Common use of CONTRACTOR/HHS RESPONSIBILITY Clause in Contracts

CONTRACTOR/HHS RESPONSIBILITY. 1. The Contractor will not be responsible for the costs of covered health insurance claims filed by enrollees in the high risk pool program or for the administrative expenses of operating those programs to the extent that those claims and administrative expenses are in excess of the premiums collected by the high risk pool program. The Contractor will be responsible for operating the high risk pool program in accordance with the terms of the contract. HHS will pay or reimburse the Contractor for claims for covered services and for administrative expenses that are in excess of the premiums collected by the Contractor. Contractor agrees to use its best efforts, in consultation with HHS, to limit the amount of anticipated expenses to the amounts identified in this contract or any modification thereto, for Contractor’s operation of the high risk pool program. 2. The Contractor acknowledges that HHS, as are all Government agencies, is bound by certain laws limiting the available funds for programs and, in particular the appropriation set out in section 1101 of the Affordable Care Act, as may be amended from time to time. For this reason the Contractor has the following responsibilities: (a) The Contractor shall notify HHS within 5 business days of reaching a number of active high risk pool enrollees that equals or exceeds 75% of the enrollment projected for the current time period in Table 2 of the Cost Proposal. (b) As part of each monthly report, the Contractor will notify HHS if its available claims data indicate that the projected claims for the year to date would result in the Contractor exceeding the per member per month claims amounts projected in Table 2 of the Cost Proposal.. (c) The Contractor shall notify HHS within 5 business days of learning of any potential future development or event that is likely to cause the Contractor to exceed 75% of the projected enrollment, or is likely to cause the Contractor to project that Total Claims Against the Federal Fund Allotment would exceed the amounts as projected in Table 2 of the Cost Proposal. 3. In the event an action is brought against the Contractor in any court or administrative forum regarding the operation or performance of this Contract, the Contractor shall immediately, as described in paragraph G.18 of this Contract, notify HHS and provide a copy of the complaint and summons or other documentation to HHS. HHS will, upon notification and after consultation with the U.S. Department of Justice, determine whether it will intervene in, or otherwise defend, the action brought against the Contractor and promptly notify the Contractor of this decision in writing. 4. The Contractor will not be responsible for the defense of, or the cost to defend any action brought against HHS, the Contractor, or HHS and the Contractor relating to (1) the constitutionality or legality of the Affordable Care Act or this contract; (2) any policies, procedures or operational requirements implemented by HHS or by Contractor at HHS’s direction, or actions undertaken or omissions made by HHS, in relation to this contract; (3) inability to cover individuals or pay claims because of the unavailability of federal funding; or (4) the Contractor’s operation of the high risk pool program in accordance with the terms of this Contract. 5. The Contractor will provide information and support to assist HHS in defending any such action as requested by HHS. 6. The Contractor's costs associated with any law suit, including monetary judgment, will be an allowable expense insofar as permitted under OMB Circular A-87, “Cost Principles for State, Local, and Indian Tribal Governments, and will not be subject to the 10 percent limitation under C.3, below. 7. Nothing in this Contract shall be deemed a waiver of HHS's right to prosecute any claim under the False Claims Act, any Federal criminal violation, or any violation of the Internal Revenue Code. 8. This provision shall survive termination of this Contract for any reason, so long as the action stems from, or is the result of, the operation of the program or the performance of this Contract.