Common use of Determination of Rates Clause in Contracts

Determination of Rates. A. DHCS shall determine an actuarially sound the capitation rates per Enrollee to be paid under this Contract, in accordance with Federal Medicaid principles and the provisions of Welfare and Institutions Code Section 15910.3. Rates shall be reflected in Exhibit B, Budget Detail and Payment Provisions. B. Contractor shall be entitled to payment of rates on a quarterly basis based on the number of Enrollees in the LIHP for that quarter, determined in accordance with instructions issued by DHCS. C. Rate payments shall be made only to the extent that DHCS has received intergovernmental transfers from the Contractor, a governmental entity with which it is affiliated, or any other eligible public entity that voluntarily agrees to participate in funding the LIHP in an amount adequate to fund the non-federal share of the rates, as authorized in State Law. D. DHCS shall consult with Contractor in the development of the capitation rate, and shall base the capitation rate upon a detailed proposal submitted by Contractor pursuant to Welfare and Institutions Code Section 15910.3(a). E. DHCS shall determine the Contractor’s capitation rates annually, beginning with Demonstration Year 7. The capitation rates shall be determined prior to the beginning of the Demonstration Year. However, for Demonstration Year 7, Contractor shall be paid on a cost-basis using CPEs on an interim basis only until the capitation rate is determined. Upon final approval, the capitation rate for Demonstration Year 7 will be paid retroactive to July 1, 2011 and reconciled against the interim payments received by Contractor based on CPEs for the interim period. F. Once DHCS has established actuarially sound capitation rates, it may in consultation with Contractor, determine capitation rates for subsequent years based on appropriate increases or decreases to that rate. Any changes to the capitation rate shall be effectuated through a change order to this Contract in accordance with the provisions of Exhibit F, Program Terms and Conditions, Provision 3, Amendment Process and 4, Change Requirements, subject to the following provisions: 1) The change order shall be effective as of July 1 of each year covered by this Contract. 2) In the event there is any delay in a determination to increase or decrease capitation rates, so that a change order may not be processed in time to permit payment of new rates commencing July 1, the payment to Contractor shall continue at the rates then in effect. Those continued payments shall constitute interim payment only. Upon final approval of the change order providing for the rate change, DHCS shall make retroactive adjustments for those months for which interim payment was made. 3) By accepting payment of new annual rates prior to full approval by all control agencies of the change order to this Contract implementing such new rates, Contractor stipulates to a confession of judgment for any amounts received in excess of the final approved rate. If the final approved rate differs from the rates established by DHCS or agreed upon by Contractor and DHCS: a) Any underpayment by the State shall be paid to Contractor within 30 calendar days after final approval of the new rates. b) The FFP amount of any overpayment to Contractor shall be recaptured by the State's withholding the amount due from Contractor's next capitation check. If the amount to be withheld from that capitation check exceeds 25 percent of the capitation payment for that month, amounts up to 25 percent shall be withheld from successive capitation payments until the overpayment is fully recovered by the State. 4) DHCS shall not redetermine rates pursuant to this section or Provision 6, below without consulting with Contractor. G. If mutual agreement between DHCS and Contractor cannot be attained on capitation rates, Contractor shall retain the right to terminate the Contract, or to elect to be reimbursed under this Contract on a cost basis.

