Capitation PPG Capitated Services. HEALTH NET shall pay PPG the applicable Capitation described in Exhibit 2 to this Addendum for each Medi-Cal HMO Member entitled to receive PPG Capitated Services from PPG during the month to which the Capitation applies by wire transfer, on or before the ( ) day following HEALTH NET’s receipt of payment for that month from the DHS. Notwithstanding any provision in this paragraph to the contrary, only one Capitation shall be paid by HEALTH NET for both mother and newborn child during the child’s month of birth and the following month
Capitation PPG Capitated Services. Subsection 3.1 Capitation Rate shall be deleted and replaced with the following;
Capitation PPG Capitated Services. 3.1 Capitation Rate. PPG shall be compensated for rendering professional in-Network Services to Medicare POS Members at the percent of Monthly Revenue for Medicare HMO Members as set forth in this Addendum C, less a ten percent (10%) withhold (Professional Out-of-Network Withhold), for each Medicare POS Member eligible to receive such services from PPC during any particular month. In the event PPG’s enrollment exceeds five hundred (500) Medicare POS Members, the Professional Out-of-Network Withhold percentage shall be equal to (i) PPG’s prior year’s professional Out-of-Network costs, divided by the total of PPG’s Capitation for Medicare POS Members (prior to the Professional Out-of-Network Withhold) rounded to the nearest multiple of five, plus *** or (ii) *** if there is no prior year experience or if PPG has 500 or less Medicare POS Members. On or before December 15th of each year, HMO shall notify PPG of PPG’s Out-of-Network experience incurred between July 1 of the previous year and June 30 of the current year and the calculation noted above and such shall be PPG’s Professional Out-of-Network Withhold percentage for the following year. Capitation shall be calculated on the basis of the most current information available and shall be paid by HMO by wire transfer on or before the fifteenth (15th) day of each month, or the first business day following the fifteenth if the fifteenth is a holiday or on a weekend, or within two (2) days of CMS’s payment to HMO, whichever is later. Each Capitation payment shall be accompanied by a remittance summary. The remittance summary identifies the total Capitation payable and those Medicare POS Members for whom Capitation is being paid. In the event of a Capitation overpayment or underpayment to PPG, HMO shall adjust subsequent Capitation to offset such error.
Capitation PPG Capitated Services
