Increases in Reimbursement Rates for PCPs and Specialists Sample Clauses

Increases in Reimbursement Rates for PCPs and Specialists. The parties acknowledge and agree that the reimbursement rates presently in effect are based on AMERICAID's fee schedule (HMO agrees to provide CCPN with a complete copy of the fee schedule in effect within thirty (30) days of CCPN's request). To ensure that such reimbursement rates continue to reasonably reflect the then current Medicaid reimbursement/payment methodologies and that subsequent increases agreed to between CCPN and its providers will not inequitably increase the medical expense ratio under the Pediatric Pool and can be administered by HMO under its claims payment system, CCPN agrees that the fee schedule shall not be increased more than once a year and that CCPN shall provide HMO with prior written notice of any proposed increase. The notice shall include in reasonable detail the reasons therefor and contain pro forma calculations that have been prepared using CCPN's usual and customary accounting practices and, where applicable, reasonable actuarial assumptions. HMO's consent to such increase shall be required unless (i) the increase to the fee schedule represents an increase in the rates of five percent (5%) or less (as calculated on a weighted average basis; i.e., taking into account whether the impact of all rate adjustments causes an increase in the aggregate pro forma physician reimbursement of five percent (5%) or less) or (ii) CCPN provides pro forma calculations which reflect the expected adverse effect, if any, of the greater than five percent (5%) increase in the fee schedule and, in connection with the settlements described in Section VI below, CCPN holds HMO harmless from any actual adverse effect resulting from a greater than five percent (5%) increase in the physician reimbursement. The foregoing notwithstanding, no increase may be effected in any year unless (a) a Pediatric Pool Surplus existed for the immediately preceding Contract Year and (b) the pro forma calculations for the Contract Year in which the increase is proposed to be effective indicate an expected Pediatric Pool Surplus for such year as well. Because of system configuration requirements, any change required by the fore- 125 going may be delayed by HMO for up to, but not more than, sixty (60) days.
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Related to Increases in Reimbursement Rates for PCPs and Specialists

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