PMPM Rates Sample Clauses

PMPM Rates. The PMPM rates provided under the Global Commitment to Health Demonstration will comply with the actuarial certification requirements of 42 CFR Part 438. AHS shall ensure that no claims paid by DVHA to a network provider, out-of-network provider, subcontractor or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates.

PMPM Rates. ‌ (a) The PMPM rate process and resulting rates are mechanisms that support program monitoring but do not affect available program funding. AHS shall ensure that no claims paid by DVHA to a network provider, out-of-network provider, subcontractor, or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates. (b) DVHA must maintain an MLR of at least 85 percent. If DVHA is unable to maintain at least an 85 percent MLR, the PMPM capitation rates must be reduced to the extent necessary to achieve an 85 percent medical loss ratio. (c) The PMPM capitation rate will: (i) Be developed for 12-month periods consistent with the requirements in 42 CFR 438.5 and based on DVHA’s actual experience and expected costs; (ii) Not include any administrative services and costs that are required to be incurred by AHS as the Single State Agency under federal law, regulation, or the Global Commitment to Health Medicaid Demonstration STCs. Such administrative services and costs that cannot be part of the capitation rate include: eligibility determinations, Single State Agency Central Office and EQRO, administration of a State Fair Hearing system, the Beneficiary Support System in 42 CFR 438.71 and STC 31, and the provider screening and enrollment process under 42 CFR 438.602(b); (iii) Include only costs for services included under 42 CFR 438.3(c)(1)(ii) and services specifically authorized in the Global Commitment to Health Medicaid Demonstration STCs; and DocuSign Envelope ID: F73EF454-508D-44AC-ABD8-2A528194331A (v) Not include any costs for “investments” as described in STC #11.1.