CONTRACTOR." SECTION 2.06 MODIFICATION TO ARTICLE 11, CHIP ELIGIBILITY, ENROLLMENT, DISENROLLMENT, AND COST-SHARING Section 11.06, Cost-Sharing, is modified as follows: CHIP COST SHARING (as of September 1, 2005)
SIX-MONTH ENROLLMENT FEES: CHARGE - -------------------------- ------ At or below 133% of FPL $ 0 133% up to and including 150% of FPL $25 Above 150% up to an including 185% of FPL $35 Above 185% up to and including 200% of FPL $50
CO-PAYS & DEDUCTIBLES (PER VISIT): AT OR BELOW 100% OF FPL CHARGE - ---------------------------------- ------ Office Visit $ 3 ER $ 3 Generic Drug $ 0 Brand Drug $ 3 Co-pay Cap 1.25% (of family's income) Deductible, non-institutional $ 0 Deductible, institutional $ 0 Facility Co-pay, Inpatient $ 10 Facility Co-pay, Outpatient $ 0 101% TO 150% OF FPL Office Visit $ 5 ER $ 5 Generic Drug $ 0 Brand Drug $ 5 Co-pay Cap 1.25% (of family's income) Deductible, non-institutional $ 0 Deductible, institutional $ 0 Facility Co-pay, Inpatient (per admission) $ 25 Facility Co-pay, Outpatient $ 0 151% TO 185% OF FPL. Office Visit $ 7 ER $ 50 Generic Drug $ 5 Brand Drug $ 20 Co-pay Cap 2.5% (of family's income) Deductible, non-institutional $ 0 Deductible, institutional $ 0 Facility Co-pay, Inpatient (per admission) $ 50 Facility Co-pay, Outpatient $ 0 186% TO 200% OF FPL Office Visit $ 10 ER $ 50 Generic Drug $ 5 Brand Drug $ 20
Page 4 of 8 CHIP COST SHARING (as of September 1, 2005) Co-pay Cap 2.5% (of family's income) Deductible, non-institutional $ 0 Deductible, institutional $ 0 Facility Co-pay, Inpatient (per admission) $100 Facility Co-pay, Outpatient $ 0
SECTION 2.07 MODIFICATION TO ARTICLE 12, SCOPE OF CHIP COVERED SERVICES Section 12.03, Value-added Services, is modified as follows: "SECTION 12.03 VALUE ADDED SERVICES. CONTRACTOR must also provide or arrange for the provision of the Value-added services, offered by CONTRACTOR in its proposal. CONTRACTOR must provide these Value-added Services at no additional cost to HHSC. CONTRACTOR must not pass on the cost of the Value-added Services to providers. CONTRACTOR must specify the conditions and specific parameters regarding the delivery of the Value-added Services in CONTRACTOR'S marketing materials and evidence of coverage or member handbook. CONTRACTOR must clearly state to Members any limitations or conditions specific to the Value-added Services. Value-added Services can be added or removed only by written amendment of this Agreement one time per fiscal year to be effective September 1 of the fiscal year, except when services are amended by HHSC during the fiscal year. CONTRACTOR cannot include a Value-added Service in any material distributed to Members or prospective Members until this Agreement has been amended to include that Value-added Service. If a Value-added Service is deleted by amendment, CONTRACTOR must notify each Member that the service is no longer available through CONTRACTOR. CONTRACTOR must also revise all materials distributed to prospective Members to reflect the change in Value-added Services." SECTION 2.08 MODIFICATION TO ARTICLE 17, REPORTING REQUIREMENTS Article 17. Reporting Requirements, is modified with the addition of a new Section 17.17 as follows: "SECTION 17.17 CONTRACTOR AGREEMENTS WITH THIRD PARTIES. a) An agreement between CONTRACTOR and a third party (including affiliates or other related entities) whereby the third party receives all or a portion of the Capitation Payment or other payment made to CONTRACTOR, pursuant to or related to the execution of this contract, must be in writing. b) An agreement between CONTRACTOR and a third party (including affiliates or other related entities) whereby the third party receives payment or other consideration (whether a lump sum or series of payments or services) totaling $10,000 or more in any fiscal year, Page 5 of 8 pursuant to or related to the execution of this contract, must be in writing. c) All agreements described in subsections (a) and (b) must show the dollar amount, the percentage of money, or the value of any consideration that is being paid to the third party. d) All agreements whereby CONTRACTOR receives rebates, recoupments, discounts, payments, or other consideration from a third party (including affiliates or other related entities), pursuant to or related to the execution of this contract, must be in writing. e) All agreements described in subsection (d) must show the dollar amount, the percentage of money, or the value of any consideration that CONTRACTOR is receiving from the third party. f) Copies of agreements described in subsections (a), (b), and (d) valued at less than $100,000 for the fiscal year must be maintained and available for review by HHSC. g) Copies of agreements described in subsections (a), (b), and (d) valued at $100,000 or more for the fiscal year must be submitted to HHSC by September 30, 2005. Copies of agreements that are entered into after the effective date of this contract must be submitted to HHSC no later than 30 days prior to the date of execution of the agreement. h) This section shall not apply to those agreements that are covered under Section 15.01 (Provider Subcontracts) or Article 19 (Non-Provider Subcontracting)." SECTION 2.09 MODIFICATION TO ARTICLE 19, NON-PROVIDER SUBCONTRACTING Section 19.01, Written Subcontracts, is modified as follows: "SECTION 19.01 WRITTEN SUBCONTRACTS. CONTRACTOR must enter into written contracts with all Non-Provider Subcontractors and maintain copies of the Subcontracts in CONTRACTOR'S administrative office. CONTRACTOR must submit two copies of all Non-Provider Subcontracts to HHSC for approval no later than 60 days after the Effective Date of this Agreement. Subcontracts entered into after the Effective Date of this Agreement must be submitted no later than 30 days prior to the date of execution of the Subcontract. CONTRACTOR must also make Non-Provider Subcontracts available to HHSC upon request, at the time and location requested by HHSC. HHSC has 15 business days to review the Subcontract and recommend any suggestions or required changes. If HHSC has not responded to CONTRACTOR by the fifteenth day, CONTRACTOR may execute the Subcontract. HHSC reserves the right to request CONTRACTOR to modify any Subcontract that has been deemed approved. The form and substance of all Subcontracts, including subsequent amendments, are subject to approval by HHSC. HHSC retains the Page 6 of 8 authority to reject or require changes to any provisions of the Subcontract that do not comply with the requirements or duties and responsibilities of this Agreement or create significant barriers for HHSC in carrying out its duty to monitor compliance with the Agreement. Additionally, if CONTRACTOR desires to enter into a Non-Provider Subcontract that has a value over $100,000, CONTRACTOR must obtain prior written approval from HHSC. HHSC reserves the right to require the replacement of any Non-Provider Subcontractor, which HHSC will not unreasonably require. For SFY 2006, all current non-provider management and administrative subcontracts valued at $100,000 or more per year must be resubmitted to HHSC for review and approval. These subcontracts must be submitted to HHSC by September 30, 2005. HHSC approvals will be completed by November 30, 2005. HHSC reserves the right to request CONTRACTOR to modify any subcontract that has been executed and/or approved." SECTION 2.10 MODIFICATION TO APPENDIX C, SCOPE OF BENEFITS Appendix C, Scope of Benefits, is modified as shown in the copy of Appendix C that accompanies this Amendment as Exhibit 1. which is incorporated into the Agreement by reference. SECTION 2.11 MODIFICATION TO APPENDIX D, CHIP FINANCIAL-STATISTICAL REPORT, OF THE AGREEMENT Appendix D is modified as shown in the copy of Appendix D that accompanies this Amendment as Exhibit 2. which is incorporated into the Agreement by reference. SECTION 2.12 MODIFICATION TO APPENDIX E, REPORTS Appendix E is modified by the addition of Appendix E.8, Delivery Supplemental Payment Report, which accompanies this Amendment as Exhibit 3, and which is incorporated into the Agreement by reference. Page 7 of 8 ARTICLE 3. REPRESENTATIONS AND AGREEMENT OF THE PARTIES The Parties contract and agree that the terms of the Agreement will remain in effect and continue to govern except to the extent modified in this Amendment. By signing this Amendment, the Parties expressly understand and agree that this Amendment is hereby made a part of the Agreement as though it were set out word for word in the Agreement. IN WITNESS HEREOF, HHSC AND THE CONTRACTOR HAVE EACH CAUSED THIS AMENDMENT TO BE SIGNED AND DELIVERED BY ITS DULY AUTHORIZED REPRESENTATIVE. AMERIGROUP TEXAS, INC. HEALTH & HUMAN SERVICES COMMISSION By: /s/ Fred Dunlap By: /s/ C E Bell M O for --------------------------------- ------------------------------- Fred Dunlap Albert Hawkins Senior Vice President, Health Plan Executive Commissioner Operations Date: 8/4/05 Date: 8/23/05 Page 8 of 8 EXHIBIT 1 APPENDIX C CHIP SCOPE OF BENEFITS CHIP SCOPE OF BENEFITS Covered CHIP services must meet the CHIP definition of "medically necessary." "Medically necessary" health services are: A. Physical: - - Reasonable and necessary to prevent illnesses or medical conditions, or provide early screening, interventions, and/or treatments for conditions that cause suffering or pain, cause physical malformation or limitations in function, threaten to cause or worsen a disability, cause illness or infirmity of a Member, or endanger life; - - provided at appropriate facilities and at the appropriate levels of care for the treatment of Members' medical conditions; - - consistent with health care practice guidelines and standards that are issued by professionally recognized health care organizations or governmental agencies; - - consistent with the diagnoses of the conditions; and - - no more intrusive or restrictive than necessary to provide a proper balance of safety, effectiveness, and efficiency. These "medically necessary" health services: - - could not be omitted without adversely affecting the Member's physical health or the quality of care rendered. B. Behavioral: - - reasonable and necessary for the diagnosis or treatment of a mental health or chemical dependency disorder or to improve or to maintain or to prevent deterioration of function resulting from the disorder; and - - provided in accordance with professionally accepted clinical guidelines and standards of practice in behavioral health care. Emergency care is a covered CHIP service. "Emergency" and "emergency condition" means a medical condition of recent onset and severity, including, but not limited to, severe pain that would lead a prudent layperson, possessing an average knowledge of medicine and health, to believe that the child's condition, sickness, or injury is of such a nature that failure to get immediate care could result in: - - placing the child's health in serious jeopardy; - - serious impairment to bodily functions; - - serious dysfunction of any bodily organ or part; - - serious disfigurement; or - - in the case of a pregnant woman, serious jeopardy to the health of the fetus. "Emergency services" and "emergency care" means health care services provided in an in-network or out-of-network hospital emergency department or other comparable facility by in-network or out-of network physicians, providers, or facility staff to evaluate and stabilize medical conditions. Emergency services also include, but are not limited to any medical screening examination or other evaluation required by state or federal law that is necessary to determine whether an emergency condition exists. There is no lifetime maximum on benefits; however, 12-month period, enrollment period (a 6-month period) or lifetime limitations do apply to certain services, as specified in the following chart. If services with a 12-month limit are all used within one 6-month enrollment period, these particular services are not available during the second 6-month enrollment period. Co-pays apply until a family reaches its specific cost-sharing maximum. 1
