Medicaid Medical Loss Ratio Sample Clauses

Medicaid Medical Loss Ratio. (MLR). If at any point for Medicaid rating periods beginning on or after July 1, 2017, the joint MLR covering both Medicare and Medicaid, as described above in 4.3.1, ceases, the Contractor is required to calculate and report their MLR experience for Medicaid, consistent with the requirements at 42 CFR 42 C.F.R. §438.4, §438.5, §438.8 and §438.74.
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Medicaid Medical Loss Ratio. If at any point for Medicaid rating periods beginning on or after July 1, 2017, the joint MLR covering both Medicare and Medicaid, as described in Section 4.3.1, ceases, the ICO is required to calculate and report their MLR experience for Medicaid consistent with the requirements at 42 C.F.R. §§ 438.4, 438.5, 438.8 and 438.74. 6. This Addendum deletes Subsection 4.4.3.8 and replaces it with the following Subsection 0.0.0.0:
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Medicaid Medical Loss Ratio. The MCO is required to maintain a Medical Loss Ratio (MLR) of at least eighty five (85) percent during the fiscal year reporting period for both the Mountain Health Trust (TANF and SSI populations) and West Virginia Health Bridge programs. The Department will calculate MLR for each MCO program using the methodology as described in Appendix H of this Contract. If the MCO reports a MLR of less than eighty-five (85) percent for the Mountain Trust Health or West Virginia Health Bridge program, the MCO must rebate one hundred (100) percent of the amount under to the Department using the methodology, time and form described in Appendix H of this Contract. For the Mountain Health Trust and West Virginia Health Bridge program, any MLR percentage less than eighty-five (85) percent shall be reimbursable to the State. The MCO is responsible for a fifty (50) percent share of any MLR less than eighty-eight (88) but greater than eighty-five (85) percent. The Department may exclude the MCO from the MLR reporting requirement for the first Contract year it is present in a state.
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Medicaid Medical Loss Ratio. If at any point for Medicaid rating periods beginning on or after July 1, 2017, the joint MLR covering both Medicare and Medicaid, as described in Section 4.3.1, ceases, the ICO is required to calculate and report their MLR experience for Medicaid consistent with the requirements at 42 C.F.R. §§ 438.4, 438.5, 438.8 and 438.74. Payment Terms Timing of Capitation Payments CMS and MDHHS will each make monthly Capitation Payments to the ICO. If an individual is enrolled with the ICO on the first day of a month, the ICO has the responsibility of providing Covered Services to that Enrollee for that month, even if the Enrollee moves to another locality. Any and all costs incurred by the ICO in excess of the Capitation Payment will be borne in full by the ICO, except as described in Section 4.3.1 and in the application of rules related to Medicare Part D. The ICO shall accept MDHHS electronic transfer of funds to receive Capitation Payments. The Medicare Parts A/B Component will be the product of the Enrollee’s CMS-HCC risk score multiplied by the relevant standard county payment rate (or the ESRD dialysis State rate by the HCC ESRD risk score, as applicable). The Medicare Part D Component will be the product of the Enrollee’s RxHCC risk score multiplied by the Part D NAMBA, with the addition of the estimated average monthly prospective payment for the low-income cost sharing subsidy and federal reinsurance amounts. The Medicaid Component for each rate cell will be the product of the number of Enrollees in each category multiplied by the payment rate for that rate cell. Enrollee contribution to care amounts (Patient Pay Amounts (PPA) for Enrollees on a traditional Medicaid nursing home stay) will be deducted from the Medicaid Component of the monthly Capitation Payment amount, in accordance with Section 4.2.1. Enrollments CMS will make monthly PMPM Capitation Payment to the ICO. The PMPM Capitation Payment for a particular month will reflect payment for the Enrollees with effective Enrollment into the ICO as of the first day of that month. MDHHS will make monthly PMPM Capitation Payments to the ICO prospectively for the current month’s Enrollment (e.g., payment for June Enrollment will occur in June). The PMPM Capitation Payment for a particular month will reflect payment for the Enrollees with effective Enrollment into the ICO as of the first day of the current month. Disenrollments The final PMPM Capitation Payment...
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Related to Medicaid Medical Loss Ratio

  • Family Care and Medical Leave An unpaid Family Care and Medical Leave shall be granted, to the extent of and subject to the restrictions as set forth below, to an employee who has been employed for at least twelve (12) months and who has served for 130 workdays during the twelve (12) months immediately preceding the effective date of the leave. For purposes of this Section, furlough days and days worked during off-basis time shall count as "workdays". Family Care and Medical Leave absences of twenty (20) consecutive working days or less can be granted by the immediate administrator or designee. Leaves of twenty (20) or more consecutive working days can be granted only by submission of a formal leave application to the Personnel Commission.

  • Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.

  • Federal Medicaid System Security Requirements Compliance Party shall provide a security plan, risk assessment, and security controls review document within three months of the start date of this Agreement (and update it annually thereafter) in order to support audit compliance with 45 CFR 95.621 subpart F, ADP System Security Requirements and Review Process.

  • Family and Medical Leave (FMLA FMLA leave shall be granted pursuant to applicable law.

  • Compassionate Care Leave 1. For the purposes of this article “family member” means:

  • Dental Care Plan The Welfare Plan will include a Dental Care Plan which will reimburse members for expenses incurred in respect of the coverages summarized in Appendix "1". The Plan will not duplicate benefits provided now or which may be provided in the future by any government program.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE

  • Medicaid Enrollment Treatment Grantees shall enroll as a provider with Texas Medicaid and Healthcare Partnership (TMHP) and all Medicaid Managed Care organizations in Grantee’s service region within the first quarter of this procurement term and maintain through the procurement term.

