Agreement Between the District of Columbia Financial Responsibility and Management Assistance Authority and Greater Southeast Community Hospital Corporation I
Exhibits and Attachments
April 12, 2001

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Schedule of Exhibits and Attachments

Exhibit A Statement of Work
Exhibit B Loan Agreement
Exhibit C Promissory Note
Exhibit D Management Reports
Exhibit E Health Care Services Amount and Administrative Services Amount for the First Contract Year; Trauma Subsidy (Excludes School Health Services, Other Miscellaneous Health Services and Corrections Health Care Services)
Exhibit F School Health Services Amount
Exhibit G Corrections Services Amount
Exhibit H Lease/Sublease
Exhibit I Estimated Total Amount Payable Under the Agreement

STATEMENT OF WORK (EXHIBIT A)

1. Target Population

Persons will be eligible for the D.C. Healthcare Alliance program (the "program") if they meet the following criteria (the "Eligible Uninsured"):

• District of Columbia resident;
• Lacks third party insurance; and
• Family income equal to or below 200% of the federal poverty level. 

The Contractor shall enroll eligible individuals (the "enrolled Eligible Uninsured") in the program.

2. Cultural and Linguistic Competence

2.1 The Contractor shall develop a cultural competency plan (the "Cultural Competency Plan") based on the following assumptions:

• Only culturally competent practitioners and administrators working within a culturally competent system of care can ensure both culturally competent assessment and provision of appropriate health care services; 

• Cultural, ethnic, and linguistic diversity enhances the personal and professional experiences of all stakeholders;

• Services must be geographically, temporally, physiologically, culturally, and linguistically accessible;

• Culturally specific data on prevalence, incidence, utilization and outcomes must guide system level service design;

• The imperatives of safety and permanence are common to all populations;

• There may be a significant diversity of response to treatment modalities among ethnically diverse individuals; and

• A community based, culturally competent, prevention and early intervention focused system of care facilitates high quality, cost-effective outcomes.

2.2 The Cultural Competency Plan shall be submitted to the Authority within three (3) months of the award of the contract and submitted annually (on the anniversary date of the contract award) thereafter.

2.3 The Cultural Competency Plan shall address, and the Contractor shall function according to, a cultural competence philosophy through which the Contractor will monitor and evaluate cultural appropriateness of outreach and interventions, identify opportunities for improving effectiveness and access, establish initiatives to accomplish agreed upon opportunities for improvements and monitor resolution of problem areas. Contractor's Cultural Competency Plan is an ongoing process that shall span every aspect of program operation. 

3. Services to be Performed by the Contractor

The Contractor shall be required to provide health care services in the amount, duration and scope of health care services previously provided by the PBC unless otherwise specified by the Authority or any designee or assignee thereof. Generally, the Contractor shall not be required to provide any health care services that were not previously provided by the PBC, except (i) as specified herein, (ii) as directed by the Authority or the District pursuant to the terms of the Agreement, or (iii) as otherwise agreed upon by the Parties.

4. Health Care Services

The Contractor shall deliver to enrolled Eligible Uninsureds the following health care services ("Health Care Services"):

4.1 Community Based Primary Care Services

The Contractor shall initially maintain and manage no more than the six (6) neighborhood health centers that are currently managed by the Public Benefit Corporation (the "PBC"). After conducting a comprehensive assessment of all available primary care services and ensuring that accessibility to primary care services will not be constrained the Contractor may recommend to the Authority the closure, consolidation or relocation of neighborhood health centers.

4.2 Inpatient Hospital Services

4.2.1 The Contractor shall provide all necessary inpatient hospital services and all other ancillary and support services needed during an inpatient hospitalization, consistent with the level and scope of services, as evidenced by diagnosis-related groups ("DRGs"), provided by the PBC or by Greater Southeast Community Hospital at any time during the twenty-four (24) months prior to the execution of this Agreement.

4.2.2 The Contractor shall facilitate the return of hospitalized patients to the primary care system upon discharge from the hospital.

4.3 Emergency Room Services and Trauma Care

4.3.1 The Contractor shall provide comprehensive emergency room care at Greater Southeast Community Hospital consistent with the level and scope of emergency room services provided by the PBC.

4.3.2 The Contractor shall provide on-site at the current DC General Hospital location an emergency room that operates 24 hours per day, 7 days per week.

4.3.3 Contractor shall ensure that necessary follow-up care at the most appropriate level is made available to all enrolled Eligible Uninsureds who are treated and released from emergency room care.

4.3.4 The Contractor shall be responsible for ensuring the provision of trauma services to enrolled Eligible Uninsureds consistent with the trauma services that were provided at D.C. General during the twelve (12) month period immediately preceding the date this Agreement is executed ("Comparable Trauma Services"). The Contractor shall arrange for the provision of such Comparable Trauma Services on-site at D.C. General Hospital until the cessation of inpatient services at D.C. General Hospital, and subsequently on-site at the Contractor's primary hospital site at Greater Southeast Community Hospital. 

4.3.5 Contractor shall initiate Comparable Trauma Services at Greater Southeast Community Hospital no later than August 31, 2001, and maintain such Comparable Trauma Services for the duration of the Agreement; provided, however, that if Contractor is unable to initiate such Comparable Trauma Services at Greater Southeast Community Hospital by August 31, 2001, Contractor shall ensure the availability of such services through agreements with other providers within the District of Columbia. 

4.3.6 From and after the initiation by Contractor of Comparable Trauma Services at Greater Southeast Community Hospital, the Authority shall provide an annual subsidy to Contractor for the maintenance of such Comparable Trauma Services at Greater Southeast Community during the term of the Agreement, in an amount as specified in the Agreement.

4.4 Ambulatory Care Services

The Contractor shall ensure the provision of all specialty and subspecialty ambulatory care consistent with the level and scope of services provided by D.C. General Hospital as set forth in Attachment 4.4.

4.5 Dentistry

The Contractor shall provide comprehensive diagnostic, preventive, therapeutic and emergency dental services to adults and children on an inpatient and outpatient basis in the same scope provided by the PBC, as described more specifically in Attachment 4.5.

At a minimum the Contractor shall provide:

• Twenty-four hour emergency maxillofacial services, including structures, by a team of maxillofacial surgeons and dental staff;
• Comprehensive general dentistry services to medically compromised patients with special needs and patients referred for oral health problems; 
• Diagnostic, preventive and therapeutic periodontal services; 
• Comprehensive pediatric dental services for all children; 
• Ambulatory adult and pediatric anesthesia during complex dental procedures;
• Maxillofacial prosthodontics for patients requiring oral facial reconstruction and prosthesis; 
• Endodontic services necessary to support the restorative treatment of patients; and 
• Comprehensive dental services for oncology patients.

4.6 Pharmacy Services

The Contractor shall be responsible for the acquisition, dispensing, tracking, reporting and administering a pharmaceutical program for the enrolled Eligible Uninsureds.

4.7 Mental Health and Substance Abuse Services

4.7.1 Although the Contractor is not responsible either programmatically or financially for mental health care or substance abuse services for the enrolled Eligible Uninsured, the Contractor shall develop a coordination plan that ensures that enrolled Eligible Uninsureds with mental health and substance abuse issues have timely access to the mental health and substance abuse services provided by the District.

4.7.2 The Contractor shall ensure that appropriate referrals are made for the provision of medical detoxification services for enrolled Eligible Uninsureds requiring such services in an acute care hospital setting. 

