Md. Code Regs. 10.09.44.21

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.44.21 - Payment Rates and Procedures

A. The Department shall:

(1) Pay the PACE provider for each participant based on the fixed capitation payment or payments specified in §E of this regulation; and

(2) Calculate the capitation payment or payments for the PACE provider using the methodology described in §B of this regulation.

B. Calculation of PACE Capitation Payments.

(1) PACE capitation payments are calculated on a per-member per-month basis.

(2) Capitation payments are specific to both the regional service area, as described in §C of this regulation, and the participant age and coverage status, as described in §D of this regulation.

(3) Capitation payments are calculated using an AWOP analysis, which is determined using a base period of Medicaid fee for service participant data that:

(a) Spans two State fiscal years;

(b) Is specific to the PACE eligible population;

(c) Is weighted by the expected ratio of participants receiving long-term care services in institutional and community-based settings; and

(d) Excludes participants enrolled in the following programs:

(i) Medicaid managed care programs;

(ii) PACE; and

(iii) Home and community-based services waivers operated by the Developmental Disabilities Administration.

(4) The Department shall set the PACE capitation rate as 98 percent of the calculated AWOP.

(5) The Department shall recalculate PACE capitation rates annually by trending forward the base period by 1 year.

(6) No adjustments for administrative costs associated with PACE are included, and certain categories of costs not associated with a PACE-eligible, nursing facility-certified population are excluded from the claims data.

C. Capitation rates shall be categorized by regional service area as follows:

(1) Baltimore Metro - Baltimore City and Anne Arundel, Baltimore, Carroll, Cecil, Harford, and Howard counties;

(2) Washington Metro - Calvert, Charles, Frederick, Montgomery, Prince George's, and St. Mary's counties; and

(3) Rural Regions - Allegany, Caroline, Dorchester, Garrett, Kent, Queen Anne's, Somerset, Talbot, Washington, Wicomico, and Worcester counties.

D. Capitation rates shall be categorized by participant age and coverage status as follows:

(1) Ages 55-64, Medicaid-only;

(2) Ages 65 and over, Medicaid-only;

(3) Ages 55-64, dual eligibility; and

(4) Ages 65 and over, dual eligibility.

E. For services provided on or after January 1, 2023, the Department shall pay the PACE provider at the following per-member per-month capitation rates:

Category/Region	Baltimore	Washington	Rural
55-64 Medicaid only	$8,570	$8,445	$6,107
55-64 full dual	$4,937	$4,865	$3,518
65+ Medicaid only	$6,263	$6,172	$4,463
65+ full dual	$4,492	$4,427	$3,201

F. The capitation rate paid by the Department to the PACE provider for a participant shall be accepted as payment in full for the PACE provider benefit package provided by the PACE provider according to its provider agreement, and additional charge may not be made to the participant, the Department, or any other entity except as provided under Regulation .05 of this chapter.

G. The Department shall recover any overpayments made to the PACE provider.

H. A capitation payment may not be made to the PACE provider on behalf of a participant for whom fee-for-service or a capitation payment for the same period has been made by the Department to any other provider, HMO, or managed care organization.

I. Capitation payment may not be made to the PACE provider on behalf of a participant if the Department's eligibility verification system indicates that the participant is not eligible for Medicaid benefits.

J. The Department shall provide retroactive capitation to the PACE provider on behalf of a participant when:

(1) The Department's eligibility verification system indicates that the participant has established a retroactive eligibility period to a previous PACE enrollment period; and

(2) Services were provided by the PACE provider and no other fee-for-service provider.

K. Program Changes.

(1) Amendments, revisions, or additions to the State Plan or the State or federal regulations, guidelines, or policies shall, insofar as they affect the scope or nature of Program benefits available to eligible persons, be considered as amendments to the PACE provider benefit package, unless the Department shall otherwise notify the PACE provider.

(2) The Department or PACE may determine that a change in the PACE provider benefit package, or in the Program's reporting or other administrative requirements, is a substantial modification of the financial or other responsibilities of the PACE provider, and so may request an adjustment in the PACE provider's capitation payment.

(3) Refusal of an adjustment in the PACE provider's capitation payment by the other party shall, at the discretion of the party making the request, be grounds for termination of the Provider agreement.

Md. Code Regs. 10.09.44.21

Regulations .21 adopted as an emergency provision effective November 1, 2002 (29:25 Md. R. 1979); adopted permanently effective April 28, 2003 (30:8 Md. R. 540); amended effective 51:16 Md. R. 742, eff. 8/19/2024.