CHIP Perinatal Program Capitation Structure Sample Clauses

CHIP Perinatal Program Capitation Structure. CHIP Perinatal Program Rate Cells. CHIP Perinatal Capitation Rates are defined on a per Member per month basis by the Rate Cells applicable to a Service Area. CHIP Perinatal Rate Cells are based on the Member’s birth status and household income as follows:
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CHIP Perinatal Program Capitation Structure. (a) CHIP Perinatal Program Rate Cells. CHIP Perinatal Capitation Rates are defined on a per Member per month basis by the Rate Cells applicable to a Service Area. CHIP Perinatal Rate Cells are based on the Member’s birth status and household income as follows: (1) CHIP Perinate 0% to 185% of FPL; (2) CHIP Perinate Above 185% to 200% of FPL; (3) CHIP Perinate Newborn 0% to 185% of FPL (born before September 1, 2010); and (4) CHIP Perinate Newborn Above 185% to 200% of FPL. (b) CHIP Perinatal Program Capitation Rate Development (1) Until such time as adequate encounter data is available to set rates, CHIP Perinatal Program capitation rates will be established based on experience from comparable populations in the Medicaid Fee-for-Service and STAR programs. This analysis will include: a review of historical enrollment and claims experience information; changes to Covered Services and covered populations; rate changes specified by the Texas Legislature; and any other relevant information. HHSC may modify the Service Area based Capitation Rate using diagnosis-based risk adjusters to yield the final Capitation Rates. (2) Effective 4/1/07, on a prospective basis, the monthly Capitation Rate for CHIP Perinate Members at or below 185% of the Federal Poverty Level (FPL)has been increased. All physicians involved in a labor with delivery for CHIP Perinate Members at or below 185% FPL will share in the increase. For services provided on or after April 1, 2007 to CHIP Perinate Members, the HMO must increase its fee schedule in effect on March 31, 2007 by at least 26.1% for the procedure codes related to labor with delivery. The HMO’s Chief Executive Officer will attest that the HMO has appropriately increased physician fees as required above. HHSC will perform sample audits to verify payments to physicians are in accordance with this Contract requirement. (c) Value-added Services will not be included in the rate-setting process.
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