1
EXHIBIT 99.17
78
2
99.17
SKILLED NURSING FACILITY AGREEMENT
HEALTH CARE SERVICE CORPORATION,
A MUTUAL LEGAL RESERVE COMPANY
(BLUE CROSS AND BLUE SHIELD OF ILLINOIS)
233 North Michigan Avenue
Chicago, Illinois 60601-5655
THIS AGREEMENT made this 15th day of July, 1996, by and between Health
Care Service Corporation, a Mutual Legal Reserve Company (Blue Cross and Blue
Shield of Illinois), a not-for-profit Illinois corporation (hereinafter
referred to as "Blue Cross") and Rosewood Care Center, et al. of Illinois and
----------------------------
Missouri, and its wholly owned subsidiaries listed in Exhibit C, attached
hereto, (hereinafter referred to as the "Provider").
WHEREAS, Blue Cross has established and is maintaining a health care
service plan and is operating as a mutual legal reserve company; and
WHEREAS, the Provider is an institution furnishing skilled nursing
services and is duly licensed under the Illinois Nursing Home Care Act of
1979, as amended, or under the Illinois Hospital Licensing Act of Illinois,
as amended; and
WHEREAS, Blue Cross intends by entering into this Agreement to make
available skilled nursing services to its members by contracting with
Provider; and
WHEREAS, the Provider intends to provide such health care in a cost
efficient manner; and
WHEREAS, this Agreement is intended to implement a relationship between
Blue Cross and Provider based upon cost effective methods of health care
delivery and financing;
NOW, THEREFORE, in consideration of the mutual covenants and agreements
herein contained, the parties hereto agree as follows:
ARTICLE I
DEFINITIONS
A. "Coverage Agreement" means any policy, contract or certificate entered
into or issued by Blue Cross entitling Covered Persons to receive benefits
for the Covered Services designated therein. Coverage Agreement also includes
any agreement between Blue Cross and an employer or group for the furnishing
of administrative services in support of such employer's or group's health
care program.
B. "Covered Person" means any person entitled to receive Covered Services
pursuant to the terms of a Coverage Agreement.
ALL REFERENCES TO "ILLINOIS" IN THIS AGREEMENT SHALL BE DEEMED TO MEAN
- ----------------------------------------------------------------------
ILLINOIS OR MISSOURI.
- ---------------------
C. "Covered Services" means those Inpatient and Outpatient services and
supplies which are specified as benefits pursuant to the terms of a Coverage
Agreement. Covered Services includes services and supplies which by the terms
of a Coverage Agreement, are subject to deductible and co-payment amounts.
79
3
D. "Inpatient" means a person formally admitted to the Provider for bed
occupancy for purposes of receiving Inpatient Provider services, with the
reasonable expectation that the person will occupy a bed and remain at least
overnight even though it later develops that the person is discharged or
transferred to another provider and does not actually use a Provider bed
overnight.
E. "Medical Services Advisory (MSA) Program" (hereinafter referred to as the
"MSA Program") means a program performed by Blue Cross to assist Covered
Persons in managing benefits under Coverage Agreements. The MSA Program
includes, but is not limited to, the performance of pre-admission and length
of stay reviews and the pre-certification of certain Outpatient services.
F. "Medically Necessary" means Covered Services which, under the provisions
of this Agreement, are determined through Utilization Review to be:
(1) Appropriate and necessary for the treatment of the medical condition, and
(2) Provided for the direct care and treatment of the medical condition, and
(3) Within standards of good medical practice within the organized medical
community, and
(4) Not primarily for the convenience of the Covered Person, the Covered
Person's physician or another provider, and
(5) The most efficient and economical supply or level of service which can
safely be provided. For Provider stays, this means that care as an Inpatient
in a licensed skilled care bed is necessary due to the kind of services the
Covered Person is receiving or the severity of the Covered Person's
condition, and that safe and adequate care cannot be received as an
Outpatient, or in some other less intensified setting.
G. "Non-Covered Services" means those services or supplies which are not
Covered Services under a Coverage Agreement.
H. "Outpatient" means a person treated by the Provider as other than an
Inpatient.
I. "Utilization Review" means a function performed by the Provider or Blue
Cross or by an organization or entity acting as an agent of Blue Cross to
review and determine whether Covered Services are Medically Necessary.
