Shared Risk Reinsurance Sample Clauses

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance Program. The cost to PPG for such participation shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: *** of Shared Risk Budget. Out-of-Area Emergency and Urgently Needed Services are reimbursed at eighty percent (80%) of allowed amount, and the remaining *** shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk Services: *** of Shared Risk Budget. The cost of In-Area Shared Risk Services utilized by a Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: *** of any amount over ***.

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance Program. The cost to PPG for such participation shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: *** of Shared Risk Budget. Out-of-Area Emergency and Urgently Needed Services are reimbursed at *** of allowed amount, and the remaining *** shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk Services: *** of Shared Risk Budget. The cost of in-area Shared Risk services utilized by a Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: twenty percent (20%) of any amount over *** up to ***; and *** of any amount over ***. (c) Transfer Reinsurance: $ 0.15 PMPM, shall be deducted from the Shared Risk Budget. Ten percent (10%) of eligible charges shall be charged against the Shared Risk Budget.

Shared Risk Reinsurance. The program through which the PPG’s risk for Shared Risk Claims shall be limited per assigned HMO Member in a Reconciliation Period.

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance program. The cost to the PPG for the Shared Risk Reinsurance program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed services: *** of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed services are reimbursed at *** of cost, and the remaining *** of the cost shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk services: 0.06 % of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. The cost of in-area Shared Risk services utilized by a Medicare HMO Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: *** any amount over ***.

Shared Risk Reinsurance. PPG shall participate in the POS Shared Risk Reinsurance Program. The cost to the PPG for the POS Shared Risk Reinsurance Program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: 0.75% % of applicable Medicare POS Member’s HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed Services are reimbursed at *** cent *** of cost, and the remaining *** of the cost shall be charged against the POS Shared Risk Budget. (b) In-Network and Out-of-Network POS Shared Risk Services: 0.04 % of applicable Medicare POS Member’s HCFA payment and county premium, if any. The cost of In-Network and Out-of-Network POS Shared Risk Services during the Reconciliation Period shall be charged against the POS Shared Risk Budget as follows: *** of any amount over ***.

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance program. The cost to the PPG for the Shared Risk Reinsurance program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed services: *** of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed services are reimbursed at eighty percent (80%) of cost, and the remaining *** of the cost shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk services: *** of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. The cost of In-Area Shared Risk services utilized by a Medicare HMO Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: twenty percent (20%) of any amount over $100,000. Effective January 1, 2001, PPG shall participate in the Shared Risk Reinsurance program. The cost to the PPG for the Shared Risk Reinsurance program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed services: 1.28% of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed services are reimbursed at eighty percent (80%) of cost, and the remaining twenty percent (20%) of the cost shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk services: 3.12% of the applicable Medicare HMO Member’s HCFA payment and county premium, if any. The cost of In-Area Shared Risk services utilized by a Medicare HMO Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: twenty percent (20%) of any amount over $100,000.

Shared Risk Reinsurance. PPG shall participate in the POS Shared Risk Reinsurance Program. The cost to the PPG for the POS Shared Risk Reinsurance Program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: *** of applicable Medicare POS Member’s HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed Services are reimbursed at *** of cost, and the remaining *** of the cost shall be charged against the POS Shared Risk Budget. (b) In-Network and Out-of-Network POS Shared Risk Services: *** of applicable Medicare POS Member’s HCFA payment and county premium, if any. The cost of In-Network and Out-of-Network POS Shared Risk Services during the Reconciliation Period shall be charged against the POS Shared Risk Budget as follows: *** of any amount over ***. Effective January 1, 2001, In-Network and Out-of-Network POS Shared Risk Services: 3.78% of applicable Medicare POS Member’s HCFA payment and county premium, if any. The cost of In-Network and Out-of-Network POS Shared Risk Services during the Reconciliation Period shall be charged against the POS Shared Risk Budget as follows: *** of any amount over ***.

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance program. The cost to the PPG for the Shared Risk Reinsurance program shall be calculated as follows. (a) Out-of-Area Emergency and Urgently Needed services: *** of the applicable Medicare HMO Member’s CMS payment and county premium, if any. Out-of-Area Emergency and Urgently Needed services are reimbursed at *** of cost, and the remaining *** of the cost shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk services *** of the applicable Medicare HMO Member’s CMS payment and county premium, if any. The cost of In-Area Shared Risk services utilized by a Medicare HMO Member in a Reconciliation Period shall be charged against the Shared Risk Budget as follows: *** of any amount over ***.

Shared Risk Reinsurance. PPG shall participate in the Shared Risk Reinsurance Program. The cost to PPG for such participation shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: *** of Shared Risk Budget. Out-of-Area Emergency and Urgently Needed Services are reimbursed at eighty percent (80%) of allowed Amount, and the remaining *** shall be charged against the Shared Risk Budget. (b) In-Area Shared Risk Services *** of Shared Risk The age, sex and benefit plan factors shall be developed by HEALTH NET based upon actuarial assumptions consistent with existing actuarial assumptions and HEALTH NET’s utilization experience. Such factors, as updated approximately every three years to reflect changing demographic and utilization patterns, shall be forwarded to PPG and are incorporated into this Agreement by reference.

Shared Risk Reinsurance. PPG shall participate in the POS Shared Risk Reinsurance Program. The cost to the PPG for the POS Shared Risk Reinsurance Program shall be calculated as follows: (a) Out-of-Area Emergency and Urgently Needed Services: 0.75% at applicable Medicare POS Members HCFA payment and county premium, if any. Out-of-Area Emergency and Urgently Needed Services are reimbursed eighty percent (80%) of cost, and the remaining twenty percent (20%) of the cost shall be charged against the POS Shared Risk Budget. (b) In-Network and Out-of-Network POS Shared Risk Services 0.04 % of applicable Medicare POS Member’s HCFA payment and county premium, if any. The cost of In-Network and Out-of-Network POS Shared Risk Services during the Reconciliation Period shall be charged against the POS Shared Risk Budget as follows ten percent (10%) of any amount over one hundred fifty thousand dollars ($150,000.00).