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. Rate updates will take place on January 1st of each calendar year for the Medicare components of the rates, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates will take place at least once each California state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable payment rates for the Demonstration. Such changes may be based on, the following factors: shifts in enrollment assumptions; changes due to litigation; changes in Federal law and/or State policy; changes in coding intensity, and other factors as determined appropriate and approved by CMS and the State. B. If Congress acts to suspend or overturn the applicable 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 in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, as well. If other 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 usual rate development process.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Rate updates Updates to the Medicare portion of the capitated rate will take place on January 1st of each calendar year for year, while updates to the Medicare components Medicaid portion of the ratesrate will occur at the beginning of the state fiscal year, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates will take place at least once each California Texas state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the THTQIP 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this the Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline (and therefore to the corresponding payment rate) outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable accurate payment rates for the Demonstration. Such For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes outside the annual rate update process may be based on, on the following factors: shifts in enrollment assumptions; changes due to litigation; , major changes in Federal federal law and/or State policy; state law or policy compared to assumptions about federal law and/or state law or policy used in the development of baseline estimates, changes in coding intensity. CMS and/or the State will make changes to baseline estimates after the need for such change is identified, and other factors as determined appropriate and approved by CMS and the Statechanges will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month. B. If Congress acts Changes to suspend or overturn the applicable Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise savings percentages would have been in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, as well. If other statutory changes enacted after the annual baseline determination occur if and rate development process are jointly determined by when CMS and the State jointly determine that changes in Medicare Part D spending have resulted in materially higher or lower savings that need to have a material be recouped through higher or lower savings percentages applied to the Medicare Parts A/B baselines, or if and when CMS and the State jointly determine the change in baseline estimates for any given payment yearis necessary to calculate reasonable, baseline estimates and corresponding standardized appropriate payment rates shall be updated outside of for the usual rate development processDemonstration.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Rate updates will take place on January 1st of each calendar year for the Medicare components of the rates, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates will take place at least once each California state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline Medicare baselines (and therefore the corresponding payment rate) outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable accurate payment rates for the Demonstration. Such For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes may be based on, on the following factors: shifts in enrollment assumptions; major changes due to litigation; changes or discrepancies in Federal law and/or State policypolicy compared to the assumptions about Federal law and/or State law or policy used in the development of baseline estimates; and changes in coding intensity. CMS and/or the State will make changes to baseline estimates after identification of the need for such changes, and other factors as determined appropriate changes will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month. B. Changes to the savings percentages would occur if and approved by when CMS and the StateState jointly determine that changes in Medicare 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. B. C. If Congress acts there are major changes to suspend or overturn the applicable Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment ratesCMS-HCC methodology for Medicare-Medicaid Enrollees, CMS CMS, in consultation with the State, will adjust revisit the Medicare baseline for beneficiaries who otherwise would have been appropriateness of the “Rate-to-FFS-Ratio” methodology described in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, as well. Section X. D. If other 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 usual annual rate development process.

Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Rate updates The Medicaid rate will take place on January 1st be updated annually applying the risk adjustment methodology described in V to the most updated estimate of each calendar year the enrolled population for a given year, and to apply that year’s savings and quality withhold percentages along with an updated estimate of Medicaid trend. The Medicare rate will be updated with the annual adjustments to Medicare baseline rates, yearly savings and quality withholds. Other changes to the Medicare components of the rates, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the and Medicaid component of the rates will take place at least once each California state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline baselines outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable accurate payment rates for the Demonstration. Such changes may be based on, on the following factors: shifts in enrollment assumptions; changes due to litigation; major changes in Federal law and/or State policy; and changes in coding intensity, and other factors as determined appropriate and approved by CMS and the State. B. If Congress acts to suspend delay or overturn replace the applicable 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 Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is cuts are scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, retroactively as well. If other 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 usual 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. Rate updates will take place on January 1st of each calendar year for the Medicare components of the rates, with changes to the savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates rate will take place at least once each California state New York State fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the 1115(a) demonstration waiver program (i.e., MLTC program) that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline (and therefore to the corresponding payment rate) outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable accurate payment rates for the Demonstration. Such For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes may be based on, on the following factors: shifts in enrollment assumptions; major changes due to litigation; changes or discrepancies in Federal law and/or State law or policy, compared to assumptions about Federal law and/or State law or policy used in the development of baseline estimates; and changes in coding intensity. CMS and/or the State will make changes to baseline estimates within 30 days of identification of the need for such changes, and other factors changes will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month. CMS will also evaluate Participant risk scores in Demonstration Year 1 and Demonstration Year 2 to determine whether coding intensity in either or both years supports the need for adjustments to the baseline in Demonstration Year 3. CMS will incorporate such adjustments into the Demonstration Year 3 baseline, as determined appropriate and approved by CMS and the Stateappropriate, on a prospective basis to prevent overpayments due to increased coding intensity. B. If Congress acts Changes to suspend or overturn the applicable Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise savings percentages would have been in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, as well. If other statutory changes enacted after the annual baseline determination occur if and rate development process are jointly determined by when CMS and the State jointly determine that changes in Part D spending have resulted in materially higher or lower savings that need 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 recouped through higher or lower savings percentages applied to the usual rate development processMedicare 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. Rate updates will take place on January 1st of each calendar year for the Medicare components of the rates, with changes to the savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates rate will take place at least once each California state fiscal year on January 1st and may be more often as necessary to match adjustments made if material changes to the Medicaid capitation rates in program occur or if the contracts that support the 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component financial performance of the rates may be done retroactively, if necessary to match the Medicaid baseline ratesFIDA-IDD Plan necessitate a rate change. Changes to the baseline (and therefore to the corresponding payment rate) outside of the annual Medicare Advantage rate announcement and/or typical and annual Medicaid rate adjustment process update would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable accurate payment rates for the Demonstration. Such For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes may be based on, on the following factors: shifts in enrollment assumptions; major changes due to litigation; changes or discrepancies in Federal law and/or State law or policy, compared to assumptions about Federal law and/or State law or policy used in the development of baseline estimates; and changes in coding intensity. CMS and/or the State will make changes to baseline estimates within 30 days of identification of the need for such changes, and other factors changes will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month. CMS will also evaluate Participant risk scores in Demonstration Year 1 and Demonstration Year 2 to determine whether coding intensity in either or both years supports the need for adjustments to the baseline in Demonstration Year 3. CMS will incorporate such adjustments into the Demonstration Year 3 baseline, as determined appropriate and approved by CMS and the Stateappropriate, on a prospective basis to prevent overpayments due to increased coding intensity. B. If Congress acts Changes to suspend or overturn the applicable Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise savings percentages would have been in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR formula is scheduled to go in effect but applies changes retroactively, CMS will adjust the rates here retroactively, as well. If other statutory changes enacted after the annual baseline determination occur if and rate development process are jointly determined by when CMS and the State jointly determine that changes in Medicare Part D spending have resulted in materially higher or lower savings that need 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 recouped through higher or lower savings percentages applied to the usual rate development processMedicare A/B baselines.