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- --------------------------- INPATIENT GENERAL Medically necessary services - [Requires] [May require] [Does not - Applicable level of ACUTE AND INPATIENT include, but are not limited to, require] prior authorization for non- inpatient co-pay REHABILITATION the following: emergency care and following applies stabilization of an emergency condition HOSPITAL SERVICES - Hospital-provided physician or provider services - [Requires] [May require] [Does not require] prior authorization for in- - Semi-private room and board network or out-of-network facility for (or private if medically a mother and her newborn(s) after 48 necessary as certified by hours following an uncomplicated attending) vaginal delivery and after 96 hours following an uncomplicated delivery by - General nursing care caesarian section - ICU and services - Patient meals and special diets - Operating, recovery and other treatment rooms - Anesthesia and administration (facility technical component) - Surgical dressings, trays, casts, splints - Drugs, medications and biologicals, blood or blood products not provided free-of-charge to the patient and their administration - X-rays, imaging and other radiological tests (facility technical component) - Laboratory and pathology services (facility technical component) - Machine diagnostic tests (EEGs, EKGs, etc) - Oxygen services and inhalation therapy - Radiation and chemotherapy - Access to DSHS- designated Level III perinatal centers or hospitals meeting equivalent levels of care - In-network or out-of- network facility for a mother and her newborn(s) for a minimum of 48 hours
2
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- --------------------------- following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section - Hospital, physician and related medical services, such as anesthesia, associated with dental care TRANSPLANTS Medically necessary - [Requires] [May require] [Does not - Co-pays do not apply services include: require] authorization - Using up-to-date FDA guidelines, all non-experimental human organ and tissue transplants and all forms of non-experimental corneal, bone marrow and peripheral stem cell transplants, including donor medical expenses SKILLED NURSING Medically necessary - [Requires] [May require] [Does not - Co-pays do not apply FACILITIES services include, but are require] authorization and physician (INCLUDES not limited to, the prescription REHABILITATION following: HOSPITALS) - Semi-private room and board - 60 days per 12-month period limit - Regular nursing services - Rehabilitation services - Medical supplies and use of appliances and equipment furnished by the facility
3
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- --------------------------- OUTPATIENT HOSPITAL, Medically necessary services - [Requires] [May require] [Does not - Applicable level of COMPREHENSIVE include, but are not limited to, require] prior authorization and co-pay applies to OUTPATIENT the following services provided physician prescription prescription drug REHABILITATION in a hospital clinic, a clinic services HOSPITAL, CLINIC or health center, hospital-based (INCLUDING HEALTH emergency department or an - Co-pays do not apply CENTER) AND ambulatory health care setting: to preventive services AMBULATORY HEALTH CARE CENTER - X-ray, imaging, and radiological tests (technical component) - Laboratory and pathology services (technical component) - Machine diagnostic tests - Ambulatory surgical facility services - Drugs, medications and biologicals - Casts, splints, dressings - Preventive health services - Physical, occupational and speech therapy - Renal dialysis - Respiratory Services - Radiation and chemotherapy - Blood or blood products not provided free-of-charge to the patient and the administration of these products - Facility and related medical services, such as anesthesia, associated with dental care, when provided in a licensed ambulatory surgical facility. PHYSICIAN/PHYSICIAN Medically necessary services - [Requires] [May require] [Does not - Applicable level of EXTENDER include, but are not limited to, require] prior authorization for co-pay applies to PROFESSIONAL the following: specialty services office visits SERVICES - American Academy of - Co-pays do not apply Pediatrics recommended to preventive visits well-child exams and or to prenatal visits preventive health services after the first visit (including but not limited to vision and hearing screening and immunizations) - Physician office visits, inpatient and outpatient
4
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- --------------------------- services - Laboratory, x-rays, imaging and pathology services, including technical component and/or professional interpretation - Medications, biologicals and materials administered in physician's office - Allergy testing, serum and injections - Professional component (in/outpatient) of surgical services, including: - Surgeons and assistant surgeons for surgical procedures including appropriate follow-up care - Administration of anesthesia by physician (other than surgeon) or CRN A - Second surgical opinions - Same-day surgery performed in a hospital without an over-night stay - Invasive diagnostic procedures such as endoscopic examination - Hospital-based physician services - (including physician-performed technical and interpretative components) - In-network and out-of-network physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an
5
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- uncomplicated delivery by caesarian section - Physician services medically necessary to support a dentist providing dental services to a CHIP member such as general anesthesia or intravenous (IV) sedation. DURABLE MEDICAL Covered services include DME - [Requires] [May require] [Does not - Co-pays do not apply EQUIPMENT (DME), (equipment which can withstand require] prior authorization and PROSTHETIC DEVICES repeated use, and is primarily physician prescription AND DISPOSABLE and customarily used to serve a MEDICAL SUPPLIES medical purpose, generally is - $20,000 12-month period limit for DME, not useful to a person in the prosthetics, devices and disposable absence of illness, injury or medical supplies (diabetic supplies and disability, and is appropriate equipment are not counted against this for use in the home), devices cap) and supplies that are medically necessary and necessary for one or more activities of daily living, and appropriate to assist in the treatment of a medical condition, including, but not limited to: - Orthotic braces and orthotics - Prosthetic devices such as artificial eyes, limbs and braces - Prosthetic eyeglasses and contact lenses for the management of severe ophthalmologic disease - Hearing aids - Other artificial aids - Implantable devices are covered under Inpatient and Outpatient services and do not count towards the DME 12-month period limit. - Diagnosis-specific medical supplies, including diagnosis-specific prescribed specialty formulas and dietary supplements
6
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- HOME AND COMMUNITY Medically necessary services are - [Requires] [May require] [Does not - Co-pays do not apply HEALTH SERVICES provided in the home and require] authorization and physician community and include, but are prescription not limited to: - Services are not intended to replace - Home infusion the child's caretaker or to provide relief for the caretaker - Respiratory therapy - Skilled nursing visits are provided on - Visits for private duty intermittent level and not intended to nursing (R.N., L.V.N.) provide 24-hour skilled nursing services - Skilled nursing visits as defined for home health - Services are not intended to replace purposes (may include R.N. 24-hour inpatient or skilled nursing or L.V.N.). facility services - Home health aide when included as part of a plan of care during a period that skilled visits have been approved - Speech, physical and occupational therapies. INPATIENT MENTAL Medically necessary services - [Requires] [May require] [Does not - Applicable level of HEALTH SERVICES include, but are not limited to: require] prior authorization for inpatient co-pay non-emergency services applies - mental health services furnished in a free- - Does not require PCP referral. standing psychiatric hospital, psychiatric units - Inpatient mental health services are of general acute care limited to: hospitals and state-operated facilities. - 45 days 12-month period inpatient limit - Neuropsychological and - Includes inpatient psychiatric psychological testing. services, up to 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities. Court order serves as binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. - 25 days of the inpatient benefit can be converted to residential treatment, therapeutic foster care or other 24-hour therapeutically planned and structured services or sub-acute
7
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- outpatient (partial hospitalization or rehabilitative day treatment) mental health services on the basis of financial equivalence against the inpatient per diem cost - 20 of the inpatient days must be held in reserve for inpatient use only OUTPATIENT MENTAL - Medically necessary - [Requires] [May require] - Applicable level of HEALTH SERVICES services include, but are [Does not require] prior co-pay applies to not limited to, mental authorization. office visits. health services provided on an outpatient basis. - Does not require PCP referral. - Medication management visits do not count against - The visits can be furnished the outpatient visit limit. in a variety of community-based settings - Neuropsychological and (including school and psychological testing. home-based) or in a state-operated facility. - Up to 60 days 12-month period limit for rehabilitative day treatment. - 60 outpatient visits 12-month period limit - 60 rehabilitative day treatment days can be converted to outpatient visits on the basis of financial equivalence against the day treatment per diem cost. - 60 outpatient visits can be converted to skills training (psycho educational skills development) or rehabilitative day treatment on the basis of financial equivalence against the outpatient visit cost. - Includes outpatient psychiatric services, up to 12-month period limit, ordered by a court of competent jurisdiction under the provisions of Chapters 573 and 574 of the Texas Health and Safety Code, relating to court ordered commitments to psychiatric facilities. Court order serves as
8
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- binding determination of medical necessity. Any modification or termination of services must be presented to the court with jurisdiction over the matter for determination. - Inpatient days converted to sub-acute outpatient services are in addition to the outpatient limits and do not count towards those limits. - A Qualified Mental Health Professional (QMHP), as defined by and credentialed through the Texas Department of State Health Services (DSHS) standards (TAC Title 25, Part 11, Chapter 412), is a Local Mental Health Authorities provider. A QMHP must be working under the authority of a DSHS entity and be supervised by a licensed mental health professional or physician. QMHPs are acceptable providers as long as the services would be within the scope of the services that are typically provided by QMHPs. Those services include individual and group skills training (which can be components of interventions such as day treatment and in-home services), patient and family education, and crisis services.