ARTICLE II
PROVIDER SERVICES AND RESPONSIBILITIES
A. Provider shall provide to Covered Persons Covered Services in accordance
with this Agreement which are Medically Necessary, when such services are
ordered by a licensed physician or, to the extent permitted by law, other
health care practitioners.
B. Provider shall provide Covered Services to Covered Persons in the same
manner and quality as those services are provided to all other patients of
Provider.
80
4
C. Provider agrees to participate in Utilization Review, as provided in
Article VII, and to abide by decisions resulting from that review, subject to
rights of reconsideration and review provided therein.
D. Provider agrees to cooperate with Blue Cross towards establishing cost
containment programs which can reasonably be expected to result in the cost
effective delivery of Covered Services to Covered Persons. Such programs
include, but are not limited to, discharge planning and generic drug
substitution. Provider will maintain adequate records on these programs and
their utilization by Covered Persons for review by Blue Cross. Blue Cross
agrees to provide assistance to Provider for the establishment and
maintenance of its cost containment programs.
E. Provider represents that it is duly licensed under the Illinois Nursing
Home Care Act of 1979, as amended or under the Illinois Hospital Licensing
Act of Illinois, as amended.
F. Provider agrees to notify Blue Cross in writing immediately upon any
change in licensure or accreditation status by the Joint Commission on
Accreditation of Healthcare Organizations or similar accrediting body, or the
addition or deletion of any facility and/or program subject to such licensure
or accreditation.
G. Subject to Article VII F, Provider agrees, in the event that it is
determined by Blue Cross that the care rendered by the Provider to a Covered
Person was not Medically Necessary, that it will not charge or attempt to
collect from Blue Cross or the Covered Person, and Blue Cross and the Covered
Person shall not be obligated to pay the Provider for the care or any portion
of the care rendered by the Provider to the Covered Person. The Provider may
appeal such determination by giving written notice to Blue Cross. Such notice
shall include medical information that the Provider believes supports its
contention that the care was Medically Necessary. The notice shall also
include evidence that the care rendered to the Covered Person has been
reviewed by the Provider's Utilization Review Program and shall include the
results of that review. Blue Cross shall review the information and provide a
written notice of its decision to the Provider within thirty (30) calendar
days after receipt of such notice. Provider agrees that the decision of Blue
Cross shall be final and binding.
H. Provider agrees to cooperate with Blue Cross in its provider assessment
activities including but not limited to on-site visits by Blue Cross.
I. Provider's Schedule of Facility Charges for Covered Services rendered to
Covered Persons are set forth in Exhibit A, attached to and made a part of
this Agreement. Provider agrees to furnish Blue Cross with thirty (30) days
prior written notice of any increase in charges.
J. Provider agrees to abide by decisions of the Illinois Health Facilities
Planning Board and/or local planning agencies, and, if the Provider should
initiate or expand a service or add to or alter its facilities in a manner
that is inconsistent with the decisions of the Illinois Health Facilities
Planning Board and/or local planning agencies, Blue Cross is not obligated to
reimburse the Provider for any costs associated with such services or
facilities that are used in providing Covered Services to Covered Persons. In
such event, the Provider shall so notify in writing each Covered Person
seeking such services or services in or through such facilities of the
non-coverage of such services or facilities by virtue of the fact that they
are inconsistent with the decisions
81
5
of the Illinois Health Facilities Planning Board and/or local planning agencies,
prior to the rendering of any such services. If the Provider does not so notify
each Covered Person, then Provider agrees to indemnify and hold harmless Blue
Cross and each such Covered Person from any and all Provider charges for such
services or services provided in or through such facilities.
K. Except for any amounts attributable to deductibles and co-payments as
specified in the particular Coverage Agreement, Provider agrees not to charge
or collect from any Covered Person any amount whatsoever for Covered
Services. The Provider may charge, and shall have the sole responsibility for
collecting from, Covered Persons amounts attributable to deductibles and
co-payments as specified in the particular Coverage Agreement and amounts
attributable to Non-Covered Services.
