Library: Policy

317:55-5-21. Payment to CEs and DBMs

Revised 7-1-23

(a) Capitation rates. In consideration for all services rendered by a CE or DBM under a contract with the OHCA, the CE and DBM will receive a monthly capitation payment for each Enrollee pursuant to 42 C.F.R. §§ 438.3(c), 438.4 and any other applicable state and/or federal regulation.

(b) Capitation reconciliation. The CE and DBM shall perform monthly reconciliation of enrollment roster data against capitation payments and notify discrepancies to the OHCA on schedule and as defined by the OHCA.

(c) Denial of payment. Capitation payments to the CE or DBM will be denied for new Enrollees when, and for so long as, payment for those Enrollees is denied by CMS under 42 C.F.R. § 438.730(e). CMS may deny payment to OHCA for new Enrollees if its determination is not contested timely by the CE. OHCA will define in writing to the CE the conditions for lifting the payment denials.

(d) Recoupment for Medicare eligible Enrollees. In the event an Enrollee becomes retroactively Medicare eligible, the CE or DBM shall recover claims payments made to providers during the months of retroactive Medicare eligibility. The CE or DBM shall also notify the provider of the requirement to submit the claim to Medicare for reimbursement. OHCA will recoup the capitation payments paid for months of retroactive Medicare eligibility.