Common use of Capitation Rates Clause in Contracts

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 eligibility category. 3. At such time as the Agency receives legislative direction to assess Health Plans for enrollment and disenrollment services costs, the Agency shall apply assessments, in quarterly installments each Contract year, against the Health Plan’s next capitation payment to pay for the enrollment and disenrollment services contractor as follows: a. July 1, for costs estimated for the Agency’s enrollment and disenrollment services contractor system and Contract for July and the following two (2) months. b. October 1, for costs related to the third party enrollment and disenrollment services Contract for October and the following two (2) months. c. January 1, for costs related to maintaining the third party enrollment and services Contract for January and the following two (2) months. d. April 1, for costs related to maintaining the third party enrollment and disenrollment services contract for April and the following two (2) months. 4. Unless otherwise specified in this Contract, the Health Plan shall accept the capitation payment received each month as payment in full by the Agency for all services provided to enrollees covered under this Contract and the administrative costs incurred by the Health Plan in providing or arranging for such services. Any and all costs incurred by the Health Plan in excess of the capitation payment shall be borne in total by the Health Plan. 5. The Agency shall pay a retroactive capitation rate for each newborn enrolled in the Health Plan for up to the first three (3) months of life, provided the newborn was enrolled through the unborn activation process. a. The Health Plan shall use the unborn activation process to enroll all babies born to pregnant enrollees as specified in Attachment II, Section III, Eligibility and Enrollment, B.3, Unborn Activation and Newborn Enrollment. b. The Health Plan is responsible for payment of all covered services provided to newborns enrolled through the unborn activation process.

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 eligibility category. a. The Agency will pay the Health Plan the HIV/AIDS capitation rate only for those enrollees who have been identified and verified as having an HIV/AIDS diagnosis. The HIV/AIDS capitation rate is provided in Attachment I. (1) The Agency shall not pay the HIV/AIDS capitation rate for any enrollee who was not identified as HIV/AIDS prior to enrollment processing for the month for which the capitation payment is made, nor shall the Agency make a retroactive capitation payment at the HIV/AIDS capitation rate if the enrollee was identified as HIV/AIDS after enrollment processing. (2) Non-Reform HMO that specializes in HIV/AIDS enrollees who are family members of enrollees identified as diagnosed with HIV/AIDS, and who are not identified as diagnosed with HIV/AIDS, will receive a capitation rate based on their respective eligibility categories in capitation rate tables in Attachment I. 3. At such time as the Agency receives legislative direction to assess Health Plans for enrollment and disenrollment services costs, the Agency shall apply assessments, in quarterly installments each Contract year, against the Health Plan’s next capitation payment to pay for the enrollment and disenrollment services contractor as follows: a. July 1, for costs estimated for the Agency’s enrollment and disenrollment services contractor system and Contract for July and the following two (2) months. b. October 1, for costs related to the third party enrollment and disenrollment services Contract for October and the following two (2) months. c. January 1, for costs related to maintaining the third party enrollment and services Contract for January and the following two (2) months. d. April 1, for costs related to maintaining the third party enrollment and disenrollment services contract Contract for April and the following two (2) months. 4. Unless otherwise specified in this Contract, the Health Plan shall accept the capitation payment received each month as payment in full by the Agency for all services provided to enrollees covered under this Contract and the administrative costs incurred by the Health Plan in providing or arranging for such services. Any and all costs incurred by the Health Plan in excess of the capitation payment shall be borne in total by the Health Plan. 5. The Agency shall pay a retroactive capitation rate for each newborn enrolled in the Health Plan for up to the first three (3) months of life, provided the newborn was enrolled through the unborn activation process. a. The Health Plan shall use the unborn activation process to enroll all babies born to pregnant enrollees as specified in Attachment II, Section III, Eligibility and Enrollment, B.3, Unborn Activation and Newborn Enrollment. b. The Health Plan is responsible for payment of all covered services provided to newborns enrolled through the unborn activation process.

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 fee-forservice 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, AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract 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 eligibility category. 3. At such time as the Agency receives legislative direction to assess Health Plans for enrollment and disenrollment services costs, the Agency shall apply assessments, in quarterly installments each Contract year, against the Health Plan’s next capitation payment to pay for the enrollment and disenrollment services contractor as follows: a. July 1, for costs estimated for the Agency’s enrollment and disenrollment services contractor system and Contract for July and the following two (2) months. b. October 1, for costs related to the third party enrollment and disenrollment services Contract for October and the following two (2) months. c. January 1, for costs related to maintaining the third party enrollment and services Contract for January and the following two (2) months. d. April 1, for costs related to maintaining the third party enrollment and disenrollment services contract for April and the following two (2) months. 4. Unless otherwise specified in this Contract, the Health Plan shall accept the capitation payment received each month as payment in full by the Agency for all services provided to enrollees covered under this Contract and the administrative costs incurred by the Health Plan in providing or arranging for such services. Any and all costs incurred by the Health Plan in excess of the capitation payment shall be borne in total by the Health Plan. 5. The Agency shall pay a retroactive capitation rate for each newborn enrolled in the Health Plan for up to the first three (3) months of life, provided the newborn was enrolled through the unborn activation process.. AMERIGROUP Florida, Inc. d/b/a Medicaid Non-Reform and Reform AMERIGROUP Community Care HMO Contract a. The Health Plan shall use the unborn activation process to enroll all babies born to pregnant enrollees as specified in Attachment II, Section III, Eligibility and Enrollment, B.3, Unborn Activation and Newborn Enrollment. b. The Health Plan is responsible for payment of all covered services provided to newborns enrolled through the unborn activation process.

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.”titled 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 eligibility category. 3. At such time as the Agency receives legislative direction to assess Health Plans for enrollment and disenrollment services costs, the Agency shall apply assessments, in quarterly installments each Contract year, against the Health Plan’s next capitation payment to pay for the enrollment and disenrollment services contractor as follows: a. July 1, for costs estimated for the Agency’s enrollment and disenrollment services contractor system and Contract for July and the following two (2) months. b. October 1, for costs related to the third party enrollment and disenrollment services Contract for October and the following two (2) months. c. January 1, for costs related to maintaining the third party enrollment and services Contract for January and the following two (2) months. d. April 1, for costs related to maintaining the third party enrollment and disenrollment services contract for April and the following two (2) months. 4. Unless otherwise specified in this Contract, the Health Plan shall accept the capitation payment received each month as payment in full by the Agency for all services provided to enrollees covered under this Contract and the administrative costs incurred by the Health Plan in providing or arranging for such services. Any and all costs incurred by the Health Plan in excess of the capitation payment shall be borne in total by the Health Plan. 5. The Agency shall pay a retroactive capitation rate for each newborn enrolled in the Health Plan for up to the first three (3) months of life, provided the newborn was enrolled through the unborn activation process. a. The Health Plan shall use the unborn activation process to enroll all babies born to pregnant enrollees as specified in Attachment II, Section III, Eligibility and Enrollment, B.3, Unborn Activation and Newborn Enrollment. b. The Health Plan is responsible for payment of all covered services provided to newborns enrolled through the unborn activation process.