Medical Loss Ratio Requirements Sample Clauses

Medical Loss Ratio Requirements. For all Demonstration Years in which a risk corridor mechanism is available, the Medicare Advantage MLR requirements as per 42 C.F.R. 422 Subpart X and 42 C.F.R. 423 Subpart X, are waived. To the extent the risk corridor ceases, the prevailing Medicare Advantage MLR requirements will be reinstated for any applicable years in which the risk corridor is not in effect. Any remittances owed as a result of applying the prevailing Medicare Advantage MLR requirements would be shared between EOHHS and Medicare proportionally based on each payor’s contribution to the total premiums subject to the MLR calculation. The MLR calculation shall include costs associated with Covered Services and care management as patient care, rather than administrative, costs.

Medical Loss Ratio Requirements. Under the Maryland Mandatory Medicaid Managed Care Program, the Department has the authority to reduce Gross Capitation Rates paid to an MCO if the MCO's medical loss ratio is less than mandated by applicable law. In the event the law sets, or the Department defines, "medical loss ratio" in a manner that would require material modification of the terms of this Agreement in order to avoid a reduction in Gross Capitation Rates paid by the Department to PHCP, both parties shall take all reasonable steps within the limits of applicable law and regulation, including such lobbying efforts as may be permitted by law, to avoid a reduction of Gross Capitation Rates while maintaining the substance of the financial terms contemplated hereunder. In the event PHCP receives notification from the Department of a possible or pending reduction in Gross Capitation Rates due to the medical loss ratio requirements, PHCP shall provide a copy of said notice to JHMSC within two (2) business days of receipt of the same. In the event of a reduction in Gross Capitation Rates due to the medical loss ratio requirements, either party would have the right to terminate this Agreement upon thirty (30) days prior written notice to the other. In the event notice is provided by either party, the following would apply: 1. If, during the notice period, either party takes steps to eliminate any adverse impact of the reduced Gross Capitation Rates upon the other party, such as by supplementing the other party's compensation, the notice of termination shall be withdrawn and deemed void. 2. In the event notice of termination is not withdrawn, then either of the following options shall apply, at JHMSC's election: (a) Termination of the Agreement shall be effective as of the end of the then-current Contract Year, and, for the balance of the then-current Contract Year, JHMSC shall be compensated as a multi-specialty provider on the basis set forth in Article VI, Sections C and D. In addition, JHMSC shall pay to PHCP twenty-five percent (25%) of the fair market value of the Members, not to exceed Two Million Five Hundred Thousand Dollars ($2,500,000), as of the date notice was provided pursuant to the procedures set forth in Article X, Section C, in which event PHCP and its Affiliates shall not contract, directly or indirectly, with Primary Care Providers located in the Exclusive Area to provide Covered Services to Members during the remaining term of the Agreement and during the one-year period foll...