Common use of Capitation Payments to Managed Care Organization Clause in Contracts

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible members. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period March 1, 2020, through June 30, 2020 (State Fiscal Year 2020). State Fiscal Year 2020 capitation rate ranges will be determined by the Department no later than October 1, 2019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. No payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State plan. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR 438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (enrollee months) were developed based on historical FFS participation. SED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a PMPM rate set by the State, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. In addition, the MCO, serving as an Administrative Service Organization (ASO), shall be paid a fixed monthly amount for ASO services related to socially necessary services (SNS) administration. This payment shall be issued by the Bureau for Children and Families.

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible membersmembers that have completed the enrollment process through the Department’s Enrollment Broker. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period March July 1, 20202023, through June 30, 2020 2024 (State Fiscal Year 20202024). State Fiscal Year 2020 capitation rate ranges will be determined by the Department no later than October 1, 2019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. No Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State planMCO. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (enrollee months) were developed based on historical FFS program participation. SED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a PMPM rate set by the Stateper member per month (PMPM) basis2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. In addition, the MCO, serving as an Administrative Service Organization (ASO), shall Payment will be paid a fixed based on actual monthly amount for ASO services related to socially necessary services (SNS) administrationparticipation. This The final payment shall will be issued made upon determination by the Bureau for Children and FamiliesBMS that all contractual requirements have been completed.

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible members. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, the Department agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period March July 1, 20202023, through June 30, 2020 2024 (State Fiscal Year 20202024). State Fiscal Year 2020 capitation rate ranges will be determined by the Department no later than October 1, 2019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the Department. No payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State plan. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by the Centers for Medicare and Medicaid (CMS). CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (enrollee months) were developed based on historical FFS participation. SED CSED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a PMPM rate set by the State, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. In addition, the MCO, serving as an Administrative Service Organization (ASO), shall be paid a fixed monthly amount for ASO services related to socially necessary services (SNS) administration. This payment shall be issued by the Bureau for Children and FamiliesSocial Services.

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible membersmembers that have completed the enrollment process through the Department’s Enrollment Broker. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period March July 1, 20202021, through June 30, 2020 2022 (State Fiscal Year 20202022). State Fiscal Year 2020 capitation rate ranges will be determined by the Department no later than October 1, 2019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. No Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State planMCO. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by CMS. CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (enrollee months) were developed based on historical FFS program participation. SED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a PMPM rate set by the Stateper member per month (PMPM) basis 2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. In addition, the MCO, serving as an Administrative Service Organization (ASO), shall Payment will be paid a fixed based on actual monthly amount for ASO services related to socially necessary services (SNS) administrationparticipation. This The final payment shall will be issued made upon determination by the Bureau for Children and FamiliesBMS that all contractual requirements have been completed.

Capitation Payments to Managed Care Organization. Payment to the MCO will be based on the enrollment data transmitted from the Department’s eligibility vendor to its Fiscal Agent each month for MCO-eligible membersmembers that have completed the enrollment process through the Department’s Enrollment Broker. The MCO must notify BMS in writing of any inconsistency between enrollment and payment data no later than within forty-five (45) calendar days from the day inconsistency was determined by the MCO. BMS agrees to provide to the MCO information needed to determine the source of the inconsistency within ten (10) business days after receiving written notice of the request to furnish such information. BMS will recoup overpayments or reimburse underpayments as soon as administratively possible. The adjusted payment (representing reinstated enrollees) for each month of coverage will be included in the next monthly capitation payment, based on updated MCO enrollment information for that month of coverage. Any retrospective adjustments to prior capitations will be made in the form of an addition to or subtraction from the current month’s capitation payment. Positive adjustments are particularly likely for newborns, where the MCO may be aware of the birth before BMS. In full consideration of Contract services rendered by the MCO, the Department BMS agrees to pay the MCO monthly payments based on the methodology specified in Appendix B. Department payments. BMS capitation payments to the MCO will apply to the time period March July 1, 20202023, through June 30, 2020 2024 (State Fiscal Year 20202024). State Fiscal Year 2020 capitation rate ranges will be determined by the Department no later than October 1, 2019, or upon CMS approval, whichever is later. The MCO assumes risk for the cost of services covered under this Contract and will incur loss if the cost of furnishing the services exceeds the payments under the Contract. The MCO must accept as payment in full, the amount paid by the DepartmentBMS. No Except for emergency services, no payment will be made for services furnished by a provider other than the MCO provider, if the services were available under the provider Contract unless otherwise authorized by the MCO except when these payments are specifically required to be made by the State in Title XIX of the Act, in 42 CFR chapter IV, or when the State agency makes direct payments to network providers for graduate medical education costs approved under the State planMCO. Payments for medical services provided for under the Contract will be denied for new enrollees when, and for so long as, payment for those enrollees is denied by the Centers for Medicare & Medicaid (CMS). CMS may deny payment for new enrollees to the State if its determination is not timely contested by the MCO per 42 CFR §438.726(b) and §438.730. The Department BMS is obligated to make payment either by mail or electronic transfer to the MCO. Capitation payments will be made for the month in which services are being provided according to the payment schedule for the month, as set forth in this Contract. The Department BMS reserves the right to change the payment process, but the payment timing described above will remain the same. Participant population (enrollee months) were developed based on historical FFS program participation. SED waiver enrollee capitation amounts were based on other state experience, PRTF costs, projected service utilization and other factors. The MCO will be paid a capitated rate on a PMPM rate set by the Stateper member per month (PMPM) basis2, which shall be firm and fixed for the period of the contract, subject to any rate adjustments warranted for modifications to State or Federal regulation, waiver amendments, State Plan amendments, etc. In addition, the MCO, serving as an Administrative Service Organization (ASO), shall Payment will be paid a fixed based on actual monthly amount for ASO services related to socially necessary services (SNS) administrationparticipation. This The final payment shall will be issued made upon determination by the Bureau for Children and FamiliesBMS that all contractual requirements have been completed.