9
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- INPATIENT SUBSTANCE - Medically necessary - [Requires] [May require] [Does not - Applicable level ABUSE TREATMENT services include, but are require] prior authorization for of inpatient SERVICES not limited to, inpatient non-emergency services co-pay applies and residential substance abuse treatment services - Does not require PCP referral. including detoxification and crisis stabilization, - Medically necessary and 24-hour residential detoxification/stabilization services, rehabilitation programs. limited to 14 days per 12-month period. - 24-hour residential rehabilitation programs, or the equivalent, up to 60 days per 12-month period. - 30 days may be converted to partial hospitalization or intensive outpatient rehabilitation, on the basis of financial equivalence against the inpatient per diem cost. - 30 days must be held in reserve for inpatient use only. OUTPATIENT SUBSTANCE - Medically necessary - [Requires] [May require] [Does not - Applicable level ABUSE TREATMENT outpatient substance abuse require] prior authorization. of co-pay applies SERVICES treatment services include, to office visits. but are not limited to, - Does not require PCP referral. prevention and intervention services that are provided - Outpatient treatment services up to a by physician and maximum of: non-physician providers, such as screening, - Intensive outpatient program (up to 12 assessment and referral for weeks per 12-month period). chemical dependency disorders. - Outpatient services (up to six-months per 12-month period) - Intensive outpatient services is defined as an organized non-residential service providing structured group and individual therapy, educational services, and life skills training which consists of at least 10 hours per week for four to 12 weeks, but less than 24 hours per day. - Outpatient treatment service is defined as consisting of at least one to two hours per week
10
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- providing structured group and individual therapy, educational services, and life skills training. REHABILITATION - Medically necessary - [Requires] [May require] [Does not - Co-pays do not apply SERVICES habilitation (the process require] authorization and physician of supplying a child with prescription the means to reach age-appropriate developmental milestones through therapy or treatment) and rehabilitation services include, but are not limited to, the following: - Physical, occupational and speech therapy - Developmental assessment HOSPICE CARE Medically necessary hospice - [Requires] [May require] [Does not - Co-pays do not apply SERVICES services include, but are not require] authorization and physician limited to: prescription - Palliative care, including - Services apply to the hospice diagnosis medical and support services, for those - Up to a maximum of 120 days with a 6 children who have six month life expectancy months or less to live, to keep patients comfortable - Patients electing hospice services during the last weeks and waive their rights to treatment related months before death to their terminal illnesses; however, they may cancel this election at - Treatment for unrelated anytime conditions is unaffected
11
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- EMERGENCY SERVICES, Health plan cannot require - [Requires] [May require] [Does not - Applicable co-pays INCLUDING EMERGENCY authorization as a condition for require] authorization for apply to emergency HOSPITALS, payment for emergency conditions post-stabilization services room visits (facility PHYSICIANS, AND or labor and delivery. only) AMBULANCE SERVICES Medically necessary covered services include: - Emergency services based on prudent lay person definition of emergency health condition - Hospital emergency department room and ancillary services and physician services 24 hours a day, 7 days a week, both by in-network and out-of-network providers - Medical screening examination - Stabilization services - Access to DSHS designated Level I and Level II trauma centers or hospitals meeting equivalent levels of care for emergency services - Emergency ground, air or water transportation VISION BENEFIT Medically necessary services The health plan may reasonably limit the - Applicable level of include: cost of the frames/lenses. co-pay applies to office visits billed - One examination of the eyes - [Requires] [May require] [Does not for refractive exam to determine the need for require] authorization for protective and prescription for and polycarbonate lenses when medically corrective lenses per necessary as part of a treatment plan 12-month period, without for covered diseases of the eye. authorization - One pair of non-prosthetic eyewear per 12-month period CHIROPRACTIC Medically necessary services do - [Requires] [May require] [Does not - Applicable level of SERVICES not require physician require] authorization for twelve co-pay applies to prescription and are limited to visits per 12-month period limit chiropractic office spinal subluxation (regardless of number of services or visits modalities provided in one visit) - Requires authorization for additional visits.
12
TYPE OF BENEFIT DESCRIPTION OF BENEFIT LIMITATIONS CO-PAY --------------- -------------------------------- -------------------------------------------- ------------------------- TOBACCO CESSATION - Covered up to $100 for a - [Requires] [May require] [Does not - Co-pays do not apply PROGRAMS 12-month period limit for a require] authorization plan- approved program - Health Plan defines plan-approved program. - May be subject to formulary requirements.
13 EXCLUSIONS - - Inpatient and outpatient infertility treatments or reproductive services other than prenatal care, labor and delivery, and care related to disease, illnesses, or abnormalities related to the reproductive system - - Personal comfort items including but not limited to personal care kits provided on inpatient admission, telephone, television, newborn infant photographs, meals for guests of patient, and other articles which are not required for the specific treatment of sickness or injury - - Experimental and/or investigational medical, surgical or other health care procedures or services which are not generally employed or recognized within the medical community - - Treatment or evaluations required by third parties including, but not limited to, those for schools, employment, flight clearance, camps, insurance or court - - Private duty nursing services when performed on an inpatient basis or in a skilled nursing facility - - Mechanical organ replacement devices including, but not limited to artificial heart - - Hospital services and supplies when confinement is solely for diagnostic testing purposes, unless otherwise pre-authorized by Health Plan - - Prostate and mammography screening - - Elective surgery to correct vision - - Gastric procedures for weight loss - - Cosmetic surgery/services solely for cosmetic purposes - - Out-of-network services not authorized by the Health Plan except for emergency care and physician services for a mother and her newborn(s) for a minimum of 48 hours following an uncomplicated vaginal delivery and 96 hours following an uncomplicated delivery by caesarian section - - Services, supplies, meal replacements or supplements provided for weight control or the treatment of obesity, except for the services associated with the treatment for morbid obesity as part of a treatment plan approved by the Health Plan - - Acupuncture services, naturopathy and hypnotherapy - - Immunizations solely for foreign travel - - Routine foot care such as hygienic care - - Diagnosis and treatment of weak, strained, or flat feet and the cutting or removal of corns, calluses and toenails (this does not apply to the removal of nail roots or surgical treatment of conditions underlying corns, calluses or ingrown toenails) - - Replacement or repair of prosthetic devices and durable medical equipment due to misuse, abuse or loss when confirmed by the Member or the vendor - - Corrective orthopedic shoes - - Convenience items - - Orthotics primarily used for athletic or recreational purposes - - Custodial care (care that assists a child with the activities of daily living, such as assistance in walking, getting in and out of bed, bathing, dressing, feeding, toileting, special diet preparation, and medication supervision that is usually self-administered or provided by a parent. This care does not require the continuing attention of trained medical or paramedical personnel.) This exclusion does not apply to hospice. - - Housekeeping - - Public facility services and care for conditions that federal, state, or local law requires be provided in a public facility or care provided while in the custody of legal authorities - - Services or supplies received from a nurse, which do not require the skill and training of a nurse - - Vision training and vision therapy - - Reimbursement for school-based physical therapy, occupational therapy, or speech therapy services are not covered except when ordered by a Physician/PCP - - Donor non-medical expenses - - Charges incurred as a donor of an organ when the recipient is not covered under this health plan 14 DME/SUPPLIES
