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RESPONSE - RFP - P682 BENEFITS (15)
PacifiCare ° PacifiCare Review, your utilization review program for PPO and indemnity plans, can help you become a wise health care consumer. It guards against overspending health care dollars, making sure you are receiving treatment that is necessary and appropriate. Make the most of your benefits by knowing what is required BEFORE you receive medical care or treatment. This is especially important for services that require your doc- tor to call Utilization Review BEFORE the treatment or service takes place. Benefits may be reduced and/or an additional deductible may be applied.* It is your responsibility to make sure preauthorization is done prior to the following: 1 Hospital Admissions (includes Skilled Nursing Facility stays and Inpatient Rehabilitation) Outpatient Surgeries performed in other than the doctors office PacifiCare Review 1 Home Health Care 1 Inpatient and Outpatient Hospice Care Please be sure to call at least five days before you are to receive these services. For maternity cases, it is recommended that a call be made to PacifiCare Review as soon as pregnancy is confirmed. For emergency or urgent hospital admissions, the call must be made within 48 hours or on the next business day if the admission is on a weekend, holiday, or after 5 p.m. on Friday. Call toll -free, 1-800-255-1189. Certification of utilization review does not guarantee benefits or that all charges are covered under the policy. Charges submitted for payment are subject to all terms and conditions of the policy. *Failure -to -Call Penal: Certification must be obtained before services are received. If the Insured Individual fails to call PacifiCare Review as required, a penalty of an additional deductible of $250 will apply. This penalty is in addition to any other deductible under the policy and will not apply toward the satisfaction of a deductible, copayment or stop -loss. a Caan1V� a im pWIMMaal Calerol 55 South Yosemite Street EM 1401 ! Englewood, Co 80111 Some medications not covered on the pharmacy benefit include over-the-counter medications and hospital take-home drugs provided by the hospital at the time of discharge. Please refer to your Evidence of Coverage for details regarding drugs not covered. Prescription Units A prescription unit is the amount of medication you can receive for one copayment. Most prescription units are based on trade -size packaging, a full course of treatment or a 30-day supply of ongoing therapy. Antibiotics, liquids, non -oral products and more strictly controlled medicines may be dis- pensed in less than a 30-day supply. If you receive more than one prescription unit, you will have a copayment for each unit. For example, an inhaler is a prescription unit. If you receive two, you will pay two copayments. The Prescription Mail Service Program Having a prescription filled now is easier and less expensive than ever. The Prescription Mail Service program provides convenient service and savings on medications you take on a regular basis, sometimes referred to as "maintenance medications." In fact, for most plans you pay only two copayments for up to a 90-day supply of medication dispensed through mail order, which saves you one copayment. That explains why mail service is such a popular feature of our prescription drug program! Save Time and Money with the Convenient Prescription Mail Service Program Having your prescriptions filled by mail is easy. Just follow these steps: law, -prescriptions can only be filled for the quantity indicated on the prescription. 1. Complete the prescription mail service form. A new form for your next order will be mailed back along with your medication. The new form will show the number of refills you have left. 2. Enclose your written prescriptions and a check or money order for the appropriate copayment Contact your physician's office, identify yourself as a PacifiCare member, and inform them that you would like to use the Prescription Mail Service Program to obtain your maintenance medications. Ask your physician for a written prescription (90-day supply) of each medication you need. Be sure that your doctor writes the prescription with additional refills. Your physician will inform you when you can pick up your written prescriptions. NOTE: PacifiCare must have a new prescription to process any new mail service request. By amount. 3. Apply postage and mail. NOTE: If you are starting a new maintenance medication, request two prescriptions: one for a 30-day supply and one for a 90-day supply. Have one filled immediately, and then when you are confident you'll continue on it, mail the second prescription for a 90-day supply to the mail service provider. Always ask your doctor to prescribe a 90-day supply, plus refills. Refilling Prescriptions Currently on File with the Prescription Mail Service Program Once you've ordered a prescription through the mail service program, simply follow these steps to reorder: 1. Complete the mail service reorder form, which will be included with your prescriptions. 2. At least two weeks before you need refills, mail the order form with the appropriate copayment in the pre -addressed envelope. Your prescrip- tion must indicate you have refills remaining. II your prescription indicates zero (0) refills, you will need to contact your physician for a new written prescription, or you may order refills by phone and charge them to your credit card, 1-800-562-6223. Questions? If you have any questions about your prescription drug coverage, please call PacifiCare Customer Service at 1-800-877-9777. 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 PAID CLAIMS ONLY (NO CAPITATION) L Paid Claims By Cause The following table illustrates the paid claims by Cause (ICD-9 grouping). Here the claimant count increases to show the claimants by ICD-9 codes. Paid Claims (both inpatient and outpatient, excluding pharmacy) for this period were as follows: Paid % of % of LCause Claims Paid Days Days Claimants Birth Defects 43,767 24.5 4 30.8 2 L Respiratory System 21,305 11.9 0 0.0 104 Symptoms & Signs 20,549 11.5 2 15.4 86 Skeleton & Muscle System 15,638 8.8 0 0.0 56 Circulatory System 15,410 8.6 0 0.0 18 Nervous Sys/Sense Organs 13,772 7.7 0 0.0 24 Digestive System 13,720 7.7 6 46.2 19 I Injury & Poisoning 12,659 7.1 1 7.7 51 l■ All Others/Supplementary 4,463 2.5 0 0.0 35 Genitourinary System 4,099 2.3 0 0.0 35 Glands & Metabolism Tumors 3,287 3,268 1.8 1.8 0 0 0.0 0.0 31 31 Pregnancy & Childbirth 2,801 1.6 0 0.0 20 Infections & Parasitic 1,833 1.0 0 0.0 23 L Skin & Skin Related 991 0.6 0 0.0 12 Blood Related 473 0.3 0 0.0 3 Mental & Substance Abuse 430 0.2 0 0.0 7 Perinatal Conditions 0 0.0 0 0.0 0 Total $178,464 13 557 leading individual (medical) ICD-9 diagnoses were: LThe Paid % of % of LICD-9 Diagnosis Claims Paid Days Days Claimants 746 HRT CONGEN ANOMALIES 43,767 24.5 4 30.8 2 424 ENDOCARDIUM OTHER DIS 12,083 6.8 0 0.0 1 L 474 CHR T/A DISEASE 11,678 6.5 0 0.0 2 361 RETINAL DETACHMENT 9,396 5.3 0 0.0 2 789 ABD/PELVIS SYMPT INVO 8,694 4.9 2 15.4 9 L 724 BACK DISORDER NEC N 6,007 3.4 0 0.0 13 786 RESP SYS/OTH CHEST SY 4,930 2.8 0 0.0 20 555 ENTERITIS REGIONAL 4,862 2.7 0 0.0 5 560 INTEST OSTRU W/O HERN 3,969 2.2 4 30.8 1 L 540 APPENDICIT ACUTE 3,808 2.1 2 15.4 1 Page 7 1 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 Page s 6 _ Provider Information Claim payments went to the following recipients: Paid % of Claims Paid Paid Directly to Hospitals $120,525 57.7 Paid to Non -Hospital Providers $88,284 42.3 The leading hospital providers for this time frame were: (' denotes a PacifiCare Preferred or Network Provider) Paid Provider Name City State Days Claims *POUDRE VALLEY HEALTH CARE-1P FORT COLLINS CO 13 59,985 *POUDRE VALLEY HEALTH CARE -OP FORT COLLINS CO 0 40,622 *CEDARS SINAI MED CTR LOS ANGELES CA 0 13,073 *MCKEE MEDICAL CENTER -OP LOVELAND CO 0 2,689 *SURGERY CENTER OF FORT COLLIN FORT COLLINS CO 0 1,119 *PORTER HOSPITAL O/P DENVER CO 0 668 *NORTH CO MEDICAL CENTER - OP GREELEY CO 0 607 *CHILDREN'S HOSP-OUTPATIENT DENVER CO 0 433 *LITTLETON HOSPITAL O/P LITTLETON CO 0 264 ST LUKES HOSPITAL-PHYS ST LOUIS 140 0 251 L FOUNTAIN VALLEY HOSPITAL-IP- FOUNTAIN VALLEY CA 0 239 OJAI VALLEY COMM HOSP-IP OJAI CA 0 178 *UNIVERSITY HOSPITAL -OP DENVER CO 0 172 ` HIGHLAND HOSPITAL -OP ROCHESTER NY 0 116 *PENROSE COMMUNITY -OUTPATIENT COLORADO SPRING CO 0 112 L L L01 COLLINS POS 0RS00 Page 9 /2000 - 06/2000 CITY OF FORT L ` Non -Hospital Provider Information L The leading non -hospital providers were: Paid Provider Name City State Days Claims *CHRIS CRIBARI MD FORT COLLINS CO 0 3,330 *FT COLLINS RADIOLOGIC ASSOC FORT COLLINS CO 0 2,781 *JEROME SMITH MD FORT COLLINS CO 0 2,529 ` *RICHARD BOOTH MD FORT COLLINS CO 0 2,088 *DENNIS LARSON MD FORT COLLINS CO 0 1,861 *KIRK KINDSFATER MD FORT COLLINS CO 0 1,840 L *MARK PAULSEN MD FORT COLLINS CO 0 1,822 *WILLIAM NEFF MD FORT COLLINS CO 0 1,700 *STEVEN BROMAN MD FORT COLLINS CO 0 1,485 L *MICHAEL CURIEL MD FORT COLLINS CO 0 1,366 *JULIO SALIMBENI MD FORT COLLINS CO 0 1,149 *LANDMARK CHIRO IPA OF CO INC SACRAMENTO CA 0 1,114 *THOMAS NEVRIVY MD FORT COLLINS CO 0 999 *JOHN ONEILL MD FORT COLLINS CO 0 945 *EMERGENCY PHYS OF FT COLLINS FORT COLLINS CO 0 853 L The leading Pharmacy providers were: Paid Provider Name City State Days Claims L*KING SOOPERS PHARMACY #18 FT COLLINS CO 0 4,321 *ALBERTSONS PHARMACY 8814 FORT COLLINS CO 0 3,654 *KING SOOPERS PHARMACY 73 FORT COLLINS CO 0 3,043 L *LONGS DRUG STORE 226 FT COLLINS CO 0 2,400 *KING SOOPERS PHARMACY #9 FT COLLINS CO 0 2,243 *POUDRE PHARMACY FT COLLINS CO 0 2,154 L *KING SOOPERS PHARMACY 74 LOVELAND CO 0 1,987 *SAFEWAY PHARMACY 2913 FT COLLINS CO 0 1,972 *PRESCRIPTION SOLUTIONS M SAN DIEGO CA 0 1,348 *WALGREEN DRUG STORE 01245 FT COLLINS CO 0 1,319 *TODDY'S PHARMACY FT COLLINS CO 0 1,282 *ALBERTSONS PHARMACY 8918 FT COLLINS CO 0 1,129 *SAFEWAY PHARMACY 1552 FORT COLLINS CO 0 599 *SAFEWAY PHARMACY 0914 LOVELAND CO 0 530 *KING SOOPERS PHARMACY 44 LOVELAND CO 0 4% L L L L L 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 L LProvider And Vendor Discount Savings Page 10 LThe savings from Provider and Vendor Discounts amounted to $40,550 and the details are as follows: --------------------- Network --------------------- Category Charged Allowed Savings L Hospital Facility Physician Service 119,960.30 95,745.41 102,525.88 74,135.87 17,434.42 21,609.54 Other 8,508.18 7,002.60 1,505.58 f 4 TOTALS $224,213.89 $183,664.35 $40,549.54 -- Non -Network -- LCategory Hospital Facility Charged 884.75 Lother Physician Service 7,871.30 243.25 TOTALS $8,999.30 LOverall percentage savings for in -network client charges were 18.1 %, and 96.1 % of charges were from network providers. L LThe Payments By Benefit Category medical payments by benefit category during this period were: Paid % of PacifiCare LAmount Paid Norm Hospital Expense 119,727 57.3 46.0 L Pharmacy Medical Care 31,227 15.0 21,176 10.1 29.5 10.0 Surgery 13,914 6.7 4.5 Miscellaneous 9,508 4.6 6.9 L X-Ray & Lab 9,283 4.4 4.1 Anesthesia 2,737 1.3 2.0 Emergency Care 1,238 0.6 1.7 L 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORSOO L LInpatient Utilization LThe total number of inpatient admissions in this period was 5, and totaled 13 days. Due to the medical management of the HMO Utilization Review program, unnecessary hospital confinements have been eliminated. Because of this, HMO patients admitted to hospitals tend to be sicker, and appear to consume more services and incur longer lengths of stay. However, overall days and admissions per 1000 members are lower than non -HMO experience. L Admission Statistics L Total Admissions Total Days Average length of stay Admissions per 1000 members Days per 1000 members Average admission paid total Average daily paid LAdmission Total Paid Analysis L L L L L L L Total Hospital Average Professional Fees Average Other Expense Average Client 5 13 2.6 41 105 $13,229 $5,088 $11,997 $939 $292 Regional HMO 4.0 36 147 $6,582 $1,629 $6,344 $586 $-348 Admission Type Admissions Days ALOS Ave S/Adm Ave $/Day Medical 4 9 2.3 4,300 1,911 Surgical 1 4 4.0 48,944 12,236 Pregnancy - Normal Delivery 0 0 0.0 0 0 - Cesarean Section 0 0 0.0 0 0 - Newborn 0 0 0.0 0 0 Mental - Psych 0 0 0.0 0 0 - Substance Abuse 0 0 0.0 0 0 Page 11 t. 01 /2000 - 06/2000 L L L L L L L L L L L L L L L L Catastrophic Illness CITY OF FORT COLLINS POS ORS00 A catastrophic illness is defined as paid amounts in excess of $25,000 to a single individual for a single cause. Catastrophic illnesses totaled $43,334, or 20.8% of medical claims. This total was incurred by 1 claimants, or 0.1 % of the total. The PacifiCare regional norms are about 14.0% of the claims caused by about 0.0% of the claimants. The average paid per claimant was $43,334. The average PacifiCare catastrophic claim was $61,719. Catastrophic Illness Cases by Diagnostic Category: Average Paid Cause Claimants Days Payment per Claimant Birth Defects 1 4 43,334 43,334 Total 1 4 $43,334 $43,334 Catastrophic Illness Cases by Relationship: Average Paid Relationship Claimants Days Payment per Claimant Employees 1 4 43,334 43,334 Catastrophic Illness Cases by Age Band: Average Paid Age Band Claimants Days Payment per Claimant 35-49 1 4 43,334 43,334 Page 12 t 1 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORSOO L L Analysis Of Birth Defects LBirth Defects claims accounted for 24.5% of the payments in this period, and 0.4% of the claimants. L L L L L L L L L L L L L L Average Paid Relationship Claimants Days Payment per Claimant Employees 1 4 43,334 43,334 Children 1 0 433 433 Total 2 4 543,767 $21,884 Age Band Claimants Days Payment Ave Paid 1.19 1 0 433 433 35-49 1 4 43,334 43,334 Leading Diagnosis Claimants Days Payment Ave Paid 746 HRT CONGEN ANOMALIES 2 4 43,767 21,884 Admission Type Admits ALOS Ave Paid Ave/Day Surgical 1 4.0 48,944 12,236 Total 1 4.0 48,944 12,236 Page 13 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORSOO Analysis Of Respiratory System Respiratory System claims accounted for 11.9% of the payments in this period, and 18.7% of the claimants. Relationship Employees Spouses Children Total Age Band Less than 1 1-19 20-34 35-49 50-64 Leading Diagnosis 474 CHR T/A DISEASE 473 CHRONIC SINUSITIS 477 ALLERGIC RHINITIS 462 AC PHARYNGITIS 519 RESP SYST DIS OTHER 461 SINUSITIS ACUTE 493 ASTHMA 465 AC URI MULT SITES/NOS 490 BRONCHITIS NOS 470 DEVIATED NASAL SEPTUM Claimants Days 38 0 17 0 49 0 104 0 Claimants Days 1 0 45 0 11 0 26 0 21 0 Claimants Days 2 0 19 0 12 0 17 0 2 0 7 0 7 0 6 0 7 0 1 0 Average Paid Payment per Claimant 4,305 113 2,429 143 14,572 297 $21,305 $205 Payment Ave Paid 50 50 14,377 319 2,731 248 1,752 67 2,396 114 Payment Ave Paid 11,678 5,839 1,537 81 1,383 115 1,269 75 1,151 575 723 103 666 95 445 74 383 55 338 338 Page 14 1 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 i Analysis Of Symptoms & Signs Page 15 Symptoms & Signs claims accounted for 11.5% of the payments in this period, and 15.4% of the claimants. Le Lea L 78 7 V7 7 78 78 796 78 79 78 Admission Type LMedical Total L L Relationship Employees Spouses Children Total Age Band Less than 1 1-19 20-34 35-49 50-64 Diagnosis ABD/PELVIS SYMPT INVOLVI RESP SYS/OTH CHEST SYMP EXAMINATION NOS HEAD/NECK SYMPT INVOLV GENERAL SYMPTOMS CVS ABN FIND NONSPECIFIC OTH 7 GI SYSTEM SYMPTOMS 4 ABN FUNC STUDIES RESULTS 2 SKIN SYMPTOMS 9 86 2 84 0 5 Claimants Days 48 0 17 2 21 0 86 2 Claimants Days 2 0 15 0 11 0 32 0 26 2 Claimants Days 9 2 20 0 24 0 8 0 8 0 1 0 1 0 3 0 2 0 3 0 Average Paid Payment per Claimant 10,669 222 8,502 500 1,378 66 $20,549 $239 Payment Ave Paid 179 89 896 60 1,886 171 3,652 114 13,936 536 Payment Ave Paid 8,694 966 4,930 247 2,765 115 1,757 220 1,185 148 268 268 216 216 184 61 173 86 143 48 Admits ALOS Ave Paid Ave/Day 1 2.0 6,514 3,257 1 2.0 6,514 3,257 101/2000 - 06/2000 CITY OF FORT COLLINS POS ORSOO Page 16 Analysis Of Skeleton & Muscle System Skeleton & Muscle System claims accounted for 8.8% of the payments in this period, and 10.1 % of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 Leading Diagnosis 724 BACK DISORDER NEC NOS 717 KNEE INT DERANGEMENT 719 JOINT DISORDER NEC NOS 723 CERV RGN DISORDERS OTHER 716 ARTHROPATHIES NEC/NOS 722 INTERVERTEBRAL DISC D1S 739 SOMATIC DYSFUNCTION 728 MUSCLE DISEASE 726 PERIPH ENTHESOPATHiES 720 SPONDYLOPATHIES INFLAM Claimants Days 34 0 15 0 7 0 56 0 Claimants Days 6 0 9 0 32 0 9 0 Claimants Days 13 0 6 0 9 0 3 0 3 0 3 0 6 0 3 0 2 0 1 0 Average Paid Payment per Claimant 9,536 280 3,615 241 2,487 355 515,638 S279 Payment Ave Paid 2,213 369 3,320 369 9,697 303 408 45 Payment Ave Paid 6,007 462 2,215 369 2,200 244 1,757 566 1,024 341 969 323 403 67 345 115 291 146 145 145 PacifiCare Behavioral Health There's Help When you Need It. There may be times in your life when you find yourself feeling out of control. Maybe it's a family conflict. Or maybe it's a stress -related problem. Or perhaps you could be struggling with an alcoholic addiction. Whatever the problem, you don't need to handle it alone. We can help. Your health care partner, PacifiCare of Colorado and PacifiCare Behavioral Health can provide you with the support you need to weather the storm. PacifiCare Behavioral Health (PBH) specializes in providing behavioral health care. You benefit in several ways by receiving your behavioral health care benefits through a company specializing in behavioral health. First, because of our strict provider credentialing process and ongoing evaluations, you can feel good about the quality of care you'll receive. Also, we take the guess work out of finding a behavioral health provider and can match your specific needs with the appropriate provider. And since Ivy can call PBH's toll -free number (1-888-777-2735) at any time, you can receive a confidential referral directly on or after January 1, 1998. Your primary care physician can also request a referral on your behalf by calling PBH directly. How to Access Your Benefits To access your behavioral health benefits, call PBH directly at our toll -free number, which is available 24 hours a day. When you call, you'll speak with an intake coordinator who'll check your eligibility, gather basic demographic information and help determine the type of service you need. A clinical interviewer will then talk to you in detail about the problem that you're experiencing and assess what provider and treatment would be best for your situation. If you're referred to a PBH provider, you'll be authorized for a specific number of visits or a specified period of time. We Select Our Providers Carefully All of our providers are carefully screened and meet extensive licensing, I- 01 r /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 Page 17 1 Analysis Of Circulatory System Circulatory system claims accounted for 8.6% of the payments in this period, and 3.2% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 15 0 15,176 1,012 Spouses 3 0 234 78 Total 18 0 $15,410 $856 Age Band Claimants Days Payment Ave Paid t35-49 11 0 14,661 1,333 50-64 7 0 749 107 Leading Diagnosis Claimants Days Payment Ave Paid 424 ENDOCARDIUM OTHER DISEAS 1 0 12,083 12,083 414 ISCHEMIC HRT DISCHRONIC 3 0 1,873 624 401 HYPERTENS ESSENTIAL 6 0 560 93 455 HEMORRHOIDS 2 0 328 164 423 PERICARDIA DISEASES OF 0 1 0 202 202 443 PERIPH VAS DIS OTHER 1 0 139 139 428 HEART FAILURE 1 0 106 106 427 CARDIAC DYSRHYTHMIAS 1 0 58 58 433 OCCLUS'N/STENOSIS OF ART 1 0 44 44 Page: 1 PacifiCare Healthplan Administrators City of Fort Collins 08/23/2001 Jan-01 $ 166,141 $ 42,884 $ 3,136 $ 31,316 $ 243,477 246 136 119 278 Feb-01 $ 137,935 $ 37,064 $ 3,572 $ 31,316 $ 209,887 245 135 119 280 Mar-01 $ 332,013 $ 34,199 $ 2,793 $ 31,718 $ 400,723 248 139 121 281 Apr-01 $ 239,471 $ 40,775 $ 3,578 $ 31,838 $ 315,662 246 141 121 284 May-01 $ 191,685 $ 39,907 $ 3,626 $ 32,160 $ 267,378 252 141 123 284 Jun-01 $ 426,894 $ 41,698 $ 3,604 $ 32,522 $ 504,717 257 139 125 288 Jul-01 $ 186,219 $ 35,971 $ 291 $ 32,723 $ 255,204 259 141 127 287 Aug-01 $ - $ - $ - $ - $ - 0 0 0 0 Sep-01 $ - $ - $ - $ - $ - 0 0 0 0 Oct-01 $ - $ - $ - $ _ $ - 0 0 0 0 Nov-01 $ - $ - $ - $ - $ - 0 0 0 0 Dec-01 $ - $ - $ - 0 Total: $ 1,680,358 $ 272,498 $ 20,600 $223,592 $2,197,048 1753 972 855 1982 POS Jan-01 $ 17,665 $ 5,140 $ 501 $ 4,491 $ 27,797 33 20 24 34 Feb-01 $ 18,994 $ 4,859 $ 502 $ 4,491 $ 28,846 33 20 24 34 Mar-01 $ 55,453 $ 4,639 $ 488 $ 4,451 $ 65,031 32 21 23 34 Apr-01 $ 40,397 $ 4,752 $ 497 $ 4,451 $ 50,097 32 21 23 34 May-01 $ 27,391 $ 5,428 $ 495 $ 4,451 $ 37,765 32 21 24 33 Jun-01 $ 34,087 $ 6,107 $ 494 $ 4,410 $ 45,098 32 21 23 33 Jul-01 $ 31,663 $ 4,510 $ 497 $ 4,451 $ 41,121 32 19 20 39 Aug-01 $ - $ - $ - $ - $ - 0 0 0 0 Sep-01 $ - $ - $ - $ - $ - 0 0 0 0 Oct-01 $ - $ - $ - $ - $ - 0 0 0 0 Nov-01 $ - $ - $ - $ - 0 0 0 0 Dec-01 $ - $ - $ - 0 Total: $ 225,650 $ 35,435 $ 3,474 $ 31,195 $ 295,754 226 143 161 241 Page: 2 Summary PacifiCare Healthplan Administrators City of Fort Collins 08/23/2001 Jan-01 $ 183,806 $ 48,024 $ 3,637 $ 35,807 $ 271,274 279 156 143 312 Feb-01 $ 156,929 $ 41,923 $ 4,074 $ 35,807 $ 238,733 278 155 143 314 Mar-01 $ 387,466 $ 38,838 $ 3,281 $ 36,168 $ 465,753 280 160 144 315 Apr-01 $ 279,868 $ 45,527 $ 4,075 $ 36,289 $ 365,769 278 162 144 318 May-01 $ 219,076 $ 45,335 $ 4,121 $ 36,611 $ 305,143 284 162 147 317 Jun-01 $ 460,981 $ 47,805 $ 4,098 $ 36,932 $ 549,815 289 160 148 321 Jul-01 $ 217,882 $ 40,481 $ 788 $ 37,173 $ 296,324 291 160 147 326 Aug-01 $ - $ - $ - $ - $ - 0 0 0 0 Sep-01 $ - $ - $ - $ - $ - 0 0 0 0 Oct-01 $ - $ - $ - $ - $ - 0 0 0 0 Nov-01 $ - $ - $ - $ - $ - 0 0 0 0 Dec-01 $ - $ - $ - $ - $ - 0 0 0 0 Total: $ 1,906,008 $ 307,933 $ 24,074 $254,787 $2,492,802 1979 1115 1016 2223 Self Fund ASO only PERFORMANCE GUARANTEES 5% OF ACTUAL ADMINISTRATIVE FEES $52.04 PEPM X .660(MEDICAL MANAGEMENT REMOVED) X 914 EMPLOYEES THIS NUMBER WILL BE BASED ON ACTUAL COUNTS AT THE END OF THE YEAR) X 12 MONTHS X 5% EQUALS $189837.54 APX. RISK Note: this calculation would take place at the end of the contract year. PacifiCare would base these numbers on actual membership within each medical plan I.E.: EPO and POS. EPO Fee $52.04 POS Fee $52.20 PACIFICARE 2001 PERFORMANCE STANDARDS (SAMPLE) Category Standard Timeframe of Measurement CLAIMS PROCESSING In accordance with 10-16-106.5 (C.R.S), PacifiCare will agree to The turnaround time (TAT) will be tracked 100% of clean claims complete in 30 business days. monthly. Following the Contract Year, PacifiCare will average the monthly results and report to Definitions: CLIENT NAME the yearly average as part of an A claim is considered "received" when it is received by the mail- annual year-end report. room. A claim is considered "processed" once it has been entered into the system and is ready for payment as part of the next check run, which may be semi-monthly depending upon the type of provider. A clean claim includes all of the following information submitted correctly and completely: • Patient name • Patient ID number including suffix • Patient date of birth • Referring physician's name or referral/authorization number • Dates of service for each service • Medicare place of service code for each service • Valid CPT-4 or HCPCS procedure codes, valid modifiers, and appropriate units for each service • ICD-9-CM diagnosis codes for each service • Charges for each service • Total charges on the claim • Provider name, address, and telephone number • Provider ID number including suffix 2001 Performance Guarantees 0 s r 2 nub"� t4 Ct x . PacifiCare is excited to introduce "extra -special" programs just for our members. PacifiCare Perks'" is a members -only program which includes discounts through vendor arrangements for safety products, health clubs, alternative -care, vitamins, LASIK eye surgery, body care products, and much more! Fitness & Weight Management of staying healthy �� is watching your weight and engaging in exercise. Through s , you have access to discounts with: 7 61177Part hers®" ■ Fitness Accessories rticipation) ■ Health Clubs Certificate Healthy Moms/Kids PacifiCare cares about mothers & babies. We want them to be happy and healthy With PacifiCare Perks'", our members have access to discounts for: ■ Gymboree Play and Music Programs ■ Safe Beginnings (home safety products) ■ Clear Plan Easy1m Fertility Monitor ■ Breast Feeding Accessories Clear Vision ■ Vision Discounts for: — LASIK/PRK Eye Surgery — Contact Lenses and Frames Complementary & Alternative Care Through our special arrangement with American Specialty Health Networks, you'll have access to discounts with: o Chiropractors ■ Massage Therapists ■ Acupuncturists Additionally, you'll receive discounts for: ■ Body Care Products ■ Herbal Supplements ■ Health Information/Educational Materials ■ Yoga Instructional Videos ■ And More! * PacifiCare Perks` services and/or products are administered through PacifiCare Health Plan Administrators, a subsidiary of PacifiCare Health Systems. ** WEIGHT WATCHERS is the registered trademark of Weight Watchers International, Inc. ® 2000 All rights reserved. Discount does not apply to sales tax or shipping charges, and may not be combined with any other discounts. Certain items may be excluded from discount. RtciftCare does not endorse or guarantee products noted ©2000 by PacifiCare Health Systems, Inc. CM-400-17605.13.5 PEW7209 PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80001 ARVADA JEFFERSON CO 80002 ARVADA WHEAT RIDGE JEFFERSON CO 80003 ARVADA WESTMINSTER JEFFERSON CO 80004 ARVADA JEFFERSON CO 80005 ARVADA BROOMFIELD JEFFERSON CO 80006 ARVADA JEFFERSON CO 80007 ARVADA JEFFERSON CO 80010 AURORA ARAPAHOE CO 80011 AURORA BUCKLEY AIR NATL GUARD BASE ADAMS CO 80012 AURORA ARAPAHOE CO 80013 AURORA ARAPAHOE CO 80014 AURORA DENVER ARAPAHOE CO 80015 AURORA ARAPAHOE CO 80016 AURORA FOXFIELD ARAPAHOE CO 80017 AURORA ARAPAHOE CO 80018 AURORA ARAPAHOE CO 80019 AURORA ADAMS CO 80020 BROOMFIELD THORNTON BOULDER CO 80021 BROOMFIELD ARVADA BOULDER CO 80022 COMMERCE CITY IRONDALE ADAMS CO 80024 DUPONT ADAMS CO 80025 ELDORADO SPRINGS BOULDER CO 80026 LAFAYETTE BOULDER CO 80027 LOUISVILLE SUPERIOR BOULDER CO 80028 LOUISVILLE STORAGE TECHNOLOGY CORP BOULDER CO 80030 WESTMINSTER ADAMS CO 6 80031 WESTMINSTER ADAMS CO 80033 WHEAT RIDGE LAKEWOOD JEFFERSON CO 80034 WHEAT RIDGE JEFFERSON CO 80035 WESTMINSTER ADAMS CO 80036 WESTMINSTER ADAMS CO 80037 COMMERCE CITY ADAMS CO 80038 BROOMFIELD BOULDER CO 80040 AURORA ADAMS CO 80041 AURORA ARAPAHOE CO 80042 AURORA ADAMS CO 80044 AURORA ADAMS CO 80045 AURORA FITZSIMONS ARMY MEDICAL CTR ADAMS CO 80046 AURORA ARAPAHOE CO 80047 AURORA ARAPAHOE CO 80101 AGATE ELBERT CO 80102 BENNETT ARAPAHOE CO 80103 BYERS ARAPAHOE CO 80104 CASTLE ROCK DOUGLAS CO 80105 DEER TRAIL ARAPAHOE CO 80106 ELBERT BLACK FOREST ELBERT CO 80107 ELIZABETH ELBERT CO PacifiCare Pagel 09/13/2001 PacifiCare of Colorado, Inc. Service Area Zip Codes 1 L Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80110 ENGLEWOOD CHERRY HILLS VILLAGE ARAPAHOE CO E 80111 ENGLEWOOD CHERRY HILLS VILLAGE ARAPAHOE CO 80112 ENGLEWOOD GREENWOOD VILLAGE ARAPAHOE CO 80116 FRANKTOWN DOUGLAS CO C 80117 KIOWA ELBERT CO 80118 LARKSPUR DOUGLAS CO 80120 LITTLETON ARAPAHOE CO 80121 LITTLETON GREENWOOD VILLAGE ARAPAHOE CO 80122 LITTLETON ARAPAHOE CO 80123 LITTLETON BOW MAR DENVER CO 80124 LITTLETON HIGHLANDS RANCH DOUGLAS CO 80125 LITTLETON DOUGLAS CO 80126 LITTLETON HIGHLANDS RANCH DOUGLAS CO 80127 LITTLETON DENVER JEFFERSON CO 80128 LITTLETON COLUMBINE HILLS JEFFERSON CO 80129 LITTLETON DOUGLAS CO 80130 LITTLETON DOUGLAS CO 80131 LOUVIERS DOUGLAS CO 80132 MONUMENT WOODMOOR EL PASO CO 80133 PALMER LAKE EL PASO CO 80134 PARKER DOUGLAS CO 80135 SEDALIA DECKERS DOUGLAS CO 80136 STRASBURG ADAMS CO 80137 WATKINS ADAMS CO 80138 PARKER DOUGLAS CO i 80150 ENGLEWOOD ARAPAHOE CO 80151 ENGLEWOOD ARAPAHOE CO 80154 ENGLEWOOD ARAPAHOE CO 80155 ENGLEWOOD DENVER CO k 80160 LITTLETON ARAPAHOE CO 80161 LITTLETON ARAPAHOE CO ! 80162 LITTLETON JEFFERSON CO 80163 LITTLETON HIGHLANDS RANCH DOUGLAS CO 80165 LITTLETON LITTLETON CITY OFFICES ARAPAHOE CO 80166 LITTLETON ARAPAHOE COUNTY OFFICES ARAPAHOE CO 80201 DENVER DENVER CO 80202 DENVER DENVER CO 80203 DENVER DENVER CO 80204 DENVER DENVER CO 80205 DENVER DENVER CO I' 80206 DENVER DENVER CO 80207 DENVER DENVER CO 80208 DENVER UNIVERSITY OF DENVER DENVER CO 80209 DENVER DENVER CO 80210 DENVER DENVER CO 80211 DENVER DENVER CO 80212 DENVER WHEAT RIDGE DENVER CO fPacifiCare Y Page 2 09/13/2001 PaciriCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80214 DENVER EDGEWATER JEFFERSON CO 80215 DENVER LAKEWOOD JEFFERSON CO 80216 DENVER DENVER CO 80217 DENVER DENVER CO 80218 DENVER DENVER CO 80219 DENVER DENVER CO 80220 DENVER AURORA DENVER CO 80221 DENVER FEDERAL HEIGHTS ADAMS CO 80222 DENVER DENVER CO 80223 DENVER DENVER CO 80224 DENVER DENVER CO 80225 DENVER DENVER FEDERAL CENTER JEFFERSON CO 80226 DENVER LAKEWOOD JEFFERSON CO 80227 DENVER LAKEWOOD JEFFERSON CO 80228 DENVER GREEN MOUNTAIN JEFFERSON CO 80229 DENVER THORNTON ADAMS CO 80230 DENVER LOWRY DENVER CO 80231 DENVER AURORA ARAPAHOE CO 80232 DENVER LAKEWOOD JEFFERSON CO 80233 DENVER NORTHGLENN ADAMS CO 80234 DENVER BROOMFIELD ADAMS CO 80235 DENVER LAKEWOOD JEFFERSON CO 80236 DENVER FORT LOGAN DENVER CO 80237 DENVER DENVERCO 80238 DENVER MONTBELLO DENVER CO 80239 DENVER DENVER CO 80241 DENVER NORTHGLENN ADAMS CO 80243 DENVER COLORADO D M V DEPT OF REV DENVER CO 80244 DENVER U S WEST COMMUNICATIONS DENVER CO 80246 DENVER GLENDALE ARAPAHOE CO 80248 DENVER DENVER CO 80249 DENVER DENVER CO 80250 DENVER DENVER CO 80251 DENVER NATIONAL FARMERS UNION ARAPAHOE CO 80252 DENVER BANK AMERICARD DENVER CO 80254 DENVER DENVER WATER BOARD ADAMS CO 80255 DENVER PUBLIC SERVICE COMPANY DENVER CO 80256 DENVER COLORADO NATIONAL BANK DENVER CO 80257 DENVER US COURT OF APPEALS IOTH CIR DENVER CO 80259 DENVER SMALL BUSINESS ADM DENVER CO 80260 DENVER DENVER CO 80261 DENVER COLORADO DEPT OF REVENUE DENVER CO 80262 DENVER UNIV OF COLORADO MED CTR DENVER CO 80263 DENVER AFFILIATED BANKS SERVICE CO DENVER CO 80264 DENVER DENVER CO 80265 DENVER DENVER CO 80266 DENVER DENVER CO `. PacifiCare Page 3 09/13/2001 a PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80270 DENVER FIRST INTERSTATE BANK DENVER CO 80271 DENVER FIRST INTERSTATE BANK DENVER CO 80273 DENVER BLUE CROSS BLUE SHIELD OF CO DENVER CO 80274 DENVER NORWEST BANK DENVER DENVER CO 80275 DENVER ATT INFORMATION SYSTEMS DENVER CO 80279 DENVER DENVER CO 80280 DENVER AF RESERVE PERS CTR DENVER CO 80281 DENVER NORWEST BANK DENVER DENVER CO 80290 DENVER DENVER CO 80291 DENVER NORWEST BANK DENVER DENVER CO 80292 DENVER CENTRAL BANK & TRUST DENVER CO 80293 DENVER DENVER CO 80294 DENVER FEDERAL BLDGIUS COURTHOUSE DENVER CO 80295 DENVER DENVER CO 80299 DENVER WESTERN AREA DENVER CO 80301 BOULDER BOULDER CO 80302 BOULDER BOULDER CO 80303 BOULDER BOULDER CO 80304 BOULDER BOULDER CO 80306 BOULDER BOULDER CO 80305 BOULDER BOULDER CO 80307 BOULDER BOULDER CO 80308 BOULDER BOULDER CO 80309 BOULDER UNIVERSITY OF COLORADO BOULDER CO 80310 BOULDER RESIDENCE HALLS UNIV OF CO BOULDER CO 80314 BOULDER IBM BOULDER CO 80321 BOULDER NEODATA BUSINESS REPLY BOULDER CO 80322 BOULDER NEODATA BOULDER CO 80323 BOULDER NEODATA BOULDER CO 80328 BOULDER NEODATA BUSINESS REPLY BOULDER CO 80329 BOULDER NEODATA BOULDER CO 80401 GOLDEN LAKEWOOD JEFFERSON CO 80402 GOLDEN JEFFERSON CO 80403 GOLDEN JEFFERSON CO 80419 GOLDEN JEFFERSON COUNTY JEFFERSON CO 80420 ALMA PARK CO 80421 BAILEY PARK CO 80422 BLACK HAWK GILPIN CO 80425 BUFFALO CREEK JEFFERSON CO 80427 CENTRAL CITY GILPIN CO 80432 COMO FAIRPLAY PARK CO 80433 CONIFER FOXTON JEFFERSON CO 80436 DUMONT CLEAR CREEK CO 80437 EVERGREEN JEFFERSON CO 80438 EMPIRE CLEAR CREEK CO 80439 EVERGREEN JEFFERSON CO 80440 FAIRPLAY PARK CO PacifiCare Page 4 09/13/2001 accreditation and program Questions and PBH -- A Leader in requirements. They Answers Behavioral Health Care include contracted hospitals, residential Is pre -authorization If you need to access your treatment centers, always necessary to start behavioral health benefits, outpatient chemical a treatment program? you want to feel good dependency programs and about the company providing individual professionals Yes, all benefits must be them. throughout Colorado. pre -authorized by PBH. If you do not go through Here are just a few of our PBH, no benefits will be qualifications: We Maintain paid -- except in an Confidentiality emergency. We are a wholly owned subsidiary of PacifiCare With PBH, you can be Health Systems, one of the assured that what you How long does it take to nation's most respected discuss with our intake get an appointment? and financially stable coordinators and managed -care organizations. interviewers is kept The Standards we set with We are a behavioral health strictly confidential. We our providers are: care company that is here provide information only • Routine Referrals: for the long term. • We've been serving the to the professionals delivering your treatment. 