L.1. Certain Coverage Agreements provide that certain required communications
with the MSA Program be made by the Provider. The identification cards issued
by Blue Cross to Covered Persons and/or Blue Cross' normal admitting
notification process will identify Covered Persons covered under such
Coverage Agreements. For all such Covered Persons the Provider agrees as
follows:
a: Prior to all non-emergency Inpatient (elective) admissions of, and
prior to rendering certain Outpatient services designated by Blue Cross for
specific groups to, Covered Persons, the Provider agrees to contact the MSA
Program by telephone at a number to be supplied by Blue Cross. The Provider
shall advise the MSA Program of such pending Inpatient admission of or
Outpatient service regarding the Covered Person. Blue Cross will confirm such
telephone notice to the Provider in writing, or by notification through Blue
Cross' normal electronic admitting process. Blue Cross will provide the
Provider, from time to time, with notice of the certain Outpatient services
so designated by Blue Cross and the particular groups to which such MSA
Program notification applies.
b. In the event of an Inpatient emergency admission, the Provider
agrees to notify Blue Cross of the admission by telephone, at a number to be
supplied by Blue Cross, as soon as possible but in no event later than one
(1) working day after such admission. Blue Cross will confirm such telephone
notice to the Provider in writing, or by notification through Blue Cross'
normal electronic admitting process.
c. In the event the Provider does not notify Blue Cross of a particular
Inpatient admission or certain Outpatient service as required in this
Paragraph L, Blue Cross shall not be obligated to pay the Provider, nor shall
the Provider charge the Covered Person, for any portion of the particular
admission or for the certain Outpatient service if it is determined to be not
Medically Necessary pursuant to Article VII of this Agreement entitled
"Utilization Review".
2. Blue Cross may, from time to time, inform the Provider of the preadmission
and pre-certification processes required by other Blue Cross and/or Blue
Shield Plans, the Blue Cross and Blue Shield Association ("BCBSA") National
Program and the BCBSA Managed Care Program. Provider agrees to comply with
all such preadmission and pre-certification processes. Provided, however,
that once duly certified by Blue Cross, Covered Services rendered by Provider
shall not be subject to retrospective denial.
82
6
ARTICLE III
BLUE CROSS SERVICES AND RESPONSIBILITIES
A. Blue Cross agrees to pay Provider compensation pursuant to the provisions
of Articles IV, V and VI.
B. Blue Cross agrees to provide Provider with information relating to
Coverage Agreements.
C. Blue Cross agrees to grant Provider the status of "Participating
Provider", and to identify Provider as a Blue Cross participating skilled
nursing facility upon receiving inquiries from its staff, employers, groups
and Covered Persons.
ARTICLE IV
COMPENSATION AND BILLING
A. Blue Cross shall pay Provider for the provision of Covered Services
rendered to Covered Persons in accordance with the provisions of this Article
IV. The payment from Blue Cross shall be limited to the amounts referred to
in Article IV B, less deductible and co-payment amounts as provided in
Article IV C and less amounts received from sources other than Blue Cross
pursuant to the coordination of benefits ("COB") provisions of a particular
Coverage Agreement.
B. Provider shall accept the Payment Rate set forth in Exhibit B, attached to
and made part of this Agreement, for Covered Services provided to Covered
Persons as of the Effective Date of this Agreement.
C. Provider agrees that the only charges for which a Covered Person may be
liable and be billed by Provider shall be for Non-Covered Services and for
deductible and co-payment amounts required by the applicable Coverage
Agreement and for those Covered Services which are not Medically Necessary
but for which the Covered Person has been notified pursuant to Article IV G.
D. Blue Cross shall deduct from payment due Provider from Blue Cross pursuant
to this Agreement, the appropriate amount of deductibles and co-payments
required to be paid by the Covered Person pursuant to the applicable Coverage
Agreement. The Provider's normal schedule of rates for patients who are not
Covered Persons or covered under Medicare or Medicaid programs shall be the
base from which the deductible shall be subtracted and for computing or
determining the co-payment pursuant to this paragraph. Blue Cross shall pay
only those amounts, if any, which when added to the deductibles and
co-payments due the Provider from Covered Persons, and COB amounts as
provided in Article IV E below, pursuant to this Article, equal One Hundred
Percent (100%) of the amount required by this Agreement.
E. Payment for claims for which Blue Cross had other than primary liability
under the coordination of benefits ("COB") provisions of a particular
Coverage Agreement, shall be limited to that amount, if any, which, when
added to amounts receivable by the Provider from all other sources, pursuant
to applicable COB rules, equals one hundred percent (100%) of the amount for
which the Provider would have been paid pursuant to this Agreement had Blue
Cross had primary liability under the particular Coverage Agreement.
F. Provider shall bill Blue Cross in a manner acceptable to Blue Cross.
Provider shall furnish, on request, all information reasonably required by
Blue Cross to verify and substantiate the provision of Covered Services and
the charges for
83
7
such services. Blue Cross reserves the right to review any and all statements
submitted by Provider.
