Adjusted Medical Expenditures definition

Adjusted Medical Expenditures means encounter data submitted by the Contractor that are priced for internal providers to reflect the State’s fee schedule and using the paid amount on the encounter data for external providers, and exclude any and all administrative costs and amounts equal to any Co-Payments the Contractor imposes or could impose on Enrollees. Actual Medical Expenditures must be reduced by any recoveries from other payers including those pursuant to coordination of benefits, third party liability, reinsurance, rebates, or adjustments in claims paid or from providers, including adjustments to claims paid.
Sample 1
Adjusted Medical Expenditures means expenditures submitted by the Contractor that are adjusted to reflect the lesser of the plan’s actual medical expenditures, or 105% of the State’s fee-for-service level, in aggregate, for all medical services (with the exception of Pharmacy and Transportation services which shall be included as Adjusted Medical Expenditures based on Actual Medical Expenditures). Expenditures will exclude any and all case management and administrative costs and amounts equal to any Co-Payments the Contractor imposes or could impose on Enrollees. Any administrative capitation pmpm paid to a provider in addition to medical fee for services reimbursement shall be excluded as a case management cost and not a medical cost for purposes of calculating medical expenditures. Actual medical expenditures must be reduced by any recoveries from other payers including those pursuant to coordination of benefits, third party liability, reinsurance (net of reinsurance premiums), rebates, or adjustments in claims paid, or from providers including adjustments to claims paid. Adjusted Medical Expenditures excludes non-State Plan services.
Sample 1
Adjusted Medical Expenditures means expenditures submitted by the Contractor that are adjusted to reflect the lesser of the plan’s actual medical expenditures, or 105% of the State’s fee-for-service level, in aggregate, for all medical services (with the exception of Pharmacy and Transportation services which shall be included as Adjusted Medical Expenditures based on Actual Medical Expenditures). Expenditures will exclude any and all case management and administrative costs and amounts equal to any Co-Payments the Contractor imposes or could impose on Enrollees. Any administrative capitation pmpm paid to a provider in addition to medical fee for services reimbursement shall be excluded as a case management cost and not a medical cost for purposes of calculating medical expenditures. Actual medical expenditures must be reduced by any recoveries from other payers including those pursuant to coordination of benefits, third party liability, reinsurance (net of reinsurance premiums), rebates, or adjustments in claims paid, or from providers including adjustments to claims paid. Adjusted Medical Expenditures excludes non-State Plan services. 2.3.6.3.1.2 “Routine Encounter Data” as defined by CMS means, "Detailed data about individual services provided by a capitated managed care entity. The level of detail about each service reported is similar to that of a standard claim form.” 2.3.6.3.1.3 “Total Adjusted Expenditures” is defined as the sum of the Adjusted Medical expenditures plus the Administrative amount plus the privilege fee amount. 2.3.6.3.1.4 “Actual Medical Expenditures” is defined as the Contractor’s actual amount paid for medical expenditures. 2.3.6.3.1.5 “Total Capitation Rate(s)” is defined as capitation and delivery payments to Contractor. 2.3.6.3.2 Risk Sharing 2.3.6.3.2.1 The Contractor and KDHE-DHCF will share the financial risk for medical expenditures for Contract Year 2012 based on a calculation of the Adjusted Medical Expenditures for all enrolees, by engaging in a risk sharing corridor reconciliation for any amounts due to or from the Contractor as follows: 2.3.6.3.2. Adjusted Medical Expenditures shall be determined by KDHE-DHCF based on Encounter Data and plan financial data submitted by the Contractor pursuant to Section D below. Risk Sharing Final Settlement for the Contractor’s actual medical expenditures for covered services for Contract Year 2012. Adjusted Medical Expenditures excludes Non-State Plan services. 2.3.6.3.2. KDHE-DHCF reserves the right to audit med...
Sample 1

More Definitions of Adjusted Medical Expenditures

Adjusted Medical Expenditures means encounter data submitted by the Contractor that are priced for internal providers to reflect the State’s fee schedule and using the paid amount on the encounter data for external providers, and exclude any and all administrative costs and amounts equal to the Co-Payments in place for Medicaid FFS at the time, regardless of whether the Contractor collected on the Co-payments from Enrollees or not. Actual Medical Expenditures must be reduced by any recoveries from other payers including those pursuant to coordination of benefits, third party liability, reinsurance, rebates, or adjustments in claims paid or from providers, including adjustments to claims paid.
Sample 1

Related to Adjusted Medical Expenditures

  • Net Capital Expenditures means for any period the amount by which Capital Expenditures during such period exceeds reimbursements for such items during such period from any fund established pursuant to the Loan Documents.

