Common use of Cost Reconciliation Process Clause in Contracts

Cost Reconciliation Process. The aggregate PCCB is used in the Agency’s cost reconciliation process to determine cost- savings and refunds due. If the actual Medicaid costs for Health Plan covered services are less than the aggregate PCCB, then cost-savings have occurred, and the Health Plan may receive a share of those cost-savings. If the actual Medicaid costs for Health Plan covered services provided to the Health Plan’s enrollees are greater than the aggregate PCCB, then cost savings have not occurred and the Health Plan may be required to refund a portion of the administrative allocation it received. 1. The Agency’s reconciliation process will occur on a periodic basis, culminating with a final reconciliation for each reconciliation period. 2. In performing the reconciliation process, the Agency will compare actual Medicaid payments for Health Plan covered services, paid for by the Agency on behalf of Health Plan enrollees, to the aggregate PCCB for the time period being reconciled. 3. For Reform enrollees, the following reconciliation specifications also apply: a. Enrollees with HIV or AIDS, who are identified as a result of the reconciliation process, but not by the Health Plan prior to enrollment processing for the month for which enrollment payment is made, will not be reclassified to the higher rate. See Attachment II, Section XII, Reporting Requirements, Table 1, for information regarding the HIV/AIDS reporting requirements. b. If the Health Plan provides services for which kick payments would have been paid under a capitated health plan contract, these payments will be added to the aggregate PCCB for reconciliation in the amounts and for the procedure codes listed in Attachment I for services for which claims are submitted. c. For a Health Plan that receives a capitated payment for Reform transportation, transportation services will not be included in the actual Medicaid costs for Health Plan covered services used in the reconciliation.

Cost Reconciliation Process. The aggregate PCCB is used in the Agency’s cost reconciliation process to determine cost- savings and refunds due. If the actual Medicaid costs for Health Plan covered services are less than the aggregate PCCB, then cost-savings have occurred, and the Health Plan may receive a share of those cost-savings. If the actual Medicaid costs for Health Plan covered services provided to the Health Plan’s enrollees are greater than the aggregate PCCB, then cost savings have not occurred and the Health Plan may be required to refund a portion of the administrative allocation it received. 1. The Agency’s reconciliation process will occur on a periodic basis, culminating with a final reconciliation for each reconciliation period. 2. In performing the reconciliation process, the Agency will compare actual Medicaid payments for Health Plan covered services, paid for by the Agency on behalf of Health Plan enrollees, to the aggregate PCCB for the time period being reconciled. 3. For Reform enrollees, the following reconciliation specifications also apply: a. Enrollees with HIV or AIDS, who are identified as a result of the reconciliation process, but not by the Health Plan prior to enrollment processing for the month for which enrollment payment is made, will not be reclassified to the higher rate. See Attachment II, Section XII, Reporting Requirements, Table 1, for information regarding the HIV/AIDS reporting requirements. b. If the Health Plan provides services for which kick payments would have been paid under a capitated health plan contract, these payments will be added to the aggregate PCCB for reconciliation in the amounts and for the procedure codes listed in Attachment I for services for which claims are submitted. c. For a Health Plan that receives a capitated payment for Reform transportation, transportation services will not be included in the actual Medicaid costs for Health Plan covered services used in the reconciliation.

Cost Reconciliation Process. The aggregate PCCB is used in the Agency’s cost reconciliation process to determine cost- savings and refunds due. If the actual Medicaid costs for Health Plan covered services are less than the aggregate PCCB, then cost-savings have occurred, and the Health Plan may receive a share of those cost-savings. If the actual Medicaid costs for Health Plan covered services provided to the Health Plan’s enrollees are greater than the aggregate PCCB, then cost savings have not occurred and the Health Plan may be required to refund a portion of the administrative allocation it received. 1. The Agency’s reconciliation process will occur on a periodic basis, culminating with a final reconciliation for each reconciliation period. 2. In performing the reconciliation process, the Agency will compare actual Medicaid payments for Health Plan covered services, paid for by the Agency on behalf of Health Plan enrollees, to the aggregate PCCB for the time period being reconciled. 3. For Reform enrollees, the following reconciliation specifications also apply: a. Enrollees with HIV or AIDS, who are identified as a result of the reconciliation process, but not by the Health Plan prior to enrollment processing for the month for which enrollment payment is made, will not be reclassified to the higher rate. See Attachment II, Section XII, Reporting Requirements, Table 1, for information regarding the HIV/AIDS reporting requirements. b. If the Health Plan provides services for which kick payments would have been paid under a capitated health plan contract, these payments will be added to the aggregate PCCB for reconciliation in the amounts and for the procedure codes listed in Attachment I for services for which claims are submitted. c. For a Health Plan that receives a capitated payment for Reform transportation, transportation services will not be included in the actual Medicaid costs for Health Plan covered services used in the reconciliation.