Fifth Amendment to Managed Care Alliance Agreement between CIGNA Health Corporation and Gentiva CareCentrix, Inc.
Contract Categories:
Business Finance
›
Modification Agreements
Summary
This amendment, effective February 1, 2006, updates the Managed Care Alliance Agreement between CIGNA Health Corporation and Gentiva CareCentrix, Inc. It extends the agreement's term, revises definitions for covered home care services, and excludes certain home medical equipment and services. The amendment also updates compensation terms, procedures for urgent care, and obligations upon termination or amendment of the agreement. Both parties agree to cooperate in transitioning care if services are terminated or amended, and compensation terms are clarified for continued services after termination.
EX-10.30 2 ex10_30.txt Exhibit 10.30 FIFTH AMENDMENT TO MANAGED CARE ALLIANCE AGREEMENT THIS AMENDMENT (the "Amendment") is entered into this 27th day of October, 2005 by and between CIGNA Health Corporation, for and on behalf of its CIGNA Affiliates (individually and collectively, "CIGNA"), and Gentiva CareCentrix, Inc. ("MCA"). WITNESSETH WHEREAS, CIGNA and MCA entered into a Managed Care Alliance Agreement which became effective January 1, 2004 (the "Agreement") whereby MCA agreed to provide or arrange for the provision of certain home health care services to Participants, as that term is defined in the Agreement; WHEREAS, the parties wish to amend the Agreement to extend the term of the Agreement and to exclude certain home medical equipment/durable medical equipment from the Agreement, including but not limited to, home oxygen, respiratory equipment and services and enteral nutrition, effective February 1, 2006; NOW THEREFORE, CIGNA and MCA agree to amend the Agreement as follows: 1. The provisions in this Amendment shall be effective on February 1, 2006, unless otherwise provided below. 2. The definition for the term Covered Home Care Services is replaced in its entirety with the following: Covered Home Care Services means the Medically Necessary Home Health Services, Home Infusion Therapy Services and select Home Medical Equipment/Durable Medical Equipment provided to a Participant in accordance with a Service Agreement. It also includes the following services with respect to Participants receiving Covered Home Care services: (a) training and education; (b) family orientation; (c) family/caregiver training, if required; and (d) instructional literature. 3. The definition for the term Home Care Services is replaced in its entirety with the following: Home Care Services means those Home Health Services, Home Infusion Therapy Services, select Home Medical Equipment, as defined below, appropriately and safely (see Exhibit IX Safe Home Care Admission Criteria) provided in a Home Setting (except that Home Infusion Therapy Services includes the administration of the first dose of home infusion therapies in a controlled medical setting for the purpose of managing potential acute anaphylactic reactions, and Home Medical Equipment includes medical equipment used in the Home Setting, except in preparation for hospital discharge), subject to the conditions and limitations of this Agreement. 4. The definition for the term Home Medical Equipment (HME)/Durable Medical Equipment (DME) is replaced in its entirety with the following definition: Home Medical Equipment (HME)/Durable Medical Equipment (DME) means equipment that can stand repeated use, is primarily and customarily used to serve a 1 medical purpose, is generally not useful to a Participant in the absence of an illness or injury and is one of the home medical equipment/durable medical equipment services listed in the fee schedules set forth in Exhibit A to the Program Attachments to the Agreement. It is ordered or prescribed by a physician for a Participant (including all services, training, supplies, maintenance and repairs necessary for use of such equipment) including durable medical equipment provided in accordance with Exhibit XIII (DME Guidelines Grid). 5. The definition for the term Urgent Care is replaced in its entirety with the following definition: Urgent Care means services required, as directed by physician orders, within 4 hours from receipt of a Complete Order (see EXHIBIT III). Services which will be considered urgent for the purposes of this agreement shall include the following: hydration therapy for pregnant members with diagnosis of hyperemesis, hydration therapy for pediatric members and infusion therapies with less than an every 12 hour dosing schedule. Urgent care services also include same day discharges requiring pain management. Urgent care services are not intended to replace appropriate discharge planning when the Participant has been in the facility for greater than 23 hours. Inappropriate utilization of same day and urgent request for same day hospital discharge will be monitored. 