Ala. Admin. Code r. 560-X-53-.16

Current through Register Vol. 42, No. 10, July 31, 2024

Section 560-X-53-.16 - Medicaid And Medicare Payments, And Participant Premiums

(1) AMA will make a monthly capitation payment to a PO for each Medicaid participant enrolled in the program and will be generated by the Medicaid Management Information System (MMIS). The monthly capitation payment will be a fixed amount, regardless of changes in a participant's health or placement into a nursing facility, and will be specified in the agreement. The amount paid will be less than the amount that would be paid if a participant were not enrolled in the PACE program. The capitation payment must be accepted in full for Medicaid participants. The PO may not bill, charge, collect, or receive any other form of payment for the participant unless based on the exceptions listed in §460.182 (c).

(2) CMS will make a monthly capitation payment to the PO for each participant eligible for Medicare. This payment is an all-inclusive payment for Medicare benefits provided to participants. Guidelines for Medicare payments are in §460.180.

(3) A participant cannot be charged a premium if he or she is eligible for Medicaid and Medicare, or for Medicaid only. The premium amount a PO can charge must meet the guidelines in §460.186.

Ala. Admin. Code r. 560-X-53-.16

New Rule: Filed November 10, 2011; effective December 15, 2011.

Author: Linda Lackey, Medicaid Administrator, LTC Project Development Unit.

Statutory Authority: State Plan, Attachment 2.2-A, Attachment 3.1-A and Supplement 3; 4 2 CFR 460 Subpart J.