Determination of Rates. A. DHCS shall DHS will determine an actuarially sound the capitation rates per Enrollee for the initial period December 1, 1995, or the Contract effective date of operations if later, through September 30, 1997. Subsequent to be paid under this September 30, 1997 and through the duration of the Contract, in accordance with Federal Medicaid principles DHS will make an annual redetermination of rates for each rate year defined as the 12 month period from October 1, through September 30. DHS reserves the right to redetermine rates on an actuarial basis or move to a negotiated rate for each rate year. All payments beyond June 1996 and rate adjustments beyond September 1997 are subject to future appropriations of funds by the Legislature and the provisions Department of Welfare and Institutions Code Section 15910.3Finance approval. Rates shall be reflected in Exhibit BFurther, Budget Detail and Payment Provisions. B. Contractor shall be entitled all payments are subject to payment the availability of Federal congressional appropriation of funds. If DHS redetermines rates on a quarterly basis based on an actuarial basis, DHS will determine whether the number of Enrollees in rates will be increased, decreased, or remain the LIHP for same. If it is determined by DHS that quarter, determined in accordance with instructions issued by DHCS. C. Rate payments shall be made only to the extent that DHCS has received intergovernmental transfers from the Contractor, a governmental entity with which it is affiliated, or any other eligible public entity that voluntarily agrees to participate in funding the LIHP in an amount adequate to fund the non-federal share of the rates, as authorized in State Law. D. DHCS shall consult with Contractor in the development of the capitation rate, and shall base the capitation rate upon a detailed proposal submitted by Contractor pursuant to Welfare and Institutions Code Section 15910.3(a). E. DHCS shall determine the Contractor’s 's capitation rates annually, beginning with Demonstration Year 7. The capitation rates shall be determined prior to the beginning of the Demonstration Year. However, for Demonstration Year 7, Contractor shall be paid on a cost-basis using CPEs on an interim basis only until the capitation rate is determined. Upon final approval, the capitation rate for Demonstration Year 7 will be paid retroactive to July 1increased or decreased, 2011 and reconciled against the interim payments received by Contractor based on CPEs for the interim period. F. Once DHCS has established actuarially sound capitation rates, it may in consultation with Contractor, determine capitation rates for subsequent years based on appropriate increases that increase or decreases to that rate. Any changes to the capitation rate shall decrease will be effectuated through a change order Change Order to this Contract in accordance with the provisions of Exhibit FArticle III, Program Terms and Conditions, Provision 3, Amendment Process and 4Section 3.34, Change Requirements, subject to the following provisions: 1) A. The change order shall Change Order will be effective as of July October 1 of each year covered by this Contract. 2) B. In the event there is a any delay in a determination to increase or decrease capitation rates, so that a change order Change Order may not be processed in time to permit payment of new rates commencing July October 1, the payment to the Contractor shall will continue at the rates then in effect. Those continued payments shall will constitute interim payment only. Upon final approval of the change order Change Order providing for the rate change, DHCS shall DHS will make retroactive adjustments for those months for which interim payment was made. 3) C. Notwithstanding paragraph B, payment of the new annual rates will commence no later than December 1, provided that a Change Order providing for the new annual rates has been issued by DHS. By accepting payment of new annual rates prior to full approval by all control agencies of the change order Change Order to this Contract implementing such new rates, the Contractor stipulates to a confession of judgment for any amounts received in excess of the final approved rate. If the final approved rate differs from the rates established by DHCS or agreed upon by the Contractor and DHCSDHS: a) 1. Any underpayment by the State shall will be paid to the Contractor within 30 calendar days after final approval of the new rates.. 50 Xxxxxx Medical Centers 95-23637 ARTICLE V b) The FFP amount of any 2. Any overpayment to the Contractor shall will be recaptured by the State's withholding the amount due from the Contractor's next capitation check. If the amount to be withheld from that capitation check exceeds 25 percent of the capitation payment for that month, amounts up to 25 percent shall will be withheld from successive capitation payments until the overpayment is fully recovered by the State. 4) DHCS shall not redetermine rates pursuant to this section or Provision 6, below without consulting with Contractor. G. If mutual agreement between DHCS and Contractor cannot be attained on capitation rates, Contractor shall retain the right to terminate the Contract, or to elect to be reimbursed under this Contract on a cost basis.

