California Code of Regulations › Title 22 - Social Security › Division 3 - Health Care Services › Subdivision 1 - California Medical Assistance Program › Chapter 4.1 - Two-Plan Model Managed Care Program › Article 6 - Operational Requirements › Section 53869 - Capitation Payment, Payment Rate Determination/Redetermination

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) In making
					 capitation payments, the department shall adhere to the requirements specified
					 in section
					 53320. Per capita rates of
					 payment, by the department, for services provided to beneficiaries enrolled in
					 each plan in a designated region shall be payable effective the date a
					 beneficiary's enrollment takes effect. Capitation payments by a plan to a
					 primary care provider or clinic contracting with a plan on a capitation basis
					 shall be payable effective the date of the beneficiary's enrollment where the
					 beneficiary's assignment to or selection of a plan has been confirmed by the
					 plan. However, capitation payments by a plan to a primary care provider for a
					 beneficiary whose assignment to or selection of a primary care provider was not
					 confirmed by the plan on the date of the beneficiary's enrollment, but is later
					 confirmed by the plan, shall be payable no later than 30 days after the
					 beneficiary's enrollment.
(b) The
					 department shall determine capitation payment rates annually by actuarial
					 methods with assistance from an actuary or consulting actuary, except that the
					 department reserves the right to redetermine rates on an actuarial basis or
					 move to a negotiated rate for each rate year.
(c) The rates shall not exceed actuarially
					 equivalent Medi-Cal fee-for-service costs. These costs shall be determined by
					 viewing the total services and requirements, including administration, provided
					 under this Chapter by a local initiative or commercial plan, as though such
					 services and requirements were reimbursable under Chapter 3. For the purposes
					 of this section:
(1) Costs of administration
					 include, but are not limited to:
(A)
					 Salaries, bonuses or benefits paid or incurred with respect to the officers,
					 directors, partners, trustees or other principal management of the plan, minus,
					 to the extent that such persons also are providers of health care services, the
					 minimum reasonable cost of obtaining such health care services from other
					 persons.
(B) Cost of
					 marketing.
(C) Legal and accounting
					 fees and expenses.
(D) Costs
					 associated with the establishment and maintenance of agreements with providers
					 of health care services, excluding the cost of reviewing quality and
					 utilization of such services and cost of reviewing utilization of health care
					 services on a referral basis.
(E)
					 Premium on required fidelity and surety bonds and any insurance maintained
					 pursuant to Health and Safety Code, section
					 1377,
					 and any insurance or other expense incurred for the purpose of complying with
					 Health and Safety Code, section
					 1375.1.
(F) Costs of preparing reports required by
					 this Chapter.
(G) Costs of
					 maintaining facilities for administrative services.