4.8 Long Term Care and Long Term Rehabilitation

Although the Contractor is not responsible either programmatically or financially for long term care and long-term rehabilitation services for the enrolled Eligible Uninsured, the Contractor shall develop and implement a coordination plan that ensures that the enrolled Eligible Uninsured have timely access to long-term care and long-term rehabilitation.

The Contractor will perform the following administrative services with respect to the Health Care Services provided to the enrolled Eligible Uninsured and the other health services provided to other categories of individuals pursuant to this Agreement (the "Administrative Services"):

5.1 Enrollment and Eligibility

5.1.1 The Contractor shall enroll eligible individuals in the program.

5.1.2 Eligibility for the program will be determined using the following criteria:

• District of Columbia resident;
• Lacks third party insurance; and
• Family income equal to or below 200% of the federal poverty level.

5.1.3 Homeless persons and undocumented aliens will be assigned the address of the neighborhood health center closest to them as their DC address.

5.1.4 Once determined eligible, an individual will have continuous and ongoing eligibility unless the individual:

• gains insurance coverage;
• changes permanent residence to a non DC address;
• fails to provide verification documents requested in the time frame described below; or
• earns an income above 200% of the federal poverty level.

5.1.5 It is expected that Contractor's staff will regularly assess the following for each enrolled Eligible Uninsured that presents for Health Care Services:

• Current residency;
• Proof of identity; and
• Status of pending insurance application (Medicaid, Medicare, other 3rd party) or initiation of application if one has not been done.

5.1.6 Enrolled Eligible Uninsureds may be required to sign a certification with each visit attesting to the validity of the information provided. If it is later determined by the Authority that the information provided is untrue, the case will be reported to Department of Health, which will notify the fraud and abuse unit of the District's Office of the Inspector General. However, any such report or finding shall not affect payments to Contractor from the Authority.

5.2 User Registration

5.2.1 The Contractor shall develop a database of enrolled Eligible Uninsureds that will include each person's name, age, sex, date of birth, social security number, place of residence, other relevant demographic information, as available, and detailed cost and utilization data.

5.2.2 The Contractor' shall develop policies and procedures and informational forms that describe the enrollment and registration process and shall make such information readily available to potential Eligible Uninsureds.

5.2.3 The Contractor must enroll uninsured persons who meet the eligibility requirements and who present for care through this program regardless of race, color, creed, religion, age, sex, income status (provided that such person's income is equal to or less than 200% of the federal poverty level), national origin, ancestry, marital status, sexual orientation, health status, physical or mental handicap or anticipated need for health care.

5.3 Identification Cards 

5.3.1 The Contractor shall issue identification cards or use other mechanisms to facilitate the access of enrolled Eligible Uninsureds to needed services and the appropriate tracking of their utilization of services.

5.3.2 The Contractor shall use best efforts to verify the identity of the person requesting health care services prior to delivering such services, except when an enrolled Eligible Uninsured presents for service with a life threatening emergent condition.

5.4 Third Party Liability 

Individuals who are determined to have or be eligible for other third party resources will not be eligible to receive Health Care Services under this program. In such case, the Contractor is expected to provide necessary services and submit invoices to such other appropriate payer for reimbursement.

5.5 Medicaid Eligibility

5.5.1 The Contractor shall screen each individual presenting for health care services under this contract for Medicaid eligibility. If an individual is determined to be Medicaid eligible, the Contractor will refer the individual to the Income Maintenance Administration.

5.5.2 The Income Maintenance Administration will assign two (2) out-stationed eligibility workers to the Contractor for purposes of determining Medicaid eligibility. The Contractor shall determine the placement of such eligibility workers.

5.6 Provider Services

5.6.1 Contractor shall provide provider services functions at least during regular business hours (9:00 am. to 5:00 p.m., Monday through Friday). Provider services functions include, but are not limited to, the following:

• Assisting providers with questions concerning patient eligibility status.
• Assisting providers with Contractor prior authorization and referral procedures.
• Assisting providers with claims payment procedures and handling provider complaints.
• Facilitating transfer of patient medical records among medical providers, as necessary.
• Developing a process to respond to provider inquiries regarding current enrollment.
• Developing a process to identify for providers all enrolled Eligible Uninsureds who have selected or been assigned to them for primary care.

5.6.2 The Contractor must make available to all enrolled Eligible Uninsureds, upon request, a manual identifying the primary, specialty care, and ancillary care providers participating in the program.

5.6.3 The Contractor must develop a provider training and education plan that ensures ongoing compliance with the requirements of this program, including, but not limited to:

• Well child care services training for any providers who serve patients age twenty-one (21) and under.
• Identification and appropriate referral for mental health and substance abuse services.
• Sensitivity training on diverse and special needs populations.
• Cultural competence.
• Administrative processes that include, but are not limited to, coordination of benefits, dual eligibles, and encounter reporting.

5.7 Provider Network

The Contractor shall establish and maintain an adequate provider network to serve the enrolled Eligible Uninsured population in a timely manner. The provider network shall include, but not be limited to: hospitals, specialty clinics, trauma centers, community clinics, facilities for high-risk deliveries and neonates, medical and surgical specialists, dentists, orthodontists, physicians and pharmacies for dispensing drugs provided by the Department.

5.8 Network Composition

5.8.1 The Contractor shall ensure that its provider network is adequate to provide the enrolled Eligible Uninsured with appropriate access to quality care through participating professionals, in a timely manner, and without the need to travel excessive distances. Upon the request of the Authority, the Contractor shall supply to the Authority geographic access maps detailing the number, location and specialties of the providers in their provider network in order to verify accessibility of providers within their network. The Authority may require additional numbers of primary care physicians, specialists and ancillary providers should it be determined that geographic access is not adequate. The Contractor must make all reasonable efforts to honor a patient's choice of providers in the network.

5.8.2 The Contractor shall:

(i) Make available to every enrolled Eligible Uninsured a choice of at least two (2) appropriate PCPs whose offices are located within a travel time no greater than thirty (30) minutes from the enrolled Eligible Uninsured's home. This travel time is measured via public transportation.

(ii) Enrolled Eligible Uninsureds may, at their discretion, select PCPs located further from their homes.

(iii) Ensure an adequate number of pediatricians to permit all enrolled Eligible Uninsureds who want a pediatrician as a PCP to have a choice of two (2) for their child(ren) within the travel time limits (30 minutes).

(iv) Ensure access to Certified Registered Nurse Practitioners ("CRNP") in situations where the CRNP is designated as a PCP.

(v) Offer enrolled Eligible Uninsureds freedom of choice in selecting a PCP. At a minimum, the Contractor must have or provide one (1) full-time equivalent (FTE) PCP who serves no more than Two Thousand (2,000) enrolled Eligible Uninsureds. The number of enrolled Eligible Uninsureds assigned to a PCP should be decreased by the Contractor if necessary to maintain the appointment availability standards set forth in Section 5.11 below.

(vi) Work with the Authority to avoid a PCP having a caseload or medical practice composed predominantly of enrolled Eligible Uninsured. In addition, Contractor shall organize its PCP sites so as to ensure continuity of care to enrolled Eligible Uninsureds, and the Contractor shall assign a specific PCP within the site for each enrolled Eligible Uninsured. The Contractor may apply to the Authority for a waiver of these requirements on a site-specific basis, and the Authority may waive these requirements for good cause demonstrated by the Contractor.

(vii) Demonstrate its ability to provide appropriate access to physician specialists for PCP referrals, and must employ or contract with adult and pediatric specialists in sufficient numbers to ensure that specialty services are made available in a timely, geographically, and physically accessible manner, particularly for those enrolled Eligible Uninsured in special needs populations. The Contractor must ensure a choice of at least two (2) appropriate specialists for each enrolled Eligible Uninsured.

