AMENDMENTS

Section 2 shall be amended to add the following terms and its definition:

With the exceptions noted below, the Contractor shall negotiate rates with Providers, and such rates shall be specified in the Provider Contract. Payment arrangements may take any form allowed under Federal law and the laws of Puerto Rico, including Capitation payments, Fee-for-Service payment, and salary, if any, subject to Section 10.6 concerning permitted risk arrangements.

Claims submitted for professional services that are listed in the current Medicare Part B fee schedule, as established under Section 1848(b) of the Social Security Act, and as applicable to the Puerto Rico locality, shall be reimbursed by the Contractor at not less than 70 percent (70%) of the payment that would apply to such services if they were furnished under Medicare Part B during the applicable fiscal year, disregarding services that are paid through sub-capitated arrangements. Any claims subject to reimbursement in accordance with this Section 10.5.1.5.1 that have been reimbursed at less than 70 percent (70%) of the corresponding rates on the Medicare Part B fee schedule shall be re-adjudicated for payment in compliance with this Section.  The Contractor shall comply with all data collection and reporting requests from ASES, in the manner and frequency set forth by ASES, to validate the Contractor’s compliance with this Section.  ASES reserves the right to apply this section retroactively to January 1, 2020 if approved by CMS, the Puerto Rico Office of the Comptroller, and the Financial Oversight and Management Board for Puerto Rico. Nothing in this Section requires the reduction of fees paid above the 70% of Medicare Part B fee schedule

Dental services as described in Section 7.6 shall be reimbursed in an amount no less than those amounts specified in Attachment 11-A to this Contract and shall not be subject to the requirements set forth in Section 10.5.1.5.1.

Immediately following Section 10.6.1, a new Section 10.6.2 shall be inserted stating as follows:

The Contractor shall ensure that PMGs subject to a risk sharing arrangement with the Contractor receive an adjustment in budget, considering  the difference between current fee for service reimbursements for which the PMG is at risk and increases in reimbursement amounts necessary to meet new minimum reimbursement thresholds, as established in Section 10.5.1.5.1, unless a new financial arrangement is negotiated between and agreed upon by the Contractor and the PMG.

Immediately following Section 22.1.1.1, a new Section 22.1.1.2 shall be inserted stating as follows:

The GHP (Vital) PMPM Payment rates included in Attachment 11 to this Contract, as amended, shall be effective to account for new requirements set forth in Section 10.5.1.5.1. ASES will increase the per member per month (PMPM) capitation rates to MCOs to account for the additional costs incurred by the MCOs with respect to the minimum fee schedule, as of the effective date of the Amendment.  If Section 10.5.1.5.1 is applied retroactively to January 1, 2020, Attachment 11 shall be further amended to the extent necessary to accommodate additional impacts caused by such retroactivity to current PMPM Payment rates.

RATIFICATION

EFFECT; CMS APPROVAL

Notwithstanding the foregoing, because Updated PMPM Payment Rates are subject to CMS and FOMB approval, ASES shall continue to pay Contractor at the PMPM Payment Rates that existed prior to the Amendment Effective Date until such time as the Updated PMPM Payment Rates have been approved by CMS and FOMB;

Within thirty (30) calendar days following CMS and FOMB approval of Updated PMPM Payment Rates, the parties shall begin to reconcile any difference in (i) PMPM Payments made by ASES to Contractor after the Amendment Effective Date or January 1, 2020, as applicable, and (ii) Updated PMPM Payment Rates.

The Contractor’s obligation as contemplated in Section 10.6.2 shall be effective after (i) approval from CMS and FOMB is granted; (ii) the parties reconcile any difference in PMPM as of the Amendment Effective Date; and (iii) the reconciled increase in PMPM capitation rates are paid to the Contractor.

AMENDMENT EFFECTIVE DATE

ENTIRE AGREEMENT