Allowable Expenditures. a. CMS and EOHHS shall jointly determine the Adjusted Service Expenditures and the Adjusted Non-Service Expenditures, based on encounter data, cost data, and financial reporting data submitted by the Contractor (as required by Section 4.6.B.4 below, and Section 2.15-2.17 of this Contract). CMS and EOHHS reserve the right to audit Actual and Adjusted Service and Non-Service Expenditure data. b. CMS, EOHHS, and the Contractor agree that to the extent there are differences in expenditure data reported across various sources, including the encounter, cost, financial reporting, or other data submitted by the Contractor, CMS, EOHHS and the Contractor will confer and make a good faith effort to reconcile those differences before the calculation of the interim and final settlements. The review procedures may include a review of the Contractor’s encounter data and/or audit, to be performed by the CMS and/or EOHHS, or either party’s authorized agents, to verify that all paid claims for Enrollees by the Contractor are for Covered Services and/or that provider reimbursement is not excessive. c. EOHHS and CMS reserve the right to adjust expenditures for services that are reimbursed at more than 5% above the average reimbursement rate of all ICOs. Notwithstanding any contractual provision or legal right to the contrary, the Contractor agrees that there shall be no redress against CMS or EOHHS for a determination to adjust or a failure to adjust expenditures for services of any ICO. Aggregate Risk Sharing Corridors The Demonstration will utilize a tiered Contractor-level symmetrical risk corridor to include all Medicare A/B and Medicaid eligible Adjusted Service and Non-Service Expenditures. The risk corridors will be reconciled after application of any HCRP or risk adjustment methodologies (e.g. CMS-HCC), and as if all Contractors had received the full quality withhold payment. Risk Corridor Share The Medicare and Medicaid contributions to risk corridor payments or recoupments will be in proportion to their contributions to the Adjusted Capitation Rate Revenue. Medicare will participate in risk corridor payments/recoupments of 1.1% through 8.9% of Contractor gains or losses. All remaining payments or recoveries once Medicare has reached its maximum shall be treated as Medicaid expenditures eligible for FMAP. Losses and gains will be determined using the Risk Corridor Percentage.
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Samples: Three Way Contract for Capitated Model, Three Way Contract for Capitated Model
Allowable Expenditures. a. CMS and EOHHS shall jointly determine the Adjusted Service Expenditures and the Adjusted Non-Service Expenditures, based on encounter data, cost data, and financial reporting data submitted by the Contractor (as required by Section 4.6.B.4 below, and Section 2.15-2.17 of this Contract). CMS and EOHHS reserve the right to audit Actual and Adjusted Service and Non-Service Expenditure data.
b. CMS, EOHHS, and the Contractor agree that to the extent there are differences in expenditure data reported across various sources, including the encounter, cost, financial reporting, or other data submitted by the Contractor, CMS, EOHHS and the Contractor will confer and make a good faith effort to reconcile those differences before the calculation of the interim and final settlements. The review procedures may include a review of the Contractor’s encounter data and/or audit, to be performed by the CMS and/or EOHHS, or either party’s authorized agents, to verify that all paid claims for Enrollees by the Contractor are for Covered Services and/or that provider reimbursement is not excessive.
c. EOHHS and CMS reserve the right to adjust expenditures for services that are reimbursed at more than 5% above the average reimbursement rate of all ICOs. Notwithstanding any contractual provision or legal right to the contrary, the Contractor agrees that there shall be no redress against CMS or EOHHS for a determination to adjust or a failure to adjust expenditures for services of any ICO. Aggregate Risk Sharing Corridors The Demonstration will utilize a tiered Contractor-level symmetrical risk corridor to include all Medicare A/B and Medicaid eligible Adjusted Service and Non-Service Expenditures. The risk corridors will be reconciled after application of any HCRP or risk adjustment methodologies (e.g. CMS-HCC), and as if all Contractors had received the full quality withhold payment. Risk Corridor Share The Medicare and Medicaid contributions to risk corridor payments or recoupments will be in proportion to their contributions to the Adjusted Capitation Rate Revenue. Medicare will participate in risk corridor payments/recoupments of 1.1% through 8.9% of Contractor gains or losses. All remaining payments or recoveries once Medicare has reached its maximum shall be treated as Medicaid expenditures eligible for FMAP. Losses and gains will be determined using the Risk Corridor Percentage.. Risk Corridor Percentage and Payment/Recoupment Demonstration Year 1 - If the Contractor participates in the Demonstration at least through June 30, 2015, the following risk corridors apply for the experience during Demonstration Year 1:
1. For the portion of gains and/or losses of 10.1% through 20.0%, the Contractor bears 50% of the gain/loss and EOHHS and CMS share in the other 50%, as described in Section 4.6.B.1. As further described in Section 4.6.B.2.a.(2) and 4.6.B.2.a.(8) below, for the portion of gains and/or losses of greater than 20.0%, the Contractor bears 100% of the gain/loss. For Risk Corridor Percentages greater than 120.0%, EOHHS and CMS will make payment to the Contractor of 13.1% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is at full financial risk for amounts greater than 120.0%. For Risk Corridor Percentages of 110.1% through 120.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 110.0%], plus the amount described in Section 4.6.B.2.a(4), with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 101.1% through 110.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 101.0%], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 99.0% through 101.0%, no payment will be made by EOHHS and CMS to the Contractor, or by the Contractor to EOHHS and CMS. For Risk Corridor Percentages of 90.0% through 98.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 89.9%], with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 80.0% through 89.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 79.9%], plus the amount described in Section 4.6.B.2.a(6), with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages less than 80.0%, the Contractor will make payment to EOHHS and CMS of 13.1% of the Adjusted Capitation Rate Revenue, with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is not obligated to make any additional payment for amounts below 80.0%. Demonstration Year 2:
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Allowable Expenditures. a. CMS and EOHHS shall jointly determine the Adjusted Service Expenditures and the Adjusted Non-Service Expenditures, based on encounter data, cost data, and financial reporting data submitted by the Contractor (as required by Section 4.6.B.4 below, and Section 2.15-2.17 of this Contract). CMS and EOHHS reserve the right to audit Actual and Adjusted Service and Non-Service Expenditure data.
