Common use of Case Management Stop-Loss Clause in Contracts

Case Management Stop-Loss. A. The Case Management Program is a program in which a Member’s medical needs are assessed by PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case Manager prior to the Member achieving the applicable Case Management Stop-Loss Threshold, as described below. B. For PARTICIPATING MEDICAL GROUPs with enrollment of *** or more Member Months for the calendar year, the Case Management Stop-Loss Threshold for an individual Member shall be *** of Non-Capitated Expenses incurred during that calendar year. For PARTICIPATING MEDICAL GROUPs with enrollment of less than *** Member Months, the Case Management Stop-Loss Threshold shall be *** of Non-Capitated Expenses incurred during that calendar year. C. Authorized expenses for Member’s Non-Capitated Services, up to the Case Management Stop-Loss Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Additionally, *** of expenses between the applicable Case Management Stop-loss Threshold and *** incurred by an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Non-Capitated expenses greater than *** for any individual Member will not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. D. The Case Management Stop-loss Thresholds described above will apply to Members whose treatment includes transplants (solid organ and bone marrow/stem cell), except in those cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.

Case Management Stop-Loss. A. The Case Management Program is a program in which a Member’s medical needs are assessed by PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case Manager prior to the Member achieving the applicable Case Management Stop-Loss Threshold, as described below. B. For PARTICIPATING MEDICAL GROUPs with enrollment of *** or more Member Months for the calendar year, the Case Management Stop-Loss Threshold for an individual Member shall be *** of Non-Capitated Expenses incurred during that calendar yearExpenses. For PARTICIPATING MEDICAL GROUPs with enrollment of less than *** Member Months, the Case Management Stop-Loss Threshold shall be *** of Non-Capitated Expenses incurred during that calendar yearExpenses. C. Authorized expenses for Member’s Non-Capitated Services, up to the Case Management Stop-Loss Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Additionally, *** of expenses between the applicable Case Management Stop-loss Threshold and *** incurred by an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Non-Capitated expenses greater than *** a for any individual Member will not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. D. The Case Management Stop-loss Thresholds described above will apply to Members whose treatment includes transplants (solid organ and bone marrow/stem cell), except in those cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.

Case Management Stop-Loss. A. The Case Management Program is a program in which a Member’s medical needs are assessed by PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case Manager prior to the Member achieving the applicable Case Management Stop-Loss Threshold, as described below. B. For PARTICIPATING MEDICAL GROUPs with enrollment of *** Twenty-Four Thousand (24,000) or more Member Months for the calendar year, the Case Management Stop-Loss Threshold for an individual Member shall be *** SIXTY THOUSAND DOLLARS ($60,000.00) of Non-Capitated Expenses incurred during that calendar yearExpenses. For PARTICIPATING MEDICAL GROUPs with enrollment of less than *** Twenty-Four Thousand (24,000) Member Months, the Case Management Stop-Loss Threshold shall be *** THIRTY-FIVE THOUSAND DOLLARS ($35,000.00) of Non-Capitated Expenses incurred during that calendar yearExpenses. C. Authorized expenses for Member’s Non-Capitated Services, up to the Case Management Stop-Loss Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Additionally, *** ten percent (10%) of expenses between the applicable Case Management Stop-loss Threshold and *** ONE HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) incurred by an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Non-Non- Capitated expenses greater than *** ONE HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) for any individual Member will not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. D. The Case Management Stop-loss Thresholds described above will apply to Members whose treatment includes transplants (solid organ and bone marrow/stem cell), except in those cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.

Case Management Stop-Loss. A. The Case Management Program is a program in which a Member’s 's medical needs are assessed by PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case Manager prior to the Member achieving the applicable Case Management Stop-Loss Threshold, as described below. B. For PARTICIPATING MEDICAL GROUPs with enrollment of *[ ** ] or more Member Months for the calendar year, the Case Management Stop-Loss Threshold for an individual Member shall be *[ ** ] of Non-Capitated Expenses incurred during that calendar yearExpenses. For PARTICIPATING MEDICAL GROUPs with enrollment of less than *[ ** ] Member Months, the Case Management Stop-Loss Threshold shall be *[ ** ] of Non-Capitated Expenses incurred during that calendar yearExpenses. C. Authorized expenses for Member’s 's Non-Capitated Services, up to the Case Management Stop-Loss Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s 's PMPM Non-Capitated Expenses. Additionally, *[ ** ] of expenses between the applicable Case Management Stop-loss Threshold and *[ ** ] incurred by an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s 's PMPM Non-Capitated Expenses. Non-Capitated expenses greater than *[ ** ] for any individual Member will not be included in PARTICIPATING MEDICAL GROUP’s 's PMPM Non-Capitated Expenses. D. The Case Management Stop-loss Thresholds described above will apply to Members whose treatment includes transplants (solid organ and bone marrow/stem cell), except in those cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s 's Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s 's PMPM Non-Capitated Expenses.

Case Management Stop-Loss. A. The Case Management Program is a program in which a Member’s medical needs are assessed by PARTICIPATING MEDICAL GROUP in conjunction with a CALIFORNIACARE Case Manager to explore and coordinate treatment alternatives. PARTICIPATING MEDICAL GROUP should notify the CALIFORNIACARE Case Manager prior to the Member achieving the applicable Case Management Stop-Loss Threshold, as described below. B. For PARTICIPATING MEDICAL GROUPs with enrollment of *** Twenty-Four Thousand (24,000) or more Member Months for the calendar year, the Case Management Stop-Loss Threshold for an individual Member shall be *** SIXTY THOUSAND DOLLARS ($60,000.00) of Non-Capitated Expenses incurred during that calendar year. For PARTICIPATING MEDICAL GROUPs with enrollment of less than *** Twenty-Four Thousand (24,000) Member Months, the Case Management Stop-Loss Threshold shall be *** THIRTY-FIVE THOUSAND DOLLARS ($35,000.00) of Non-Capitated Expenses incurred during that calendar year. C. Authorized expenses for Member’s Non-Capitated Services, up to the Case Management Stop-Loss Threshold specified above will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Additionally, *** ten percent (10%) of expenses between the applicable Case Management Stop-loss Threshold and *** ONE HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) incurred by an individual Member will be accrued toward PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. Non-Capitated expenses greater than *** ONE HUNDRED AND FIFTY THOUSAND DOLLARS ($150,000) for any individual Member will not be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses. D. The Case Management Stop-loss Thresholds described above will apply to Members whose treatment includes transplants (solid organ and bone marrow/stem cell), except in those cases where PARTICIPATING MEDICAL GROUP fails to notify BLUE CROSS, as described in Section 4.02F. When PARTICIPATING MEDICAL GROUP fails to provide such notice, all of that Member’s Non-Capitated Expenses will be included in PARTICIPATING MEDICAL GROUP’s PMPM Non-Capitated Expenses.