Section 482-4-006 - PAYMENT FOR SERVICESThe Department pays a monthly capitation fee health plan for each enrolled member for each month of Heritage Health coverage (per member per month). The monthly capitation fee includes payment for all services in the core benefits package.
006.01TIMELY PAYMENT FOR SERVICES. The health plan must provide payment to providers for services rendered on a timely basis consistent with Medicaid claims payment procedures, unless the health care provider and organization agree to an alternative payment schedule.006.02PAYMENT IN FULL. Payment to the health plan is payment in full for all services included in the core benefits package. The health plan shall not request additional payment from the Department or the member.006.03CAPITATION RATES. The capitation rates are actuarially determined and are based on geographic location, eligibility category, gender, age and type of services. The Department will adjust rates, and complete all necessary contract amendments, when it is determined appropriate, based on any changes in Medicaid fee-for-service rates, or in instances where an error or omission in the calculation of the rates has been identified.006.04INCORRECT PAYMENTS. Medicaid shall not normally recoup payments from health plans. However, in situations where payments are made incorrectly, Medicaid shall work with the health plan to identify the discrepancy and shall recoup/reconcile such payments.006.05ENROLLMENT REPORT. On or before the first day of each month, the Department or the enrollment broker will provide to each health plan a monthly enrollment report that lists all enrolled and disenrolled members for that month. This report will be used as the basis for the monthly capitation payments to the health plan. The health plan is responsible for payment of all services in the core benefits package provided to members listed on the enrollment report generated for the month of coverage. If an enrollment report does not list an eligible member, the Department will be responsible for all medical expenses.006.06COVERAGE FOR PREGNANT WOMEN, NEWBORNS, AND 599 CHIP. Coverage for pregnant women, newborns, and 599 CHIP is provided within the following parameters: (A) Pregnant Woman and Newborn are Medicaid Eligible: Coverage is provided for the pregnant woman from the month of enrollment until disenrollment occurs; and for the newborn from the month of birth until disenrollment occurs. Payment to the health plan is made for the month(s) of enrollment for the pregnant woman and the newborn until disenrollment occurs;(B) Only the Newborn is Medicaid Eligible: Coverage is provided for the pregnant woman from the month of enrollment until disenrollment occurs. Coverage for the birth and post-partum care for the mother is provided for the month of birth through the month in which the sixtieth 60th day following the month of birth occurs. Coverage for only the newborn continues past the sixty (60)-day postpartum period as long as the newborn remains eligible and enrolled. Payment to the health plan is made for the month(s) of enrollment for the pregnant woman and the newborn until disenrollment occurs; and(C) 599 CHIP: Coverage is provided for the unborn child of the pregnant woman that is otherwise ineligible for Medicaid under 599 CHIP. Coverage is limited to prenatal care and pregnancy-related services solely for the unborn child. This coverage does not include postpartum care and medical issues separate to the mother and unrelated to the pregnancy.006.07BILLING THE MEMBER, The health plan may not bill a member for a Medicaid coverable service, regardless of the circumstances. The provider may only bill the member pursuant to Title 471 NAC. 006.07(A)OUT-OF-NETWORK. The health plan may or may not be responsible for an out-of-network service if the service is a Medicaid-coverable service. The agreement the health plan has with the provider will determine whether the health plan is responsible to pay the provider. In some cases, the plan may not pay the provider. The health plan is not required to pay a non-Medicaid enrolled provider for a Medicaid-covered service.006.08REINVESTMENT AND FORFEITED FUNDS. The health plan must provide for the reinvestment of profits in excess of the contracted amount, performance contingencies imposed by the department, and any unearned (forfeited) hold back funds, pursuant to Neb. Rev. Stat. § 71-831, and any successor statutes. The health plan must establish and manage two accounts: a hold back account and a reinvestment account. Both accounts must be separate from other accounts. Neither accounts can have risk-bearing investments. Both accounts must be created and operated in full compliance with the Nebraska Uniform Trust Code (Neb. Rev. Stat. § 30-3801 to 30-38,110 ).006.09QUALITY PERFORMANCE PROGRAM AND HOLD BACKS. The health plan must participate in the Department's quality performance program. The quality performance program must be in accordance with Neb. Rev. Stat. § 71-831 and any successor statutes. Pursuant to Neb. Rev. Stat. § 71-831, and any successor statutes, the health plans must hold back a pre-determined amount in a separate account. The hold back is the aggregate of all income and revenue earned by the health plans and related parties under the contract and constitutes the maximum amount available to the health plan to earn via the quality performance program. The health plans must report its performance measures that affect its eligibility to earn the hold back funds, as the Department requires: (A) Each year of the contract constitutes a performance year, beginning on the contract start date. The Department will assess the health plan performance based on the measures annually and notify the health plan of the amount of the earned hold back and unearned (forfeited) hold back. The Department will make this determination within six (6) months after the end of each contract year;(B) All earned hold back funds become the property of the health plan;(C) The health plan must deposit unearned (forfeited) hold back funds into the reinvestment account. The Department will reimburse the Federal share of the forfeited funds to the Centers for Medicare and Medicaid Services. The remaining State share of the forfeited hold back funds will become the property of the Department;(D) No interest will be due to either party on hold back funds retained by the health plan or returned to the Department; and(E) Any earned hold back will not be included in the health plan's income for the year nor considered part of the medical loss ratio calculation.006.10HOLD BACKS, PENALTIES, AND LIQUIDATED DAMAGES. A percentage of the aggregate of all income and revenue the health plan and related parties under the contract earn must be at risk as a penalty if the health plan fails to meet minimum performance metrics, pursuant to Neb. Rev. Stat. § 71-831 and any successor statutes. The Department will provide the minimum performance metrics to the health plans prior to year two (2) of the contract. The health plans must report its performance on the minimum performance metrics, as the Department requires: (A) The Department reserves the right to modify annually the measures and criteria for earning the hold back funds and assessing liquidated damages; and(B) In the event the Department modifies the measures or criteria, the Department will provide the health plans sixty (60) calendar days advance written notice. These measures will include operational or administrative measures that reflect the health plans' business processes and may lead to improved access to and quality of care, Centers for Medicare and Medicaid Services Medicaid Adult and Child Core Measure sets, healthcare effectiveness data and information set measures, and Departmental-identified measures that represent opportunities for improvement as indicated by Heritage Health historical performance.006.11DEPARTMENTAL RESPONSIBILITIES. The Department will ensure the following: (A) The annual financial reporting package, including the medical loss ratio rebate calculation, risk corridor calculation, and earned/unearned hold back calculation is reviewed, and written approval is provided, within forty-five (45) calendar days after receipt from the health plan;(B) The health plan will transfer all funds deposited into the reinvestment holding account to the State by the health plan for reconciliation and reimbursement of the Federal share via reporting on Centers for Medicare and Medicaid Services Form 64;(C) The federal share of such dollars is determined and reimbursed to the federal government;(D) The remaining State share will return to the health plan for deposit into the reinvestment distribution account, which the health plan manages, subject to contractual requirements; and(E) The Department will hold the health plan responsible and accountable for the necessary fiduciary duties and functions required to administer the reinvestment holding and reinvestment distribution accounts. Oversight of the financial accounting will be in accordance with the financial management reporting requirements.482 Neb. Admin. Code, ch. 4, § 006
Amended effective 7/29/2020Amended effective 9/27/2021