SUPPLIES COVERED EXCLUDED COMMENTS/MEMBER -------- ------- -------- CONTRACT PROVISIONS ------------------- Ace Bandages X Exception: If provided by and billed through the clinic or home care agency it is covered as an incidental supply. Alcohol, rubbing X Over-the-counter supply. Alcohol, swabs X Over-the-counter supply not covered, (diabetic) unless RX provided at time of dispensing.. Alcohol, swabs X Covered only when received with IV therapy or central line kits/supplies. Ana Kit Epinephrine X A self-injection kit used by patients highly allergic to bee stings. Arm Sling X Dispensed as part of office visit. Attends (Diapers) X Coverage limited to children age 4 or over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Bandages X Basal Thermometer X Over-the-counter supply. Batteries - initial X For covered DME items Batteries - X For covered DME when replacement is replacement necessary due to normal use. Betadine X See IV therapy supplies. Books X Clinitest X For monitoring of diabetes. Colostomy Bags See Ostomy Supplies. Communication X Devices Contraceptive Jelly X Over-the-counter supply. Contraceptives are not covered under the plan. Cranial Head Mold X Diabetic Supplies X Monitor calibrating solution, insulin syringes, needles, lancets, lancet device, and glucose strips. Diapers/Incontinent X Coverage limited to children age 4 or Briefs/Chux over only when prescribed by a physician and used to provide care for a covered diagnosis as outlined in a treatment care plan Diaphragm X Contraceptives are not covered under the plan. Diastix X For monitoring diabetes. Diet, Special X Distilled Water X Dressing X Syringes, needles, Tegaderm, alcohol Supplies/Central Line swabs, Betadine swabs or ointment, tape. Many times these items are dispensed in a kit when includes all necessary items for one dressing site change. Dressing X Eligible for coverage only if receiving Supplies/Decubitus covered home care for wound care. Dressing X Eligible for coverage only if receiving Supplies/Peripheral home IV therapy. IV Therapy Dressing X Supplies/Other Dust Mask X Ear Molds X Custom made, post inner or middle ear surgery Electrodes X Eligible for coverage when used with a covered DME. Enema Supplies X Over-the-counter supply. Enteral Nutrition X Necessary supplies (e.g., bags, tubing, Supplies connectors, catheters, etc.) are eligible for coverage. Enteral nutrition products are not covered except for those prescribed for hereditary metabolic disorders, a non-function or disease of the structures that
15
COMMENTS/MEMBER SUPPLIES COVERED EXCLUDED CONTRACT PROVISIONS -------- ------- -------- ------------------- normally permit food to reach the small bowel, or malabsorption due to disease Eye Patches X Covered for patients with amblyopia. Formula X Exception: Eligible for coverage only for chronic hereditary metabolic disorders a non-function or disease of the structures that normally permit food to reach the small bowel; or malabsorption due to disease (expected to last longer than 60 days when prescribed by the physician and_authorized by plan.) Physician documentation to justify prescription of formula must include: - Identification of a metabolic disorder, dysphagia that results in a medical need for a liquid diet, presence of a gastrostomy, or disease resulting in malabsorption that requires a medically necessary nutritional product Does not include formula: - For members who could be sustained on an age-appropriate diet. - Traditionally used for infant feeding - In pudding form (except for clients with documented oropharyngeal motor dysfunction who receive greater than 50 percent of their daily caloric intake from this product) - For the primary diagnosis of failure to thrive, failure to gain weight, or lack of growth or for infants less than twelve months of age unless medical necessity is documented and other criteria, listed above, are met. Food thickeners, baby food, or other regular grocery products that can be blenderized and used with an enteral system that are not medically necessary, are not covered, regardless of whether these regular food products are taken orally or parenterally. Gloves X Exception: Central line dressings or wound care provided by home care agency. Hydrogen Peroxide X Over-the-counter supply. Hygiene Items X Incontinent Pads X Coverage limited to children age 4 or over only when prescribed by a physician_and used to provide care for a covered diagnosis as outlined in a treatment care plan Insulin Pump X Supplies (e.g., infusion sets, syringe (External) Supplies reservoir and dressing, etc.) are eligible for coverage if the pump is a covered item. Irrigation Sets, X Eligible for coverage when used during Wound Care covered home care for wound care. Irrigation Sets, X Eligible for coverage for individual Urinary with an indwelling urinary catheter. IV Therapy Supplies X Tubing, filter, cassettes, IV pole, alcohol swabs, needles, syringes and any other related supplies necessary for home IV therapy. K-Y Jelly X Over-the-counter supply. Lancet Device X Limited to one device only. Lancets X Eligible for individuals with diabetes. Med Ejector X Needles and See Diabetic Supplies Syringes/Diabetic Needles and See IV Therapy and Dressing Syringes/IV and Supplies/Central Line. Central Line
16
COMMENTS/MEMBER SUPPLIES COVERED EXCLUDED CONTRACT PROVISIONS -------- ------- -------- ------------------- Needles and X Eligible for coverage if a covered IM or Syringes/Other SubQ medication is being administered at home. Normal Saline See Saline, Normal Novopen X Ostomy Supplies X Items eligible for coverage include: belt, pouch, bags, wafer, face plate, insert, barrier, filter, gasket, plug, irrigation kit/sleeve, tape, skin prep, adhesives, drain sets, adhesive remover, and pouch deodorant. Items not eligible for coverage include: scissors, room deodorants, cleaners, rubber gloves, gauze, pouch covers, soaps, and lotions. Parenteral X Necessary supplies (e.g., tubing, Nutrition/Supplies filters, connectors, etc.) are eligible for coverage when the parenteral nutrition has been authorized by the Health Plan. Saline, Normal X Eligible for coverage: a) when used to dilute medications for nebulizer treatments; b) as part of covered home care for wound care; c) for indwelling urinary catheter irrigation. Stump Sleeve X Stump Socks X Suction Catheters X Syringes See Needles/Syringes. Tape See Dressing Supplies, Ostomy Supplies, IV Therapy Supplies. Tracheostomy X Cannulas, Tubes, Ties, Holders, Cleaning Supplies Kits, etc. are eligible for coverage. Under Pads See Diapers/Incontinent Briefs/Chux. Unna Boot X Eligible for coverage when part of wound care in the home setting. Incidental charge when applied during office visit. Urinary, External X Exception: Covered when used by Catheter & Supplies incontinent male where injury to the urethra prohibits use of an indwelling catheter ordered by the PCP and approved by the plan Urinary, Indwelling X Cover catheter, drainage bag with Catheter & Supplies tubing, insertion tray, irrigation set and normal saline if needed. Urinary, Intermittent X Cover supplies needed for intermittent or straight catherization. Urine Test Kit X When determined to be medically necessary. Urostomy supplies See Ostomy Supplies.
17 EXHIBIT 2 APPENDIX D CHIP FINANCIAL-STATISTICAL REPORT APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION OBJECTIVE All MCOs contracting with the State of Texas to arrange for or to provide healthcare to enrollees in the CHIP Program must submit CHIP MCO FSRs for each Service Delivery Area (SDA) in accordance with the Contract for Services between HHSC and MCO and in accordance with the instructions below. The MCO must also submit Delegated Network (DN) FSRs for each entity in each SDA with which the MCO subcontracts the responsibility to arrange for or to provide healthcare services to CHIP Program enrollees in accordance with the CHIP Program DN FSR Instructions for Completion. DN FSR reporting is not required for "global" capitation related to dental, vision, or behavioral health services. GENERAL All CHIP MCO FSRs must be completed using the locked Microsoft Excel template provided by HHSC. Data integrity is critical to the automated compilation of the data. Do not alter the file name, sheet names, existing cell locations, or formatting of the data in the file and sheets. Do not add or delete any columns or rows. ANY DEVIATIONS FROM THE LOCKED TEMPLATE WILL RENDER THE FSR UNREADABLE BY THE SOFTWARE APPLICATION AND THEREFORE UNACCEPTABLE TO HHSC. All shaded data fields in the FSR represent fields where data input is required. All data fields not shaded represents referenced data or calculations. All line numbers in these instructions refer to the line numbers in column A on each worksheet. The following note is included on all FSR pages "NOTE: REPORTING IS ON AN INCURRED BASIS. ALL PRIOR MONTHS' DATA MUST BE UPDATED TO REFLECT EACH REPORTED MONTH ON AN INCURRED BASIS, INCLUDING REVISED MONTHLY IBNR ESTIMATES." Member months data must also be updated in accordance with information provided by the enrollment broker. FSR PAGE HEADERS Enter the following information on Part 1. All other page headers are referenced from Part 1. Organization: The MCO's official name in Texas, e.g., Amerigroup Texas, Inc. Service Area: Bexar, Dallas, El Paso, Harris, Lubbock, Nueces, Tarrant, or Travis Submission Date: Month, day and year, e.g., December 31, 2002 Submission Type: Quarterly; Year End + 90 Days; Year End + 334 Days Accrual Date: Month, day and year, e.g., November 30, 2002 The Accrual Date is the last day of the last month included in the period reported, and that Accrual Date relates to all months reported in the MCO FSR. PART 1: SUMMARY INCOME STATEMENTS, ALL COVERAGE GROUPS COMBINED - PAGE 1 Line 1 Total Member Months Referenced from Part 3, Line 15 Total Member Months. Line 2 Premiums (HHSC Capitation) Referenced from Part 3, Line 5 Total Premiums. -1- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 3 Delivery Supplemental Payments Referenced from Part 3.3 DSP Input, Line 4. Line 4 Investment Income Enter all interest and dividend income resulting from investment of funds received from the State and Federal Governments under the Managed Care Contract. Line 5 Other Revenue Enter any and all income generated from the CHIP Medicaid Program other than Premiums (HHSC Capitation), Delivery Supplemental Payments (DSPs), and Investment Income. Examples of Other Revenue items are: - - Any funds received from HHSC other than HHSC Capitation and/or DSPs. - - Invoiced Third Party Administration (TPA) Fees for services rendered to Delegated Networks and/or other organizations that relate to the CHIP Medicaid Program. Line 6 Total Revenues Calculated as the sum of Line 2 Premiums (HHSC Capitation), Line 3 Delivery Supplemental Payments, Line 4 Investment Income, and Line 5 Other Revenue. Line 7 Medical Expenses, Capitated Services, Single Service Referenced from Part 4, Line 16 Total Single Service Capitation. Line 8 Medical Expenses, Capitated Services, Delegated Networks Referenced from Part 4, Line 17 Total Delegated Networks. Line 9 Medical Expenses, Fee-For-Service Calculated as Line 11 Total Medical Expenses minus the sum of Line 7 Single Service, Line 8 Delegated Networks, and Line 10IBNR