  • local expenditures means expenditures in the currency of the Borrower or for goods or services supplied from the territory of the Borrower; and

  • Medical Expense means an expense incurred at the time a past member or his or her health reimbursement account dependent is furnished the medical care or service. To be considered a medical expense under this act, the expense shall meet all of the following conditions:

  • Consolidated Maintenance Capital Expenditures means, for any period, the aggregate amount of expenditures for additions to property, plant, and equipment that are not Consolidated Expansion Capital Expenditures.

  • Maintenance Capital Expenditures means cash expenditures (including expenditures for the addition or improvement to the capital assets owned by any Group Member or for the acquisition of existing, or the construction of new, capital assets) if such expenditures are made to maintain, including over the long term, the operating capacity or revenues of the Partnership Group.

  • Capital Expenditures means, with respect to any Person for any period, the aggregate amount of all expenditures (whether paid in cash or accrued as a liability) by such Person during that period for the acquisition or leasing (pursuant to a Capital Lease) of fixed or capital assets or additions to property, plant, or equipment (including replacements, capitalized repairs, and improvements) which should be capitalized on the balance sheet of such Person in accordance with GAAP.

  • Consolidated Capital Expenditures means, with reference to any period, the Capital Expenditures of the Borrower and its Subsidiaries calculated on a consolidated basis for such period.

  • Eligible Expenditures means the expenditures for goods, works and consultants’ services referred to in Section 2.02 of this Agreement;

  • Investment Capital Expenditures means capital expenditures other than Maintenance Capital Expenditures and Expansion Capital Expenditures.

  • Medical Expenses means those expenses that an Insured Person has necessarily and actually incurred for medical treatment on account of Illness or Accident on the advice of a Medical Practitioner, as long as these are no more than would have been payable if the Insured Person had not been insured and no more than other hospitals or doctors in the same locality would have charged for the same medical treatment.

  • Planned Expenditures shall have the meaning provided in the definition of the term Excess Cash Flow.

  • Approved Capital Expenditures means Capital Expenditures incurred by Borrower and either (i) included in the Approved Annual Budget or (ii) approved by Lender, which approval shall not be unreasonably withheld or delayed.

  • Permitted Capital Expenditures has the meaning given that term in Section 9.12(b).

  • Independent expenditure means an expenditure by a person:

  • Qualified rehabilitation expenditures means capital

  • Expansion Capital Expenditures means cash expenditures for Acquisitions or Capital Improvements. Expansion Capital Expenditures shall include interest (including periodic net payments under related interest rate swap agreements) and related fees paid during the Construction Period on Construction Debt. Where cash expenditures are made in part for Expansion Capital Expenditures and in part for other purposes, the General Partner shall determine the allocation between the amounts paid for each.

  • Operating Expenditures means all Partnership Group expenditures, including, but not limited to, taxes, reimbursements of the General Partner, repayment of Working Capital Borrowings, debt service payments and capital expenditures, subject to the following:

  • Maintenance Capital Expenditure means cash expenditures (including expenditures for the construction of new capital assets or the replacement, improvement or expansion of existing capital assets) by a Group Member made to maintain, over the long term, the operating capacity or operating income of the Partnership Group. For purposes of this definition, “long term” generally refers to a period of not less than twelve months.

  • Capital Expenditure Budget shall constitute an estimate for the applicable period of the capital expenditures required to (i) accomplish capital enhancement projects included in the most recently approved Strategic Plan, (ii) maintain and preserve the Partnership's assets in good operating condition and repair and (iii) achieve or maintain compliance with any HSE Law.

  • Capital Expenses expenses that are capital in nature or required under GAAP to be capitalized.

  • Unfinanced Capital Expenditures means, for any period, Capital Expenditures made during such period which are not financed from the proceeds of any Indebtedness (other than the Revolving Loans; it being understood and agreed that, to the extent any Capital Expenditures are financed with Revolving Loans, such Capital Expenditures shall be deemed Unfinanced Capital Expenditures).

  • Capital Expenditure Reserve means, on an annual basis, an amount equal to $0.15 per square foot for each property owned by a Borrower or the Parent (or a Subsidiary thereof).

  • Emergency Expenditures means any of the eligible expenditures set forth in the CERC Manual referred to in Section I.F.1(a) of Schedule 2 to this Agreement and required for the Contingent Emergency Response Part.

  • Capital Expenditure means expenditure on:

  • Ineligible Expenditures means the costs that are ineligible for payment under the terms and conditions of the Agreement, and that are described in Schedule “E” (Eligible Expenditures and Ineligible Expenditures).

  • Uncovered expenditures means the costs to the health care