Sub-capitation Sample Clauses

Sub-capitation. An applicant may sub-capitate for shared risk with its provider network, including CMHSPs, MCPNs, and core providers. The actuarially-sound methodology and rates for sub-capitation, by contractor, must be submitted to MDCH. MDCH retains the right to disapprove any sub-capitation arrangement that is determined not to be actuarially sound or where the arrangement has a high probability to adversely impact the State’s risk-sharing. Sub-capitation rates shall be reasonable when compared to other service rates for similar services. Sub-capitation shall not contribute to risk reserve accumulation that exceeds seven and one-half percent (7.5 percent) of annual per eligible/per month, or an amount consistent with Governmental Accounting Standards Board Statement 10, whichever is less, within the applicant’s region.

Sub-capitation. Sub-capitated data is identified separately in both the encounter and cost report experience. Encounter Data: MCOs indicated whether an encounter is sub-capitated and “shadow priced” at the detail and header level, depending on how the encounter was paid. In the payment arrangement field (‘CDE_PAY_ARR’), code ‘05’ indicates sub-capitated arrangements. This field was used to separate sub-capitated encounter data from the non-sub-capitated encounter data. The MCOs provided additional information related to sub-capitated services through their MCO Survey submissions. These submissions provide insight into areas where a sub- capitated arrangement is present, yet the claims are not “shadow priced” in the submitted encounter data. We relied on this information for the purpose of properly identifying sub-capitated MCO encounter data.