95% of members receive behavioral health care needs Confidentiality is built an appointment within 5 of organizations since 1986 into the operations of business days. and our employee assistance PBH through a system of • Urgent/Emergent program has been helping control and security that Referrals: All members employers since 1975. protects both written and receive treatment within • We serve a combined computer -based 24 hours. Inpatient membership of 2 million information. admissions should occur members in a variety of immediately. industries. What happens in an emergency? In an emergency, our first concem is for your health and well-being. Get to a treatment center first, then, as soon as possible (or within 24 hours of admission), call PBH at our toll -free number, 1-888-777-2735. pWomi2 PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80444 GEORGETOWN CLEAR CREEK CO 80448 GRANT PARK CO 80449 HARTSEL PARK CO 80452 IDAHO SPRINGS CLEAR CREEK CO 80453 IDLEDALE JEFFERSON CO 80454 INDIAN HILLS JEFFERSON CO 80455 JAMESTOWN BOULDER CO 80456 JEFFERSON FAIRPLAY PARK CO 80457 KITTREDGE JEFFERSON CO 80465 MORRISON JEFFERSON CO 80466 NEDERLAND BOULDER CO 80470 PINE JEFFERSON CO 80471 PINECLIFFE BOULDER CO 80474 ROLLINSVILLE GILPIN CO 80475 SHAWNEE PARK CO 80476 SILVER PLUME CLEAR CREEK CO 80481 WARD BOULDER CO 80501 LONGMONT BOULDER CO 80502 LONGMONT BOULDER CO 80503 LONGMONT NIWOT BOULDER CO 80504 LONGMONT WELD CO 80510 ALLENSPARK BOULDER CO 80511 ESTES PARK LARIMER CO 80512 BELLVUE LARIMER CO 80513 BERTHOUD LARIMER CO 80514 DACONO WELD CO 80515 DRAKE LARIMER CO 80516 ERIE WELD CO 80517 ESTES PARK ROCKY MOUNTAIN NATIONAL PARK LARIMER CO 80520 FIRESTONE WELD CO 80521 FORT COLLINS LARIMER CO 80522 FORT COLLINS LARIMER CO 80523 FORT COLLINS COLORADO STATE UNIVERSITY LARIMER CO 80524 FORT COLLINS LARIMER CO 80525 FORT COLLINS LARIMER CO 80526 FORT COLLINS LARIMER CO 80527 FORT COLLINS LARIMER CO 80528 FORT COLLINS LARIMER CO 80530 FREDERICK WELD CO 80532 GLEN HAVEN LARIMER CO 80533 HYGIENE BOULDER CO 80534 JOHNSTOWN WELD CO 80535 LAPORTE LARIMER CO 80536 LIVERMORE RED FEATHER LAKES LARIMER CO 80537 LOVELAND LARIMER CO 80538 LOVELAND LARIMER CO 80539 LOVELAND LARIMER CO PacifiCare Page 5 09/13/2001 PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80540 LYONS BOULDER CO 80541 MASONVILLE LARIMER CO 80542 MEAD WELD CO 80543 MILLIKEN WELD CO 80544 NIWOT BOULDER CO 80545 RED FEATHER LAKES LARIMER CO 80546 SEVERANCE WELD CO 80547 TIMNATH LARIMER CO 80549 WELLINGTON LARIMER CO 80550 WINDSOR WELD CO 80551 WINDSOR EASTMAN KODAK CO WELD CO 80553 FORT COLLINS LARIMER CO 80601 BRIGHTON LOCHBUIE ADAMS CO 80602 BRIGHTON ADAMS CO 80603 BRIGHTON LOCHBUIE ADAMS CO 80610 AULT WELD CO 80611 BRIGGSDALE WELD CO 80612 CARR WELD CO 80614 EASTLAKE ADAMS CO 80615 EATON WELD CO 80620 EVANS WELD CO 80621 FORT LUPTON WELD CO 80622 GALETON WELD CO 80623 GILCREST WELD CO 80624 GILL WELD CO 80631 GREELEY GARDEN CITY WELD CO 80632 GREELEY WELD CO 80633 GREELEY WELD CO 80634 GREELEY WELD CO 80638 GREELEY STATE FARM INS WELD CO 80639 GREELEY UNIV OF NORTHERN COLORADO WELD CO 80640 HENDERSON ADAMS CO 80642 HUDSON WELD CO 80643 KEENESBURG WELD CO 80644 KERSEY WELD CO 80645 LA SALLE WELD CO 80646 LUCERNE WELD CO 80648 NUNN WELD CO 80649 ORCHARD MORGAN CO 80650 PIERCE WELD CO 80651 PLATTEVILLE WELD CO 80652 ROGGEN WELD CO 80653 WELDONA MORGAN CO 80654 WIGGINS HOYT MORGAN CO 80701 FORT MORGAN MORGAN CO 80705 LOG LANE VILLAGE FORT MORGAN MORGAN CO 80720 AKRON WASHINGTON CO PacifiCare Page 6 09/13/2001 L L PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80722 ATWOOD LOGAN CO 80723 BRUSH MORGAN CO 80726 CROOK LOGAN CO 80728 FLEMING LOGAN CO 80729 GROVER WELD CO 80733 HILLROSE MORGAN CO 80732 HEREFORD WELD CO 80736 ILIFF LOGAN CO 80740 LINDON WASHINGTON CO 80741 MERINO WILLARD LOGAN CO 80742 NEW RAYMER FORT MORGAN WELD CO 80743 OTIS WASHINGTON CO 80745 PADRONI LOGAN CO 80747 PEETZ LOGAN CO 80750 SNYDER MORGAN CO 80751 STERLING LOGAN CO 80754 STONEHAM WELD CO 80757 WOODROW LAST CHANCE WASHINGTON CO 80801 ANTON ARICKAREE WASHINGTON CO 80804 ARRIBA LINCOLN CO 80808 CALHAN ELLICOTT EL PASO CO 80809 CASCADE CHIPITA PARK EL PASO CO 80812 COPE WASHINGTON CO 80813 CRIPPLE CREEK TELLER CO 80814 DIVIDE TELLER CO 80816 FLORISSANT FLORISSANT FOSSIL BEDS NATIO TELLER CO 80817 FOUNTAIN EL PASO CO 80818 GENOA BOVINA LINCOLN CO 80819 GREEN MOUNTAIN FALLS UTE PASS EL PASO CO 80820 GUFFEY PARK CO 80821 HUGO BOYERO LINCOLN CO 80823 KARVAL LINCOLN CO 80826 LIMON LIMON CORRECTIONAL FACILITY LINCOLN CO 80827 LAKE GEORGE TARRYALL PARK CO 80828 LIMON LINCOLN CO 80829 MANITOU SPRINGS CRYSTAL HILLS EL PASO CO 80830 MATHESON ELBERT CO 80831 PEYTON AMO EL PASO CO 80832 RAMAH EL PASO CO 80833 RUSH EL PASO CO 80835 SIMLA ELBERT CO 80840 U S A F ACADEMY EL PASO CO 80841 U S A F ACADEMY CADET STATION EL PASO CO 80860 VICTOR ELKTON TELLER CO 80863 WOODLAND PARK CRYSTOLA TELLER CO 80864 YODER EDISON EL PASO CO 80866 WOODLAND PARK TELLER CO PacifiCare Page 7 09/13/2001 III I 1 r I r r I ■7 PacifiCare of Colorado, Inc. Service Area Zip Codes Effective 5/1/2001 ZIP CODE CITY CITY NUMBER 2 COUNTY 80901 COLORADO SPRINGS EL PASO CO 80903 COLORADO SPRINGS EL PASO CO 80904 COLORADO SPRINGS EL PASO CO 80905 COLORADO SPRINGS EL PASO CO 80906 COLORADO SPRINGS EL PASO CO 80907 COLORADO SPRINGS EL PASO CO 80908 COLORADO SPRINGS BLACK FOREST EL PASO CO 80909 COLORADO SPRINGS EL PASO CO 80910 COLORADO SPRINGS EL PASO CO 80911 COLORADO SPRINGS EL PASO CO 80912 COLORADO SPRINGS EL PASO CO 80913 COLORADO SPRINGS EL PASO CO 80914 COLORADO SPRINGS CHEYENNE MOUNTAIN AFB EL PASO CO 80915 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80916 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80917 COLORADO SPRINGS EL PASO CO 80918 COLORADO SPRINGS EL PASO CO 80919 COLORADO SPRINGS EL PASO CO 80920 COLORADO SPRINGS EL PASO CO 80921 COLORADO SPRINGS EL PASO CO 80922 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80925 COLORADO SPRINGS EL PASO CO 80926 COLORADO SPRINGS EL PASO CO 80928 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80929 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80930 COLORADO SPRINGS CIMARRON HILLS EL PASO CO 80931 COLORADO SPRINGS EL PASO CO 80932 COLORADO SPRINGS EL PASO CO 80933 COLORADO SPRINGS EL PASO CO 80934 COLORADO SPRINGS EL PASO CO 80935 COLORADO SPRINGS EL PASO CO 80936 COLORADO SPRINGS EL PASO CO 80937 COLORADO SPRINGS EL PASO CO 80940 COLORADO SPRINGS WALTER DRAKE EL PASO CO 80941 COLORADO SPRINGS CURRENT INC EL PASO CO 80942 COLORADO SPRINGS FIRST NATIONAL BANK EL PASO CO 80943 COLORADO SPRINGS EXCHANGE NATL BANK EL PASO CO 80944 COLORADO SPRINGS C O INTERSTATE GAS EL PASO CO 80945 COLORADO SPRINGS CABLEVISION EL PASO CO 80946 COLORADO SPRINGS COLORADO COLLEGE EL PASO CO 80947 COLORADO SPRINGS CO SPGS UTILITIES EL PASO CO 80949 COLORADO SPRINGS ROCKRIMMON EL PASO CO 80950 COLORADO SPRINGS OLYMPIC COMM EL PASO CO 80960 COLORADO SPRINGS EL PASO CO 80962 COLORADO SPRINGS EL PASO CO 80970 COLORADO SPRINGS EL PASO CO 80977 COLORADO SPRINGS US OLYMPIC COMMITTEE EL PASO CO 09/13/2001 PacifiCare Page 8 1` 1 L7 GS ZIp CODE CO ORADO SS 4GS 80995 COAlOO D V '0991%1'21 81212 CANON CITY CREEK 81215 81221 COAL COALDALE 81222 COTOPAXI 81223 FLORENCE 81226 KILLSIDE 81232 RONVNRD 81233 PENROSE 81240 81244 ROCKY ALE CITY 81246 CP,14014 FLORENCE 81290 PaciflCare Of Co 0r Codes c' $e ice Area UP Effective 51I1200I CITY N gER 2 IJ1vI Y FOCLS ON Ta FAMIL I TIONAL COMPASSION INTERN BIJCKSI{IN JOE T�S CREEK BREwS`1'EIt COUNTY ELPASO CO EL PASO CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FREMONT CO FEDERAL CORRECTIONAL C04 a 09/13/2001 Why Pacl*fiCare ?, 1 1 Local presence — Medical Management — Provider Contracting — Michael Paddack, M.D., Medical Director — Sales and Marketing Largest Plan statewide and in Northern Colorado — 400,000 members statewide — 55,000 in Northern Colorado S Knowledge and longevity of marketplace r — Nearly 25 years in the local HMO business Product diversity — EPO, PPO, Point of Service — Secure Horizons in Loveland and Greeley — Funding mechanisms Reporting capabilities Financial stability -- 1 1� - �n 1 A = S's $.83 or more of total expense dollars stays iY n community Seasoned team who all know self -funding and TPA side of business as well as all products — Single point of contact — Synergy is created PacifiCare For All Your Needs z r ., r��rr..... ...r. -r------ -r-- rc om :HWVN SI(MID :HWVN S,(r7IH) :aWVN S,HSfIOdS :MVN S,H3HIHDSH3S O � b❑ ., c, C� Q ❑�❑ Q •i. ice.. d O E OG', � L 't •Li ° C C � D' '•�C N Cd aa�i ❑ " o ` " ti 3 W U ° a ON Qn el >> o a a c " T ° a e' e� a a a cd v° rX o IL d C a o O G o v 3 c s°' d a c v o c°' ° 6 a� a }y c A a o a a0'. o •� E � a � � � � � � � a E E o � b � � v -°'o h -o Q ❑ � � O .� � � � a E o ❑T � 3 � � N �w � � C � 00 Go o. n T _ H v o 0 Co Go T" C. onO Y y O .� It Go -al CL go Obc d^❑C❑ y a C �L O C O O O m i� a`. C ca A. -V W T 1. . n ...-.- F..-... :-fit-- + _ Experienced account management team Commitment to customer service Individualized customer needs Acknowledgment of local market needs Ease of administration with one carrier Performance standards available PacifiCare's Long -Term Commitment to The City of Fort Collins - 1 r R n�lr 171 : PacifiCare ® of Colorado NCQA's HEDIS® 3.0/1998 CY 1997 PacifiCare of Colorado prepared for the Commercial HMO Product July 1998 The Health Plan Employer Data and Information Set (HEDIS®) is a registered trademark of NCQA. HEDIS® 3.0/1998 - CY 1997 FOREWORD HEDIS®3.0/1998 Health Plan Employer Data and Information Set provides a standardized and uniform set of performance indicators for the health care industry. HEDIS allows a health plan to document for purchasers its value and accountability in meeting member needs. HEDIS measures a health plan's performance in seven key domains: • Effectiveness of Care • Access / Availability of Care • Satisfaction with the Experience of Care • Health Plan Stability • Use of Services • Cost of Care • Health Plan Descriptive Information The measurement set is sponsored and maintained by the National Committee for Quality Assurance (NCQA), a non-profit quality oversight organization for the managed care industry. A health plan's participation in reporting HEDIS is voluntary. Intended to be updated annually, HEDIS reporting is a dynamic process moving toward greater accountability in health care, ultimately providing the public with consistent delivery of quality care. HEDIS® 3.0/1998 - CY 1997 TABLE OF CONTENTS Effectiveness of Care Domain • Childhood Immunization Status • Adolescent Immunization Status • Breast Cancer Screening • Cervical Cancer Screening • Prenatal Care in First Trimester • Check-ups After Delivery • Beta Blocker Treatment After a Heart Attack • Advising Smokers to Quit • Eye Exams for People with Diabetes • Follow-up After Hospitalization for Mental Illness • Comparisons to HEDIS® 3.0 - CY 1996 Results 2. Access/Availability of Care Domain • Adults' Access to Preventive/Ambulatory Health Services • Availability of Primary Care Providers • Availability of Language Interpretation Services 3. Satisfaction with the Experience of Care Domain • Member Satisfaction Survey 4. Health Plan Stability Domain • Disenrollment • Provider Turnover • Years in Business • Indicators of Financial Stability 5. Use of Services Domain • Well -Child Visits in the First 15 Months of Life • Well -Child Visits in the Third, Fourth, Fifth and Sixth Year of Life • Adolescent Well -Care Visits • Frequency of Selected Procedures • Inpatient Utilization - General Hospital/Acute Care • Ambulatory Care • Inpatient Utilization - Nonacute Care • Discharge and Average Length of Stay - Maternity Care • Cesarean Section Rate and Vaginal Birth After Cesarean Section Rate • Births and Average Length of Stay, Newborns • Mental Health Utilization - Inpatient Discharges and Average Length of Stay • Mental Health Utilization - Percentage of Members Receiving Care • Readmission for Selected Mental Health Disorders • Chemical Dependency Utilization - Inpatient Discharges and Average Length of Stay • Chemical Dependency Utilization - Percentage of Members Receiving Care • Readmission for Chemical Dependency • Outpatient Drug Utilization 6. Cost of Care Domain • Rate Trends • High-Occurrence/High Cost DRGs 7. Health Plan Descriptive Information Domain • Provider Network • Enrollment HEDIS® 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE DOMAIN: EFFECTIVENESS OF CARE This domain is designed to provide information about the quality of clinical care provided by the plan. The individual measures address specific areas of prevention, early detection and screening, maternity, acute and chronic illnesses, and behavioral health. The domain includes information related to the following issues: • CHILDHOOD IMMUNIZATION STATUS • ADOLESCENT IMMUNIZATION STATUS • BREAST CANCER SCREENING • CERVICAL CANCER SCREENING • PRENATAL CARE IN FIRST TRIMESTER • CHECK-UPS AFTER DELIVERY • BETA BLOCKER TREATMENT AFTER A HEART ATTACK • ADVISING SMOKERS TO QUIT • EYE EXAMS FOR PEOPLE WITH DIABETES • FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS • COMPARISONS TO HEDIS® 3.0 - CY 1996 RESULTS PacifiCare of Colorado Page 1 of 7 7/31/98 HEDISQD 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE CHILDHOOD IMMUNIZATION STATUS Childhood immunizations help prevent serious illnesses, such as polio, tetanus, whooping cough and meningitis.' The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 90% the proportion of children under age two who receive the basic immunization series? This measure reports the percentage of children in the plan who received the appropriate immunizations by their second birthday. Combination 1 listed below is comparable to 1996 reported results. Denominator = - Total children who turned two years old in 1997 and were continuously enrolled for twelve months immediately preceding their second birthday 411 Of members above, total who received: Number Percent 4 DTP immunizations by 2' birthday 350 85.2% 3 OPV immunizations by 2nd birthday 376 91.5% 1 MMR immunization between ? and tad birthdays 375 91.2% 2 H influenza type b immunizations (HIB) by 2"d birthday (at least 1 after 1" birthday) 346 84.2% 2 hepatitis B immunizations by 2nd birthday (1 after 6 months of age) 336 81.8% 1 chicken pox immunization (VZV) between 1" and 2"d birthdays 134 32.6% Combination 1: All immunizations listed above except 1 HIB after ? birthday and VZV 281 68.4% Combination 2: All immunizations listed above except VZV 278 67.6% Combination 3: All immunizations listed above 100 24.3% Healthy People 2000 Goal: 90.0% ADOLESCENT IMMUNIZATION STATUS Immunizations are a proven defense against serious illnesses, such as hepatitis B, polio, tetanus and diphtheria.' Therefore, health plans should help ensure that adolescents are vaccinated according to schedule. The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 90% the proportion of children up to age 12 who are fully immunized.' This measure reports the percentage of children in the plan who received the appropriate immunizations by their 13' birthday. The MMR only is comparable to 1996 reported results. Denominator = Total adolescents who turned 13 years old in 1997 and were continuously enrolled for 12 months prior to their 13th birthday Of members above, total who received: Second dose of WAR between 4' and 13' birthdays 324 78.8% 3 hepatitis B immunizations by 13' birthday 105 25.6% 1 chicken pox vaccine or documented history of chicken pox by 13' birthday 46 11.2% All immunizations listed above 16 3.9% Healthy People 2000 Goal: 90.0% 1. NCQA, Health Plan Employer Data & Information Set (HEDIS 3.0), July 1996. 2. Source for National Data - NCHS, Healthy People 2000 Review. Health, United States, 1992. Hyattsville, Maryland: Public Health Service, 1993. PacifiCare of Colorado Page 2 of 7 7/31 /98 HEDIS® 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE BREAST CANCER SCREENING Breast cancer is the most common type of cancer among American women --each year in the United States, more than 175,000 women are diagnosed with breast cancer. Mammograms are the most effective method for detecting breast cancer at a time when it is most likely to be treatable.' The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 60% the proportion of females age 50 and older who have received a mammogram in the preceding two years.' This measure reports the percentage of the plan's female members between the ages of 52 and 69 who had at least one mammogram during the past two years. = 16,063 Total women age 52 through 69 as of December 31, 1997 and continuously enrolled for 2 years (from January 1. 1996) a mammogram in 1996 or Percent 2000 Goal: 60.0% CERVICAL CANCER SCREENING Approximately 13,000 new cases of cervical cancer are diagnosed annually. Cervical cancer can be detected in its early stages by screening with the Pap smear test, which has been credited with reducing the number of deaths by as much as 75%.' The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 85% the proportion of females age 18 and older who have received a Pap test in the preceding three years' This measure reports the percentage of female members in the plan ages 21 to 64 who had at least one Pap smear during the past 3 years. Denominator = 82,943 Total women age 21 through 64 as of December 31, 1997 and continuously enrolled for 1 year (from January 1, 1997) Number Percent Of members above, total who had a Pap smear in 1995, 1996 or 1997 60,832 73.3% Healthy People 2000 Goal: 85.0% 1. NCQA, Health Plan Employer Data & Information Set (HEDIS 3.0), July 1996. 2. Source for National Data - NCHS, Healthy People 2000 Review. Health, United States, 1992. Hyattsville, Maryland: Public Health Service, 1993. PacifiCare of Colorado Page 3 of 7 7/31/98 HEDIS® 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE PRENATAL CARE IN THE FIRST TRIMESTER Health plans that provide timely, thorough and effective prenatal care can help reduce a woman's likelihood of delivering a low birth weight infant, detect and address maternal health problems early in the pregnancy and play a critical role in reducing infant mortality.' The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 90% the proportion of females who receive prenatal care in the fast trimester.' This measure reports the percentage of women in the plan who delivered a live birth and began prenatal care during the fast trimester of pregnancy. Denominator = 258 Total women who delivered a live birth in 1997 and were continuously enrolled for 280 days prior to delivery Number Percent Of members above, total who had a prenatal care visit 176 to 280 days prior to 238 92.3% delivery 2000 Goal: 90.0% CHECK-UPS AFTER DELIVERY The six weeks after giving birth are a period of physical, emotional and social changes for the mother. So that a new mother can be evaluated and receive any necessary assistance, the American College of Obstetricians and Gynecologists recommends that women see their health care provider at least once by the 42nd day after giving birth.' This measure reports the percentage of women in the plan who delivered a live birth and received postpartum care' Lenommator = Total women who delivered a live birth between January 1 and November 5 of 1997 and were continuously enrolled for 56 days after delivery Number IOf members above, total who had a postpartum visit between 21 and 56 days 334 81.3% after delivery 1. NCQA, Health Plan Employer Data & Information Set (HEDIS 3.0), July 1996. 2. Source for National Data - NCHS, Healthy People 2000 Review. Health, United States, 1992. Hyattsville, Maryland: Public Health Service, 1993. 3. Due to revisions in 1997 HEDIS specifications, these rates are not comparable to 1996 reported results. PacifiCare of Colorado Page 4 of 7 7/31 /98 :a)gQ alloxd aKll;LVU () :auogd :pauSIS uods ugld oI uopgulao3ul asgalaa oI suogn o uogduasaa _ aalraMaapun ao `aolgalstunupu `aos 'airDulagd dq alggMopg ao alggdgd Iou saSag a ao to s dsaa a n9 aumsse oI panddg aq pinogs anp Iunoun Io ssaaxa uI Iualudgd q 3 �q q Ig• q I 'laaaaoa sr uraol slyl no uonEWJOJUI aqI dpuaa dgaaaq I •drLgLvJ,s :Ann opeJO10310 suOZIJOH aanaag/aie3ilised :gMdnoxs :HRMM 3NOHd NVIDIMJ :Smaav :gwvN Bdummas :HINVN NVI)ISARd da03 N"d m 899NaN QI K89RI�S9aS adds so IuRd asga a rs asaanaa uo sasgaslp aluoaga ao suoglpuoa gap;aq `sal& ur Snap dug aigarpur asgaid `suogagaalu1 Snap p;r>uaI do 0 Id ' p aoliuO'u oI sn Mops oy •suognlos uogdraasaad oI alggdgd sxaaga a}Igm asgald adolanua pagavlag aqI ul uanlaa pug Wool sTgl alaldmoa asua[d 606£ lZIZ6V7 `oYaeQ uvs `OZl clans laasls saldvQt IOK `suollnyos uoaldwsa.[d:ol l:vyy pa8uvgo svy uo=?vuuo u: anod a ao wo sta .nod to a .i .% •� 1 ,� .� laldutioo rCluO O A ti y" MFF■■�iil �-. N _N V �• CO _� OCOOD ■ ■ O _C70 �^. [D fD G ,�.., H .r". A (CDC �' C—D • O C W yy �. 'O R' �i'• n p�o Q C rD Vi 9 0- '••1 Q Oro rD 00c 0 a `L �e-R— `G C e., O �mr et v` rD P n •� c � O (D HEDIS® 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE BETA BLOCKER TREATMENT AFTER A HEART ATTACK Annually, about 1.5 million persons experience a heart attack and about a third of them die from it. People who have had a heart attack are at higher risk of having another one. One medical therapy that has been shown to lower that risk is the use of beta blockers, which reduce how hard the heart has to work and lower blood pressure. ` This measure reports the percentage of members discharged from the hospital after a heart attack who received a prescription for beta blockers.' Denominator = 148 Total members age 35 years and older in 1997, hospitalized and discharged alive from January I' and December 24°i of the reporting year with a diagnosis of acute myocardial infarction and were continuously enrolled for 7 days after Percent Of members above, total who received a prescription for beta blockers within 7 84 56.8% days after discharge or 30 days prior to admission ADVISING SMOKERS TO QUIT Seventy percent of smokers are interested in stopping smoking completely, and smokers report that they would be more likely to stop smoking if a doctor advised them to quit. A number of clinical trials have demonstrated that getting even brief advice to quit from a doctor is associated with a 30 percent increase in the number of smokers who quit.' The U.S. Public Health Service established the following objective for the year 2000: to reduce cigarette smoking prevalence to no more than 15% of adults? This measure reports the percent of adult smokers or recent quitters, ages 18 years and older, who received advice to quit smoking from a health care professional. 90 Total current smokers or recent quitters having one or more visits with a plan provider in 1997, age 18 years and older as of December 31, 1997 and continuously enrolled for 1 year (from January 1. 1997) IOf members above, total who were advised to quit smoking by a doctor or other 61 67.8% health professional in their plan 1. NCQA, Health Plan Employer Data & Information Set (HEDIS 3.0), July 1996. 2. Source for National Data - NCHS, Healthy People 2000 Review. Health, United States, 1992. Hyattsville, Maryland: Public Health Service, 1993. 3. Due to revisions in 1997 HEDIS specifications, these rates are not comparable to 1996 reported results. PacifiCare of Colorado Page 5 of 7 7/31/98 HEDIV 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE EYE EXAMS FOR PEOPLE WITH DIABETES Diabetes is the leading cause of blindness in the United States. Therefore, it is important that people with diabetes have their eyes examined regularly so that appropriate treatment can be initiated at the first sign of a problem.' The U.S. Public Health Service established the following objective for the year 2000: to increase to at least 70% the proportion of diabetics who have a dilated retinal exam performed annually by an eye care specialist' This measure reports the percentage of diabetic plan members who had at least one eye exam in the past year.' Denominator = Total diabetics age 31 years and older as of December 31, 1997 and continuously enrolled for 1 year (from January 1. 1997) Of members above, total who had a retinal ophthalmoscopic examination 2,013 performed by an eye care professional in 1997 2000 Goal: 70.0% FOLLOW-UP AFTER HOSPITALIZATION FOR MENTAL ILLNESS An outpatient visit with a mental health practitioner within 30 days of discharge is necessary to make sure that the patient's transition to the home or work environment is supported and that gains made during hospitalization are not lost. It also helps health care providers detect early post -hospitalization reactions or medication problems and provide continual care.' This measure reports the percentage of plan members hospitalized for selected mental health disorders who were seen on an outpatient basis by a mental health provider within 30 days after their discharge' Denominator = Total members hospitalized for treatment of selected mental health disorders during the first 335 days of 1997, were age 6 year or older at the time of discharge and continuously enrolled for 30 days after discharge Of members above, total who were seen on an ambulatory basis or in day/night 353 85.9% treatment within 30 days of hospital discharge 1. NCQA, Health Plan Employer Data & Information Set (HEDIS 3.0), July 1996. 2. Source for National Data - NCHS, Healthy People 2000 Review. Health, United States, 1992. Hyattsville, Maryland: Public Health Service, 1993. 3. Due to revisions in 1997 HEDIS specifications, these rates are not comparable to 1996 reported results. PacifiCare of Colorado Page 6 of 7 7/31/98 HEDIS® 3.0/1998 - CY 1997 EFFECTIVENESS OF CARE COMPARISONS TO HEDIS® 3.0 - CY 1996 RESULTS The Effectiveness of Care measures that are comparable to 1996 results are shown below. While some measures remained unchanged, or had only minor revisions, for reporting year 1997, others underwent major revisions and therefore are not included in the comparison chart. Measure National Averages 1996' Plan Results CY 1996 Plan Results CY 1997 % Change CY 1996 - CY 1997 Childhood Immunization Status' 65.3% 60.1% 68.4% +13.8% Adolescent Immunization Status " 53.8% 36.2% 78.8% +117.7% Breast Cancer Screening 71.7% 75.2% 69.9% -7.0% Cervical Cancer Screening 70.4% 71.0% 73.3% +3.2% Prenatal Care in First Trimester 84.5% 81.3% 92.3% +13.2% Eye Exams for People with Diabetes 38.4% 46.3% 42.1% -9.1% Advising Smokers to Quit 61.1% NA 67.8% NA * Compares Combination 1 for 1997 to 1996 total results. Combination I includes all immunizations except the VZV and second MB. These were not required in 1996. ** Compares MMR only. The VZV and HepB vaccines were not required in 1996. 1. Source for National Averages - NCQA's Quality Compass'" 1997. PacifiCare of Colorado Page 7 of 7 7/31/98 HEDIS® 3.0/1998 - CY 1997 ACCESS/AVAILABILITY OF CARE DOMAIN: ACCESS/AVAILABILITY OF CARE This domain is designed to provide information on the extent to which a health plan has providers available to serve members and the proportion of members using preventive and ambulatory services. The domain includes information on the following measures: • ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES • AVAILABILITY OF PRIMARY CARE PROVIDERS • AVAILABILITY OF LANGUAGE INTERPRETATION SERVICES - PART II: SPECIFICATIONS FOR OUT -OF -PLAN INTERPRETER SERVICES PacifiCare of Colorado Page 1 of 3 7/31/98 HEDIS® 3.0/1998 - CY 1997 ACCESS/AVAILABILITY OF CARE TABLE 2: ADULTS' ACCESS TO PREVENTIVE/AMBULATORY HEALTH SERVICES This measurement set reports the percent of commercial members, enrolled with no more than one break of up to 45 days per year, who have had an ambulatory or preventive -care visit during the reporting year or the two calendar years preceding the reporting year. Age is calculated as of 12/31 of the reporting year. Number of Percentage of Members with Number of Members with One or More Members One or More Age Category Visits Visits 20-44 years 45,831 49,695 92.2% 45-64 years 44,470 47,238 94.1% 65 + years 4,480 4,684 95.6% Notes: Excludes inpatient procedures, hospitalizations, and emergency room visits. Excludes services pertaining to mental health and chemical dependency. TABLE 2A: AVAILABILITY OF PRIMARY CARE PROVIDERS This measure reports the number and percentage of primary care providers who are available to serve members and accept new members. Primary care providers are defined as health care practitioners whom members are able to select as their first point of entry into the system and who are defined by the plan as primary care providers for that purpose. Primary care providers may include the following providers: • general or family practitioners, • general geriatricians, • general internal medicine physicians, • general pediatricians, or • physician assistants and nurse practitioners. Primary Care Providers: 1,253 Number of PCPs Percent of PCPs Actual number of providers currently serving this population 1,192 95.1% Number of primary care providers, by office site 1,256 100.0% No restrictions on number of new plan members accepted, by office site (completely open) 950 75.6% Some restrictions on number of new plan members accepted, by office site 67 5.3% No new plan members accepted, by office site (completely closed) 239 19.0% PacifiCare of Colorado Page 2 of 3 7/31/98 HEDIS® 3.0/1998 - CY 1997 ACCESS/AVAILABILITY OF CARE TABLE 2G: AVAILABILITY OF LANGUAGE INTERPRETATION SERVICES - PART II SPECIFICATIONS FOR OUT -OF -PLAN INTERPRETER SERVICES This table describes the non -staff arrangements through which the plan secured interpreter services during the reporting year. Language Interpreter Services Description Type of Agreement Restrictions on Availability Hearing Impaired Center on Deafness In -person Letter of agreement — NR (CMP/PACIFICARE) Hearing Impaired Sign Language of In -person Informal (NMO NR Denver Orientations) Hearing Impaired Colorado Center for In -person Informal NR Deafness, Colorado Springs Hearing Impaired Northern Colorado In -person Informal NR Center for Deafness, Fort Collin Hearing Impaired Sign Language In -person Informal NR Network, Colorado Springs PacifiCare of Colorado Page 3 of 3 7/31 /98 HEDIS® 3.0/1998 - CY 1997 SATISFACTION WITH THE EXPERIENCE OF CARE DOMAIN: SATISFACTION WITH THE EXPERIENCE OF CARE This domain provides consumers and purchasers with information about members' level of satisfaction pertaining to a wide range of experiences they have with the health plan. Sampling, data collection, processing, data submission and summary reports were conducted and prepared by an independent survey research firm not owned by the plan. The process complies with the protocols outlined in HEDIS 3.0 Volume III: Member Satisfaction Survey. This domain includes information related to the following issues: • MEMBER SATISFACTION SURVEY PacifiCare of Colorado Page 1 of 3 7/31/98 HEDIS® 3.0/1998 - CY 1997 SATISFACTION WITH THE EXPERIENCE OF CARE MEMBER SATISFACTION SURVEY The plan places great importance on achieving a high level of member satisfaction and devotes significant resources toward continuous monitoring and improvement of member satisfaction. The revised Annual Member Health Care Survey - the Member Satisfaction Survey was introduced as a part of HEDIS 3.0. This standardized survey, administered by an independent survey research firm, was conducted with a sample of our members. The results are as follows: Member Satisfaction Overall satisfaction with the plan Total Responses 564 Completely Satisfied 13% Very Satisfied 47% Somewhat Satisfied 24% Neither Satisfied nor Dissatisfied 8% Somewhat Dissatisfied 6% Very Dissatisfied 2% Completely Dissatisfied 1 % Overall Positive Response 84% Member Response Overall Total Defin Probab Probab Definite Positive Responses Yes Yes Not Not Response Would recommend the plan to others 562 24% 61% 12% 3% 85% Intend to switch to another health plan 551 2% 90/0 64% 25% 89% Member Response overall Total Positive Responses Biz Problem Small Problem No Problem Response Referral Process Delays in medical care while waiting for approval 556 5% 12% 83% 83% Difficulty receiving necessary care 552 4°/a 11% 85% 85% Ease of referral to specialist 552 60/9 13% 81% 81% Member Response Overall Total Very Positive Responses Poor Fair Good Good Excellent Response Selection of Providers Number of physicians to choose from 517 7% 14% 35% 26% 18% 79% Ease of choosing a personal physician 529 6% 10% 35% 29% 20% 84% Provider Care Ease of making appointments by telephone 550 5% 13% 290/9 33% 21% 83% Thoroughness of the treatment received 548 4% 12% 29% 33% 22% 84% Overall quality of care received 548 3% 12% 30% 34% 20% 84% Helped by patient care received 538 4% 13% 30% 34% 19% 93% Attention given to patient comments 544 4% 12% 28% 30% 26% 84% Plan Service Types of services covered by the plan 542 3% 15% 36% 34% 12% 82% Availability of information about eligibility, 541 5% 17% 39% 29% 11% 79% covered services or administrative issues Note: "Member Response" reflects reporting requested by NCQA. "Overall Positive Response' reflects the total positive responses. PacifiCare of Colorado Page 2 of 3 7/31/98 HEDIS® 3.0/1998 - CY 1997 SATISFACTION WITH THE EXPERIENCE OF CARE Wait Times Total Same 1-3 4-7 8-14 15-30 31-60 61+ Responses 2a Days Days Days Days Days Days Time between making appointment and seeing provider Routine care 519 6% 29% 23% 18% 13% 80/0 3% Minor illness or injury 453 34% 53% 90/0 2% 00/0 00/0 00/0 Chronic or ongoing condition 332 20% 44% 18% 90/0 5% 20/0 1% Urgent care 324 820/6 15% 2% 1% 0% 09/8 00/0 Total <1 1 - <4 4 - < 7 7 - <24 24+ Responses hour hours hours hours hours Time between calling for medical 401 14% 43% 22% 11% 9% information and return call from provider Wait time in provider's office for appointment Total <10 10-15 16-30 31-44 45min Responses min min min min —1 hr 532 13% 39% 33% 8% 6°/u 1-2 2+ hrs hrs 2% 0% PacifiCare of Colorado 7/31/98 Page 3 of 3 HEDIS®10/1998 - CY 1997 HEALTH PLAN STABILITY DOMAIN: HEALTH PLAN STABILITY This domain is designed to provide information for purchasers in evaluating the stability of a health care company. The domain includes information related to the following issues: • DISENROLLMENT • PROVIDER TURNOVER • YEARS IN BUSINESS/TOTAL MEMBERSHIP • INDICATORS OF FINANCIAL STABILITY PacifiCare of Colorado Page I of 4 7/31 /98 City of Fort Collins Copayment Schedule Some benefits are subject to limitations. These limitations may include length of treatment, frequency of treatment and/or maximum amount payable under your plan. See Chapter Three of this Evidence of Coverage for details on your benefits. Following are the copayments applicable to your plan. To determine which copayments apply to you, please see your ID card or call PacifiCare Customer Service at 1-800-877-9777 if you would like additional information. __M City of Fon Collins Active Employees City of Fort Collins Retirees Deductible & None None Coinsurance Physician's Office Visits $10 per visit $10 per visit Preventive Care $10 per visit $10 per visit Maternity Care $10 per visit $10 per visit Allergy Testing and $10 per visit $10 per visit Treatment Allergy Injections $5 per visit $5 per visit Lab & X-Rays no copayment no copayment Infertility Evaluation 50% copayment up to an out-of-pocket maximum 50% copayment up to an out-of-pocket maximum of $2,500 per individual per contract year of $2,500 per individual per contract year Emergency Room $50 copayment per