Part B Fund. A Part B Fund shall be established to pay for Part B Expenses. The fund shall be calculated as follows: Part B Fund Revenue Part B Fund Revenue shall consist of amounts equal to the appropriate funding for those MA HMO Members covered under this Agreement. Such amounts shall be credited to the Part B Fund as "Part B Revenue". The funding is LESS amounts that may be paid by Humana to PPM Primary Care Physician as a primary care capitation and/or Fee For Service. Part B Fund Expenses Part B Fund Expenses shall consist of amounts equal to the claims and/or capitation paid to providers by Humana for Covered Services provided to Members assigned to PPM Primary Care Physician, plus an actuarially determined amount for claims incurred but not reported (IBNR) as calculated by Humana for Part B Expenses. Part B Expenses are all costs for Covered Services not defined as Part A Expenses. Part B Expenses include, but may not be limited to, hospital based physician fees, specialists fees, hospital outpatient services, costs for applicable disease management programs, outpatient prescription drugs and the cost for stop-loss coverage if provided by Humana. Part B Expenses also include the cost of other Covered Services or costs which may be determined to be Part B Expenses by Humana in the normal course of business or as may be determined by CMS to be a Part B Covered Service.
Part B Fund. A Part B Fund shall be established to pay for Part B Expenses. The fund shall be calculated as follows: Part B Revenue An amount equal to the product of the capitation for each age/sex category listed on Exhibit C-1, Commercial Capitation (column titled "REF"), multiplied by the number of Members in each category; plus, An amount for Supplemental Benefits as listed on Exhibit C-1 (column titled "Drug" and "Vision"), multiplied by the number of Members who have selected such supplemental benefits, will be allocated to the Part B Fund as "Part B Revenue." Part B Expenses An amount equal to the claims paid by Humana, plus a calculated amount for claims incurred but not reported or paid (IBNR) for Part B costs which Humana is expected to pay; plus An amount allocated to the Stop Loss Pool, plus An amount allocated to the Maternity Pool, will be charged to the Part B Fund as "Part B Expenses." Part B Expenses are all costs for Covered Services not defined as Part A Expenses. Part B Expenses include, but may not be limited to, hospital based physician fees, specialists fees, hospital outpatient services and supplemental benefits costs. Part B Revenue, less Part B Expenses, shall be calculated on a monthly basis, beginning with the fourth month of this Agreement. If the calculation reflects a positive balance then the balance is a surplus. One Hundred Percent (100%) of the surplus shall be credited to the Provider on a monthly basis. If the monthly calculation reflects a negative balance, then the balance is a deficit. One Hundred Percent (100%) of the deficit amount will be owed by Provider to Humana.
Part B Fund. A Part B Fund shall be established to pay for Part B Expenses. The fund shall be calculated as follows: Part B Revenue An amount equal to the product of the capitation for each age/sex category listed on Exhibit C-2, Medicare Capitation (section B titled "Medicare Part B Referral Capitation"), multiplied by the number of Members in each category; plus, An amount for Supplemental Benefits as listed on Exhibit C-2 (section D titled "Medicare Supplemental Benefits Capitation"), multiplied by the number of Members who are eligible for Medicare, Part A. Part B Expenses An amount equal to the claims paid by Humana, plus a calculated amount for claims incurred but not reported or paid (IBNR) for Part B costs which Humana is expected to pay; plus An amount allocated to the Stop Loss Pool. Part B Expenses are all costs for Covered Services not defined as Part A Expenses. Part B Expenses include, but may not be limited to, hospital based physician fees, specialists fees, hospital outpatient services and supplemental benefits costs. Part B Revenue, less Part B Expenses, shall be calculated on a monthly basis, beginning with the fourth month of the Agreement. If the calculation reflects a positive balance then the balance is a surplus. One Hundred Percent (100%) of the surplus shall be credited to the Provider on a monthly basis. If the monthly calculation reflects a negative balance, then the balance is a deficit. One Hundred Percent (100%) of the deficit amount will be owed by Provider to Humana.