6. Section II.B.8. of the Agreement is replaced in its entirety with the following provision: For Home Medical Equipment, MCA agrees to a rental cap at purchase price. Payor shall pay a fee equal to one (1) month's rental charge every six (6) months to compensate for the cost of maintaining the equipment. MCA or Represented Provider, as applicable, shall retain title to the equipment. Payor may continue to rent the equipment until the rental cap is met or purchase the piece of equipment with a maximum of two (2) months rental payments applied to the purchase price. 7. Section II.G.10. is deleted in its entirety. 8. Section III.C.2. entitled "Services Upon Termination" is replaced in its entirety with the following: Services Upon Termination or Amendment. --------------------------------------- a. Upon termination of this Agreement or upon an amendment to this Agreement which results in the termination of the provision of any services under this Agreement, MCA through its Represented Providers shall continue to provide Covered Services for specific conditions for which a Participant was under Represented Provider's care at the time of such termination or amendment, as applicable, so long as the Participant retains eligibility under a Service Agreement, until the earlier of completion of such services, CIGNA's provision for the assumption of such treatment by another provider, or the expiration of *. MCA shall be compensated for Covered Services provided to any such Participant in accordance with the compensation arrangements under this Agreement until * following such amendment or termination, and compensation thereafter for continued services authorized by CIGNA shall be at the fee for service rates contained in the Agreement prior to this Amendment. MCA and its Represented Providers have no obligation under this Agreement to provide services to individuals who cease to be Participants. * Confidential treatment requested. 2 b. Upon receipt of notice of termination of this Agreement or upon the execution of an amendment to this Agreement which results in the termination of the provision of any services under this Agreement (the services affected by such termination or amendment shall be referred to as the "Terminated Services"), MCA and its Represented Providers shall cooperate as necessary to ensure a smooth transitioning of care of the Terminated Services. MCA and CIGNA agree to evaluate all requests for Terminated Services commencing 30 days prior to the effective date of such termination or amendment to limit unnecessary Participant transition of care during the period following the effective date of such termination or amendment. Upon and following the effective date of such termination or amendment, MCA shall refer all requests for Terminated Services to a Participating Provider designated by CIGNA. 9. Section II.B.9. of the HMO Program Attachment to the Managed Care Alliance Agreement (Capitation) is deleted in its entirety. 10. Section II.B.9. of the Gatekeeper Program Attachment to the Managed Care Alliance Agreement (Capitation) is deleted in its entirety. 11. Exhibit XIII. is replaced in its entirety with the attached Exhibit XIII. 12. The Agreement is amended to add the following new provision to Section II.B. entitled "Compensation and Billing": Commencing February 1, 2007, utilization will be measured periodically for all * issued to all Participants, both under this Agreement and by other providers outside this Agreement. If the ratio of * units to * units for * exceeds *, the * for * under this Agreement shall be amended to bring the average cost * to below *. If MCA is unwilling to amend the Agreement to reflect this revised rate, CIGNA shall have the right to exclude * from this Agreement upon 90 days advance notice to MCA. 13. The Agreement is amended to add the following new provision to Section II.B. entitled "Compensation and Billing": CIGNA may exclude * and * from this Agreement at any time on or after February 1, 2007. CIGNA must provide MCA with 90 days advance notice of its intent to exclude such services. 14. Effective upon execution of this Amendment, Section 8 in the Second Amendment to the Agreement effective January 1, 2005 relating to * is replaced in its entirety with the following provision: CIGNA may exclude * from this Agreement at any time on or after January 1, 2006. CIGNA must provide MCA with thirty (30) days advance notice of its intent to exclude such services. Ninety (90) days following such notice, the rates indicated in Section 2A(1) will apply to any remaining existing patients and new patient referral to MCA requested to be taken by CIGNA. 