Capitation Rate Clause Samples

Capitation Rate. For Capitated Services, PPG shall be compensated for rendering professional In-Nctwork Services to Medicare POS Members at the percent of Monthly Revenue for Medicare HMO Members as set forth in this Addendum C, less a *** withhold (Professional Out-of-Network Withhold), for each Medicare POS Member eligible to receive such services from PPG during any particular month. In the event PPG’s enrollment exceeds *** Medicare POS Members, the Professional Out-of-Network Withhold percentage shall be equal to (i) PPG’s prior year’s professional Out-of-Network costs, divided by the total of PPG’s Capitation for Medicare POS Members (prior to the Professional Out-of-Network Withhold) rounded to the nearest multiple of five, ***, or (ii) *** if there is no prior year experience or if PPG has *** less Medicare POS Members. On or before December 15th of each year, HMO shall notify PPG of PPG’s Out-of-Network experience incurred between July 1 of the previous year and June 30 of the current year and the calculation noted above, and such shall be PPG’s Professional Out-of-Network Withhold percentage for the following year. Capitation shall be calculated on the basis of the most current information available and shall be paid by HMO by wire transfer on or before the fifteenth (15th) day of each month, or the first business day following the fifteenth if the fifteenth is a holiday or on a weekend, or within two (2) days of HCFA’s payment to HMO, whichever is later. Each Capitation payment shall be accompanied by a remittance summary. The remittance summary identifies the total Capitation payable and those Medicare POS Members for whom Capitation is being paid. In the event of a Capitation error, resulting in an overpayment or underpayment to PPG, HMO shall adjust subsequent Capitation to offset such error.

Capitation Rate. The Capitation rate for fiscal years 2006 and 2007 will consist of separately calculated elements as outlined below: 1. The Medical Services capitation will be calculated on a rate per inmate per day based on a guaranteed sector population of 120,300. For TDCJ offender populations above 117,894 but less than or equal to 122,706, UTMB agrees to deliver Medical Services at no additional costs. If for two consecutive months, the UTMB sector offender population falls below or rises above the population range specified in this paragraph, an adjusted Medical Services capitation will be negotiated by mutual agreement of the parties and shall be based on actual documented costs. For both Fiscal Year 2006 and Fiscal Year 2007 the Medical Services capitation rate shall be $6.235. 2. The Mental Health Services capitation payments shall be based on the performance factors and rates outlined below: a) Psychiatric Inpatient Services Capitation rate shall be $30.00 per inpatient per day based as follows: Skyview Unit: 500 Jester IV Unit: 500 b) Mentally Retarded Offender Program (MROP) Capitation rate shall be $ 9.00 per offender enrolled in MROP per day based as follows: ▇▇▇▇▇ Unit: 710 c) Psychiatric Outpatient Services Capitation rate shall be $2.60 per outpatient per day based on outpatient caseloads as follows: FY 2006 and FY 2007: 13,000

Capitation Rate. The Capitation rate for fiscal years 2010 and 2011 will consist of separately calculated elements as outlined below: 1. The Medical Services capitation will be calculated on a rate per inmate per day based on a guaranteed sector population of 120,180. For TDCJ offender populations above 115,372 but less than or equal to 124,987, ▇▇▇▇ agrees to deliver Medical Services at no additional costs. If for two consecutive months, the UTMB sector offender population falls below or rises above the population range specified in this paragraph, an adjusted Medical Services capitation will be negotiated by mutual agreement of the parties and shall be based on actual documented costs. The Medical Services capitation rate shall be: $7.7049 in FY 2010; and, $7.6388 in FY 2011. 2. The Mental Health Services capitation payments shall be calculated using the same guaranteed sector population and population ranges as outlined in paragraph III.B.1 above. The Mental Health Services capitation rate shall be: $0.6402 in FY 2010; and, $0.6402 in FY 2011. It is that intent of the parties that the Mental Health Services capitation provides for the following approximate levels of service: a. Psychiatric Inpatient Services average census of 1,015 offender patients. b. Mentally Retarded Offender Program (MROP) average census of 710 offender patients. c. Psychiatric Outpatient Services average caseload of 15,000 offender patients. 3. In Fiscal Year 2011, contingent upon completion of renovations to the ▇▇▇▇▇▇ Medical Facility: a. Startup equipment funding in the amount of $773,000 to be paid September 15th or 60 days prior to the anticipated occupancy date whichever is later; and, b. Annual operating funding in the amount of $4,070,986, to be paid in quarterly installments in conjunction with the payments as follows; Date Payment is Due Amount Due The above amounts assume a September 1, 2010 occupancy date. Should the occupancy date occur later than that date, the amount of such payments shall be prorated based on the actual occupancy date.

Capitation Rate. The Capitation rate for fiscal years 2010 and 2011 will consist of separately calculated elements as outlined below: 1. The Medical Services capitation will be calculated on a rate per inmate per day based on a guaranteed sector population of 31,554. For TDCJ offender populations above 30,291 but less than or equal to 32,816, TTUHSC agrees to deliver Medical Services at no additional costs. If for two consecutive months, the TTUHSC sector offender population falls below or rises above the population range specified in this paragraph, an adjusted Medical Services capitation will be negotiated by mutual agreement of the parties and shall be based on actual documented costs. The Medical Services capitation rate shall be: $7.4973 in FY 2010; and, $7.4963 in FY 2011. 2. The Mental Health Services capitation payments shall be calculated using the same guaranteed sector population and population ranges as outlined in paragraph III.B.1 above. The Mental Health Services capitation rate shall be: $1.1537 in FY 2010; and, $1. 1537 in FY 2011. It is that intent of the parties that the Mental Health Services capitation provides for the following approximate level of service: a. Psychiatric Inpatient Services average census of 523 offender patients. b. Program for the Aggressive Mentally-Ill Offender (PAMIO) average census of 425 offender patients. c. Psychiatric Outpatient Services average caseload of 4,200 offender patients.

Capitation Rate. The amount to be paid to APS for each Enrollee per month that is specified in and adjusted by Attachment A to this Agreement.

Capitation Rate. PPG shall be compensated for rendering professional In-Network Services to Medicare POS Members at the percent of Monthly Revenue for Medicare HMO Members as set forth in this Addendum C, less a *** withhold (Professional Out-of-Network Withhold), for each Medicare POS Member eligible to receive such services from PPG during any particular month. Effective September 1, 2001 PPG shall be compensated for rendering professional In-Network Services to Medicare POS Members at the percent of Monthly Revenue for Medicare HMO Members as set forth in this Addendum C, less a zero (0.0%) withhold (Professional Out-of-Network Withhold), for each Medicare POS Member eligible to receive such services from PPG during any particular month. Capitation shall be calculated on the basis of the most current information available and shall be paid by HMO by wire transfer on or before the fifteenth (15th) day of each month, or the first business day following the fifteenth if the fifteenth is a holiday or on a weekend, or within two (2) days of HCFA’s payment to HMO, whichever is later. Each Capitation payment shall be accompanied by a remittance summary. The remittance summary identifies the total Capitation payable and those Medicare POS Members for whom Capitation is being paid. In the event of a Capitation error, resulting in an overpayment or underpayment to PPG, HMO shall adjust subsequent Capitation to offset such error.