Determination of Rates. A. DHCS DHS shall determine an actuarially sound the capitation rates per Enrollee for the initial period December 1, 1995, or the Contract effective date of operations if later, through September 30, 1997. Subsequent to be paid under this September 30, 1997 and through the duration of the Contract, in accordance with Federal Medicaid principles DHS shall make an annual redetermination of rates for each rate year defined as the 12-month period from October 1, through September 30. DHS reserves the right to redetermine rates on an actuarial basis or move to a negotiated rate for each rate year. All payments beyond June 1996 and rate adjustments beyond September 1997 are subject to future appropriations of funds by the Legislature and the provisions Department of Welfare Finance approval. Further, all payments are subject to Xxxxx 00, XXX 447.361 and Institutions Code Section 15910.3the availability of Federal congressional appropriation of funds. Rates If DHS redetermines rates on an actuarial basis, DHS shall determine whether the rates shall be reflected in Exhibit Bincreased, Budget Detail and Payment Provisions. B. Contractor shall be entitled to payment of rates on a quarterly basis based on decreased, or remain the number of Enrollees in the LIHP for that quarter, determined in accordance with instructions issued by DHCS. C. Rate payments shall be made only to the extent that DHCS has received intergovernmental transfers from the Contractor, a governmental entity with which same. If it is affiliated, or any other eligible public entity determined by DHS that voluntarily agrees to participate in funding the LIHP in an amount adequate to fund the non-federal share of the rates, as authorized in State Law. D. DHCS shall consult with Contractor in the development of the capitation rate, and shall base the capitation rate upon a detailed proposal submitted by Contractor pursuant to Welfare and Institutions Code Section 15910.3(a). E. DHCS shall determine the Contractor’s capitation rates annually, beginning with Demonstration Year 7. The 's capitation rates shall be determined prior to the beginning of the Demonstration Year. Howeverincreased or decreased, for Demonstration Year 7, Contractor shall be paid on a cost-basis using CPEs on an interim basis only until the capitation rate is determined. Upon final approval, the capitation rate for Demonstration Year 7 will be paid retroactive to July 1, 2011 and reconciled against the interim payments received by Contractor based on CPEs for the interim period. F. Once DHCS has established actuarially sound capitation rates, it may in consultation with Contractor, determine capitation rates for subsequent years based on appropriate increases that increase or decreases to that rate. Any changes to the capitation rate decrease shall be effectuated through a change order Change Order to this Contract in accordance with the provisions of Exhibit FArticle III, Program Terms and Conditions, Provision 3, Amendment Process and 4Section 3.35, Change Requirements, subject to the following provisions: 1) A. The change order Change Order shall be effective as of July October 1 of each year covered by this Contract. 2) B. In the event there is any delay in a determination to increase or decrease capitation rates, so that a change order Change Order may not be processed in time to permit payment of new rates commencing July October 1, the payment to Contractor shall continue at the rates then in effect. Those continued payments shall constitute interim payment only. Upon final approval of the change order Change Order providing for the rate change, DHCS DHS shall make retroactive adjustments for those months for which interim payment was made.. XXXXXX MEDICAL CENTERS, INC. 95-23637-A03 3) C. Notwithstanding paragraph B, payment of the new annual rates shall commence no later than December 1, provided that a Change Order providing for the new annual rates has been issued by DHS. By accepting payment of new annual rates prior to full approval by all control agencies of the change order Change Order to this Contract implementing such new rates, Contractor stipulates to a confession of judgment for any amounts received in excess of the final approved rate. If the final approved rate differs from the rates established by DHCS or agreed upon by Contractor and DHCSDHS: a) 1. Any underpayment by the State shall be paid to Contractor within 30 calendar days after final approval of the new rates. b) The FFP amount of any 2. Any overpayment to Contractor shall be recaptured by the State's withholding the amount due from Contractor's next capitation check. If the amount to be withheld from that capitation check exceeds 25 percent of the capitation payment for that month, amounts up to 25 percent shall be withheld from successive capitation payments until the overpayment is fully recovered by the State. 4) DHCS shall not redetermine rates pursuant to this section or Provision 6, below without consulting with Contractor. G. D. If mutual agreement between DHCS DHS and Contractor cannot be attained on capitation ratesrates for rate years subsequent to September 30, 1997 (resulting from a rate change pursuant to Section 5.5 or 5.6), Contractor shall retain the right to terminate the Contract, but no earlier than September 30, 1998. Notification of intent to terminate a Contract shall be in writing and provided to DHS at least nine (9) months prior to the effective date of termination, subject to any earlier termination date negotiated in accordance with Article III, Section 3.18.2, Termination - Contractor. DHS shall pay the capitation rates last offered for that rate period until the Contract is terminated. E. DHS shall make every effort to notify and consult with Contractor regarding proposed redetermination of rates pursuant to this section or Section 5.6 at the earliest possible time prior to elect implementation of the new rate. XXXXXX MEDICAL CENTERS, INC. 95-23637-A03 81. Article V, PAYMENT PROVISIONS, Section 5.6, Redetermination of Rates - Obligation Changes, is amended to be reimbursed under this Contract on a cost basis.read:

