Common use of Alternative Format Clause in Contracts

Alternative Format. Provision of Enrollee information in a format that takes into consideration the special needs of those who, for example, are visually impaired or have limited reading proficiency. Examples of Alternative Formats shall include, but not be limited to, Braille, large font, audio tape, video tape, and enrollment information read aloud to Enrollee. Appeal — Enrollee’s request for review of an Adverse Action of the CICO in accordance with Section 2.11 of the Contract. Effective no later than the rating period starting on or after July 1, 2017, a Medicaid-based Appeal is defined as a review by the CICO of an Adverse Benefit Determination and no longer based on an Adverse Action. Behavioral Health Inpatient Services – Services provided in a hospital setting to include inpatient medical/surgical/psychiatric services. Behavioral Health Outpatient Services – Services that are provided in the home or community setting and to Enrollees who are able to return home after care without an overnight stay in a hospital or other inpatient facility. Behavioral Health & Substance Abuse Treatment Services- Inpatient, outpatient, and community mental health and rehabilitative services that are covered by the Demonstration. Benchmark Review- Review conducted by SCDHHS and its EQRO to determine a CICO’s readiness to proceed to the next transition phase of HCBS authority. Capitated Financial Alignment Model (“the Demonstration”) — A model where a State, CMS, and a health plan enter into a three-way contract, and the health plan receives a prospective blended payment to provide comprehensive, integrated, and coordinated care. Capitation Payment – A payment CMS and SCDHHS make periodically to a CICO on behalf of each Enrollee enrolled under a Contract for the provision of services within this Demonstration, regardless of whether the Enrollees receives services during the period covered by the payment. Any and all costs incurred by the CICO in excess of a capitation payment shall be born in full by the CICO. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A of this Contract) including: 1) the application of risk adjustment methodologies as described in Section 4.2.4 and 2) any payment adjustments as a result of the reconciliation described in Section 4.6. Total Capitation Rate revenue will be calculated as if all CICOs had received the full quality withhold payment.

Alternative Format. Provision of Enrollee Enrollee information in a format that takes into consideration the special needs of those who, for example, are visually impaired or have limited reading proficiency. Examples of Alternative Formats shall include, but not be limited to, Braillebraille, large font, audio tapeaudio, video tapevideo, and enrollment information read aloud to Enrollee. Appeal — Enrollee’s request for review of an Adverse Action Benefit Determination of the CICO CICO in accordance with Section 2.11 of the Contract. Effective no later than the rating period starting on or after July 1, 2017, a Medicaid-based Appeal is defined as a review by the CICO of an Adverse Benefit Determination and no longer based on an Adverse Action. Behavioral Health Inpatient Services – Services provided in a hospital setting to include inpatient medical/surgical/psychiatric services. Behavioral Health Outpatient Services – Services that are provided in the home or community setting and to Enrollees Enrollees who are able to return home after care without an overnight stay in a hospital or other inpatient facility. Behavioral Health & Substance Abuse Treatment Services- Inpatient, outpatient, and community mental health and rehabilitative services that are covered by the Demonstration. Benchmark Review- Review conducted by SCDHHS and its EQRO to determine a CICOCICO’s readiness to proceed to the next transition phase of HCBS authority. Capitated Financial Alignment Model (“the Demonstration”) — A model where a State, CMS, and a health plan enter into a three-way contract, and the health plan receives a prospective blended payment to provide comprehensive, integrated, and coordinated care. Capitation Payment – A payment CMS and SCDHHS make periodically to a CICO CICO on behalf of each Enrollee Enrollee enrolled under a Contract for the provision of services within this Demonstration, regardless of whether the Enrollees Enrollees receives services during the period covered by the payment. Any and all costs incurred by the CICO CICO in excess of a capitation payment shall be born in full by the CICO. CICO. Capitation Rate — The sum of the monthly capitation payments for Demonstration Year 1 (reflecting coverage of Medicare Parts A & B services, Medicare Part D services, and Medicaid services, pursuant to Appendix A of this Contract) including: 1) the application of risk adjustment methodologies as described in Section 4.2.4 4.2.4. and 2) any payment adjustments as a result of the reconciliation described in Section 4.6. .. Total Capitation Rate revenue will be calculated as if all CICOs CICOs had received the full quality withhold payment.