15. Effective upon execution of this Amendment, the parties agree to continue to implement the leakage abatement program described in Attachment A for Home Health Services, Home Infusion Therapy Services and Home Medical Equipment/Durable Medical Equipment. Effective February 1, 2006, the leakage program will continue for Home Health Services, Home Infusion Therapy Services and the select Home Medical Equipment/Durable Medical Equipment, included in Exhibit A to the Program Attachments, for the remainder of the term of the Agreement. * Confidential treatment requested. 3 16. Effective February 1, 2006, Exhibit A HMO Program Attachment - Capitation Schedule of Capitation Rates is hereby deleted and replaced with a new Exhibit A HMO Program Attachment - Capitation Schedule of Capitation Rates attached hereto. 17. Effective February 1, 2006, Exhibit A HMO Program Attachment - Fee for Service Reimbursement For Other Services is hereby deleted and replaced with a new Exhibit A HMO Program Attachment - Fee for Service Reimbursement For Other Services attached hereto. 18. Effective February 1, 2006, Exhibit A PPO & Indemnity Program Attachment - Fee for Service Reimbursement For Other Services is hereby deleted and replaced with a new Exhibit A PPO & Indemnity Program Attachment Reimbursement For Other Services attached hereto. 19. Effective February 1, 2006, Exhibit A Gatekeeper Program Attachment - Capitation Schedule of Capitation Rates is hereby deleted and replaced with a new Exhibit A Gatekeeper Program Attachment -Capitation Schedule of Capitation Rates attached hereto. 20. Effective February 1, 2006, Exhibit A Gatekeeper Program Attachment - Fee for Service Reimbursement For Other Services is hereby deleted and replaced with a new Exhibit A Gatekeeper Program Attachment - Fee for Service Reimbursement For Other Services attached hereto. 21. Section III.B. entitled Term of the Agreement shall be replaced in its entirety with the following provision: This Agreement shall be in full force and effect for a three (3) year period terminating on January 31, 2009. MCA shall present its proposal to CIGNA for the * rates on or before *. If 1) MCA timely submits such proposal; 2) the proposal includes a * that exceeds * per member per month or an increase to the fee-for-service rates that exceeds the permitted inflation ceiling as set forth in Exhibit A to the Program Attachments; and 3) the parties are unable to reach agreement on the *, either party may terminate this Agreement effective * by providing written notice to the other party on or before *. If neither party exercises such right to terminate this Agreement or if MCA fails to timely submit its proposal for the * rates, then the existing rates will remain in place and this Agreement shall automatically renew for consecutive one year terms without any further action by either party, unless either party elects not to renew this Agreement by providing at least ninety (90) days advance written notice to the other party, prior to the commencement of the next term. Notwithstanding the expiration or non-renewal of this Agreement pursuant to this Section B., this Agreement shall continue in effect with respect to those Payors covered under Service Agreements in effect as of the end of the term of this Agreement or the notice period, as applicable, but not to exceed * from the effective date of termination or expiration. 22. To the extent that the provisions in the Agreement, including any prior amendments, conflict with the terms of this Amendment (including the exhibits and schedules hereto), the terms in this Amendment shall supersede and control. All other terms and conditions of the Agreement, as previously amended, including the Program Attachments and the Exhibits attached thereto, shall remain the same and in full force and effect. Capitalized terms not defined herein but defined in the Agreement shall have the same meaning as defined in the Agreement. * Confidential treatment requested. 4 IN WITNESS WHEREOF, CIGNA and MCA have caused their duly authorized representatives to execute this Amendment as of the date first written above. CIGNA HEALTH CORPORATION By: _________________________________ Its: _________________________________ Dated: _________________________________ GENTIVA CARECENTRIX, INC. By: _________________________________ Its: _________________________________ Dated: _________________________________ 5 EXHIBIT XIII. DME GUIDELINES GRID Durable Medical Equipment (DME) is defined as equipment that can stand repeated use, is primarily and customarily used to serve a medical purpose, and is generally not useful to a person in the absence of an illness or injury. DME items have the following characteristics: 1. The equipment is prescribed by a physician; 2. The equipment meets the definition of DME; 3. The equipment is necessary and reasonable for the treatment of a patient's illness or injury. 