Determination of Rates. A. DHCS CDHS shall determine the capitation rates for the initial period April 1, 2007 or the Contract effective date of operations, through September 30, 2007. Subsequent to September 30, 2007 and through the duration of the Contract, CDHS shall make an annual redetermination of rates in accordance with Title 22, CCR, Section 53869 for each rate year defined as the 12-month period from October 1, through September 30. CDHS reserves the right to establish rates on an actuarial basis for each rate year. All payments and rate adjustments are subject to appropriations of funds by the Legislature and the Department of Finance approval. Further, all payments are subject to the availability of Federal congressional appropriation of funds. B. Once CDHS establishes rates on an actuarially sound basis, it shall determine whether the capitation rates per Enrollee to be paid under this Contract, in accordance with Federal Medicaid principles and the provisions of Welfare and Institutions Code Section 15910.3. Rates shall be reflected in Exhibit Bincreased, Budget Detail and Payment Provisions. B. Contractor shall be entitled to payment of rates on a quarterly basis based on decreased, or remain the number of Enrollees in the LIHP for that quarter, determined in accordance with instructions issued by DHCS. C. Rate payments shall be made only to the extent that DHCS has received intergovernmental transfers from the Contractor, a governmental entity with which same. If it is affiliated, or any other eligible public entity determined by CDHS that voluntarily agrees to participate in funding the LIHP in an amount adequate to fund the non-federal share of the rates, as authorized in State Law. D. DHCS shall consult with Contractor in the development of the capitation rate, and shall base the capitation rate upon a detailed proposal submitted by Contractor pursuant to Welfare and Institutions Code Section 15910.3(a). E. DHCS shall determine the Contractor’s capitation rates annually, beginning with Demonstration Year 7. The capitation rates shall be determined prior to the beginning of the Demonstration Year. However, for Demonstration Year 7, Contractor shall be paid on a cost-basis using CPEs on an interim basis only until the capitation rate is determined. Upon final approvalincreased or decreased, the capitation rate for Demonstration Year 7 will be paid retroactive to July 1, 2011 and reconciled against the interim payments received by Contractor based on CPEs for the interim period. F. Once DHCS has established actuarially sound capitation rates, it may in consultation with Contractor, determine capitation rates for subsequent years based on appropriate increases increase or decreases to that rate. Any changes to the capitation rate decrease shall be effectuated through a change order to this Contract in accordance with the provisions of Exhibit FE, Program Terms and ConditionsAttachment 2, Provision 3, Amendment Process and provision 4, . Change Requirements, subject to the following provisions: 1) The change order shall be effective as of July October 1 of each year covered by this Contract. 2) In the event there is any delay in a determination to increase or decrease capitation rates, so that a change order may not be processed in time to permit payment of new rates commencing July October 1, the payment to Contractor shall continue at the rates then in effect. Those continued payments shall constitute interim payment only. Upon final approval of the change order providing for the rate change, DHCS CDHS shall make retroactive adjustments for those months for which interim payment was made. 3) By accepting payment of new annual rates prior to full approval by all control agencies of the change order to this Contract implementing such new rates, Contractor stipulates to a confession of judgment for any amounts received in excess of the final approved rate. If the final approved rate differs from the rates established by DHCS CDHS or agreed upon by Contractor and DHCSCDHS: a) Any underpayment by the State shall be paid to Contractor within 30 calendar days after final approval of the new rates. b) The FFP amount of any Any overpayment to Contractor shall be recaptured by the State's ’s withholding the amount due from Contractor's ’s next capitation check. If the amount to be withheld from that capitation check exceeds 25 percent of the capitation payment for that month, amounts up to 25 percent shall be withheld from successive capitation payments until the overpayment is fully recovered by the State. 4) DHCS shall not redetermine rates pursuant to this section or Provision 6, below without consulting with Contractor. G. If mutual agreement between DHCS CDHS and Contractor cannot be attained on capitation ratesrates for rate years subsequent to September 30, 2007 resulting from a rate change pursuant to this provision 6 or provision 7 below, Contractor shall retain the right to terminate the Contract, but no earlier than September 30, 2008. Notification of intent to terminate a Contract shall be in writing and provided to CDHS at least nine months prior to the effective date of termination, subject to any earlier termination date negotiated in accordance with Exhibit E, Attachment 2, provision 14, regarding Termination – Contractor. CDHS shall pay the capitation rates last offered for that rate period until the Contract is terminated. 5) CDHS shall make every effort to notify and consult with Contractor regarding proposed redetermination of rates pursuant to this section or provision 7, below at the earliest possible time prior to elect to be reimbursed under this Contract on a cost basisimplementation of the new rate.