Payment Types and Rates a. The terms and conditions of Paragraph a of Section 1, Exhibit C in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
b. The terms and conditions of Paragraph b of Section 1, Exhibit C in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
c. The terms and conditions of Paragraph c of Section 1, Exhibit C in the Medicaid Contract are incorporated by reference and have the same force and effect as though they are fully set forth herein.
d. RQWUDFWRU¶V VHSDUDWH 0HGLFDLG &RQWUDFW LQ Payments (QDPs), which are State-directed payments governed by CMS Medicaid managed care regulations. The CMS managed care regulations relating to QDPs permit States to include terms
(a) ±(f) of Sub.Para.
(1) below of this Para. d. All of the IRUHJRLQJ 4'3V DUH DOVR LQFOXGHG LQ DQG UH Medicaid Contract and the amounts payable thereunder shall be based on the services provided under and data related to the Medicaid Contract only.
(a) ±(f) of Sub.Para.
(1) below and the flexibility relating to Alternative Payment Methodologies in Sub.Para.
(2) below.
(1) The QDPs required to be paid out under this Non-Medicaid Contract are as follows:
(a) “Increased Payments for Assertive Community Treatment (ACT), Supported Employment Services (SE), Outpatient Mental Health Treatment and Services (OP MH), and Outpatient Substance Use Disorder Treatment and Services (OP SUD) for Primarily Medicaid Providers.” The terms and conditions applicable to the foregoing QDP are set forth in Ex. C, Sec. 1, Para. d, Sub.Para. (2)
Payment Types and Rates a. In consideration of all the Work to be performed under this Agreement, TCMC shall pay XXX x XXX payment for each Member enrolled with RAE under this Agreement according to TCMC’s records (“RAE Payment”). OHA will prorate the RAE Payment for Members who are enrolled mid-month with RAE. The amount of the RAE Payment for each Member shall be:
(1) The amount described in Exhibit C, Attachment 2 of the Core Contract, which shall be adjusted pursuant to TCMC’s risk adjustment policy adopted by the TCMC Board of Directors;
(2) Less an amount determined by the TCMC Board of Directors and all TCMC members to account for the costs of TCMC administration, reserve funding, transformation funding, and any other costs reasonable and necessary for the effective implementation of this Agreement.
Payment Types and Rates a. In consideration of all the Work to be performed under this Contract, OHA will pay Contractor a monthly CCO Payment for each Member enrolled under the Contract according to OHA records. The monthly CCO Payment Rate authorized for each Member is that amount indicated in Exhibit C-Attachment 1 (CCO Payment Rates) for each Member’s Rate Group. OHA may withhold Payment for new Members when, and for so long as, OHA Imposes suspension or denial of Payments as a Sanction under Ex. B, Part 9, Sec. 3, Para. b.
b. The monthly CCO Payment may include risk adjustment based factors such as expected cost of care or health status and may reflect one or more Risk Corridors in accordance with Sec. 6 below of this Ex. C.
c. Contractor shall comply with all applicable payment obligations to IHCPs as set forth in 25 USC
Payment Types and Rates a. In consideration of all the Work to be performed under this Contract, OHA will pay Contractor a monthly CCO Payment for each Member enrolled under the Contract according to OHA records. The monthly CCO Payment Rate authorized for each Member is that amount indicated in Exhibit C-Attachment 1 (CCO Payment Rates) for each Member’s Rate Group. OHA will prorate the CCO Payment for Members who are enrolled or disenrolled mid-month. OHA may withhold Payment for new Members when, and for so long as, OHA Imposes suspension or denial of Payments as a Sanction under Ex. B, Part 9, Sec. 3, Para. b.
b. The monthly CCO Payment may include risk adjustment based on factors such as expected cost of care or health status and may reflect one or more Risk Corridors in accordance with Sec. 6 below of this Ex. C.