(viii) Ensure that ER staff and physicians know the procedures for reporting suspected abuse and neglect.

5.8.3 The Contractor must limit its PCP network to appropriately qualified providers:

(i) At least seventy-five percent (75%) of the Contractor's network shall consist of PCPs who have completed an approved primary care residency in family medicine, osteopathic general medicine, internal medicine or pediatrics; and

(ii) No more than twenty-five percent (25%) of the Contractor's network shall consist of PCPs without appropriate residencies but who have, within the past five (5) years, post-training clinical practice experience in family medicine, osteopathic general medicine, internal medicine or pediatrics.

5.8.4 The Contractor must inspect the office of any PCP or dentist who seeks to participate in the Contractor's provider network (excluding offices located in hospitals) to determine whether the office is architecturally accessible to persons with mobility impairments. Architectural accessibility means compliance with ADA accessibility guidelines with reference to parking (if any), path of travel to an entrance, and the entrance to both the building and the office of the provider, if different from the building entrance. The Contractor shall use best efforts to ensure that a sufficient number of PCPs and dentists in the Contractor's provider network have offices or facilities that are accessible to persons with mobility impairments.

5.8.5 The Contractor shall ensure that all laboratory testing sites providing services have either a Clinical Laboratory Improvement Amendment ("CLIA") certificate of waiver or a certificate of registration along with a CLIA identification number in accordance with CLIA 1988. Those laboratories with certificates of waiver will provide only the eight (8) types of tests permitted under the terms of their waiver. Laboratories with certificates of registration may perform a full range of laboratory tests.

5.9 Provider Agreements

5.9.1 The Contractor shall have written provider agreements with a sufficient number of providers to ensure enrolled Eligible Uninsured appropriate access to all medically necessary services consistent with the scope and level of services provided by the PBC.

5.9.2 The Contractor shall include a provision in all provider agreements which states that the PCPs who serve enrolled Eligible Uninsureds under the age of twenty-one (21) are responsible for conducting all well child care for individuals on their panel under the age of twenty one (21). Should the PCP be unable to conduct the necessary well child care, the PCP is responsible for arranging to have the necessary well child care conducted by another network provider and ensuring that all relevant medical information, including the results of the well child care, is incorporated into the enrolled Eligible Uninsured's PCP medical record.

5.9.3 The Contractor shall not discriminate with respect to participation, reimbursement, or indemnification as to any provider who is acting within the scope of the provider's license or certification under applicable State law, solely on the basis of such license or certification. This paragraph must not be construed to prohibit Contractor from including providers only to the extent necessary to meet the needs of the enrolled Eligible Uninsured or from establishing any measure designed to maintain quality and control costs consistent with the responsibilities of the Contractor. 

5.9.4 Both the Contractor and providers shall demonstrate cultural competency and understand that cultural differences between providers and the enrolled Eligible Uninsured cannot be permitted to present barriers to accessing and receiving quality health care; providers must demonstrate the willingness and ability to make the necessary distinctions between traditional treatment methods and/or non-traditional treatment methods that are consistent with the enrolled Eligible Uninsured's cultural background and which may be equally or more effective and appropriate for the particular enrolled Eligible Uninsured; and providers must demonstrate consistency in providing quality care across a variety of cultures. For example, language, religious beliefs,, cultural norms, social-economic conditions, diet, etc., .may make one treatment method more palatable to an enrolled Eligible Uninsured of a particular culture than to another of an differing culture.

5.10 Primary Care Practitioner (PCP) Responsibilities 

5.10.1 The Contractor must have written policies and procedures for assigning every enrolled Eligible Uninsured to a PCP. The PCP shall serve as the enrolled Eligible Uninsured's initial and most important point of contact regarding health care needs. As such, PCP responsibilities shall include, at a minimum:

(i) Providing primary and preventive care and acting as the enrolled Eligible Uninsured's advocate by providing, recommending and arranging for care. 

(ii) Documenting all care rendered in a complete and accurate encounter record that meets or exceeds the Authority's data specifications.

(iii) Maintaining continuity of each enrolled Eligible Uninsured's health care.

(iv) Making referrals for specialty care and other medically necessary services.

(v) Maintaining a current medical record for the enrolled Eligible Uninsured, including documentation of all services provided to the enrolled Eligible Uninsured by the PCP, as well as any specialty or referral services.

(vi) Referral and collection of referral data for inpatient behavioral health services and other necessary ancillary health care services.

5.10.2 The Contractor agrees to retain responsibility for monitoring PCP actions to ensure they comply with the provisions of this Agreement.

5.10.3 The Contractor shall notify the Authority promptly of any changes to the composition of its provider network that materially affects the Contractor's ability to make available all services covered by this Agreement in a timely manner. The Contractor shall also develop procedures to address changes in its network that negatively affect the ability of enrolled Eligible Uninsured to access services. Material changes in network composition that negatively affect access to services may be grounds for termination of this Agreement.

5.10.4 For PCP terminations, when possible, the Contractor must provide thirty (30) days advance written notice to all enrolled Eligible Uninsureds assigned to the PCP and must provide for or assist with the assignment of those enrolled Eligible Uninsureds to another PCP. The Contractor must ensure the timely and complete transfer of medical records to the new PCP.

5.11 Appointment Standards

5.11.1 Emergency cases shall be seen immediately or referred to an emergency facility. If it is determined that emergency medical care is not required, but urgent care is required, the enrolled Eligible Uninsured must be seen promptly by an available PCP or referred to an open urgent care clinic.

5.11.2 Cases requiring urgent medical care must be scheduled within twentyfour (24) hours.

5.11.3 Routine appointments must be scheduled within two (2) weeks.

5.11.4 The Contractor shall use best efforts to ensure that all individuals requesting Health Care Services through this program receive a health risk assessment. The Contractor shall use best efforts to ensure that enrolled Eligible Uninsureds presenting for care are scheduled for health assessment/general physical examinations and first examinations within four (4) weeks of enrollment.

5.11.5 The Contractor shall provide the Authority with its protocol for ensuring that an enrolled Eligible Uninsured's average office waiting time is normally thirty (30) minutes or less, or one (1) hour when the provider encounters an unanticipated urgent medical condition visit or is treating an enrolled Eligible Uninsured with a difficult medical condition.

5.12 Patient Services

5.12.1 The Contractor shall provide patient services functions at least during regular business hours (9:00 a.m. to 5:00 p.m., Monday through Friday) to address non-emergency problems encountered by enrolled Eligible Uninsureds. Arrangements shall be made to receive, identify, and resolve emergency enrolled Eligible Uninsured issues, including prior authorization and medical necessity determinations for urgent/emergency services, on a twenty-four (24) hour, seven (7) day a-week basis.

5.12.2 The Contractor shall maintain and staff a twenty-four (24) hour, seven (7) day-a-week toll-free dedicated hotline to respond to enrolled Eligible Uninsureds' inquiries, complaints and problems raised regarding services. The Contractor's internal Eligible Uninsured hotline staff are required to ask the caller whether or not they are satisfied with the response given to their call. All calls must be documented, and if the caller is not satisfied, the Contractor must ensure that the call is referred to the appropriate individual for follow up and/or resolution. This referral must take place within forty-eight (48) hours of the call.

5.12.3 The Contractor shall develop, implement, and maintain a complaint and grievance process that provides for settlement of enrolled Eligible Uninsureds' complaints and grievances. The Contractor must have written policies and procedures for resolving enrolled Eligible Uninsured complaints and for processing grievances.

