Medical Loss Ratio Adjustment. Annually on a state fiscal year basis, the total annual Capitation Payment made to the Contractor for the combined ACA and Non-ACA populations and their associated healthcare costs shall be evaluated against a ninety (90) percent Minimum Medical Loss Ratio (MLR) Requirement to determine whether a Payment Adjustment is warranted (determined pursuant to Appendix E “Medical Loss Ratio Calculation.” A Payment Adjustment (premium refund) shall occur if: A. The Contractor has a MLR of less than ninety percent (90%) but greater than or equal to eighty-six percent (86%). The Contractor shall submit a Payment Adjustment (premium refund) to the Commonwealth for seventy-five percent (75%) of the difference between the dollar amount corresponding to actual MLR and the dollar amount corresponding to a ninety percent (90%) Medical Loss Ratio. B. The Contractor has a MLR less than eighty six percent (86%). The Contractor shall submit a Payment Adjustment (premium refund) to the Commonwealth for the sum of: (a) seventy-five percent (75%) of the difference between the dollar amount corresponding to an eighty six percent (86%) MLR and the dollar amount corresponding to a ninety percent (90%) MLR; and
Appears in 5 contracts
Samples: Medicaid Managed Care Contract, Medicaid Managed Care Contract, Medicaid Managed Care Contract