4. The equipment is manufactured primarily for use in the home environment but is not limited to use in the home. Portable equipment for use outside the home may be covered as an alternative to a stationery unit when the cost of the portable unit is equal to or less than the stationery unit and the member's medical condition supports the need for the equipment periodically outside the home setting. Equipment intended for extended use in the home, but which is appropriately delivered for use and education in an inpatient environment for up to five days will be delivered to the member either in the inpatient environment prior to discharge , or in the member's home prior to an admission. 5. Institutional equipment requested by CIGNA to be provided by Gentiva in an inpatient facility for use in the facility when the equipment is not part of the discharge plan for use in the member's home, or when the member is not a permanent resident of the facility, is not covered under the member's DME benefit. Initial attempts should be made to have the facility provide the equipment as part of their facility charges. When this cannot be accomplished, Gentiva will contact contracted vendors to obtain the requested equipment for CIGNA on a discount FFS basis. If the health plan is not available to issue the FFS authorization (week-ends and after hours) the request will be sent to the health plan and it is expected that a FFS authorization number will be issued by the health plan. It should be noted that Home Medical Equipment vendors do not have all institutional type equipment in stock and there may be a need to special order the equipment HOME: The home is defined as either the member's home; the home of a family member or primary care giver within the national CIGNA/ Gentiva service area. Member's who have been permanently admitted to an inpatient skilled nursing facility or inpatient hospice and who have changed their home address to that of the SNF or hospice will have the SNF or hospice defined as their home. DME covered under cap in the home would be covered under cap in these facilities. Products. A listing of the contracted items, or group of items, that are or may be perceived as home medical equipment. This listing, while reasonably complete is not intended to quantify the entire spectrum of products that may be considered DME either now or in the future. Installation of equipment that requires attachment to the structure of the home or making home modifications (construction/renovation) is not the responsibility of GENTIVA Care Centrix. Coverage Criteria. Conditions under which DME coverage is justified. These guidelines are a combination of Medicare guidelines, CIGNA benefit interpretations, and DME industry standards. Equipment noted as "not covered" only refer to coverage under the DME capitation, but may be covered under other benefit plans such as pharmacy, consumable medical supplies, external prosthetic appliances or hospital benefits. Efforts should be made to provide "not covered" items on a discount fee for service basis to assist in meeting CIGNA and patient's needs. Items may have separate coverage guidelines noted for medicare coverage issues and are identified by italics. HCPC. Medicare HCFA Common Procedure Coding system. For reference only, note that the existence of a Medicare code does not indicate coverage or reimbursement acceptance. Diagnosis. These are typical diagnosis indicated for each type of DME; this list is a general guideline and is not exhaustive of all potential qualifying diagnosis. Site of Service, Training and Supplies. A listing of common industry practices that are the minimal accepted levels noting how equipment is to be delivered to the patient (or picked up), who is responsible for patient education and how it is accomplished, and which accessories and supplies are included in the DME benefit. Minimum standards will be adjusted on a state by state basis to meet legal and regulatory requirements. Supplies listed as included reflect 6 capitated coverage only, fee for service and Medicare will generally pay additional charges for supplies used with CPM. BRAND Supplied. When completed, it will list typical manufacturers and their model numbers as specific examples of items provided for these product descriptions, but are not considered inclusive of all products that could be offered. If there is an established clinical need for a model number or product other than those listed it will be considered under capitated coverage. Rent/Purchase. Used internally at GENTIVA CareCentrix to determine the appropriate time to make the financial decision when it is more cost effective to purchase equipment versus ongoing rental. Patients' diagnosis, prognosis, level of care and equipment maintenance needs will be the key factors. All discount FFS equivalent rental amounts will be applied to the purchase price of any purchased equipment. Coverage Statements for General Categories. General policies for coverage of items that may fall under multiple benefits are listed beginning on page 39, are unique in their requirements, or are generally excluded from all coverage. Many of these items can be purchased at local drug stores, hardware stores or retail outlets. 