D.C. Mun. Regs. r. 29-8811

Current through Register Vol. 71, No. 33, August 16, 2024

Rule 29-8811 - REIMBURSEMENT

8811.1

Under the PACE program agreement, CMS shall make a prospective monthly payment to the PACE organization of a capitation amount for each Medicare participant, in accordance with 42 CFR § 460.180.

8811.2

Under the PACE program agreement, DHCF shall make a prospective monthly payment to the PACE organization of a capitation amount for each Medicaid participant, in accordance with 42 CFR § 460.182.

8811.3

The monthly capitation payment amount is negotiated between the PACE organization and DHCF and specified in the PACE program agreement. The monthly capitation amount represents the following:

(a) Is less than the amount that would otherwise have been paid under the State plan if the participants were not enrolled under the PACE program;

(b) Takes into account the comparative frailty of PACE participants;

(c) Is a fixed amount regardless of changes in the participant's health status; and

(d) Can be renegotiated on an annual basis.

8811.4

The PACE organization must accept the capitation amount as payment in full for Medicaid participants and may not bill, charge, collect, or receive any other form of payment from DHCF or from, or on behalf of, the participant or authorized representative, except as follows:

(a) Payment with respect to any applicable spend-down liability and any amounts due under the post-eligibility treatment of income process;

(b) Medicare payment received from CMS or from other payers, in accordance with 42 CFR § 460.180(d).

D.C. Mun. Regs. r. 29-8811

Final Rulemaking published at 69 DCR 6400 (6/3/2022)