Pennsylvania Code
Title 55 - HUMAN SERVICES
Part III - MEDICAL ASSISTANCE MANUAL
Chapter 1229 - HEALTH MAINTENANCE ORGANIZATION SERVICES
PAYMENT FOR HEALTH MAINTENANCE ORGANIZATION SERVICES
Section 1229.51 - General payment policy

Universal Citation: 55 PA Code ยง 1229.51

Current through Register Vol. 54, No. 44, November 2, 2024

(a) Payment for Health Maintenance Organization (HMO) services is made according to a capitation rate which is negotiated by the Department with each participating HMO. The Department will negotiate contracts with qualified HMOs in accordance with the established policy of the Commonwealth for competitive bidding and in accordance with applicable Federal regulations. A model contract shall be made available to a Federally qualified HMO that desires to provide services to Medical Assistance eligible recipients.

(b) No payment will be made to providers other than the HMO for services rendered to an enrolled recipient if the services were available to the recipient under the contract.

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