  • Durable Medical Equipment (DME), Medical Supplies, Prosthetic Devices, Enteral Formula or Food, and Hair Prosthesis (Wigs) This plan covers durable medical equipment and supplies, prosthetic devices and enteral formula or food as described in this section. DME is equipment which: • can withstand repeated use; • is primarily and customarily used to serve a medical purpose; • is not useful to a person in the absence of an illness or injury; and • is for use in the home. DME includes supplies necessary for the effective use of the equipment. This plan covers the following DME: • wheelchairs, hospital beds, and other DME items used only for medical treatment; and • replacement of purchased equipment which is needed due to a change in your medical condition or if the device is not functional, no longer under warranty, or cannot be repaired. DME may be classified as a rental item or a purchased item. In most cases, this plan only pays for a rental DME up to our allowance for a purchased DME. Repairs and supplies for rental DME are included in the rental allowance. Medical supplies are consumable supplies that are disposable and not intended for re- use. Medical supplies require an order by a physician and must be essential for the care or treatment of an illness, injury, or congenital defect. Covered medical supplies include: • essential accessories such as hoses, tubes and mouthpieces for use with medically necessary DME (these accessories are included as part of the rental allowance for rented DME); • catheters, colostomy and ileostomy supplies, irrigation trays and surgical dressings; and • respiratory therapy equipment. This plan covers diabetic equipment and supplies for the treatment of diabetes in accordance with R.I. General Law §27-20-30. Covered diabetic equipment and supplies include: • therapeutic or molded shoes and inserts for custom-molded shoes for the prevention of amputation; • blood glucose monitors including those with special features for the legally blind, external insulin infusion pumps and accessories, insulin infusion devices and injection aids; and • lancets and test strips for glucose monitors including those with special features for the legally blind, and infusion sets for external insulin pumps. The amount you pay differs based on whether the equipment and supplies are bought from a durable medical equipment provider or from a pharmacy. See the Summary of Pharmacy Benefits and the Summary of Medical Benefits for details. Coverage for some diabetic equipment and supplies may only be available from either a DME provider or from a pharmacy. Visit our website to determine if this is applicable or call our Customer Service Department. Prosthetic devices replace or substitute all or part of an internal body part, including contiguous tissue, or replace all or part of the function of a permanently inoperative or malfunctioning body part and alleviate functional loss or impairment due to an illness, injury or congenital defect. Prosthetic devices do not include dental prosthetics. This plan covers the following prosthetic devices as required under R.I. General Law § 27-20-52: • prosthetic appliances such as artificial limbs, breasts, larynxes and eyes; • replacement or adjustment of prosthetic appliances if there is a change in your medical condition or if the device is not functional, no longer under warranty and cannot be repaired; • devices, accessories, batteries and supplies necessary for prosthetic devices; • orthopedic braces except corrective shoes and orthotic devices used in connection with footwear; and • breast prosthesis following a mastectomy, in accordance with the Women’s Health and Cancer Rights Act of 1998 and R.I. General Law 27-20-29. The prosthetic device must be ordered or provided by a physician, or by a provider under the direction of a physician. When you are prescribed a prosthetic device as an inpatient and it is billed by a provider other than the hospital where you are an inpatient, the outpatient benefit limit will apply. Enteral formula or food is nutrition that is absorbed through the intestinal tract, whether delivered through a feeding tube or taken orally. Enteral nutrition is covered when it is the sole source of nutrition and prescribed by the physician for home use. In accordance with R.I. General Law §27-20-56, this plan covers enteral formula taken orally for the treatment of: • malabsorption caused by Crohn’s Disease; • ulcerative colitis; • gastroesophageal reflux; • chronic intestinal pseudo obstruction; and • inherited diseases of amino acids and organic acids. Food products modified to be low protein are covered for the treatment of inherited diseases of amino acids and organic acids. Preauthorization may be required. The amount that you pay may differ depending on whether the nutrition is delivered through a feeding tube or taken orally. When enteral formula is delivered through a feeding tube, associated supplies are also covered. This plan covers hair prosthetics (wigs) worn for hair loss suffered as a result of cancer treatment in accordance with R.I. General Law § 27-20-54 and subject to the benefit limit and copayment listed in the Summary of Medical Benefits. This plan will reimburse the lesser of the provider’s charge or the benefit limit shown in the Summary of Medical Benefits. If the provider’s charge is more than the benefit limit, you are responsible for paying any difference. This plan covers Early Intervention Services in accordance with R.I. General Law §27- 20-50. Early Intervention Services are educational, developmental, health, and social services provided to children from birth to thirty-six (36) months. The child must be certified by the Rhode Island Department of Human Services (DHS) to enroll in an approved Early Intervention Services program. Services must be provided by a licensed Early Intervention provider and rendered to a Rhode Island resident. Members not living in Rhode Island may seek services from the state in which they reside; however, those services are not covered under this plan. Early Intervention Services as defined by DHS include but are not limited to the following: • speech and language therapy; • physical and occupational therapy; • evaluation; • case management; • nutrition; • service plan development and review; • nursing services; and • assistive technology services and devices.

  • Extended Health Care Plan ‌ The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable extended health care plan.

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