Common use of Rate Setting Methodology Clause in Contracts

Rate Setting Methodology. 3 – Blending of FFS and Managed Care Data A. Definition of a Party in Interest - As defined in Section 1318(b) of the Public Health Service Act, a party in interest is: (1) Any director, officer, partner or employee responsible for management or administration of a LME; any person who is directly or indirectly the beneficial owner of more than five (5) % of the equity of the LME; any person who is the beneficial owner of more than five (5) % of the LME or, in the case of a LME organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation laws; (2) Any organization in which a person described in subsection 1 is director, officer or partner; has directly or indirectly a beneficial interest of more than five (5)% of the equity of the LME ; or has a mortgage, deed of trust, note, or other interest valuing more than five (5) % of the assets of the LME ; (3) Any person directly or indirectly controlling, controlled by, or under common control with a LME; or (4) Any spouse, child, or parent of an individual described in subsections 1, 2, or 3. B. Types of Transactions Which Must Be Disclosed - Business transactions which must be disclosed include: (1) Any sale, exchanges or lease of any property between the LME and a party interest; (2) Any lending of money or other extension of credit between the LME and a party interest; and (3) Any furnishing for consideration of goods, services (including management services) or facilities between the LME and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment. C. The information, which must be disclosed in the transactions, listed in subsection B between a LME and a party in interest includes: (1) The name of the party in interest for each transaction; (1) A description of each transaction and the quantity or units involved; (2) The accrued dollar value of each transaction during the fiscal year; and (3) Justification of the reasonableness of each transaction. If this LME contract is being renewed or extended, the LME must disclose information on these business transactions, which occurred during the prior contract period. If the contract is an initial contract with Medicaid, but the LME has operated previously in the commercial or Medicare markets, information on business transactions for the entire year preceding the initial contract period must be disclosed. The business transactions, which must be reported, are not limited to transactions related to serving the Medicaid enrollment. All of these LME business transactions must be reported.

Rate Setting Methodology. 3 – Blending of FFS and Managed Care Data A. Definition of a Party in Interest - As defined in Section 1318(b) of the Public Health Service Act, a party in interest is: (1) Any director, officer, partner or employee responsible for management or administration of a LMEMCO; any person who is directly or indirectly the beneficial owner of more than five (5) % of the equity of the LMEMCO; any person who is the beneficial owner of more than five (5) % of the LME MCO or, in the case of a LME An MCO organized as a nonprofit corporation, an incorporator or member of such corporation under applicable State corporation laws; (2) Any organization in which a person described in subsection 1 is director, officer or partner; has directly or indirectly a beneficial interest of more than five (5)% of the equity of the LME MCO ; or has a mortgage, deed of trust, note, or other interest valuing more than five (5) % of the assets of the LME MCO ; (3) Any person directly or indirectly controlling, controlled by, or under common control with a LMEMCO; or (4) Any spouse, child, or parent of an individual described in subsections 1, 2, or 3. B. Types of Transactions Which Must Be Disclosed - Business transactions which must be disclosed include: (1) Any sale, exchanges or lease of any property between the LME MCO and a party interest; (2) Any lending of money or other extension of credit between the LME MCO and a party interest; and (3) Any furnishing for consideration of goods, services (including management services) or facilities between the LME MCO and the party in interest. This does not include salaries paid to employees for services provided in the normal course of their employment. C. The information, which must be disclosed in the transactions, listed in subsection B between a LME MCO and a party in interest includes: (1) The name of the party in interest for each transaction; (1) A description of each transaction and the quantity or units involved; (2) The accrued dollar value of each transaction during the fiscal year; and (3) Justification of the reasonableness of each transaction. If this LME MCO contract is being renewed or extended, the LME MCO must disclose information on these business transactions, which occurred during the prior contract period. If the contract is an initial contract with Medicaid, but the LME MCO has operated previously in the commercial or Medicare markets, information on business transactions for the entire year preceding the initial contract period must be disclosed. The business transactions, which must be reported, are not limited to transactions related to serving the Medicaid enrollment. All of these LME MCO business transactions must be reported.