Accrual. Line 10 Medical Expenses, IBNR Accrual Referenced from Part 4, Line 13 Incurred But Not Reported. Line 11 Total Medical Expenses Referenced from Part 4, Line 15 Total Medical Expenses. Line 12 Total Administrative Expenses Referenced from Part 5, Line 21 Total Administrative Expenses. Line 13 Total Expenses Calculated as the sum of Line 11 Total Medical Expenses and Line 12 Total Administrative Expenses. Line 14 Net Income Before Taxes Calculated as Line 6 Total Revenues minus Line 13 Total Expenses. Line 15% of Medical Expense to Premiums and DSPs Calculated as Line 11 Total Medical Expenses divided by the sum of Line 2 Premiums and Line 3 Delivery Supplemental Payments. Line 16% of Administrative Cost to Premiums Calculated as Line 12 Total Administrative Expenses divided by the sum of Line 2 Premiums and Line 13 Delivery Supplemental Payments. -2- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 17% of Net Income to Total Revenues Calculated as Line 14 Net Income Before Taxes divided by Line 6 Total Revenues. Line 18 Performance Assessment Enter the amount of at-risk premium assessed due to substandard performance as a negative amount in the YTD column. Line 19 Quality Challenge Award Enter the amount of Quality Challenge Award earned as a positive amount in the YTD column. Line 20 Liquidated Damages Enter the amount of liquidated damages paid to the State as a negative amount in the column of the month paid. PART 2: STATISTICAL SUMMARY, ALL COVERAGE GROUPS COMBINED - PAGE 2 Line 1 Member Months Referenced from Part 3, Line 15 Total Member Months. Lines 2 through 7 are $PMPM Line 2 Premiums Referenced from Part 3, Line 5. Line 3 Medical Expenses (Excludes Deliveries) Calculated as the difference between Part 4, Line 15 Total Medical Expenses and Part 3.3 DSP Input, Line 18 Total Delivery Expenses divided by Part 3, Line 15 Total Member Months. Line 4 Premiums > Medical Expenses Calculated as the difference between Line 2 and Line 3. Line 5 Delivery Supplemental Payments (DSPs) Referenced from Part 3.3 DSP Input Line 12. Line 6 Delivery Expenses Calculated as Part 3.3 DSP Input, Line 18 Total Delivery Expenses divided by the sum of Part 3 Member Months for appropriate coverage groups on Lines 13 and 14, Age 6-14 and Age 15-18. Line 7 DSPs > Delivery Expenses Calculated as the difference between Line 5 and Line 6. Line 8 Average Cost per Delivery Referenced from Part 3.3 DSP Input Line 21. Lines 9 through 11 are Medical Loss Ratios (MLR). Line 9 MLR Excluding Deliveries Calculated as Part 4 Line 15 Total Medical Expenses excluding Part 3.3 DSP Input Line 18 Total Delivery Expenses divided by Part 3 Line 5 Total Premiums. Line 10 Deliveries Only Calculated as Part 3.3 DSP Input Line 18 Total Delivery Expenses divided by Part 3.3 DSP Input Line 4 Total DSPs. Line 11 MLR Including Deliveries Referenced from Part 3.1 Line 58 Total Medical Loss Ratio. Line 12 Paid Medical Expenses Completion Factors Calculated as the difference between Part 4 Line 15 Total Medical Expenses and Part 4 Line 13 Incurred But Not Reported divided by Part 4 Line 15. -3- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION PART 3: FINANCIAL SUMMARIES, BY COVERAGE GROUPS - PREMIUMS AND ENROLLMENT - PAGE 3 Lines 1 through 4 Premiums Calculated. Each cell in this matrix is the product of the corresponding capitation rate in the matrix of Lines 6 through 9 and the corresponding member months in the matrix of Lines 11 through 14. Line 5 Total Premiums Calculated as the sum of Lines 1 through 4. Lines 6 through 9 Premium $PMPM Enter each coverage group's capitation rate applicable to each month. HHSC CAPITATION RATES MAY CHANGE DURING THE CONTRACT PERIOD. Line 10 Total Premiums $PMPM Calculated as Line 5 Total Premiums divided by Line 15 Total Member Months. Lines 11 through 14 Member Months Enter the member months based on the Recipient Month Distribution By Risk Group included with the Purchase Voucher Supplement that supports the monthly HHSC capitation payments to the MCO. The Recipient Month Distribution By Risk Group identifies the member months by risk group by eligible months. Line 15 Total Member Months Calculated as the sum of Lines 11 through 14. PART 3.1: FINANCIAL SUMMARIES, BY COVERAGE GROUPS - TOTAL MEDICAL EXPENSE AND MEDICAL LOSS RATIOS - PAGE 4 Lines 16 through 19 Total Medical Expense Referenced from the corresponding cells in the four matrices on the Part 3.2 MedExpInput worksheet. The medical expenses reported in the cells at Lines 16 through 19 include the MCO-paid claims, paid single service capitation and delegated network, paid reinsurance premiums, net of collected reinsurance recoveries, and incurred but not reported medical expenses. Line 20 Total Medical Expense Calculated as the sum of Lines 16 through 19. If Part 3.1, Line 20 does not equal Part 4, Line 15, the cell will display "Not Balanced." The unnumbered line above line 20 may be used to enter a rounding/adjustment number to facilitate the balancing. The rounding/adjustment number should be an immaterial amount. Lines 21 through 24 Medical Expense $PMPM Calculated as Total Medical Expense for each coverage group as reported on Lines 16 through 19 divided by the corresponding Member Months for each coverage group as reported on Part 3, Lines 11 through 14. Line 25 Total Medical Expense $PMPM Calculated as Line 20 Total Medical Expense divided by the Part 3, Line 15 Total Member Months. Lines 26 through 29 Medical Loss Ratios Calculated. Each cell in this matrix is calculated as follows: - - The numerator is Total Medical Expense from the matrix on Lines 16 through 19. -4- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION - - The denominator is Premium from the matrix on Part 3, Lines 1 through 4 plus the Delivery Supplemental Payments for the eligible coverage groups. The DSPs are equal to Part 3.3 DSP Input, Line 1 Contracted DSP Amount multiplied by the corresponding Number of DSPs on Part 3.3 DSP Input, Lines 5 through 6, plus an allocation of Line 7 Incurred But DSP Not Received. The allocation of Line 7 is based on the ratio of each coverage group's number of DSPs relative to the total number of DSPs reported on Lines 5 through 6. Line 30 Total Medical Loss Ratio Calculated as Line 20 Total Medical Expenses divided by the sum of Part 3 Line 5 Total Premiums plus Part 3.3 DSP Input Line 4 Total Delivery Supplemental Payments. PART 3.2: TOTAL MEDICAL EXPENSES INPUT WORKSHEET - BY COVERAGE GROUPS - PAGE 5 Lines 16 through 19 Paid Claims Input Enter MCO-paid claims by coverage groups as incurred, i.e., by the month during which the services were rendered. Include any incentives paid directly to physicians (not networks) as reported on Part 4 Line 14. Line 20 Total Paid Claims Input Calculated as the sum of Lines 16 though 19. Lines 16 through 19 Paid Single Service Capitation and Delegated Network Input Enter the single service capitation and delegated network payments by coverage groups by the service months covered by the capitation payments. Include Network Risk Retention/(Loss) as reported on Part 4 Line 14 as a delegated network cost. Line 20 Total Paid Capitation Input Calculated as the sum of Lines 16 though 19. Lines 16 through 19 Paid Reinsurance Premiums, Net of Collected Reinsurance Recoveries Input Enter the paid reinsurance premiums, net of collected reinsurance recoveries specific to each coverage group by the months the reinsurance coverage was effective. Collected Reinsurance Recoveries are reported by the appropriate coverage group and by the incurred month of the services to which the recoveries relate. See Part 4 Lines 11 and 12. Line 20 Total Net Reinsurance Input Calculated as the sum of Lines 16 though 19. Lines 16 through 19 IBNR Input Enter the MCO's Incurred But Not Reported estimate by coverage group. See Part 4 Line 13. Line 20 Total IBNR Calculated as the sum of Lines 16 though 19. PART 3.3: DELIVERY SUPPLEMENTAL PAYMENTS AND DELIVERY EXPENSES - PAGE 6 Line 1 Contracted DSP Amount Enter the DSP rate applicable to each month. Note that HHSC DSP rates may change during the contract period. Delivery Supplemental Payments ($) Line 2 DSPs Received by MCO Calculated as the sum of Lines 5 and 6 multiplied by Line 1 Contracted DSP Amount. -5- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 3 Incurred But DSP Not Received Calculated as the product of Line 1 and Line 7. Line 4 Total DSPs Calculated as the sum of Line 2 and Line 3. Lines 5 through 6 Number of Deliveries Enter the sum of the delivery counts from (1) the accepted DSP records in the monthly DSP submission files, (2) the accepted DSP records that were previously rejected by file edit 102, and (3) the accepted appealed DSP records; reported by coverage groups and incurred months. Line 7 Incurred But DSP Not Received Enter the difference between the total number of facility delivery discharges based on the IBNR Plan and the sum of Lines 5 through 6. Line 8 Total Number of Deliveries Calculated as the sum of Lines 5 through 7. Lines 9 through 10, DSP $PMPM Calculated as the product of Line 1 Contracted DSP Amount and each corresponding cell on Lines 5 through 6, divided by the corresponding Member Months at Part 3, Lines 13 and 14. Line 11 Incurred But DSP Not Received Calculated as Line 3 Incurred But DSP Not Received divided by the sum of Member Months at Part 3, Lines 13 and 14. Line 12 Total DSP $PMPM Calculated as Line 4 Total DSPs divided by the sum of Member Months at Part 3, Lines 13 and 14. Line 13 Paid Claims Calculated as the sum of Lines 5 through 6. Line 14 Incurred But Not Paid Referenced from Line 10. Line 15 Total Number of Deliveries Incurred Calculated as sum of Line 13 and Line 14. Line 16 Paid Claims Referenced from Part 4, Line 18 Total Delivery Expenses. Line 17 Incurred But Not Paid Enter the unpaid expenses for incurred delivery services based on the MCO's IBNR Plan and the number of incurred deliveries reported on Line 7. Include unpaid delivery expenses incurred by the MCO's delegated networks. Line 18 Total Delivery Expenses Calculated as the sum of Line 16 and Line 17. Line 19 Average Cost Per Delivery, Paid Claims Calculated as Line 16 Delivery Expenses, Paid Claims divided by Line 13 Number of Deliveries Incurred, Paid Claims. Line 20 Average Cost per Delivery