Capitation Payment. The aggregate payment CMS and the State make periodically to a STAR+PLUS MMP on behalf of all of the Enrollees enrolled under this Contract for the provision of services within this Demonstration, regardless of whether a specific Enrollees receives services during the period covered by the payment. Except as provided in this Contract, any and all costs incurred by the STAR+PLUS MMP in excess of a Capitation Payment shall be born in full by the STAR+PLUS MMP.
Capitation Payment. The Department shall pay Contractor on a Capitation basis, based on the rate cell of the Enrollee as shown on the table in Attachment IV, a sum equal to the product of the approved Capitation rate and the number of Enrollees enrolled in that category as of the first day of that month. An Enrollee’s rate cell shall be determined by the Department at the time of the Enrollee’s enrollment and the Enrollee’s rate cell shall not change during the first year of the Enrollee’s enrollment, regardless of any change in the Enrollee’s circumstances, except as provided in Section 7.3. Capitation is due to Contractor by the fifteenth day of the service month. Rates reflected in Attachment IV are for the period as set forth in said Attachment, except as adjusted pursuant to this Article VII. Rates may be updated periodically to reflect future time periods, additional Service Packages and additional populations. The Department will provide Contractor with an opportunity to review, comment and accept in writing any such update, including supporting data, before such update is implemented. The Parties will work together to resolve any discrepancies.
Capitation Payment. The Department shall pay Contractor on a Capitation basis, based on the rate cell of the Enrollee as shown on the table in Attachment IV, a sum equal to the product of the approved Capitation rate and the number of Enrollees enrolled in that category as of the first day of that month. The Capitation rates for the Nursing Facility rate cell and the HCBS Other Waivers rate cell will include a component for Service Package I and Service Package II. Except as provided in Subsections 7.1.1 through 7.1.4, an Enrollee’s rate cell will be determined by his or her residential status as of the first day of the month (e.g., NF resident, HCBS Waiver Enrollee). The Department will use its eligibility system to determine an Enrollee’s rate cell. Delays in changes to an Enrollee’s residential status being reflected in the Department’s eligibility system will cause adjustments to past Capitation payments to be made. Capitation is due to Contractor by the fifteenth day of the service month. Rates reflected in Attachment IV are for the period as set forth in said Attachment, except as adjusted pursuant to this Article
Capitation Payment. The Department shall pay the Contractor on a Capitation basis, based on the age and gender categories of the Enrollcc as shown on the table in Attachment I, a sum equal to the product of the approved Capitation rate and the number of Enrollees enrolled in that category as of the first day of that month. Rates reflected in Attachment I are for the period August 1, 2006 through July 31, 2008. At the end of the two year period, the Department will develop an update to the rates which will be offered to the Contractor through an amendment to the Contract.
Capitation Payment. The Department shall pay the Contractor on a Capitation basis, based on the age and gender categories of the Enrollee as shown on the table in Attachment I, a sum equal to the product of the approved Capitation rate and the number of Enrollees enrolled in that category as of the first day of that month. Rates reflected in Attachment I are for the period August 1, 2003 through July 31, 2005. At the end of the two year period, the Department will develop an update to the rates which will be offered to the Contractor through an amendment to the Contract.
Capitation Payment. A. The Department will pay a Capitation Payment to the Contractor for each Participant calculated on an actuarially sound basis. The Capitation Payment rates and methodology for calculating the rates are described in Appendix I.
B. The Department will pay the Contractor a Capitation Payment for each Participant as of the effective date of the Participant's enrollment.
C. The Department will pay a State-Funded Residential Habilitation Subsidy to the Contractor for each Participant receiving Residential Habilitation services. The State-Funded Residential Habilitation Subsidy will be equal to the amount paid to providers of Adult Autism Waiver services for ineligible residential habilitation services, which is specified in a notice in the Pennsylvania Bulletin. If the Participant is receiving services in a Community Home, the Contractor will receive the rate specified for Residential Habilitation Community Home and if the Participant is receiving services in a Family Living Home, the Contractor will receive the rate specified for Residential Habilitation Family Living Home.