c. Contractor shall comply with all applicable payment obligations to ICHPs as set forth in 25 USC
d. Contractor’s separate Medicaid Contract includes provisions relating to Qualified Directed Payments (QDPs), which are State-directed payments governed by CMS Medicaid managed care regulations. The CMS managed care regulations relating to QDPs permit States direct such payments for specific purposes, including expenses incurred by managed care plans that relate to the implementation of delivery system and provider payment initiatives under Medicaid managed care contracts. Contractor’s separate Medicaid Contract includes QDPs built into the CCO Payment Rates (“QDPs within CCO Payment Rates”), which are required to be used to increase Behavioral Health Provider payment rates (“BH QDPs”), as required by, and with funds appropriated to OHA under, Enrolled Oregon House Bill 5202 (2022) and consistent with the associated CMS preprints, which are subject to CMS approval. The CCO Payment Rates in Exhibit C-Attachment 1 to this Non-Medicaid Contract include an adjustment which is subject to the same directed payment parameters included in the separate Medicaid Contract, which is subject to CMS approval. Contractor shall utilize the QDPs within CCO Payment Rates included in this Non- Medicaid Contract to increase Behavioral Health Provider payment rates in accordance with the CMS approved preprints for services provided to HOP Members covered under this Non-Medicaid Contract. OHA will provide a Guidance Document to assist Contractor with complying with the BH QDP requirements.
e. As described in OAR 410-141-3565, OHA may require Contractor to reimburse a Rural Type A Hospital...
Payment Types and Rates a. In consideration of all the Work to be performed under this Contract, OHA will pay Contractor a monthly CCO Payment for each Member enrolled under the Contract according to OHA records. The monthly CCO Payment rate authorized for each Member is that amount indicated in this Exhibit, Attachment 2, CCO Rates, for each Member’s Rate Group as “Total Services with Admin.” OHA will prorate the CCO Payment for Members who are enrolled mid-month. OHA may withhold payment for new Members when, and for so long as, OHX xetermines that Contractor meets the circumstances cited in 42 CFR 434.67.
b. The general description of the basis for calculating CCO Payments is described in Exhibit C, Attachment 1, Calculation of CCO Payment Rates.
Payment Types and Rates a. In consideration of all work to be performed by Contractor under this Contract, DHS will pay Contractor a monthly Capitation Payment for each OHP Member, for the period beginning on the date of Enrollment and ending on the date of Disenrollment. Contractor shall be paid a Capitation Payment only for those OHP Members who are enrolled with Contractor according to DHS records. Where the date of an OHP Member’s Enrollment or Disenrollment is during mid-month, the Capitation Payment for that OHP Member shall be prorated. DHS may withhold payment for new OHP Members when, and for so long as, DHS determines that Contractor meets the circumstances cited in 42 CFR 434.67. Contractor shall be responsible for all federal and state taxes applicable to compensation or payments paid to Contractor under this Contract and, unless Contractor is subject to backup withholding, DHS will not withhold from such compensation or payments any amounts to cover Contractor’s federal or state tax obligations. Contractor is not eligible for any social security, unemployment insurance or workers’ compensation benefits from compensation or payments paid to Contractor under this Contract, except as a self-employed individual.
(1) For each month during the designated period, for the tables contained in Attachment 2, to this Exhibit C, DHS will pay Contractor the Capitation amount listed for each OHP Member falling within the designated rate category/county who is enrolled with Contractor for the full month. For any month when one or more OHP Members are enrolled for only part of the month, the Capitation amount for each OHP Member shall be prorated based upon the number of days such OHP Member is enrolled during the month.
(a) DHS has developed actuarially set Adjusted Per Capita Costs necessary to cover the reasonable costs of the services to be provided under this Contract. A full description of the methodology used to calculate per capita costs and Capitation Payments may be found in the documents described in Attachment 2, to this Exhibit C.
(b) DHS will provide, upon Contractor request, and when available, documents produced by the actuarial firm which document and describe the Capitation rate development process.
(2) In addition to the base Capitation Payment rate paid to Contractor, DHS shall pay a hospital reimbursement adjustment and graduate medical education adjustment to the Capitation Payment rate to Contractor in accordance with the Capitation Payments calculation reflect...