visit $50 copayment per visit Services Ambulance $25 copayment per episode $25 copayment per episode Emergency Services $25 per visit $25 per visit After Hours in a Physician's Office or Urgent Care Center Hospital Inpatient $100 copay per admission (maximum 2 copays per $100 copay per admission (maximum 2 copays per individual per contract year, maximum 5 copays individual per contract year, maximum 5 copays per family per contract year) per family per contract year) Hospital Outpatient $50 copayment per visit $50 copayment per visit (includes ambulatory surgery) Physical, Occupational & $10 per visit, maximum of 20 visits per condition $10 per visit, maximum of 20 visits per condition Speech Therapy Inpatient Mental Health* $50 copayment per day, $25 copayment per partial $50 copayment per day, $25 copayment per partial day; maximum of 45 days (90 partial days) per day; maximum of 45 days (90 partial days) per contract year contract year Outpatient Mental No copayment for visits 1-5, $10 copayment No copayment for visits 1-5, $10 copayment Health* thereafter thereafter Inpatient Alcohol & $50 copayment per day, maximum of 21 days per $50 copayment per day, maximum of 21 days per Substance Abuse contract year contract year Outpatient Alcohol & No copayment for visits 1-5, $10 copayment No copayment for visits 1-5, $10 copayment Substance Abuse thereafter thereafter Skilled Nursing Facility No copayment; maximum of 120 days per contract No copayment; maximum of 120 days per contract year year Home Health Care No copayment No copayment Hospice Care No copayment No copayment Durable Medical No copayment; $1,000 maximum benefit per No copayment; $1,000 maximum benefit per Equipment (DME) contract year (an additional $500 is available for contract year (an additional $500 is available for the use of oxygen) the use of oxygen) Chiropractic Care $10 copayment; 20 visit maximum $10 copayment; 20 visit maximum Prescription drugs $5 per prescription $5 per prescription, $5,000 maximum per year Out -of -Pocket Maximums $3,600 per individual, $10,000 per family $3,600 per individual, $10,000 per family Maximum Benefit $2,000,000 lifetime per individual Annual: $95,000 per individual for medical; $5,000 per individual for prescription drugs Lifetime: $2 000 000 per individual *Coverage for biologically -based mental illnesses is no less extensive than the coverage for any other physical illness. HEDIS® 3.0/1998 - CY 1997 HEALTH PLAN STABILITY TABLE 4A-1: ANNUAL AGGREGATE DISENROLLMENT RATE FOR COMMERCIAL MEMBERS Total members enrolled as of 12/31/96 283,673 Of members above, the total number enrolled as of 12/31/97 214,989 Disenrollment Rate 24.2% Note: The annual disenrollment rate is intended only as a measure of stability of membership of the health plan. The measure should not be used as a proxy for dissatisfaction because it does not differentiate between voluntary and involuntary disenrollment. TABLE 4B: TURNOVER IN PROVIDERS SERVING COMMERCIAL MEMBERS Affiliated as of Not A e as o 12131 ofthe 12131 ofthe umover Provider Type Preceding Year Reporting Year Rate Primary Care Physicians 1,074 84 7. /o Non -Physician Primary Care Providers NR NR NR Notes: There are no exclusions from the denominator of the turnover rates. Primary care and other providers are counted regardless of reasons for their change in affiliation with the plan. PacifiCare of Colorado Page 2 of 4 7/31/98 HEDIS® 3.0/1998 - CY 1997 HEALTH PLAN STABILITY TABLE 4C: YEARS IN BUSINESS/TOTAL MEMBERSHIP Years in Product Line Business Members HMO (Total) 24 349,009 Medicaid NR NR Commercial 24 266,705 Medicare risk 11 53,260 Medicare cost NR NR Self -Insured 10 27,669 Other (specify) 24 1,375 PPO (Total) 24 26,475 Medicaid NR NR Commercial 24 5,855 Medicare risk NR NR Medicare cost NR NR Self -Insured 24 20,531 Other (specify) 6 89 POS (Total) 9 24,150 Medicaid NR NR Commercial 9 20,037 Medicare risk NR NR Medicare cost NR NR Self -Insured 2 4,113 Other (specify) NR NR Notes: The number of years of operation should be considered when evaluating a health plan's financial profile. The total category equals the health plan's total membership as of December 31 of the reporting year. PacifiCare of Colorado Page 3 of 4 7/31 /98-R HEDIS® 3.0/1998 - CY 1997 HEALTH PLAN STABILITY TABLE 41): INDICATORS OF FINANCIAL STABILITY Chg from %Chg from Reporting Year 1995 1996 1997 96 to '97 196 to 197 Total Membership 311,004 325,694 341,377 15,683 4.8% Performance Indicators Total revenue $524,869,466 $596,530,957 $655,582,048 $59,051,091 9.9% Net income $21,682,002 $14,625,437 $26,411,581 $11,786,144 80.6% Net worth $25,483,200 $20,308,670 $32,178,437 $11,869,767 58.4% Debt -to -service ratio N/A N/A N/A NR NR Overall loss ratio 94.0% 96.0% 95.0% -1.0% -1.0% Administrative loss ratio 12.0% 13.0% 12.0% -1.0% -7.7% Medical loss ratio 81.0% 83.0% 83.0% 0.0% 0.00/0 Operating profit margin 6.0% 4.0% 5.0% 1.00/0 25.0% Overall profit margin 6.0% 5.0% 6.0% 1.00/0 20.0% Liquidity Indicators Days cash on hand 29 30 24 -6 -20.0% Ratio of cash to claims payable 64.0 74.0 84.0 10.0 13.5% Efficiency Indicators Days in receivables 13 11 9 -2 -18.2% Days in unpaid claims 46 46 33 -13 -28.3% Statutory Indicators State minimum reserve requirement $17,000,000 $17,000,000 $17,000,000 $0 0.0% Actual reserve held by plan $25,483,200 $20,308,670 $32,178,437 $11,869,767 58.4% PacifiCare of Colorado Page 4 of 4 7/31 /98-R HEDIS 3.0/1998 - CY 1997 USE OF SERVICES DOMAIN: USE OF SERVICES This domain provides information on how a plan manages and expends its resources, which may give purchasers a sense of the plan's priorities. Use of services is affected by many member characteristics that can vary greatly among health plans, including current medical condition, socioeconomic status, sex and race, and therefore this information should serve as a starting point for discussions with the plan. The domain includes information related to the following services: • WELL -CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE • WELL -CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEAR OF LIFE • ADOLESCENT WELL -CARE VISITS • FREQUENCY OF SELECTED PROCEDURES • INPATIENT UTILIZATION - GENERAL HOSPITAL/ACUTE CARE • AMBULATORY CARE • INPATIENT UTILIZATION - NONACUTE CARE • MATERNITY CARE - DISCHARGE AND AVERAGE LENGTH OF STAY • CESAREAN SECTION RATE AND VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC) RATE • NEWBORNS - BIRTHS AND AVERAGE LENGTH OF STAY • MENTAL HEALTH UTILIZATION - INPATIENT DISCHARGES AND AVERAGE LENGTH OF STAY • MENTAL HEALTH UTILIZATION - PERCENT OF MEMBERS RECEIVING INPATIENT, DAY/NIGHT CARE AND AMBULATORY SERVICES • READMISSION FOR SELECTED MENTAL HEALTH DISORDERS • CHEMICAL DEPENDENCY UTILIZATION - INPATIENT DISCHARGES AND AVERAGE LENGTH OF STAY • CHEMICAL DEPENDENCY UTILIZATION - PERCENT OF MEMBERS RECEIVING INPATIENT, DAY/NIGHT CARE AND AMBULATORY SERVICES • READMISSION FOR CHEMICAL DEPENDENCY • OUTPATIENT DRUG UTILIZATION PacifiCare of Colorado Page 1 of 16 7/31/98 HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES WELL -CHILD VISITS IN THE FIRST 15 MONTHS OF LIFE The percentage of children who had zero, one, two, three, four, five or six or more well -child visits with a primary care provider during their first 15 months of life. Denominator = 2,536 Total children who turned 15 months of age in 1997 and were continuously enrolled from 31 days of aee Of members above, total who had well -child visits by a primary care provider - in first 15 months of life 0 visits 75 3.0% 1 visit 36 1.4% 2 visits 14 0.6% 3 visits 45 1.8% 4 visits 20 0.8% 5 visits 65 2.6% 6+ visits 2,281 89.9% WELL -CHILD VISITS IN THE THIRD, FOURTH, FIFTH AND SIXTH YEAR OF LIFE The percentage of children ages 3 through 6 who had at least one well -child visit with a primary care provider during the past year. Total children who were 3, 4, 5 or 6 years old as of December 31, 1997 and were continuously enrolled for 1 year (from January 1, 1997) one or more wets -care visit(s) wtm a care provider in 1997 Percent ADOLESCENT WELL CARE VISITS The percentage of members ages 12 through 21 who had at least one comprehensive well -care visit with a primary care provider during the past year. lienommator = Total children who were 12 through 21 years old as of December 31, 1997 and were continuously enrolled for 1 year (from January 1, 1997) Number I Percent I(Jr members above, total wno had one or more comprehensive well -care 1 Y,ubz 4Y.Vlo I visit(s) with a Drimary care provider in 1997 PacifiCare of Colorado Page 2 of 16 7/31/98 HEDIe 3.0/1998 - CY 1997 USE OF SERVICES Table 5C-2b: Frequency of Selected Procedures an Mile Member Montbs Female Tohl 04 234,901 0-9 .................................................. 509,195 .. 5-19 ..................................................... 943,405 10-19 ..................................................... 569,111 15-44 988,994 ..................................................... 20-64 1,034,999 ............ _...................... 1,211,994 30.64 ........................ ........... 970,469 .................................... 45.64 ••••••••••••.................. •-••-•••, .................................... 458,261 ................................... Procedure Age Sec Number of Procedures Procedures PTMPY Myringotomy 04 Male and Female 340 17.4 5-19 Male and Female .......... _........... .............. .............. ..................................................... 73 1.0 .......... ........... ............ ................. Tonsillectomy ...... ................. ................................................. 0-9 Male and Female ..................... .................... .......... ._.................................................. 249 5.9 Adenoideetomy 10.19 Male amd Female ................ ..................... _............. .............. 149 _.......... ..... _................... 3.1 ............................ . ............................. Dilation & . ............................................ 1544 . ..................... Female ..................................................... ..................................................... 210 2.8 Curettage 45-64 Female ....................._.............................. ...... 170 _................. _.......................... 4.5 ................................................._......................_...-............................._................. Hysterectomy 1544 Female ................................... _................ ............... 436 _.... _.............................. 5.9 45-64 Female ...................................... _............ ..................... 273 _.............................. 7.1 Choletystectomy, 30-64 Male 15 0.2 open 1544 .. Female ...... ......... _................................ ............ 14 _.._................................... 0.2 45-64 .._ Female ..... _.......................................... ..................................................... 26 0.7 _._........._............. ................................... Cholecystectomy, _....................... _............................ ...........-............ ........................... ................. ........... ...... ................ 30-64 Male 108 1.5 closed 1544 ........... Female -........................................ I ...................... 281 _........... . ............... 3.8 (lspsroscopic) 45.64 ...... Female . ............................................. ................................... 235 __.............. 6.2 ...................... _............ ................... Lamineetomy .............. .................... 20.64 _.................................. ...................... Male _.._......................... .......... 214 -................................... _.... 2.5 Diskeetomy 20-64 ............................. Female -...................... ........................................ 193 _........... 1.9 .. ...................................................... Angioplasty _..................................... 45-64 _.......... _.................. .......................... Male -......................... ..................................................... 181 5.2 (PICA) .......... .............................._.............................................................................. 45-64 ..................................................... Female _..... ..................................................... ..................................................... 38 ..................................................... 1.0 Cardiac 45-64 Male ..................................................... 275 ..................................................... 7.9 Catheterization ._............ _................................................................................_............................. 45-64 Female ........... _........... _........................... 107 ..................................................... 2.8 CABG 45-64 Male ..................................................... 91 ....................................... 2.6 _............ Female 18 0.5 ................................................................._............................_............................... 45-64 ..................................................... ..................................................... Prostatectomy 45-64 Male 70 2.0 PacifiCare of Colorado 7/31 /98 m..x6 Ua T.11sS .2 BINS Page 3 of 16 HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 5D-2b: General Hospital/Acute Care an Member Month <1 44,567 ....................... 1-9 464,628 ....................... 10.19 569,111 ...................... 20.44 1,372,217 ..................... 45.64 874,776 ....................... 65-74 51,561 .............. 75-84 8,335 85+ 1,255 Total Member Months 3,396,450 ......... .......... _........................ Age Discharges Discharges P774" Days Days PTMPY Average Length of Stay Total Inpatient <1 ........ 282. .....»75 9. .........................1.545. .....416.0 ......................»5.5 . 1-9 ........................... 401 _...... 10.4 .................................. ..................... 1,092 _........... ......................... 29.2 _......... 2.7 ..................................... 10-19 .................................. 627 13.2 .................................. ............................... 2,061 ..................»................ 43.5 3.3 .................................... 20.44 ....... 5,203 ..... ..................... 45.5 ................................................... 13,287 ..... .............................._....._...... 116.2 2.6 ...... _............................. 45.64 .................................. 3,389 46.5 ........................ _........ ..................... 14,498 _........... .................................... 199.9 4.3 ..................................... 65-74 ................................... 448 104.3 .................................................................... 2,306 .... 536.7 ....................... _...... 5.1 ..................................... 75-94 .................................. 140 201.6 .................................. ..................... 774 _....... ... ............................ 1,114.3 _. _... 5.5 ...................... _............. 85+ _................................ 24 229.5 .................................................................... 115 .................................... 1,099.6 4.9 ...... »............................. Unlmown ......._.. ................. �:... ..............................0 0.0 .....»..:.. ................... .......... ............................. Total »................... 10,514 .. 37.3 .................................. ................................ 35,678 ............................ 126.4 _...... 3.4 ..................................... Medicine <1 .................................. 257 69.2 ................................................................... 1,443 .................................... 388.5 5.6 ......... ............ .............. 1-9 .......... 341 ......... .............. 8.9 ........................................... 912 ................... ... .................................... 23.6 2.7 ......... _.......................... 10-19 ................................... 266 5.6 ................................................................... 1,055 ............................_...... 22.2 4.0 ....... ............................ 20-44 ....................»............. 1,003 8.8 .................................................... 3,166 _..... ............................_............... 27.7 3.2 ....... _............................ 45.64 ................................... 1,754 24.1 ................................_.................................. 6,983 ..........»........................ 95.8 4.0 ..................................... 65-74 ........... 256 ....................... 59.6 .................................................. 1,270 ........ .................................... 295.6 5.0 ..................................... 75-84 ........................ 90 _......... 129.6 .................................................... 450 ...... ........ .................................... 647.9 5.0 ..................................... 85+ ..»19. .............I81:... .�............................822.3 .....................»4:5. Unknown .................._.. ............... ...................._... ......................... ..............................»°:°. ............................................................ Total ................................... 3,986 14.1 ......... _....................... ................ 15,365 _................ .. 54.4 _..»............................ 3.9 ..................................... Surgery <1 .......... 25 ........................ 6.7 ................................................................... 102 ....... 27.5 ....... .................... 4.1 ............. _...................... 1-9 .......... 52 _....................... 1.3 ...... ......... ................. ................................. 171 .................................... 4.4 3.3 ..................................... 10.19..........................._156. ................ .................................. ...13:4. .............................._...1 20.44 ......................... 1,193 _........ 10.4 .»................................................................. 3,816 ....... 33.4 _........................... 3.2 ............... . .................... 45-64 ................. 1,627 ...... .»...»... 22.3 ............»...................................................... 7,472 .................................... 102.5 4.6 ..................................... 65-74 ................................... 192 44.7 ................................................................... 1,036 .......»».._..................... 241.1 5.4 ..................................... 75-84 ................ 50 _................. 72.0 .................................................................. 324 .. .................................... 466.5 6.5 ...... ............................... 85+ .................................. 5 47.9 .................................................................... 29 ... 277.3 ..... .......................... 5.8 ................................... Unknown ......................................... .............................»... .............»��. ...»..:.. ............................................................ Total .............................».... 3,300 11.7 ............................»...................................... 13,586 ......... 48.1 _.. _...... _............. 4.1 ................................... Maternity 10-19 ................................... 205 4.3 ................................................................... 370 ............. 7.8 _..................... 1.8 ..................................... 20-44 ..3:� 06 ......................... 26:3. ......................._6.296. .............55... .............................._..:.. 45-64................................6. ................ ......................._..........................-0.. .............................._.. 8. Other...............................»8. I........................... �:... .. » ......... - .........0.2 .. ..........:.. Total ................................... 3,225 11.4 .................................................................... 6,692 .................................... 23.7 2.1 ..................................... PacifiCare of Colorado 7131/98 Page 4 of 16 m .e ua T.em SIM 3 VIM HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 5E-2b: Ambulatory Care Member Age Months <1 44,567 1-9 464,628 10-19 569,111 ........................ 20-44 1,372,217 ~ 45-64 874,776 ......................... 65-74 51,561 ................ 75-94 A8.335 85+ 1,255 ......................... Outpatient Visits Ambulatory Surgery/ Observation Room Stays Age (Excludes NMCD) Emergency Room Visits Procedures Resulting in Discharge Procedures Visits Visits PTMPY Visits Visits PTMPY Procedures PTMPY Stays Stays PTMPY <1 28,732 _....._...................................... 7,736.3 745 ............ ...................... 200.6 ..... ......................... 120 ............................ 32.3 ......................... 8 ................... 2.2 ........ 1-9 100,650 »..........................._...................... 2,599.5 3,575 ».......................... 92.3 .... 653 .................... ............. 16.9 »............. ......................... 14 ............................. 0.4 10-19 91,868 1,937.1 3,745 79.0 782 16.5 27 0.6 20-44 244,931 ........ ................ .....................................................................»......._.........................................................._........»...................................... 2,141.9 8,483 74.2 4,737 41.4 143 1.3 45-64 209,804 .............................................................. 2,878.0 5,138 _...................................... 70.5 ».......................... 5,557 ............................ 76.2 ..... _.................. 62 ......... 0.9 ............ _.... 65-74 15,976 ....... »..............................._..................... 3,718.2 448 .......... _.......... 104.3 _.................. ......................... 444 ......... 103.3 ..... ............ .................. 10 »............................. 2.3 ».. 75-84 2,836 ................. ....... ............................ 4,083.0 ....................... 127 ............................. 182.8 ......................... 75 ........................ 108.0 _........................... 2 ............................. 2.9 85+ 364 ......................... ............................ 3,480.5 ......................... 22 .......................... 210.4 _......................... 4 ..... _..................... 38.2 ....................... 0 _ I .................... 0.0 _...... Unlmown 0 ......................... ................ 0.0 ........... .... 0 .................... ............................ 0.0 ......................... 0 ........... 0.0 _............... ............ 0 _.......... .»»........................ 0.0 Total 695,161 2,463.3 22,283 79.0 _... _....... ......................... 12,372 ............... 43.8 »........... .................. 266 ...... ........... 0.9 . ................ PacifiCare of Colorado 7/31/98 Page 5 of 16 m u -Ift UR Tab* SEA ] 7n11ft HEDIe 3.0/1998 - CY 1997 USE OF SERVICES Table 5F-2b: Inpatient Utilization - Nonacute Care Age Member Months <1 44,567 ....................................... 1-9 464,628 ....................................... 10-19 569,111 ....................................... 20-44 1,372,217 ....................................... 45-64 874,776 ....................................... 65-74 51,561 ....................................... 75-84 8,335 .................. _ ................... 85+ 1,255 ....................................... Age Discharges Discharges PTMPY Days Days PTMPY Average Length of Stay <1 1 .... _..... _.......... ....... ....... ._ 0.3 ...................._...................................._......................-...................................................._...................................... 17 4.6 17.0 1-9 1 ....................... _.............. ...................................................... 0.0 .................................. 1 .............................................. 0.0 1.0 ........................................ _... 10-19 2 ................ -..................... ...................................................... 0.0 ....... 18 -......................... .......... 0.4 _.................... ............. 9.0 ................... _........................ 20 44 ....- ..........................2I... .........................._..:�................................. .._..................................�:�. 10... ............................................. 45-64 110 ..................... _................ 1.5 -.... -.............................................. ....................... 1,083 -......... ...... 14.9 -................................. .... 9.8 ....... -.................................... 65-74 25 ....................................... .- 5.8 ................... _.............................. .......................... 271 _...... ................ 63.1 _........ ............. ..... 10.8 .... .......... ........ .................... 75-84 12 ................. _.................... ................................................ 17.3 -.... ............. 320 _................... ............................... 460.7 _............. 26.7 ............................................. 85+ 2 ......................... _............ ......................... 19.1 _..................... -.... ......................... 34 _....... ............................... 325.1 _............. 17.0 ... .......... -............................. Unknown 0 ....................._.................._............................................................................................._..........._.........................................-.........-............. 0.0 0 0.0 0.0 Total 174 ...................... _............... .......... 0.6 _.......................................... .................................. 1,971 ..... 7.0 ........ _....... _.................... 11.3 ............ .................. ........ ----- PacifiCare of Colorado 7/31/98 Page 6 of 16 cc u As UR TaW SF. 3M198 HEW 3.0/1998 - CY 1997 USE OF SERVICES Table 5G-2b: Discharge and Average Length of Stay - Maternity Care Agr 10-14 141,221 ..................................... 15-19 135,251 ..................................... 20-34 363,109 3549 565,661 Other* 552,914 ..................................... Total 1,758,156 Average Length Age Discharges Discharges PTMPY Days Days PTMPY of Stay Total Deliveries 10-14 3 .... ...... ... ..................... .. 0.3 ............................... ..................... ...... 4 _.._................... 0.3 ........................ ........... .... ...-........... 1.3 ................. 15-19 178 ..... ..... ... ................. _...................................... 15.8 -.................. .......... 320 -................... 28.4 ........................................................................... 1.8 20-34 2,218 ............ ........................- 73.3 ......... _........................................... ............ 4,514 _..... ............ 149.2 .............................._...._..... 2.0 _............................. 35-49 592 ..... ......... ......... ........... .......................................... 12.6 _............ ............................... 1,354 28.7 ........................................................................... 2.3 Other* 10 ..................................... ....................... 0.2 . ............................... ............................... 11 0.2 ......................................... ............... 1.1 _.... ............ Total 3,001 ................................ 20.5 _. . ................... ............................... 6,203 42.3 ..................... . .................. ............... 2.1 . ................. Total Vaginal Deliveries: Live Births 10-14 3 ..... . ...................................................................................... 0.3 .......-...................... 4 0.3 ...................... _................. ...... 1.3 _.......................... 15-19 157 13.9 ................................................... ............................... 262 23.2 ........................................................................... 1.7 20-34 1,886 ...................................._..................................................... 62.3 ......................_....... 3,408 112.6 ................................. _...... ................... 1.8 ..... ........ 35-49 .....470.............................................._10... ...........-930 ....................19:... .................. Other* Others 10 ................................. _.......................................................... 0.2 ............................... 11 0.2 .............................. -........ . 1.1 ................................ Total 2,526 ........................................................ 17.2 .... 4,615 _........... ........_... 31.5 ..............._........................... 1.8 -............................. Total Cesarean Deliveries: Live Births 10-14 0 ....................................................................... 0.0 _.................... .................... 0 _......... 0.0 ........................................................................... 0.0 15-19 21 ............................................................................................. 1.9 ............................... 58 5.1 ............................. _.......... .................................. 2.8 20-34 332 _......................................... 11.0 ............. _........................ ......... .... 1,106 _.... _........ ........... 36.6 ....................................................................... 3.3 _.. 35-49 122 .......................... -......... ........................................................ 2.6 ............................... 424 9.0 ........... _............................ ................. 3.5 ........ ....... Other* 0 ............................................................................................. 0.0 .. 0 ...... ..................... 0.0 ......... _.............................. .................................. 0.0 Total 475 ........................................................ 3.2 _................................... ............................... 1,588 10.8 ........................................................................... 3.3 ' "Other" includes femal s age 0-9, 50+ and of unknown age. PacifiCare of Colorado 7/31/98 m uos.x MTMc5C-2 M Page 7 of 16 PacifiCare ° Your employer has elected to offer coverage for chiropractic care. You pay your office visit copayment per visit. Benefit is limited to a maximum of 20 visits per contract year. Covered chiropractic services are those within the scope of chiropractic care which are necessary to help members achieve the physical state enjoyed before an injury or illness, and which are determined to be chiropracticly necessary and generally furnished for the diagnosis and/or treatment of a neuromusculoskeletal condition associated with an injury or illness, including: 1 Chiropractic manipulations and adjustments and physiotherapy Diagnostic radiological services generally provided by participating chiropractors 1 Examination and treatment for the aggravation of an illness or injury Examination and treatment for the exacerbation of an illness or injury 6455 S. Yosemite St. Englewood, CO 80111 Chiropractic Benefit Chiropractic benefits are available to members in accordance with the following provisions: 1 Covered services are available only from participating chiropractors The member does not need a referral from the primary care physician to make an appointment with a participating chiropractor This information contains the major features of the chiropractic benefit and is not intended to replace the legal documents that contain the complete provisions of these benefits. Please refer to your Evidence of Coverage and Owner's Manual for a complete description of this benefit. Copyright © 1997 PacifiCare of Colorado EM05008.00 597 HEDIS 3.0/1998 - CY 1997 USE OF SERVICES Table 5H: Cesarean Section Rate and VBAC Section Rate Discharges: Average Length of Discharges: Age Cesarean Deliveries Days Stay Total Deliveries C-Section Rate 10-14 0 .......................................................... 0 .................. 0.0 ...................................................................... 3 ......................... ... 0.09/0 ........................................... 15-19 21 .......................................................... 58 ................... 2.8 _............................... _........ ......................................................... 178 11.80/6 .......... -............................... 20-34 332 ......................................... -............... 1,106 ................... 3.3 .._............................._........._........................_............................ 2,218 15.0% ......._.................................. 3549 122 ...... .......... ........................................ I 424 .................. 3.5 . ......................................... ._.............................. 592 ....................... 20.60/a ........................................... Other" ......................................................... ................. ..................................... .........10 ............-0.0% Total 475 ................... ........................... _....... 1,588 ........_......_. 3.3 ............................................_........................ ................. 