Sec. 10.67.04.19. MCO Reimbursement

A. Generally.

(1) Payment to an MCO for each enrollee shall be at a fixed capitation rate, as specified in §B(4) of this regulation.

(2) An MCO shall be reimbursed at rates set forth in this regulation only for individuals enrolled under the Maryland Medicaid Managed Care Program.

(3) The capitation rate paid to an MCO by the Department shall be accepted as payment in full for all benefits provided by the MCO.

(4) An MCO shall conform to the Department's computer coding requirements.

(5) A capitation payment may not be made to an MCO on behalf of an enrollee for whom capitation payment for the same period has been made to any other MCO having an agreement with the Department.

(6) The Department may consider a retroactive capitation payment to an MCO, if the MCO notifies the Department within 9 months of the first missed capitation payment for an enrollee for whom the MCO has not received all appropriate capitation payments.

(7) Monies collected by an MCO for third party liability, as described in Regulation .18 of this chapter, are considered when calculating the capitation payments in §B(4) of this regulation.

B. Capitation Rate-Setting Methodology.

(1) Families and Children. Capitation rates for enrollees who are waiver-eligible based upon receipt of benefits through TCA or programs for medically needy families and children, including SOBRA children and Maryland Children's Health Program (MCHP), shall be established as follows:

(a) For enrollees eligible under COMAR 10.67.02.01A(1) or (3), and for children eligible under COMAR 10.67.02.01A(2) for whom the Department has sufficient clinical data, the Department shall:

(i) Determine an adjusted clinical group (ACG) assignment utilizing an enrollee's past diagnostic record;

(ii) Utilizing aggregated enrollee ACG data, on an annual basis define a limited number of risk adjustment categories that reflect levels of relatively homogenous resource utilization by ACG assignment; and

(iii) Assign an enrollee to a risk adjustment category based upon the enrollee's ACG assignment;

(b) Except as provided in §B(1)(c) of this regulation, for enrollees for whom the Department has insufficient data to generate an ACG assignment, the Department shall assign the enrollee to a risk adjustment category that reflects the enrollee's:

(i) Age, residence, and gender; and

(ii) Birth weight with respect to an enrollee born after December 31, 2004; and

(c) On the basis of the enrollee's residence, the Department shall assign:

(i) All SOBRA mothers enrolled pursuant to COMAR 10.67.02.01A(2) to one of the two "SOBRA mother" payment categories set forth in §B(4)(a) of this regulation; and

(ii) Enrollees with HIV to one of the two HIV payment categories set forth in §B(4)(a) of this regulation.

(2) Disabled. Capitation rates for enrollees who are waiver-eligible based upon receipt of benefits through SSI or as medically needy, aged, blind, or disabled shall be established as follows:

(a) Except as provided in §B(2)(c) of this regulation, for enrollees for whom the Department has sufficient clinical data, the Department shall:

(i) Determine an adjusted clinical group (ACG) assignment utilizing an enrollee's diagnostic record;

(ii) Utilizing aggregated enrollee ACG data, on an annual basis define a limited number of risk adjustment categories that reflect levels of nearly homogenous resource utilization by ACG assignment; and

(iii) Assign an enrollee to a risk adjustment category (RAC) based upon the enrollee's ACG assignment; and

(b) Except as provided in §B(2)(c) of this regulation, for enrollees for whom the Department has insufficient data to generate an ACG assignment, the Department shall assign the enrollee to a risk adjustment category that reflects the enrollee's age, residence, and gender; and

(c) On the basis of the enrollee's residence, the Department shall assign:

(i) Enrollees with HIV to one of the two HIV payment categories set forth in §B(4)(b) of this regulation; and

(ii) Enrollees with AIDS to one of the two AIDS payment categories set forth in §B(4)(b) of this regulation.

(3) Supplemental Delivery/Newborn Payments.

