Iowa Admin. Code r. 441-88.28 - Payment
Current through Register Vol. 44, No. 12, December 15, 2021
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88.28(1) Medicaid payment to PACE organization. Under a PACE program agreement, the department shall make a prospective monthly payment to the PACE organization of a capitation amount for each Medicaid enrollee. The monthly capitation payment amount shall be negotiated between the PACE organization and the department and shall be specified in the PACE program agreement.
a. The amount of the capitation payment:
(1) Shall be less than the amount that would otherwise have been paid under the Medicaid program if the enrollees were not enrolled under the PACE program.
(2) Shall be a fixed amount regardless of changes in the enrollee’s health status.
(3) May be renegotiated on an annual basis.
b. The PACE organization must accept the capitation payment amount as payment in full for Medicaid enrollees. The organization shall not collect or receive any other form of payment from the department or from, or on behalf of, the enrollee except for any amounts due from the enrollee pursuant to subrule 88.88(2).
88.28(2) Liability of Medicaid enrollee. A Medicaid enrollee shall contribute toward the cost of the enrollee’s care according to the terms of this subrule. A PACE organization may not charge a premium to a Medicaid enrollee except for any amounts due pursuant to this subrule.
a. Institutionalized enrollees. Medicaid enrollees who reside in a medical facility are liable to the PACE organization for the Medicaid capitation payment to the extent of their total monthly income, with the exceptions allowed by 441—subrule 75.16(1) and the deductions allowed by 441—subrule 75.16(2).
b. Noninstitutionalized enrollees. Medicaid enrollees who do not reside in a medical facility are liable to the PACE organization for the Medicaid capitation payment to the extent of their total monthly income, with the deductions required by 42 CFR Section 435.726(c) as amended to July 25, 1994, with maintenance needs amounts set at the following levels:
(1) The amount for the maintenance needs of the enrollee is set at 300 percent of the maximum SSI grant for an individual.
(2) The additional amount for the maintenance needs of a spouse at home is set at the Iowa Medicaid program’s medically needy income standard for one person.
(3) The additional amount for the maintenance needs of a family at home is set at the Iowa Medicaid program’s medically needy income standard for a family of the same size, to the extent that amount exceeds any amount allowed for the maintenance needs of a spouse at home.
[ARC 2358C, IAB 1/6/16, effective 1/1/16]