MANAGED CARE ORGANIZATION Clause Samples
The Managed Care Organization clause defines the role and responsibilities of an entity that coordinates and manages healthcare services for members, typically under a contractual arrangement with healthcare providers and payers. This clause outlines how the organization will oversee the delivery of medical services, manage provider networks, and ensure compliance with quality and cost-control standards. By establishing clear expectations for the management of care, the clause helps streamline healthcare delivery, control costs, and ensure that members receive appropriate and efficient medical services.
MANAGED CARE ORGANIZATION. By enrollment into the NFIB/Ohio SP, Participant agrees that NFIB-MSC shall have the right to recommend a Managed Care Organization for the NFIB/Ohio SP in the event that the OBWC provides for a period of open enrollment in its Health Partnership Program pursuant to Ohio Revised Code Section 4121.441 during the term of this Agreement.
MANAGED CARE ORGANIZATION. Employees who sustain an injury which is compensable under any workers’ compensation law shall participate in the County’s MCO program.
MANAGED CARE ORGANIZATION. By enrollment into the Program, Participant agrees that NFIB-MSC shall have the right to recommend a Managed Care Organization for the Program in the event that the OBWC provides for a period of open enrollment in its Health Partnership Program pursuant to Ohio Revised Code Section 4121.441 during the term of this Agreement.
MANAGED CARE ORGANIZATION. 1.1. Contractor shall provide the managed care services for physical health as described in this Exhibit B, for the Member population enrolled in Contractor’s limited managed care capitation initiative (also referred to as Managed Care Organization or MCO).
1.1.1. Contractor shall perform duties described in this Exhibit B, under the state authority found in § 25.5-5-415, C.R.S. and as a limited managed care capitation initiative or managed care organization (MCO) within the Department’s Accountable Care Collaboration (ACC) program.
1.1.2. Contractor shall manage the MCO such that the capitation rates may be set at two percent or more below the fee-for-service equivalent. The savings target of two percent may be adjusted based on mutual agreement by the Department and Contractor upon completion of an actuarial and data review process. The actuarial and data review process shall be completed in advance of the annual rates setting process for rates effective on July 1, 2025, and every year thereafter. The Department and Contractor may agree to set an alternate target, as appropriate to reflect policy objectives regarding the total cost of care and value-based payment, upon completion of the actuarial review process. In no case shall the target be set at a level greater than 100% of the Medicaid Fee-For-Service (FFS) equivalent, pursuant to budget neutrality requirements set forth in the Colorado statutes.
1.2. Contractor shall provide physical health managed care services for Members who meet the eligibility requirements necessary to be enrolled in the MCO and reside in the following service area(s): Adams, Arapahoe, Denver, and Jefferson counties.
1.2.1. Contractor shall administer this MCO in compliance with the requirements for an MCO and as one program that integrates clinical care, operations, management, and data system aligned with the managed care authorities in the Contract.
1.3. Contractor shall be licensed pursuant to § ▇▇-▇▇-▇▇▇, et seq., C.R.S., as a Health Maintenance Organization.
1.3.1. Contractor shall notify the Department within two Business Days of any action on the part of the Colorado Commissioner of Insurance, suspending, revoking, denying renewal, or notifying Contractor of any noncompliance pursuant to § ▇▇-▇▇-▇▇▇, et seq, C.R.S. Any revocation, withdrawal, or non-renewal of necessary licenses, certifications, approvals, insurance, permits, etc. required by this section, may be grounds for the immediate termination of this Contract b...
MANAGED CARE ORGANIZATION. An entity that has a comprehensive risk contract with ASES to provide healthcare services to GHP enrollees.