Stop Loss Protection Sample Clauses

Stop Loss Protection. Provider acknowledges and agrees that, except as otherwise provided below, once the accumulated annual claims expense for a Designated Covered Person exceeds the reinsurance threshold amount, payments for Covered Services provided to any individual Designated Covered Person in excess of the reinsurance threshold amount will not be considered when calculating Provider’s HBR as set forth in this Exhibit.

Stop Loss Protection. If Contractor puts a physician/physician group at substantial financial risk for services not provided by the physician/physician group, Contractor must ensure that the physician/physician group has adequate stop-loss protection. See: Section 1903(m)(2)(A)(x) of the Social Security Act; 42 C.F.R. § 422.208(c)(2); 42 C.F.R. § 438.3(i); 42 C.F.R. § 457.1201(h). {From CMSC E.8.02}.

Stop Loss Protection i. Contracted Provider agrees (A) to participate in Health Plan’s Stop Loss Program made available to Participating Providers under bonus or risk sharing arrangements with Health Plan,

Stop Loss Protection i. Contracted Provider agrees (A) to participate in Health Plan’s Stop Loss Program made available to Participating Providers under risk sharing arrangements with Health Plan, (B) that Contracted Provider remains financially responsible for amounts paid for Covered Services rendered by Providers and Referral Services up to and including the identified deductible, as well as the remaining ten percent of amounts paid for Covered Services rendered by Providers and any Referral Services in excess of the identified deductible, (C) that the monthly payment for such participation shall be deducted from the Operating Fund, (D) that the monthly financial benefit for such participation shall be credited to the Operating Fund, and (E) the amount of monthly payments for participation in the Stop Loss Program are set annually by Health Plan and based in part on the aggregate patient panel size of all Primary Care Providers in or around January of each year during the term of this Agreement as reported to Health Plan by Contracted Provider. ii. Prior to implementation of the shared risk arrangement and each year thereafter during the term of the Agreement in which it applies, Health Plan will provide notice to Contracted Provider of the set Stop Loss Program monthly payments for that calendar year. iii. Contracted Provider represents and warrants that with respect to the aggregate patient panel size of all Primary Care Providers reported prior to execution of the Agreement and each January thereafter during the term of this Agreement, Contracted Provider meets the five pooling requirements set out in 42 CFR §§ 422.208 and 417.479. Contracted Provider shall submit updated aggregated patient panel sizes as indicated above in January of each year during the term of this Agreement along with such other documentation as may be required by Health Plan to maintain compliance with Laws and Program Requirements regarding Physician Incentive Plans. iv. Contracted Provider shall indemnify and hold harmless Health Plan from any costs, charges, fines, fees or other liabilities incurred, including attorneys’ fees, as a result of or arising from Contracted Provider’s misrepresentation of compliance with any Laws or Program Requirements regarding Physician Incentive Plans or inaccurate information given to Health Plan hereunder. v. Stop Loss Program Cost. Health Plan will establish the cost of stop loss protection for Contracted Provider, which shall be a monthly per member per month a...