Common use of Cost of Care Clause in Contracts

Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred percent (100%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred percent (100%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty percent (50%) of billed charges or amount determined under PacifiCare’s Fee Schedule.

Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred percent (100%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred percent (100%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty seventy-five percent (5075%) of billed charges or amount determined under PacifiCare’s Fee Schedule.

Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred eighty-five percent (10085%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred percent (100%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty percent (50%) of billed charges or amount determined under PacifiCare’s Fee Schedule.

Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred eighty–five percent (10085%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred percent (100%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty percent (50%) of billed charges or amount determined under PacifiCare’s Fee Schedule.

Cost of Care. Certain provisions of this Agreement require that Medical Group provide or arrange health care services which are not covered by Capitation Payments at Cost of Care and certain provisions of this Agreement require that than Covered Services be valued at Cost of Care. For purposes of this Agreement, “Cost of Care” shall be calculated using the lesser of billed charges charges, Medical Group’s cost for the services, or in accordance with the PacifiCare Fee Schedule. The PacifiCare Fee Schedule shall be based upon the following: ; (i) for professional services that are included under the Medicare RBRVS Fee Schedule, reimbursement shall be one hundred and ten percent (100%) of Medicare’s geographically adjusted fee schedule according to the Medicare payment locality the provider resides in; (ii) for all other health care services (other than inpatient and outpatient Hospital Services) that are not included in the RBRVS but included in a Medicare Fee Schedule, reimbursement shall be one hundred and ten percent (100110%) of the Medicare rate for the current period as released by HCFA by December of the preceding year; (iii) for inpatient and outpatient Hospital Services, the Cost of Care shall be the actual amounts paid by PacifiCare; (iv) for any other Covered Services that do not fall within any of the above specified categories, specific categories (other than inpatient and outpatient Hospital Services), reimbursement shall be the lesser of fifty percent (50%) of billed charges or amount determined under PacifiCare’s Fee Schedule.