7 SITE OF SERVICE DEFINITIONS Category I (product only) - Delivered to patients home by small package delivery service (i.e. UPS or U.S. mail) is an acceptable site of service if: Consumer agrees to small package delivery via telephone or in writing. 1. Meets patients or caregivers requirements for timeliness, same day delivery may incur additional charges; 2. Is a purchase item only; 3. Requires minimal or no assembly; 4. Setup and training can be easily accomplished via written (or video) instruction; 5. Is a supply reorder; and 6. Is easily transported and can sustain shipping and handling. Category II (product and service, outpatient) - Items can be picked up at DME provider or from PCP (consigned from contracted DME provider) location if: 1. It meets the patients or caregivers requirements for timeliness; 2. Requires specialized fitting and measurement that can be best accomplished in a professional environment; 3. May be a stat or rush order; 4. Needs minimal patient or caregiver training (or training completed at physicians office); 5. Requires a written physician order upon pickup; 6. Can easily be transported; 7. Includes all category I items. Category III (product and service at patients home) - Delivered by DME company employee (clinical staff if noted) to patients residence if: 1. Patient or caregiver training required; 2. Clinical assistance required; 3. Is too bulky for easy transport; 4. Is considered a hazardous material; 5. Is a stat or rush order (may apply to all categories) 6. Requires installation and setup; 7. Requires an environmental site inspection; 8. Includes category II items where customer pickup cannot be accomplished; This option may include delivery to physician office or hospital. 8
9
10
11
12
13 EXHIBIT A LEAKAGE ABATEMENT PROGRAM Leakage Abatement - -----------------
- ------------------------------------------------------------------------------------------------------------- 6 Forward CareCentrix National Forward refund check from provider to CIGNA for Claim Center (NCC) adjustment to member account - ------------------------------------------------------------------------------------------------------------- Forward refund check with Special Handle instructions to 7 Forward CIGNA Electronic Mailroom (EMR) for coding and scanning of check and documentation. - ------------------------------------------------------------------------------------------------------------- EMR forwards scanned check to Bank Of America for 8 Forward EMR deposit. - ------------------------------------------------------------------------------------------------------------- Post refund and reverse original (direct) claims and 9 Post CIGNA issue corrected EOBs to member - ------------------------------------------------------------------------------------------------------------- 10 Notification CIGNA Once refund is posted, CIGNA notifies Gentiva that refund is complete - ------------------------------------------------------------------------------------------------------------- 11 Re-invoice CareCentrix National Invoice CIGNA for claim(s) involved Billing Center (NBC) - ------------------------------------------------------------------------------------------------------------- 12 Re-payment CIGNA Pay CareCentrix for claim(s) per contracted rates and issue new EOB(s) to CareCenrix and member - -------------------------------------------------------------------------------------------------------------
EXHIBIT A HMO PROGRAM ATTACHMENT - CAPITATION SCHEDULE OF CAPITATION RATES CAPITATION RATES EFFECTIVE 2/1/06 - 1/31/07 These are the capitation rates that apply to services rendered to Patient Panel Participants enrolled in HMO Programs. An "HMO Program" means a non-governmental, fully insured HMO or Point of Service product that is underwritten based on a community rating methodology (i.e. community rating, community rating by class, adjusted community rating by class). - ---------------------------------------------------------------------------------------------------- Gentiva Homehealth Infusion and DME/HME Capitation Rate PMPM - ----------------------------------------------------------------------------------------------------
