Payment and Financial Provisions. 137 4.1. General Financial Provisions 139 4.2. Capitated Rate Structure 140 4.3. Payment Terms 151 4.4. Payment in Full 157 Section 5. Additional Terms and Conditions 160 5.1. Administration 160 5.2. Confidentiality 169 5.3. General Terms and Conditions 171 5.4. Record Retention, Inspection, and Audit 181 5.5. Termination of Contract 182 5.6. Order of Precedence 185 5.7. Contract Term 186 5.8. Amendments 186 5.9. Written Notices 186 Section 6. Signatures 188 Section 7. Appendices 197 Appendix A. Covered Services 198 Appendix B. Beneficiary Rights 201 Appendix C. Relationship With First Tier, Downstream, And Related Entities 204 Appendix D. Part D Addendum 208 Appendix E. Data Use Attestation 218 Appendix F. Model File & Use Certification Form Error! Bookmark not defined. Appendix G. Medicare Mark License Agreement 221 Appendix H. Service Area 224 Appendix I. Additional Medicare Waivers 225 This Contract, effective on November 1, 2023, is between the Department of Health and Human Services, acting by and through the Centers for Medicare & Medicaid Services (CMS), the State of Ohio, acting by and through the State of Ohio Department of Medicaid (ODM) and (the ICDS Plan). The ICDS Plan's principal place of business is .
Payment and Financial Provisions. Section 4.2.A.2 is hereby amended by deleting it in its entirety and replacing it with the following:
Payment and Financial Provisions. 1. Section 4.4.B of the Contract is hereby amended by striking the following language: “an Enrollee residing in the community is determined to owe a monthly deductible amount, or”.
Payment and Financial Provisions. 17. Section 4 is hereby amended by deleting each instance of “PCC Plan Management Support Services” and inserting in place thereof “PCC Plan Support Services”.
Payment and Financial Provisions. Section 6.5- Special Payment Requirements, Paragraphs A through E; Section 6.6, Funding and Approval, Paragraph B4; Section 6.9, Expenditures Incurred But Not Reported (IBNR); and Section 6.10, Payment for Services – Non-Medicaid, Paragraph F, are amended to update the date and fiscal year references and shall read as follows:
Payment and Financial Provisions. 5. Section 10.17 is hereby amended by deleting it in its entirety and replacing it with the following language:
Payment and Financial Provisions. Section 4.1General Financial Provisions A.Capitation Payments EOHHS will make monthly capitation payments to the Contractor in accordance with the rates of payment and payment provisions set forth herein for all Covered Services actually and properly delivered to eligible Enrollees in accordance with and subject to all applicable federal and State laws, regulations, rules, billing instructions, and bulletins, as amended. The Contractor will receive two monthly capitation payments for each Dual Eligible Enrollee: one amount from Medicare and a second amount from MassHealth. Medicare and MassHealth each produce different Rate Cells (RCs) according to the individual Enrollee’s clinical and demographic status and setting of care. For those Enrollees who are eligible for MassHealth only, the Contractor will receive one monthly capitation payment from MassHealth.
Payment and Financial Provisions. Section 5.1 Limited Incorporation of Section 4 of the MCO Contract
Payment and Financial Provisions. For services provided pursuant to this Agreement, MBHP shall pay Provider in accordance with the terms set forth in Exhibit C attached hereto. In the event that MBHP reviews the ESP Services provided by Provider and determines that such services were not provided pursuant to this agreement, MBHP may retroactively deny payment and recoup or offset those amounts that should not have been paid. Any such action by MBHP shall be subject to your rights of appeal set forth in the Administrative Operations section of the Provider Manual.
