Cost Reallocation Clause Samples

Cost Reallocation. If a Medicare Member transfers to a PCP that is a MSO Provider from a PCP that is a Participating Provider contracted with or employed by another globally­capitated provider network (*Subject Medicare Member") and MSO incurs more than thirty thousand dollars ($30,000) in paid claims for Covered Services for such Subject Medicare Member within the first ninety (90) days after such transfer, one-hundred percent (100%) of the paid claims for Covered Services incurred by the Subject Medicare Member during such ninety (90) day period shall be excluded from and not made part of the Fund Deductions. Further, the applicable percentage of the premium per Section 3.A. of this Attachment A for such Subject Medicare Member during such ninety (90) day period shall be be excluded from and not made part of the Fund Revenue. If a Medicare Member transfers from a PCP that is a MSO Provider to a PCP that is a non-MSO Provider ("Subject Transferred Member') and Health Plan or other applicable financially-responsible party incurs more than thirty thousand dollars ($30,000) in paid claims for Covered Services for such Subject Transferred Member within the first ninety (90) days after such transfer, one-hundred percent (100%) of the paid claims for Covered Services incurred by the Subject Transferred Member during such ninety (90) day period shall be included in and made part of the Fund Deductions. Further, the applicable percentage of the premium per Section 3.A. of this Attachment A for such Subject Transferred Member during such ninety (90) day period shall be included in and made part of the Fund Revenue. Both parties agree to make all reasonable efforts to make requests for reimbursement and payment under this provision within thirty (30) days of the determination of any such qualifying event, but in no event more than one (1) year from the last day of the ninety (90) day post-transfer period for the Subject Medicare Member or Subject Transferred Member. Requests received after this one-year period may be denied by the other party.