Capitation Rates. PPG Capitation for Individual HMO Members shall be determined on a monthly basis by multiplying the following normalized PMPM rates by the age, sex and benefit plan factors set forth in Addendum B for each assigned Member. Normalized PMPM rates represent the PMPM prior to the adjustment for PPG’s assigned Members’ age, sex and benefit plan. Actual PPG gross Capitation shall fluctuate from month to month to the extent that PPG’s age, sex and benefit plan mix fluctuates.
Capitation Rates. PPG Capitation for Small Group HMO Members shall be determined on a monthly basis by multiplying the following normalized PMPM rates by the age, sex and benefit plan factors set forth in Addendum B for each assigned Member. Normalized PMPM rates represent the PMPM prior to the adjustment for PPG’s assigned Members’ age, sex and benefit plan. Actual PPG gross Capitation shall fluctuate from month to month to the extent that PPG’s age, sex and benefit plan mix fluctuates. January 1, 1998 to June 30, 1998 $ *** PMPM July 1, 1998 to August 31, 1998 $ *** PMPM September 1, 1998 $ PMPM (See Section A8 above)
Capitation Rates. PPG Capitation rates for Medicare Supplement Members shall be at the following PMPM levels, subject to age, sex and benefit plan factors set forth in Addendum B:
Capitation Rates. The Agency shall pay the applicable capitation rate for each eligible enrollee whose name appears on the HIPAA-compliant X12 820 file for each month, except that the Agency shall not pay for, and shall recoup, any part of the total enrollment that exceeds the maximum authorized enrollment level(s) expressed in Attachment I. The total payment amount to the Health Plan shall depend upon the number of enrollees in each eligibility category and each rate group, as provided for by this Contract, or as adjusted pursuant to the Contract when necessary. The Health Plan is obligated to provide services pursuant to the terms of this Contract for all enrollees for whom the Health Plan has received capitation payment and for whom the Agency has assured the Health Plan that capitation payment is forthcoming.
1. The Agency’s capitation rates are developed using historical rates paid by Medicaid FFS for similar services in the same service area, adjusted for inflation, where applicable, in accordance with 42 CFR 438.6(c). These rates are included as Attachment I, titled “ESTIMATED HEALTH PLAN RATES; NOT FOR USE UNLESS APPROVED BY CMS.”
a. The Agency may use, or may amend and use these rates, only after certification by its actuary and approval by the Centers for Medicare and Medicaid Services. Inclusion of these rates is not intended to convey or imply any rights, duties or obligations of either party, nor is it intended to restrict, restrain or control the rights of either party that may have existed independently of this section of the Contract.
b. By signature on this Contract, the parties explicitly agree that this section shall not independently convey any inherent rights, responsibilities or obligations of either party, relative to these rates, and shall not itself be the basis for any cause of administrative, legal or equitable action brought by either party. In the event that the rates certified by the actuary and approved by CMS are different from the rates included in this Contract, the Health Plan agrees to accept a reconciliation performed by the Agency to bring payments to the Health Plan in line with the approved rates. The Agency may amend and use the CMS-approved rates by notice to the Health Plan through an amendment to the Contract.
2. The capitation rates to be paid specific to the Health Plan shall be as indicated in Attachment I, which indicates the initial and maximum authorized enrollment levels and capitation rates applicable to each authorized el...
Capitation Rates. The table below includes the capitation rates per member per month (PMPM) effective January 1, 2011 – December 31, 2011 varying by region and rate cell. Each CCO will be paid based on the distribution of members they have in each rate cell. In addition, CCO capitation payments will vary based on their members’ county of residence. Each county has been assigned to one of the following regions: north, central, or south. The capitation rates for each rate cell will be further adjusted for each CCO using the combined Chronic Illness and Disability Payment System and Medicaid Rx risk adjuster (CDPS + Rx). The CDPS + Rx risk adjuster will be used to adjust for the acuity differences among the enrolled populations of each CCO. The CDPS + Rx weights will be specific to the non-inpatient services covered by MississippiCAN and calculated using Mississippi fee-for-service data.
Capitation Rates. PPG Capitation rates for Medicare Supplement Members shall be at the following PMPM levels, subject to age, sex and benefit plan factors set forth in Addendum B: January 1, 1998 to June 30, 1998 $ *** PMPM $ *** PMPM July 1, 1998 to August 31, 1998 $ *** PMPM $ *** PMPM September 1, 1998 $ PMPM (See Section A8 above) $ PMPM (See Section A8 above)
Capitation Rates. The State has taken into account historical and/or anticipated cost avoidance and recovery due to the existence of liable third parties in setting capitation rates and determining the payment amounts. These factors do not include any reductions due to tort recoveries, or to recoveries made by the State from the estates of deceased Medicaid beneficiaries. In addition, future rates may be based upon the contractor's actual or expected performance involving TPL. Consequently, it is in the interests of both the State and the contractor for the contractor to maximize its revenue by fully exhausting all sources of available third party coverage.
Capitation Rates. PPG Capitation for Healthy Families Members shall be determined on a monthly basis by multiplying the number of members by the flat capitation amount set forth in Addendum I.
Capitation Rates. In consideration of full compliance by the HMO with contract requirements, the Department agrees to pay the HMO monthly payments based on the capitation rates specified in Addendum III. The HMO accepts the monthly capitation payment as payment in full except for cost payments from third party payers and payments under the contract for NICU, AIDS and Vent services. The HMO assumes full risk for the cost of services covered by the capitation payment. The capitation rate does not include any amount for recoupment of losses incurred by the HMO under previous contracts nor does it include services that are not covered under the State Plan. The Department’s enhanced funding policies include NICU risk sharing, ventilator dependent and AIDS/HIV enrollees. HMOs cannot submit a request for enhanced funding under more than one of the three funding policies for the same enrollee for the same date(s) of service.
Capitation Rates i. The Department will pay the PCO based on a schedule of PMPM capitation rates.
ii. At a minimum the Department will annually propose a schedule of PMPM capitation rates to the PCO that will apply to a time period subsequent to the end date of the rate schedule in this Agreement, or that is intended to replace the schedule of rates in the Agreement. When new rates are proposed by the Department, the Department will make itself available to consider and discuss PCO input. The Department may choose to impose strict deadlines for a PCO proposal, completion of discussions, or PCO signature on an amendment that provides updated rates or other terms.
iii. The Department will risk adjust the rates provided by Xxxxxxxx 0x, Xxxxxxxxxx Xxxxx, beginning January 2016, or at some later date determined by the Department. The Department will share detailed information with the PCO on the risk adjusted rate methodology. The PCO will accept capitation rates that are adjusted upward or downward, using rate adjustment factors computed by the Department, consistent with the risk adjustment methodology shared by the Department with the PCO.
