Common use of Transfer Reinsurance Clause in Contracts

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 HMO 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 four thousand six hundred dollars ($4,600) in PPG Capitated Services or thirty five thousand dollars ($35,000) 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 dollar basis, this Program shall cover *** of the allowed Program charges. PPG shall be responsible for the remaining *** Capitated Services. Ten percent (10%) of Shared Risk Claims shall be charged against the Shared Risk Budget. PPG shall submit claims to HMO within ninety (90) calendar days of meeting the threshold. This Program shall cover eligible Member charges 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 for 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, HMO reserves the right to discontinue this Program after any calendar year. In the event HMO continues this Program, HMO shall communicate the reinsurance premiums for any calendar year by December 15th of the prior year.

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 HMO and PPG, as set forth in the Operations Manual. The Transfer Reinsurance Program is not applicable to Members who have: 1I) 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 four thousand six hundred dollars ($4,600) *** in PPG Capitated Services or thirty five thousand dollars ($35,000) *** 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 dollar basis, this Program shall cover *** of the allowed Program charges. PPG shall be responsible for the remaining *** of PPG Capitated Services. Ten percent (10%) *** of Shared Risk Claims shall be charged against the Shared Risk Budget. PPG shall submit claims to HMO within ninety (90) calendar days of meeting the threshold. threshold This Program shall cover eligible Member charges until such Member’s next open enrollment date. Members covered under the AIDS or Transplant Reinsurance Program Programs shall not qualify for coverage under this Program. In the event a Member qualifies for 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, HMO reserves the right to discontinue this Program after any calendar year. In the event HMO continues this Program, . HMO shall communicate the reinsurance premiums for any calendar year by December 15th of the prior year.,

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 HMO 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 four thousand six hundred dollars ($4,600) *** in PPG Capitated Services or thirty five thousand dollars ($35,000) *** 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 dollar collar basis, this Program shall cover *** of the allowed Program charges. PPG shall be responsible for the remaining *** of PPG Capitated Services. Ten percent (10%) *** of Shared Risk Claims shall be charged against the Shared Risk Budget. Budget PPG shall submit claims to HMO HEALTH NET within ninety (90) calendar days of meeting the threshold. This Program shall cover eligible Member charges 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 for per coverage under both this Program and any another reinsurance program, the other reinsurance program shall be primary. The Transfer transfer Reinsurance Program shall cover charges only up to the beginning of those other reinsurance programs. Notwithstanding any other provision in this Agreement, HMO . HEALTH NET reserves the right to discontinue this Program after any calendar year. In the event HMO HEALTH NET continues this Program, HMO Program HEALTH NET shall communicate the reinsurance premiums for any calendar year by December 15th of the prior year.

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 HMO 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 four thousand six hundred dollars ($4,600) in PPG Capitated Services or thirty five thousand dollars ($35,000) 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 dollar basis, this Program shall cover *** ninety percent (90%) of the allowed Program charges. PPG shall be responsible for the remaining *** ten percent (10%) of PPG Capitated Services. Ten percent (10%) of Shared Risk Claims shall be charged against the Shared Risk Budget. PPG shall submit claims to HMO within ninety (90) calendar days of meeting the threshold. This Program shall cover eligible Member charges until such Member’s next open enrollment date. Members covered under the AIDS or Transplant Reinsurance Program Programs shall not qualify for coverage under this Program. In the event a Member qualifies for 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, HMO reserves the right to discontinue this Program after any calendar yearyear 1998. In the event HMO continues this Program, HMO shall communicate the reinsurance premiums for any calendar year by December 15th of the prior year.