G. Provider shall not charge Covered Persons for Provider services denied as
not being Medically Necessary under Article VII B, unless Provider has duly
provided notice to that Covered Person in accordance with Article VII F.
H. Blue Cross shall not be liable for any claim not received on or before
December 31st of the calendar year following the year in which the Covered
Services were rendered. For the purposes of this paragraph, Covered Services
furnished in the last month of a particular calendar year shall be considered
to have been furnished in the succeeding calendar year. It is expressly
agreed that the Provider shall not bill or seek to collect from a Covered
Person the amount, or any part thereof, ineligible for payment by Blue Cross
as a result of the Provider's failure to comply with the claim submission
time limit specified in this paragraph.
I. Charges for services rendered to Covered Persons shall not exceed the
Provider's charges made to persons other than Covered Persons for the same
services, except Medicare and Medicaid. If multiple charge schedules are
maintained by Provider, the one which generates the lowest aggregate charge
per case shall be used for Covered Persons.
ARTICLE V
INTERIM PAYMENT PROVISIONS
A. Blue Cross, at its option, may pay Provider via the Uniform Payment
Program (UPP). If Blue Cross pays Provider via UPP, then Blue Cross agrees to
pay Provider a prospectively determined weekly payment for Covered Services
rendered to Covered Persons. The amount of the payment will be computed by
Blue Cross as follows:
Projected weekly Provider charges for Covered Services rendered to Covered
Persons
LESS
Projected weekly amount of Covered Person's deductibles, co-payments and COB
amounts for Covered Services rendered to Covered Persons
LESS
Projected weekly Blue Cross Allowance (the amount retained by Blue Cross that
represents the difference between Provider charges for Covered Services
rendered to Covered Persons less deductibles, co-payments and COB amounts,
and the amount due Provider from Blue Cross for these Covered Services
pursuant to Article to Article IV of this Agreement)
EQUALS
The weekly interim payment for Covered Services rendered to Covered Persons.
Such weekly interim payment will be reviewed and adjusted by Blue Cross as
necessary to reflect actual Blue Cross claims for Covered Services rendered
to Covered Persons by the Provider during the particular year as evidenced by
Blue Cross processed claims data. The interim payments made pursuant to this
Article
84
8
V are subject to the Payment Reconciliation Process in accordance with Article
VI.
ARTICLE VI
PAYMENT RECONCILIATION PROCESS
A. A periodic reconciliation shall be made by Blue Cross from time to time
during the Term of this Agreement in order to reconcile the payment by Blue
Cross to the Provider pursuant to Article V, Interim Payment Provisions, and
the Compensation provisions specified in Article IV.
B. The reconciliation process shall be completed, and the Provider shall be
notified in writing of the results thereof. If the reconciliation process
results in a determination that an amount is due to Blue Cross, the Provider
shall pay Blue Cross that amount no later than thirty (30) calendar days
after Provider's receipt of the aforesaid notice. In the event such payment
to Blue Cross is not made by the Provider when due, Blue Cross may, at its
option, deduct all or any part of the amount from the next payment or
payments due the Provider pursuant to Article V of this Agreement, until such
outstanding amount is recovered in full.
ARTICLE VII
UTILIZATION REVIEW
A. Provider shall establish a Utilization Review Program applicable, at a
minimum, to Covered Persons.
B. A Utilization Review Program, whether performed by the Provider or Blue
Cross pursuant to the terms of this Agreement, shall provide for reviews of
admissions, durations of stays and Provider services rendered to determine
whether they are Medically Necessary and shall conform with generally
accepted principles of Utilization Review. A Utilization Review Program shall
include, at a minimum, the following, to the extent required by Blue Cross:
(1) "Admission Review" which means a review to determine whether an Inpatient
admission is Medically Necessary.
(2) "Concurrent Review" which means a review to determine whether a continued
Inpatient Provider stay and services and supplies provided incident thereto
are Medically Necessary;
(3) "Discharge Planning" which means the process of planning in advance for
the continuation of appropriate health care services for a patient's
treatment and/or convalescence, subsequent to discharge from the Provider;
(4) "Outpatient Review" which means a review to determine whether Outpatient
services or the continuance of Outpatient services are Medically Necessary;
(5) Provisions requiring compliance with all requirements of Blue Cross,
including, but not limited to, the furnishing to Blue Cross of copies of
medical records and other medical information on request.