5.12.4 The Contractor shall provide Eligible Uninsureds with access to information regarding the program. The Contractor shall supply information to individuals who present at or call any of their sites. The Contractor shall collect data about the number and types of calls received. The Contractor shall provide patient/customer service programs designed to maintain and/or improve patient satisfaction and address patient complaints and grievances in an expeditious and fair manner.

5.12.5 The 'Contractor shall develop a process that ensures access to specialty and ancillary care for enrolled Eligible Uninsureds. The Contractor shall submit policies and procedures describing this process to the Authority for review.

5.13 Staffing Requirements

The Contractor shall ensure that it has sufficient staffing resources to ensure compliance with the requirements of this program. At a minimum, the Contractor must include in its executive management structure: 

• A full time manager responsible for day-to-day oversight of this program;
• A financial director or manager responsible for ensuring the financial integrity of the program; and
• A medical director responsible for all clinical aspects of the program.

5.14 Management Information System

The Contractor shall track the eligibility, enrollment, and utilization of all services provided pursuant to this program. The Contractor shall provide the District with complete, detailed, patient-specific demographic and utilization data in a computerized format mutually agreed upon by the parties. As specified by the Authority or the Department of Health, the Contractor shall provide the District with monthly, quarterly and annual reports that document the use and cost of services, in total and by type; key patterns of use, cost, and illness; and other important trends. The Contractor shall be able to track and demonstrate that the quality of care; the accessibility of care; the availability of specialty, ancillary and other services; and enrollment in Medicaid have all improved under this program.

5.15 Quality Management and Utilization Management

5.15.1 The Contractor shall operate a well-defined utilization management ("UM") system that ensures adequate control over high cost and high risk services and coordination of care of high cost enrolled Eligible Uninsureds.

5.15.2 The Contractor shall include in their annual quality improvement plans at least one study that addresses the needs of the uninsured or the needs of this program.

5.15.3 Contractor shall submit to the Authority for its review the list of services that will require prior authorization or approval and include timeframes and standards for response to request for services requiring authorization.

5.15.4 The Contractor shall implement a case management program and submit a comprehensive description of the program to the Authority for review.

5.15.5 The Contractor shall also implement a process that ensures the availability of second opinions when there is a question concerning a diagnosis or treatment. The Contractor shall carefully document all requests for second opinions and their response to such requests.

5.15.6 The Contractor must comply with the QM and UM program standards and requirements described herein. All criteria used must be consistent with national guidelines, industry standards or promulgated by professional medical associations or other expert committees. The Authority retains the right of advance written approval and to review programs, including subsequent changes. The Contractor must comply with all QM and UM program reporting requirements and must submit data in formats mutually agreed upon by the Contractor, the Authority and the Department.

5.15.7 The QM and UM programs shall include a written program description and annual work plan with a timetable of all activities and performance improvement initiatives for the coming year. The Department, in collaboration with the Contractor, retains the right to determine and prioritize QM and UM activities and initiatives based on areas identified as being of importance to the Department and areas identified through its analysis of external quality review (EQR) findings, Health Plan Employer Data and Information Set (HEDIS) measures, and encounter data submitted by the Contractor. The Contractor .must implement and abide by the program description and work plan or amended plan as approved by the Department. The QM and UM programs must:

(i) Include methodologies that allow for statistically valid performance based monitoring of the QM and UM programs and include documentation that all QM and UM activities and initiatives are selected through clinical and financial analysis of encounter and patient demographic data.

(ii) Provide evidence of evaluation and re-measurement of the Contractor QM and UM activities and initiatives in order to determine sustained improvement or the need for further action.

(iii) Address development, implementation, and performance measurement of disease management programs that are intended for selected conditions among targeted populations in order to improve outcomes through the quality of care provided while effectively managing utilization.

5.15.8 The Contractor shall ensure that all utilization review decisions are made using medically necessary criteria. The Contractor must take steps to ensure that determinations made by individual clinical reviewers on whether or not requested care and services are medically necessary are consistent with determinations for care and services that would be found to be medically necessary.

5.15.9 The Contractor shall develop polices and procedures that allow for prospective, concurrent, and retrospective determination of medical necessity, which are based on the medically necessary criteria and meet specified timeframes for the processing of requests for urgent and emergency services. In addition, the Contractor shall submit utilization review criteria and policies/procedures that contain utilization review criteria used to determine medical necessity to the Department for review.

5.15.10 Healthplan Employer Data Information Set Hedis -- The 'Contractor shall submit HEDIS data to the Department annually. Since the calendar year is the standard measurement year for HEDIS data, HEDIS data must be submitted in June of each year. HEDIS measures are specified for one of three data collection methodologies: administrative, hybrid or survey. The administrative methodology requires that contractors identify the denominator and numerator using transaction data or other administrative databases. The denominator includes all enrolled Eligible Uninsureds. The Contractor will report a rate based on all enrolled Eligible Uninsureds who meet the criteria who are found through administrative data to have received the service identified in the numerator data. The hybrid methodology requires that the Contractor identify the denominator and the numerator through both administrative and medical record data. The denominator consists of a systematic sample of enrolled Eligible Uninsureds drawn from the measure's eligible population.

5.15.11 The Contractor shall report a rate based on those enrolled Eligible Uninsureds in the sample who are found through either administrative or medical record data to have received the service identified in the numerator.

5.15.12 The Contractor may not report a measure using the hybrid method when the numerator is derived solely from administrative data.

5.15.13 External Quality Review (EQR) -- The Contractor agrees to cooperate fully with any external evaluations and assessments of its performance authorized by the Authority or the Department under this Agreement. The Contractor agrees to cooperate fully with external clinical record reviews that assess the Contractor's quality of care, access to care, and timeliness of care i.e., any studies as determined by the Authority or the Department.

5.15.14 The Contractor agrees to assist in the identification and collection of any data or clinical records to be reviewed by the independent evaluation team for enrolled Eligible Uninsureds. In addition, the Contractor must provide to the External Quality Review Organization (EQRO) complete medical records in the timeframe allowed by the EQRO.

5.15.15 The Contractor shall ensure that data, clinical records and workspace located at the Contractor's work site are available to the independent review team and to the Authority and Department, after two (2) business days' notice.

5.15.16 The Contractor shall demonstrate how the results of the External Quality Review are incorporated into the overall Quality and Utilization Management programs.

5.15.17 QM/UM program Reporting Requirements. The-Contractor agrees to:

(i) Provide the Department with uniform QM, UM, and patient satisfaction/complaint data, in a format to be determined by the Department and the Contractor, on a regular basis;

(ii) Collaborate with the Department in carrying out data validation steps;

(iii) Maintain and make available to the Department, upon request, studies, reports, protocols, standards, worksheets, minutes or other such documentation as may be appropriate; and

(iv) Submit reports based on the most current version of HEDIS measures.

5.15.18 The Contractor agrees to comply with all QM and UM program reporting requirements and time frames outlined in this Agreement. The Authority or the Department will, on a periodic basis, review the required reports and make changes to the information/data and/or formats requested based on the changing needs of the uninsured health care program. The Contractor shall comply with all reasonably requested changes to the report information, reporting times and formats as deemed necessary by the Authority or the Department.

5.15.19 The Contractor shall develop a strategy for ensuring that the program promotes and furthers the goals of the District's Healthy People 2010 initiative.

5.16 Oversight

5.16.1 The Contractor shall, and shall ensure that its subcontractor(s) shall, make available to the Authority or the Department upon request, data, clinical and other records and reports for review of quality of care, access and utilization issues including but not limited to EQRO, HEDIS, Encounter Data Validation, and other related activities. The Contractor shall submit a plan, as determined by the Department, and within time frames mutually established by the Department and the Contractor, to resolve any performance or quality of care deficiencies identified by the Department's ongoing monitoring activities and any independent assessments or evaluations requested by the Department. The Contractor shall obtain advance written approval from the Department before releasing or sharing data, correspondence and/or improvements from the Department regarding the Contractor's internal QM and UM programs or any external entity.

5.16.2 The Contractor shall obtain advance written approval from the Department before participating with any entity-in or providing letters of support for QM or UM data studies and/or any data related external research projects relating to the enrolled Eligible Uninsured.

5.17 Reporting Requirements

5.17.1 The Contractor shall submit the reports and information specified by the Authority, in a format mutually agreed upon by the Parties. The Contractor shall report to the Authority instances of suspected fraud and abuse by providers and/or enrolled Eligible Uninsureds. The Authority will specify the reporting periods and the due dates of all data reports. The Contractor may be subject to financial penalties in accordance with Section 1.36 of the Agreement, for failure to submit accurate data in accordance with report submission timeframes.

5.17.2 The Contractor shall transmit substantial amounts of data to the Authority via telephone or Internet. This data will include client demographic and utilization data and may include service authorization data. As such, the Contractor shall have the ability to collect, sort, query, report, store and transmit all such information for each enrolled Eligible Uninsured served.

5.17.3 The Contractor shall supply data to the Authority in agreed upon formats that will permit the Authority to measure the cost, utilization and types of services being provided. Contractors may be subject to financial penalties in accordance with Section 1.36 of the Agreement, for failure to comply with specified formats or for failure to provide the Authority with access to data as specified by the Authority.

5.17.4 The Contractor shall submit reports according to the following timelines:

(i) Annual reports shall be submitted within ninety (90 ) days following the last day of the contract period; 

(ii) Semiannual reports shall be submitted sixty (60) days following the last day of each six-month period;

(iii) Quarterly reports shall be submitted thirty (30) days following the end of the preceding quarter or by April 30, July 30, October 30, and January 30, assuming the contract period coincides with the calendar year; and

(iv) Monthly reports shall be submitted thirty (30) days following the end of each month.

5.17.5 Failure to submit timely, accurate and comprehensive reports may result in reductions in the Administrative Services Fee in accordance with Section 1.36 of the Agreement.

5.17.6 The following reports will be required of the Contractor. The Authority or the Department in collaboration with the Contractor will determine the forinat for report submission.

5.18 Performance Standards

5.18.1 The Contractor shall be responsible for the following performance standards and others addressed elsewhere in this Agreement. These performance standards will be evaluated periodically by the Authority or by the Department to determine the need for adjustments or revisions of the standard. Any sanction imposed shall be in accordance with Section 1.40 of the Agreement.

5.18.2 For the following additional performance standards, the parties acknowledge and agree that the base year utilized for the measurement of these services shall be the first contract year (i.e., May 1, 2001 through April 30, 2002).

6. School Health Services

During the term of the Agreement, the Contractor shall provide the following services (collectively, the "School Health Services"): .

6.1 The Contractor will assume responsibility for administering the School Health program consistent with the requirements set forth in Attachment 6.1.

6.2 The School Health program shall be available to all students enrolled in the 147 District of Columbia public schools and public charter schools (the "Schools").

6.3 The School Health program must provide services in accordance with District of Columbia laws and regulations, and shall provide twenty (20) hours of clinical services each week at each of the schools.

6.4 At a minimum, and consistent with District of Columbia regulation, the School Health program shall provide basic health services such as review of immunization status, basic health screenings, and comprehensive education and prevention programs for smoking, nutrition, pregnancy, HIV/AIDS, substance abuse and mental illness.

6.5 The Contractor shall also be responsible through the School Health program for identifying and referring to appropriate care, all pregnant students during their first trimester of pregnancy.

6.6 School health nurses are also responsible for implementing effective referrals into the larger health care system when a health need is identified. 

6.7 The Contractor shall facilitate or coordinate services between the School Health program and community based providers, hospitals and managed care organizations for those students that are enrolled in Medicaid and receive care through a Medicaid HMO.

6.8 The Contractor will have in place appropriate training and competency standards to ensure the nursing staff's ability to perform the duties they are assigned.

6.9 The Contractor shall facilitate a partnership with the D.C. Public School administration and embrace parental involvement in the School Health program.

6.10 The Contractor shall track, trend and report on utilization data on the School Health program and shall provide reports to the Authority on a quarterly basis setting forth such data in a format mutually agreed upon by the Authority and the Contractor.

6.11 If the District of Columbia law changes the requirements for the School Health program from the level and scope specified in Attachment 6.1, the Contractor's obligation to provide such other services shall be consistent with the appropriate budget agreed upon by the parties to provide such additional or other services. 

6.12 The Contractor shall be compensated for the provision of the School Health Services as set forth in the Agreement.

7. Other Miscellaneous Health Care Services

Contractor shall also manage the following block grant or other health care programs (the "Other Miscellaneous Health Care Services"), as agreed upon by the Contractor and the Authority or the Department: 

• WIC program 
• DOH/HIV
• Maternal Child Health program
• Day Care program

8.1 The Contractor shall be responsible for administering health care services for prisoners in custody of the District of Columbia (the "Corrections Health Care Services") and providing administrative services related thereto (the "Corrections Administrative Services"). Health care services required by prisoners in custody shall be provided consistent with requirements established by the Department of Corrections and the Youth Services Administration. Contractor agrees to provide such services at the rates and anticipated utilization levels set forth in the Agreement.

8.2 Reimbursement for Corrections Health Care Services shall be made on the following basis, as set forth more specifically in the Agreement:

8.2.1 Health care services comparable to the Health Care Services provided to the enrolled Eligible Uninsured shall be provided at the same rates as set forth in the Agreement.

8.2.2 Health care services are comparable to Health Care Services when such services are in the same DRGs as Health Care Services. Health care services that are not comparable to the services provided pursuant to this Agreement shall be provided at mutually agreed upon rates.

9. Health Care Services to Other District Agencies

Through a modification or amendment to this Agreement, and at the District's option, health care services comparable to the Health Care Services provided to the. enrolled Eligible Uninsured shall be provided by Contractor pursuant to various block grant programs and to the Youth Services Administration at the same payment rates as set forth in the Agreement (the "Health Care Services to Other District Agencies"). The fees for Health Care Services to Other District Agencies shall be billed directly to the agency for which the services were provided. Inpatient health care services are comparable to Health Care Services when such services are in the same DRG as Health Care Services. If additional health care services are requested to be provided to the block grant programs or Youth Services Administration that are not comparable to the Health Care Services provided pursuant to this Agreement, Contractor shall provide such services at mutually agreed upon rates.

Attachment 4.4 Ambulatory Care Services
Attachment 4.6 Dentistry
Attachment 6.1 School Health Services

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EXHIBIT B: LOAN AGREEMENT

THIS LOAN AGREEMENT (the "Loan Agreement") is entered into _____, 200_ and effective as of _____, 200_ (the "Effective Date")-by and between THE DISTRICT OF COLUMBIA FINANCIAL RESPONSIBILITY AND MANAGEMENT ASSISTANCE AUTHORITY (the "Lender"), and GREATER SOUTHEAST COMMUNITY HOSPITAL CORPORATION I (the "Borrower").