D. Payment to the Contractor will be automatically generated on a monthly basis via the Provider Reimbursement and Operations Management Information System (PROMISe™).
1. The Contractor will receive payment from the Department at the current Capitation Rate minus any applicable Participant Liability amount. The Contractor is responsible to collect any Participant Liability amount from the Participant.
2. The Contractor will receive payment from the Department of the State-Funded Residential Habilitation Subsidy for any Participant receiving Residential Habilitation services.
E. The Contractor shall accept the Capitation Payment and any applicable Participant Liability or State-Funded Habilitation Subsidy as payment for providing or arranging for all Medically Necessary Authorized Services to Participants as described in Article II.
F. The Contractor shall be liable for payment of all claims for Authorized Services provided to a Participant from the effective date of the Participant's enrollment in the Plan.
G. Except as specified in Section 3.1.G, the Capitation Payment and State-Funded Residential Habilitation Subsidy, if applicable, for a disenrolled individual shall be terminated effective on the date of disenrollment. The effective date of disenrollment is the last day of the month in which the Participant is disenrolling. Should the Contractor receive any Capitation Payment or State-F...
Capitation Payment. Capitation Payment means a payment for each premium rate category EOHHS makes periodically to Contractor on behalf of each member enrolled under a contract for the provision of medical services under the State plan. EOHHS makes the payment to the Contractor regardless of whether the particular member receives services during the period covered by the payment.
Capitation Payment. The fee that is paid by T ENNCARE to the CONTRACTOR for each member covered by this Agreement. The CONTRACTOR is at financial risk as specified in Section 3 of this Agreement for the payment of services incurred in excess of the amount of the capitation payment. “Capitation Payment” includes Base Capitation Rate payments unless otherwise specified. Capitation Rate – The amount established by T ENNCARE pursuant to the methodology described in Section 3 of this Agreement, including the base capitation rates.
Capitation Payment.
7.1.1 The Department shall pay Contractor on a Capitation basis, based on the rate cell of the Enrollee as shown on the table in Attachment IV, a sum equal to the product of the approved Capitation rate and the number of Enrollees enrolled in that category as of the first day of that month. The Capitation rates for the nursing facility rate cell and the HCBS other waivers rate cell will include a component for Service Package I and Service Package II. In such circumstance, an Enrollee’s rate cell will be determined by the Enrollee’s residential status (e.g., NF resident, HCBS Waiver) as of the first day of the month. The Department will use its eligibility system to determine an Enrollee’s rate cell. Delays in changes to an Enrollee’s residential status being reflected in the Department’s eligibility system will cause adjustments to past Capitation payments to be made. Capitation is due to Contractor by the fifteenth (15th) day of the service month. Rates reflected in Attachment IV are for the period as set forth in Attachment IV, except as adjusted pursuant to this Article VII. Rates may be updated periodically to reflect future time periods, additional service packages, additional populations, or changes that affect the cost of providing covered services that the Department determines to be actuarially significant. The Department will provide Contractor with an opportunity to review, comment on, and accept in writing any such update, including supporting data, before such update is implemented. The parties will work together to resolve any discrepancies.
7.1.2 The Department shall pay Contractor a monthly Capitation payment for an Enrollee receiving inpatient treatment in an Institution for Mental Diseases provided all requirements of 42 CFR §438.6(e) are met.
7.1.3 The Department shall pay Contractor a separate, State-funded-only monthly Capitation payment for an Enrollee who is residing in an Institution for Mental Diseases on the first day of the month. The monthly Capitation is shown as “State Only IMD” rate cell in Attachment IV.
Capitation Payment. A payment EOHHS makes periodically to the Contractor on behalf of each enrolled Member, which is based on the actuarially sound Capitation Rate, for the provision of services under the Agreement. EOHHS makes the Capitation Payment regardless of whether the Member receives services during the period covered by the payment. [42 C.F.R. § 438.2]