3,001 15.8% ......._......_.......................... Discharges: Discharges: Vaginal Deliveries Average Length of Total Deliveries Age with Prior C-Section Days Stay with Prior C-Section VRAC Rate 10-14 ..............._..........................._.._........ 0 0 ................... 0.0 .................................................................................................... 0 .................... 0.00/0 _..................... 15-19 ............................................ _.. _........ 2 4 ................... 2.0 ... ........... .................. ........ ......................................................... 3 ........................................... 66.7% 20-34 .......... .......................... _..__............ 66 111 ................... 1.7 .................................................................................................... 148 ........................................... 44.6% 3549 .................................. _..... ...... _........ 19 33 ................... 1.7 ............................ _............. . 61 _................................................................................................. 31.1% Other* ................................ ........ _.............. 0 0 ................... 0.0 ..................... ............... ..... ......................................................... 0 ...................... 0.0% _................... Total 87 148 1.7 212 41.0% "Other" includes females age 0-9, 50+ and of unknown age. PacifiCare of Colorado 7/31/98 m Ros.als UR Table 5H 8/1M Page 8 of 16 HEDIS0 3.0/1998 - CY 1997 USE OF SERVICES Table 5I-2b: Births and Average Length of Stay, Newborns Member Months Total (All Ages) 3,386,450 Female(10-49) 1,205,242 .............................. Newborns/ 1,000 Female Newborns Members Discharges/ Average Number of Per Year 1,000 Members Days Length of Newborns (10-49) Per Year Days PTMPY Stay All Newborns Mother is Plan Member (10-49) 3,039 ....................................................................................................................................................................................... 30.3 10.9 5,684 20.4 1.9 Mother is Plan Member -other 10 .............................. ......................... 0 ............................... 0.0 Mother is Not Plan Member 30 .............................. ......................... 63 ............................... 2.1 Well Newborns Mother is Plan Member (10-49) 2,910 ....................................................................................................................................................................................... 29.0 10.4 2,999 10.8 1.0 Mother is Plan Member -other 10 .............................. ......................... 12 ............................... 1.2 Mother is Not Plan Member 27 35 1.3 Complex Newborns Mother is Plan Member (10-49) 129 ...................................................................................................... 1.3 0.5 ................................................................................. 2,685 9.6 20.8 Mother is Plan Member -other 0 .............................. ......................... 0 ............................... 0.0 Mother is Not Plan Member 3 .............................. ......................... 28 ............................... 9.3 •laclude all covered babies born to mothers who are not members of the health plan. PacifiCare of Colorado 7/31/98-R Page 9 of 16 � uw..].URTa k51-2 MIN8 HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 5J-2b: Mental Health Utilization - Inpatient Discharges and Average Length of Stay, by Age and Sex Age Male Member Months Female Total 0-12 361,555 .......................................................................................................................... 324,062 685,617 13-17 151,973 143,643 295,616 18-64 1,083,791 ......... ...................................................................... 1,260,275 2,344,666 65+ 30,975 30,176 61,151 Unknown 0 .................. .................. ............................. 0 -............. ........... 0 -._............. ............. Total 1,628,294 1,758,156 3,386,450 Discharges Average Length Age Sex Discharges PTMPY Days a of Stay 0-12 Male 12 ................_............_.....__.........................................................._...._..._..................................................... 0.4 48 4.0 Female 14 ..........:5 ............4.1_...................................9 Total...................26 .................-0:5 89.................... ...................3:4 _....... 13-17 Male 69 ...................._................._..........................................._........................_.................................-.................. 5.4 297 4.3 Female....................74 .........................6:� ..............................260 .......3:5 Total-143 .................:�....................557................................3:9 -. . ... ............. 18-64 Male 158 ..................... .............. _....... 1.7 ........................................... 599 .................................. 3.8 ............................................ Female 254 ..............................................._...................................... 2.4 1,224 _..................................................-........................ 4.8 Total 412 ...................................................................................................................................._............................... 2.1 1,823 4.4 65+ Male 4 ............................................ 1.5 ........................................... 0 ................... _............. 0.0 ....................................... .... Female...................-6 . _. .......2:4 _. .......43....................................:? -. Total 10 ---------- ........................................................ 2.0 ..................... 43 ................... _............. 4.3 ............................................ Unknown Male 0 ..... 0.0 ...................... ........... .......... 0 .................... ... ......... 0.0 ............ _....................... ...... Female 0 ......... .............. ............... .... 0.0 ---- ..................................................... 0 _.................. 0.0 ............................................ Total 0 ............................................ 0.0 ........................................ _. 0 .................................. 0.0 ............................................ Total Male 243 ........................................................................................................................................I............................ 1.8 944 3.9 Female 348 ..................... ....................... 2.4 ..................................... _.... 1,568 .......................................................................... 4.5... Total 591 ..................................................................................................................................................................... 2.1 2,512 4.3 'This table should reflect inpatient days only. Days associated with day/night or partial hospitalisation should not be included in this table. PacifiCare of Colorado 7/31/98 m vocals UR Table 31-] 3 WIM Page 10 of 16 HEDIe 3.0/1998 - CY 1997 USE OF SERVICES Table 5K-2b: Mental Health Utilization - Percent of Members Receiving Inpatient, Day/Night Care and Ambulatory Services Age Member Male Months Total Female 0-12 361,555 324,062 685,617 13-17 151,973 ................................................ 143,643 ...... 295,616 18 64 1,083,791 ............ ........... 1,260,275 ................................................ 2,344,066 65+ 30,975 ........................ 30,176 _...................... .......... 61,151 .............. Unknown 0 ....................... 0 ............ -- ....... ........................ 0 Total 1,628,294 _.......................... 1,758,156 .......... 3,386,450 ......._..... Day/Night Ambulatory Any Mental Inpatient Mental Mental Health Mental Health Health Services Health Services Services Services Age Sex Number Percent Number Percent Number Percent Number Percent 0-12 Male ........................ 611 ...................... 2.0% _........................... 10 0.00/0 ..................... _ 5 ... ...................................... 0.00/0 ...... 605 ........................ _........................ 2.0% Female . 316 ...................... ._......................................_..........._._......._.._....._.............................................................................................. 1.2% 10 0.00/0 0 0.00/0 311 1.2% Total ........................ 927 .................. 1.6% _............................... 20 0.00/0 ....................... 5 ... _............................................ 0.00/0 916 ................ .......... 1.6% ...................... 13-17 Male .................... 571 ... ................................................... 4.5% 64 0.5% ....................... 1 .... ....................... 0.0% ..... .............. 553 .................................................. 4.4% Female ............. 650 _......... ............................................... 5.4% 67 _.. 0.60/6 ................ _..... 2 ............ _ 0.0% .................. ................. 625 ............................ 5.2% ...... .............. Total ................. 1,221 ....... .. 5.0016 ... _........................................... 131 0.5% ....................... 3 ..... ........ 0.0% _................................. 1,178 ........_........................._............. 4.8% 18-64 Male ........... 2,461 . ........... ................................................... 2.7% 135 0.1% .... »................. 7 ........ ... __ 0.0% ................................. 2410 .... ......................... 2.7% ................... Female ....... 4,933 -................................................................................................................................ 4.7% 212 0.2% 6 0.00/0 -........ 4885 ............................... 4.7% . ................. Total ........... 7,394 _........ _...................................................................._.........._....................................................................................._.... 3.8% 347 0.2% 13 0.00/0 7,295 3.7% 65+ Male ....... 22 . ............... ................................................... 0.90/0 2 0.1% ... _.................. 0 ............... 0.00/0 _..... ..................... .... 21 .................................................. 0.80/0 Female ............................ 40 1.6% ............................. 6 ................. 0.2% ............. »........ 1 ................................................. 0.00/0 36 ................ . ................................ 1.4% Total .............. 62 .......... ................................................... 1.2% 8 0.2% .............. ......... 1 ................................................. 0.00/0 57 ._............................................... 1.1% Unknown Male ............................................... 0 0.00/0 -.......................... 0 0.0% ....................... 0 ...................... 0.0% -..............-........................................................... 0 0.0% Female ........................ 0 ........... 0.00/0 .................. 0 _.................... 0.0% ....................... 0 ...................................... 0.0% -....... 0 ........ ........... -............................ 0.0% Total .............................. 0 0.0% ............ ............................... 0 0.00/0 ....................... 0 ...................... 0.0% ...-..................... 0 .................................................. 0.0% Total Male ................... 3,665 ..... ........................... 2.7% 211 ..... ................. 0.2% ....................... 13 ................................................. 0.0% 3,589 ............_.............................._.... 2.6% Female ................. 5,939 ....... ....... 4.1% ......... ......... 295 ....................... 0.2% ... ............... ... 9 ................................................. 0.0% 5,857 ................................_................ 4.00/9 Total ................................................_..........................................................................................._............-.. 9,604 3.4% 506 0.2% 22 0.00/0 9,446 3.3% - PacifiCare of Colorado Page 11 of 16 7/31/98 m uos M Talle SK VIM HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 51.-2b: Readmission for Selected Mental Health Disorders Hospitalized in Readmitted within 90 Days Year Prior to of Prior Year's Index Age Sex Reporting Year Discharge Number Percent Readmitted within 365 Days of Prior Year's Index Discharge Number Percent 0-12 Male 10 2 20.0% 2 20.0% Female .».............................................................................»...................».................................................................................. 5 0 0.0 0 0 0.0% Total _..............................................._..................................................................................................... 15 2 13.3% 2 13.3 0 13-17 Male 34 1 2.9% 6 17.6% Female 37 2 5.4% 2 5.4% Total ................. .................... .................. 71 ................... .............. 3 ....................... 4.2% .................. ................... ... ......... 8 ........................ 11.3% 18-64 Male _............._......................»...................»..................................._....._...................._.............................................._. 48 3 6.3% 12 25.0 0 Female ......................»...».........................................................................».......................................................».............»......... 125 3 2.4% 18 14.4% Total 173 6 3.5% 30 17.3% 65+ Male ...........................»........................................................._.............»..........._.............._..........._................................_.._. 2 0 0.0% 0 0.00/0 Female 3 0 0.00/0 0 0.00/0 Total 0.0% Unknown Male »5 »0 0 .0 »0.00/0 Female .0....._. 0 ..............................0.0% 0 0.0% _............................_0.0% 0 0.0% Total _................»................................................................................................._................6..................... 0 0 0.0% 0 0.0% Total Male 94 6 6.4% 20 21.3% Female ...... _......................... ... 170 _........................................................................................................................................... 5 2.9% 20 _. 11.80/9 Total 264 11 4.2% 40 15.2% PacifiCare of Colorado 7/31/98 Page 12 of 16 co oo$. s UR Table 51. 7I71= HEDIS* 3.0/1998 - CY 1997 USE OF SERVICES Table 5M-2b: Chemical Dependency Utilization - Inpatient Discharges and Average Length of Stay, by Age and Sex An Male Member Months Female Total 0-12 361,555 324,062 685,617 13-17 151,973 143,643 295,616 18-64 1,083,791 1,260,275 2,344,066 65+ 30,975 30,176 61,151 Unknown 0 ....................-� .. ...................... Total 1,628,294 1,758,156 3,386,450 Discharges Average Length Age Sex Discharges PTWY Days* of Stay 0.12 Male ........._0 0.0 ......................... _.............._. _.............._. .......-0.0 Female 0 0.0 0 0.0 Total-0 ........................................................................................-0.0 _.... 13-17 Male 18 .......... ............................ ........._........................._........................................................................................... 1.4 65 3.6 Female ......_8 0.7 ..._18..................................-..::3....... Total 26 .............................. ........... . . 0.1 83 . 3.2 18-64 Male 157 ..................... -.................. 1.7 .................................... 626 .................. -. 4.0 -......................................... ..... Female 140 1.3 657 4.7 Total 297 ................._.................................................................................._........_........................................................ 1.5 1,283 4.3 65+ Male 2 ................................. _........ 0.8 .................. _........................................ 6 _.._............................................................ 3.0 Female 2 .................................................................................................... 0.8 4 .................. 2.0 . . ................................ Total 4 ---------- ..................._................................ 0.8 ...... _.................... 10 ...... -................. 2.5 -...................................... ........ Unknown Male 0 _................................................._....._........................ 0.0 0 ................... ...................... 0.0 ...................... -....... Female 0 ........................................... 0.0 ............................................................................. 0 0.0 -............. . .... -.......................... Total 0 .......................... ................. 0.0 ............................................................................................................ 0 0.0 - ....... -....... TotalMale 177 1........................................................................................... -.......... Female 150 _.......................................................................................... 1.0 679 ....................................... 4.5 -......................... Total 327 1.2 1,376 4.2 • This table should reflect inpatient days only. Days associated with day/night or partial hospitalization should not be included in this table. PacifiCare of Colorado 7/31/98 Page 13 of 16 m e xb UR Table SM2 3 7n Ing HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 5N-2b: Chemical Dependency Utilization - Percent of Members Receiving Inpatient, Day/Night Care and Ambulatory Services Age Member Male Months Female Total 0-12 361,555 ........................................................................... 324,062 685,617 13-17 151,973 ................ ....... 143,643 ........................ ........ 295,616 ................... 18-64 1,083,791 ........................................................................... 1,260,275 2,344,066 65+ 30,975 30,176 61,151 Unknown 0 ....... ................................................................... 0 0 Total 1,628,294 ........................................................................... 1,758,156 3,386,450 Day/Night Ambulatory Any Chemical Inpatient Chemical Chemical Health Chemical Health Health Services Health Services Services Services Age Sex Number Percent Number Percent Number Percent Number Percent 0-12 Male 1 .............. ......................... 0.00/0 ......... ............................ 0 0.00/0 ...................... 0 ................................. 0.0% -.............. 1 ....................... -.......................... 0.0% Female 0 0.00/0 0 0.00/a 0 0.00/0 0 0.0% Total 1 .............. ......... . 0.00/0 .............. .......... .... 0 .................... 0.0% ...................... 0 ................................. 0.00/0 _.............. 1 ................................................... 0.0% 13-17 Male 73 ...................... .. 0.6% .......................... -. 17 .... -............... 0.1% ...................... 1 ........... -............................. 0.0% -..... 60 ..................... ................. 0.5% _........... Female 49 ........................ .». 0.4% ............................... 7 _................ 0.1% ............... ...... I ............................... 0.0% __....... _..... 43 ................ _.............................. 0.4% -. Total 122 ........... .... .... ... ................ 0.5% .................... 24 _................ 0.1% ...................... 2 ................ 0.00/0 _............... -.............. 103 ............ _..-................................. 0.4% 18-64 Male 332 0.4% 130 0.1% 20 0.00/0 205 0.2% Female 219 ............. ...... ... ............... 0.2% ._.................................... 111 0.1% ...................... 13 ................................................. 0.00/0 120 ................ -................................. 0.1% Total .............. 551 .......... ............................. 0.3% _ 241 ....................... 0.1% ...................... 33 ........ ».... _» 0.00/0 ............................... 325 ................ _................................. 0.2% 65+ Male ........................ 5 .................................................... 0.2% 2 . 0.1% .......... -.-....... 0 ........ -....................................... 0.00/0 3 ..................... .............................. 0.1% Female ................ 2 .... -..._ 0.1% .................................................. 2 0.1% ...................... 0 ................................................. 0.00/0 I ._...................................... 0.0% -........ Total .................... 7 ... ..» 0.1% .............................................. 4 _.. 0.1% ...................... 0 ..................................... 0.0% _.......... 4 ................... -.............................. 0.1% Unknown Male .............. 0 ..... -..................... 0.00/0 _................................. 0 0.00/00 ......... ............ ................................................. 0.0% 0 ...................................... 0.00/0 -..-....... Female ............. 0 _..... ... ............................ 0.00/0 ................ 0 ........ 0.0% ...................... 0 ....... _.................................. 0.0% _.... 0 ................. _................................ 0.0% Total ........................ 0 .................... 0.00/0 _............. 0 .................. 0.00/0 ...................... 0 .......................... 0.0% _..................... 0 ................ _................................. 0.00/0 Total Male ........................ 411 ......................... 0.3% _.._ 149 .... .................. 0.1% ... .................. 21 .......................... 0.0% _..................... 269 ................ _............. 0.2% -.................. Female ........................ 270 ............................. 0.2% - 120 ....................... 0.1% ............. _....... 14 ...... _......................................... 0.00/a 164 ................................................... 0.1% Total 681 02% 269 0.1% 35 0.00/0 433 0.20/0 PacifiCare of Colorado Page 14 of 16 7/31/98 we ..b UR Table 5N WIN8 HEDIe 3.0/1998 - CY 1997 USE OF SERVICES Table 50-2b: Readmission for Chemical Dependency Hospitalized in Readmitted within 90 Days Readmitted within 365 Days Year Prior to of Prior Year's Index of Prior Year's Index Age Sex Reporting Year Discharge Discharge Number Percent Number Percent 0-12 Male 0 .............. »....... ..... .............. ....................................... 0 0.00/0 .............. _.............. _....... 0 0.0% ....................................... ....... ........................... ... Female.0 _0 Total 0 ............... .... ..»..... ............. _0.0%..............................._ 0 6.0% ................................0.0% 0 0.0% 13-17 Male .... 10 _._.............................. ............... ...................... . 0 0.0% ................ »..................... ............... _..................... 0 0.0% Female 7 ............. ..... .»_. Total 17 _0. .0.0% ......_..............». .......»...» 0 0.0 0 »�..». »0:0% . ....». ................. 0 0.0% 18-64 Male 74 ................... »....... »............. .................. 1 1.4% 7 9.5% Female 62 _.............._._....».......»........................................................................_.............................................. .».... »..»»..................._........................................ 4 6.5% .... .............................................. .»......... 11 17.7% Total 136 .... .......... ».... ........ ............. ....................................................................._.....................»............................................................. 5 3.7% ................ ....................... 18 13.2% 65+ Male 3 0 0.0% 1 33.3 0 Female 0 0 0.0% 0 0.0% Total 3 0 0.0% 1 33.3% Unknown Male ».....»_........................................................................... 0 ........ 0 _.0......................................................... 0 ...0% Female 0 6.0% 0 0.0% 0 0.00/0 Total 0 0 0.0% 0 0.0% Total Male Female 69 4 5.8% 11 15.9% Total ................. ..................».»...................._.................................._.__...................................................................................»......... 156 5 3.2% 19 12.2% PacifiCare of Colorado 7/31/98 Page 15 of 16 m_uw.xb lRt Tale 50 WIM HEDIS® 3.0/1998 - CY 1997 USE OF SERVICES Table 5P-2b: Outpatient Drug Utilization Agg Member Months 0-9 ....................................................... 509,195 10-19 ....................................................... 569,111 20-44 ....................... 1,372,217 45-64 ....................................................... 874,776 65-74 .......... .......... 51,561 75-84 ........................... 8,335 _..................... _... 85+ ..................................... 1,255 _........ _...... Specification Documentation: Prescription defined as (check one) One 30-day (or less) supply of pharmaceuticals Qx One supply of pharmaceuticals for which the health plan accepts a copayment Average Cost of Average Number Total Cost of Prescription per Total Number of Prescriptions per Age Prescriptions Members per Month of Prescriptions Members per Year 0-9 $1,855,297 _ $3.64 ................ _............ ................... ....................._........_....................._........_................................................. 103,655 2.4 10-19 ................... $3,510,559 _................... ........ ....... $6.17 ....... ..............._............-_............................................ 130,032 ........................ 2.7 .......................................... 20-44 $20,273,476 $14.77 .................................... _........................................_ 685,126 ....................... -.......... 6.0 ...................................................... 45-64 .................... $26,205,638 ........_..................._................................................... $29.96 ....... ................................................. 893,816 -... 12.3 ........... .................................. 65-74 $2,281,181 _............................... $44.24 .... _................ .............................................................. 81,910 ...... 19.1 75-94 ........................._..................._.........._....................................................._.........................................._..........._............................................. $365,308 $43.83 14,167 ...... -.............................................. 20.4 85+ $35,466 _.........................................._......................................................................................................................................... $28.26 1,726 16.5 Unknown .......................................... $0 _........... $0.00 ..... _............................................... ........................................... 0 _ 0.0 Tom $54,526,925 $16.10 ......... 1,910,432 ............. _............................ -......... 6.8 PacifiCare of Colorado 7/31/98 Page 16 of 16 W .wsuarael sSPWI e HEDIS® 3.0/1998 - CY 1997 COST OF CARE DOMAIN: COST OF CARE This domain is designed to provide information on the plan's long-term average rate increases as well as actual expenditures per member per month. The domain includes information related to the following issues: • RATE TRENDS • HIGH-OCCURRENCE/HIGH-COST DRGs PacifiCare of Colorado Page I of 3 7/31/98 Pacif2Care ° Your employer has elected to offer coverage for routine eye examinations. Routine eye examinations, including refractions for prescription lenses, are covered once every 24 months. Services must be obtained from a partici- pating American Vision Services (AVS) provider. You will need an authorization number prior to visiting an AVS provider for an eye exam. The authorization number can be obtained by calling AVS at (303) 759-3839 in Denver or 1-800-736-0571 outside the metropolitan Denver area. AVS will then send you a current AVS directory along with your authorization number. You must give your authorization number to the provider when you make your appointment. For medical conditions of the eye, you must see your primary care physician (PCP). If necessary, your PCP will refer you to the appropriate provider for medical/surgical eye care. Your office visit copayment applies. Not Covered: Fitting of contact lenses, vision therapy and/or radial keratotomy, keratomilieusis and excimer laser surgery. 6455 S. Yosemite St. Englewood, CO 80111 Eye Exam Summary of Benefits 24-month Eye care for Crowley, Fremont, Huerfano, Otero and Pueblo County members If you reside in Crowley, Fremont, Huerfano, Otero or Pueblo County, you may only visit one of the participating AVS providers located in Canon City or Pueblo for routine eye care or your claim will be denied. To access these providers you will need an authorization number. The number can be obtained by calling American Vision Services at 1-800-736-0571. This information contains only highlights of the eye examination benefit and is not intended to replace the legal documents that contain the complete provisions of these benefits. Please refer to your Evidence of Coverage and Owner's Manual for a complete description of this benefit. Copyright © 1997 PacifiCare of Colorado EM05001.00 597 HEDIS® 3.0/1998 - CY 1997 COST OF CARE RATE TRENDS An effective managed care organization is expected to control the rate of increase in premiums. This measure provides information on a health plan's actual expenses per member per month (PMPM) and prospective rate trend assumptions for the reporting year and the two preceding years. TABLE 6A: ACTUAL EXPENSE PMPM - COMMERCIAL Reporting Year 1995 1996 1997 Total Actual Expense PMPM Percent Change $114.45 NA $115.29 0.7% $120.79 4.8% TABLE 6B: RATE TREND ASSUMPTIONS - COMMERCIAL Reporting Year 1995 1996 1997 Rate Trends 2.0%1 2.00/6 1.5% PacifiCare of Colorado Page 2 of 3 7/31 /98 HEDIS® 3.0/1998 - CY 1997 COST OF CARE TABLE 6C: HIGH OCCURRENCE/HIGH-COST DRGs DISCHARGE, AVERAGE COST PER STAY AND AVERAGE LENGTH OF STAY SCHEDULE - COMMERCIAL This table includes discharges per 1,000 members, cost per discharge and average length of stay for nine high - occurrence/ high -cost DR.Gs for the commercial population. Total cost and average cost per discharge may reflect the contracted value of the service for hospitals with capitated payment arrangements rather than the actual cost to the health plan. Age en Months 0-64 3,325,299 0-17 981,228 DRG Discharges Total Cost Discharges/ Ave Cost / ALOS Days 1,000mems Discharge 14: Specific Cerebrovascular Disorders 79 588 $536,887 0.3 $6,796 7.4 15: TIA and Precerebral Occlusions 51 154 $105,179 0.2 $2,062 3.0 16: Nonspecific Cerebrovascular Dis w/ CC 2 9 $5,860 0.0 $2,930 4.5 17: Nonspecific Cerebrovascular Dis w/o CC 5 10 $4,067 0.0 $813 2.0 Cerebrovascular tot 137 761 S635117M 0.5 $4,759 5. 81: Respiratory Infections & Inflamations, Age 0-17 8 66 $109,255 0.1 $13,657 8.3 91: Simple Pneumonia and Pleurisy, Age 0-17 67 274 $227,153 0.8 $3,390 4.1 98: Bronchitis & Asthma, Age 0-17 184 649 $523,065 2.3 $2,843 3.5 Respiratory Infections/Asthnia Subtotal 259 989 5 ,4 3.2 .8 140: Angina Pectoris 63 295 $177,105 0.2 1,11 4.7 143: Chest Pain 236 552 $394,165 0.9 $1,670 2.3 azdiovasu tot 299 847 $5-71,270 1.1 1, 11 PacifiCare of Colorado Page 3 of 3 7/31/98 HEDIS' 3.0/1998 - CY 1997 HEALTH PLAN DESCRIPTIVE INFORMATION DOMAIN: HEALTH PLAN DESCRIPTIVE INFORMATION This domain is designed to provide consumers and purchasers with information about the plan's structure, rules, staffmg and management philosophy, and how these factors contribute to the plan's ability to provide its members with effective health care. The domain includes information related to the following issues: • PROVIDER NETWORK Board Certification/Residency Completion Provider Compensation Physicians Under Capitation • ENROLLMENT Total Enrollment Commercial Enrollment PacifiCare of Colorado Page 1 of 6 7/31/98 HEDIS® 3.0/1998 - CY 1"7 HEALTH PLAN DESCRIPTIVE INFORMATION PROVIDER NETWORK TABLE 8A: BOARD CERTIFICATION/RESIDENCY COMPLETION This section presents the percentage of providers that have completed residency training or fellowship training and/or are board certified as of 12/31 of the reporting year. Commercial Physician Network Type of Provider Total Number of Physicians Board Certification Residency Completion Number Percent Number Percent Primary Care Physician 1,192 %1 81% 1,078 900/0 Physician Specialists 1,385 1,072 77% 1,268 92% OB/GYN Physicians 216 209 97% 213 990/0 Pediatric Physician Specialists 116 78 67% 102 88% Geriatricians NA NA NR NA NR Notes: Primary care includes General Internal Medicine, General Practice, Family Practice and General Pediatrics. Physician specialists includes all other categories except pediatric physician specialties, OB/GYN physicians, and geriatricians. The numbers in the column labeled "Total Number of Physicians" will not be the same as plan's actual number of physicians in that area, as some physicians may be board certified in more than one area and therefore will be counted in the denominators of several rates. PacifiCare of Colorado Page 2 of 6 7/31/98 HEDIS® 3.0/1998 - CY 1997 HEALTH PLAN DESCRIPTIVE INFORMATION DOMAIN: HEALTH PLAN DESCRIPTIVE INFORMATION TABLE 8B: PHYSICIAN PAYMENT ARRANGEMENT This section presents quantitative and qualitative information on the plan's compensation arrangements with providers as of 12/31 of the reporting year. Primary Care Physician Payment Number Percentage Basis of Mechanism Bonus/Withhold Salary without withhold or bonus NR NR NR Salary with withhold. NR NR NR Range of withhold: xx to xx %. Salary with bonus. NR NR NR Range of bonus: xx to xx % Fee for service without withhold or NR NR NR bonus. Fee for service with withhold. NR NR NR Range of withhold: xx to xx % Fee for service with bonus. 