Common use of Payments to Managed Care Organization Clause in Contracts

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 2017, through June 30, 2018 (State Fiscal Year 2018). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Capitation payments for services under this contract will be designed using a braided funding stream, with Medicaid and Bureau for Children and Families dollars being blended to develop a monthly capitation payment for holistic care of enrollees. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 20172019, through June 30, 2018 2021 (State Fiscal Year 20182021). State Fiscal Year 2018 2020 capitation rate ranges will be determined by the Department no later than April 15, 20172019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR 438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program fee for service participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with set by the vendor’s price bid as set forth in Exhibit AState, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) 45 days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. B . Department capitation payments to the MCO will apply to the time period July 1, 20172016, through June 30, 2018 2017 (State Fiscal Year 20182017). State Fiscal Year 2018 2017 capitation rate ranges will be determined by the Department no later than April 15, 20172016, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible month for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoiceMCO-eligible members. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 20172022, through June 30, 2018 2023 (State Fiscal Year 20182023). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no No payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCOMCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State plan. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program FFS participation. Vendors SED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a per member per month basis in accordance with PMPM rate set by the vendor’s price bid as set forth in Exhibit AState, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will In addition, the MCO, serving as an Administrative Service Organization (ASO), shall be based on actual paid a fixed monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments amount for ASO services related to retainage will socially necessary services (SNS) administration. This payment shall be processed after issued by the Contract termination date due to timing of information availabilityBureau for Children and Families.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of month for MCO-eligible members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between that have completed the enrollment data and process through the MCO monthly claims invoiceDepartment’s Enrollment Broker. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period July 1, 20172020, through June 30, 2018 2021 (State Fiscal Year 20182021). State Fiscal Year 2018 2021 capitation rate ranges rates will be determined by the Department BMS no later than April 15, 20172021, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR 438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program participation. Vendors The MCO will be paid a capitated rate on a per member per month (PMPM) basis in accordance with the vendor’s price bid as set forth in Exhibit A2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent fiscal agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agentfiscal agent. The Fiscal Agent fiscal agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is will be responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) 45 days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix Exhibit B. Department capitation payments to the MCO will apply to the time period July 1, 20172015, through June 30, 2018 2016 (State Fiscal Year 20182016). State Fiscal Year 2018 2017 capitation rate ranges payments will be determined by the Department no later than April 15, 20172016, or upon CMS approval whichever is later. If the Department does not provide the capitation rates to the MCO by April 15, 2016, or upon CMS approval, whichever is laterand the MCO decides not to renew the Contract with the Department for the subsequent State Fiscal Year such that the Department cannot be given 90 days written notice, the MCO and the Department will mutually agree to the effective date for termination. All other termination provisions would apply. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO providerMCO, if the services were available under the provider Contract unless otherwise authorized by the MCOcontract. Payments provided for under the Contract contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will shall be based on the enrollment data transmitted from the Department to its Fiscal Agent fiscal agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agentfiscal agent. The Fiscal Agent fiscal agent will reconcile these data, and will not pay a capitation on behalf of members clients who appear on only one of the two sources. The MCO is will be responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoiceinconsistency. The MCO must shall notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) days from the day inconsistency was determined by the MCOdata. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possibleunderpayments. The adjusted payment (representing reinstated membersrecipients) for each month of coverage will shall be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix Exhibit B. Department capitation payments to the MCO will apply to the time period July 1, 2017, 2011 through June 30, 2018 2012 (State Fiscal Year 20182012). State Fiscal Year 2018 2013 capitation rate ranges payments will be determined by the Department no later than April March 15, 20172012. If the Department does not publish the capitation rates by March 15, or upon CMS approval2012, whichever is laterand the MCO decides not to renew the contract with the Department for the subsequent State Fiscal Year such that the Department cannot be given 90 days written notice, the MCO and the Department will mutually agree to the effective date for termination. All other termination provisions would apply. The MCO assumes risk for the cost of services covered under this Contract contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contractcontract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO providerMCO, if the services were available under the provider Contract unless otherwise authorized by the MCOcontract. Payments provided for under the Contract contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMSCMS under 42 CFR 438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contractcontract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of month for MCO-eligible members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between that have completed the enrollment data and process through the MCO monthly claims invoiceDepartment’s Enrollment Broker. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period July 1, 20172021, through June 30, 2018 2022 (State Fiscal Year 20182022). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program participation. Vendors The MCO will be paid a capitated rate on a per member per month (PMPM) basis in accordance with the vendor’s price bid as set forth in Exhibit A2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan 2 Enrollees will only be enrolled on the first of the month and must stay with the MCO until the 30th before changing MCO’s. amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of month for MCO-eligible members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between that have completed the enrollment data and process through the MCO monthly claims invoiceDepartment’s Enrollment Broker. