Rate Review Process. CMS and the State will review Demonstration Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the Demonstration Plans and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific Demonstration Plans to assess financing issues. In the event that two or more Demonstration Plans show MLRs below 85%, or in the event that two or more Demonstration Plans show annual losses exceeding 5%, CMS will convene the following parties, or their designees, to assess the factors resulting in the payment or loss and, as warranted, evaluate the payment parameters, including the respective projected baselines, savings percentages, and risk adjustment methodology: (1) CMS participants: Administrator, Chief Actuary or his/her designee, Director of the Center for Medicare, Director of the Center for Medicaid and CHIP Services, Director of the Medicare-Medicaid Coordination Office; (2) Office of Management and Budget participants: Medicare Branch Chief, Medicaid Branch Chief; (3) State participants: Medicaid Director or his/her designee and actuarial consultant. These parties will review available data, as applicable, including data on enrollment, utilization patterns, health plan expenditures, and risk adjustment to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. (i) In the event that at any time during the term hereof District's cost to contract with EMS Provider for the performance all Services within the Service Area under this Agreement increases, District shall provide written notice thereof to County and City. District, County and City agree to work together in good faith during such budgeting process with respect to the payment by County and City of additional funds to District for Services furnished hereunder. In the event that County and City refuse to enter into such negotiations, or such negotiations do not result in funds approved by both County and City that is acceptable to District, in its sole discretion, then District may terminate this Agreement upon sixty (60) days’ notice to County and City.
Rate Review Process. In the event that one-third of Participating Plans experience annual losses in Demonstration Year 1 exceeding 3% of revenue over all regions in which those plans participate, based on at least 20 months of data from Demonstration Year 1, the savings percentage for Demonstration Year 3 will be reduced to 3%. In the event that one-third of Participating Plans show MMLRs below 90% over all regions in which those plans participate, CMS and the Commonwealth will review the Participating Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the Participating Plans and the appropriateness of capitation payments. At any point, the Commonwealth may request that CMS review documentation from specific plans to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. CMS and the State will review ICDS Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the ICDS Plans and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific plans to assess financing issues. In the event that two or more ICDS Plans show MMLRs below 90% over all regions in which those plans participate, or in the event that two or more ICDS Plans show annual losses exceeding 5% over all regions in which those plans participate, CMS will convene the following parties, or their designees, to assess the factors resulting in the payment or loss and, as warranted, evaluate the payment parameters, including the respective projected baselines, savings targets, and risk adjustment methodology: (1) CMS participants: Administrator, Chief Actuary or his/her designee, Director of the Center for Medicare, Director of the Center for Medicaid and CHIP Services, Director of the Medicare-Medicaid Coordination Office; (2) Office of Management and Budget participants: Medicare Branch Chief, Medicaid Branch Chief; (3) State participants: Medicaid Director and actuarial consultant. These parties will review available data, as applicable, including data on enrollment, utilization patterns, health plan expenditures, and risk adjustment to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. CMS and HCA will review MMIP financial reports, encounter data, and other information to assess the ongoing financial stability of the MMIPs and the appropriateness of capitation payments. In the event that both MMIPs show MLRs below 85% when aggregated over both counties in which those MMIPs plans participate, or in the event that both MMIPs show MLRs above 95%, CMS and the State will review the MMIP financial reports, encounter data, and other information to assess the ongoing financial stability of the MMIPs and the appropriateness of capitation payments. At any point, the State may request CMS review documentation from specific MMIPs to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. CMS and the State will review the FIDA-IDD Plan’s financial reports, encounter data, and other information to assess the ongoing financial stability of the FIDA-IDD Plan and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific FIDA-IDD Plan to assess finance related issues. If deemed necessary, CMS and the State will review available data, as applicable, including data on enrollment, utilization patterns, health plan expenditures, and risk adjustment to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. CMS and the State will review FIDA Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the FIDA Plans and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific FIDA Plans to assess finance related issues. If deemed necessary, CMS and the State will review available data, as applicable, including data on enrollment, utilization patterns, health plan expenditures, and risk adjustment to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.
Rate Review Process. CMS and the State will review CICO financial reports, encounter data, and other information to assess the ongoing financial stability of the CICOs and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific CICOs to assess financing issues.