Incurred But Not Paid Calculated as Line 17 Delivery Expenses Incurred But Not Paid divided by Line 14 Number of Deliveries Incurred But Not Paid. Line 21 Average Cost per Delivery Calculated as Line 18 Total Delivery Expenses divided by Lines 15 Total Number of Deliveries Incurred. -6- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION PART 4: TOTAL MEDICAL EXPENSES, ALL COVERAGE GROUPS COMBINED - PAGE 7 Line 1 Physician Services, Primary Care Enter all paid expenses related to the medical care provided to a member-patient by a physician (M.D. and D.O.) upon first contact with the health care system for treatment of an illness or injury before referral. The PCP performs or directs the performance of primary care services which include, but are not limited to, case management, consultations, family planning, emergency room visits, inpatient visits, maternity care services, office visits, preventive care services, dispensing or prescribing medical supplies and Pharmaceuticals, authorizing referrals to specialists, etc. Under the Texas Medicaid Managed Care Program, all members are required to have a primary care physician (PCP) when enrolling in a MCO. For expenses to be classified as PCP services, the performing provider at 24K on a CMS-1500 claim must be the member-patient's assigned PCP, and the services do not represent Deliveries - Professional Component. The total amount paid covering all charges on a CMS-1500 claim is classified as PCP expense when the performing provider is the member-patient's PCP. Line 2 Physician Services, Specialist Enter all paid expenses related to the medical care provided to a patient by a physician (M.D. and D.O.) whose practice is limited to a particular branch of medicine or surgery, e.g., cardiology or radiology, in which a physician specializes and/or is certified by a board of physicians. Generally, a member-patient must have a referral authorized by his/her assigned PCP to receive services from a specialist. For expenses to be classified as Specialist Physician Services, the performing provider identified at 24K on a CMS-1500 claim must be a physician who is not the member-patient's assigned PCP, and the services do not represent Deliveries - - Professional Component. The total amount paid covering all charges on a CMS-1500 claim is classified as Specialist Physician Services when the performing provider is a physician who is not the member-patient's PCP. Line 3 Physician Services, Deliveries - Professional Component Enter paid expenses for the services of the delivering physician and the anesthesiologist, unless they are billed as part of the facility charge. Only the delivering physician and the anesthesiologist charges are included on Line 3, as they are the only charges included in the professional component of the DSP. Only those amounts paid for charges on a CMS-1500 claim identified with Delivery CPT Codes (and the HCPCS Codes with Modifiers for the FQHCs and RHCs) are classified as Delivery -- Professional Component. All other amounts paid for charges on the same CMS-1500 claim that are not identified with Delivery Procedure Codes are classified as PCP or Specialist based on the criteria at Lines 1 and 2, respectively. Line 4 Non-Physician Professional Services Enter all paid expenses for medical care provided by non-physician, healthcare services providers. These include, but are not limited to, audiologists, chiropractors, counselors, dentists, home health aides, licensed vocational nurses, occupational therapists, opticians, optometrists, physical therapists, psychologists, registered nurses, respiratory therapists, social workers, speech therapists, etc. The total amount paid covering all charges on a CMS-1500 claim is classified as Non-Physician Professional Services when the performing provider at 24K is a non-physician, healthcare -7- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION services provider. DN FSR reporting is not required for "global" capitation related to dental or vision health services. Line 5 Emergency Room Services Enter all paid expenses incurred during an encounter in an emergency room, i.e., the section of a healthcare facility intended to provide rapid treatment for victims of sudden illness or trauma. Includes the costs of the emergency room equipment, facility usage, staff, and supplies. The costs of emergency department ancillary services including laboratory services, radiology services, respiratory therapy services, and diagnostic studies, such as EKGs, CT scans, and supplies are also included on Line 5. Excludes any non-staff, attending or consulting physician; billed separately as PCP and/or specialist services. The total amount paid by the MCO or DN covering all charges on a UB 92 claim that are incurred during an emergency room encounter are classified as Emergency Room Services. Any amount(s) paid for any charges on a UB 92 claim that include emergency room services that were incurred on a different service date than the emergency room encounter are classified as Outpatient Facility Services, unless they represent (an) additional emergency room encounter(s). Line 6 Outpatient Facility Services Enter all paid expenses for services rendered to a member-patient that remains in a hospital based or freestanding facility, such as an ambulatory surgical center, for less than 24 consecutive hours and the member-patient is discharged from an outpatient status, except for emergency room services. Outpatient facility services include, but are not limited to, the following items and services performed on an outpatient basis in a hospital based or freestanding facility: - - Observation, operating, and recovery room charges - - Surgical operations or procedures, day surgery - - Laboratory, nuclear medicine, pathology, and radiological services - - Diagnostic, therapeutic, and rehabilitative clinic and/or treatment services - - Injections, drugs, and medical supplies - - All medically necessary services and supplies ordered by a physician. Excludes any non-staff, attending or consulting physician; billed separately as PCP or specialist services. The total amount paid covering all charges on a UB-92 claim is classified as Outpatient Facility Services if the Type of Bill indicates the claim is for outpatient facility services, and there are no emergency room charges included. Line 7 Inpatient Facility Services, Medical/Surgical Enter all paid expenses for acute care facilities covering inpatient services for medical/surgical stays, intensive care units (ICUs), cardiac/coronary care units (CCUs), burn units, cancer treatment centers, etc. Also includes the expenses of non-acute care inpatient services rendered at extended care/skilled nursing facilities. Inpatient medical/surgical services include, but are not limited to, the following items and services performed on an inpatient basis: - - Bed and board in semiprivate accommodations or in an intensive care or coronary care unit including meals, special diets, and general nursing services; and an allowance for bed and -8- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION board in private accommodations including meals, special diets, and general nursing services up to the hospital's charge for its most prevalent semiprivate accommodations. - - Whole blood and packed red cells reasonable and necessary for treatment of illness or injury. - - Newborn care including routine care and specialized nursery care for newborns with specific problems. - - Other inpatient services include organ/tissue transplant services and rehabilitation services. - - All medically necessary services and supplies ordered by a physician. The total amount paid covering all charges on a UB-92 claim is classified as Inpatient Facility Services if the Type of Bill indicates the claim is for inpatient facility services, and there are no delivery charges included. Line 8 Inpatient Facility Services, Deliveries - Facility Component Enter paid expenses of all delivery services and supplies provided by the facility where the birth takes place, except for the Professional Component. Only those amount(s) paid for charges on a UB-92 claim identified with Delivery ICD-9 Codes are classified as Delivery - Facility Component. Any amount(s) paid for any charges on the same UB-92 inpatient claim that are not identified with Delivery ICD-9 Codes are classified as Inpatient Facility Services - Medical/Surgical. Line 9 Behavioral Health Services Enter all paid expenses incurred for inpatient and outpatient mental health services and inpatient and outpatient chemical dependency services including both treatment and detoxification of alcohol and substance abuse. Only those amount(s) paid for charges on a CMS-1500 or UB-92 claim identified with Behavioral Health Services ICD-9 and/or Revenue Codes are classified as Behavioral Health Services. Any amount(s) paid for any charges on the same CMS-1500 or UB-92 claim that are not identified with Behavioral Health Services ICD-9 and/or Revenue Codes should be classified in the appropriate medical expense classification. DN FSR reporting is not required for "global" capitation related to behavioral health services. Line 10 Other Medical Services Enter all paid expenses of all medical services and supplies rendered that are not classified in any of the medical expense classifications above. Other Medical Expenses include, but are not limited to, ambulance services and durable medical equipment (DME), oxygen, and other medical supplies obtained directly from these suppliers, i.e., not obtained incidental to physician, non-physician professional, or facility encounters. The total amount paid covering all charges on a CMS-1500 claim is classified as Other Medical Services. Line 11 Reinsurance Premiums Enter paid expenses to obtain reinsurance coverage from reinsurance companies that assume all or part of the financial risks associated with catastrophic medical expenses that could, otherwise, be ruinous to the MCO. Also termed Premiums Ceded for Reinsurance. Offset any reinsurance premiums collected for any reinsurance risks assumed. Line 12 Reinsurance Recoveries Enter any and all return of funds or recovery of paid losses that have been collected from reinsurers associated with a particular case where catastrophic