Transfer Reinsurance Sample Clauses

Transfer Reinsurance. Professional and institutional costs incurred by Members undergoing medical treatment who have transferred from another participating physician group to PPG, shall be the shared financial responsibility of HEALTH NET and PPG, as set forth in the Operations Manual. The Transfer Reinsurance Program is not applicable to Members who have: 1) selected PPG through the open enrollment process: 2) changed a home or work address, or 3) been assigned to PPG due to a physician termination or physician affiliation change. This Program shall be effective when the other participating physician group is located within PPG’s Service Area. This Program shall cover eligible Members who accumulate more than *** in PPG Capitated Services or *** in Shared Risk Services. Such threshold shall be calculated using the most current Medicare allowable charges for PPG Capitated Services or actual amount paid for Shared Risk Services and shall be accumulated within one hundred eighty (180) days of the Member’s transfer to PPG. On a first collar basis, this Program shall cover *** of the allowed Program charges. PPG shall be responsible for the remaining *** of PPG Capitated Services. *** of Shared Risk Claims shall be charged against the Shared Risk Budget PPG shall submit claims to HEALTH NET within ninety (90) calendar days of meeting the threshold. This Program shall cover eligible Member changes until such Member’s next open enrollment date. Members covered under the AIDS Reinsurance Program shall not qualify for coverage under this Program. In the event a Member qualifies per coverage under both this Program and any another reinsurance program, the other reinsurance program shall be primary. The transfer Reinsurance Program shall cover charges only up to the beginning of those other reinsurance programs. Notwithstanding any other provision in this Agreement. HEALTH NET reserves the right to discontinue this Program after any calendar year. In the event HEALTH NET continues this Program HEALTH NET shall communicate the reinsurance premiums for any calendar year by December 15th of the prior year.