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period July 1, 20172022, through June 30, 2018 2023 (State Fiscal Year 20182023). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program participation. Vendors The MCO will be paid a capitated rate on a per member per month basis in accordance (PMPM) basis2, 2 Enrollees will only be enrolled on the first of the month and must stay with the vendor’s price bid as set forth in Exhibit A, MCO until the 30th before changing MCO’s. which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent fiscal agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agentfiscal agent. The Fiscal Agent fiscal agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is will be responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) 45 days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix Exhibit B. Department capitation payments to the MCO will apply to the time period July 1, 20172014, through June 30, 2018 2015 (State Fiscal Year 20182015). State Fiscal Year 2018 2016 capitation rate ranges payments will be determined by the Department no later than April 15, 20172015, or upon CMS approval whichever is later. If the Department does not provide the capitation rates to the MCO by April 15, 2015, or upon CMS approval, whichever is laterand the MCO decides not to renew the contract with the Department for the subsequent State Fiscal Year such that the Department cannot be given 90 days written notice, the MCO and the Department will mutually agree to the effective date for termination. All other termination provisions would apply. The MCO assumes risk for the cost of services covered under this Contract contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contractcontract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO providerMCO, if the services were available under the provider Contract unless otherwise authorized by the MCOcontract. Payments provided for under the Contract contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMSCMS under 42 CFR 438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contractcontract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoice. The MCO must notify the Department in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) days from the day inconsistency was determined by the MCO. The Department agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working days after receiving written notice of the request to furnish such information. The Department will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated members) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the Department. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 20172018, through June 30, 2018 2019 (State Fiscal Year 20182019). State Fiscal Year 2018 capitation 2019capitation rate ranges will be determined by the Department no later than April 15, 20172018, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR 438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member months) were developed based on historical program participation. Vendors will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of members who appear on only one of the two sources. The MCO is responsible month for detecting the source of the inconsistency between the enrollment data and the MCO monthly claims invoiceMCO-eligible members. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July 1, 20172023, through June 30, 2018 2024 (State Fiscal Year 20182024). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. Except for emergency services, no No payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCOMCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State plan. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program FFS participation. Vendors CSED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a per member per month basis in accordance with PMPM rate set by the vendor’s price bid as set forth in Exhibit AState, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will In addition, the MCO, serving as an Administrative Service Organization (ASO), shall be based on actual paid a fixed monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments amount for ASO services related to retainage will socially necessary services (SNS) administration. This payment shall be processed after issued by the Contract termination date due to timing of information availabilityBureau for Social Services.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of month for MCO-eligible members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between that have completed the enrollment data and process through the MCO monthly claims invoiceDepartment’s Enrollment Broker. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period July 1, 20172023, through June 30, 2018 2024 (State Fiscal Year 20182024). State Fiscal Year 2018 capitation rate ranges will be determined by the Department no later than April 15, 2017, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program participation. Vendors The MCO will be paid a capitated rate on a per member per month basis in accordance with the vendor’s price bid as set forth in Exhibit A(PMPM) basis2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.

Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department Department’s eligibility vendor to its Fiscal Agent each month, and upon the monthly claims invoices submitted by the MCO to the Fiscal Agent. The Fiscal Agent will reconcile these data, and will not pay a capitation on behalf of month for MCO-eligible members who appear on only one of the two sources. The MCO is responsible for detecting the source of the inconsistency between that have completed the enrollment data and process through the MCO monthly claims invoiceDepartment’s Enrollment Broker. The MCO must notify the Department BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. The Department BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten working (10) business days after receiving written notice of the request to furnish such information. The Department BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated membersenrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before the DepartmentBMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments.. BMS capitation payments to the MCO will apply to the time period July 1, 20172019, through June 30, 2018 2020 (State Fiscal Year 20182020). State Fiscal Year 2018 2020 capitation rate ranges will be determined by the Department BMS no later than April 15, 20172019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO. Payments provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. The Department CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR 438.726(b) and §438.730. BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (member enrollee months) were developed based on historical program participation. Vendors The MCO will be paid a capitated rate on a per member per month (PMPM) basis in accordance with the vendor’s price bid as set forth in Exhibit A2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed. Payments related to retainage will be processed after the Contract termination date due to timing of information availability.