Current through Register Vol. 35, No. 18, September 24, 2024
A.
Payment for services: HSD shall make actuarially sound payments,
in accordance with
42 C.F.R.
438.6(c), for the provision
of the managed care medicaid benefit package, under capitated risk contracts to
the designated managed care organizations (MCOs). Rates whether
set by HSD or negotiated between HSD and the MCO are confidential.
(1) At the sole discretion of HSD, rates
shall be appropriate for the medicaid populations to be covered and the
services to be furnished under the contract. Rates may be adjusted based on
factors, including but not limited to, changes in the scope of work; CMS
requiring a modification of the 1115(a) waiver; new or amended federal or state
statutes, regulations or rules; inflation; significant changes in the
demographic characteristics of the member population; or the disproportionate
enrollment selection of the MCO by members in certain rate cohorts.
(2) The MCO shall be responsible for the
provision of services for members during the month of capitation. A medicaid
eligible recipient shall not be liable for debts or costs incurred by an MCO
under the MCO's managed care contract for providing health care to them. This
includes but is not limited to:
(a) the MCO's
debts in the event of its insolvency;
(b) services provided to the member that are
not included in the medicaid benefit package and for which HSD does not pay the
MCO, e.g., value added services;
(c) instances when the MCO does not pay the
health care provider who furnishes the services under contractual, referral, or
other arrangement;
(d) payments for
covered services furnished under contract, referral, or other arrangement to
the extent that those payments are in excess of the amount that the member
would owe if the MCO provided the service directly; and
(e) if a MCO member loses eligibility for any
reason and is reinstated as eligible by HSD before the end of the month, the
MCO shall accept a retroactive capitation payment for that month of eligibility
and assume financial responsibility for all medically-necessary covered benefit
services supplied to the member.
(3) Retroactive capitation payments may not
be issued for a member for the same coverage month in which fee-for-service
claims have already been paid by HSD except in special situations determined by
HSD.
B.
Capitation
disbursement requirements: HSD shall pay a capitated amount to the MCO
for the provision of the managed care benefit package at specified rates. The
monthly rate is based on actuarially sound capitation rate cells. The MCO shall
accept the capitation rate paid each month by HSD as payment in full for all
services including all administrative costs associated therewith, including
gross receipts tax payable to the provider. The MCO is at risk of incurring
losses if the cost of providing the managed care medicaid benefit package
exceeds its capitation payment. HSD shall not provide retroactive payment
adjustments to the MCO to reflect the actual cost of services furnished by the
MCO.
C.
Capitation
recoupments: HSD shall have the discretion to recoup capitations or
payments as provided for in its contract with the MCO.
(1) Instances when HSD shall recoup payments
for members include, but are not limited to:
(a) member incorrectly enrolled with more
than one MCO;
(b) member who dies
prior to the enrollment month for which payment was made; or
(c) member who HSD later determines was not
eligible for medicaid during the enrollment month, including retroactive months
for which payment was made.
(2) HSD acknowledges and agrees that in the
event of any recoupment pursuant to this rule, the MCO shall have the right to
recoup from a provider or another person to whom the MCO has made payment
during this period of time; however, may not recoup payments for any value
added services provided. Recouped payments to a provider is subject to the time
periods governed by the MCO provider agreement.
(3) Any duplicate payment identified by
either the MCO or HSD shall be recouped upon identification.
(4) The MCO has the right to dispute any
recoupment action in accordance with contractual provisions.
D.
Patient liability:
HSD monthly capitation payments will be net of patient liability. The
capitation payments are developed on "gross" cost and will be reduced by the
amount of average patient member responsibility each month. The MCO shall
delegate the collection of patient member liability to the nursing facility or
community-based residential alternative facility and shall pay the facility net
of the applicable patient member liability amount. The MCO shall submit patient
member liability information associated with claim payments in their encounter
data submissions.
E.
