Contractor Financial Liability. Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her Effective Date of Enrollment in the Contractor's plan.
Contractor Financial Liability. 3.12 Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care (MMC) Enrollees
3.13 Mental Health Stop-Loss for MMC Enrollees
3.14 Residential Health Care Facility (Nursing Home) Stop-Loss for MMC Enrollees
3.15 Stop-Loss Documentation and Procedures for the MMC Program
3.16 Family Health Plus (FHPlus) Reinsurance
3.17 Tracking Visits Provided by Indian Health Clinics – Applies to MMC Program Only
3.18 Payment for Patient Centered Medical Homes and Adirondack Health Care Home Multipayor Demonstration Program
3.19 Prohibition on Payments to Institutions or Entities Located Outside of the United States 3.20 Primary Care Rate Increase 3.21 Payment for Long Term Placement in Residential Health Care Facilities (Nursing Homes)
Contractor Financial Liability. Inpatient Hospital Stop-Loss Insurance for Medicaid Managed Care (MMC) Enrollees
Contractor Financial Liability. Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her effective date of enrollment in the Contractor's Medicare Platino Product.
Contractor Financial Liability. Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her Effective Date of Enrollment in the Contractor's D-SNP Product.
Contractor Financial Liability. The Contractor shall be held liable for any disallowed cost incurred as a result of a participant being found ineligible or for any other cause specified under applicable laws, regulations, policies or the contract. The Contractor shall immediately reimburse the Board for any cost disallowed, in writing, by the CEO. In the event of a dispute resulting in an appeal, the Contractor, with the exception of units of state or local government, may be required by the Board, in the Board’s discretion, to pay the questioned amount to the Board pending a final decision, and such payment shall be made within 30 days from date of receipt of the CEO’s decision disallowing the questioned cost. Any appeal of a disallowed cost shall be submitted in accordance with the procedure set forth in Section 12 for disputes over questions of fact.
Contractor Financial Liability. Contractor shall not be financially liable for any services rendered to an Enrollee prior to his or her Effective Date of Enrollment in the Contractor's plan.
3.11 Inpatient Hospital Stop-Loss Insurance The Contractor must obtain stop-loss coverage for inpatient hospital services. A Contractor may elect to purchase stop-loss coverage from New York State. In such cases, the Capitation Rates paid to the Contractor shall be adjusted to reflect the cost of such stop-loss coverage. The cost of such coverage shall be determined by SDOH. Under NYS stop-loss coverage, if the hospital inpatient expenses incurred by the Contractor for an individual Enrollee during any calendar year reaches $50,000, the Contractor shall be compensated for 80% of the cost of hospital inpatient services in excess of this amount up to a maximum of $250,000. Above that amount, the Contractor will be compensated for 100% of cost. All compensation shall be based on the lower of the Contractor's negotiated hospital rate or Medicaid rates of payment. [ ] The Contractor has elected to have NYS provide stop-loss reinsurance. OR [x] Contractor has not elected to have NYS provide stop-loss reinsurance.
