Commercial Payer definition

Commercial Payer means a third party Payer of Covered Services other than the Medicare program, which has entered into a Program Agreement with KYOne HP, including, any employer, union group, association, managed care plan, insurer, HMO, PPO, federal, state, or government Payer, including any applicable Medicaid program or any third party administrator contracting on behalf of any such entity.

Split View

AI-Powered Contracts

Draft, Review & Redline at the Speed of AI

Get StartedSchedule a Demo

Commercial Payer means health insurance plans holding a certificate of authority from Vermont’s Commissioner of Financial Regulation. This term does not include coverage for accident or disability income insurance, liability insurance, coverage issued as a supplement to liability insurance, workers' compensation or similar insurance, automobile medical payment insurance, credit-only insurance, coverage for on-site medical clinics, or other similar insurance coverage if benefits for health services are secondary or incidental to other insurance benefits. This term includes Medicare Advantage plans, but does not include stand-alone dental or vision benefits; long-term care insurance; specific disease or other limited benefit coverage, Medicare supplemental health benefits, and other similar benefits.

Commercial Payer means a third-party payer of covered services, other than Medicare and Medicaid, including any state government, employer, Health Maintenance Organization (“HMO”), Medicare Advantage, or any third-party administrator contracting on behalf of any such entity.

Examples of Commercial Payer in a sentence

• If the State fails ensure at least one Commercial Payer operating in the State offers a Commercial Payer Hospital Global Budget to Participant Hospitals by the start of PY2.

• No later than the end of PY1, the State must submit to CMS its plan to use available State legislative or regulatory authority to ensure Commercial Payer adoption of the Commercial Payer Hospital Global Budget methodology by PY3.

• The State must establish a Commercial Payer Hospital Global Budget methodology no later than PY2 that aligns with the Hospital Global Budget Alignment Requirements for State-Designed Medicare FFS Hospital Global Budget Methodologies articulated in Appendix D for use in PY2, and maintain a Commercial Payer Hospital Global Budget methodology for each subsequent PY.

• The State must use available State legislative or regulatory authority to ensure Commercial Payer adoption of the Commercial Payer Hospital Global Budget methodology by PY3.

• The State must provide a copy of any agreement, Memorandum of Understanding (MOU), or other legal instrument entered into between the State and a Commercial Payer that effectuates the Commercial Payer Hospital Global Budgets to CMS no later than 90 days before the start of PY2.

• During the Implementation Period of the Model, to the extent allowable by law, the State must establish data use agreements with each Commercial Payer operating in the State to acquire data needed to calculate the Statewide All-Payer TCOC Growth Target, All-Payer Primary Care Investment Targets, and set appropriate hospital global budgets for the Participant Hospitals.

• CMS will offer technical assistance to the State to facilitate Commercial Payer alignment with primary care transformation under AHEAD.

• The State must ensure that at least one Commercial Payer operating in the State offers a Commercial Payer Hospital Global Budget to Participant Hospitals by the start of PY2.

• Commercial Payer and ACO desire to participate in the Commercial Population Based Accountable Care Organization Shared Savings Pilot Program on the terms and conditions hereinafter set forth.

• In the event that ACO or Commercial Payer reports noncompliance to the GMCB, GMCB may provide the Parties with notice of noncompliance and the opportunity to object or cure.

More Definitions of Commercial Payer

Commercial Payer means a third party Payer of Covered Services other than the Medicare program, which has entered into a CIN Agreement with AHN, including, any employer, union group, association, managed care plan, insurer, HMO, PPO, federal, state, or government Payer, including any applicable Medicaid program or any third party administrator contracting on behalf of any such entity.