Cost of Care is the valuation of Covered Services and other health care services provided or arranged by Medical Group, as described in Section 5.7.
Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred percent (100%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred percent (100%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty percent (50%) of billed charges or amount determined under PacifiCare’s Fee Schedule.
Cost of Care is the value of Medical Services as defined in this Agreement and as calculated pursuant to the formula set forth in Attachment A4, incorporated in full herein by reference.
Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, "Cost of Care" shall mean the amount determined to be payable for such health care services or Covered Services by PacifiCare as follows: (i) for professional services which are paid under the Medicare Fee Schedule, the Cost of Care shall be the lesser of billed charges or amount payable under the Medicare Fee Schedule; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) which are paid by Medicare, the Cost of Care shall be the lesser of billed charges or amount payable by Medicare; (iii) for any other Covered Services or health care services covered under a Managed Care Plan which do not fall within any of the above specified categories, other than inpatient and outpatient Hospital Services, the Cost of Care shall be the lesser of billed charges or the amount determined under PacifiCare's allowable fee schedule.
Cost of Care. Definition Cost of care for Medicaid clients with diabetes Target Population(s) • Medicaid clients with a diagnosis of diabetes Measure Xxxxxxx or Source N/A Technical Specifications Clients with diabetes have a diagnosis according to the HEDIS® Value Set: Diabetes Cost of care based on all encounters data for each client with diabetes during the measurement period Exclusion Criteria STAR+PLUS eligible members 65 years and older Medicare/Medicaid (dual eligible). Data Source(s)/ Data Collection Method(s) • Medicaid encounter data • Medicaid enrollment file Comparison Group(s)/ Subgroup(s) • RHP and/or RHP tier • Race/ethnicity Analytic Method(s) • Difference-in-difference comparison of cost of care for Medicaid clients with diabetes seen by a DSRIP performing provider versus those seen by non-DSRIP providers o Proposed pre-period: DY4 o Proposed post-period: DY8 Benchmark • None Hypothesis 1.3: DSRIP incentivized performing providers to improve quality-related outcomes, specified as Category C population-based clinical outcome measures.
Cost of Care. Certain provisions of this Agreement require that Medical Group provide health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Medical Group Services be valued at
Cost of Care. Another person who has voluntarily agreed to pay with his/her own funds (list below). _________________________________________________________________________________
Cost of Care. Certain provisions of this Agreement require that Medical Group provide health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Medical Group Services be valued at Cost of Care. For purposes of this Agreement, "Cost of Care" shall mean the amount determined under Health Plan's fee schedule, attached as EXHIBIT 1 to the Base Agreement for such services. Health Plan may revise its fee-schedule from time to time by providing thirty (30) days prior written notice to Medical Group; provided, however, that the fee schedule utilized under this Agreement shall be no less favorable to Medical Group than the fee schedule utilized by Health Plan for other Participating Providers in the state.
Cost of Care a. The self-pay Resident agrees to pay AH the sum of $ per day, payable monthly in advance for services outlined in this agreement.
b. If the Resident has filed a Medicaid application or is in the process of filing a Medicaid application, he/she must pay AH the monthly rate stated in the paragraph above until her/his Medicaid application is approved. AH shall refund any and all excess payment on the account upon receipt of the Medicaid approval.
c. If the Resident is covered by Medicaid, he/she must remit his/her monthly income from different sources, known as Net Annual Monthly Income (NAMI), to AH as specified by the Department of Social Services. It is the responsibility of the Resident or Responsible Party to remit payment within five days into the current month.
d. When a Resident applies for Medicaid coverage (while his or her Medicaid application is pending), he/she must start remitting his/her estimated NAMI to AH on a monthly basis from the desired effective date of coverage.