Capitation Rate Compensation Terms - ---------------------------------- The following rates are established for the provision of Home Care Services rendered to Program Participants covered under the HMO and Gatekeeper plans: February 1, 2006 - January 31, 2007 $* per member per month February 1, 2007 - January 31, 2008 $* per member per month February 1, 2008 - January 31, 2009 $* per member per month The capitation rate listed above for each twelve month period is allocated between HMO and Gatekeeper Program participants in accordance with established business practices. On or about December 1 of each year, the parties shall reconcile the allocation and settle any payment difference no later than December 31 of each calendar year. If an outlier calculation for * demonstrates a patient per thousand (PPK) increase in excess of *, (* ppk), then MCA reserves the right to propose an * pmpm outlier adjustment no later than September 1. CIGNA may elect to accept the proposed adjustment or * and * from this agreement. * Confidential treatment requested. EXHIBIT A HMO PROGRAM ATTACHMENT - FEE FOR SERVICE REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS: - --------------------------------------------------------------------------------------------------------------- STATE RATE AREA RATE DESIGNATION - ---------------------------------------------------------------------------------------------------------------
* Confidential treatment requested. TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31, 2007
NOTES: 1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL CHILD HEALTH VISITS, which have no maximum duration). 2. Hourly rate for visits exceeding two (2) hours in duration, starting with hour 3. 3. CIGNA does not reimburse for travel time, weekend, holiday or evening differentials. 4. Above prices have no exclusions. 5. All services not listed above will be billed at * until rates are mutually established and become part of the fee schedule. 6. RN High Tech Infusion visit and hourly utilization/costs to be reported with HIT. 7. Respiratory Therapist visit utilization/costs to be reported with HME/RT. 8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty certification which is not readily available in the home care environment. Use requires special coordination. 9. There shall be a ceiling for annual inflation increases in Home Health Services of *. * Confidential treatment requested. HOME INFUSION RATES RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31, 2007 - -------------------------------------------------------------------------------- The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP (if applicable), and there is NO price difference between primary and multiple therapies
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP, and there IS a price difference between primary and multiple anti-infective therapies
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rate EXCLUDES drugs. Drugs are priced per vial, and there is NO price difference between primary and multiple anti-infective therapies - --------------------------------------------------------------------------------
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rates INCLUDE drugs, and there is NO price difference between primary and multiple therapies - --------------------------------------------------------------------------------
* Confidential treatment requested. SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES NOTES: 1. Per Diems EXCLUDING drugs include all costs related to the therapy except the cost of drugs, including but not limited to facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 2. Per Diems INCLUDING drugs include ALL costs - including but not limited to cost of drugs, facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the home infusion provider. 4. "PER DIEM" costs are the same for primary or multiple treatments for all drug categories, except ANTI-INFECTIVES. 5. The per diem rate shall only be charged for those days the Participant receives medication. 6. For home infusion pharmaceuticals not listed on fee schedule, * will apply. 7. There shall be a ceiling for annual inflation increases in Home Infusion Therapy of*. 8. There shall be a ceiling for annual inflation increases in Medications under *. 9. All Medications are subject to MAC pricing, where applicable. - ------------------------------------------------------------------------------------------------------------------- The following are for the stated item ONLY. Unless otherwise noted, nursing, supplies, etc. are NOT included. - -------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested. SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES - ------------------------------------------------------------------------------------------------------------------- Factor Concentrates - ------------------------------------------------------------------------------------------------------------------- Vial price Unit Price - -------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested. SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES - ------------------------------------------------------------------------------------------------------------------- Factor Concentrates - ------------------------------------------------------------------------------------------------------------------- Vial price Unit Price - -------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested.