(a) In addition to the monthly payment specified in §B(4)(a) or (b) of this regulation for an enrollee's payment category, the Department shall pay an MCO one supplemental payment per pregnancy in the amount specified in §B(4)(c) of this regulation, upon delivery of one or more infants without regard to method, timing, or place of delivery.

(b) An MCO shall have 12 months from the date of delivery to bill for the supplemental payment.

(4) Except to the extent of adjustments required by §D of this regulation or by Regulations .19-1-.19-4 of this chapter, the Department shall make payments monthly at the rates specified in the following tables:

(a) Rate Table for Families and Children Effective January 1, 2019 - December 31, 2019

	Age/RAC	Gender	PMPM Baltimore City	PMPM Montgomery County	PMPM Rest of State
	Under age 1 Birth Weight 1500 grams or less	Both	$10,633.45	$9,884.60	$10,042.70
	Under age 1 Birth Weight over 1500 grams	Both	$503.91	$468.42	$475.91
	1-5	Male	$201.37	$187.18	$190.18
		Female	$171.52	$159.44	$161.99
	6-14	Male	$115.66	$107.51	$109.23
		Female	$110.78	$102.98	$104.63
	15-20	Male	$137.88	$128.17	$130.22
		Female	$189.12	$175.80	$178.62
	21-44	Male	$271.41	$225.13	$235.22
		Female	$384.69	$319.09	$333.38
	45-64	Male	$519.10	$430.59	$449.87
		Female	$638.23	$529.41	$553.12
ACG-adjusted cells
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339	RAC 1F	Both	$243.24	$201.77	$210.80
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340	RAC 2F	Both	$391.81	$325.00	$339.55
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820	RAC 3F	Both	$506.38	$420.03	$438.85
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040	RAC 4F	Both	$704.46	$584.34	$610.52
ACG 4430, 4730, 4930, 5030, 5050	RAC 5F	Both	$997.30	$827.24	$864.30
ACG 4940, 5060	RAC 6F	Both	$1,281.41	$1,062.91	$1,110.52
ACG 5070	RAC 7F	Both	$2,083.82	$1,728.50	$1,805.92
ACG 100, 200, 300, 500, 600, 1100, 1600, 2000, 2400, 3400, 5100, 5110, 5200	RAC 1G	Both	$89.37	$83.08	$84.41
ACG 400, 700, 900, 1000, 1200, 1300, 1710, 1711, 1712, 1800, 1900, 2100, 2200, 2300, 2800, 2900, 3000, 3100, 5310	RAC 2G	Both	$114.64	$106.57	$108.27
ACG 1720, 1721, 1722, 1731, 1732, 1730, 2500, 3200, 3300, 3500, 3800, 4210, 5230, 5339	RAC 3G	Both	$144.33	$134.16	$136.31
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340	RAC 4G	Both	$205.57	$191.09	$194.15
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820	RAC 5G	Both	$326.72	$303.71	$308.56
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040	RAC 6G	Both	$395.20	$367.37	$373.24
ACG 4430, 4730, 4930,4940, 5030, 5050, 5060, 5070	RAC 7G	Both	$1,030.02	$957.48	$972.79
SOBRA Mothers			$691.48	$573.58	$599.27
Persons with HIV	ALL	Both	$678.39	$678.39	$678.39

(b) Rate Table for Disabled Individuals Effective January 1, 2019 - December 31, 2019

	Age/RAC	Gender	PMPM Baltimore City	PMPM Montgomery County	PMPM Rest of State
	Under Age 1	Both	$6,429.19	$6,429.19	$6,429.19
	1-5	Male	$1,326.70	$1,326.70	$1,326.70
		Female	$900.96	$900.96	$900.96
	6-14	Male	$298.83	$298.83	$298.83
		Female	$470.97	$470.97	$470.97
	15-20	Male	$238.55	$238.55	$238.55
		Female	$290.24	$290.24	$290.24
	21-44	Male	$649.59	$471.43	$553.89
		Female	$848.77	$615.99	$723.73
	45-64	Male	$2,098.31	$1,522.84	$1,789.20
	45-64	Female	$2,229.06	$1,617.73	$1,900.68
ACG-adjusted cells
ACG 100, 200, 300, 1100, 1300, 1400, 1500, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1900, 2400, 2600, 2900, 3400, 5100, 5110, 5200, 5310	RAC 10	Both	$296.35	$215.07	$252.69
ACG 400, 500, 700, 900, 1000, 1200, 1740, 1741, 1742, 1750, 1751, 1752 1800, 2000, 2100, 2200, 2300, 2500, 2700, 2800, 3000, 3100, 3200, 3300, 3500, 3900, 4000, 4310, 5330	RAC 11	Both	$364.82	$264.76	$311.07
ACG 600, 1760, 1761, 1762, 3600, 3700, 4100, 4320, 4410, 4710, 4810, 4820	RAC 12	Both	$699.42	$507.60	$596.38
ACG 3800, 4210, 4220, 4330, 4420, 4720, 4910, 5320	RAC 13	Both	$783.85	$568.51	$667.95
ACG 800, 4430, 4510, 4610, 5040, 5340	RAC 14	Both	$1,096.47	$795.76	$934.94
ACG 1770, 1771, 1772, 4520, 4620, 4830, 4920, 5050	RAC 15	Both	$1,381.88	$1,002.89	$1,178.30
ACG 4730, 4930, 5010	RAC 16	Both	$1,423.21	$1,032.88	$1,213.54
ACG 4940, 5020, 5060	RAC 17	Both	$2,170.47	$1,575.21	$1,850.72
ACG 5030, 5070	RAC 18	Both	$3,872.14	$2,810.08	$3,301.70
Persons with AIDS	All	Both	$1,982.61	$1,269.36	$1,269.36
Persons with HIV	All	Both	$1,997.41	$1,997.41	$1,997.41

(c) Rate Table for Supplemental Payments for Delivery/Newborn and Hepatitis C Therapy Effective January 1, 2019 - December 31, 2019

	Age	Gender	Baltimore City	Montgomery County	Rest of State
Supplemental Payment Cells
Delivery/Newborn-all births except live birth weight 1,500 grams or less and gestational age of 21 weeks or more	All	Both	$16,395.64	$12,953.96	$14,130.96
Delivery/Newborn - live birth weight 1,500 grams or less and a gestational age of 21 weeks or more	All	Both	$86,211.08	$86,211.08	$86,211.08
Delivery/Newborn by same enrollee - subsequent live birth weight 1,500 grams or less with a gestational age less than 21 weeks or does not meet the requirements in §B(4)(i) of this regulation	All	Both	$16,395.64	$12,953.96	$14,130.96
Hepatitis C Therapy	All	Both	$20,598.22	$20,598.22	$20,598.22

(d) Rate Table for Childless Adult Population Effective January 1, 2019 - December 31, 2019

	Age/RAC	Gender	PMPM Baltimore City	Montgomery County	PMPM Rest of State
	19-44	Male	$347.86	$277.04	$316.60
	19-44	Female	$412.94	$328.87	$375.82
	45-64	Male	$940.05	$748.66	$855.56
	45-64	Female	$865.06	$688.94	$787.30
ACG-adjusted cells
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339	RAC 1H	Both	$308.54	$245.72	$280.81
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340	RAC 2H	Both	$464.28	$369.75	$422.55
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820	RAC 3H	Both	$483.85	$385.02	$439.99
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040	RAC 4H	Both	$838.59	$667.86	$763.22
ACG 4430, 4730, 4930, 5030, 5050	RAC 5H	Both	$1,049.48	$835.81	$955.15
ACG 4940, 5060	RAC 6H	Both	$1,356.64	$1,080.43	$1,234.70
ACG 5070	RAC 7H	Both	$2,178.60	$1,735.05	$1,982.78
HIV	19-64	Both	$577.22	$577.22	$577.22

(e) Interpretation of Rate Table for Families and Children. The table found at §B(4)(a) of this regulation shows capitation rates for individuals who are:

(i) Waiver eligible based on receipt of benefits through TCA or programs for medically needy families and children;

(ii) SOBRA children;

(iii) SOBRA mothers; and

(iv) The Maryland Children's Health Program.

(f) Interpretation of Rate Table for Disabled Individuals. The table found at §B(4)(b) of this regulation shows the capitation rates for individuals who are waiver-eligible based upon receipt of benefits through SSI or as medically needy, aged, blind, or disabled.

(g) Interpretation of Rate Table for Supplemental Payment for Delivery/Newborn. The table found at §B(4)(c) of this regulation shows a supplemental payment made in connection with deliveries of MCO enrollees, regardless of the enrollee's payment category under COMAR 10.67.04.19B(4)(a) or (b).

(h) Interpretation of Rate Tables in §B(4) of this regulation. "PMPM" means the per member per month payment rate.

(i) An MCO is eligible to receive the subsequent very low birth weight payment in §B(4)(c) of this regulation if the mother:

(i) Had a prior spontaneous preterm delivery;

(ii) Has a current singleton pregnancy;

(iii) Is eligible to receive hydroxyprogesterone caproate;

(iv) Has received the first hydroxyprogesterone caproate injection between 16 weeks gestation and 24 weeks gestation and continued receiving injections until delivery or week 37 gestation; and

(v) Has received at least 2 hydroxyprogesterone caproate injections.

(5) Consistent with the terms set forth in Regulation .19-5 of this chapter, the Department may, in consultation with the Commissioner, adjust the capitation payment of an MCO if it determines that the MCO's loss ratio, not including any rebate received by the MCO is less than 85 percent.

C. The Department shall reimburse fee-for-service:

(1) The Departmental share for any enrollee participating in the Stop Loss Program pursuant to Regulation .22 of this chapter; and

(2) The cost of those services specified in COMAR 10.09.69.06-.13 provided to the participant that have been authorized by the participant's case manager in accordance with the participant's plan of care.

D. Interim Rates Adjustments.

(1) Under the circumstances described in §D(2) and (3) of this regulation, the Department shall adjust the capitation rates set forth in §B(4)(a) and (b) of this regulation to reflect changes in service costs during the contract year due to an occurrence listed in §D(2) of this regulation.

(2) The Department shall adjust the payment rates specified in §B(4)(a)-(d) of this regulation to reflect service cost changes that qualify under §D(3) of this regulation and result from:

(a) An addition or deletion of services covered under the HealthChoice benefits package;

(b) An increase or decrease in Medicaid fee-for-service payment rates or copayments, if the MCOs are obligated to adjust their payment rates to providers as a result of those fee-for-service rate changes;

(c) An increase or decrease in the inpatient charge per case as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided; or

(d) An increase or decrease in the outpatient charge per visit as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided.

(3) The Department shall make an interim rates adjustment if the effect of an occurrence listed in §D(2) of this regulation is sufficient to result in program-wide overpayment or underpayment of at least 0.2 percent because of the difference between:

(a) Service cost projections used to develop the rates set forth in §B(4)(a) and (b) of this regulation; and

(b) Service costs for the same period, taking into account an occurrence that is listed in §D(2) of this regulation.

(4) The Department shall make any interim rates adjustments required by this section in amounts that are proportionate to the overpayment or underpayments described in §D(3) of this regulation.

(5) Provider rate adjustments as specified in §D(2)(b) of this regulation may not require the MCOs to pay providers more than the Medicaid fee-for-service rate.

(6) The Department shall make supplemental payments to an MCO that reflect increases in MCO provider payments for trauma services described in COMAR 10.25.10.