(6) Provisions requiring compliance with all requirements of the MSA Program,
including, but not limited to, the furnishing to the MSA Program of copies
medical of records and other medical information on request.
85
9
C. The Provider shall submit to Blue Cross a written description of any
modification to its Utilization Review Program at least thirty (30) calendar
days prior to implementing any such modification, unless such prior notice is
waived by Blue Cross in writing. Blue Cross will notify the Provider of its
acceptance or non-acceptance of the modification no later than thirty (30)
calendar days after receipt of the description of modification.
D. To determine continued acceptance of the Providers Utilization Review
Program, Blue Cross will evaluate the results of Blue Cross' monitoring and
evaluating the utilization patterns as reflected in utilization profiles
developed by Blue Cross on the basis of its claim data for the Provider. Blue
Cross' evaluation of the Provider's Utilization Review Program shall also
include comparisons of Blue Cross data for the Provider and its peer groups.
Blue Cross may also, at its option, evaluate the effectiveness of the
Provider's Utilization Review Program through the retrospective review of the
appropriateness of services provided to specific Covered Persons. Further,
the Provider agrees to allow Blue Cross to audit and to make on-site
examinations of the Provider's Utilization Review Program and medical records
of Covered Persons.
E. In the event Blue Cross determines at any time that the Provider's
Utilization Review Program, or any element thereof, or any proposed
modification thereto, is unacceptable, Blue Cross shall notify the Provider
in writing specifying the unacceptable element(s) of the Program or proposed
modification. The Provider shall evaluate such element(s) and respond in
writing to Blue Cross, no later than fifteen (15) calendar days after the
Hospital's receipt of such notice, regarding specific plans and timeframes
for correction of the unacceptable element(s).
F. The Utilization Review Program, whether performed by the Provider or Blue
Cross or its agent, shall include a procedure whereby benefits may be
terminated in advance of the Provider's rendering services or rendering
further services. Such procedure shall provide that the Provider shall not
charge Blue Cross or Covered Persons for services determined through
Admission Review, Concurrent Review, or Outpatient Review to be not Medically
Necessary. However, the Provider may charge a Covered Person for such
services if the Provider has furnished the Covered Person with written notice
that the services to be rendered will not be Covered Services and that the
Covered Person will have responsibility for payment. Such notification shall
provide the Covered Person with the procedure to appeal the Review decision
and shall clearly state that the Covered Person shall be responsible for
payment of all Provider services rendered after the Covered Person's receipt
of notification of the Review decision.
G. The parties expressly agree that the cost of the Provider's performing
Utilization Review is included in the compensation provisions specified in
Article IV.
ARTICLE VIII
RECORDS MAINTENANCE, AVAILABILITY, INSPECTION AND AUDIT
A. MEDICAL RELEASES AND CONFIDENTIALITY
The Provider shall obtain medical releases from each Covered Person as The
Provider deems necessary in order for it to release Hospital medical records
to Blue Cross regarding claims submitted for such Covered Person. Neither party
86
10
shall disclose or cause to be disclosed to anyone, patient-specific
information provided by the other party without the agreement of the patient
about whom such information pertains unless otherwise required or permitted
by pertinent law or valid court order.
B. PROVIDER RECORD AUDITS
The Provider will permit Blue Cross access to examine and audit all medical
records and other documents reasonably related to the Covered Services
provided to any Covered Person during the term of this Agreement upon
reasonable prior written notice to the Provider.
ARTICLE IX
TERM
This Agreement shall be effective for a term commencing on July 1, 1996, and
ending June 30, 1997 (the "Contract Term"). Thereafter, this Agreement shall
be automatically renewed on a year-to-year basis, unless terminated pursuant
to Article X of this Agreement, "Termination of Agreement".
ARTICLE X
TERMINATION OF AGREEMENT
A. Either party may terminate this Agreement upon at least thirty (30)
calendar days prior written notice to the other.
B. If a party believes a material breach of this Agreement has been
committed, it shall give written notice describing such material breach to
the other party. In such event, the parties shall promptly confer to seek to
resolve the matter. If the breach is not resolved within thirty (30) days of
the allegedly breaching party's receipt of the aforesaid written notice, this
Agreement may be terminated for material breach effective immediately upon
written notice to the allegedly breaching party.
