N.J. Admin. Code § 10:74-12.4

Current through Register Vol. 56, No. 18, September 16, 2024

Section 10:74-12.4 - Payment of capitation to contractor

(a) The monthly capitation payments are due to the contractor from the enrollees' effective dates of enrollment until the effective dates of disenrollment or termination of the MCO's contract, whichever occurs first.

(b) When DMAHS's capitation payment obligation is computed, capitation payment for any partial month of enrollment is adjusted to reflect the number of days enrolled.

(c) Capitation payments for full month coverage shall be recovered from the contractor on a prorated basis if the individual moves out-of-State, from the individual's date of death or when an individual is admitted to a nursing or intermediate care facility in excess of 30 days, or is admitted to an extended acute psychiatric care facility or other institution. The individual shall be disenrolled from the contractor's plan on the day prior to such admission, including incarceration.

(d) When an enrollee is shown on the enrollment roster as covered by a contractor's plan, the contractor shall be responsible for providing services to that person from the first day of coverage shown to the last day of the calendar month of the effective date of disenrollment, and DMAHS will pay the contractor its capitation rate during this period of time, except in cases of member's death, moving out-of-State or continuation of care in a nursing facility beyond 30 days, upon admission to a long-term psychiatric hospital or facility or an ICF/MR where capitation will be prorated back to the date of the event.

N.J. Admin. Code § 10:74-12.4

Recodified from N.J.A.C. 10:74-12.5 and amended by R.2000 d.370, effective 9/18/2000 (operative October 1, 2000).
See: 32 N.J.R. 1352(a), 32 N.J.R. 3426(a).
Rewrote section. Former N.J.A.C. 10:74-12.4, Adjustment of capitation rates, recodified to N.J.A.C. 10:74-12.3.
Amended by R.2006 d.17, effective 1/3/2006.
See: 37 N.J.R. 2787(a), 38 N.J.R. 294(d).
In (a), substituted "MCO's" for "HMO's".
Amended by R.2012 d.041, effective 2/21/2012.
See: 43 N.J.R. 257(b), 44 N.J.R. 494(a).
Rewrote (b), (c) and (d).