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 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, BMS agrees to pay the MCO monthly payments. BMS capitation payments to the MCO will apply to the time period July 1, 2023, through June 30, 2024 (State Fiscal Year 2024). 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 BMS. 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. Payments 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. 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. 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 program participation. The MCO will be paid a capitated rate on a per 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. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS 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 that have completed the enrollment process through the Department’s Enrollment Brokermembers. 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, BMS the Department agrees to pay the MCO monthly payments. BMS payments based on the methodology specified in Appendix B. Department capitation payments to the MCO will apply to the time period July March 1, 20232020, through June 30, 2024 2020 (State Fiscal Year 20242020). 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 BMSthe Department. Except for emergency services, no 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 MCOMCO 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 & 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. BMS 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. BMS 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 program 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 per member per month (PMPM) basis2PMPM 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. Payment will In addition, the MCO, serving as an Administrative Service Organization (ASO), shall be based on actual paid a fixed monthly participationamount for ASO services related to socially necessary services (SNS) administration. The final This payment will shall be made upon determination issued by BMS that all contractual requirements have been completedthe 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 members 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, BMS agrees to pay the MCO monthly payments. BMS capitation payments to the MCO will apply to the time period July 1, 20232021, through June 30, 2024 2022 (State Fiscal Year 20242022). 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 BMS. 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. Payments 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. 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. 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 program participation. The MCO will be paid a capitated rate on a per member per month (PMPM) basis2basis 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. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS 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 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, BMS agrees to pay the MCO monthly payments. BMS capitation payments to the MCO will apply to the time period July 1, 2023, through June 30, 2024 (State Fiscal Year 2024). 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 BMS. 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. Payments 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. 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. 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 program participation. The MCO will be paid a capitated rate on a per 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. Payment will be based on actual monthly participation. The final payment will be made upon determination by BMS that all contractual requirements have been completed.