Change Order No. 11 to Medi-Cal Agreement Between California Department of Health Services and Molina Healthcare of California
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This agreement is a change order between the California Department of Health Services and Molina Healthcare of California. It updates the capitation rates paid to Molina for providing Medi-Cal managed care services in Riverside and San Bernardino counties, reflecting increases in outpatient hospital rates for specific periods between July 2001 and September 2002. The new rates are effective retroactively and will be included in future payments, with retroactive adjustments processed within four to six weeks. The agreement also clarifies that these capitation rates constitute full payment for covered services during the specified periods.
EX-10.16 4 dex1016.txt CHANGE ORDER NO. 11 TO MEDI-CAL AGREEMENT [LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES] EXHIBIT 10.16 AUG 8-2002 Mr. George Goldstein President/CEO Molina Healthcare of California dba: Molina One Golden Shore Dr. Long Beach, CA 90802 Dear Mr. Goldstein In accordance with Article V, Section 5.5 of your Contract, the enclosed Change Order No.11 transmits (Molina Healthcare of California dba: Molina) adjusted capitation rates to incorporate Fee-For-Service out-patient hospital rate increases for the rate periods of July 1, 2001 through September 30, 2001, and October 1, 2001 through September 30, 2002. The rates from this Change Order will be reflected in your August 2002 capitation payment. Payments for the retroactive portion of these rates will be processed in approximately four to six weeks. If you have any questions, please contact your contract manager. Sincerely, /s/ Cheri Rice Cheri Rice, Chief Medi-Cal Managed Care Division Enclosure [LETTERHEAD OF DEPARTMENT OF HEALTH SERVICES] CHANGE ORDER NUMBER C11 TO CONTRACT NUMBER 95-23673: ADJUSTING THE CAPITATION RATES TO INCORPORATE FEE-FOR-SERVICE OUT-PATIENT HOSPITAL RATE INCREASES FOR THE PERIODS OF JULY 1, 2001 THROUGH SEPTEMBER 30, 2001, AND OCTOBER 1, 2001 THROUGH SEPTEMBER 30, 2002, BY CHANGING CONTRACT SECTION 5.3 CAPITATION RATES; AND, 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL. This Change order is effective July 1, 2001. 1. 5.3 CAPITATION RATES FOR THE PERIOD 10/01/01 - 9/30/02 RIVERSIDE --------------------------------------------------------------------------- Groups Aid Codes Rate --------------------------------------------------------------------------- Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40, 42, 47, 54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 3U, 4F, 4G, 4M, 5X, 7X, 8P $ 88.56 Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R, 6V $ 237.62 Aged 1H, 10, 14, 16, 18 $ 172.56 Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, 7A, 7J, 8R $ 99.56 Adult 86 $ 856.66 Aids $ 894.05 Beneficiary FOR THE PERIOD 7/01/01 - 9/30/01 RIVERSIDE --------------------------------------------------------------------------- Groups Aid Codes Rate --------------------------------------------------------------------------- Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40, 42, 47, 54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 3U, 4F, 4G, 4M, 5X, 7X, 8P $ 87.83 Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R, 6V $ 227.39 Aged 1H, 10, 14, 16, 18 $ 162.29 Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, 7A, 7J, 8R $ 90.89 Adult 86 $ 855.50 Aids Beneficiary $ 863.77 FOR THE PERIOD 10/01/01 - 9/30/02 SAN BERNARDINO --------------------------------------------------------------------------- Groups Aid Codes Rate --------------------------------------------------------------------------- Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40, 42, 47, 54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 3U, 4F, 4G, 4M, 5X, 7X, 8P $ 89.50 Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R, 6V $ 239.21 Aged 1H, 10, 14, 16, 18 $ 174.39 Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, 7A, 7J, 8R $ 106.65 Adult 86 $ 937.88 Aids Beneficiary $ 938.00 2 FOR THE PERIOD 7/01/01 - 9/30/01 SAN BERNARDINO -------------------------------------------------------------------------- Groups Aid Codes Rate -------------------------------------------------------------------------- Family 01, 0A, 02, 08, 30, 32, 33, 34, 35, 38, 39, 40, 42, 47, 54, 59, 72, 3A, 3C, 3E, 3G, 3H, 3L, 3M, 3N, 3P, 3R, 3U, 4F, 4G, 4M, 5X, 7X, 8P $ 84.14 Disabled 20, 24, 26, 28, 36, 60, 64, 66, 68, 6A, 6C, 6H, 6N, 6P, 6R, 6V $ 227.01 Aged 1H, 10, 14, 16, 18 $ 153.35 Child 03, 04, 4A, 4C, 4K, 5K, 45, 82, 7A, 7J, 8R $ 95.25 Adult 86 $ 934.96 Aids Beneficiary $ 906.96 If DHS creates a new aid code that is split or derived from an existing aid code covered under this Contract, and the aid code has a neutral revenue effect for the Contractor, then the split aid code will automatically be included in the same aid code category as is the original aid code covered services to the Members at the monthly capitation rate specified for the original aid code. DHS shall confirm all aid code splits, and the rates of payment for such new aid codes, in writing to Contractor as soon as practicable after such aid code splits occur. 2. 