Common use of Medical Loss Ratio Guarantee Clause in Contracts

Medical Loss Ratio Guarantee. The Contractor has a Target Medical Loss Ratio of eighty-five percent (85%). If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, the Contractor shall refund to the Department and CMS an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department and CMS shall calculate a Medical Loss Ratio for Enrollees under this Contract for each Coverage Year, and shall provide to the Contractor the amount to be refunded, if any, to the Department and CMS respectively. Any refunded amounts will be distributed back to the Medicaid and Medicare programs, with the amount to each payor based on the proportion between the Medicare and Medicaid Components. At the option of CMS and the Department, separately, any amount to be refunded may be recovered either by requiring the Contractor to make a payment or by an offset to future Capitation payment. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department and CMS may adopt NAIC reporting standards and protocols after giving written notice to the Contractor.

Medical Loss Ratio Guarantee. The Contractor has a Target Medical Loss Ratio of eighty-five percent (85%)) for Demonstration Years 1 through 5, eighty-six percent (86%) for Demonstration Year 6, eighty- seven percent (87%) for Demonstration Year 7, and eighty-eight percent (88%) for Demonstration Year 8. As described below, any collected remittances would be distributed proportionally back to the Medicaid and Medicare programs on a percent of premium basis. If the Medical Loss Ratio calculated as set forth below is less than the Target Medical Loss Ratio, the Contractor shall refund to the Department and CMS an amount equal to the difference between the calculated Medical Loss Ratio and the Target Medical Loss Ratio (expressed as a percentage) multiplied by the Coverage Year Revenue. The Department and CMS shall calculate a Medical Loss Ratio for Enrollees under this Contract for each Coverage Year, and shall provide to the Contractor the amount to be refunded, if any, to the Department and CMS respectively. Any refunded amounts will be distributed back to the Medicaid and Medicare programs, with the amount to each payor based on the proportion between the Medicare and Medicaid Components. At the option of CMS and the Department, separately, any amount to be refunded may be recovered either by requiring the Contractor to make a payment or by an offset to future Capitation payment. The Medical Loss Ratio Calculation shall be determined as set forth below; however, the Department and CMS may adopt NAIC reporting standards and protocols after giving written notice to the Contractor.