145 12.2% Bed day report Range of bonus: 0 to 10 % Capitated without withhold or 1,047 87.8% Bed day report bonus. Physicians as: _ individuals (list services included under capitation), x IPA or affiliated network or pool, _ capitated group model. Capitated with withhold. NR NR NR Physicians as: _ individuals (list services included under capitation), _ IPA or affiliated network or pool, _ capitated group model. Capitated with bonus. NR NR NR Physicians as: _ individuals (list services included under capitation), _ IPA or affiliated network or pool, _ capitated group model. Other NR NR NR Total 1,192 100.0% Notes: Table 813 refers to the payment arrangement from the health plan to the provider organization. Payment arrangements to individual providers within medical groups are not included. PacifiCare of Colorado Page 3 of 6 7/31198-R HEDIS® 3.0/1998 - CY 1997 HEALTH PLAN DESCRIPTIVE INFORMATION TABLE 8E: DATA ON ENROLLMENT: PERCENT OF PLAN'S TOTAL MEMBER MONTHS BY PAYER, AGE AND SEX Age Sex %Medicaid %Commercial %Medicare Risk %Other Total <l Male 0.00% 100.000/0 0.00% 0.00% 100.00% Female 0.00% 100.000/0 0.00% 0.000/0 100.000/0 14 Male 0.000/a 100.000/0 0.00% 0.00% 100.000/0 Female 0.000/0 100.00% 0.00% 0.00% 100.000/0 5-9 Male 0.00% 100.000/0 0.00% 0.000/0 100.000/0 Female 0.00% 100.000/0 0.00% 0.00% 100.000/0 10-14 Male 0.000/0 100.00% 0.00% 0.00% 100.00% Female 0.000/0 100.00% 0.00% 0.00% 100.000/0 15-17 Male 0.000/0 100.00% 0.000/0 0.00% 100.000/0 Female 0.00% 100.00% 0.00% 0.00% 100.00% 18-19 Male 0.00% 99.98% 0.02% 0.00% 100.000/0 Female 0.00% 99.99% 0.01% 0.00% 100.00% Subtotal: Male 0.00% 100.00% 0.000/e 0.00% 100.000/0 0-19 Female 0.00% 100.00% 0.000/0 0.00% 100.000/0 Total 0.00% 100.00% 0.000/0 0.00% 100.000/0 20-24 Male 0.000/0 99.89% 0.11% 0.00% 100.000/0 Female 0.000/0 99.93% 0.07% 0.000/0 100.000/0 25-29 Male 0.00% 99.71% 0.29% 0.000/0 100.000/0 Female 0.000/0 99.80% 0.20% 0.000/0 100.00% 30-34 Male 0.000/0 99.59% 0.41% 0.00% 100.00% Female 0.00% 99.57% 0.43% 0.00% 100.00% 35-39 Male 0.00% 99.100/0 0.90% 0.00% 100.000/0 Female 0.000/0 99.35% 0.65% 0.00% 100.000/0 40-44 Male 0.00% 98.76% 1.24% 0,00% 100.000/0 Female 0.00% 99.04% 0.96°/a 0.000/0 100.008/0 Subtotal: Male 0.00% 99.29% 0.71% 0.00% 100.000/0 20-44 Female 0.00% 99.45% 0.55% 0.00% 100.000/0 Total 0.00% 99.38% 0.62% 0.00% 100.000/9 45-49 Male 0.00% 98.38% 1.62% 0.00% 100.00°/ Female 0.00% 98.65% 1.35% 0.00% 100.000/6 50-54 Male 0.00% 97.41% 2.59% 0.000/0 100.000/0 Female 0.000/0 97.70% 2.30% 0.00% 100.000/0 55-59 Male 0.000/0 93.92% 6.08% 0.00% 100.000/0 Female 0.000/0 95.200/6 4.80% 0.00% 100.000/0 60-64 Male 0.00% 87.77% 12.23% 0.00% 100.000/0 Female 0.00% 90.27% 9.73% 0.000/0 100.000/0 Subtotal: Male 0.00% 95.57% 4.43% 0.000/0 100.00% 45-64 Female 0.00% 96.41% 3.59% 0.000/a 100.000/a Total 0.00% 96.01% 3.99% 0.00% 100.000/0 PacifiCare of Colorado Page 4 of 6 7/31/1998-R HEDIS® 3.0/1998 - CY 1997 o HEALTH PLAN DESCRIPTIVE INFORMATION TABLE 8E: DATA ON ENROLLMENT: PERCENT OF PLAN'S TOTAL MEMBER MONTHS BY PAYER, AGE AND SEX Age Sex %Medicaid %Commercial %Medicare Risk %Other Total 65-69 Male 0.00% 16.56% 83.44% 0.000/0 100.000/0 Female 0.00% 13.97% 86.03% 0.000/0 100.000/0 70-74 Male 0.00% 10.71% 89.29% 0.00% 100.00% Female 0.00% 8.79% 91.21% 0.00% 100.00% 75-79 Male 0.00% 6.40% 93.60% 0.00% 100.000/0 Female 0.00% 4.52% 95.48% 0.000/0 100.000/0 80-84 Male 0.00% 3.92% 96.08% 0.00% 100.00% Female 0.00% 2.72% 97.28% 0.00% 100.00% >=85 Male 0.00% 3.54% 96.46% 0.000/0 100.00% Female 0.000/0 2.15% 97.85% 0.00% 100.00% >=90 Male 0.00% 3.92% 96.08% 0.00% 100.00% Female 0.00% 2.95% 97.05% 0.00% 100.000/0 Subtotal: Male 0.00% 11.26% 88.74% 0.00% 100.00o/u > 65 Female. 0.00% 8.48% 91.52% 0.00°/a 100.00% Total 0.00% 9.69% 90.31% 0.00% 100.00% Age Unknown 0.00% 0.00% 0.000/0 0.00% 0.000/0 Total 0.00o/u 84.64% 15.36% 0.00% 100.00% PacifiCare of Colorado Page 5 of 6 7/31/1998-R HEDIS0 3.0/1998 - CY 1997 HEALTH PLAN DESCRIPTIVE INFORMATION TABLE 8F - 5: MEMBER YEARS OF ENROLLMENT BY AGE AND SEX: COMMERCIAL Age Male Female Total <1 2,037 1,677 3,714 1-4 8,476 7,386 15,862 5-9 11,961 10,897 22,858 10-14 12,731 11,768 24,499 15-17 7,590 7,248 14,838 18-19 4,066 4,023 8,089 0-19 Subtotal 46,861 42,999 89,860 0-19 Subtotal: % 16.6% 15.2% 31.8% 20-24 6,264 7,658 13,922 25-29 7,447 9,719 17,166 30-34 10,243 12,882 23,125 35-39 13,423 16,099 29,522 40-44 14,164 16,453 30,617 2044 Subtotal 51,541 62,811 114,352 20-44 Subtotal: % 18.3% 22.3% 40.5% 45-49 13,149 14,586 27,735 50-54 9,970 10,687 20,657 55-59 6,550 7,325 13,875 60-64 5,041 5,590 10,631 45-64 Subtotal 34,710 38,188 72,8 88 45-64 Subtotal: % 12.3% 13.5% 25.8% 65-69 1,501 1,393 2,894 70-74 687 716 1,403 75-79 270 252 522 80-84 81 91 172 >=85 29 39 68 >=90 12 24 36 >=65 Subtotal 2,580 2,515 5,095 >=65 Subtotal: % 0.9% 0.9% 1.8% Age Unknown 0 0 0 Total 135,692 146,513 282,205 Total 48.1% 51.9% 100.0% PacifiCare of Colorado Page 6 of 6 7/31 / 1998-R No Text =F g Charge of 0Y00 our Health6m Health information foryou and your family Healthwise Knowledgebase" The Healthwise Knowledgebase' is a quick, easy way for you to find health information. Developed by medical experts and written in consumer -friendly language, this resource contains 27,000 pages of health information, including: Information on 500 health problems 1 Answers to 600 questions about medical tests and procedures 1 Information on 500 self-help and support groups An electronic drug reference that includes 8,000 medications Easy as 1-2-3 To access the Knowledgebase, simply: 1. Go to www.pacificare.com/colorado (you can also reach this site through www.pacificare.com) 2. Click on the Taking Charge of Your Health icon 3. Type in your member ID number, including the two -digit suffix, and your ZIP code. (This information is on your PacifiCare member ID card.)* Questions? Call the PacifiCare Service Center at 1-800-877-9777. *PacifiCare will not monitor your use of this system in any way, and your viewing of this information is strictly confidential. Your member ID number is required to ensure that the Knowledgebase is available exclusively to our customers, and to meet certain licensing requirements. semi V08 City of Fort Collins Point -of -Service Copayment Schedule Some benefits are subject to limitations. These limitations may include length of treatment, frequency of treatment and/or maximum amount payable under your plan. See Chapter Three of this Evidence of Coverage for details on your benefits. Following are the copayments applicable to your plan. To determine which copayments apply to you, please see your ID card or call PacifiCare Customer Service at 1-800-877-9777 if you would like additional information. City of Fort Collins EmployeesBenefit Active • • Deductible & Coinsurance None $200 per individual, $400 per family. None $200 per individual, $400 per family. In most cases, plan pays 80% of In most cases, plan pays 80% of allowable charges following allowable charges following deductible. In most cases, individual deductible. In most cases, individual pays 20% following deductible pays 20% following deductible Physician's Office Visits $10 per visit Subject to deductible and 20% $10 per visit Subject to deductible and 20% coinsurance coinsurance Preventive Care $10 per visit Subject to deductible and 20% $10 per visit Subject to deductible and 20% coinsurance coinsurance Maternity Care $10 per visit Subject to deductible and 20% $10 per visit Subject to deductible and 20% coinsurance coinsurance Allergy Testing and $10 per visit Subject to deductible and 20% $10 per visit Subject to deductible and 20% Treatment coinsurance coinsurance Allergy Injections $5 per visit Subject to deductible and 20% $5 per visit Subject to deductible and 20% coinsurance coinsurance Lab & X-Rays no copayment Subject to deductible and 20% no copayment Subject to deductible and 20% coinsurance coinsurance Infertility Evaluation 50% copayment up to an out -of- Not covered 50% copayment up to an out -of- Not covered pocket maximum of $2,500 per pocket maximum of $2,500 per individual per contract year individual per contract year Emergency Room Services $50 copayment per visit Subject to deductible and 50% $50 copayment per visit Subject to deductible and 50% coinsurance coinsurance Ambulance $25 copayment per episode Subject to deductible and 20% $25 copayment per episode Subject to deductible and 20% coinsurance coinsurance Emergency Services After $25 per visit Subject to deductible and 50% $25 per visit Subject to deductible and 50% Hours in a Physician's coinsurance coinsurance Office or Urgent Care Center Hospital Inpatient $100 copay per admission (maximum Subject to deductible and 20% $100 copay per admission (maximum Subject to deductible and 20% 2 copays per individual per contract coinsurance when authorized, 40% 2 copays per individual per contract coinsurance when authorized, 40% year, maximum 5 copays per family when not authorized year, maximum 5 copays per family when not authorized per contract year) per contract year) Hospital Outpatient $50 copayment per visit Subject to deductible and 20% copayment per visit Subject to deductible and 20% (includes ambulatory J$50 coinsurance when authorized, 40% coinsurance when authorized, 40% surgery) when not authorized when not authorized Pacificare PacifiCare of Colorado 6455 South Yosemite Street Englewood, Colorado 80111 10 303-220-5800 September 31 1998 City of Fort Collins Purchasing Division 256 West Mountain Ave. Fort Collins, CO 80521 Enclosed you will find the PaciflCare of Colorado HEDIS report. It was stated within the RFP that a copy would be forwarded to you as soon as it was available. Please phone me at (303)714-3240 if you have any questions. Thank you, qj&)�VC Stacy J. Stark Proposal Analyst FULL NCQA N2 9/97 - 7/99 Physical, Occupational & $10 per visit, maximum of 20 visits Subject to deductible and 20% $10 per visit, maximum of 20 visits Subject to deductible and 20% Speech Therapy per condition coinsurance. Limited to $500 per per condition coinsurance. Limited to $500 per type of therapy type of therapy Inpatient Mental Health* $50 copayment per day, $25 Subject to deductible and 50% $50 copayment per day, $25 Subject to deductible and 50% copayment per partial day; maximum coinsurance. Maximum of 45 days copayment per partial day; maximum coinsurance. Maximum of 45 days of 45 days (90 partial days) per (90 partial days) per individual per of 45 days (90 partial days) per (90 partial days) per individual per contract year contract year contract year contract year Outpatient Mental Health* No copayment for visits 1-5, $10 Subject to deductible and 20% No copayment for visits 1-5, $10 Subject to deductible and 20% copayment Ogolt er coinsurance. Limited to $1,000 copayment thereafter coinsurance. Limited to $1,000 benefit maximum benefit maximum Inpatient Alcohol & $50 copayment per day, maximum of Subject to deductible and 50% $50 copayment per day, maximum of Subject to deductible and 50% Substance Abuse 21 days per contract year coinsurance. Limited to 45 days per 21 days per contract year coinsurance. Limited to 45 days per individual per contract year individual per contract year Outpatient Alcohol & No copayment for visits 1-5, $10 Subject to deductible and 20% No copayment for visits 1-5, $10 Subject to deductible and 20% Substance Abuse copayment thereafter coinsurance. Limited to $500 benefit copayment thereafter coinsurance. Limited to $500 benefit maximum maximum Skilled Nursing Facility No copayment; maximum of 120 Subject to deductible and 20% No copayment; maximum of 120 Subject to deductible and 20% days per contract year coinsurance for up to 30 days when days per contract year coinsurance for up to 30 days when preauthorized, 40% when not preauthorized, 40% when not reauthorized preauthorized Home Health Care No copayment Subject to deductible and 20% No copayment Subject to deductible and 20% coinsurance. Limited to 60 visits per coinsurance. Limited to 60 visits per contract year contract year Hospice Care No copayment Inpatient: you pay nothing; No copayment Inpatient: you pay nothing; maximum of 30 days. Outpatient: maximum of 30 days. Outpatient: you pay 20% after deductible; you pay 20% after deductible; maximum of 270 days, $55 per day maximum of 270 days, $55 per day Durable Medical No copayment; $1,000 maximum Subject to deductible and 20% No copayment; $1,000 maximum Subject to deductible and 20% Equipment (DME) benefit per contract year (an coinsurance. Limited to $1,000 benefit per contract year (an coinsurance. Limited to $1,000 additional $500 is available for the benefit maximum additional $500 is available for the benefit maximum use of oxygen) use of oxygen) Chiropractic Care $10 copayment, 20 visit maximum Covered as physical therapy $10 copayment, 20 visit maximum Covered as physical therapy Prescription Drugs $5 per prescription Subject to deductible and 30% $5 per prescription Subject to deductible and 30% coinsurance. coinsurance. Out -of -Pocket Maximums $3,600 per individual, $10,000 per $2,500 per individual, $5,000 per $3,600 per individual, $10,000 per $2,500 per individual, $5,000 per family family family family Maximum Benefit $2,000,000 lifetime per individual $1,000,000 lifetime per individual Annual: $95,000/medical; Annual: $95,000/medical; $5,000/1'rescription drugs per $5,000/1'rescription drugs per individual. individual Lifetime: $2,000,000 per individual Lifetime: $2,000,000 per individual *Coverage for biologically -based mental illnesses is no less extensive than the coverage for any other physical illness. Pad iCare ° You, your doctor and PacifiCare No Text pa are F, . CR1t F01"'t- co111.nS e t �. y. . Janua ' rY 9�02 `tenewal ` Y. ... L Y fin^ Y/,qe IL '`�. � a F .�. i � f' �� � is �' % • 'i' i.� � '` � t I IP IL = t t � ` • li You, your doctor h k k an&'PacrfiCare City of Fort Collins January 1, 2002 Renewal • Executive Summary • Current Benefits • 2002 Plan Changes • Claim Experience - 1/1/2000 - 6/30/2000 - 1/1/2001 - 6/30/2001 • Monthly Experience Summary • Performance Standards • Perks • Zip Code Service Area PacifiCare Executive Summary PacifiCare is excited to have the opportunity to continue its health care partnership with the City of Ft. Collins, providing high quality and affordable healthcare to their employees. The City has been a valued client for several years. As one of the largest health plans in Colorado, PacifiCare has the experience necessary to satisfy the benefit needs of the City of Ft. Collins. The financial stability of PacifiCare is unquestioned. PacifiCare Health Systems is one of the nation's largest managed care services companies. We serve approximately 4 million members with managed care products such as HMO, POS and PPO. Vincent, as you know, PacifiCare of Colorado recently announced Is1 and 2°d quarter financial profitability, which is evidence that our initiatives are beginning to pay off. However, we recognize that two successful quarters does not mean that we do not have challenges ahead. PacifiCare of Colorado will continue to focus on strengthening its core business. We are profitable, continue to be in full compliance with all bank covenants, had an average of $140 million in free unencumbered cash during the 2°d of 2001, and have strong free cash flow. Our balance sheet and capital structure is comparable to key competitors. Recently, PacifiCare announced the execution of an agreement with our lenders to extend the maturity date of our $800 million credit facility to January 2, 2003. The attached press release provides more details. PacifiCare is a strong, stable company that is positioned for continued success in meeting the health care needs of Coloradans. Although this is a time of great change in the health care industry, we believe there are solutions to the challenges faced by health plans, providers, purchasers and consumers of health care. We are optimistic about the future, and are well positioned to capitalize on the opportunities ahead. ➢ PacifiCare's excellent 25-year track record in Colorado speaks to our ability to succeed even in an extremely challenging health care climate. ➢ We continue to explore ways to improve service to our customers. By gaining additional efficiencies and managing medical costs, PacifiCare will work to ensure affordable health care coverage for consumers. PacifiCare's network provides access to the care our members need. In Northern Colorado we have the largest and most stable HMO network. It is our goal to contract with the right partners to balance our provider's need for financial success with our customer's need for affordable health care. This is an important balance and not a compromise on access or quality. Page Two City of Ft. Collins As one of Colorado's leading health plans, PacifiCare takes its duty to be a responsible and thoughtful steward of our customer's claim dollars seriously. Despite a healthy economy, resources to pay for medical services remain limited. We continuously look for new ways to improve our structure, while working with providers to make sure members get the appropriate level of cost-effective medical care. ➢ Medical cost management. PacifiCare has considerable expertise in medical management. Disappointed by some physician groups' recent failed attempts to effectively manage utilization and administrative functions, PacifiCare took back many of these quality and cost management functions — referral, preauthorizations, etc. that the physician organizations performed in 1999 and more recently in Northern Colorado in 2001. Our goal is to collaborate closely with physicians and hospitals to see to it that our members get appropriate medical care. PacifiCare of Colorado is an industry leader in performance standards and accomplishments. We were the only Colorado health plan, and one of just 21 plans nationally to participate in the 1994 Landmark Health Plan Pilot Report Card project directed by the National Committee for Quality Assurance (NCQA). Additionally, PacifiCare is one of the few plans to have participated in the Colorado Report Card Project/Health Matters since its inception in 1995. In 1999, PacifiCare achieved one of the highest ratings for membership satisfaction in the Health Matters project. PacifiCare also complies with the nationally recognized standards set forth in the Health Employer Data Information Set (HEDIS), NCQA and Healthy People 2000. 1999-2000 hospital costs rose 31%, while physician costs increased nearly 21%. Additionally, prescription drugs costs are expected to rise +20% moving forward in the next year. We expect significant increases in claim costs in Northern Colorado due to changing provider contracts. As the current TPA, the PacifiCare proposal presents 2002 administrative rates for the current EPO/POS medical and prescription designs. The renewal Service Fees for the current EPO and POS plan designs required ai$i [i1 52.7%; however, we are cappi,►d: ilidiiai` 4 29,. This year we evaluated our actual cost for administering this book of business and adjusted our base rates. The City's contract size is significantly higher than our block of business. Performance Guarantees I have enclosed another copy of our Standard Performance Guarantees. Vincent, as a valued client, and as a result of our recent claims audit PacifiCare is willing to put 5% of the administrative premium at risk for 2002. The 2002 standards have evolved with HEDIS and NCQA reporting. I have provided the formula that relates to these standards under the Performance Guarantee Tab. Page Three City of Ft. Collins Please let us know which areas of these guarantees are most important (topic I.E. claim turnaround, speed to answer, ID cards etc.). We will need to mutually agree to all standards and percentage of allocation (per standard) prior to the effective date. The claim history and the Monthly Experience Summary (MES), year to date report, have been provided under the Claim Experience Tab. The medical plan outlines for the current EPO & POS options along with the prescription rider can be located behind the Benefits Tab. As we do every year, PacifiCare will be making adjustments to all our commercial standard medical plans. I have provided a copy of this document behind 2002 Benefit Tab. These changes will apply to both of your medical options come January 1, 2002. Vincent, you have requested that PacifiCare apply copayments for laboratory charges. Although we respect you request, PacifiCare does not charged for these services. Because our laboratories have never had to charge for these services, I would not be able to assure you that this charge would be collected. After you review the enclosed 2002 adjustments and enhancements document it will be apparent PacifiCare also felt the need to start charging copayments in other areas. The changes have targeted radiology services that are highly utilized and should reduce unnecessary utilization. Thank you for presenting PacifiCare with the opportunity to submit a proposal that would continue our long and mutually beneficial relationship with The City of Fort Collins. We look forward to addressing any questions you may have regarding our proposal at a time that will be convenient. Feel free to call me at (303) 714-3457 if I can be of assistance. Sincerely, Cindy Kunkel Sr. Account Manager Cc: Phil Goldstein, William M. Mercer, Inc. Barb Towle, PacifiCare I ,I CURRENT EPO BENEFITS h h LMedical Summary of Benefits L City of Ft. Collins Following are highlights of your plan. Please call PacifiCare Customer Service at 1-800-877-9777 if you would Llike additional information. Physician Care 1 Primary Care Physician (PCP) Office Visits............................................................. $10 copayment per visit Specialist Care and Consultants, including Second Opinions .............................. $10 copayment per visit 1 Allergy Testing........................................................................................................ $10 copayment per visit Allergy Injections...................................................................................................... $5 copayment per visit ICardiac Rehabilitation........................................................................................................... no copayment ■ coverage for maximum of $1,000 within 90 days I Short -Term Physical/Occupational Therapy.......................................................... $10 copayment per visit ` ■ coverage for maximum of 20 sessions per acute condition 1 Speech Therapy...................................................................................................... $10 copayment per visit ■ coverage for maximum of 20 sessions for certain acute conditions 6 Preventive Care PhysicalExam....................................................................................................... $10 copayment per exam I Well -Woman Exam............................................................................................... $10 copayment per exam ` ■ gynecological tests and treatment once per year I Well-Baby/Well-Child Care..................................................................................... $10 copayment per visit ■ immunizations, injections and pediatric visits ` MaternityCare ........................................................................................................ $10 copayment per visit ■ prenatal and postnatal Hospital Care ` Inpatient......................................................................................................$100 copayment per admission • semiprivate room, labor/delivery rooms, operating room and related services Outpatient Surgery or Observation Room............................................................. $50 copayment per visit Emergency Care 1 Emergency Room Setting - Inside and Outside Service Area ................................ $50 copayment per visit I Urgent Care ............................................................................................................ $25 copayment per visit ` ■ urgent care center inside service area or after normal hours in a physician's office Urgent Care/Emergency Follow -Up Outside Service Area ■ coverage for maximum of $400 per member per contract year ■ emergency room.......................................................................................... $50 copayment per visit physician's office or urgent care center ....................................................... $25 copayment per visit ` I Ambulance Service........................................................................................... $25 copayment per episode Mental Health Care A referral from your PCP is not required; however, you must call PacifiCare Behavioral Health (PBH) at 1-888-777-2735 to access mental health services. ` I Inpatient............................................................... $50 copayment per day; $25 copayment per partial day ■ coverage for maximum of 45 full days or 90 partial days per contract year I Inpatient for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, L specific obsessive -compulsive disorder and panic disorder ......... inpatient hospital care copayment applies 1 Outpatient ................................................ no copayment for visits 1-5; $10 copayment per visit thereafter ■ number of visits covered based on medical necessity ` 1 Alcohol/Drug Rehabilitation ■ limited to one course of treatment per contract year, two courses of treatment during the member's Llifetime DelVecchio Nick A DC 7595 W 66th Ave Arvada. CO 80003 (303)422-3657 Jones Jeffrey D DC 12330 W 58th Ave. Ste 4 Arvada, CO 80002 (303)420-4270 Lewin Fred DC 6609 Wadsworth Blvd Arvada, CO 80003 Pardee Trudy DC 7705 Wadsworth Blvd Suite G Arvada, CO 80003 (303)421-3639 Perkins Daniel L DC 12189 Ralston Rd Suite 102 Arvada. CO 80004 (303)424-9549 Peterson Steven L DC 7705 Wadsworth Blvd Suite G Arvada, CO 80003 (303)421-3639 Reinke Joseph DC 7100 Grandview Avenue Suite 6 Arvada, CO 80002 (303)467-1950 Sanders David L DC 7375 W 52nd Ave Suite 220 Arvada, CO 80002 (303)425-W34 Slizeski John DC 6622 Wadsworth Blvd Arvada, CO 90003 (303)123-5000 Sole Scott A DC 7500 N Wadsworth Blvd Arvada, CO 80003 (303)420-5441 Landmark Chiropractic All Regions/Alphabetically by City Tuesday, June 16, 1998 Spears Gary E DC Fell Dawn DC Waring John DC 12189 Ralston Rd Suite 102 13690 E Iliff Ste C 11275 E Mississippi Suite I E8 Arvada, CO 80004 Aurora, CO 80014 Aurora, CO 80012 (30))425-8730 (303)755-8665 (303)363-9095 Spresser Ken DC Hatt DC Steven J 8lIfYli *.� 7535 W 80th Ave 2600 S Parker road Suite 1-111 Murzyn John L DC Arvada, CO 80003 Aurora, CO 80014 280 Colfax Ave (303)425-9057 (303)745-3222 Bennett, CO 80102 Wagner Keith DC Kemlage Robert A DC (303)644-3789 5716 Ammons St 1 1175 E Mississippi Ave Ste 120 BOOIdls Arvada, CO 80002 Aurora, CO 80012 Cahn Mare S DC (303)940-0666 (303)341-1383 350 Broadway Ste 102 White William DC Murzyn John DC Boulder, CO 80303 7878 Wadsworth Blvd Suite 200 390 S Potomac Way Suite D (303)499-4500 Arvada, CO 80003 Aurora, CO 80012 Campbell Steven DC (303)425-6262 (303)344-4505 1450 28th Street ■ Odekirk Rick V DC Boulder, CO 80303 Anderson James DC 1390 Chambers Road (303)443-0123 3045 S Parker Rd Suite 259 Aurora, CO 80011 Frieder Lawrence DC Aurora, CO 80014 (303)340.3250 625 S Broadway (303) 805-8305 Odekirk Todd L DC Boulder, CO 80303 Chumbley Ann Roe DC 1390 Chambers Road (303)494-0944 13697-2 E Iliff Ave Aurora, CO 80011 Helburg Daniel L DC Aurora, CO 80014 (303)364-8253 2500 Broadway (303)337-5299 Truppo Michael A DC Boulder, CO 80304 Coady Michael B DC 13170 E Mississippi Ave (303)449-9280 14099 E Exposition Ave Aurora, CO 80012 Hudgens Tony R DC Aurora, CO SM12 (303)745-4544 6560 Gunpark Dr Suite D (303)3414366 VerMeer Eugene A DC Boulder, CO 80301 Crises Jennifer Lyn DC 13734 E Quincy Ave (303)530-0220 2600 S Parka Road Suite I I I Aurora, CO SW15 Johnson Dean A DC Aurora, CO 30014 (303)690-0292 2500 N Broadway (303)750-986g Vetanze Nelson DC Boulder, CO 80304 Doke@ Michael L DC 4090 S Parker Rd Ste 125 (303)449-9280 15101 E Iliff Suite 120 Aurora CO 80014 Morse Edward DC Aurora, CO 80014 (303)699.6394 4730 Table Mesa Drive Suite K (303)695-1609 Wadley Ted DC Boulder, CO 80303 Doherty Edward DC 11175 E Mississippi Ave Ste 12 (303)499-0500 4090 S Parker Rd Suite 125 Aurora, CO 80012 Nebring Michael J DC Aurora, CO 80014 (303)341-1383 350 Broadway Suite 102 (303)693-2225 Boulder, CO 80303 (303)494-7052 PD05003.000-1 1 April, 1998 6 6 L 19 • inpatient..................................................................................................... $50 copayment per day • coverage for maximum of 21 days • outpatient ................................... no copayment for visits 1-5; $10 copayment per visit thereafter • number of visits covered based on medical necessity • detoxification................................................................ inpatient hospital care copayment applies Other HomeHealth Care................................................................................................................. no copayment I Skilled Nursing Facility .................................................... no copayment ■ up to 120 days per contract year Injectablesfor Home Use..................................................................................................... $10 copayment Durable Medical Equipment................................................................................................. no copayment coverage for maximum of $1,500 per member per contract year; additional $500 may be available for podiatric shoe inserts InfertilityEvaluation............................................................................................................ 50% copayment IHospice Care.......................................................................................................................... no copayment I Laboratory and X-ray no copayment Medical Plan Benefit Limitations and Exclusions I Any service not performed, authorized or referred limb -threatening emergency. I Any service that is not reasonably and medically necessary. I Cosmetic surgery, unless medically necessary. I Post -mastectomy breast reconstruction if mastectomy occurred while not covered under PacifiCare. Internal prosthesis is not covered. I Personal comfort items in and out of the hospital (e.g., television, telephone). I Dental care or dental X-ray, unless covered as a supplemental benefit. I Health services and associated expenses for organ and tissue transplants, except for those transplants specifically stated as covered in the Evidence of Coverage. Heart, combined heart/lung, combined kidney/pancreas, and liver (for members eighteen and over) transplants are subject to limitations as stated in the Evidence of Coverage. I The following are not covered transplants: heart/ lung; lung; multiple organs; pancreas; non -human and artificial organs and their implantation; and chemotherapy or radiation therapy requiring a bone marrow or stem cell transplant or stem cell rescue for the treatment of any disease, including stage 1 and N breast cancer or other solid tumor cancers except as specifically stated as covered in the Evidence of Coverage. I All necessary services for covered transplants must be performed at designated transplant facilities. I Physical exams required by a third party (e.g., employment, insurance, licensing). I Custodial care, nursing home, rest cures and domiciliary care. I Reversal of sterilization. I Long-term rehabilitation. PacifiCmv by a primary care physician other than for a life- or I Services for which coverage is provided or is required by law. I Medical supplies. I Complications of non -covered services, unless medically necessary. Outpatient prescription drugs, unless covered under an optional prescription drug benefit purchased by the subscribing group. I Health services and expenses for experimental or unproven procedures, treatments, devices and pharmacological regimes. I In vitro fertilization, embryo transport, gamete intrafallopian transfer, surrogate parenting, donor semen or outpatient injectable substances and supplies related to infertility. I Abortions in excess of two per lifetime. I Services of a chiropractor. Member must complete the authorized course of treatment to be covered for inpatient or outpatient care for substance abuse. If a newly enrolled member is hospitalized on the effective date of coverage, the member must notify PacifiCare within 48 hours or as soon as medically possible so that responsibility for care can be transferred to PacifiCare, if no other group coverage exists. At PacifiCare's option, care may be continued by a primary care, referral physician or the attending physician. This summary contains only highlights of the Benefit Plan and is not intended to replace the legal documents that contain the complete provisions of these benefits. Please see the Evidence of Coverage and Owner's Manual for a complete description of benefits, benefit limitations and exclusions. 