Iowa Admin. Code r. 441-73.22 - Payment to the MCP
(1)
Capitation rate. In consideration for all services rendered by
an MCP under a contract with the department , the MCP will receive a payment
each month for each enrolled member . The monthly reimbursement may be reduced
by amounts withheld for pay-for-performance components of the contract . The
withheld amounts will be distributed based on the terms described in the
managed care contract . Additionally, the department will make an allowance for
obligations resulting from Section 9010 of the Patient Protection and
Affordable Care Act, the health insurance providers fee. This capitation rate,
inclusive of the amounts withheld and the health insurance providers fee,
represents the total obligation of the department with respect to the costs of
medical care and services provided to enrolled members under the contract
except as otherwise designated in the contract rate. Pay-for-performance terms
will allow for incentive reimbursement if the MCP meets metrics described in
the MCP contract .
(2)
Determination of rate. The actuarially sound capitation rate
will be determined according to the terms of federal funding requirements,
including 42 CFR
438.6 as amended to July 19, 2022, Actuarial
Standards of Practice 49, and other related CMS regulations and generally
accepted actuarial principles and practices.
(3)
Third-party liability.
If an enrolled member has health insurance coverage or a responsible party
other than the Medicaid program available for payment of medical or dental
expenses, it is the right and responsibility of MCP to investigate these
third-party resources and attempt to obtain payment.
a. The MCP shall have a time limit to attempt
to collect from third-party resources. The time limit shall be determined by
the department .
b. The MCP shall
retain all funds collected from third-party resources during the time
limit.
c. A complete record of all
third-party collections must be maintained and made available to the department
on request.
d. In the event that
the MCP no longer contracts with the department , the department has the right
to seek recovery of any third-party collections not collected by the time the
contract ends and retain the funds. This includes but is not limited to
subrogation cases.
e. The
department has the right to retain all funds collected from third-party
resources after the MCP time limit.
(4)
Medical loss ratio . The
MCP shall report the experienced medical loss ratio for each contract rate
period. In the event that the medical loss ratio falls below the
department -designated target, the department shall recoup excess capitation
paid to the MCP .
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.