Rate Setting Methodology Clause Samples
Rate Setting Methodology. Capitation Rates are determined using a prospective methodology whereby cost, utilization and other rate-setting data available for the time period prior to the time period covered by the rates are used to establish premiums. Capitation rates will not be retroactively adjusted to reflect actual fee-for-service data or plan experience for the time period covered by the rates.
Rate Setting Methodology a) Capitation rates shall be determined prospectively and shall not be retroactively adjusted to reflect actual Medicaid fee-for-service data or Contractor experience for the time period covered by the rates. Capitated rates in effect as of April 1, 2006 and thereafter, shall be certified to be actuarially sound in accordance with 42 CFR Section 438.6(c).
b) Notwithstanding the provisions set forth in Section 3.3(a) above, the DOHMH reserves the right to terminate this Agreement, in its entirety or in specified counties of the Contractor’s service area as set forth in Appendix M, pursuant to Section 2.7 of this Agreement, upon determination by SDOH that the aggregate monthly Capitation Rates are not cost effective.
Rate Setting Methodology. 3 – Blending of FFS and Managed Care Data
A. Definition of a Party in Interest - As defined in Section 1318(b) of the Public Health Service Act, a party in interest is:
(1) Any director, officer, partner or employee responsible for management or administration of a LME; any person who is directly or indirectly the beneficial owner of more than five (5) % of the equity of the LME; any person who is the beneficial owner of more than five (5) % of the LME or, in the case of a LME organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation laws;
(2) Any organization in which a person described in subsection 1 is director, officer or partner; has directly or indirectly a beneficial interest of more than five (5)% of the equity of the LME ; or has a mortgage, deed of trust, note, or other interest valuing more than five (5) % of the assets of the LME ;
(3) Any person directly or indirectly controlling, controlled by, or under common control with a LME; or
(4) Any spouse, child, or parent of an individual described in subsections 1, 2, or 3.
B. Types of Transactions Which Must Be Disclosed - Business transactions which must be disclosed include:
(1) Any sale, exchanges or lease of any property between the LME and a party interest;
(2) Any lending of money or other extension of credit between the LME and a party interest; and
(3) Any furnishing for consideration of goods, services (including management services) or facilities between the LME and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment.
C. The information, which must be disclosed in the transactions, listed in subsection B between a LME and a party in interest includes:
(1) The name of the party in interest for each transaction;
(1) A description of each transaction and the quantity or units involved;
(2) The accrued dollar value of each transaction during the fiscal year; and
(3) Justification of the reasonableness of each transaction. If this LME contract is being renewed or extended, the LME must disclose information on these business transactions, which occurred during the prior contract period. If the contract is an initial contract with Medicaid, but the LME has operated previously in the commercial or Medicare markets, information on business transactions for the entire year preceding the initial contract period must be disclosed. The business transactions,...
Rate Setting Methodology a) Capitation rates shall be determined prospectively and shall not be retroactively adjusted to reflect actual Medicaid fee-for-service data or Contractor experience for the time period covered by the rates. Capitated rates in effect as of April 1, 2006 and thereafter, shall be certified to be actuarially sound in accordance with 42 CFR§ 438.6(c).
b) Notwithstanding the provisions set forth in Section 3.3(a) above, the SDOH reserves the right to terminate this Agreement, in its entirety for either the Contractor's MMC or FHPlus product, or for either or both products in specified counties of the Contractor's service area, pursuant to Section 2.7 of this Agreement, upon determination by SDOH that the aggregate monthly Capitation Rates are not cost effective. (COMPENSATION) October 1, 2005
Rate Setting Methodology. DSHS sets actuarially-sound managed care rates that:
Rate Setting Methodology. A. Premium Rates shall be determined prospectively and shall not be retroactively adjusted to reflect actual fee-for-service data or plan experience for the time period covered by the rates. Please refer to the methodology provided in Appendix A.2 of this contract.
B. Notwithstanding the provisions set forth in Article 3.3 above, the DHS reserves the right to terminate this contract in its entirety, or for specified counties of the Contractor’s service area, pursuant to Article 7 of this contract, upon determination by DHS that the aggregate monthly Premium Rates are not cost effective.
Rate Setting Methodology a) Capitation Rates shall be determined prospectively and shall not be retroactively adjusted to reflect actual fee-for-service data or plan experience for the time period covered by the rates.
b) Capitated rates in effect as of April 1, 2006 and thereafter, shall be certified to be actuarially sound in accordance with 42 CFR § 438.6 (c ).
c) Notwithstanding the provisions set forth in Section 3.3 (a) and (b) above, the SDOH reserves the right to terminate this Agreement in its entirety, or for specified counties of the Contractor's service area, pursuant to Section 2.7 of this Agreement, upon determination by SDOH that the aggregate monthly Capitation Rates are not cost effective.