Capitation Payment Rates Sample Clauses

Capitation Payment Rates. The Capitation Payment Rate is equal to the Risk Adjusted Rate. The Department will pay the sum of the applicable monthly Capitation Payment Rate plus the ACA Rate Supplement to the PH-MCO for each Member enrolled in the PH-MCO’s program. This amount will be the payment for each month the MCO Plan Factor remains at 0.971. As each recalculation of the MCO Plan Factor occurs, the PH-MCO will be paid a revised Capitation Payment Rate in effect for each month that each TANF Philadelphia Member is enrolled in the PH-MCO’s program. In addition, the Department will, when specified by this Agreement, pay applicable Pay For performance amounts; and the applicable Maternity Care Payments; and any amounts that are owed in accordance with the Risk Sharing provisions as defined in the Home Nursing Risk Sharing Arrangement(s) of this Agreement; and any amounts that are owed in accordance with Appendix 3k, High Cost Risk Pool, of this Agreement.

Capitation Payment Rates. The Capitation Payment Rate is equal to the Risk Adjusted Rate. The Department will pay the applicable monthly Capitation Payment Rate to the PH-MCO for each Member enrolled in the PH-MCO’s program. Capitation Payment Rate equals the Risk Adjusted Rate of $97.10. This will be paid for each month the MCO Plan Factor of 0.971 is in effect. As each recalculation of the MCO Plan Factor occurs, the PH-MCO will be paid the revised Capitation Payment Rate in effect for each month that each TANF Philadelphia Member is enrolled in the PH-MCO’s program. In addition, the Department will, when specified by this Agreement, pay applicable Pay For performance amounts; and the applicable Maternity Care Payments; and any amounts that are owed in accordance with the Risk Sharing provisions as defined in the Home Nursing Risk Sharing Arrangement(s) of this Agreement; and any amounts that are owed in accordance with Appendix 3k, High Cost Risk Pool, of this Agreement. Federal HC Agreement New West Updated March 26, 2012

Capitation Payment Rates. 3.3.1 The CONTRACTOR will be paid a base capitation rate for each enrollee based on the enrollee’s rate category. Rate categories are based on various factors, including the enrollee’s enrollment in CHOICES, category of aid, age/sex combination and the Grand Region served by the CONTRACTOR under this Agreement. The rate categories and the specific rates associated with each rate category are specified in Attachment XII. 3.3.2 The major aid categories are as follows: 3.3.2.1 Medicaid; 3.3.2.2 Uninsured/Uninsurable; 3.3.2.3 Disabled — The disabled rate is only for those enrollees who are eligible for Medicaid as a result of a disability; and 3.3.2.4 Duals/Waiver Duals — For the purpose of capitation rates, Duals/Waiver Duals are TennCare Medicaid or TennCare Standard enrollees who have Medicare eligibility. 3.3.3 The CONTRACTOR will also be paid a priority add-on rate for behavioral health services in accordance with the rates specified in Attachment XII for each priority enrollee. The CONTRACTOR will be paid the priority add-on rate for priority enrollees, as defined in this Agreement, who have received behavioral health services as reported pursuant to Section 2.23.4 of this Agreement, within the preceding twelve (12) months from the date of the calculation of the monthly payment, and who have had a valid CRG/TPG assessment within the preceding twelve (12) months from the date of the calculation of the monthly payment. 3.3.4 TENNCARE will determine the appropriate rate category to which each enrollee is assigned for payment purposes under this Agreement. 3.3.5 TENNCARE’s assignment of an enrollee to a rate category is for payment purposes under this Agreement, only, and is not an “adverse action” or determination of the benefits to which an enrollee is entitled under the TennCare program, TennCare rules and regulations, TennCare policies and procedures, the TennCare waiver or relevant court orders or consent decrees.