Payment
time frames: A clean claim shall be paid by the MCO to contracted and
non-contracted providers according to the following timeframe: ninety percent
within 30 calendar days of the date of receipt and ninety-nine percent within
90 calendar days of the date of receipt, as required by federal guidelines in
the code of federal regulations Section
42 CFR
447.45. The date of receipt is the date the
MCO first receives the claim either manually or electronically. The MCO is
required to date stamp all claims on the date of receipt. The date of payment
is the date of the check or other form of payment. An exception to this
requirement may be made if the MCO and its providers by mutual agreement
establish an alternative payment schedule. However, any such alternative
payment schedule shall first be incorporated into the contract between HSD and
the MCO. The MCO shall be financially responsible for paying all claims for all
covered, emergency and post-stabilization services that are furnished by
non-contracted providers, at no more than the medicaid fee-for-service rate,
including medically or clinically necessary testing to determine if a physical
or behavioral health emergency exists.
(1) The
MCO shall pay a contracted and non-contracted provider interest on the MCO's
liability at the rate of one and one-half percent per month on the amount of a
clean claim (based upon the current medicaid fee schedule) submitted by the
participating provider and not paid within 30 calendar days of the date of
receipt of an electronic claim and 45 calendar days of receipt of a paper
claim. Interest shall accrue from the 31st calendar day for electronic claims
and from the 46th calendar day for manual claims. The MCO shall be required to
report the number of claims and the amount of interest paid, on a timeframe
determined by HSD/MAD.
(2) No
contract between the MCO and a participating provider shall include a clause
that has the effect of relieving either party of liability for its actions or
inactions.
(3) If the MCO is unable
to determine liability for or refuses to pay a claim of a participating
provider within the times specified above, the MCO shall make a good-faith
effort to notify the participating provider by fax, electronically or via other
written communication within 30 calendar days of receipt of the claim, stating
specific reasons why it is not liable for the claim or request specific
information necessary to determine liability for the claim.
F.
Special payment
requirements: This section lists special payment requirements by
provider type.
(1) Reimbursement to a
federally qualified health center (FQHC) and a rural health clinic (RHC): a
contracted and non-contracted FQHC or RHC shall be reimbursed at a minimum of
the prospective payment system (PPS) as determined by HSD or its designee or an
alternative payment methodology in compliance with Section 1905(a)(2)(C) of the
1902 Social Security Act, as established by HSD.
(2) Reimbursement to Indian health service
(IHS), tribal health providers, and urban Indian providers authorized to
provide services as defined in the Indian Health Care Improvement Act,
25 U.S.C.
1601 et seq.
(a) The MCO shall reimburse IHS and tribal
compact contracted and non-contracted provider as identified by HSD, at a
minimum of one hundred percent of the rate established for an IHS facility or
federally-leased facility by the office of management and budget (OMB). For
services designated by HSD to be paid at fee schedule rates rather than OMB
rates, the MCO shall reimburse the IHS or tribal contract provider at not less
than the MAD fee schedule rate.
(b)
IHS facilities, tribal health providers and urban Indian providers shall have
up to two years from a claim's first date of service to submit a claim; claims
not submitted within two years of the first date of service are not eligible
for reimbursement.
(c) With the
exception of residential treatment center services, services provided by IHS or
a tribal 638 facility is not subject to prior authorization.
(3) Reimbursement for family
planning services: the MCOs shall reimburse an out-of-network family planning
provider for services provided to a MCO member at a rate that is at least equal
to the MAD fee-schedule rate for the provider type.
(4) Reimbursement for an individual in their
second or third trimester of pregnancy: If an individual is in the second or
third trimester of pregnancy and is receiving medically necessary covered
prenatal care services prior to their enrollment in the MCO, the receiving MCO
will be responsible for providing continued access to their prenatal care
provider (whether a contracted or non-contracted provider) through the 12-month
postpartum period without any form of prior approval.
(5) Reimbursement for a MCO member who
disenrolls transitions while hospitalized: If an eligible recipient is
hospitalized at the time of enrollment into or disenrollment from managed care
or upon an approved switch from one MCO to another, the relinquishing MCO shall
be responsible for payment of all covered inpatient facility and professional
services provided within a licensed acute care facility, or a non-psychiatric
specialty unit or hospitals as designated by the New Mexico department of
health (DOH). The payer at the date of admission remains responsible for the
services until the date of discharge. Upon discharge, the member will then
become the financial responsibility of the receiving MCO receiving capitation
payments. The relinquishing MCO shall be responsible for payment of all covered
inpatient facility and professional services up to the date of disenrollment
from the MCO.
