Section 29-5607. PAYMENT FOR SERVICES

 

5607.1The Department shall not make any payment for Medicaid services to the managed care provider unless the provider has executed a Medicaid managed care provider agreement.

 

5607.2The managed care provider’s Medicaid managed care provider agreement with the Department shall be for a twelve (12) month period.

 

5607.3The managed care provider shall be paid by the Department on a fixed, monthly per capita basis for the covered services it provides to eligible children enrolled in the provider’s plan.

 

5607.4The capitation rates shall be based on the actuarially adjusted per capita fee-for-service cost of providing services covered by the Medicaid managed care provider agreement to the eligible population for the most recent completed fiscal year as reported through the Department’s Medicaid Management Information System.

 

5607.5The managed care provider shall not be paid a monthly capitation rate in excess of historical Medicaid program costs for the eligible Medicaid population inflated forward from the base year.

 

5607.6Reimbursement to the managed care provider shall not exceed the upper limits defined in 42 C.F.R. §447.361 for services provided under a risk contract.

 

5607.7The managed care provider shall enter into a risk sharing arrangement to limit the financial gains and losses for the demonstration. The arrangement shall establish risk corridors around an eighty-five percent (85%) target medical claims ratio. The actual medical claims ratio for any year is equal to the claims paid for that year for services covered under the managed care provider’s evidence of coverage divided by total capitation payments made by the Department to the managed care provider. The risk corridors are as follows:

 

	Percent Gain / Loss Assumed
Actual Medical Claims Ratio	Department	Provider
85%	- -	- -
80% - <85%, >85% - <90%	15%	85%
75% - <80%, >90% - <95%	50%	50%
<75%, >95%	85%	15%

 

5607.8The risk sharing arrangement shall include an annual settlement process. The actual medical claims ratio shall be calculated on an incurred basis. The settlement process shall be completed no later than ninety-two (92) days after the end of the fiscal year.

 

5607.9The managed care provider shall assume financial responsibility and provide reasonable reimbursement for emergency services that are obtained by children enrolled in the managed care provider’s plan from providers and suppliers outside the managed care provider’s plan even in the absence of the managed care provider’s prior approval.

 

5607.10The managed care provider’s Medicaid managed care provider agreement shall provide that, in the case of medically necessary services which were provided (1) to a child enrolled with the managed care provider under the agreement and entitled to benefits with respect to such services under the State’s Plan and (2) other than through the managed care provider because the services were immediately required due to unforeseen illness, injury, or condition, the managed care provider provides for reimbursement with respect to those services.

 

5607.11Services not covered under the managed care provider’s Medicaid managed care provider agreement but covered by the Medicaid program shall be reimbursed by the Department on a fee-for-service basis in accordance with the rate or methodology described in the State Plan of Medical Assistance.

 

5607.12If the Medicaid program institutes a change in Medicaid services that leads to an increase or decrease of three percent (3%) or more in the total cost of care within the term of the Medicaid managed care provider agreement, the capitated rate shall be recalculated within thirty (30) days of the effective date of change, and increased or decreased accordingly.

 

5607.13No capitation rate increase or decrease shall be effective until thirty (30) days after the notice of the rate change has been published in the D.C. Register.

 

5607.14The Department shall, at the written request of the managed care provider, make available to the data utilized to compute the capitation rates and reports that attest to the actuarial soundness of the method.

 

5607.15If the managed care provider subcontracts with a Federally Qualified Health Center (FQHC), the managed care provider shall permit the FQHC to elect to be paid at one hundred percent (100%) of reasonable costs for the services described in §1905(a)(2)(C) of the Social Security Act (42 U.S.C. §1396d(a)(2)(C)) in accordance with the requirements of §1903(m)(2)(A) of the Social Security Act (42 U.S.C. §1396b(m)(2)(A)).

 

5607.16Each capitation rate specified in the contract shall be in effect for the entire twelve (12) month term of the Medicaid managed care provider agreement, except as provided in §5607.13.

 

5607.17The managed care provider shall not impose co-payment requirements or other fees on enrolled children.

 

5607.18The Department shall pay a capitated payment to the managed care provider each month for each child enrolled as of the fifteenth (15) day of the previous month. The Department shall send each prepaid, capitated provider a roster of enrolled children five (5) days before the first day of the month which shall serve as the basis for determining payment for that month.

 

5607.17If an enrolled child loses Medicaid eligibility or voluntarily elects to return to the Medicaid fee-for-service program, the Department shall cease payments to the managed care provider for that child effective the last day of the month in which eligibility is terminated or the disenrollment becomes effective.

 

5607.18The Department reserves the right to withhold capitated payments for children enrolled in the managed care provider’s plan for whom accurate addresses or current locations cannot be determined.

 

source

Final Rulemaking published at 43 DCR 4833, 4845 (September 6, 1996).