WHEREAS, the Borrower has entered into an agreement with the Lender dated April __, 2001, whereby the Borrower will provide health care services to certain eligible uninsured residents of the District of Columbia and other persons (the "Health Care Services Agreement");

WHEREAS, in connection with the Health Care Services Agreement, the Lender has agreed to lend to the Borrower certain funds for the purpose of performing capital improvements at Greater Southeast Community Hospital.

NOW THEREFORE, in consideration of the premises set forth above and the terms, covenants and conditions set forth below, the parties mutually agree as follows:

ARTICLE I
AMOUNTS AND TERMS OF THE LOAN

1.02 Note. Subject to Section 1.03, the Borrower shall repay to Lender all amounts advanced to the Borrower pursuant to Section 1.01 and not previously repaid, on the following terms. Upon the execution of this Loan Agreement, the Borrower shall execute and deliver to Lender a promissory note (the "Note") in the form of Attachment B, attached hereto and incorporated herein, in an amount equal to the maximum amount of monies subject to repayment which may be advanced to Borrower under Section 1.01. Except as otherwise forgiven pursuant to Section 1.03 below, the Note shall be payable to Lender, on an annual basis, in five (5) equal annual installments of principal (the "Repayment Period"), and shall bear interest at the rate of the prime rate of interest, as publicly announced by the bank with which the Lender has its primary banking relationship as of the date each principal payment is due, plus one percent (1%). The Lender, in its sole discretion, may determine that the Note shall be secured by the accounts receivable of the Borrower or such other property owned by or related to the Borrower. The outstanding balance may be prepaid at any time without penalty. The Repayment Period shall commence on the date which is twelve months after the date of this Loan Agreement; provided, that the Borrower shall not be required to repay any such portion of the Loan unless Lender shall have terminated that certain Health Care Services Agreement between Lender and Borrower, and; provided, further, that the Borrower shall not be required to repay any such portion of the Loan if Lender shall have terminated the Health Care Services Agreement at the Convenience of the Lender pursuant to Section 1.23 of the Health Care Services Agreement.

1.03 Loan Forgiveness. During the term of the Health Care Services Agreement, the outstanding balance of the Loan shall be forgiven in equal portions over a five (5) year period, as set forth in the following schedule:

Notwithstanding anything to the contrary, any capital improvement made to Greater Southeast Community Hospital for purposes of providing Corrections Services as described in Section 1.10 of the Health Care Services Agreement shall be ratably forgiven prior to the forgiveness of any other capital improvement amounts hereof.

ARTICLE II
REPRESENTATIONS AND WARRANTIES OF THE BORROWER

The Borrower hereby represents and warrants that the following representations and warranties shall be correct as of the Effective Date.

2.01 Execution. The execution, delivery and performance by the Borrower of this Loan Agreement and the Note does not contravene any law or any contractual restrictions binding on or affecting the Borrower.

2.02 Enforceability. This Loan Agreement is, and the Note when delivered hereunder shall be, legal, valid and binding obligations of the Borrower enforceable against .the Borrower, in accordance with their respective terms.

ARTICLE III
AFFIRMATIVE COVENANTS OF THE BORROWER

So long as the Note shall remain unpaid or the Lender shall have any remaining outstanding unpaid balance hereunder, the Borrower shall, unless the Lender otherwise consents in writing: (i) comply in all material respects with all applicable laws, rules and regulations, except that any noncompliance with any such law, rules or regulations that shall not have, in any one case or in the aggregate, a material adverse effect oh the-business or financial condition of the Borrower shall not be deemed a default; and (ii) perform all of its obligations unddr the Health Care Services Agreement, this Loan Agreement and under the Note when due.

ARTICLE IV
TERM AND TERMINATION

4.01 Term. The term of this Loan Agreement (the "Term") shall begin on the Effective Date and expire on the earlier of (i) the repayment of all sums required to be repaid hereunder or (ii) forgiveness of such obligations as specified herein.

(a) By Lender in the event that Lender terminates the Health Care Services Agreement due to an event of default by Borrower pursuant to Section 1.18 of the Health Care Services Agreement;

(b) By Lender upon the failure of the Borrower to pay any principal or accrued interest then due and payable under the Note and such failure remains unremedied for thirty (30) days after written notice thereof shall have been given to the Borrower by the Lender;

(c) By Lender upon the failure of the Borrower to perform or discharge in any material respects any obligation, covenant, term or condition contained in this Loan Agreement or in the Note on its part to be performed or discharged, and such failure remains unremedied for forty five (45) days after written notice thereof shall have been given to the Borrower by the Lender; or

(d) In the event that the Health Care Services Agreement is terminated by the Lender for the convenience of the Lender pursuant to Section 1.23 of the Health Care Services Agreement, this Loan Agreement shall be automatically terminated.

(a) Upon the termination of this Loan Agreement under Sections 4.02(a), 4.02(b) or 4.02(c), payments under the Note by the Borrower shall be accelerated and the full amount due under the Note shall be due three (3) months from the date of the termination of this Loan Agreement, and Lender, at its option, may add delinquent accrued interest to principal on the Note for the purposes of calculating interest and may pursue such other remedies as may be available to it under the District of Columbia Uniform Commercial Code or any applicable law. All rights and remedies of the Lender shall be cumulative and may be exercised successively or concurrently and, to the extent consistent with the exercise of any such right, without impairment of the security interest of the Lender in the collateral, if any.

(b) If this Loan Agreement is terminated pursuant to Section 4.02(d), the Borrower shall not be obligated to repay the Loan.

(c) Except as otherwise set forth in this Loan Agreement, termination of this Loan Agreement shall not terminate any obligations of any party which arose prior to termination of this Loan Agreement. Further, any termination of this Loan Agreement shall be without prejudice to any other right or remedy to which the terminating party may be entitled, either at law or in equity, under this Loan Agreement, the Note, or otherwise.

ARTICLE V
MISCELLANEOUS

5.02 Notices. Notices provided for herein, unless expressly provided for otherwise in this Agreement shall be in writing and may be delivered personally or by placing them in the U. mail, first class and certified, return receipt requested, with postage prepaid and addressed as follows:

District of Columbia Financial Responsibility and Management Assistance Authority
441 Fourth Street, N.W., Suite 570N
Washington, D.C. 20001
Attention: Contracting Officer (Contract No. DCFRA#00-C-039)
Tel: 202-504-3400

Greater Southeast Community Hospital Corporation 1
1310 Southern Avenue, SE
Washington D.C. 20032
Attention: Ana Raley, Chief Executive Officer
Attention: Cindy Sehr, Esq., Legal Department
Tel: 202-574-6611

or to such other addresses or persons as may be designated by the Lender or the Borrower from time to time in accordance with the provisions of this Section 5.02.

5.03 No Waiver of Rights or Remedies. No failure or delay on the part of the Lender in exercising any right hereunder or under the Note shall operate as a waiver thereof; nor shall any single or partial exercise of any right hereunder or under the Note preclude any other or further exercise of any other right.

5.04 Severability. In the event any provision or part of any provision of this Loan Agreement or of the Note is rendered invalid or unenforceable by the enactment of any applicable statute, regulation or ordinance, or is made or declared unenforceable by any court of competent jurisdiction, the remaining parts or provisions of this Loan Agreement or of the Note shall continue in full force and effect.

5.05 Captions. Any captions or headings to the articles or sections of this Loan Agreement are solely for the convenience of the parties, are not a part of this Loan Agreement, and shall not be used for the interpretation or determination of the validity of this Loan Agreement or any provision hereof.