NOTES: 1. Whether rental or purchase, rates include all shipping, labor and set-up. 2. If item is rented, rates include all supplies to enable the equipment to function effectively with the exception Suction and CPM. Such exception supplies will be billed at *. 3. If item is rented, rates include repair and maintenance costs. * Confidential treatment requested. EXHIBIT A PPO & INDEMNITY PROGRAM ATTACHMENT - FEE FOR SERVICE REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS:
* Confidential treatment requested. TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
NOTES: 1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL CHILD HEALTH VISITS, which have no maximum duration). 2. Hourly rate for visits exceeding two (2) hours in duration, starting with hour 3. 3. CIGNA does not reimburse for travel time, weekend, holiday or evening differentials. 4. Above prices have no exclusions. 5. All services not listed above will be billed at * until rates are mutually established and become part of the fee schedule. 6. RN High Tech Infusion visit and hourly utilization/costs to be reported with HIT. 7. Respiratory Therapist visit utilization/costs to be reported with HME/RT. 8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty certification which is not readily available in the home care environment. Use requires special coordination. 9. There shall be a ceiling for annual inflation increases in Home Health Services of*. * Confidential treatment requested. HOME INFUSION RATES RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007 - ------------------------------------------------------------------------------- The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP (if applicable), and there is NO price difference between primary and multiple therapies - -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rates EXCLUDE drugs. Drugs are priced as a percentage discount off AWP, and there IS a price difference between primary and multiple anti-infective therapies - --------------------------------------------------------------------------------
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rate EXCLUDES drugs. Drugs are priced per vial, and there is NO price difference between primary and multiple anti-infective therapies - --------------------------------------------------------------------------------
- -------------------------------------------------------------------------------- The following Home Infusion Therapy service rates INCLUDE drugs, and there is NO price difference between primary and multiple therapies - --------------------------------------------------------------------------------
* Confidential treatment requested. SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES NOTES: 1. Per Diems EXCLUDING drugs include all costs related to the therapy except the cost of drugs, including but not limited to facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 2. Per Diems INCLUDING drugs include ALL costs - including but not limited to cost of drugs, facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the home infusion provider. 4. "PER DIEM" costs are the same for primary or multiple treatments for all drug categories, except ANTI-INFECTIVES. 5. The per diem rate shall only be charged for those days the Participant receives medication. 6. For home infusion pharmaceuticals not listed on fee schedule, * will apply. 7. There shall be a ceiling for annual inflation increases in Home Infusion Therapy of *. 8. There shall be a ceiling for annual inflation increases in Medications under *. 9. All Medications are subject to MAC pricing, where applicable * Confidential treatment requested. - ------------------------------------------------------------------------------------------------------------------- The following are for the stated item ONLY. Unless otherwise noted, nursing, supplies, etc. are NOT included. - -------------------------------------------------------------------------------------------------------------------
* Confidential treatment requested. SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
* Confidential treatment requested. SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
* Confidential treatment requested. DME / HME RESPIRATORY RATES: RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2009
NOTES: 1. Whether rental or purchase, rates include all shipping, labor and set-up. 2. If item is rented, rates include all supplies to enable the equipment to function effectively with the exception Suction and CPM. Such exception supplies will be billed at *. 3. If item is rented, rates include repair and maintenance costs. * Confidential treatment requested. EXHIBIT A GATEKEEPER PROGRAM ATTACHMENT - CAPITATION SCHEDULE OF CAPITATION RATES CAPITATION RATES EFFECTIVE 2/1/06 - 1/31/07 These are the capitation rates that apply to services rendered to Patient Panel Participants enrolled in Gatekeeper Programs. An "Gatekeeper Program" means (i) a product that includes fully insured Standard HMO, Point of Service, or Gatekkeper PPO benefits and which is underwritten by a licensed insurance company based on an experience rating methodology, or (ii) a self funded product which includes Standard HMO, Point of Service, or Gatekeeper PPO benefits. This definition includes, but is not limited to, Participants covered under Flexcare plans insured/administered by Connecticut Life Insurance Company.
