Common use of Monitoring Cost Share or Patient Liability Clause in Contracts

Monitoring Cost Share or Patient Liability. The MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The MCO is also responsible for knowing what the member’s ongoing medical/remedial expenses are and reporting changes in those amounts to the income maintenance agency. The MCO is also responsible to report changes in other circumstances of members that may affect the amount of cost share or patient liability to the income maintenance agency within ten (10) calendar days of the MCO becoming aware of the change. Members shall use their own income to pay for the cost of room and board. Any MCO contribution to member room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. For each member who resides in community-based residential care as defined in Addendum VII.A.17, the MCO is responsible for all of the following tasks: The MCO determines the member’s room and board obligation in the facility in which the member resides. The MCO shall use one method for all its members. It shall select one of the three following methods: Actual Cost Methodology This method requires calculation of actual room and board costs for each community residential facility with which the MCO contracts. Facility- specific costs are split between care and supervision on the one hand and room and board on the other. Total costs attributable to room and board are divided by the number of residents licensed or certified for the living arrangement to get a room and board rate. Costs attributable to Room and Board: Rent, mortgage payments, title insurance, mortgage insurance Property and casualty insurance Building and grounds maintenance costs Residents’ food Household supplies and equipment necessary for the room and board of the individual Furnishings used by the individual (does not include office furnishings)

Monitoring Cost Share or Patient Liability. The MCO is responsible for the ongoing monitoring of the cost share or patient liability amounts of its members. The MCO is also responsible for knowing what the member’s ongoing medical/remedial expenses are and reporting changes in those amounts to the income maintenance agency. The MCO is also responsible to report changes in other circumstances of members that may affect the amount of cost share or patient liability to the income maintenance agency within ten (10) calendar days of the MCO becoming aware of the change. Members shall use their own income to pay for the cost of room and board. Any MCO contribution to supplementation of member payment of room and board obligation from capitation revenue shall not be considered a countable expense in developing MCO capitation rates. For each member who resides in community-based residential care as defined in Addendum VII.A.17VIII.A.16, the MCO is responsible for all of the following tasks: The MCO determines the member’s cost of room and board obligation in the facility in which the member resides. The MCO shall use one method for all its members. It shall select one of the three following methods: Actual Cost Methodology This method requires calculation of actual room and board costs for each community residential facility with which the MCO contracts. Facility- specific costs are split between care and supervision on the one hand and room and board on the other. Total costs attributable to room and board are divided by the number of residents licensed or certified for the living arrangement to get a room and board rate. Costs attributable to Room and Board: Rent, mortgage payments, title insurance, mortgage insurance Property and casualty insurance Building and grounds maintenance costs Residents’ food Household supplies and equipment necessary for the room and board of the individual Furnishings used by the individual (does not include office furnishings)