medical expenses have been incurred. Offset any reinsurance recoveries paid for reinsurance risks assumed. Reinsurance Recoveries are recorded in the month(s) in which the healthcare services were rendered to which the recoveries relate. -9- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 13 Incurred But Not Reported Enter the total medical expenses accrual based on the MCO's IBNR Plan, which includes: - - Reported claims in process for adjudication, - - An estimated expense of the incurred but not reported healthcare services, - - Amounts withheld from paid claims and capitations, - - Any capitation payable to providers, and - - Any reinsurance payable to reinsurers for ceded risk, net of any reinsurance receivable for assumed risk. The IBNR medical expenses accrual is an estimate of the expected healthcare expenses incurred but not paid based on claims lag schedules and completion factors, as well as, any counts of services rendered but not billed, e.g., pre-authorized hospital days. Any major change in the claims processing function that was not in effect during the period of time covered by the lag schedules could materially impact the estimated IBNR accrual; hence, actuarial judgment and adjustment may sometimes be needed. NOTE: NO IBNR SHOULD BE REPORTED ON THE SECOND FINAL FSR REFLECTING EXPENSES PAID THROUGH THE 334TH DAY AFTER THE END OF THE CONTRACT PERIOD. Line 14 Incentives and/or Network Risk Retention 1. Enter any incentives paid directly to physicians, i.e., bonuses paid based on quality compliance measures. And/Or 2. Enter the total difference (total balancing amount) between: - The sum of the total "global" capitation and other payments paid to all DNs by the MCO reported in the appropriate months to which the capitation applies, and - The sum of the total paid claims, total paid single service capitation, and total IBNR medical expense accruals of all DNs for all healthcare services covered by the "global" capitation payments paid to the DNs by the MCO reported in the months in which the services are rendered. Line 15 Total Medical Expenses Calculated as the sum of Lines 1 through 14. Included in Total Medical Above: Line 16 Total Single Service Capitation Enter the total single service capitation paid to providers that do not pay claims to other providers from the capitation payments received. The single service capitation provider does not assume risks beyond a single medical expense classification that the provider agrees to perform in return for the capitation. Line 17 Total Delegated Networks Enter the total "global" capitation paid to subcontracted IPAs in which the "global" capitation is the funding source for paying claims for healthcare services performed by an integrated delivery system under contract with the IPA specific to each Texas Medicaid SDA. The Delegated Network assumes risks pertaining to the adequacy of the "global" capitation relative to the paid claims for healthcare services classified in more than one -10- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION medical expense category. Include Network Risk Retention/(Loss) as a delegated network cost (see Line 14). Line 18 Total Delivery Expenses Calculated as the sum of Line 3 and Line 8 above. Line 19 Total Related Party Expenses Enter the total medical expenses paid to any companies affiliated with the MCO through common ownership for providing healthcare services in support of the Texas Medicaid SDA operations of the MCO. Line 20 Not Included in Total Medical Above, Total Value Added Services Enter the expenses paid by the MCO or its DN for healthcare services to Medicaid enrollees that are not covered under the HHSC Capitation nor reimbursed by HHSC. These expenses are the financial responsibility of the MCO and/or its DN. They are not included in Total Medical Expenses in the MCO FSR nor DN FSR, and represent a reconciling item between the HHSC and TDI reportings. The specific Value Added Services are included in the Contract for Services between HHSC and MCO. PART 5: TOTAL ADMINISTRATIVE EXPENSES, ALL COVERAGE GROUPS COMBINED - PAGE 8 See APPENDIX L, COST PRINCIPLES FOR ADMINISTRATIVE EXPENSES for allowable administrative expenses. Include only administrative expenses that are directly or indirectly in support of the Texas Medicaid service delivery area operations of the MCO. For all expenses other than depreciation, include only paid administrative expenses in the Final FSR. Enter the appropriate amounts on the following lines: Line 1 Salaries, Wages, and Other Benefits Line 2 Employee Bonuses and Commissions Line 3 Payroll Taxes Line 4 Legal Fees and Expenses Line 5 Auditing, Actuarial, and Other Consulting Line 6 Travel Expenses Line 7 Marketing and Advertising Line 8 Postage, Express, and Telephone Line 9 Printing and Office Supplies Line 10 Space Rental Line 11 Utilities and Maintenance -11- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 12 Building Depreciation Line 13 Equipment Depreciation Line 14 Equipment Rental Line 15 Outsourced Services (EDP, Claims, etc.) Line 16 Insurance, Except on Real Estate Excludes Reinsurance Premiums. Line 17 Premium Tax Line 18 Regulatory Authority Licenses and Fees Line 19 Affiliated Company Allocations/Charges Enter that portion of any affiliated company management fees and/or other allocations/charges incurred by the affiliate on behalf of the MCO that are charged to the Texas Medicaid SDA operations, which are not allocable to Lines 1 through 18. An MCO paying any management fees to an affiliated company must allocate the costs to the appropriate administrative expense classifications as if the costs had been paid directly by the MCO. The MCO may estimate these expense allocations based on a formula or other reasonable basis and should use the method chosen consistently from year to year, as applicable. Affiliated company management fees, or any portion thereof, are not to be reported on Line 20 Other Expenses. Line 20 Other Expenses Enter the total of all other expenses not specifically identified in any of the above administrative expense classifications. Include that portion of any non-affiliated management fees that are charged to the Texas Medicaid operations, which are not allocable to Lines 1 through 18. Non-affiliated company management fees, or any portion thereof, are not to be reported on Line 19 Affiliate Company Allocations/Charges. Line 21 Total Administrative Expenses Calculated as the sum of Lines 1 through 20. Included in Total Administrative Above: Line 22 Total Management Fees Enter the total management and/or other similar fees, paid or payable to either affiliates and/or non-affiliates for the management and/or administration of all or part of the MCO's operations. Refer to Line 19 for allocation of affiliate management fees, and Line 20 for allocation of non-affiliate management fees. Line 23 Total Related Party Expenses Enter the total administrative expenses paid or payable to any companies affiliated with the MCO through common ownership for goods and/or services. Line 24 Total Administrative Expenses Accrual Enter the total accrual for administrative expenses payable for goods and services received but not paid for as of the end of the period reported in the FSR. Accruals for administrative expenses reported on Line 24 in a previously submitted FSR that have been paid should be reported as zero (0) in the subsequent FSR. Not Included in Total Administrative Above -12- APPENDIX D CHIP MCO PROGRAM FINANCIAL STATISTICAL REPORT (FSR) INSTRUCTIONS FOR COMPLETION Line 25 Allowable Pre-implementation Costs Enter the Pre-implementation Costs that are allowable expenses to the initial contract period only, and are costs incurred between signing the initial contract and the implementation date of the contract. These costs are excluded from Administrative Expenses, but are taken into account in calculating the first contract period Experience Rebate. If the MCO does not have a profit in the first contract period, these costs are a moot point. If the MCO has a profit, the Pre-implementation Costs are subtracted from the Net Income Before Taxes before applying the experience rebate calculations. -13- APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: SERVICE AREA: SUBMISSION DATE: SUBMISSION TYPE: ACCRUAL DATE: PART 1: SUMMARY INCOME STATEMENTS (DOLLARS), ALL COVERAGE GROUPS COMBINED
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 1 Total Member Months 0 0 0 0 0 0 0 0 0 0 0 0 0 Revenues: 2 Premiums (HHSC Capitation) 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Delivery Supplemental Payments 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Investment Income 0 5 Other Revenue 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 6 Total Revenues 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- Medical Expenses: Capitated Services: 7 Single Service 0 0 0 0 0 0 0 0 0 0 0 0 0 8 Delegated Networks 0 0 0 0 0 0 0 0 0 0 0 0 0 9 Fee-For-Service 0 0 0 0 0 0 0 0 0 0 0 0 0 10 IBNR Accrual 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 11 Total Medical Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 12 Total Administrative Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 13 Total Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 14 Net Income Before Taxes 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= 15 % of Medical Exp to Premiums + DSP #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 16 % of Administrative Exp to Premiums + DSP #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 17 % of Net Income to Total Revenues #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 18 Performance Assessment 19 Quality Challenge Award 20 Liquidated Damages 0
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 1 Page 1 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT HHSC O SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 2: STATISTICAL SUMMARY, ALL COVERAGE GROUPS COMBINED