5.06 Costs and Expenses. The Borrower shall pay on demand all costs and expenses, if any (including reasonable attorneys' fees and expenses), in connection with the enforcement of this Loan Agreement and the Note.

5.07 Assignment. The Borrower may not assign any rights or delegate any duties under this Loan Agreement without the prior written consent of the Lender. This Loan Agreement may be assigned by the Lender to any governmental agency, affiliate, successor or assign. Any unauthorized attempted assignment by the Borrower shall be void and of no force and effect and shall constitute a material breach of this Loan Agreement. All covenants, conditions and provisions of this Loan Agreement shall be binding upon and shall inure to the benefit of the parties and their representatives, successors and assigns.

5.08 District of Columbia Law. This Loan Agreement and the Note shall be construed in accordance with and governed by the laws of the District of Columbia without regard to principles of conflicts or choice of law.

5.09 Entire Agreement. This Loan Agreement and the Note supersede any and all other agreements, whether oral or written, between the parties with respect to the subject matter hereof, and there are no representations, covenants or undertakings other than those expressly set forth in this Loan Agreement or in the Note.

Lender: District of Columbia Financial Responsibility and Management Assistance Authority

By: _____________

Title: _____________

Print Name: ___________

Borrower: Greater Southeast Community Hospital Corporation I

By: ________________

Title:________________

Print Name: ________________

Attachment A to Loan Agreement: Purpose of Loan and Description of Capital Improvements

Attachment B to Loan Agreement: Form of Promissory Note

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EXHIBIT C: PROMISSORY NOTE

PROMISSORY NOTE

THIS PROMISSORY NOTE is the note referred to in Section 1.02 of the Loan Agreement between "THE DISTRICT OF COLUMBIA FINANCIAL RESPONSIBILITY AND MANAGEMENT ASSISTANCE AUTHORITY (the "Payee"), and GREATER SOUTHEAST COMMUNITY HOSPITAL CORPORATION I (the "Maker"), dated _____, 200_, and this Note shall be subject to the terms and provisions of the Loan Agreement, including acceleration in repayment hereof and forgiveness of principal as set forth in Sections 4.03 and 1.03 of the Loan Agreement.

In the event of a default in the payment of any installment of principal and interest required by this Note, and if the default is not cured within thirty (30) days after the date such installment was due, the Payee may, without notice to the Maker or any other person, declare the remainder of the unpaid principal amount and accrued interest of this Note to be immediately due and payable three (3) months from the date of the termination of the Loan Agreement. Further, this Note may be accelerated as provided in Section 4.03(a) of the Loan Agreement. Failure by Payee to exercise these rights of acceleration at any time shall not constitute a waiver of the right to exercise the same right at any other time.

Upon default, the Payee may employ an attorney to enforce the Payee's rights and remedies pursuant to this Note and the Maker agrees to pay to the Payee the actual costs incurred for reasonable expenses incurred by the Payee in exercising any of the Payee's rights and remedies upon default.

This Note may be prepaid in part or in whole at any time with no penalty to the Maker. The principal sum advanced to the Maker under Section 1.01 of the Loan Agreement shall be forgiven in whole or in part in accordance with Section 1.03 of the Loan Agreement, and if such Loan Agreement shall remain in full force and effect until April 30, 2006 and on such date expire in accordance with its terms, all amounts due pursuant to Section 1.01 shall be forgiven. The Payee agrees to deliver to the Maker, upon full satisfaction of this Note, this Note marked cancelled.

This Note is to be governed and construed in accordance with the laws of the District of Columbia. If any provision or portion of this Note shall, to any extent, be deemed invalid or unenforceable, the remainder of this Note shall not be affected thereby, and each provision of this Note shall be valid and enforceable to the fullest extent permitted by law.

The Maker hereby waives presentment for payment, demand, protest and notice of dishonor, and all defenses on the ground of extension of time for the payment hereof which may be given by the Payee to the Maker or to anyone who has assumed the payment of this Note.

IN WITNESS WHEREOF, the Maker has caused this Note to be executed on the day and year first above written. 

MAKER: Greater Southeast Community Hospital Corporation I

By ___________

Title: __________

Print Name: __________

ATTACHMENT A TO THE NOTE
SUMMARY OF LOAN ADVANCES AND PAYMENTS

______________________________________________

_______________________________________________

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Exhibit D: Management Reports

1. Monthly bank account statements and other information for the segregated account into which all payments under this Agreement shall be deposited.

2. Monthly reports in the formats attached hereto.

3. Such other reports as requested by the Authority or the Department of Health from time to time.

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Exhibit E

Health Care Services Amount and Administrative Services Amount for the First Contract Year; Trauma Subsidy (Excludes School Health Services, Other Miscellaneous Health Services and Corrections Health Care Services)

The Monthly Health Care Services Amount is equal to $4,482,971.33, which is the sum of the following amounts:

1. Inpatient Hospital Services (excluding physician fees)
   1. Standard Base Rate (SBR) = $5,315.01
   2. Expected Casemix Index = 1.1742
   3. Expected Outlier Adjustment = 1.0382
   4. Adjusted Standard Base Payment Rate = $6,479.27
   5. Expected Number of Discharges/Month = 316.67
   6. Amount Per Month = $2,051,793.83
2. ER Services (excluding physician fees)
   1. All-Inclusive Payment Rate Per ER Visit = $295.02
   2. Expected Number of ER Visits Per Month = 2,797.25
   3. Amount Per Month = $825,244.70
3. Ambulatory Surgery (excluding physician fees)
   1. All-Inclusive Payment Rate Per Ambulatory Surgery Visit=$617.50
   2. Expected Number of Visits Per Month = 148.92
   3. Amount Per Month = $91,956.04
4. Other Hospital Outpatient Visits (excluding physician fees)
   1. All-Inclusive Payment Rate Per Visit = $130.15
   2. Expected Number of Visits Per Month = 3,195.50
   3. Amount Per Month = $415,894.33
5. Community Clinic Services (including physician fees)
   1. All-Inclusive Payment Rate Per Visit = $156.75
   2. Expected Number of Visits Per Month = 2,721.67
   3. Amount Per Month = $426,621.25
6. Physician Services. The Total Physician Services Amount Per Month = $475,171.08 (i.e., the sum of the Per Month amounts shown below for the various categories of Physician Services)
   1. Primary Care Services
      1. Primary Care Payment Rate Per Visit = $40.00
      2. Expected Number of Visits Per Month = 2,008
      3. Amount Per Month = $80,320.00
   2. Specialty Care Services
      1. Specialty Care Payment Rate Per Visit = $39.39
      2. Expected Number of Visits Per Month = 6,494.75
      3. Amount Per Month = $255,828.17
   3. Inpatient Surgery Services
      1. Inpatient Surgery Payment Rate Per Visit = $400.00
      2. Inpatient Surgery Visits Per Month = 82.58
      3. Amount Per Month = $33,033.33
   4. Ambulatory Surgery Services
      1. Payment Rate Per Ambulatory Surgery Visit = $200.00
      2. Ambulatory Surgery Visits Per Month = 148.92
      3. Amount Per Month = $29,783.33
   5. Hospital-Based Physician Services
      1. Payment Rate Per Hospital-Based Procedures = $25:00
      2. Hospital-Based Procedures Per Month = 3,048.25
      3. Amount Per Month = $76,206.25
7. Dental Health Services
   1. Payment Rate Per Visit = $118.75
   2. Expected Number of Visits = 1,098.58
   3. Amount Per Month = $130,456.77
8. Other Health Care Services
   The Other Health Care Services Amount Per Month = $65,833.33
   The Payment Rates for these Other Health Care Services shall be equal to the Medicaid Rates in effect for these services during the Contract Year.

