Common use of Rate Review Process Clause in Contracts

Rate Review Process. CMS and the State will review Demonstration Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the Demonstration Plans and the appropriateness of capitation payments. At any point, the State may request that CMS staff review documentation from specific Demonstration Plans to assess financing issues. In the event that two or more Demonstration Plans show MLRs below 85%, or in the event that two or more Demonstration Plans show annual losses exceeding 5%, CMS will convene the following parties, or their designees, to assess the factors resulting in the payment or loss and, as warranted, evaluate the payment parameters, including the respective projected baselines, savings percentages, and risk adjustment methodology: (1) CMS participants: Administrator, Chief Actuary or his/her designee, Director of the Center for Medicare, Director of the Center for Medicaid and CHIP Services, Director of the Medicare-Medicaid Coordination Office; (2) Office of Management and Budget participants: Medicare Branch Chief, Medicaid Branch Chief; (3) State participants: Medicaid Director or his/her designee and actuarial consultant. These parties will review available data, as applicable, including data on enrollment, utilization patterns, health plan expenditures, and risk adjustment to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings.