Sec. 10.09.44.21. Payment Rates and Procedures

A. The Department shall:

(1) Pay the PACE provider for each participant based on the fixed capitation payment or payments specified in the provider agreement for the PACE provider benefit package; and

(2) Calculate the PACE provider's capitation payment or payments as a percentage of the cost to the program specified in the provider agreement of providing the same benefit package on a fee-for-service basis to an actuarially equivalent nonenrolled group of recipients.

B. The capitation rate paid by the Department to the PACE provider for a participant shall be accepted as payment in full for the PACE provider benefit package provided by the PACE provider according to its provider agreement, and additional charge may not be made to the participant, the Department, or any other entity except as provided under Regulation .05 of this chapter.

C. The Department shall recover any overpayments made to the PACE provider.

D. A capitation payment may not be made to the PACE provider on behalf of a participant for whom fee-for-service or a capitation payment for the same period has been made by the Department to any other provider, HMO, or managed care organization.

E. Capitation payment may not be made to the PACE provider on behalf of a participant if the Department's eligibility verification system indicates that the participant is not eligible for Medicaid benefits.

F. The Department shall provide retroactive capitation to the PACE provider on behalf of a participant when:

(1) The Department's eligibility verification system indicates that the participant has established a retroactive eligibility period to a previous PACE enrollment period; and

(2) Services were provided by the PACE provider and no other fee-for-service provider.

G. Program Changes.

(1) Amendments, revisions, or additions to the State Plan or the State or federal regulations, guidelines, or policies shall, insofar as they affect the scope or nature of Program benefits available to eligible persons, be considered as amendments to the PACE provider benefit package, unless the Department shall otherwise notify the PACE provider.

(2) The Department or PACE may determine that a change in the PACE provider benefit package, or in the Program's reporting or other administrative requirements, is a substantial modification of the financial or other responsibilities of the PACE provider, and so may request an adjustment in the PACE provider's capitation payment.

(3) Refusal of an adjustment in the PACE provider's capitation payment by the other party shall, at the discretion of the party making the request, be grounds for termination of the Provider agreement.