Capitation Payment Rates. The Capitation Payment Rate is equal to the Risk Adjusted Rate. The Department will pay the sum of the applicable monthly Capitation Payment Rate plus the ACA Rate Supplement to the PH-MCO for each Member enrolled in the PH-MCO’s program. has provided the PH-MCO with a RAR MCO Plan Factor of 0.9710 for TANF Members in Philadelphia. $100.00 multiplied by 0.971 equals $97.10, which is the Risk Adjusted Rate. The Risk Sharing Withhold amount for Home Nursing is $2.41, and the HCRPAA is $1.21, but these amounts are not incorporated in the calculation of the Capitation Payment Rate. The ACA Rate Supplement is $15.00. This rate of $15.00 is added to the Capitation Payment Rate of $97.10 to total $112.10, which is the final capitation payment issued for the TANF member. This amount will be the payment for each month the MCO Plan Factor remains at 0.971. As each recalculation of the MCO Plan Factor occurs, the PH-MCO will be paid a revised Capitation Payment Rate in effect for each month that each TANF Philadelphia Member is enrolled in the PH-MCO’s program. In addition, the Department will, when specified by this Agreement, pay applicable Pay For performance amounts; and the applicable Maternity Care Payments; and any amounts that are owed in accordance with the Risk Sharing provisions as defined in the Home Nursing Risk Sharing Arrangement(s) of this Agreement; and any amounts that are owed in accordance with Appendix 3k, High Cost Risk Pool, of this Agreement. Federal HC Agreement 13-14 Amendment – NW Updated July 18, 2013 This Agreement establishes a risk sharing arrangement (Arrangement) between the Department and the PH-MCO for certain HealthChoices Members who incur significant costs for home nursing services. This Appendix 3c supersedes any previous version to define the Arrangement for the Arrangement Year beginning January 1, 2014 and subsequent Arrangement Years.

Capitation Payment Rates. 3.3.1 The CONTRACTOR will be paid a base capitation rate for each enrollee based on the enrollee’s category of aid and age/sex combination and the Grand Region served by the CONTRACTOR under this Agreement in accordance with the rates specified in Attachment X. 3.3.2 The major aid categories are as follows: 3.3.2.1 Medicaid; 3.3.2.2 Uninsured/Uninsurable; 3.3.2.3 Disabled — The disabled rate is only for those enrollees who are eligible for Medicaid as a result of a disability;

Capitation Payment Rates. Payments for all Enrollees, except dual eligible Enrollees 65 and over, shall be the sum of payments under A. and B. below, which have an actuarial basis and which shall not exceed the payments limits set forth in 42 C.F.R. 447.361. Dual eligible Enrollees 65 and over shall be paid under A only, but at 100% instead of 95%. The HEALTH PLAN shall receive for each Enrollee the rate of the county of service. A. Until the date specified in Section 4.1.4., monthly payments paid by the STATE to the HEALTH PLAN shall be paid at 95% of the rates in Appendix A, Column (3), plus the MERC and DPA rates in Appendix A, Columns (4) and (5) ; This amount is shown in Appendix B, Column (1). After the date specified in Section 4.1.4., the amount is shown in Appendix B, Column (2). B. Monthly payments paid by the STATE to the HEALTH PLAN shall be at 5% of the statewide Base Rate in Appendix B, Column (4), multiplied by the HEALTH PLAN’s risk factor for each eligibility group in Appendix B, Column (3). The dollar value of this add-on is shown in Appendix B, Column (5), and will change on a quarterly basis. The sum of (A) and (B) is the total capitation payment to the HEALTH PLAN and is identified in Appendix B, Column (6). Section 4.2.1. Assignment of Rate Cells shall be made based on information on the STATE MMIS and information provided by the HEALTH PLAN to the STATE. Section 4.2.2. The STATE will periodically review information in MMIS related to the assignment of Rate Cells to verify that appropriate rates are being paid. Section 4.2.3. The HEALTH PLAN shall promptly pay all valid claims, whether provided within or outside the Service Area of this Contract consistent with Sections 1816(c)(2) (42 U.S.C. 1395(h)(c)(2)), 1842(c)(2) (42 U.S.C. 1395u(c)(2)) and 1902(a)(37)(a) (42 U.S.C. Section 4.2.4. The prepaid capitation rates for Recipients enrolled in the HEALTH PLAN shall be subject to renegotiation not more than annually unless required by State or federal law or regulation, or necessary due to changes in eligibility and benefits. Section 4.2.5. The capitation rate shall not include payment for recoupment of losses incurred by the HEALTH PLAN from prior years or under previous contracts.