Common use of Payments in Future Years and Mid-Year Rate Adjustments Clause in Contracts

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the baseline outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State law or policy; and changes in coding intensity. B. If Congress acts to delay or replace the Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise would have been enrolled in Original FFS Medicare to reflect the revised current law physician payment rates. If Congress applies changes retroactively after the SGR cuts are scheduled to go into effect, CMS will adjust the rates retroactively as well. If other State or federal statutory changes enacted after the annual baseline determination and rate development process are jointly determined by CMS and the State to have a material change in baseline estimates for any given payment year, baseline estimates and corresponding standardized payment rates shall be updated outside of the annual rate development process. C. Changes to the savings percentages would occur if and when CMS and the State jointly determine that changes in Part D spending have resulted in materially higher or lower savings that need to be recouped through higher or lower savings percentages applied to the Medicare A/B baselines.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the baseline Medicare and Medicaid baselines outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State Commonwealth jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State law or policy; and changes in coding intensity. B. If Congress acts to delay or replace the Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise would have been enrolled in Original FFS Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress applies changes retroactively acts after the SGR cuts are scheduled to go into effectin effect but applies changes retroactively, CMS will adjust the rates retroactively as well. If other State or federal statutory changes enacted after the annual baseline determination and rate development process are jointly determined by CMS and the State Commonwealth to have a material change in baseline estimates for any given payment year, baseline estimates and corresponding standardized payment rates shall be updated outside of the annual rate development process. C. Changes to the savings percentages would occur if and when CMS and the State Commonwealth jointly determine that changes in Part D spending have resulted in materially higher or lower savings that need to be recouped through higher or lower savings percentages applied to the Medicare A/B baselines.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the baseline Medicare and Medicaid baselines outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State Commonwealth jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State law or policy; and changes in coding intensity. B. . If Congress acts to delay or replace the Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise would have been enrolled in Original FFS Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress applies changes retroactively acts after the SGR cuts are scheduled to go into effectin effect but applies changes retroactively, CMS will adjust the rates retroactively as well. If other State or federal statutory changes enacted after the annual baseline determination and rate development process are jointly determined by CMS and the State Commonwealth to have a material change in baseline estimates for any given payment year, baseline estimates and corresponding standardized payment rates shall be updated outside of the annual rate development process. C. Changes to the savings percentages would occur if and when CMS and the State jointly determine that changes in Part D spending have resulted in materially higher or lower savings that need to be recouped through higher or lower savings percentages applied to the Medicare A/B baselines.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the baseline outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State law or policy; and changes in coding intensity. B. If Congress acts to delay or replace the Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise would have been enrolled in Original FFS Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress applies changes retroactively acts after the SGR cuts are scheduled to go into effectin effect but applies changes retroactively, CMS will adjust the rates retroactively as well. If other State or federal statutory changes enacted after the annual baseline determination and rate development process are jointly determined by CMS and the State to have a material change in baseline estimates for any given payment year, baseline estimates and corresponding standardized payment rates shall be updated outside of the annual rate development process. C. Changes to the savings percentages would occur if and when CMS and the State jointly determine that changes in Part D spending have resulted in materially higher or lower savings that need to be recouped through higher or lower savings percentages applied to the Medicare A/B baselines.