HOSPITAL SERVICES EXPENSE. Hospital Services Expense shall be valued as the total of the following:
1. INPATIENT EXPENSE AT HOSPITAL - Inpatient costs for Hospital Services rendered at Hospital valued at the amount paid to Hospital by PacifiCare; PLUS
2. NON-INPATIENT EXPENSES AT HOSPITAL - Other Hospital Services provided by Hospital other than inpatient services valued at the amount paid to Hospital by PacifiCare; PLUS
3. HOSPITAL SERVICES NOT PROVIDED AT HOSPITAL - The actual amount paid by PacifiCare for Hospital Services not provided by Hospital; MINUS
4. REINSURANCE LIMIT - Any amount of Hospital Services Expense, as defined in subsection (c)(1)-(3) above, in excess of [ ** ] per Subscriber per Year. The [ ** ] deductible shall be effective during the Initial Term. If less than seven hundred fifty (750) Subscribers have designated IPA as their Participating Medical Group as of the anniversary of the Commencement Date, the deductible shall remain at [ ** ] for the succeeding term. If greater than seven hundred fifty (750) Subscribers have designated IPA as their Participating Medical Group as of the anniversary of the Commencement Date, the IPA will be offered the standard reinsurance package as is offered to the other Participating Medical Groups during that particular contract term.
5. COORDINATION OF BENEFITS - Any amount received by PacifiCare from third parties as described in Section 3.08 of this Agreement.
HOSPITAL SERVICES EXPENSE. Hospital Services Expense shall be equal to the sum of the following:
a. INPATIENT EXPENSES AT HOSPITAL - Inpatient costs for services rendered at Hospital shall be valued as outlined in Hospital Services Valuation Schedule (Attachment A4); PLUS,
b. NON-INPATIENT EXPENSES AT HOSPITAL - Other Hospital Services provided by Hospital other than inpatient services shall be valued as outlined in Hospital Services Valuation Schedule (Attachment A4) plus,
c. HOSPITAL SERVICES NOT PROVIDED AT HOSPITAL - The actual amount paid (1) out of the Claims Fund Withhold Amount for Outside Providers or to PacifiCare contracting hospitals other than Hospital; and (2) to providers who render covered Hospital Services outside the Service Area, provided that such services must be non-Emergency services authorized in writing by IPA, including admissions for services which are not available within the Service Area; MINUS,
d. REINSURANCE LIMIT - Any amount of Hospital Services Expense, as defined in 3(a) through (c) above, in excess of [ ** ] per Subscriber per Year; MINUS,
e. COORDINATION OF BENEFITS - Any amount Hospital receives from third parties pursuant to Section 3.08 of the Hospital Partial Risk Services Agreement between PacifiCare and Hospital. 4a. BUDGET DEFICIT - If the annual Hospital Services Expense is greater than the Hospital Services Budget upon completion of the annual calculation, the amount of this excess will be referred to as the Budget Deficit. In the event of a Budget Deficit, PacifiCare shall pay the Hospital [ ** ] of the Budget Deficit up to [ ** ] per Year. PacifiCare shall adjust IPA's Capitation Payment by retaining [ ** ] of the IPA's subsequent Capitation Payment each month until the Budget Deficit amount is paid in full by PacifiCare, on behalf of IPA, to Hospital. In the event of termination of this Agreement, PacifiCare, on behalf of IPA, shall reimburse Hospital any surplus amounts owed to Hospital within sixty (60) days of receipt of the final audited annual calculation. 4b. BUDGET SURPLUS - If the annual Hospital Services Expense is less than the Hospital Services Budget for any Year, the amount of this excess shall be referred to as a Budget Surplus. In the event of a Budget Surplus, PacifiCare shall pay IPA [ ** ] of the Budget Surplus plus a per-member-per-month ("PMPM") bonus as outlined in Attachment A4. PacifiCare will adjust Hospital's Capitation Payment by retaining [ ** ] of Hospital's Capitation Payment from the subsequent month and ...