5.4 CAPITATION RATES CONSTITUTE PAYMENT IN FULL Capitation rates for each rate period, as calculated by DHS, are prospective rates and constitute payment in full, subject to any stop loss reinsurance provision, on behalf of a Member for all Covered Services required by such Member and for all administrative Costs incurred by the Contractor in providing or arranging for such services, and subject to adjustment for federally qualified health centers in accordance with Section 14087.325 of the W&I Code but do not include payment for recoupment of current or previous losses incurred by Contractor. The actuarial basis for the determination of the capitation payment rates is outlined in Attachment 1 (consisting of 24 pages). 3 Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: Family The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 1 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: Disabled The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 2 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: Aged The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 3 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: Child The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 4 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: Adult The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 5 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 355 Date: 23-Jul-02 County: Riverside Plan Type: Commercial Plan Aid Code Grouping: AIDS The Rate Period is October 1, 2001 Capitation Payments at the to September 30, 2002 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 6 of 24 Prepared by Department of Health Services, Rate Development Branch Aid Code Grouping: Family The Rate Period is July 1, 2001 Capitation Payments at the End of the Month to September 30, 2001 Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 7 of 24 Aid Code Grouping: Disabled The Rate Period is July 1, 2001 Capitation Payments at the End of the Month to September 30, 2001 Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 8 of 24 Aid Code Grouping: Aged The Rate Period is July 1, 2001 Capitation Payments at the End of the Month to September 30, 2001 Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 9 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch Aid Code Grouping: Child The Rate Period is July 1, 2001 Capitation Payments at the End of the Month to September 30, 2001 Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 10 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch Aid Code Grouping: Adult The Rate Period is July 1, 2001 Capitation Payments at the End of the Month to September 30, 2001 Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 11 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch Aid Code Grouping: AIDS The Rate Period is July 1, 2001 Capitation Payments at the End to September 30, 2001 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 12 of 24 Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: Family The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 13 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: Disabled The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 14 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: Aged The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 15 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: Child The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 16 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: Adult The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 17 of 24 Prepared by Department of Health Services, Rate Development Branch Plan Name: Molina Medical Center Plan #: 356 Date: 23-Jul-02 County: San Bernardino Plan Type: Commercial Plan Aid Code Grouping: AIDS The Rate Period is October 1, 2001 Capitation Payments at the End to September 30, 2002 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N Lenses for eyewear N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screens N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 18 of 24 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the End to September 30, 2001 of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 19 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the to September 30, 2001 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 20 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the to September 30, 2001 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 21 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the to September 30, 2001 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 22 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the to September 30, 2001 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 23 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch The Rate Period is July 1, 2001 Capitation Payments at the to September 30, 2001 End of the Month Coverages ( C = Covered by Plan, N = NOT Covered by Plan ) CCS Indicated Claims N GHPP N Hemodialysis C Major Organ Transplants N Out-of-State C Chiropractor N Local Education Authority N Psychiatrist N Acupuncturist N Alphafeto Protein Testing N Heroin Detoxification N Direct Observed Therapy N PIA Lenses N AIDS Waiver N In Home Waiver N Model NF Waiver N Adult Day Health Care N Newborn Hearing Screening N Psychiatric Drugs N AIDS Drugs N Injections C MH - Hospital Inpatient N MH - Outpatient Services N Long Term Care for month of entry plus one C Long Term Care after month of entry plus one N CHDP C
#95-23673 C11 Attachment Page 24 of 24 7/23/2002 Prepared by Department of Health Services, Rate Development Branch
