D.C. Mun. Regs. tit. 29, r. 29-5308
The Department shall not make any payment for Medicaid services to a prepaid, capitated provider unless the provider has executed a Medicaid managed care provider agreement.
Each prepaid, capitated provider's Medicaid managed care provider agreement with the Department shall be for a twelve (12) month period.
Each prepaid, capitated provider shall be paid by the Department on a monthly fixed, per capita basis for the covered services it provides to AFDC and AFDC-related Medicaid enrollees.
Subject to § 5308.6, the capitation rates shall be based on the actuarially adjusted per capita fee-for-service cost of providing services covered by the Medicaid managed care provider agreement to the eligible population for the most recent completed fiscal year as reported through the Department's Medicaid Management Information System.
The monthly rate paid to District of Columbia Medicaid Managed Care Providers, on a prepaid, capitated basis, for all Medicaid Managed Care recipients shall be:
No prepaid, capitated provider shall be paid a monthly capitation rate in excess of ninety-two and one-half percent (92.5%) of historical Medicaid program costs for the eligible Medicaid population inflated forward from the base year.
Risk comprehensive, other risk and non -risk contracts shall be paid an interim payment that is a monthly fixed, per capita fee for the covered services provided under the contract.
Reimbursement to prepaid, capitated providers shall not exceed the upper limits defined in 42 C.F.R. §447.361 for services provided under a risk contract, or the upper limit defined in 42 C.F.R. §447.362 for services provided under a non-risk contract.
Non-risk contracts will be reimbursed the lesser of the cost of providing all required medical and administrative services to enrolled recipients, or the federal upper limits for such payments as defined in 42 C.F.R. §447.362.
Non-risk contract providers shall submit, within 60 days of the end of the contract period, an accounting of its actual expenditures for services rendered to enrolled recipients during the period to the Department. Other risk contract providers shall provide this data on the non-risk services provided. The data shall include actual encounter and expenditure data in sufficient detail that the Department can use the data to compute the amount the District would have paid for the same services had they been received from a fee-for-service provider.
The data may be presented in aggregate form, but the submission must include supporting documentation in sufficient detail to allow the Department to desegregate the data to sustain the aggregate data on audit (patient, prepaid health plan, dates of service, service provided or procedure performed, etc.) the supporting documentation must identify the patients and prepaid health plans by Medicaid managed care identification numbers, and documentation regarding medical services or procedure must identify the service or procedure using the Medicaid billing terminology in use at the time the service is provided (e.g., DRG, ICD -9, CPT 4, etc.)
At the end of the contract period, the Department shall calculate the difference between the medical and administrative costs incurred by the non-risk contract providers and on non-risk services provided on other risk contracts in rendering required services to enrolled recipients, and the total capitated payments made to these providers during the contract period. The calculation shall be completed within 60 days of the date the Department receives the required information in § 5308.10.
The Department agrees that it shall issue a final settlement payment that shall not exceed the federal upper limit for the difference described in § 5308.11. This payment shall be made within 30 days of completion of the calculation.
Emergency services provided to members of a prepaid, capitated provider's plan by a health care provider that does not have a written agreement with the prepaid, capitated provider to provide services shall be reimbursed by the Department in accordance with the rate or methodology described in the State Plan of Medical Assistance. Reimbursement by the Department is limited to emergency room services only. If the patient is admitted to a noncontract hospital, the prepaid, capitated provider is responsible for reimbursement.
Services not covered under the prepaid, capitated provider's Medicaid managed care provider agreement but covered by the Medicaid program shall be reimbursed by the Department on a fee -for -service basis in accordance with the rate or methodology described in the State Plan of Medical Assistance.
If the Medicaid program institutes a change in Medicaid services that leads to an increase or decrease of three percent (3%) or more in the total cost of care within the term of the Medicaid managed care provider agreement, the capitated rate shall be recalculated within thirty (30) days of the effective date of change, and increased or decreased accordingly.
No capitation rate increase or decrease shall be effective until thirty (30) days after the notice of the rate change has been published in the D.C. Register.
The Department shall, at the written request of the managed care organization, make available to the organization data utilized to compute the capitation rates and reports that attest to the actuarial soundness of the method.
A prepaid, capitated provider that subcontracts with a Federally Qualified Health Center (FQHC) shall permit FQHCs to elect to be paid at one hundred percent (100%) of reasonable costs for the services described in § 1905(a)(2)(C) of the Social Security Act ( 42 U.S.C. 1396d(a)(2)(C)) in accordance with the requirements of § 1903(m)(2)(A) of the Social Security Act (42 U.S.C. 1396b(m)(2)(A)) .
Each capitation rate specified in the contract shall be in effect for the entire twelve (12) month term of the Medicaid managed care provider agreement, except as provided in § 5308.15.
No prepaid, capitated provider shall impose co -payment requirements, or other fees on AFDC and AFDC-Related Medicaid enrollees.
The Department shall pay a capitated payment to the prepaid, capitated provider each month for each Medicaid recipient enrolled as of the fifteenth (15) day of the previous month. The Department shall send each prepaid, capitated provider a roster of AFDC and AFDC-related Medicaid enrollees five days before the first day of the month which shall serve as the basis for determining payment for that month.
If an enrollee loses Medicaid eligibility or voluntarily elects to change providers or is involuntarily assigned to another provider in accordance with the requirements of the program, the Department shall cease payments to the prepaid, capitated provider for that recipient effective the last day of the month in which eligibility is terminated or the disenrollment becomes effective, except as provided in § 5308.21.
If an enrollee receives a service covered by the D.C. Medicaid Managed Care program from a provider other than her/his primary care provider of record the Department shall not reimburse the provider rendering the service unless the service was authorized by the primary care provider in accordance with the requirements of the program.
The Department reserves the right to withhold capitated payments for recipients in the D.C. Medicaid Managed Care Program for whom accurate addresses or current locations cannot be determined.
D.C. Mun. Regs. tit. 29, r. 29-5308