Common use of HOOSIER HEALTHWISE SCOPE OF WORK Clause in Contracts

HOOSIER HEALTHWISE SCOPE OF WORK.  The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs.  For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out.  Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting).  Under Sub-Capitated or Sub-Contracted arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The MCE should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR is less than eighty-five percent (85%) for the Hoosier Healthwise line of business.

HOOSIER HEALTHWISE SCOPE OF WORK.  ▪ The MLR calculation shall be performed separately for each program. The MLR for the Hoosier Healthwise program shall be calculated separately from other managed care programs.  ▪ For each MLR reporting year, a preliminary calculation will be performed with six months of incurred claims run-out, and a final calculation will be performed with 18 months of incurred claims run-out.  ▪ Incurred claims reported in the MLR should relate only to members who were enrolled with the MCE on the date of service, based on data and information available on the reporting date. (Claims for members who were retroactively disenrolled should be recouped from providers and excluded from MLR reporting).  ▪ Under Sub-Capitated or Sub-Contracted arrangements, the MCE may only include amounts actually paid to providers for covered services and supplies as incurred claims. The non-benefit portion of sub-capitated and sub-contracted payments should be excluded from incurred claims. The MCE should ensure all subcontracts provide for sufficient transparency to allow for this required reporting. The Contractor shall maintain, at minimum, a MLR of eighty-five percent (85%) for its Hoosier Healthwise line of business. The Contractor is required to submit MLR reporting as described in the MCE Reporting Manual for Hoosier Healthwise. FSSA shall recoup excess capitation paid to the Contractor in the event that the Contractor’s MLR is less than eighty-five percent (85%) for the Hoosier Healthwise line of business.