Experience Rebate. (a) MCO’s duty to pay.
Experience Rebate. The portion of the STAR+PLUS MMP’s Net Income Before Taxes, if any, which is returned to HHSC in accordance with requirements in this Contract. The Experience Rebate calculation under this Contract will be separate and apart from the Experience Rebate calculation done for other contracts with HHSC. This Experience Rebate will not be included in the “consolidated basis” of other HHSC contracts. For the purposes of calculating the Experience Rebate under this Contract, Medicare Part D premium revenues, along with associated Medicare Part D costs, will be excluded. Costs under the Experience Rebate calculation are subject to the Admin Cap and the Reinsurance Cap.
Experience Rebate. (FSR calculation sheet)
1. Recalculate the experience rebate using the adjusted FSR and the calculation sheet, then compare these to the rebate submitted by the MTO.
2. Validate that any items used in the calculation spreadsheet as an adjustment to reported income have not been, in effect, double counted through both inclusion as an allowable expense and as an adjustment to the experience rebate calculation.
Experience Rebate. For the Initial Term, CONTRACTOR must pay to HHSC an experience rebate calculated in accordance with the tiered rebate method listed below based on the excess of allowable CHIP HMO revenues over allowable CHIP HMO expenses as measured by any positive amount on Line 7, Net Income Before Taxes, of "Part 1: CHIP Financial Summary, All Coverage Groups Combined" of the annual Financial-Statistical Report contained in Appendix D, as reviewed and confirmed by HHSC. GRADUATED REBATE METHOD ----------------------------------------------------------------------------------------------------- Experience Rebate as a CONTRACTOR Share HHSC Share Percentage of Revenues ----------------------------------------------------------------------------------------------------- Page 34 of 77 41 ----------------------------------------------------------------------------------------------------- 0% - 3% 100% 0% ----------------------------------------------------------------------------------------------------- Over 3% - 7% 75% 25% ----------------------------------------------------------------------------------------------------- Over 7% - 10% 50% 50% ----------------------------------------------------------------------------------------------------- Over 10% - 15% 25% 75% ----------------------------------------------------------------------------------------------------- Over 15% 0% 100% ----------------------------------------------------------------------------------------------------- The financial governance document for calculating the experience rebate is the governance document used in the Texas Medicaid STAR program on the Effective Date of this Agreement. Losses incurred for one contract year may be carried forward only to the next contract year. If CONTRACTOR operates in multiple CHIP Service Areas, losses in one CHIP Service Area cannot be used to offset net income before taxes in another CHIP Service Area. CONTRACTOR may subtract from an experience rebate that is owed to HHSC any expenses for population-based health initiatives that have been approved by HHSC. A population-based initiative is a project or program designed to improve some aspect of quality of care, quality of life, or health care knowledge for children and/or their adult caretakers, as a whole. There will be two settlements for payment(s) of the state share of the experience rebate. The first settlement shall equal 100% of the state share of the experience rebate as derived from Line 7, Net Income ...
Experience Rebate. (a) MCO’s duty to pay. At the end of each Rate Period beginning with Rate Period 1, the MCO must pay an Experience Rebate for the STAR and CHIP Programs if the MCO’s Net Income before Taxes is greater than the percentage set forth below of the total Revenue for the period. The Experience Rebate is calculated in accordance with the tiered rebate method set forth below based on the consolidated Net Income before Taxes for all of the MCO’s STAR and CHIP Service Areas included within the scope of the Contract, as measured by the Financial-Statistical Report (FSR) as reviewed and confirmed by HHSC.
Experience Rebate. For the Initial Term, CONTRACTOR must pay to HHSC an experience rebate calculated in accordance with the tiered rebate method listed below based on the excess of allowable CHIP HMO revenues over allowable CHIP HMO expenses as measured by any positive amount on Line 7, Net Income Before Taxes, of "Part 1: CHIP Financial Summary, All Coverage Groups Combined" of the annual Financial-Statistical Report contained in Appendix D, as reviewed and confirmed by HHSC. GRADUATED REBATE METHOD Experience Rebate as a Percentage of Revenues CONTRACTOR Share HHSC Share ---------------------- ---------------- ---------- 0% - 3% 100% 0% The financial governance document for calculating the experience rebate is the governance document used in the Texas Medicaid STAR program on the Effective Date of the Agreement. Losses incurred for one contract year may be carried forward only to the next contract year. If CONTRACTOR operates in multiple CHIP Service Areas, losses in one CHIP Service Area cannot be used to offset net income before taxes in another CHIP Service Area. CONTRACTOR may subtract from an experience rebate that is owed to HHSC any expenses for population-based health initiatives that have been approved by HHSC. A population-based initiative is a project or program designed to improve some aspect of quality of care, quality of life, or health care knowledge for children and/or their adult caretakers, as a whole. There will be two settlements for payment(s) of the state share of the experience rebate. The first settlement shall equal 100% of the state share of the experience rebate as derived from Line 7, Net Income Before Taxes, of "Part 1: CHIP Financial Summary, All Groups Combined" of the annual CHIP Financial- Statistical (CFS) Report contained in Appendix D and shall be paid on the same day the first annual CFS Report is submitted to the Administrative Services Contractor or HHSC. The second settlement shall be an adjustment to the first settlement and shall be paid to HHSC on the same day that the second annual CFS Report is submitted to the Administrative Services Contractor or HHSC if the adjustment is a payment from CONTRACTOR to HHSC. HHSC or its agent may audit or review the CFS reports. If HHSC determines that corrections to the CFS reports are required based on an HHSC audit/review or other documentation acceptable to HHSC, to determine an adjustment to the amount of the second settlement, then final adjustment shall be made within two years from the d...
Experience Rebate. The Demonstration will utilize a one-sided Experience Rebate, similar to that used in Texas’ STAR+PLUS program. This is separate from the Rebate currently used in the STAR+PLUS Program; for those groups of STAR+PLUS enrollees that are not part of this Demonstration, the previously existing STAR+PLUS Experience Rebate will continue to apply. The Experience Rebate is designed to limit the profits received by STAR+PLUS MMPs to a reasonable percentage of total revenue, and to encourage use of revenues for services rather than administrative expenses by putting a limit (Admin Cap) on the amount of administrative expenses that can be used to calculate Net Income Before Taxes when determining the Experience Rebate. The Experience Rebate will apply for all Demonstration Years and will include all Medicare A/B and Medicaid eligible costs. The Admin Cap will be introduced in Demonstration Year 2. Additional detail on the Experience Rebate will be included in the three-way contract.
1. The MMP will retain all the Net Income Before Taxes that is equal to or less than 3% of the total Revenues received by the MMP;
2. The State/CMS and the MMP will share that portion of the Net Income Before Taxes that is over 3% and less than or equal to 5% of the total Revenues received by the MMP, with 80% to the MMP and 20% to the State/CMS.
3. The State/CMS and the MMP will share that portion of the Net Income Before Taxes that is over 5% and less than or equal to 7% of the total Revenues received by the MMP, with 60% to the MMP and 40% to the State/CMS.
4. The State/CMS and the MMP will share that portion of the Net Income Before Taxes that is over 7% and less than or equal to 9% of the total Revenues received by the MMP, with 40% to the MMP and 60% to the State/CMS.
5. The State/CMS and the MMP will share that portion of the Net Income Before Taxes that is over 9% and less than or equal to 12% of the total Revenues received by the MMP, with 20% to the MMP and 80% to the State/CMS.
6. The State/CMS will recoup the entire portion of the Net Income Before Taxes that exceeds 12% of the total Revenues received by the MMP.
Experience Rebate. (a) HMO’s duty to pay.