b. CMS, EOHHS, and the Contractor agree that to the extent there are differences in expenditure data reported across various sources, including the encounter, cost, financial reporting, or other data submitted by the Contractor, CMS, EOHHS and the Contractor will confer and make a good faith effort to reconcile those differences before the calculation of the interim and final settlements. The review procedures may include a review of the Contractor’s encounter data and/or audit, to be performed by the CMS and/or EOHHS, or either party’s authorized agents, to verify that all paid claims for Enrollees by the Contractor are for Covered Services and/or that provider reimbursement is not excessive.
c. EOHHS and CMS reserve the right to adjust expenditures for services that are reimbursed at more than 5% above the average reimbursement rate of all ICOs. Notwithstanding any contractual provision or legal right to the contrary, the Contractor agrees that there shall be no redress against CMS or EOHHS for a determination to adjust or a failure to adjust expenditures for services of any ICO. Aggregate Risk Sharing Corridors The Demonstration will utilize a tiered Contractor-level symmetrical risk corridor to include all Medicare A/B and Medicaid eligible Adjusted Service and Non-Service Expenditures. The risk corridors will be reconciled after application of any HCRP or risk adjustment methodologies (e.g. CMS-HCC), and as if all Contractors had received the full quality withhold payment. Risk Corridor Share The Medicare and Medicaid contributions to risk corridor payments or recoupments will be in proportion to their contributions to the Adjusted Capitation Rate Revenue. Medicare will participate in risk corridor payments/recoupments of 1.1% through 8.9% of Contractor gains or losses. All remaining payments or recoveries once Medicare has reached its maximum shall be treated as Medicaid expenditures eligible for FMAP. Losses and gains will be determined using the Risk Corridor Percentage. Risk Corridor Percentage and Payment/Recoupment Demonstration Year 1 - If the Contractor participates in the Demonstration at least through June 30, 2015, the following risk corridors apply for the experience during Demonstration Year 1:
1. For the portion of gains and/or losses of 10.1% through 20.0%, the Contractor bears 50% of the gain/loss and EOHHS and CMS share in the other 50%, as described in Section 4.6.B.1. As further described in Section 4.6.B.2.a.(2) and 4.6.B.2.a.(8) below, for the portion of gains and/or losses of greater than 20.0%, the Contractor bears 100% of the gain/loss. For Risk Corridor Percentages greater than 120.0%, EOHHS and CMS will make payment to the Contractor of 13.1% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is at full financial risk for amounts greater than 120.0%. For Risk Corridor Percentages of 110.1% through 120.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 110.0%], plus the amount described in Section 4.6.B.2.a(4), with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 101.1% through 110.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 101.0%], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 99.0% through 101.0%, no payment will be made by EOHHS and CMS to the Contractor, or by the Contractor to EOHHS and CMS. For Risk Corridor Percentages of 90.0% through 98.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 89.9%], with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 80.0% through 89.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 79.9%], plus the amount described in Section 4.6.B.2.a(6), with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages less than 80.0%, the Contractor will make payment to EOHHS and CMS of 13.1% of the Adjusted Capitation Rate Revenue, with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is not obligated to make any additional payment for amounts below 80.0%. Demonstration Year 2:
1. For the portion of gains and/or losses of 10.1% and greater, the Contractor bears 100% of the gain/loss. For Risk Corridor Percentages greater than 110.0%, EOHHS and CMS will make payment to the Contractor of 3.5% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is at full financial risk for amounts greater than 110.0%. For Risk Corridor Percentages of 103.1 through 110.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 103.0%], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 97.0% through 103.0%, no payment will be made by EOHHS and CMS to the Contractor, or by the Contractor to EOHHS and CMS. For Risk Corridor Percentages of 96.9% through 90.0%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [97.0% minus the Risk Corridor Percentage], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages less than 90.0%, the Contractor will make payment to CMS and EOHHS of 3.5% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is not obligated to make any additional payment for amounts below 90.0%. Demonstration Year 3:
1. For the portion of gains and/or losses of 8.1% and greater, the Contractor bears 100% of the gain/loss. For Risk Corridor Percentages greater than 108.0%, EOHHS and CMS will make payment to the Contractor of 2.0% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is at full financial risk for amounts greater than 108.0%. For Risk Corridor Percentages of 104.1 through 108.0%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 104.0%], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 96.0% through 104.0%, no payment will be made by EOHHS and CMS to the Contractor, or by the Contractor to EOHHS and CMS. For Risk Corridor Percentages of 95.9% through 92.0%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [96.0% minus the Risk Corridor Percentage], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages less than 92.0%, the Contractor will make payment to CMS and EOHHS of 2.0% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is not obligated to make any additional payment for amounts below 92.0%. Demonstration Year 1 - If the Contractor does not participate in the Demonstration at least through June 30, 2015, the following risk corridors apply for the experience during DY1: For the portion of gains and/or losses of 0 through 1.0%, the Contractor bears 100% of the gain/loss. For the portion of gains and/or losses of 1.1% through 3.0%, the Contractor bears 10% of the gain/loss and EOHHS and CMS share in the other 90%, as described in Section 4.6.B.1. For the portion of gains and/or losses of 3.1% through 20.0%, the Contractor bears 50% of the gain/loss and EOHHS and CMS share in the other 50%, as described in Section 4.6.B.1. As further described in Section 4.6.B.2.d.(2) and 4.6.B.2.d.(8) below, for the portion of gains and/or losses of greater than 20.0%, the Contractor bears 100% of the gain/loss. For Risk Corridor Percentages greater than 120.0%, EOHHS and CMS will make payment to the Contractor of 10.3% of the Adjusted Capitation Rate Revenue, with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is at full financial risk for amounts greater than 120.0%. For Risk Corridor Percentages of 103.1% through 120.0% , EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 103.1%], plus the amount described in Section 4.6.B.2.d(4), with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 101.1% through 103.1%, EOHHS and CMS will make payment to the Contractor equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 101.0%], with the share of the payment made by EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 99.0% through 101.0%, no payment will be made by EOHHS and CMS to the Contractor, or by the Contractor to EOHHS and CMS. For Risk Corridor Percentages of 97.0% through 98.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 90% of [Risk Corridor Percentage minus 99.0%], with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages of 80.0% through 96.9%, the Contractor will make payment to EOHHS and CMS equaling the Adjusted Capitation Rate Revenue multiplied by 50% of [Risk Corridor Percentage minus 97.0%], plus the amount described in Section 4.6.B.2.d(6), with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. For Risk Corridor Percentages less than 80.0%, the Contractor will make payment to EOHHS and CMS of 10.3% of the Adjusted Capitation Rate Revenue, with the share of the payment made to EOHHS and CMS as described in Section 4.6.B.1 above. The Contractor is not obligated to make any additional payment for amounts below 80.0%. Risk Sharing Corridor Tables (for illustrative purposes only) Demonstration Year 1, if the Contractor participates in the Demonstration at least through June 30, 2015: Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >20.0% still results in risk sharing reconciliation for the loss or gain between 1.1% and 20.0%. 3 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP. Demonstration Year 2 Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >10.0% still results in risk sharing reconciliation for the loss or gain between 3.1% and 10.0%. 2 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP. Demonstration Year 3 Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >8.0% still results in risk sharing reconciliation for the loss or gain between 4.1% and 8.0%. 2 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP. Demonstration Year 1, if the Contract is terminated prior to June 30, 2015 Incremental Loss or Gain (as % of Total Adjusted Capitation Rate Revenue)1 Corresponding Risk Corridor Percentage % Contractor Risk Sharing % EOHHS & CMS Risk Sharing % CMS Risk Sharing % EOHHS Risk Sharing2 Gain > 3% and ≤ 20% 80.0% to 96.9% 50% 50% (50%) * (Medicare A/B Percent of Rate) (50%)* (Medicaid Percent of Rate) 1 Loss and gain reflected on an incremental basis, rounded to the nearest one tenth of a percent. Loss or gain >20.0% still results in risk sharing reconciliation for the loss or gain between 1.1% and 20.0%. 2 All EOHHS Risk Sharing shall be treated as Medicaid expenditures eligible for FMAP.
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