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 1 TOTAL MEMBER MONTHS 0 0 0 0 0 0 0 0 0 0 0 0 0 $PMPM: 2 Premiums #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 3 Medical Expenses (Excludes Deliveries) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 4 Premiums > Medical Expenses #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 5 Delivery Supplemental Payments (DSP) #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 6 Delivery Expenses #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 7 DSPs > Delivery Expenses #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 8 Average Cost per Delivery #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! RATIOS: Medical Loss Ratios (MLR): 9 MLR Excluding Deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 10 Deliveries Only #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 11 MLR Including Deliveries #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 12 Paid Medical Expenses Completion Factors #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 2 Page 2 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 3: FINANCIAL SUMMARIES, BY COVERAGE GROUPS - PREMIUMS AND ENROLLMENT
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- PREMIUMS (HHSC CAPITATION): 1 Age Group: less than 1 0 0 0 0 0 0 0 0 0 0 0 0 0 2 Age Group: 1-5 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Age Group: 6-14 0 0 0 0 0 0 0 0 0 0 0 0 0 4 Age Group: 15-18 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 5 Total Premiums (HHSC Capitation) 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= PREMIUM $PMPM (HHSC CAPITATION): 6 Age Group: less than 1 #DIV/0! 7 Age Group: 1-5 #DIV/0! 8 Age Group: 6-14 #DIV/0! 9 Age Group: 15-18 #DIV/0! ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 10 Total Premium $PMPM #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= MEMBER MONTHS: 11 Age Group: less than 1 0 12 Age Group: 1-5 0 13 Age Group: 6-14 0 14 Age Group: 15-18 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 15 Total Member Months 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= =======
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 3 Page 3 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 3.1: FINANCIAL SUMMARIES, BY COVERAGE GROUPS - TOTAL MEDICAL EXPENSE AND MEDICAL LOSS RATIO
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- TOTAL MEDICAL EXPENSE: 16 Age Group: less than 1 0 0 0 0 0 0 0 0 0 0 0 0 0 17 Age Group: 1-5 0 0 0 0 0 0 0 0 0 0 0 0 0 18 Age Group: 6-14 0 0 0 0 0 0 0 0 0 0 0 0 0 19 Age Group: 15-18 0 0 0 0 0 0 0 0 0 0 0 0 0 Rounding/Adjustment Input ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 20 Total Medical Expense 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= TOTAL MEDICAL EXPENSE $PMPM: 21 Age Group: less than 1 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 22 Age Group: 1-5 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 23 Age Group: 6-14 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 24 Age Group: 15-18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 25 Total Medical Expense $PMPM #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= MEDICAL LOSS RATIOS: 26 Age Group: less than 1 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 27 Age Group: 1-5 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 28 Age Group: 6-14 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 29 Age Group: 15-18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 30 Total Medical Loss Ratio #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= =======
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 3.1 Page 4 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 3.2: TOTAL MEDICAL EXPENSES INPUT WORKSHEET - BY COVERAGE GROUPS
INCURRED MONTHS: Sep-05 Oct-05 NOV-05 Dec-05 JAN-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- PAID CLAIMS INPUT (HMO ONLY): 16 Age Group: less than 1 0 17 Age Group: 1-5 0 18 Age Group: 6-14 0 19 Age Group: 15-18 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 20 Total Paid Claims Input 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === === PAID SINGLE SERVICE CAPITATION AND DELEGATED NETWORK INPUT (MCO ONLY): 16 Age Group: less than 1 0 17 AGE GROUP: 1-5 0 18 Age Group: 6-14 0 19 Age Group: 15-18 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 20 Total Paid Capitation Input 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === === PAID REINSURANCE PREMIUMS, NET OF REINSURANCE RECOVERIES INPUT (HMO ONLY): 16 Age Group: less than 1 0 17 Age Group: 1-5 0 18 Age Group: 6-14 0 19 Age Group: 15-18 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 20 Total Net Reinsurance Input 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === === IBNR INPUT (MCO ONLY): 16 Age Group: less than 1 0 17 Age Group: 1-5 0 18 Age Group: 6-14 0 19 Age Group: 15-18 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 20 Total IBNR 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === ===
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. MedExpInput Page 5 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 3.3: FINANCIAL SUMMARIES, BY COVERAGE GROUPS- DELIVERY SUPPLEMENTAL PAYMENTS AND DELIVERY EXPENSES
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 APR-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 1 CONTRACTED DSP AMOUNT DELIVERY SUPPLEMENTAL PAYMENTS ($): 2 DSPs Received by MCO 0 0 0 0 0 0 0 0 0 0 0 0 0 3 Incurred But DSP Not Received 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 4 Total DSPs ($) 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= NUMBER OF DELIVERIES 5 Age Group: 6-14 0 6 Age Group: 15-18 0 7 Incurred But DSP Not Received 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 8 Total Number of Deliveries 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= DSP $PMPM: 9 Age Group: 6-14 #DIV/0! #D!V/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 10 Age Group: 15-18 #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 11 Incurred But DSP Not Received #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 12 Total DSP $PMPM #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= NUMBER OF DELIVERIES INCURRED (#): 13 Paid Claims 0 0 0 0 0 0 0 0 0 0 0 0 0 14 Incurred But Not Paid 0 0 0 0 0 0 0 0 0 0 0 0 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 15 Total Number of Deliveries Incurred 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= DELIVERY EXPENSES ($): 16 Paid Claims 0 0 0 0 0 0 0 0 0 0 0 0 0 17 Incurred But Not Paid 0 ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 18 Total Delivery Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= AVERAGE COST PER DELIVERY ($): 19 Paid Claims #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! 20 Incurred But Not Paid #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- ------- 21 Average Cost per Delivery #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= ======= =======
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. DSP Input Page 6 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 4: TOTAL MEDICAL EXPENSES. ALL COVERAGE GROUPS COMBINED
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ --- Physician Services: 1 Primary Care 0 2 Specialist 0 3 Deliveries - Professional 0 Component 4 Non-Physician Professional 0 Services 5 Emergency Room Services 0 6 Outpatient Facility Services 0 Inpatient Facility Services: 7 Medical/Surgical 0 8 Deliveries - Facility Component 0 9 Behavioral Health Services 0 10 Other Medical Expenses 0 11 Reinsurance Premiums 0 12 Reinsurance Recoveries 0 13 Incurred But Not Reported 0 14 Incentives and/or Network Risk 0 Retention --- --- --- --- --- --- --- --- --- --- --- --- --- 15 Total Medical Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === === Included in Total Medical Above: 16 Total Single Service Capitation 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 17 Total Delegated Networks 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 18 Total Delivery Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 19 Total Related Party Expenses 0 --- --- --- --- --- --- --- --- --- --- --- --- --- Not Included in Total Medical Above: 20 Total Value Added Services 0 --- --- --- --- --- --- --- --- --- --- --- --- ---
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 4 Page 7 of 8 APPENDIX D: CHIP HMO PROGRAM FINANCIAL-STATISTICAL REPORT ORGANIZATION: 0 SERVICE AREA: 0 SUBMISSION DATE: 01/00/00 SUBMISSION TYPE: 0 ACCRUAL DATE: 01/00/00 PART 5: TOTAL ADMINISTRATIVE EXPENSES, ALL COVERAGE GROUPS COMBINED
INCURRED MONTHS: Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06 Jul-06 Aug-06 YTD - ---------------- ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ ------ --- 1 Salaries, Wages, and Other Benefits 0 2 Employee Bonuses and Commissions 0 3 Payroll Taxes 0 4 Legal Fees and Expenses 0 5 Auditing, Actuarial, and Other Consulting 0 6 Travel Expenses 0 7 Marketing and Advertising 0 8 Postage, Express, and Telephone 0 9 Printing and Office Supplies 0 10 Space Rental 0 11 Utilities and Maintenance 0 12 Building Depreciation 0 13 Equipment Depreciation 0 14 Equipment Rental 0 15 Outsourced Services (EDP, Claims, etc.) 0 16 Insurance, Except on Real Estate 0 17 Premium Tax 0 18 Regulatory Authority Licenses and Fees 0 19 Affiliated Company Allocations/Charges 0 20 Other Administrative Expenses 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 21 Total Administrative Expenses 0 0 0 0 0 0 0 0 0 0 0 0 0 === === === === === === === === === === === === === Included in Total Administrative Above: 22 Total Management Fees 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 23 Total Related Party Expenses 0 --- --- --- --- --- --- --- --- --- --- --- --- --- 24 Total Administrative Expenses Accrual 0 --- --- --- --- --- --- --- --- --- --- --- --- --- Not Included in Total Administrative Above: 25 Allowable Pre-implementation Costs 0 --- --- --- --- --- --- --- --- --- --- --- --- ---
Note: Reporting is on an incurred basis. All prior months' data must be updated to reflect each reported month on an incurred basis, including revised monthly IBNR estimates. Part 5 Page 8 of 8 EXHIBIT 3 APPENDIX E.8 DELIVERY SUPPLEMENTAL PAYMENT REPORT APPENDIX E.8 DELIVERY SUPPLEMENTAL PAYMENT (DSP) REPORT
MEM. MEM. PLAN MEMBER LAST FIRST MEM. RISK MEM. MEM. ADMIT CODE CLAIM * CHIP * NAME NAME DOB CODE YMDEFF YMDEND DIAG 1 DIAG 2 DIAG 3 PROC DT - ---- ------- ------ ---- ----- ---- ---- ------ ------ ------ ------ ------ ---- ----- PLAN DISCHARGE DELIVERY INSTITUTION PROVIDER CAP VS. CODE DT DT NAME # YMDRCVD YMDPAID CHECK * AMTPAY FFS OVR - ---- --------- -------- ----------- -------- ------- ------- ------- ------ ------- ---