B. Administrative Services Amount

C. Trauma Subsidy

The Contractor shall be paid an additional One Hundred Sixteen Thousand Six Hundred and Twenty-Seven Dollars $116,627.00 per month during the term of this Agreement for providing or arranging for the provision of trauma services at Greater Southeast Community Hospital (GSCHC). that are consistent with the trauma services that were provided at D.C. General during the twelve (12) month period immediately preceding the date this Agreement is executed ("Comparable Trauma Services"). Such monthly payments shall begin with the month in which Comparable Trauma Services become available. In return for the initiation of such Comparable Trauma Services at GSCHC, effective October 1, 2001, the D.C. Medicaid Authority shall increase the reimbursement payable to Contractor for emergency room visits at GSCHC and D.C. General by Fifty Dollars ($50.00) per visit. The District of Columbia Medicaid Authority shall have no obligation to make or continue making such increased payments to Contractor for emergency room visits if Contractor does not implement and maintain Comparable Trauma Services at GSCHC, nor shall the Authority have any obligation to make the above described trauma subsidy payments if Contractor does not provide and maintain Comparable Trauma Services at GSCHC. The Contractor shall be permitted to offset the amount of $50.00 for each Medicaid ER visit at GSCHC or at DC General against its Budget Reconciliation liabilities under this Agreement beginning on the earlier of June 1, 2001 or the date on which the Contractor begins providing Health Care Services at DC General and until such time as the District of Columbia Medicaid Authority implements the $50.00 increase in the ER rates at GSCHC and at DC General Hospital. The monthly trauma payment amount swill not be adjusted by the Index Factor prescribed elsewhere in this Agreement and will not be subject to the Budget Reconciliations prescribed elsewhere in the Agreement.

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Exhibit F: School Health Services Amount

During the First Contract Year, the School Health Services Amount shall be equal to Six Million Two Hundred Fifty Nine Thousand Three Hundred Ninety Five Dollars ($6,259,395.00) plus a twelve percent (12%) administrative services fee of Seven Hundred Fifty One Thousand One Hundred Twenty Seven Dollars ($751,127.00) for a total of Seven Million Ten Thousand Five Hundred Twenty-Two Dollars payable in equal monthly installments of Five Hundred Eighty Four Thousand Two Hundred Ten and 16/100 Dollars ($584,210.16) (the "Monthly School Health Services Amount").

During each Contract Year subsequent to the First Contract Year, the School Health Services Amount shall be adjusted by the Index Factor, as set forth in the Agreement.

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Exhibit G: Corrections Services Amount

The Corrections Services Amount is the amount paid to the Contractor for the provision of Corrections Health Care Services and Corrections Administrative Services. The Corrections Services Amount will be reconciled separately from the Budget Reconciliations that are prescribed by the Agreement for the Health Care Services and Administrative Services that are covered by Exhibit E.

Corrections Health Care Services and Corrections Administrative Services are subject to the Mid-Year Reconciliation. and Final Reconciliation Process set forth in Section 1.10; provided, however, that such reconciliations will be performed by comparing the Corrections Services Amount (i.e., the $3,317,730.00) to the Actual Costs of the Corrections Health Care Services provided by the Contractor (which shall be computed by multiplying the Payment Rates specified below during the First Contract Year by the Actual Utilization for the First Contract Year) without the application of the fifty percent (50%) adjustments or negotiations that are called for in the Budget Reconciliations that apply to the Exhibit E services.

During the First Contract Year, the Corrections Services Amount is the sum of the Corrections Health Care Services Amount of Three Million Three Hundred Seventeen Thousand, Seven Hundred Thirty Dollars ($3,317,730.00), plus a Corrections Administrative Services Amount of twelve percent (12%), for a total of Three Million Seven Hundred Fifteen Thousand, Eight Hundred Fifty Eight Dollars ($3,715,858.00), payable in equal monthly installments of Three Hundred Nine Thousand Six Hundred Fifty Five ($309,655.00 -- the "Monthly Corrections Services Amount").

During each Contract Year subsequent to the First Contract Year, the Payment Rates for Corrections Health Care Services shall be adjusted by the Index Factor, as set forth in the Agreement.

The Monthly Corrections Services Amount is equal to $309,655.00, which is the sum of the following amounts, plus the Corrections Administrative Amount of 12%:

1. Inpatient Hospital Services (excluding physician fees)
   1. Standard Base Rate (SBR) = $5,315.01
   2. Expected Casemix Index = 1.1742
   3. Expected Outlier Adjustment = 1.0382
   4. Adjusted Standard Base Payment Rate (ASBR) = $6,479.27
   5. Expected Number of Discharges/Month = 28.42
   6. Amount Per Month = $184,140.85
2. ER Services
   1. All-Inclusive Payment Rate Per ER Visit = $295.02
   2. Expected Number of ER Visits/Month = 50.75
   3. Amount Per Month = $14,972.08
3. Ambulatory Surgery
   1. All-Inclusive Payment Rate per Ambulatory Surgery Visit = $618.00
   2. Expected Number of Visits per Month = 0.00
   3. Amount Per Month = $0.00
4. Other Hospital Outpatient Visits
   1. All-Inclusive Payment Rate Per Visit = $130.15 
   2. Expected Number of Visits Per Month = 314.67 
   3. Amount Per Month = $40,953.83
5. Community Clinic Services
   1. All-Inclusive Payment Rate Per Visit = $156.75
   2. Expected Number of Visits Per Month = $0.00
   3. Amount Per Month = $0.00
      Note: The All-Inclusive Payment Rate Per Visit for Community Clinic Services includes physician services.
6. Physician Services
   The Total Physician Services Amount Per Month = $32,265 (i.e., the sum of the Per Month amounts shown below for the various categories of Physician Services)
   1. Primary Care Services
      1. Primary Care Payment Rate Per Visit = $ 40.00
      2. Expected Number of Visits Per Month = 223.17
      3. Amount Per Month = $8,926.66
   2. Specialty Care Services
      1. Specialty Care Payment Rate Per Visit = $39.39
      2. Expected Number of Visits Per Month = 333.33
      3. Amount Per Month = $13,130
   3. Inpatient Surgery Services
      1. IP Surgery Payment Rate Per Visit = $400.00
      2. Expected Number of Visits Per Month = 8.33
      3. Amount Per Month = $3,333.00
   4. Ambulatory Surgery Services
      1. Payment Rate Per Ambulatory Surgery Visit = $200.00
      2. Expected Number of Visits Per Month = 8.33
      3. Amount Per Month = $1,666.66
   5. Hospital-Based Physician Services
      1. Payment Rate Per Hospital-Based Procedure = $25.00
      2. Expected Number of Visits or Procedures Per Month = 208.33
      3. Amount Per Month = $5,208.33
7. Other Health Care Services
   1. Payment Rate Per Other Health Care Service = $50.00
   2. Expected Number of Visits or Procedures = 83.33
   3. Amount Per Month = $4,166.67
8. Dental Health Services
   1. Dental Services Payment Rate Per Visit = $118.75
   2. Expected Number of Visits Per Month = 0.00
   3. Amount Per Month = $0.00

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EXHIBIT I: ESTIMATED TOTAL AMOUNT PAYABLE UNDER THE AGREEMENT

Index Factor* 5.0%
*The actual index factor shall be determined as called for in Section 1.7.10 of the Agreement.