02000 by PacifiCare Health Systems, Inc. CM-1000-22384 MSFt. Collins Rev. 10/00 20000569 6455 South Yosemite Street Greenwood Village, Colorado 80111 Selected Benefit Descriptions Colorado Health Plan Description Form Addendum BENEFIT PRESCRIPTION DRUGS Level of coverage and restrictions on prescriptions PacifiCare of Colorado Cty of Fort Collins EPO Plan 700C1 BENEFIT LEVEL $8 formulary generic. $15 formulary brand -name. $30 for non -formulary. A 90-day supply of formulary maintenance medications, or a three -cycle maximum of formulary oral contraceptives, is available through the mail- order prescription pharmacy for two copayments. Prepackaged units dispensed through the mail-order prescription pharmacy will have two copayments apply for up to four prepackaged units. A 90-day supply of non -formulary maintenance medications and prepackaged units are available through mail-order for a $40 copayment (prepackaged units are limited to four units per copayment). For more information on the mail-order prescription drug program, or for information on drugs on our approved formulary list, call Customer Service at 1-800-877-9777. NOTE. PacifiCare's prescription drug coverage relies on a framework provided by a drugjormulary. Quite simply, a formulary is a list of preferred or recommended drugs that have been carefully selected by physicians and pharmacists based upon the safety and effectiveness of those drugs. You pay your applicable copayment for prescriptions filled at network pharmacies. • Formulary Generic • Formulary Brand • Non -Formulary PacifiCare 6455 South Yosemite Street Greenwood Village, Colorado 80111 02000 by PacifiCare Health Systems, Inc. CM-1000-22384 MSFt. Collins Rev. 10l00 20000569 L L L L L L L L L .L L CURRENT POS BENEFITS Medical Summary of Benefits City of Ft. Collins Point of Service Plan (POS) 1 Deductible.................................................................. $200 per person; $400 per family Maximum Out -of -Pocket ................................... $2,500 per person*; $5,000 per family* *(plus deductible) Here are some highlights of your plan. Please call PacifiCare Customer Service at 1-800-877-9777 if you would like additional information Physician Cal 1 Primary Cat 1 Specialist C Second Opi 1 Allergy Test 1 Allergy Inje 1 Cardiac Ref maximum c 1 Short -Term Therapy 1 Speech The Preventive Ct 1 Physical Em Well-Woma ■ gynecol once pt 1 Well-Baby/N up to age d ■ immun pediatr 1 Maternity C ■ prenata Hospital Cart Inpatient ■ semipri rooms, services 1 Outpatient • Benefit Plus Benefit e • w• Physician (PCP) Office Visits $10 copayment per visit You pay 30% ire and Consultants, including $10 copayment per visit You pay 30% pions ng $10 copayment per visit You pay 30% -tions $5 copayment per visit You pay 30% abilitation (coverage for No copayment You pay 30% f $1,000 within 90 days) Physical/Occupational $10 copayment per visit You pay 30% up to $500 per (coverage for maximum of type of therapy (chiropractic 20 sessions per acute services included under condition) physical therapy) -apy $10 copayment per visit You pay 30% up to $500 per (coverage for maximum of type of therapy 20 sessions for certain acute conditions) re In $10 copayment per exam Not a covered benefit t Exam $10 copayment per exam Not a covered benefit c)gical tests and treatment r year fell -Child Care —for members $10 copayment per visit You pay 30% (not subject irteen to deductible) zations, injections and c visits ire $10 copayment per visit You pay 30% 1 and postnatal $100 copayment per admis- You pay 30% when rate room, labor/delivery sion preauthorization is obtained operating room and related (you pay 50% when not preauthorized) iurgery or Observation Room $50 copayment You pay 30% when preauthorization is obtained (you pay 40% when not preauthorized) *All care must be arranged by the primary care physician. "*Eligible charges are paid only after the annual deductible has been met. I L Emergency Care • 1 Emergency Room Setting - Inside and $50 copayment per visit Outside Service Area 1 Urgent Care $25 copayment per visit ■ after normal hours in a physician's office or urgent care center inside L service area 1 Urgent Care/Follow-Up Outside Service Area You pay 50% You pay 50% L ■ emergency room $50 copayment per visit You pay 50% ■ physician's office or urgent care center $25 copayment per visit You pay 50% (coverage for maximum of L $400 per participant/ beneficiary per contract year) 1 Ambulance Service $25 copayment per episode You pay 30% LMental Health Care Inpatient (coverage for maximum of 45 Lfull days or 90 partial days per contract year) I Inpatient for schizophrenia, schizoaffective disorder, bipolar affective disorder, major depressive disorder, specific obsessive - compulsive disorder and panic disorder LI Outpatient (number of visits based on medical necessity) LI Outpatient for schizophrenia, schizoaffective disorder, bipolar affective disorder, major L depressive disorder, specific obsessive - compulsive disorder and panic disorder L1 Alcohol/drug Rehabilitation (limited to one course of treatment per Lduring contract year, two courses of treatment the member's lifetime) ■ inpatient (see Evidence of Coverage for benefit maximums) L■ outpatient L L ■ detoxification $50 copayment per day $25 copayment per partial day Inpatient hospital care copayment applies No copayment for visits 1-5, $10 copayment per visit thereafter No copayment for visits 1-5, $10 copayment per visit thereafter $50 copayment per day No copayment for visits 1-5, $10 copayment per visit thereafter (number of visits covered based on medical necessity) $100 copayment You pay 50% (includes hospital and medical services) You pay 30% when preauthorization is obtained (you pay 50% when not preauthorized) You pay 30% (maximum benefit $1,000) You pay 30% Alcohol/drug rehabilitation included under mental health benefit You pay 30% (maximum benefit $500) Alcohol/drug rehabilitation included under mental health benefit *All care must be arranged by the primary care physician. **Eligible charges are paid only after the annual deductible has been met. L L L L L 11 L L L L L Other Home Health Care 1 Skilled Nursing Care Injectables for Home Use 1 Durable Medical Equipment Infertility Evaluation Hospice Care ■ inpatient care ■ outpatient care 1 Outpatient Prescriptions*** No copayment No copayment $10 copayment No copayment (coverage for maximum of $1,500 per member per contract year; additional $500 may be available for podiatric shoe inserts 50% copayment No copayment No copayment See Pharmacy Benefit insert for copayments (must be filled at a PacifiCare partici- pating pharmacy) You pay 30% for up to 60 visits per year You pay 30% for up to 30 days when preauthorized; 50% when not preauthorized You pay 30% You pay 30% (maximum benefit $1,000) Not a covered benefit You pay nothing up to 30 days You pay 30% up to 270 days (maximum benefit $55 per day) You pay 30% after the deductible *All care must be arranged by the primary care physician. **Eligible charges are paid only after the annual deductible has been met. ***Not all groups offer this benefit; please check your I.D. card or with your employer. PacifiCare's PacifiCare's Plus enhances your regular PacifiCare benefits by giving you the flexibility to choose any physician, hospital or health care provider any time you want to use them. By selecting PacifiCare's Plus, you have the option of using the regular benefits and services offered by the PacifiCare HMO, with predetermined and fixed copayments, or your Plus benefits, where in most cases 70% of eligible* charges are covered after your deductible has been met. To receive your HMO benefits, your primary care physician (PCP) must arrange or provide all your health care. He or she will arrange all specialty referrals and handle all your paper- work, preauthorization for procedures and billing. Under Plus, you also have the option to go outside our participating provider network, and select your own physician. With Plus benefits, the decision to use any specialty care services is up to you. However, you are also responsible for filing your claims as well as getting preauthorization on procedures and second opinions. You also have a deductible and coinsurance. Selecting A Physician — With PacifiCare's Plus, when you need physician care, you can use the primary care physician (PCP) you have preselected from the network and take advantage of the substantial savings and convenience your PacifiCare HMO benefits offer. However, if there is a physician or health care provider you would prefer to use who is not listed in our roster, your Plus benefits give you the freedom to visit him or her and still be covered. Hospital Admissions and Surgical Authoriza- tions — Under your HMO benefits, your primary care physician (PCP) will take care of all preauthorization for hospital admissions and surgical procedures. With Plus benefits, because you have selected a provider outside of our network, you will need to work in partnership with PacifiCare in managing your care. You and your physician must obtain approval on all non -emergency hospital admissions; admissions to extended care, skilled nursing and rehabilitation facilities; and admissions to ambulatory surgical centers. In some cases, a second opinion is required for selected surgical procedures. You or your physician must call PacifiCare's Plus at 1-800-255-1189 to obtain authorization at least one week prior to the scheduled admission. If you do not obtain these when required, PacifiCare's Plus will only pay 50% of eligible charges for medically necessary services. Second Surgical Opinions — 1n some cases, a second opinion is required for selected surgical procedures. Second surgical opinions are our way of ensuring that you receive high quality and appropriate care. Under your HMO benefits, your primary care physician will arrange any needed second opinions or preauthorization for surgical procedures. Under your Plus benefits, you and your physician are responsible for this. Call PacifiCare's Plus at 1-800-255-1189 or see the PacifiCare's Plus Evidence of Coverage and Owner's Manual for L L L L L L L L L information on getting a surgical procedure precertiFied and coverage of second surgical opinions. Emergency Services — Medical emergencies are generally covered under the PacifiCare HMO benefits, provided you obtain prior authorization from your primary care physician or the emergency is life- or limb -threatening. If the situation does not qualify as an emergency under the PacifiCare benefits, then it will be considered under Plus benefits. In the case of emergency or urgent care admissions, we ask that you or your physician notify PacifiCare's Plus no later than the next business day. Your Costs — Under your HMO benefits, you are responsible for fixed, predictable copayments when you seek health care services. To take advantage of your Plus benefits, coverage will be paid at 70% of eligible charges (after the deductible has been met) on most covered benefits that have been appropriately authorized. If a benefit requiting authorization has not been authorized, PacifiCare will pay only 50% of all eligible charges. Probably one of the most outstanding features of PacifiCare's Plus is the annual maximum out-of-pocket expense provision. Once you incur the maximum amount, PacifiCare Plus pays 100% of all eligible charges on covered benefits. For an individual, the annual maximum expenditure is only $2,500 and, for a family, the annual maximum is $5,000 (plus the deductible). *'Eligible cbarge" is a term used to describe the fee PacifiCare bas agreed to pay a provider. For example, if your bill for a specific procedure is $100, and the PacftCare eligible charge is $90 for that procedure, you are responsible for the 30% of $90 plus the difference between the billed amount and the eligible amount, wbicb is $10 in this case. Medical Plan Benefit Limitations and Exclusions The following medical benefit limitations and exclusions are applicable to both in- and out -of -network benefits: Any service that is not reasonably and medically necessary. Cosmetic surgery, unless medically necessary. 1 Personal comfort items in and out of the hospital (e.g., television, telephone). 1 Dental care or dental X-ray, unless covered as a supplemental benefit. 1 Health services and associated expenses for organ and tissue transplants, except for those transplants specifically stated as covered in the Evidence of Coverage. All necessary services for covered transplants must be performed at designated transplant facilities. 1 Physical exams required by a third party (e.g., employment, insurance, licensing). 1 Custodial care, nursing home, rest cures and domiciliary care. 1 Reversal of sterilization. 1 Services for which coverage is provided or is required by law. 1 Medical supplies. 1 Complications of non -covered services, unless medically necessary. 1 Outpatient prescription drugs, unless covered under an optional prescription drug benefit purchased by the subscribing group. Health services and expenses for experimental or unproven procedures, treatments, devices and pharmacological regimes. 1 Abortions in excess of two per lifetime. 1 Member must complete the authorized course of treatment to be covered for inpatient or outpatient care for substance abuse. I If a newly enrolled member is hospitalized on the effective date of coverage, the member must notify PacifiCare within 48 hours or as soon as medically possible so that responsibil- ity for care can be transferred to PacifiCare, if no other group PacifiCare coverage exists. At PacifiCare's option, care may be contin- ued by a primary care, referral physician or the attending physician. In addition to those medical plan limitations and exclusions listed above, the following are excluded under the in -network portion of the benefits: Any service not performed, authorized or referred by a primary care physician other than for a life- or limb - threatening emergency. 1 Services of a chiropractor. 1 The following are not covered transplants: heart/lung; lung; multiple organs; pancreas; non -human and artificial organs and their implantation; and chemotherapy or radiation therapy requiring a bone marrow or stem cell transplant or stem cell rescue for the treatment of any disease, including stage I and IV breast cancer or any other solid tumor cancers except as specifically stated as covered in the Evidence of Coverage. 1 In vitro fertilization, embryo transport, gamete intrafallopian transfer, surrogate parenting, and donor semen. In addition to those medical plan limitations and exclusions listed above, the following are excluded under the out -of - network portion of the benefits: Transplants except cornea and kidney. 1 Preventive care for members age thirteen and over. I Services related to infertility. Eye refraction examination. This summary contains only highlights and is not intended to replace the legal documents that contain the complete provisions of these benefits. Please see PacifiCare's HMO and Plus Evidences of Coverage and Owner's Manuals for a complete description of benefits, benefit limitations and exclusions. 02000 by PacifiCare Health Systems, Inc. CM-1000-22400 MSFt. Collins Rev. 10/00 20000570 L 6455 South Yosemite Street Greenwood Village, Colorado 80111 Selected Benefit Descriptions Colorado Health Plan Description Form Addendum PacifiCare of Colorado City of Fort Collins Plus Plan 802C1 BENEFIT BENEFIT LEVEL In -Network BENEFIT LEVEL Out -of -Network PRESCRIPTION DRUGS $8 formulary generic. $15 formulary brand- You pay your applicable name. $30 for non -formulary. copayment plus 30% of the Level of coverage and remaining cost of the restrictions on prescriptions A 90-day supply of formulary maintenance prescription. medications, or a three -cycle maximum of • Formulary Generic + 30% formulary oral contraceptives, is available through of remaining cost the mail-order prescription pharmacy for two . Formulary Brand + 30% copayments. Formulary prepackaged units of remaining cost dispensed through the mail-order prescription . Non -Formulary + 30% of pharmacy will have two copayments apply for remaining cost up to four prepackaged units. A 90-day supply of non -formulary maintenance medications and prepackaged units are available through mail-order for a $45 copayment (prepackaged units are limited to four units per copayment). For more information on the mail-order prescription drug program, or for information on drugs on our approved formulary list, call Customer Service at 1-800-877-9777. NOTE: PacifiCare's prescription drug coverage relies on a framework provided by a drug formulary. Quite simply, a formulary is a list of preferred or recommended drugs that have been carefully selected by physicians and pharmacists based upon the safety and effectiveness of those drugs. You pay your applicable copayment for prescriptions filled at network pharmacies. • Formulary Generic • Formulary Brand • Non -Formulary PacifiCare 6455 South Yosemite Street Greenwood Village, Colorado 80111 02000 by PacifiCare Health Systems, Inc. CM-1000-22400 MSFt. Collins Rev. 10/00 20000570 6 I J 6 I 6 2002 Large Group Plan Benefit Changes Effective for large group commercial, non -uniform benefit plans renewing January 1, 2002 and after. ♦ Increase the out-of-pocket maximum to $3,500 for an individual, $8,000 for a family. Currently $2,500/$7,500. Note: Certain plan designs may have different out-of-pocket maximums. The member is responsible for notifying PacifiCare if they believe they have met the out-of- pocket maximum. ♦ Increase the emergency room copayment to $100. Currently $50. Note: Certain plan designs may have different emergency copayments. ♦ Apply a copayment of $75 for CT scans, PET scans, MRIs and SPECT scans. Currently no copayment. Note: Certain plan designs may have different radiology copayments. ♦ Apply a copayment of $75 for outpatient self injectables obtained at a pharmacy. Currently a $10 copayment applies. Note: Insulin Exempted, and will not be subject to the $75 copay for 2002. ♦ Current coverage for home nursing and homemaker services following newborn delivery will be limited to individuals who are discharged one day early based on the Federal guidelines. Currently covered for all new moms, regardless of when discharged. The Federal guidelines are 48 hours following vaginal delivery and 96 hours following a cesarean section. Under 2002 plans, to qualify for this benefit individuals must be discharged 24 hours following vaginal delivery or 72 hours following cesarean section. ♦ Medical foods associated with certain single gene metabolic conditions will be covered as required by new State legislation. A 50% copayment will apply. Currently excluded. ♦ Exclude coverage of total parenteral nutrition (TPN). Currently covered in limited circumstances. Members receiving coverage under the current benefit will be grand -fathered for the 2002 plan year. ♦ Modify the current exclusion for biofeedback to allow coverage for biofeedback related to acute pelvic muscle rehabilitation. ♦ Modify the current list of conditions for which cardiac rehabilitation is covered to include stable angina pectoris. Coverage of cardiac rehabilitation for stable angina pectoris will be limited to one course of treatment per plan year. 2002 Large Group Plan Benefit Changes.doc REVISED 8/24/01 1 of 1 L L L L L L L L L L L L L L L L L PacifiCare Testa stark A DC 1900 Folsom Street Suite 205 Boulder, CO 80302 (303)442-7170 Turner Thomas M DC 2449 Pine St Boulder. CO 80302 (303)4434115 Winkelbauer Lindy DC 2975 Valmont Road Suite 100 Abercrombie Chad DC 2504 E Pikes Peak Ave Colorado Springs. CO 80909 (719)632-4754 Adams Todd DC 1817 D North Union Blvd Colorado Springs, CO 80909 (719)634-8846 Becco Gregory DC 1819 W Colorado Ave Boulder. CO 80301 Colorado Springs, CO 80904 (303)448-9098 (719)4714174 Becco Jeffrey DC Gappa Jeffrey DC 1819 W Colorado Ave 677 E Bridge Street Colorado Springs, CO 80904 Brighton. CO 80601 (719)4714174 (303)639-0805 Burson William L DC Marchus Darrin W DC 716 W Brookside 40 South 6th Ave Colorado Springs, CO 80906 Brighton, CO 80601 (719)475-9103 (303)659-7474 Byers David A DC Quinn Richard DC 11 I W Filmore 40 South 6th Avenue Colorado Springs, CO 80907 Brighton, CO 80601 (719)447-0711 (303)659-7474 Chicoine Rene Joseph DC 4112 Austin Bluffs Parkway Lehman DeVerne C DC Colorado Springs CO 80918 7510 Hwy 287 Unit C (719)548-8611 Broomfield, CO 80020 Conner Gregory R DC (303)466-4848 824 E Fillnwre St Meyer Robert DC Colorado Springs, CO 80907 2000 W 120th Ave Suite 7 (719)636-1615 Broomfield, CO 80234 Dedolph Jon D DC (303)465-4442 824 E Filmore Snyder Randy DC Colarado Wings, CO $0907 8155 West 94th Ave (719)634-4900 Broomfield, CO 80020 Dickson Matthew T DC (303)423-46I0 245 S Academy Blvd �- Colorado Springs, CO 80910 Wayne James L DC (719)528-5656 425 S Wilcox Street Suite 200 Dragoo Jeffrey DC Castle Rock, CO 80104 2133 N Academy Blvd (303)688-9133 Colorado Springs, CO 80909 - - (719)573-0521 t Elliott Dee DC Ranney Gary DC 3440 N Academy Blvd 815 East Platte Avenue Colorado Springs, CO 90917 Colorado Springs. CO 80903 (719)597-2273 (719)634-5355 Frieling Rodney W DC Rlekemso Deborah J DC 7828 N Academy Blvd 213 East Cache La Poudre Colorado Springs, CO 80920 Colorado Springs, CO 80903 (719)592-9400 (719)630-7335 Fullerton K Blaine DC Rosenquist Scott D DC 2300 Powers Bus Plata Suite 2480 2504 E Pikes Peak Suite 105 Colorado Springs, CO 90915 Colorado Springs, CO 80909 (719)574-6162 (719)632-4754 Graham Galen DC Rosenstrauch Kara DC 1935 East Bijou Street 816 Village Center Dr Colorado Springs, CO 90909 Colorado Springs, CO 80919 (719)475-8877 (719)598-6955 Hanky Richard DC Thatcher James A DC 5664 N Acadame Blvd 3535 American Drive Colorado Springs, CO 80918 Colorado Springs, CO 80917 (719)593-7300 (719)574-3700 Knoche Randy R DC Thermally Craig DC I g02 Chapel Hills Dr Suite E 6189 Lehman Drive Suite 105 Colorado Springs, CO 80920 Colorado Springs, CO 80918 (719)531-7188 (719)594-4400 Leahy P Michael DC Waggoner Clinton DC 10 N Meade Avenue 2510 N Cascade Ave Colorado Springs, CO 80909 Colorado Springs, CO 80907 (719)473-7000 (719)634-2579 Morse S William DC Weam Randy A DC 2130 Academy Circle Suite D 619 N Cascade Ave Colorado Springs, CO 80909 Colorado Springs, CO 80903 (719)591-7711 (719)635-2029 Peterson David DC 6190 Lehman Drive Ste 108 Colorado Springs, CO 90918 (719)594-4944 Plant Steven M DC 3020-C West Colorado Ave Colorado Springs, CO 80904 (719)473-2423 Polvi Brian A DC 2300 Powers Bus Plata Suite 2490 Colorado Springs, CO 80915 (719)574-6162 Youmans Patricia A DC 4323 N Academy Colorado Springs, CO 80918 (719)528-5656 Will . Jill Gibson Robert D DC 25797 Conifer Road Suite 8106 Conifer, CO 80433 (303)838-8443 Svendsen Lawrence A DC 501 E 2nd Street Cortez, CO 81321 (970)565-7315 1 April. 1998 PD05003.000.1 7 y CITY OF FORT COLLINS EPO y COMPANY NUMBER ORS00 01 /01 /2001 - 06/30/2001 HMO MEDICAL EXPERIENCE Contents 1 Introduction . . . . . . . . . . . . . . . . . . • 1 2 Explanation Of Terms • 2 3 Overview . . . . . . . . . . . . . . . . . . . . . 3 4 5 Membership Demographics . . . . . . . . . . Member Relationship Analysis . . . • 4 • 5 6 Member Age Analysis . . . . . • 6 7 Paid Claims By Cause . . . . . . . . . . . . . . • 7 8 Provider information • 8 9 Non -Hospital Provider Information • 9 10 11 Provider And Vendor Discount Savings . . . Payments By Benefit Category . . . . . . . . . . 10 . . . 10 12 Inpatient Utilization 11 13 Catastrophic Illness . . . . . . . . . . . . . . 12 14 15 Analysis Of Symptoms & Signs . . . . . . . Analysis Of Pregnancy & Childbirth . . . 13 14 16 Analysis Of Skeleton & Muscle System 15 17 Analysis Of Injury & Poisoning . . . . . . . . . 16 4 4 L 01 /2001 - 06/2001 L ` Introduction CITY OF FORT COLLINS EPO ORS00 PacifiCare is pleased to provide you with this comprehensive reporting package which focuses on your HMO coverage. The intent is to provide an array of reports which help to explain the impact of our medical management services. Under the HMO, medical benefits are paid for in two ways: ■ Capitation - a method of pre -paying for designated medical services. ■ Negotiated fee arrangements - providers are reimbursed a specific fee for a given medical service. These are referred to as "Paid Claims" throughout this document. LThis reporting package analyzes total medical payments (claims plus capitation) for your members. The package then provides a detailed analysis of the services provided under fee arrangements ("Paid Claims"). Overall, 99% of your HMO expenses were paid claims. LAt PacifiCare, we turn data into useful information to assist you in making informed decisions about your benefit plan. L L L L L L L Page 1 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 2 Explanation Of Terms ■ Members - All eligible persons, including employees and their covered, dependents, spouses, and retirees. ■ PMPM - Per Member, Per Month. A monthly expense per member is calculated by dividing total expenses by cumulative member months. L■ Days - The number of inpatient days. ■ ALOS - Average Length of Stay. ■ Days per 1000 and Admissions per 1000 - The number of days/admissions per 1000 covered members. ` These indicies are HMO standards for measuring utilization. ■ ICD-9 Code - International coding scheme used to reflect physician diagnosis (International ` Classification of Diseases, 9th Revision). ■ Cause - Groupings of diagnostic categories (ICD-9 codes) which identify bodily systems. ■ Claimants - Members with referral claims that were not covered through capitated HMO services. ■ Admits - Number of admissions to an inpatient healthcare facility. 6 6 6 I . 1 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 3 1 ` Overview ■ This analysis contains paid claims and capitation expenses. t ■ The total expenses were $1,751,890. r ■ The total capitation expenses were $20,310, which covered these types of services: ` - OTHER ■ Medical paid claims totaled $1,731,580. Of this amount, Employees accounted for $874,265. Spouses accounted for $526,801. Children accounted for $329,940. And others accounted for $574. - Claims associated with inpatient admissions were $397,723 (23%) - Outpatient care expenses were $1,097,331 (63%). - Pharmacy expenses were $236,526 (14%)• ■ There were a total savings resulting from Coordination of Benefits of $30,028. These savings were not reflected in the paid amounts of this report where the data is categorized by benefit category or specific CPT4 codes. ■ There were a total of 47 inpatient admissions to healthcare facilities, totaling 123 days. The period covered was January 1, 2001 through June 30, 2001 and only claims and capitation paid in that period were considered. This report was processed on August 17, 2001. l 01 /2001 - 06/2001 L CITY OF FORT COLLINS EPO ORS00 Membership Demographics tMembers by Relationship and Age Bands: LAge Band Less than 1 1-19 L 20-34 35-49 L 50-64 65 and over Total LMembers by Sex and Age Bands: L Females: L L L Males: L L L Overall L L L Employee Spouse Children Total 0 0 23 23 0 1 708 709 221 108 49 378 398 216 0 614 165 92 0 257 2 2 0 5 786 420 781 1,987 AgeBand Percent Members of Total Less than 1 12 0.6% 1-19 382 19.2% 20-34 196 9.8% 35-49 321 16.2% 50-64 110 5.5% 65 and over 1 0.1% Total Females 1,021 51.4% Less than 1 12 0.6% 1-19 327 16.5% 20-34 183 9.2% 35-49 293 14.7% 50-64 147 7.4% 65 and over 4 0.2% Total Males 966 48.6% 1,987 100.0% Page 4 i L 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 L PAID CLAIMS AND CAPITATION LMember Relationship Analysis The distribution of medical expense (including capitation) by Relationship (Employee active or retired, Spouse, and Children) compared to PacifiCare experience was: Employees Spouses Children PacifiCare Regional Norms 54% 27% 19% LClient 50% 30% 19% Employees Spouses Children Total L Total Expenses: LCapitation Paid $7,440 $4,512 $8,359 $20,310 Claims Paid $874,265 $526,801 $329,940 $1,731,580 LTotal ------------------------------------------------------------ Expense $881,705 $531,313 $338,299 $1,751,890 LMember Averages: Average Members 786 420 781 1,987 LAvg. PMPM Expense $186.92 $210.84 $72.24 $146.97 Inpatient Experience: Inpatient Admissions 17 19 11 47 Inpatient Days 52 52 19 123 47 Admits per 1000 Members 43 90 28 (Annualized) Days per 1000 Members 132 248 49 124 L (Annualized) L L L Page 5 01 /2001 - 06/2001 L CITY OF FORT COLLINS EPO ORS00 il Member Age Analysis This analysis looks at the ages of the members and claimants. The ages were calculated as of the end of the period, so only a single age is assumed for the entire period. Average Age by Relationship: Relationship Average Claimant Age Average Member Age Employee 43.4 years old 41.2 years old Spouses 43.4 years old 41.4 years old Children 11.8 years old 10.9 years old Average Age 35.2 years old 29.3 years old The regional average claimant age for PacifiCare is approximately 42.5 years old. ` Experience by Sex and Age Bands: Paid Capitation Combined AgeBand Members Claims Total PMPM Females: Less than 1 12 14,046 126 199.60 1-19 382 135,353 4,105 60.85 20-34 196 262,822 2,101 225.85 35-49 321 411,904 3,451 215.54 50-64 110 233,147 1,179 355.58 65 and over 1 3,354 11 560.77 Total Females 1,021 $1,060,625 $10,972 $174.87 Males: Less than 1 12 13,907 97 200.06 1-19 327 129,621 3,517 67.79 20-34 183 96,255 1,964 89.53 35-49 293 265,420 2,495 152.48 50-64 147 159,689 1,226 182.03 277.31 65 and over 4 6,061 39 Total Males 966 $670,955 $9,339 $117.41 Overall 1,987 $1,731,580 $20,310 S146.95 Page 6 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 7 PAID CLAIMS ONLY (NO CAPITATION) Paid Claims By Cause The following table illustrates the paid claims by Cause (ICD-9 grouping). Here the claimant count increases to show the claimants by ICD-9 codes. Paid Claims (both inpatient and outpatient, excluding pharmacy) for this period were as follows: Paid % of % of Cause Claims Paid Days Days Claimants Symptoms 8 Signs 190,420 12.7 3 2.4 926 Pregnancy 8 Childbirth 170,264 11.4 53 43.1 394 Skeleton 8 Muscle System 162,190 10.8 0 0.0 429 Injury 8 Poisoning 144,398 9.7 5 4.1 368 Genitourinary System 116,091 7.8 9 7.3 291 Respiratory System 108,903 7.3 5 4.1 833 Tumors 107,618 7.2 16 13.0 256 Circulatory System 96,968 6.5 8 6.5 116 Digestive System 93,605 6.3 10 8.1 161 Mental 8 Substance Abuse 76,608 5.1 1 0.8 185 Nervous Sys/Sense Organs 61,201 4.1 1 0.8 238 Glands 8 Metabolism 55,658 3.7 7 5.7 186 All Others/Supplementary 46,101 3.1 0 0.0 243 Infections 8 Parasitic 26,186 1.8 1 0.8 243 Birth Defects 19,436 1.3 4 3.3 18 Skin 8 Skin Related 17,391 1.2 0 0.0 169 Perinatal Conditions 1,013 0.1 0 0.0 8 Blood Related 1,004 0.1 0 0.0 12 Total $1,495,054 123 5,076 The leading individual (medical) ICD-9 diagnoses were: r Paid % of % of ICD-9 Diagnosis Claims Paid Days Days Claimants r 780 GENERAL SYMPTOMS 49,465 3.3 2 1.6 123 996 GRAFT REPLACEMENT 43,241 2.9 2 1.6 9 r410 MYOCARD INFARCTION AC 36,976 2.5 7 5.7 1 789 ABD/PELVIS SYMPT INVO 31,217 2.1 0 0.0 114 V72 EXAMINATION NOS 30,208 2.0 0 0.0 268 DXM 27,996 1.9 1 0.8 50 724 BACK DISORDER NEC N 26,868 1.8 0 0.0 75 278 OBESITY/HYPERALIMENT 26,297 1.8 7 5.7 9 786 RESP SYS/OTH CHEST SY 24,846 1.7 1 0.8 141 218 LITER LEIOMYOMA 24,446 1.6 12 9.8 5 L L L• . L 1 /2001 - 06/2001 LProvider Information CITY OF FORT COLLINS EPO ORS00 6 Claim payments went to the following recipients: Paid % of Claims Paid Paid to Non -Hospital Providers $972,380 56.2 ` Paid Directly to Hospitals $758,733 43.8 Paid to Insured S467 0.0 ` The leading hospital providers for this time frame were: (* denotes a PacifiCare Preferred or Network Provider) Paid LProvider Name City State Days Claims *POUDRE VALLEY HEALTH CARE -OP FORT COLLINS CO 0 305,285 *POUDRE VALLEY HEALTH CARE-IP FORT COLLINS CO 103 253,693 ` *MCKEE MEDICAL CENTER-IP LOVELAND co 11 45,334 *SURGERY CNTR OF FT.COLLINS-OP FORT COLLINS CO 0 44,046 *MCKEE MEDICAL CENTER -OP LOVELAND CO 0 22,356 *HARMONY AMBULATORY SURGERY FORT COLLINS CO 0 20,753 *CHILDREN'S HOSP-INPATIENT DENVER CO 4 15,163 *KIDNEY STONE CENTER DENVER CO 0 9,947 L EDWARD HOSPITAL ASSOC-IP NAPERVILLE GREELEY IL Co 1 0 6,874 6,253 *NORTH CO MEDICAL CENTER - OP *PORTER HOSPITAL IP DENVER CO 4 6,032 *EYE SURGERY CNT OF NC -OP- FORT COLLINS CO 0 4,383 *ORTHOPAEDIC CTR OF THE RKS-OP FORT COLLINS CO 0 3,598 *SPRING CREEK SURGERY CTR-OP FORT COLLINS Co 0 3,437 *PORTER HOSPITAL O/P DENVER CO 0 2,926 *MOUNTAIN VIEW SURGERY CTR LOVELAND CO 0 2,178 1,157 *LITTLETON HOSPITAL O/P LITTLETON CO 0 *BOULDER COMM HOSP-OUTPATIENT BOULDER CO 0 1,036 *HOSPICE OF LARIMER CNTY-IP- FORT COLLINS CO 0 871 L LOWER KEYS MEDICAL CENTER O/P KEY WEST FL 0 726 *CHILDREN'S HOSP-OUTPATIENT DENVER CO 0 712 *MERCY MEDICAL CENTER O/P DURANGO CO 0 702 L *LONGMONT UNITED HOSPITAL -OP LONGMONT CO 0 556 IVINSON MEMORIAL HOSPITAL O/P LARAMIE WY 0 527 LFAIRVIEW SOUTHDALE HOSPITAL 0 MINNEAPOLIS MN 0 518 Page S 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 9 Non -Hospital Provider Information The leading non -hospital providers were: Paid Provider Name City State Days Claims ` *PACIFICARE BEHAVIORAL HEALTH LAGUNA HILLS CA 0 67,738 *ORTHOPAEDIC CTR OF THE RKS-OP FORT COLLINS CO 0 32,443 *FT COLLINS RADIOLOGIC ASSOC FORT COLLINS CO 0 27,671 *HARMONY IMAGING CENTER LLC FORT COLLINS CO 0 22,471 *ROCCI TRUMPER MD FORT COLLINS CO 0 16,907 *MARK ROTMAN MD FORT COLLINS CO 0 12,311 *EMERGENCY PHYS OF FT COLLINS FORT COLLINS CO 0 12,300 *STEVEN BROMAN MD FORT COLLINS CO 0 12,230 *THOMAS NEVRIVY MD FORT COLLINS CO 0 10,182 *MERLIN OTTE14AN MD FORT COLLINS CO 0 9,332 *TIMOTHY PODHAJSKY MD FORT COLLINS CO 0 9,148 *DANIEL JINICH MD FORT COLLINS CO 0 8,254 *NORMA STIGLICH MD FORT COLLINS CO 0 8,161 *JOHN ONEILL MD FORT COLLINS CO 0 8,120 HARMONY AMBULATORY SURGERY FORT COLLINS CO 0 6,949 The leading Pharmacy providers were: Paid Provider Name City State Days Claims *PRESCRIPTION SOLUTIONS M SAN DIEGO CA 0 26,212 *KING SOOPERS PHARMACY #9 FT COLLINS CO 0 24,364 *LONGS DRUG STORE 226 FT COLLINS CO 0 22,410 *KING SOOPERS PHARMACY #18 FT COLLINS CO 0 22,192 *WALGREEN DRUG STORE 01245 FT COLLINS CO 0 16,186 *ALBERTSONS PHARMACY 8814 FORT COLLINS CO 0 15,571 *KING SOOPERS PHARMACY 73 FORT COLLINS CO 0 15,371 *DMR SUBMITTED - COPAY CA 0 9,808 *SAFEWAY PHARMACY 1552 FORT COLLINS CO 0 6,616 *KING SOOPERS PHARMACY 44 LOVELAND CO 0 6,503 *TODDY'S PHARMACY FT COLLINS CO 0 5,430 *ALBERTSONS PHARMACY 8918 FT COLLINS CO 0 5,325 *SPRING CREEK PHARMACY FT COLLINS CO 0 5,072 ` *SAFEWAY PHARMACY 107 1071 FT COLLINS CO 0 5,039 *KING SOOPERS PHARMACY 74 LOVELAND CO 0 4,801 D!lYlt Hanks John DC Barton David J DC 3955 E Exposition Ave 318 5031 S Ulster Street Suite 470 Denver. CO 80209 Denver. CO 80239 (303)722-0909 (303)221-1520 Jones Irene M DC Brasher Verna DC 1761 Ogden Street 1660 S Albion Suite 915 Denver, CO 80218 Denver. CO 80222 (303)830-0565 (303)758-6155 Luck Kevin J DC Bui Conrad C DC 2768 S Wadsworth Blvd Suite A 945 S Federal Blvd Suite B Denver, CO 80227 Denver. CO 80219 (303)985-0646 (303)922-8146 Lunnon Katherine DC Carlson Jr Harry T DC 2480 Youngfield 1525 S Federal Blvd Denver, CO 80215 Denver, CO 80219 (303)237-7900 (303)936-2112 Maen Jeffrey S DC Colagrosso Drew B DC 1325 S Colorado Blvd Suite 022 3890 Federal Blvd Denver, CO 80222 Denver, CO 80211 (303)759-8333 (303)433-7117 Ohlson Robert S DC Dechert Paula DC 1660 S Albion Suite 618 2121 S Oneida Denver, CO 80222 Denver, CO 80224 (303)757-6733 (303)756-5501 Parker Jeffry T DC Drillings Marc DC 2755 S Locust St Ste 109 1660 S Albion Suite 309 Denver, CO 80222 Denver, CO 80222 (303)758-0224 (303)756-5023 Riedel Rae L DC Eldridge T Randall DC 6925 E Hampden Ave 2755 S Locust St Ste 109 Denver, CO 80224 Denver, CO 80222 (303)758-2638 (303)758-9006 Roaenquist Scott D DC Gillet Philip A DC 1776 S Jackson Ste 907 665 N Broadway Ste 100 Deaver, CO 90210 Denver, CO 80203 (303)75"599 (303)592-7273 Rowland Brian E DC Graves Keith DC 41017th Street Suite 1315 1776 S Jackson Suite 907 Denver, CO 80202 Denver, CO 80210 (303)623-5337 (303)756-0360 Santistevan Paula DC Griffiths J Eric DC 1040 S Gaylord Street Suite 100 5515 W 38th Ave Denver, CO 80209 Denver, CO 80212 (303)698-2225 (303)424-7751 3 Sarkela Lynn M DC O'Grady Bernard N1 DC 3300 E First Ave Ste 360 5020 S Federal Blvd Denver, CO 80206 Englewood, CO 801 10" (303)322-9164 (303)795-3668 So Peter DC Troeger Steven R DC 2165 S Sheridan Blvd 8200 E Belleview Ave Suite E-205 Denver. CO 80227 Englewood, CO 80111 (303)985-0764 (303)220-7554 Thomas Jeana DC EYergrus 1711 S Pearl Street Kaneko Gail DC Denver. CO 80210 27872 Meadow Drive (303)744-6567 Evergreen. CO 80439 Visentin Steven C DC (303)670-1200 1411 Krameria Street Bert Collins Denver, CO 80220 Carr Edward E DC (303)394-2273 825 S Shields St Suite 2 r Fort Collins, CO 80521 Lunnon Raymond L DC (970)224-5005 523-A S Camino Del Rio Crawford Greg L DC Durango, CO 81301 1337 E Prospect Road (970)259.1450 Fort Collins, CO 80525 (976)493-2105 Baer John DC Eakin Avram DC 3765 S Broadway 123 E Drake Rd Englewood, CO 90110 Fort Collins, CO 80525 (303)781-7825 (970)229-0083 Bray Ronald C DC Haas James M DC 3765 S Broadway 1337 E Prospect Road Englewood, CO 80110 Fort Collins, CO 80525 (303)783-0779 (970)493-8360 Burns Paul DC Hand Barry G DC 8200 E Belleview Ave. Ste 205-E 1630 S Lemay Ave Ste 4 Englewood, CO 90111 Fort Collins, CO 90525 (303)694-9759 (970)221-9300 Friedman David E DC Hakgren Glenn DC 9676 E Arapahoe Rd Suite A 3200 S Lemay Ave Englewood, CO 80112 Fort Collins, CO 80525 (303)790-4244 (970)223-1941 Malmgren Michael MD Maker Michael O DC 7030 S Yosemite Suite 220 2601 S Lemay Ave Ste 28 Englewood, CO 80112 Fort Collins, CO 80525 (303)721-9984 (970)223-4422 Morries Larry DC Michie Kevin Jess DC 4275 S Broadway Suite 300-400 3120 Remington St Englewood, CO 80110 Fort Collins, CO 80525 (303)789.2246 (970)226.6996 PD05003.000.1 April. 