Capitation Rate Compensation Terms The following rates are established for the provision of Home Care Services rendered to Program Participants covered under the HMO and Gatekeeper plans: February 1, 2006 - January 31, 2007 $*per member per month February 1, 2007 - January 31, 2008 $* per member per month February 1, 2008 - January 31, 2009 $* per member per month The capitation rate listed above will be allocated between HMO and Gatekeeper Program participants in accordance with established business practices. On or about December 1 of each year, the parties shall reconcile the allocation and settle any payment difference no later than December 31 of each calendar year. If an outlier calculation for * demonstrates a patient per thousand (PPK) increase in excess of *, (* ppk), then MCA reserves the right to propose an * pmpm outlier adjustment. CIGNA may elect to accept this adjustment or * from this agreement. * Confidential treatment requested. EXHIBIT A GATEKEEPER PROGRAM ATTACHMENT - FEE FOR SERVICE REIMBURSEMENT FOR OTHER SERVICES RATE AREA DESIGNATIONS:
* Confidential treatment requested. TRADITIONAL HOME HEALTH FEE-FOR-SERVICE RATE RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
The following Traditional Home Health Service has Hourly only rates.
The following Traditional Home Health Service is priced on a Per Diem basis.
NOTES: 1. Visits are defined as two (2) hours or less in duration (EXCEPT MATERNAL CHILD HEALTH VISITS, which have no maximum duration). 2. Hourly rate for visits exceeding two (2) hours in duration, starting with hour 3. 3. CIGNA does not reimburse for travel time, weekend, holiday or evening differentials. 4. Above prices have no exclusions. 5. All services not listed above will be billed at * until rates are mutually established and become part of the fee schedule. 6. RN High Tech Infusion visit and hourly utilization/costs to be reported with HIT. 7. Respiratory Therapist visit utilization/costs to be reported with HME/RT. 8. Diabetic Nurse, Psychiatric Nurse and Rehabilitation Nurse assume specialty certification which is not readily available in the home care environment. Use requires special coordination. 9. There shall be a ceiling for annual inflation increases in Home Health Services of*. * Confidential treatment requested. HOME INFUSION RATES RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2007
* Confidential treatment requested. SCHEDULE 2A, PAGE 2: HOME INFUSION HMO/FLEX FEE-FOR-SERVICE THERAPY RATES NOTES: 1. Per Diems EXCLUDING drugs include all costs related to the therapy except the cost of drugs, including but not limited to facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 2. Per Diems INCLUDING drugs include ALL costs - including but not limited to cost of drugs, facility overhead, supplies, delivery, professional labor including compounding and monitoring, all nursing required, maintenance of specialized catheters, equipment/patient supplies, disposables, pumps, general and administrative expenses, etc. 3. "DISPENSING FEE" is defined as per each time the drug is dispensed by the home infusion provider. 4. "PER DIEM" costs are the same for primary or multiple treatments for all drug categories, except ANTI-INFECTIVES. 5. The per diem rate shall only be charged for those days the Participant receives medication. 6. For home infusion pharmaceuticals not listed on fee schedule, * will apply. 7. There shall be a ceiling for annual inflation increases in Home Infusion Therapy of *. 8. There shall be a ceiling for annual inflation increases in Medications under *. 9. All Medications are subject to MAC pricing, where applicable
* Confidential treatment requested. SCHEDULE 2A, PAGE 3: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
* Confidential treatment requested. SCHEDULE 2A(1), PAGE 4: HOME INFUSION THERAPY HMO/FLEX FEE-FOR-SERVICE RATES
* Confidential treatment requested. DME / HME RESPIRATORY RATES: RATES EFFECTIVE FEBRUARY 1, 2006 - JANUARY 31. 2009
NOTES: 1. Whether rental or purchase, rates include all shipping, labor and set-up. 2. If item is rented, rates include all supplies to enable the equipment to function effectively with the exception Suction and CPM. Such exception supplies will be billed at *. 3. If item is rented, rates include repair and maintenance costs. * Confidential treatment requested.