C. This Agreement may be terminated by Blue Cross in accordance with the
provisions of Article XIII C in the event of a transfer of majority interest
or control of the Provider.
D. If any voluntary or involuntary petition or similar pleading under any
section or sections of any bankruptcy act shall be filed by or against either
party, or any voluntary or involuntary proceeding in any court or tribunal
shall be instituted to declare either party insolvent or unable to pay its
debts, and in the case of the involuntary petition or proceeding, the
petition or proceeding is not dismissed within sixty (60) days from the date it
is filed, the other party may terminate this Agreement upon written notice to
Provider or Blue Cross, as the case may be, effective upon receipt of such
notice.
ARTICLE XI
OBLIGATIONS AFTER TERMINATION
In the event this Agreement terminates for any reason, Provider shall
continue to furnish Covered Services in accordance with the terms of this
Agreement and the applicable Coverage Agreements to all Covered Persons who
are Inpatients on the date of such termination during the remainder of their
respective confinements or until such time as their respective eligibility for
Covered Services expires or terminates pursuant to the terms of the Coverage
Agreement,
87
11
whichever shall first occur. Blue Cross agrees to pay, in accordance with
Articles IV, V and VI of this Agreement, for Covered Services furnished during
such period of time following termination of this Agreement.
ARTICLE XII
NOTICES
A. Any notice given or required under this Agreement shall be in writing and
shall either be delivered or mailed, postage prepaid, by certified mail,
return receipt requested, as follows:
To Blue Cross:
Health Care Service Corporation,
a Mutual Legal Reserve Company
233 North Michigan Avenue
Chicago, Illinois 60601-5655
Attention: Vice President-Hospital
and Professional Affairs
To Provider:
Rosewood Care Centers, et al.
11701 Borman Drive, Suite 315
St. Louis, MO 63146
Attention: President
B. The notice shall be effective if delivered, upon delivery, and if mailed,
upon the date indicated on the return receipt.
A party's address for notice may be changed at any time by notice given to
the other in accordance with the provision of this Article.
ARTICLE XIII
MISCELLANEOUS
A. Waiver of Breach of Agreement
The failure of either party to insist upon strict performance of any of the
terms of this Agreement shall not be construed as a waiver of its respective
rights or remedies with respect to any subsequent breach or default in any of
the terms of this Agreement.
B. Assignment
This Agreement may not be assigned by either party without the express prior
written consent of the other party. If this Agreement is assigned in
violation of this provision, this Agreement shall be null and void as of the
date of such assignment.
C. Transfer of Ownership of Provider
The Provider shall give Blue Cross at least thirty (30)days written notice
prior to the transfer of majority interest or control of the Provider. Blue
Cross may elect to terminate this Agreement in the event of any such transfer
of ownership
88
12
of the Provider by giving the Provider written notice of termination no later
than thirty (30) days after receipt of the Provider's notice of such transfer,
or thirty (30) days after knowledge of such transfer if the Provider does not
provide the aforesaid notice to Blue Cross. If Blue Cross exercises its election
to terminate this Agreement pursuant to this Article, the Agreement shall
terminate thirty (30) days after the date of notice of termination or on such
later date as Blue Cross may fix in its notice of termination.
D. Limitations of Actions
No action at law or in equity pertaining to any claim or controversy arising
under this Agreement shall be maintained by either party against the other
unless such action is commenced within two (2) years from the date when the
cause of action arose.
E. Entire Agreement; Amendments
This Agreement constitutes this entire Agreement between Blue Cross and the
Provider. This Agreement may not be amended, altered or modified except by a
written amendment signed by an authorized representative of each party.
F. Applicable Law
This Agreement shall be construed and enforced in accordance with the laws of
the State of Illinois.
G. Severability
This Agreement is inseverable. If any substantive provision of this Agreement
is rendered invalid by order of any court of competent jurisdiction or by any
valid federal or state law or regulation, this Agreement shall terminate as
of the effective date of such order, law or regulation.
IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the
1st day of July 1996.
Health Care Service Corporation, a
Mutual Reserve Company
By /s/ Joseph A. Arango
--------------------
Attest
Title Director Provider Contracting
Provider
By /s/ Larry D. Vander Maten
-------------------------
Attest
/s/ Michael Brady Title President
- -----------------
89
13
EXHIBIT A
SNF SERVICES
The payment to the Provider for Covered Services rendered to Covered Persons
shall be the Provider's actual charge less twenty percent (20%), not to
exceed the following per diem rates.