1998 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 10 L Provider And Vendor Discount Savings The savings from Provider and Vendor Discounts amounted to $406,358 and the details are as follows: Category --------------------- Network --------------------- charged Allowed Savings L Hospital Facility Physician Service 741,987.88 1,139,336.24 588,111.38 896,250.82 153,876.50 243,085.42 Other 66,183.79 56,787.63 9,396.16 TOTALS $1,947,507.91 $1,541,149.83 E406,358.08 -- Non -Network -- Category Charged Hospital Facility 10,047.10 ` Physician Service Other 28,927.93 5,535.83 TOTALS $44,510.86 Overall percentage savings for in -network client charges were 20.9%, and 97.8% of charges were from network providers. Payments By Benefit Category The medical payments by benefit category during this period were: Paid % of PacifiCare LAmount Paid Norm Hospital Expense 762,119 44.0 45.7 Medical Care Pharmacy 275,845 15.9 250,937 14.5 12.1 21.5 Surgery 154,217 8.9 6.2 ` %-Ray 8 Lab Miscellaneous 102,151 5.9 90,777 5.2 6.1 8.7 Anesthesia 85,459 4.9 2.5 Obstetrics 24,935 1.4 1.2 Emergency Care 15,158 0.9 1.5 Vision 10 0.0 0.0 Coordination of Benefits -30,028 -1.7 0.0 L d I. . 101 /2001 - 0612001 CITY OF FORT COLLINS EPO ORS00 Page 11 i IInpatient Utilization The total number of inpatient admissions in this period was 47, and totaled 123 days. Due to the medical management of the HMO Utilization Review program, unnecessary hospital confinements have been eliminated. Because of this, HMO patients admitted to hospitals tend to be sicker, and appear to consume more services and incur longer lengths of stay. However, overall days and admissions per 1000 members are lower than non -HMO experience. Admission statistics Regional Client HMO Total Admissions 47 Total Days 123 Average length of stay 2.6 4.0 Admissions per 1000 members 47 49 Days per 1000 members 124 195 Average admission paid total $7,425 $7,832 Average daily paid $2,837 $1,977 Admission Total Paid Analysis Total Hospital Average $5,993 $7,097 Professional Fees Average $761 $1,049 Other Expense Average $671 $-314 The paid amounts in this section do not reflect any savings from Coordination of Benefits: Admission Type Admissions Days ALOS Ave S/Adm Ave S/Day Medical 10 25 2.5 10,249 4,100 Surgical 14 47 3.4 11,465 3,415 Pregnancy - Normal Delivery 11 24 2.2 3,799 1,741 - Cesarean Section 5 15 3.0 6,632 2,211 - Newborn 6 11 1.8 1,110 605 Mental - Psych 1 1 1.0 4,379 4,379 - Substance Abuse 0 0 0.0 0 0 1 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 12 I ICatastrophic Illness A catastrophic illness is defined as paid amounts in excess of $25,000 to a single individual for a single cause. Catastrophic illnesses totaled $71,173, or 4.1 % of medical claims. This total was incurred by 2 claimants, or 0.0% of the total. The PacifiCare regional norms are about 15.0% of the claims caused by about 0.1 % of the claimants. The average paid per claimant was $35,587. The average PacifiCare catastrophic claim was $61,542. Catastrophic Illness Cases by Diagnostic Category: Average Paid Cause Claimants Days Payment per Claimant Circulatory System 1 7 42,117 42,117 injury 8 Poisoning 1 2 29,056 29,056 Total 2 9 $71,173 $35,587 Catastrophic Illness Cases by Relationship: Average Paid Relationship Claimants Days Payment per Claimant Employees 1 2 29,056 29,056 Spouses 1 7 42,117 42,117 Catastrophic Illness Cases by Age Band: Average Paid Age Band Claimants Days Payment per Claimant 35-49 1 7 42,117 42,117 50-64 1 2 29,056 29,056 1 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Analysis Of Symptoms & Signs Page 13 Symptoms & Signs claims accounted for 12.7% of the payments in this period, and 18.2% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 449 3 106,279 237 Spouses 274 0 59,680 218 Children 201 0 23,887 119 Other 2 0 574 287 Total 926 3 $190,420 $206 Age Band Claimants Days Payment Ave Paid Less than 1 10 0 1,071 107 1-19 171 0 20,383 119 20-34 209 0 45,729 219 35-49 389 3 97,007 249 50-64 142 0 24,124 170 65 and over 5 0 2,105 421 Leading Diagnosis Claimants Days Payment Ave Paid 780 GENERAL SYMPTOMS 123 2 49,465 402 789 ABD/PELVIS SYMPT 1NVOLVI 114 0 31,217 274 V72 EXAMINATION NOS 268 0 30,208 113 786 RESP SYS/OTH CHEST SYMP 141 1 24,846 176 784 HEAD/NECK SYMPT INVOLV 55 0 19,837 361 787 GI SYSTEM SYMPTOMS 30 0 5,952 198 782 SKIN SYMPTOMS 25 0 5,036 201 795 ABN HISTOLOG/IMMUNO FIND 44 0 4,954 113 788 URIN SYS SYMP 30 0 4,301 143 785 CVS 24 0 3,889 162 Admission Type Admits ALOS Ave Paid Ave/Day Medical 1 1.0 7,224 7,224 Surgical 1 2.0 10,013 5,007 Total 2 1.5 8,619 5,746 L 01 /2001 - 06/2001 L CITY OF FORT COLLINS EPO ORS00 L Analysis Of Pregnancy & Childbirth LPregnancy & Childbirth claims accounted for 11.4% of the payments in this period, and 7.8% of the claimants. LAverage Paid Relationship Claimants Days Payment per Claimant LEmployees 87 11 50,635 582 spouses 125 31 83,685 669 Children 182 11 35,943 197 Total 394 53 $170,264 $432 LAge Band Claimants Days Payment Ave Paid Less than 1 34 10 17,193 506 1-19 145 1 18,535 128 20-34 169 41 115,313 682 35-49 43 1 18,766 436 50-64 3 0 457 152 L Ave Paid Leading Diagnosis Claimants Days Payment V20 HEALTH SUPRV INF/CHILD 150 0 22,663 151 L V25 CONTRACEPTIVE MGMT NOS 41 0 13,233 323 644 THREAT ABORT 6 0 12,765 2,127 L V30 SINGLE LIVEBORN 661 OB LABOR ABNORMALITIES 19 6 11 5 12,118 11,816 638 1,969 656 FETAL PROS AFFECTING MGT 16 5 10,419 651 660 LABOR OBSTRUCTED 2 6 10,359 5,179 L 650 OB NORMAL DEL 4 3 9,259 2,315 V22 NORMAL PREGNANCY 44 0 9,003 205 648 OB MOTHER COMPL 5 5 7,123 1,425 LAdmission Type Admits ALOS Ave Paid Ave/Day L Normal Del 11 2.2 3,799 1,741 C-Sections 5 3.0 6,632 2,211 Surgical 1 3.0 6,009 2,003 LNewborn 6 1.8 1,110 605 Total 23 2.3 3,810 1,653 L L Page 14 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 Page 15 1 Analysis Of Skeleton & Muscle System Skeleton & Muscle System claims accounted for 10.8% of the payments in this period, and 8.5% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 236 0 114,035 483 Spouses 131 0 36,764 281 Children 62 0 11,391 184 Total 429 0 $162,190 $378 Age Band Claimants Days Payment Ave Paid 1-19 56 0 9,368 167 20-34 87 0 34,167 393 35-49 192 0 71,191 371 I 50-64 92 0 47,360 515 65 and over 2 0 104 52 ` Leading Diagnosis Claimants Days Payment Ave Paid 724 BACK DISORDER NEC NOS 75 0 26,868 358 722 INTERVERTEBRAL DISC DIS 10 0 23,337 2,334 719 JOINT DISORDER NEC NOS 95 0 20,126 212 726 PERIPH ENTHESOPATHIES 34 0 17,997 529 717 KNEE INT DERANGEMENT 15 0 17,458 1,164 723 CERV RGN DISORDERS OTHER 24 0 10,222 426 735 TOE DEFORM ACQUIRED 9 0 8,987 999 733 BONE/CART DISORDERS OTHE 23 0 7,406 322 729 SOFT TISS DISORDERS OTHE 34 0 6,319 186 728 MUSCLE DISEASE 26 0 5,745 221 I . L 01 /2001 - 06/2001 CITY OF FORT COLLINS EPO ORS00 L Analysis Of Injury & Poisoning CInjury & Poisoning claims accounted for 9.7% of the payments in this period, and 7.2% of the claimants. L L L Average Paid Relationship Claimants Days Payment per Claimant Employees 134 5 89,572 668 Spouses 66 0 19,837 301 Children 168 0 34,989 208 Total 368 5 $144,398 $392 Age Band Claimants Days Payment Ave Paid 1-19 164 0 32,355 197 20-34 61 0 40,335 661 35-49 96 0 20,111 209 50-64 47 5 51,597 1,098 Leading Diagnosis Claimants Days Payment Ave Paid 996 GRAFT REPLACEMENT 9 2 43,241 4,805 844 SPRAIN KNEE 12 0 20,650 1,721 959 INJ OTH UNSPECIFIED 76 0 11,935 157 840 SPRAIN SHOULDER ARM 14 0 10,816 773 873 WND HEAD OTHER 18 0 9,382 521 836 DISL KNEE 6 0 7,731 1,289 813 FX RAD/ULNA 20 0 5,595 280 997 SURG COMPL-BODY SYST NEC 1 3 4,892 4,892 847 SPRAIN BACK 32 0 4,685 146 845 SPRAIN OF ANKLE FOOT 22 0 3,078 140 Admission Type Admits ALOS Ave Paid Ave/Day Medical 1 3.0 4,892 1,631 Surgical 1 2.0 29,886 14,943 Total 2 2.5 17,389 6,956 Page 16 CITY OF FORT COLLINS EPO COMPANY NUMBER ORS00 01 /01 /2000 - 06/30/2000 HMO MEDICAL EXPERIENCE Contents 1 Introduction . . . . . . . . . . . . . . . . . . . 1 2 Explanation Of Terms . . . . . . . . . . . . . . . 2 3 Overview . . . . . . . . . . . . . . . . . . . . . 3 4 Membership Demographics . . . . . . . . . . . . . . 4 5 Member Relationship Analysis . . . . . . . . . . . 5 6 Member Age Analysis . . . . . . . . . . . . . . . . 6 7 Paid Claims By Cause . . . . . . . . . . . . . . . 7 8 Provider Information . . . . . . . . . . . . . . . 8 9 Non -Hospital Provider Information . . . . . . . . . 9 10 Provider And vendor Discount Savings . . . . . . 10 11 Payments By Benefit Category . . . . . . . . . . 10 12 Inpatient Utilization . . . . . . . . . . . . . . 11 13 Catastrophic Illness . . . . . . . . . . . . . . 12 14 Analysis Of Skeleton & Muscle System . . . . . . 13 15 Analysis Of Respiratory System . . . . . . . . . 14 16 Analysis Of Symptoms & Signs . . . . . . . . . . 15 17 Analysis Of Pregnancy & Childbirth . . . . . . . 16 L L L L L L 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Introduction PacifiCare is pleased to provide you with this comprehensive reporting package which focuses on your HMO coverage. The intent is to provide an array of reports which help to explain the impact of our medical management services. Under the HMO, medical benefits are paid for in two ways: ■ Capitation - a method of pre -paying for designated medical services. L■ Negotiated fee arrangements - providers are reimbursed a specific fee for a given medical service. These are referred to as "Paid Claims" throughout this document. L This reporting package analyzes total medical payments (claims plus capitation) for your members. The package then provides a detailed analysis of the services provided under fee arrangements ("Paid Claims"). Overall, 98% of your HMO expenses were paid claims. LAt PacifiCare, we turn data into useful information to assist you in making informed decisions about your benefit plan. L L L L L L 1! 11 Page 1 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 L LExplanation Of Terms L■ Members - All eligible persons, including employees and their covered dependents, spouses, and retirees. L L L L L L L L L L L L L L Page 2 ■ PMPM - Per Member, Per Month. A monthly expense per member is calculated by dividing total expenses by cumulative member months. ■ Days - The number of inpatient days. ■ ALOS - Average Length of Stay. ■ Days per 1000 and Admissions per 1000 - The number of days/admissions per 1000 covered members. These indicies are HMO standards for measuring utilization. ■ ICD-9 Code - International coding scheme used to reflect physician diagnosis (International Classification of Diseases, 9th Revision). ■ Cause - Groupings of diagnostic categories (ICD-9 codes) which identify bodily systems. ■ Claimants - Members with referral claims that were not covered through capitated HMO services. ■ Admits - Number of admissions to an inpatient healthcare facility. Miller Vernon K DC 3120 Remington St Fort Collins. CO 80525 (970)223-9993 Moline Larry D DC 220 West Prospect Road Suite B Fort Collins. CO 80526 (970)482-7736 Rosoff Susan DC 333 West Drake Rd Suite 22 Fort Collins, CO 80526 (970)229-0102 Schlee Bruce DC 429 S Howes Street Fort Collins, CO 80521 (970)493-4012 Scott Mark DC 2190 West Drake D-4 Fort Collins, CO 80526 (970)482-9565 Wenbor8 Craig DC 373 West Drake Rd Fort Collins, CO 90526 Cembalisty Christopher E DC 1916 N 12th Street Grand Junction, CO 80501 (970)241-11" Hansen David J DC 2829 North Avenue Ste 104 Grand Junction, CO 81504 (970)242-8162 Sparrow Robert DC rneips Arcnur i w 1800 Colorado Blvd Suite 6 1296 Wadsworth Blvd Idaho Springs, CO 80452 Lakewood. CO 80215 (303)567-9211 (303)233-5656 V Phelps James M DC Karney Jerrilea DC 1296 Wadsworth Blvd 12 E 10th Street Lakewood. CO 80215 La Junta, CO 81050 (303)233-5656 Spatafora John A. DC (719)384-8039 Sanders Jay D DC 1916 N 12th Street == "A 7610 W Sth Ave Suite 102 Grand Junction, CO 81501 Aspegren Donald D DC Lakewood. CO 90226 (970)241-1199 11220 Colfax St (303)232-1178 nJ Lakewood, CO 80215 Bauer R,ichard DC (303)232-0588 1502 9th Ave Borman Bonnie DC Greeley, CO 80631 11220 W Colfax Ave (970)3524212 Lakewood, CO 80219 Durr Jeffrey D DC (303)232-1232 1008 8th Street Eckes Sue DC Greeley, CO 90631 8064 W Jewell Ave Suite 101 (970)356-3203 Lakewood, CO 80232 Gieters Robert J DC 2403 27th Street (970)226-5797 Greeley, CO 80631 (970)330-2171 Kremer Reiner DC Smith Craig A DC 7601 E Burning Tree Drive Suite 200 801 l lth Ave Franktown, CO 90116 Greeley, CO 80631 (303)688-1111 (970)352-7676 Smith Scott DC (303)980.4600 Haley Thomas C DC 1296 Wadsworth Blvd Lakewood, CO 90215 (303)233-3505 Hardinger Philip N DC 7625 W Hampden Suite 3 Lakewood CO 90227 (303)988-4499 Peltzmaa Steven M DC 801 I lt6 Avenue Hilbraeht Robert A DC 1429 Grand Ave Greeley, CO SN31 25 Sheridan Blvd Glenwood Springs, CO 80601 (970)352-7676 Lakewood, CO 80226 (970)945-8466 Vandergon Dean R DC (303)233-5050 _ 3624 W 10th St Holm Lewis M DC Bergeron Richard A DC erg Oraky. CO 80634 7596 W Jewell Ave Suite 302 Arapahoe (970)333-2101 Lakewood, CO 80232 Golden, CO 80401 v (303)980-1271 (303)278-1550 Fleldman Jansen H DC Knowles Roger DC 5934 S Holly Strw 12792 W Alameda Pkwy Suite E ` Brady Timothy DC Greenwood Village, CO 80111 Lakewood CO 80228 2829 North Avenue Ste 104 (303)770.4424 (303)988-8823 Grand Junction CO 81504 (970)242-8162 Miler Robert W DC 1614 Carr St Lakewood CO 80215 (303)237-6582 Warner Garry DC 10815-P West Jewell Ave Lakewood. CO 80232 (303)980.1378 Wolff Mark M DC 192 S Union Blvd Lakewood, CO 80228 (303)986-5122 Crow John N DC 700 S Main PO Box 968 Lamar, CO 81052 (719)336-7598 Carmichael Joel DC 5161 E Arapahoe Rd Suite 240 Littleton, CO 80122 (303)934-2225 Dixon John R DC 2606 W Alamo Ave Littleton, CO 80120 (303)798.9424 Eslaminia All DC 7325 S Pierce Street Suite 101 Littleton, CO 80123 (303)904-4049 Funk Gregory DC ISl W Mineral Ave Suite 105 Littleton, CO 80120 (303)730.7445 Graves Keith D DC 151 W Mineral Ave Suite 105 Littleton. CO 80120 (303)730.7445 April, 1998 PD05003.000-1 L 01 /2000 - 06/2000 L LOverview CITY OF FORT COLLINS EPO ORS00 ■ This analysis contains paid claims and capitation expenses. L■ The total expenses were $1,195,409. ■ The total capitation expenses were $20,539, which covered these types of services: L- MENTAL HEALTH Page 3 L OTHER RADIOLOGY L■ Medical paid claims totaled $1,174,736. Of this amount, Employees accounted for $543,484. Spouses accounted for $388,700. Children accounted for $242,433. And others accounted for $253. 1, - Claims associated with inpatient admissions were $240,661 (20%) Outpatient care expenses were $724,727 (62%). Pharmacy expenses were $209,348 (18%). ■ Dental paid claims totaled $133. L ■ There were a total savings resulting from Coordination of Benefits of $509. These savings were not reflected in the paid amounts of this report where the data is categorized by benefit category or ` specific CPT4 codes. L■ There were a total of 43 inpatient admissions to healthcare facilities, totaling 97 days. LThe period covered was January 1, 2000 through June 30, 2000 and only claims and capitation paid in that period were considered. This report was processed on August 17, 2001. L L [1 L 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 L LMembership Demographics LMembers by Relationship and Age Bands: { LLess Age Band than 1 1-19 L 20-34 35-49 50-64 L65 and over Total LMembers by Sex and Age Bands: Employee spouse Children Total 0 0 21 21 1 0 676 677 223 ill 50 383 384 211 1 595 134 78 0 212 2 2 0 4 744 401 749 1,893 LAgeBand Females: Less than 1 L 1-19 20-34 35-49 L 50-6464 65 and over LTotal Females Males: Less than 1 L 1-19 20-34 L 35-49 64 50-64 65 and over LTotal Males overall L L L Percent Members of Total 11 0.6% 356 18.8% 199 10.5% 299 15.8% 89 4.7% 1 0.1% 954 50.4% 11 0.6% 321 17.0% 184 9.7% 297 15.7% 123 6.5% 3 0.2% 939 49.6% 1,893 100.0% Page 4 c 01,2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 PAID CLAIMS AND CAPITATION ` Member Relationship Analysis ` The distribution of medical expense (including capitation) by Relationship (Employee active or retired, Spouse, and Children) compared to PacifiCare experience was: LEmployees Spouses Children PacifiCare Regional Norms 53% 25% 22% LClient 46% 33% 21% tEmployees Spouses Children Total ■ Total Expenses: LCapitation Paid $5,347 $1,898 $13,294 $20,539 Claims Paid $543,484 $388,700 $242,433 $1,174,736 ------------------------------------------------------------ Total Expense $548,831 $390,599 $255,727 $1,195,276 LMember Averages: Average Members 744 401 749 1,893 LAvg. PMPM Expense $122.95 $162.41 $56.94 $105.22 Inpatient Experience: Inpatient Admissions 16 13 14 43 Inpatient Days 43 30 24 97 LAdmits per 1000 Members 43 65 37 45 (Annualized) Days per 1000 Members 116 150 64 102 L L L f (Annualized) Page 5 L L L L L L L L L L L L L L L L L 0112000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Member Age Analysis This analysis looks at the ages of the members and claimants. The ages were calculated as of the end of the period, so only a single age is assumed for the entire period. Average Age by Relationship: Relationship Average Claimant Age Average Member Age Employee 43.0 years old 40.5 years old Spouses 43.1 years old 41.1 years old Children 11.5 years old 10.8 years old Average Age 34.7 years old 28.9 years old The regional average claimant age for PacifiCare is approximately 42.1 years old. Experience by Sex and Age Bands: Paid Capitation Combined AgeBand Members claims Total PMPM Females: Less than 1 11 10,868 180 175.36 1-19 356 114,662 6,248 56.55 20-34 199 141,144 2,622 120.41 35-49 299 265,365 -267 148.02 50-64 89 108,017 1,610 205.29 65 and over 1 707 19 120.95 Total Females 954 $640,763 $10,413 $113.72 Males: Less than 1 11 9,754 205 153.22 1-19 321 95,832 6,057 52.90 20-34 184 59,635 809 54.65 35-49 297 237,240 1,392 134.06 50-64 123 129,521 1,596 177.67 65 and over 3 2,125 67 109.57 Total Males 939 $534,107 $10,127 $96.58 Overall 1,894 $1,174,869 $20,539 $105.22 Page 6 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page 7 PAID CLAIMS ONLY (NO CAPITATION) ` Paid Claims By Cause The following table illustrates the paid claims by Cause (ICD-9 grouping). Here the claimant count increases to show the claimants by ICD-9 codes. Paid Claims (both inpatient and outpatient, excluding pharmacy) for this period were as follows: Paid % of % of Cause Claims Paid Days Days Claimants Skeleton & Muscle System 110,086 11.4 0 0.0 367 Respiratory System 106,200 11.0 16 16.5 725 Symptoms & Signs 102,811 10.6 3 3.1 725 Pregnancy & Childbirth 91,790 9.5 39 40.2 280 Circulatory System 75,757 7.8 6 6.2 101 Genitourinary System 71,236 7.4 8 8.2 242 Tumors 71,001 7.4 10 10.3 219 Digestive System 70,102 7.3 9 9.3 106 Injury & Poisoning 67,711 7.0 0 0.0 341 Glands & Metabolism 64,795 6.7 0 0.0 155 All others/Supplementary 46,868 4.9 0 0.0 193 Nervous Sys/Sense Organs 6 40,324 4.2 0 0.0 199 Infections & Parasitic 15,512 1.6 0 0.0 239 Skin & Skin Related 11,984 1.2 0 0.0 153 Mental & Substance Abuse 7,790 0.8 2 2.1 44 Birth Defects 6,051 0.6 0 0.0 14 Perinatal Conditions 4,321 0.4 4 4.1 9 Blood Related 1,181 0.1 0 0.0 12 Total $965,388 97 4,124 The leading individual (medical) ICD-9 diagnoses were: Paid % of % of ICD-9 Diagnosis Claims Paid Days Days Claimants 414 ISCHEMIC HRT DISCHRON 28,386 2.9 2 2.1 a 410 MYOCARD INFARCTION AC 24,665 2.6 3 3.1 4 162 CA RESP 23,346 2.4 4 4.1 5 V53 ADJUSTMNT DEVICE NEC/ 21,182 2.2 0 0.0 1 V72 EXAMINATION NOS 21,055 2.2 0 0.0 217 512 PNEUMOTHORAX 20,906 2.2 14 14.4 1 253 PITUITARY/HYPOTHALM D 20,147 2.1 0 0.0 3 575 GALLBLADDER DISORDERS 18,069 1.9 3 3.1 4 625 F GENIT PAIN & OTHER 17,617 1.8 4 4.1 30 473 CHRONIC SINUSITIS L 17,220 1.8 0 0.0 110 ! • . ■ 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO 0RS00 Page 8 L LProvider Information LClaim payments went to the following recipients: Paid % of L Claims Paid Paid to Non -Hospital Providers $650,396 55.4 Paid Directly to Hospitals $524,405 44.6 Paid to Insured $68 0.0 The leading hospital providers for this time frame were: (" denotes a PacifiCare Preferred or Network Provider) Paid LProvider Name City State Days Claims *POUDRE VALLEY HEALTH CARE -OP FORT COLLINS CO 2 244,954 *POUDRE VALLEY HEALTH CARE-IP FORT COLLINS CO 82 149,081 L *MEMORIAL HOSPITAL-OP-PREAUTH COLORADO SPRING CO 0 21,182 WYOMING MEDICAL CENTER-IP CASPER NY 3 19,467 *ORTHOPAEDIC CTR OF THE RKS-OP FORT COLLINS CO 0 19,143 *MCKEE MEDICAL CENTER -OP LOVELAND CO 0 15,673 L *MCKEE MEDICAL CENTER-IP LOVELAND CO 5 14,553 *LONGMONT UNITED HOSPITAL-IP LONGMONT CO 0 6,272 *SURGERY CENTER OF FORT COLLIN FORT COLLINS CO 0 5,479 L *EYE SURGERY CNT OF NC -OP- FORT COLLINS CO 0 4,520 *MOUNTAIN VIEW SURGERY CTR LOVELAND CO 0 4,083 *SPRING CREEK SURGERY CTR-OP FORT COLLINS CO 0 4,074 L *NORTH CO MEDICAL CENTER - OP GREELEY CO 0 4,035 CONVERSE COUNTY MEN HOSP OP DOUGLAS WY 0 3,016 *BOULDER COMM HOSP-INPATIENT BOULDER CO 2 1,786 *AURORA MED CTR COLUMBIA OP AURORA CO 0 1,649 L *BOULDER COMM HOSP-OUTPATIENT BOULDER CO 0 1,266 *CONSULT IN GASTROINTIST.-OP- FORT COLLINS CO 0 950 *CHILDREN'S HOSP-INPATIENT DENVER CO 3 895 L *CHILDREN'S HOSP-OUTPATIENT DENVER CO 0 795 *MERCY MEDICAL CENTER OR DURANGO CO 0 547 ST MARYS HOSP 8 MED CTR O/P GRAND JUNCTION CO 0 381 L MISSION HOSPITAL REGIONAL-IP- MISSION VIEJO CA 0 259 ST ELIZABETH HOSPITAL-IP DALLAS TX 0 183 MAYO CLINIC AR120NA PHOENIX AZ 0 111 L L L 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page s L LNon -Hospital Provider Information L The leading non -hospital providers were: Paid Provider Name City State Days Claims L*NEIGHBORCARE PHARMACY SERVS LOVELAND CO 0 28,283 *FT COLLINS RADIOLOGIC ASSOC FORT COLLINS CO 0 20,012 *JEROME SMITH MD FORT COLLINS CO 0 11,875 L *STEVEN BROMAN MD FORT COLLINS CO 0 10,239 *HEALTHCARE DELIVERY SYSTEMS CHICAGO IL 0 9,794 *THOMAS NEVRiVY MD FORT COLLINS CO 0 9,658 NEIGHBORCARE PHARMACY SERVS LOVELAND CO 0 8,489 *LANDMARK CHIRO IPA OF CO INC SACRAMENTO CA 0 7,666 *EMERGENCY PHYS OF FT COLLINS FORT COLLINS CO 0 7,377 *MARK ROTMAN MD FORT COLLINS CO 0 7,309 L *ROBERT MARSCHKE JR MD FORT COLLINS CO 0 6,218 *GARTH NELSON MD FORT COLLINS CO 0 6,039 L *ROCCI TRUMPER MD *SUSAN Ko2AK MD FORT COLLINS FORT COLLINS CO CO 0 0 5,981 5,878 *CHRISTOPHER ERIKSEN MD FORT COLLINS CO 0 5,844 The leading Pharmacy providers were: Paid Provider Name City State Days Claims *KING SOOPERS PHARMACY #9 FT COLLINS Co 0 27,155 *LONGS DRUG STORE 226 FT COLLINS CO 0 19,662 *PRESCRIPTION SOLUTIONS M SAN DIEGO CA 0 18,796 *KING SOOPERS PHARMACY #18 FT COLLINS CO 0 17,380 *WALGREEN DRUG STORE 01245 FT COLLINS CO 0 13,257 *KING SOOPERS PHARMACY 73 FORT COLLINS CO 0 12,916 *ALBERTSONS PHARMACY 8814 FORT COLLINS CO 0 9,025 *STEELE'S PHARMACY 1 FORT COLLINS CO 0 8,684 *KING SOOPERS PHARMACY 44 LOVELAND CO 0 7,436 *SAFEWAY PHARMACY 1552 FORT COLLINS CO 0 6,440 *SPRING CREEK PHARMACY FT COLLINS CO 0 6,134 *ALBERTSONS PHARMACY 804 LOVELAND CO 0 6,090 *SAFEWAY PHARMACY 107 1071 FT COLLINS CO 0 4,760 *STEELE'S PHARMACY 3 FORT COLLINS CO 0 4,484 *ALBERTSONS PHARMACY 8918 FT COLLINS CO 0 4,353 L . 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 L Provider And Vendor Discount Savings Page 10 LThe savings from Provider and Vendor Discounts amounted to $231,385 and the details are as follows: Category --------------------- Charged Network --------------------- Allowed Savings L Hospital Facility Physician Service 409,822.37 664,598.49 337,777.42 528,326.70 72,044.95 136,271.79 Other 118,183.06 95,114.81 23,068.25 LTOTALS $1,192,603.92 $961,218.93 $231,384.99 -- Non -Network -- LCategory Hospital Facility Charged 23,435.42 Physician Service 30,292.16 LOther 3,193.00 TOTALS $56,920.58 LOverall percentage savings for in -network client charges were 19.4%, and 95.4% of charges were from network providers. L Payments By Benefit Category LThe medical payments by benefit category during this period were: Paid % of PacifiCare LAmount Hospital Expense Paid 486,072 41.4 Norm 46.0 Pharmacy Medical Care 235,973 20.1 174,681 14.9 29.5 10.0 Miscellaneous 108,095 9.2 6.9 Surgery 70,088 6.0 4.5 X-Ray 8 Lab 50,925 4.3 4.1 Anesthesia 23,412 2.0 2.0 Obstetrics 16,390 1.4 0.9 Emergency Care Dental 9,609 0.8 133 0.0 1.7 0.0 Coordination of Benefits -509 -0.0 0.0 L L L 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page 11 L LInpatient Utilization LThe total number of inpatient admissions in this period was 43, and totaled 97 days. Due to the medical management of the HMO Utilization Review program, unnecessary hospital confinements have been eliminated. Because of this, HMO patients admitted to hospitals tend to be ` sicker, and appear to consume more services and incur longer lengths of stay. However, overall days and admissions per 1000 members are lower than non -HMO experience. L Admission Statistics Regional LClient HMO Total Admissions 43 Total Days 97 L Average length of stay 2.3 4.0 Admissions per 1000 members 45 36 L Days per 1000 members 102 147 Average admission paid total $5,334 $6,582 LAverage daily paid $2,364 $1,629 LAdmission Total Paid Analysis Total Hospital Average $4,351 56,344 Professional Fees Average S374 S586 1 Other Expense Average $609 5-348 ` The paid amounts in this section do not reflect any savings from Coordination of Benefits: LAdmission Type Medical L Surgical Pregnancy - Normal Delivery - Cesarean Section - Newborn Mental - Psych - Substance Abuse L L Admissions Days ALOS Ave S/Adm Ave S/Day 10 26 2.6 9,327 3,587 8 28 3.5 9,824 2,807 11 20 1.8 3,522 1,937 1 2 2.0 3,635 1,818 12 19 1.6 898 567 1 2 2.0 4,341 2,171 0 0 0.0 0 0 L01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page 12 L LCatastrophic Illness LA catastrophic illness is defined as paid amounts in excess of $25,000 to a single individual for a single cause. illnesses totaled $90,684, or 7.7% of medical claims. This total was incurred by 3 LCatastrophic 0.1 % the total. The PacifiCare regional norms are about 14.0% of the claims caused by claimants, or of about 0.0% of the claimants. The average paid per claimant was $30,228. The average PacifiCare Lcatastrophic claim was $61,719. Catastrophic Illness Cases by Diagnostic Category: Average Paid LCause Claimants Days Payment per claimant Circulatory System 2 5 53,802 26,901 LGlands 8 Metabolism 1 0 36,882 36,882 Total 3 5 $90,684 $30,228 ` Catastrophic Illness Cases by Relationship: Average Paid Relationship Claimants Days Payment per Claimant LSpouses 2 5 53,802 26,901 1 0 36,882 36,882 Children L Catastrophic Illness Cases by Age Band: Average Paid Age Band Claimants Days Payment per Claimant L 1-19 1 0 36,882 36,882 35-49 2 5 53,802 26,901 L L L L L L Johnson Kent L DC Bunker Lane P DC Bondarovich James DC Biby David G DC 9644 W Arlington 1322 Vivian Street 1017 S Boulder Road Suite A 29145 Highway 50 East Littleton, CO 80123 Longmont, CO 80501 Louisville. CO 80027 Pueblo, CO 81006 (303)932-9411 (303)651-7057 (303)666-7717 (719)948-2606 Kannegieter Curtis R DC Clancey Douglas A DC Scott John M DC Bowlin Damon H DC 89 W Littleton Blvd Suite B 195 S Main Suite 1 1017 S Boulder Road Suite A 908 Highway 50 West Littleton, CO 80120 Longmont, CO 80501 Louisville, CO 80027 Pueblo. CO 81008 (303)730-2414 (303)651-2060 (303)666-7717 (719)544-7744 Miller Paul DC 1080 W Connelly Che C DC Carter Wayne DC Littleton Blvd Suite A 700 Ken Pratt Blvd Suite 202 Rands Kerry L DC 1861 S Pueblo Blvd Littleton, CO 80120 Longmont, CO 80501 1717 Madison Ave Suite I Pueblo, CO 81005 (303)347-9906 (303)776-5535 Loveland, CO 80538 (719)566-1703 Nelson Cathlynn E DC Dobbins Carolyn A DC (970)667-7159 Cody Jennifer DC 5161 E Arapahoe Rd Suite 2I0 2255 Mountain View Ave Shorts Bruce DC 1507 Moore Ave Littleton, CO 80122 Longmont, CO 80501 1047 N Lincoln Ave Pueblo, CO 81005 (303)694-4515 (303)772-7760 Loveland, CO 80537 (719)560-0851 Norris William R DC Fritz Thomas DC (970)667-4062 Dressen Donald DC 7937 S Broadway 420 21 Ave Suite 102 Whittemore Lee A DC 725 Desert Flower Blvd B Littleton, CO 80122 Lon ont, CO 80501 � 2114 N Lincoln Ave Suite 202 Pueblo, CO 81001 (303)797-2122 (303)772-3982 Loveland, CO 80538 (719)544-5545 O'Hollearn Thomas DC James Thomas D DC (970)667-3393 Graham Robert J DC 5066 S Wadsworth Blvd Ste 103 Littleton, 700 Ken Pratt Blvd Suite 122 301 Colorado Ave CO 80123 Longmont, CO 80501 Roush William DC Pueblo, CO 81004 (303)972-0800 (303)651-7003 301 Colorado Ave (719)542-1399 Pederson Nancy L DC Masteller Robert M DC Mesa, CO 81004 Hendren Michael D DC 4 West Dry Creek Circle Suite 150 1750 Mountain View Ave (719)542-1399 3023 W Northern Ave Littleton, CO 80120 Longmont, CO 80501 Welch Tano E DC Pueblo, CO 81005 (303)730-7575 (303)772-9600 635 W Corona Ave Ste101 (719)564-0461 Portenier Kevin DC Starkly Wesley E DC Mesa, CO 91004 Hiatt Alan DC 5066 S Wadsworth Blvd Ste 103 2051 Terry Suite B (719)542-31 l6 1507 Moore Ave Littleton, CO 80123 (303)972-0800 Longmont, CO 80501 ■® Pueblo, CO 81005 (303)651-2525 Ogden Jimmie N DC (719)364-2273 Tankersley Craig E DC Summey Stephen DC 10791 N Washington Street Lowrance Vicky J DC 9200 W Cross Drive Suite 512 421 21st Ave Suite 2 Northglenn, CO 80233 2025 Norwood Ave Suite A Littleton, CO 90123 Longmont, CO 80501 (303)280-2225 Pueblo, CO 81001 (303)904-0722 (303)776.2939 Santilli Paul DC (719)544-7737 Wise Michael DC -� 12001 Tejon Street Suite 124 Mooring Steven 151 W Mineral Ave Suite 103 Awn Pad D DC Northglenn, CO $0234 R DC 214 Colorado Ave Littleton, CO 90120 362 S McCaslin Blvd (303)254-8700 Pueblo, CO 81004 (303)730-7445 Louisville, CO 90027 (719)544-1085 - (303)665-5405 Bellah Stephanie DC Peterson III Walter O DC Brisson Douglas DC Bammer Phillip L DC 824 W Abriendo Ave 214 Colorado Ave 639 Ken Pratt Blvd 800 Jefferson Ave Suite A Pueblo, CO 81004 Pueblo, CO 81004 Longmont, CO 80501 Louisville, CO 80027 (719)543-2273 (719)544-1085 (303)678-8489 (303)666-5151 PD05003.000-1 S April, 1999 L 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page 13 1 ` Analysis Of Skeleton & Muscle System LSkeleton & Muscle System claims accounted for 11.4% of the payments in this period, and 8.9% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 180 0 73,899 411 Spouses 115 0 22,992 200 Children 70 0 13,125 188 Other 2 0 70 35 Total 367 0 $110,086 S300 Age Band Claimants Days Payment Ave Paid 1-19 62 0 10,525 170 20-34 86 0 25,798 300 327 35-49 154 0 50,409 50-64 64 0 23,304 364 65 and over 1 0 50 50 Leading Diagnosis Claimants Days Payment Ave Paid I♦ 719 JOINT DISORDER NEC NOS 92 0 17,011 185 726 PERIPH ENTHESOPATHIES 29 0 16,475 568 724 BACK DISORDER NEC NOS 53 0 14,755 278 718 DERANGE JNT OTHER 9 0 13,646 1,516 e 722 INTERVERTEBRAL DISC DIS 11 0 9,478 862 728 MUSCLE DISEASE 21 0 6,711 320 735 TOE DEFORM ACQUIRED 4 0 6,511 1,628 . 733 BONE/CART DISORDERS OTHE 17 0 5,417 319 727 TENDON/BURSA DIS 13 0 3,718 286 721 SPONDYLOSIS ET AL 2 0 3,409 1,704 8 I.. 