TCOC Benchmark and TCOC Performance Calculations Sample Clauses

TCOC Benchmark and TCOC Performance Calculations. 1. The Contractor’s TCOC for a given period shall be calculated as follows and as further specified by EOHHS: a. TCOC shall be a risk-adjusted per-Attributed Member, per month amount representing the costs of care for Contractor’s Attributed Members over such period, as described in this Section and further specified by EOHHS; b. TCOC shall include all paid claims and encounters with dates of service during such period, where the Member receiving the service was Contractor’s Attributed Member on the date of service, except for services that are not TCOC Included Services as set forth in Appendix A of the Contract on the date of service. c. TCOC shall be based on the amounts paid for such claims and encounters, but shall incorporate certain adjustments to these amounts as further specified by EOHHS to account for effects including but not limited to the different fee schedules historically used by MassHealth and the MassHealth-contracted MCOs and price inflation for certain categories of service (e.g., pharmacy); d. Admission-level stop-loss: TCOC shall exclude an amount equal to 95 percent (95%) of allowed expenditures as specified by EOHHS in excess of $150,000 per Attributed Member hospital inpatient admission as determined by EOHHS; and e. TCOC shall be risk adjusted as further specified by EOHHS using a generally accepted diagnosis grouper and statistically developed risk model. Such risk model may include adjustments for Attributed Members’ health-related social needs. 2. The Contractor’s TCOC Benchmark shall be calculated each Contract Year according to EOHHS specifications as follows: a. The Contractor’s Historic TCOC and Contractor’s Market-Rate TCOC shall be calculated as described in this Section; b. The Contractor’s Historic TCOC and Contractor’s Market-Rate TCOC shall be blended as further specified by EOHHS. Each Contract Year, EOHHS may increase the portion of the blend that is based on Contractor’s Market Rate TCOC, as further specified by EOHHS. The resulting amount shall be the Contractor’s TCOC Benchmark. c. The Contractor’s Historic TCOC shall be calculated as follows: 1) The Contractor’s TCOC shall be calculated during a baseline period, as further specified by EOHHS; 2) Such TCOC shall be adjusted to account for anticipated trend between the baseline period and the Contract Year, and to account for the anticipated impact of changes to the MassHealth program to ensure that Contractor is not unfairly penalized or rewarded for such progra...

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