Nebraska Administrative Code › Topic - HEALTH AND HUMAN SERVICES SYSTEM › Title 482 - NEBRASKA MEDICAID MANAGED CARE › Chapter 4 - THE HERITAGE HEALTH MANAGED CARE CORE BENEFITS PACKAGE › Section 482-4-006 - PAYMENT FOR SERVICES

Current through June 17, 2024
The 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.
006.01
TIMELY 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.
006.02
PAYMENT 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.
006.03
CAPITATION
  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.
006.04
INCORRECT
  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.
006.05
ENROLLMENT
  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.
006.06
COVERAGE 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.