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 b Analysis Of Respiratory System Respiratory System claims accounted for 11.0% of the payments in this period, and 17.6% of the claimants. Relationship Average Paid Claimants Days Payment per Claimant Employees 226 14 50,134 222 Spouses 108 2 12,917 120 Children 391 0 43,150 110 Total 725 16 $1O6,2O0 $146 Age Band Claimants Days Payment Ave Paid Less than 1 11 0 656 60 1-19 372 0 41,851 113 20-34 126 0 19,898 158 35-49 156 0 13,219 85 50-64 60 16 30,576 510 Leading Diagnosis Claimants Days Payment Ave Paid 512 PNEUMOTHORAX 1 14 20,906 20,906 473 CHRONIC SINUSITIS 110 0 17,220 157 477 ALLERGIC RHINITIS 59 0 13,308 226 474 CHR T/A DISEASE 18 0 10,783 599 465 AC URI MULT SITES/NOS 135 0 7,914 59 462 AC PHARYNGITIS 150 0 6,881 46 478 OTH UPPR RESPIRATORY DIS 14 0 5,327 380 486 PNEUMONIA, ORGANISM NOS 7 2 4,791 684 493 ASTHMA 26 0 3,555 137 466 AC BRONCHITIS/BRONCHIOL 54 0 3,145 58 Admission Type Admits ALOS Ave Paid Ave/Day Medical 1 2.0 3,394 1,697 Surgical 1 14.0 22,300 1,593 Total 2 8.0 12,847 1,606 Page 14 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO ORS00 Page 15 Analysis Of Symptoms & Signs ` Symptoms & signs claims accounted for 10.6% of the payments in this period, and 17.6% of the claimants. ` Average Paid Relationship Claimants Days Payment per Claimant ` Employees 327 0 50,199 154 Spouses 219 0 37,217 170 Children 179 3 15,395 86 Total 725 3 $102,811 $142 Age Band Claimants Days Payment Ave Paid Less than 1 14 0 531 38 1-19 159 3 14,205 89 20-34 164 0 28,633 175 35-49 284 0 44,608 157 50-64 100 0 14,162 142 L 65 and over 4 0 672 168 Leading Diagnosis Claimants Days Payment Ave Paid ` V72 EXAMINATION NOS 217 0 21,055 97 786 RESP SYS/OTH CHEST SYMP 122 0 16,531 136 789 ABD/PELVIS SYMPT INVOLVI 81 0 16,190 200 780 GENERAL SYMPTOMS 82 0 13,101 160 784 HEAD/NECK SYMPT INVOLV 46 0 12,944 281 788 URIN SYS SYMP 27 0 4,278 158 782 SKIN SYMPTOMS 21 0 0 3,502 3,482 167 129 795 ABN HISTOLOG/IMMUNO FIND 27 785 CVS 10 0 2,116 212 L787 GI SYSTEM SYMPTOMS 22 0 1,910 87 Admission Type Admits ALOS Ave Paid Ave/Day Medical 1 3.0 895 298 ` Total 1 3.0 895 298 I - . 1 01 /2000 - 06/2000 CITY OF FORT COLLINS EPO 0RS00 I Analysis Of Pregnancy & Childbirth Pregnancy & Childbirth claims accounted for 9.5% of the payments in this period, and 6.8% of the claimants. L 6 6 Average Paid Relationship Claimants Days Payment per Claimant Employees 71 14 34,041 479 Spouses 57 8 32,189 565 Children 152 17 25,560 168 Total 280 39 $91,790 $328 Age Band Claimants Days Payment Ave Paid Less than 1 36 16 13,391 372 1-19 115 1 12,064 105 20-34 79 12 37,917 480 35-49 49 10 27,990 571 50-64 1 0 429 429 Leading Diagnosis Claimants Days Payment Ave Paid V20 HEALTH SUPRV INF/CHILD 129 0 14,828 115 664 PERINEAL TRAUM W DELIVER 4 9 11,446 2,862 V30 SINGLE LIVEBORN 17 17 10,210 601 650 OB NORMAL DEL 7 2 7,964 1,138 642 OB COMP HYPER 4 4 7,654 1,914 634 ABORT SPONTANEOUS 10 0 7,073 707 661 OB LABOR ABNORMALITIES 3 2 4,780 1,593 V22 NORMAL PREGNANCY 26 0 4,579 176 V25 CONTRACEPTIVE MGMT NOS 27 0 3,778 140 654 ABN PELVIC ORGAN IN PREG 1 2 3,635 3,635 Admission Type Admits ALOS Ave Paid Ave/Day Normal Del 11 1.8 3,522 1,937 C-sections 1 2.0 3,635 1,818 Newborn 11 1.5 897 581 Total 23 1.7 2,272 1,340 Page 16 l l L L L L L L L L L L L L L L L L PacifiCare CITY OF FORT COLLINS POS COMPANY NUMBER ORS00 01 /01 /2001 - 06/30/2001 HMO MEDICAL EXPERIENCE Contents 1 Introduction . . . . . . . . . . . . . . . . . . . 1 2 Explanation Of Terms . . . . . . . . . . . . . . . 2 3 Overview . . . . . . . . . . . . . . . . . . . . . 3 4 Membership Demographics . . . . . . . . . . . . . . 4 5 Member Relationship Analysis . . . . . . . . . . . 5 6 Member Age Analysis . . . . . . . . . . . . . . . . 6 7 Paid Claims By Cause . . . . . . . . . . . . . . . 7 8 Provider Information . . . . . . . . . . . . . . . 8 9 Non -Hospital Provider Information . . . . . . . . . 9 10 Provider And Vendor Discount Savings . . . . . . 10 11 Payments By Benefit Category . . . . . . . . . . 10 12 Inpatient Utilization . . . . . . . . . . . . . . 11 13 Catastrophic Illness . . . . . . . . . . . . . . 12 14 Analysis Of Injury & Poisoning . . . . . . . . . 13 15 Analysis Of Symptoms & Signs . . . . . . . . . . 14 16 Analysis Of Skeleton & Muscle System . . . . . . 15 17 Analysis Of Digestive System . . . . . . . . . . 16 18 Analysis Of Respiratory System . . . . . . . . . 17 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 1 LIntroduction PacifiCare is pleased to provide you with this comprehensive reporting package which focuses on your HMO coverage. The intent is to provide an array of reports which help to explain the impact of our medical management services. ■ Under the HMO, medical benefits are paid for in two ways: ■ Capitation - a method of pre -paying for designated medical services. ■ ■ Negotiated fee arrangements - providers are reimbursed a specific fee for a given medical service. These are referred to as "Paid Claims" throughout this document. L This reporting package analyzes total medical payments (claims plus capitation) for your members. The package then provides a detailed analysis of the services provided under fee arrangements ("Paid Claims"). Overall, 99% of your HMO expenses were paid claims. ■ At PacifiCare, we turn data into useful information to assist you in making informed decisions about your benefit plan. L ■ ■ ■ ■ ■ ■ L L L L 01 /2001 - 06/2001 L L L L L L L L L L L L L L L L Explanation Of Terms CITY OF FORT COLLINS POS ORS00 ■ Members - All eligible persons, including employees and their covered dependents, spouses, and retirees. Page 2 ■ PMPM - Per Member, Per Month. A monthly expense per member is calculated by dividing total expenses by cumulative member months. ■ Days - The number of inpatient days. ■ ALOS - Average Length of Stay. ■ Days per 1000 and Admissions per 1000 - The number of days/admissions per 1000 covered members. These indicies are HMO standards for measuring utilization. ■ ICD-9 Code - International coding scheme used to reflect physician diagnosis (International Classification of Diseases, 9th Revision). ■ Cause - Groupings of diagnostic categories (ICD-9 codes) which identify bodily systems. ■ Claimants - Members with referral claims that were not covered through capitated HMO services. ■ Admits - Number of admissions to an inpatient healthcare facility. 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 3 L LOverview L■ This analysis contains paid claims and capitation expenses. L■ The total expenses were $227,884. ■ The total capitation expenses were $2,973, which covered these types of services: L- OTHER L■ Medical paid claims totaled $224,911. Of this amount, Employees accounted for $101,394. Spouses accounted for $84,174. Children accounted for $39,343. L- Claims associated with inpatient admissions were $55,478 (25%) Outpatient care expenses were $138,509 (62%). L- Pharmacy expenses were $30,924 (14%). L■ There were a total of 7 inpatient admissions to healthcare facilities, totaling 26 days. LThe period covered was Janyary 1, 2001 through June 30, 2001 and only claims and capitation paid in that period were considered. This report was processed on August 16, 2001. L L L L L L ■ L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 4 LMembership Demographics LMembers by Relationship and Age Bands: LAge Band Employee Spouse Children Total Less than 1 0 0 2 2 1-19 0 1 100 101 20-34 19 17 10 45 35-49 62 27 0 88 50-64 29 10 0 38 65 and over 1 1 0 2 Total 110 55 112 277 LMembers by Sex and Age Bands: LAgeBand Members Percent of Total Females: L Less than 1 1 0.4% 1-19 53 19.0% 20-34 24 8.6% 35-49 42 15.2% L 50-64 14 5.0% 65 and over 1 0.4% LTotal Females 135 48.6% Males: Less than 1 1 0.2% L 1-19 49 17.5% 20-34 22 7.8% 35-49 46 16.6% L 50-64 25 8.9% 65 and over 1 0.5% LTotal Males 142 51.4% Overall 277 100.0% L L L Pool David W DC Bass Richard E DC Rode Darcy A DC 2403 Santa Fe Dr Suite 7 2150 E 88th Ave 3200 W 72nd Ave Pueblo. CO 81006 Thornton, CO 80229 Westminster, CO 80030 (719)543-7894 (303)289-2799 (303)429-2012 Pool Thomas P DC Solano Leonard DCa 2403 Santa Fe Dr 2200 E 104th Suite 114 Caldwell Shawn DC Pueblo. CO 81066 Thornton, CO 80233 12505 W 32nd Ave (719)543-7894 (303)451-5040 Wheat Ridge, CO 80033 Ratliff Richard OC (303)237-9617 W rei 2024 S Pueblo Blvd Baird Dale DC Cwalina Erica L DC Pueblo, CO 81005 8472 Federal Blvd 4045 Wadsworth Blvd Suite 300 (719)566-1550 Westminster. CO 80030 Wheat Ridge, CO 80033 Sova J William DC (303)/29-0011 (303)424-9888 2904 Hart Road Brinkman Rebecca A DC Fraser Randall C DC Pueblo, CO 81009 8753 Yates Dr Suite 104 4350 Wadsworth Blvd Suite 430 (719)542-2225 Westminster, CO 80030 Wheat Ridge, CO 80033 Spinutzi Joseph G DC (303)429-4104 (303)422-6301 1861 S Pueblo Blvd Freuden Jr Donald E DC Holland Freeman DC Pueblo, CO 81005 9464 N Federal Blvd 6295 W 38th Ave (719)566-1703 Westminster, CO 80221 Wheat Ridge, CO 80033 Thomas William R DC (303)426-8916 (303)422-7767 725 Desert Flower Blvd Koppel Lowell J DC Maipiede Ronald DC Pueblo, CO 81001 5009 W 92nd Ave 4045 Wadsworth Blvd Suite 300 (719)542-3131 Westminster, CO 80030 Wheat Ridge, CO 80033 Young Eric DC (303)427-2414 (303)424-9888 301 Colorado Ave Kloor Randall L DC Swenson Adrian W DC Pueblo. CO 81004 7590 Sheridan Blvd 7615 W 38th Ave Suite B107 (719)574-6006 Westminster. CO 80003 Wheat Ridge, CO 80033 ' (303)426-1500 (303)456-0850 Vic David DC Kockevar Mark K DC�®_ 171 Purcell Suite K 11550 N Sheridan Blvd Suite 102 Jones Scott DC Pueblo West, CO 8I007 Westminster, CO 8=0 320 South Burdette (719)547-1979 (303)465-9464 Woodland Park CO W63 �■ Kappa JR Donald M DC (719)687-6683 Spevere Gary P DC 9464 Federal Blvd Powell David DC 726 Railroad Ave Wes. CO 9=1 490 Rampart Range Rd Suite A Rifle, CO 81650 (303K26-6916 Woodland Park CO 80866 (970)625-1129 Lea Drum D DC (719xi87 6096 3200 W 72nd Ave Johnson Michael R DC Westminster, CO BM30 Sol W Main Street (303)429.2012 Sterling, CO 80751 Myhra Ron DC (970)522-3260 8787 Turnpike Dr Suite 100 Westminster, CO 80030 (303)429-8928 April. 1998 PD05003.000-1 i 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 5 PAID CLAIMS AND CAPITATION Member Relationship Analysis The distribution of medical expense (including capitation) by Relationship (Employee active or retired, Spouse, and Children) compared to PacifiCare experience was: Employees spouses Children PacifiCare Regional Norms 54% 27% 19% Client 45% 37% 18% Employees Spouses Children Total Total Expenses: ` Capitation Paid $1,183 $591 $1,198 $2,973 Claims Paid $101,394 584,174 $39,343 $224,911 ------------------------------------------------------------ Total Expense $102,577 $84,765 540,541 $227 884 Member Averages: Average Members 110 55 112 277 Avg. PMPM Expense $155.19 $256.86 $60.60 $137.28 Inpatient Experience: Inpatient Admissions 1 4 2 7 Inpatient Days 2 17 7 26 Admits per 1000 Members 18 145 36 51 (Annualized) Days per 1000 Members 36 618 126 188 (Annualized) 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 I Member Age Analysis This analysis looks at the ages of the members and claimants. The ages were calculated as of the end of the period, so only a single age is assumed for the entire period. Average Age by Relationship: Relationship Average Claimant Age Average Member Age Employee 45.9 years old 44.3 years old Spouses 44.6 years old 42.0 years old Children 11.6 years old 11.7 years old Average Age 36.7 years old 30.7 years old The regional average claimant age for PacifiCare is approximately 42.5 years old. 4 Experience by Sex and Age Bands: Paid Capitation Combined AgeBand Members Claims Total PMPM Females: Less than 1 1 2,114 12 303.77 1-19 53 21,591 566 70.12 20-34 24 23,326 254 166.06 35-49 42 46,254 453 184.61 6 50-64 14 43,919 149 530.94 65 and over 1 69 11 13.31 Total Females 135 $137,274 51,444 $171.89 Males: Less than 1 1 59 5 21.55 ` 1-19 49 12,163 521 43.59 20-34 22 11,655 231 92.14 35-49 46 42,798 494 156.86 50-64 25 15,516 263 107.34 65 and over 1 5,445 14 682.41 Total Males 142 $87,637 $1,529 $104.41 Overall 277 $224,911 $2,973 $137.2O Page 6 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 PAID CLAIMS ONLY (NO CAPITATION) Paid Claims By Cause The following table illustrates the paid claims by Cause (ICD-9 grouping). Here the claimant count increases to show the claimants by ICD-9 codes. Paid Claims (both inpatient and outpatient, excluding pharmacy) for this period were as follows: Paid % of % of Cause I Claims Paid Days Days Claimants injury & Poisoning 35,942 18.5 13 50.0 70 Symptoms & Signs 32,628 16.8 0 0.0 138 Skeleton & Muscle System 21,384 11.0 0 0.0 74 Digestive System 21,120 10.9 1 3.8 35 Respiratory System 16,923 8.7 5 19.2 125 Genitourinary System 13,782 7.1 2 7.7 39 Pregnancy & Childbirth 11,312 5.8 4 15.4 34 Mental & Substance Abuse 11,038 5.7 1 3.8 26 Tumors 7,080 3.6 0 0.0 33 Nervous Sys/Sense organs 6,280 3.2 0 0.0 34 Glands & Metabolism 5,714 2.9 0 0.0 33 ALL others/Supplementary 3,485 1.8 0 0.0 27 Skin & Skin Related 2,690 1.4 0 0.0 24 Infections & Parasitic 2,630 1.4 0 0.0 30 Circulatory System 1,216 0.6 0 0.0 13 Blood Related 418 0.2 0 0.0 4 Birth Defects 345 0.2 0 0.0 3 Perinatal Conditions 0 0.0 0 0.0 0 Total $193,987 26 742 The leading individual (medical) ICD-9 diagnoses were: Paid % of % of ICD-9 Diagnosis Claims Paid Days Days Claimants 997 SURG COMPL-BODY SYST 18,946 9.8 13 50.0 2 780 GENERAL SYMPTOMS 8,635 4.5 0 0.0 24 617 ENDOMETRIOSIS 7,494 3.9 2 7.7 1 789 ABD/PELVIS SYMPT INVO 6,818 3.5 0 0.0 20 DXM 6,263 3.2 1 3.8 12 466 AC BRONCHITIS/BRONCHI 6,016 3.1 5 19.2 11 540 APPENDICIT ACUTE 4,628 2.4 0 0.0 1 782 SKIN SYMPTOMS 4,587 2.4 0 0.0 6 784 HEAD/NECK SYMPT INVOL 4,552 2.3 0 0.0 10 577 PANCREAS DISEASES OF 4,192 2.2 1 3.8 1 Page 7 0112001 - 06/2001 r CITY OF FORT COLLINS POS 0RS00 L ` Provider Information Claim payments went to the following recipients: Paid % of Claims Paid Paid to Non -Hospital Providers $121,733 54.1 L Paid Directly to Hospitals $102,966 45.8 Paid to Insured $212 0.1 The leading hospital providers for this time frame were: (* denotes a PacifiCare Preferred or Network Provider) Paid LProvider Name City State Days claims *POUDRE VALLEY HEALTH CARE -OP FORT COLLINS CO 1 46,057 *POUDRE VALLEY HEALTH CARE-IP FORT COLLINS CO 17 22,630 L *MCKEE MEDICAL CENTER-IP LOVELAND CO 2 7,494 *MEMORIAL HOSPITAL-IP-PREAUTH COLORADO SPRING CO 5 5,418 *MCKEE MEDICAL CENTER -OP LOVELAND CO 0 4,747 L *NORTH CO MEDICAL CENTER - IP GREELEY CO 1 4,192 *MOUNTAIN VIEW SURGERY CTR LOVELAND CO 0 4,029 *HARMONY AMBULATORY SURGERY FORT COLLINS CO 0 2,601 *NATION.JEWISH PREAUTH-OP DENVER CO 0 1,639 L *SPRING CREEK SURGERY CTR-OP FORT COLLINS CO 0 1,059 *LONGMONT SURGERY CENTER LLC LONGMONT CO 0 964 L *LONGMONT UNITED HOSPITAL -OP *BOULDER COMM HOSP-OUTPATIENT LONGMONT BOULDER CO CO 0 0 728 692 *NORTH CO MEDICAL CENTER - OP GREELEY CO 0 489 *MEMORIAL HOSPITAL-OP-PREAUTH COLORADO SPRING CO 0 115 L *UNIVERSITY HOSPITAL -OP DENVER CO 0 85 IVINSON MEMORIAL HOSPITAL O/P LARAMIE WY 0 29 L l L l L Page 8 [1 L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 L L L L L L 1; L L L L L L L L L L Non -Hospital Provider Information The leading non -hospital providers were: Paid Provider Name City State Days Claims *FT COLLINS RADIOLOGIC ASSOC FORT COLLINS CO 0 4,506 *HARMONY IMAGING CENTER LLC FORT COLLINS CO 0 3,225 *PACIFICARE BEHAVIORAL HEALTH LAGUNA HILLS CA 0 2,871 *JEROME SMITH MD FORT COLLINS CO 0 2,472 *MARK DURBIN NO FORT COLLINS CO 0 2,328 *RICHARD BOOTH NO FORT COLLINS CO 0 2,235 *EMERGENCY PHYS OF FT COLLINS FORT COLLINS CO 0 2,205 WOMANCARE NURSE -MIDWIFERY FORT COLLINS CO 0 2,117 HARMONY AMBULATORY SURGERY FORT COLLINS CO 0 1,902 *THOMAS BOYLAN JR DO FORT COLLINS CO 0 1,858 *MARK PAULSEN MD FORT COLLINS CO 0 1,513 *JAMES DICKINSON MD FORT COLLINS CO 0 1,389 *THOMAS ENGLERT MD LOVELAND CO 0 1,335 *JANE SERVI NO FORT COLLINS CO 0 1,320 *RAGGIO COLBY MD FORT COLLINS CO 0 1,253 The leading Pharmacy providers were: Paid Provider Name City State Days Claims *LONGS DRUG STORE 226 FT COLLINS CO 0 3,153 *WALGREEN DRUG STORE 01245 FT COLLINS CO 0 3,034 *ALBERTSONS PHARMACY 8814 FORT COLLINS CO 0 3,030 *PRESCRIPTION SOLUTIONS M SAN DIEGO CA 0 2,769 *KING SOOPERS PHARMACY 73 FORT COLLINS CO 0 2,738 *POUDRE PHARMACY FT COLLINS CO 0 1,847 *KING SOOPERS PHARMACY #9 FT COLLINS CO 0 1,649 *KING SOOPERS PHARMACY #18 FT COLLINS CO 0 1,603 *KING SOOPERS PHARMACY 74 LOVELAND CO 0 1,341 *SAFEWAY PHARMACY 2913 FT COLLINS CO 0 1,209 *ALBERTSONS PHARMACY 8918 FT COLLINS CO 0 1,107 *SAFEWAY PHARMACY 0914 LOVELAND CO 0 1,059 *SAFEWAY PHARMACY 107 1071 FT COLLINS CO 0 1,038 *ALBERTSONS PHARMACY 8876 FORT COLLINS CO 0 753 *WAL-MART PHARMACY #1008 FT COLLINS CO 0 600 Page 9 L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Provider And Vendor Discount Savings Page 10 LThe savings from Provider and Vendor Discounts amounted to $40,783 and the details are as follows: --------------------- Network --------------------- Category Charged Allowed Savings Hospital Facility 83,568.40 74,160.17 9,408.23 Physician Service 142,982.58 112,652.97 30,329.61 Other 7,589.04 6,543.49 1,045.55 LTOTALS $234,140.02 $193,356.63 S40,783.39 -- Non -Network -- LCategory Charged Hospital Facility 245.50 L Physician Service Other 9,379.03 90.00 LOverall TOTALS percentage savings for in -network S9,714.53 client charges were 17.4%, and 96.0% of charges were from network providers. L L L L L L L L Payments By Benefit Category The medical payments by benefit category during this period were: Paid % of PacifiCare Amount Paid Norm Hospital Expense 100,739 44.8 45.7 Medical Care 35,540 15.8 12.1 Pharmacy 31,501 14.0 21.5 Surgery 19,962 8.9 6.2 X-Ray & Lab 16,966 7.5 6.1 Miscellaneous 10,113 4.5 8.7 Anesthesia 5,057 2.2 2.5 Emergency Care 2,943 1.3 1.5 Obstetrics 2,090 0.9 1.2 L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 L LInpatient Utilization LThe total number of inpatient admissions in this period was 7, and totaled 26 days. Due to the medical management of the HMO Utilization Review program, unnecessary hospital confinements have been eliminated. Because of this, HMO patients admitted to hospitals tend to be sicker, and appear to consume more services and incur longer lengths of stay. However, overall days and admissions per 1000 members are lower than non -HMO experience. L LAdmission Statistics L L L L L L L L L L L Total Admissions Total Days Average length of stay Admissions per 1000 members Days per 1000 members Average admission paid total Average daily paid Admission Total Paid Analysis Total Hospital Average Professional Fees Average Other Expense Average Client 7 26 3.7 51 188 $7,577 $2,040 56,189 $1,016 $372 Regional HMO 4.0 49 195 $7,832 $1,977 $7,097 $1,049 E-314 Admission Type Admissions Days ALOS Ave S/Adm Ave $/Day Medical 1 1 1.0 4,421 4,421 Surgical 3 20 6.7 12,693 1,904 Pregnancy - Normal Delivery 1 2 2.0 5,339 2,670 - Cesarean Section 0 0 0.0 0 0 - Newborn 1 2 2.0 1,106 553 Mental - Psych 1 1 1.0 4,092 4,092 - Substance Abuse 0 0 0.0 0 0 Page 11 L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 12 Catastrophic Illness L There are no catastrophic illnesses for this period (a catastophic illness is defined as paid amounts in excess of $25,000 to a single individual for a single cause). The regional PacifiCare norms for catastrophic illness are about 15.0% of the claim dollars paid caused by about 0.1 % of the claimants. LThe average PacifiCare catastrophic claim is about $61,542. L L 11 M L L 01 /2001 - 06/2001 L L L L L L L L L L L L L L L CITY OF FORT COLLINS POS 0RS00 Analysis Of Injury & Poisoning Injury & Poisoning claims accounted for 18.5% of the payments in this period, and 9.4% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 16 0 6,433 402 Spouses 14 13 23,782 1,699 Children 40 0 5,727 143 Total 70 13 $35,942 $513 Age Band Claimants Days Payment Ave Paid Less than 1 1 0 104 104 1-19 39 0 5,624 1" 20-34 10 0 1,335 133 35-49 13 0 9,376 721 50-64 4 13 19,015 4,754 65 and over 3 0 488 163 Leading Diagnosis Claimants Days Payment Ave Paid 997 SURG COMPL-BODY SYST NEC 2 13 18,946 9,473 980 ALCOHOL TOXICITY 1 0 3,508 3,508 881 WND ELBOW/ARM/WRIST 1 0 2,800 2,800 824 FX ANKLE 2 0 2,085 1,042 943 BURN OF ARM 1 0 1,605 1,605 959 INJ OTH UNSPECIFIED 16 0 1,550 97 847 SPRAIN BACK 6 0 682 114 810 FX CLAVICLE 3 0 658 219 813 FX RAD/ULNA 2 0 481 240 V17 FAMILY HX-CHRONIC DIS 1 0 436 436 Admission Type Admits ALOS Ave Paid Ave/Day Surgical 1 13.0 22,233 1,710 Total 1 13.0 22,233 1,710 Page 13 i 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORSOO i Analysis Of Symptoms & Signs Page 14 6 Symptoms & Signs claims accounted for 16.8% of the payments in this period, and 18.6% of the claimants. Le 7 7 7 7 V 7 7 V1 l� 7 6 80 79 Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 ading Diagnosis GENERAL SYMPTOMS 89 ABD/PELVIS SYMPT INVOLVI 82 SKIN SYMPTOMS 84 HEAD/NECK SYMPT INVOLV 72 EXAMINATION NOS 86 RESP SYS/OTH CHEST SYMP 85 US 5 HX-HEALTH HAZZARD NOS 5 ABN HISTOLOG/IMMUMO FIND 87 GI SYSTEM SYMPTOMS Claimants Days 66 0 39 0 33 0 138 0 Claimants Days 31 0 25 0 58 0 24 0 Claimants Days 24 0 20 0 6 0 10 0 37 0 21 0 4 0 1 0 5 0 4 0 Average Paid Payment per Claimant 22,898 347 5,758 148 3,971 120 $32,628 $236 Payment Ave Paid 3,833 124 7,035 281 13,633 235 8,126 339 Payment Ave Paid 8,635 360 6,818 341 4,587 764 4,552 455 3,705 100 1,807 86 612 153 575 575 500 100 276 69 is 8 s PadfiCare ° Prescription Drug Benefits Pharmacy coverage is an important part of your I. The drug must be medically necessary and/or a medical plan. PacifiCare's goal is to provide drug of choice for the treatment or prevention members with comprehensive pharmacy benefits at of a specific disease state. an affordable cost to meet their medical needs. Generic and Brand -Name Medications Medications are classified into two categories: "generic" and "brand name." PacifiCare covers most FDA -approved generic and many brand -name medications that are not other- wise excluded under the Exclusions and Limitations section of your Evidence of Coverage. By using these generics whenever possible, PacifiCare can maintain affordability without compromising quality and can maximize your pharmacy benefit. A Word About Generics A generic drug is a medication that has met the standards set by the Food and Drug Administration (FDA) to assure its equivalency to the original patented brand -name medication. When a generic drug is approved by the FDA as being equivalent, its levels of safety, purity, strength and effectiveness have been determined to be the same as the brand - name product, but often at significant savings. Formularies PacifiCare has developed a formulary to assist doctors as they prescribe medications for PacifiCare members. Aformulary is simply a primary list of prreferr+ed medications that your physician uses in your treatment. This list is developed by PacifiCare's Pharmacy and Therapeutics Committee consisting of primary care physicians, specialists and pharmacists, and it contains both generic and brand -name medications. Most therapeutic drug classes are covered. The PacifiCare Pharmacy and Therapeutics Commit- tee uses the following criteria to determine whether or not a drug should be added to or deleted from the formulary: 2. The drug must have been proven safe for general medical use. 3. The drug must have a reasonable therapeutic effectiveness -to -cost ratio when compared to other drugs in its class. If all criteria are equivalent between a new drug and one currently on the formulary, the less expensive drug will be selected. Preauthorization for Restricted Medications In order to promote appropriate use of medica- tions, PacifiCare requires prior authorization for non -formulary medications in the following drug classes: anti-inflammatory drugs, anti -ulcer drugs, cholesterol -lowering drugs, antibiotics, some drugs used to lower blood pressure, and dual -source brand -name drugs. PacifiCare recognizes that there may be instances in which a non -formulary re- stricted drug is necessary to treat a particular medical condition. In such instances, your con- tracted physician may request a review for pre - authorization on non -formulary restricted medica- tions by PacifiCare's pharmacy staff. Non -formulary drugs that are not otherwise excluded from cover- age will be preauthorized and covered by PacifiCare in the following instances: 1 If no formulary alternative is appropriate and it is agreed that the drug prescribed is medically necessary for patient care. 1 If the formulary alternative has failed after a therapeutic trial. 1 If you have experienced typical allergic reac- tions or established adverse effects related to the formulary drug that are attributed to formulations or differences in absorption, distribution, or elimination. L 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 15 L I u L L L L L L L L Analysis Of Skeleton & Muscle System Skeleton & Muscle System claims accounted for 1 1.0% of the payments in this period, and 10.0% of the claimants. Relationship Employees Spouses Children Total Age Band 1-19 20-34 35-49 50-64 65 and over Leading Diagnosis 724 BACK DISORDER NEC NOS 729 SOFT TISS DISORDERS OTHE 726 PERIPH ENTHESOPATHIES 727 TENDON/BURSA DIS 715 OSTEOARTHROSIS ET AL 717 KNEE INT DERANGEMENT 722 INTERVERTEBRAL DISC DIS 728 MUSCLE DISEASE 723 CERV RGN DISORDERS OTHER 733 BONE/CART DISORDERS OTHE Claimants Days 50 0 14 0 10 0 74 0 Claimants Days 9 0 11 0 31 0 19 0 4 0 Claimants Days 11 0 10 0 7 0 5 0 2 0 3 0 4 0 4 0 2 0 3 0 Average Paid Payment per Claimant 16,872 337 3,339 239 1,173 117 $21,384 $289 Payment Ave Paid 1,139 127 2,463 224 8,680 280 6,246 329 2,856 714 Payment Ave Paid 3,826 348 3,451 345 2,717 388 2,305 461 1,510 755 1,463 488 1,423 356 987 247 906 453 820 273 l 01 /2001 - 06/20( CITY OF FORT COLLINS POS ORS00 LAnalysis Of Digestive System Digestive System claims accounted for 10.9% of the payments in this period, and 4.7% of the claimants. L L L L L L L L L L L L Average Paid Relationship Claimants Days Payment per Claimant Employees 16 0 5,063 316 Spouses 17 1 15,667 922 Children 2 0, 390 195 Total 35 1 $21,120 $603 Age Band Claimants Days Payment Ave Paid 1-19 2 0 390 195 20-34 9 0 6,615 735 35-49 13 1 8,563 659 50-64 11 0 5,552 505 Leading Diagnosis Claimants Days Payment Ave Paid 540 APPENDICIT ACUTE 1 0 4,628 4,628 577 PANCREAS DISEASES OF 1 1 4,192 4,192 560 INTEST OSTRU W/0 HERNIA 2 0 2,695 1,347 530 ESOPHAGUS DISEASES OF 7 0 2,207 315 550 HERNIA INGUINAL 1 0 1,968 1,968 574 CHOLELITHIASIS 2 0 1,474 737 555 ENTERITIS REGIONAL 2 0 1,121 560 568 PERITONEAL DIS OF OTHER 1 0 545 545 578 GI HEMORRHAGE 4 0 501 125 569 INTEST DISORDERS OTHER 4 0 477 119 Admission Type Admits ALOS Ave Paid Ave/Day Medical 1 1.0 4,421 4,421 Total 1 1.0 4,421 4,421 Page 16 i 1 01 /2001 - 06/2001 CITY OF FORT COLLINS POS ORS00 Page 17 Analysis Of Respiratory System Respiratory System claims accounted for 8.7% of the payments in this period, and 16.8% of the claimants. Average Paid Relationship Claimants Days Payment per Claimant Employees 30 0 1,949 65 Spouses 18 0 3,890 216 Children 77 5 11,084 144 ` Total 125 5 $16,923 $135 Age Band Claimants Days Payment Ave Paid Less than 1 2 0 153 76 1-19 70 5 10,526 150 20-34 11 0 776 71 35-49 25 0 1,836 73 50-64 15 0 3,405 227 65 and over 2 0 228 114 Leading Diagnosis Claimants Days Payment Ave Paid 466 AC BRONCHITIS/BRONCHIOL 11 5 6,016 547 478 OTH UPPR RESPIRATORY DIS 3 0 2,128 709 462 AC PHARYNGITIS 36 0 2,020 56 465 AC URI MULT SITES/NOS 23 0 1,632 71 477 ALLERGIC RHINITIS 6 0 1,118 186 493 ASTHMA 7 0 1,031 147 473 CHRONIC SINUSITIS 10 0 802 80 461 SINUSITIS ACUTE 8 0 433 54 463 TONSILLITIS ACUTE 6 0 398 66 464 AC LARYNGITIS/TRACHEITIS 2 0 380 190 Admission Type Admits ALOS Ave Paid Ave/Day Surgical 1 5.0 6,383 1,277 Total 1 5.0 6,383 1,277 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 ti 4 CITY OF FORT COLLINS POS COMPANY NUMBER ORS00 01 /01 /2000 - 06/30/2000 HMO MEDICAL EXPERIENCE Contents Introduction . . . . . . . . . . . . . . . . . . . 1 Explanation Of Terms . . . . . . . . . . . . . . . 2 Overview . . . . . . . . . . . . . . . . . . . . . 3 Membership Demographics . . . . . . . . . . . . . . 4 Member Relationship Analysis . . . . . . . . . . . 5 Member Age Analysis . . . . . . . . . . . . . . . . 6 Paid Claims By Cause . . . . . . . . . . . . . . . 7 Provider Information . . . . . . . . . . . . . . . 8 Non -Hospital Provider Information . . . . . . . . . 9 Provider And Vendor Discount Savings . . . . . . 10 Payments By Benefit Category . . . . . . . . . . 10 Inpatient Utilization . . . . . . . . . . . . . . 11 Catastrophic Illness . . . . . . . . . . . . . . 12 Analysis Of Birth Defects . . . . . . . . . . . . 13 Analysis Of Respiratory System . . . . . . . . . 14 Analysis Of Symptoms & Signs . . . . . . . . . . 15 Analysis Of Skeleton & Muscle System . . . . . . 16 Analysis Of Circulatory System . . . . . . . . . 17 Is 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 Introduction PacifiCare is pleased to provide you with this comprehensive reporting package which focuses on your HMO coverage. The intent is to provide an array of reports which help to explain the impact of our medical management services. Under the HMO, medical benefits are paid for in two ways: ■ Capitation - a method of pre -paying for designated medical services. L■ Negotiated fee arrangements - providers are reimbursed a specific fee for a given medical service. These are referred to as "Paid Claims" throughout this document. L This reporting package analyzes total medical payments (claims plus capitation) for your members. The package then provides a detailed analysis of the services provided under fee arrangements ("Paid Claims"). Overall, 98% of your HMO expenses were paid claims. LAt PacifiCare, we turn data into useful information to assist you in making informed decisions about your benefit plan. L L L Lq L L L A Page 1 0 ■ 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 Page 2 L LExplanation Of Terms ■ Members - All eligible persons, including employees and their covered dependents, spouses, and retirees. L ■ PMPM - Per Member, Per Month. A monthly expense per member is calculated by dividing total expenses Lby cumulative member months. L■ Days - The number of inpatient days. ■ ALOS - Average Length of Stay. ■ Days per 1000 and Admissions per 1000 - The number of days/admissions per 1000 covered members. i These indicies are HMO standards for measuring utilization. ■ ICD-9 Code - International coding scheme used to reflect physician diagnosis (International LClassification of Diseases, 9th Revision). L■ Cause - Groupings of diagnostic categories (ICD-9 codes) which identify bodily systems. ■ Claimants - Members with referral claims that were not covered through capitated HMO services. I■ Admits - Number of admissions to an inpatient healthcare facility. i L L 01 /2000 - 06/2000 Overview CITY OF FORT COLLINS POS ORS00 ■ This analysis contains paid claims and capitation expenses. L■ The total expenses were $212,564. ■ The total capitation expenses were $3,754, which covered these types of services: L- MENTAL HEALTH - OTHER L- RADIOLOGY L L L L Page 3 ■ Medical paid claims totaled $208,810. Of this amount, Employees accounted for $127,454. Spouses accounted for $38,680. Children accounted for $42,676. - Claims associated with inpatient admissions were $66,273 (32%) - Outpatient care expenses were $112,191 (54%). - Pharmacy expenses were $30,345 (15%). ■ There were a total of 5 inpatient admissions to healthcare facilities, totaling 13 days. The period covered was January 1, 2000 through June 30, 2000 and only claims and capitation paid in that period were considered. This report was processed on August 16, 2001. 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 L Membership Demographics Members by Relationship and Age Bands: LAge Band Less than 1 r L20-3434 1-19 35-49 50-64 L65 and over Total LMembers by Sex and Age Bands: Employee Spouse Children Total 0 0 2 2 0 1 82 83 14 11 17 43 55 23 0 78 27 13 0 41 0 1 0 1 97 49 101 247 LAgeBand Females: Percent Members of Total L Less than 1 0 0.1% 1-19 43 17.4% 20-34 23 9.4% L 35-49 37 14.9% 50-64 15 6.2% 65 and over 1 0.4% Total Females 120 48.5% Males: Less than 1 1 0.5% L 1-19 40 16.4% 20-34 19 7.8% L 35-49 50-64 41 25 16.5% 10.3% 65 and over 0 0.0% LTotal Males 127 51.5% L L L Overall 247 100.0% Page 4 L 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 Page 5 L PAID CLAIMS AND CAPITATION LMember Relationship Analysis L The distribution of medical expense (including capitation) retired, Spouse, and Children) compared to PacifiCare experience by Relationship was: (Employee active or LEmployees spouses Children PacifiCare Regional Worms 53% 25% 22% LClient 61% 19% 21% LEmployees Spouses Children Total Total Expenses: LCapitation Paid $1,745 $685 $1,324 53,754 Claims Paid $127,454 $38,680 $42,676 $208,810 1 LTotal ------------------------------------------------------------ Expense $129,199 $39,365 $44,000 $212,564 I j� Member Averages: Average Members 97 49 101 247 j Avg. PMPM Expense $223.14 5134.35 $72.37 $143.62 Inpatient Experience: Inpatient Admissions 1 3 1 5 Inpatient Days 4 8 1 13 LAdmits per 1000 Members 21 123 20 41 (Annual i zed) Days per 1000 Members 83 328 20 105 L L L L L (Annualized) 11, 01 /2000 - 06/2000 CITY OF FORT COLLINS POS ORS00 L LMember Age Analysis t This analysis looks at the ages of the members and claimants. The ages were calculated as of the ` end of the period, so only a single age is assumed for the entire period. Average Age by Relationship: L LRelationship Average Claimant Age Average Member Age Employee 45.5 years old 44.2 years old Spouses 47.2 years old 43.3 years old LChildren 12.9 years old 12.7 years old Average Age 38.5 years old 31.1 years old LThe regional average claimant age for PacifiCare is approximately 42.1 years old. LExperience by Sex and Age Bands: LAgeBand Females: Less than 1 L 1-19 20-34 35-49 L 50-64 65 and over LTotal Females Males: Less than 1 L 1-19 20-34 35-49 L 50-64 Total Males LOverall L L Paid Capitation Combined Members Claims Total PMPM 0 0 10 4.92 43 10,319 586 42.27 23 17,605 198 128.08 37 18,641 649 87.28 15 23,323 232 256.03 1 -38 19 -3.18 120 $69,85O $1,695 $99.64 1 559 26 73.13 40 28,691 407 120.24 19 3,615 352 34.20 41 91,628 792 378.77 25 14,467 483 98.35 127 $138,960 $2,O6O $185.O6 247 $2O8,810 $3,754 $143.62 Page 6