$240 $350 $450
Care or Activity Level 1 Level 2 Level 3
- ---------------- ------- ------- -------
Daily Nursing up to 3.0 up to 3.0 3.0 - 4.0
Hours
Continence Infrequent Incontinent Supra pubic
incontinence Staff Needs peri-care catheter
assist with Depends Ostomy total
bathroom needs Daily enema care
Ostomy
irrigations
Medications Crushed meds Odd hour mods IVs
Multi med routes Frequent vitals Daily labs
Daily or weekly Weekly labs Unstable
vitals IM meds condition
Insulin for Insulin for
controlled unstable brittle
diabetics diabetic
Skin Cond. Wound care 1x Wound care + 1x Stage 4
Decubiti daily daily Spec. skin
care Stage 1 Stage 3 Continuos
moist Stage 2 Sterile dressings dressing
Whirlpool
Respiratory Care 02 PRN 02 Continuous IPPB RX Daily
02 Daily PRN Trach care
Suctioning IX Suction +1X
Day Daily
Nebulizer
treatment
02 concentrator
Diabetic Cond. Well controlled Difficult control Unstable
Monthly blood Daily or weekly condition
sugar check blood sugar QID blood
check sugar
Staff teach check
insulin Sliding scale
administration
Restorative PROMS daily Prosthesis Therapy 2-3
Assistive device Therapy 1-2 hours daily
Therapy 0-1 hours daily
hours daily Daily application
of brace or splint
90
14
EXHIBIT A
(continued)
The Skilled Nursing Facility services rendered to Blue Cross members shall be
an all inclusive rate, including therapies, drugs, lab and supplies as
detailed in this Exhibit. Provider agrees to itemize all services on the UB92.
EXCLUSIONS FROM PER DIEM
SNF will provide the following items requiring Case Manager Reauthorization
at it's acquisition cost plus 15% or AWP whichever is less:
Air Fluidized Therapy
Customized DME
Specialized Adaptive Equipment (Orthotics)
IV Therapy Medications (Antibiotics, Chemo)
Vivonex
Dialysis
LIMITATIONS
Provider will pay for Medications not to exceed $150.00 per month. Provider
will pay for Laboratory not to exceed $50.00 per month.
Blue Cross agrees to pay hi excess of these amounts at SNF's acquisition cost.
SERVICE EXCLUSIONS
SNF does not provide the following services:
Blood Transfusions
Telemetry Monitoring
Ventilators
If during the term of this Agreement, the Provider shall provide Covered
Services at a discount, rate, differential or other allowance more favorable
than that provided in this Agreement, then the Provider shall promptly notify
Blue Cross in writing, and Blue Cross, at its option, shall be give the
advantage of such discount, rate, differential or other allowance effective
as of the effective date of such contract or other arrangement. Provided,
however, such provision shall not apply to Covered Services rendered under
any government program.
91
15
EXHIBIT B
Facility FEIN # BLUE CROSS
PROVIDER#
Rosewood Care Center, Inc. of Alton 43-1446787 1074
3490 Humbert Road
Alton, Illinois 62002
Rosewood Care Center, Inc. of East Peoria 43-1446788 1075
900 Centennial Drive
East Peoria, Illinois 61611
Rosewood Care Center, Inc. of Edwardsville 43-1622946 1068
6277 Center Grove Road
Edwardsville, Illinois 62025
Rosewood Care Center, Inc. of Elgin 43-1620366 1069
2355 Royal Boulevard
Elgin, Illinois 60123
Rosewood Care Center, Inc. of Galesburg 43-1375391 1067
1250 W. Carl Sandburg Drive
Galesburg, Illinois 61401
Rosewood Care Center. Inc. of Joliet 43-1478199 1070
3401 Hennepin Drive
Joliet, Illinois 60431
Rosewood Care Center, Inc. of Moline 43-1453169 1071
7300- 34th Avenue
Moline, Illinois 61265
Rosewood Care Center, Inc. of Peoria 43-1446786 1072
1500 W. Northmoor Road
Peoria, Illinois 61614
Rosewood Care Center of 43-1478637 1073
St. Louis County, Inc.
11278 Schuetz Road
St. Louis, Missouri 63146
Rosewood Care Center, Inc. of Swansea 43-1375409 1077
100 Rosewood Village Drive
Swansea, Illinois 62222
92