California § 14138.15 - A principal health plan shall be compensated by the department for the APM scope

§ 14138.15. A principal health plan shall be compensated by the department for the APM scope

(a) A principal health plan shall be compensated by the department for the APM scope of services provided to its APM enrollees pursuant to this section. (b) For each principal health plan that contains at least one participating FQHC in its provider network, the department shall determine an APM supplemental capitation amount for each APM aid category to be paid by the department to the principal health plan, which shall be expressed as a PMPM amount. This supplemental capitation amount will be in addition to the funding for the APM scope of services already contained in the principal health plan’s capitated rates paid by the department and shall be actuarially sound in accordance with Section 438.4 of Title 42 of the Code of Federal Regulations. The department shall determine the APM supplemental capitation amount for each APM aid category, taking into account all of the following factors: (1) The clinic-specific PMPM amounts for each participating FQHC in the plan’s network. (2) The funding for the APM scope of services already contained in the principal health plan’s capitated rates. (3) The historical wrap-around payments paid by the department for participating FQHCs for assigned members in each APM aid category. (4) As applicable, the likely distribution of members among multiple participating FQHCs. (c) The principal health plan shall report to the department, in a form to be determined by the department in consultation with the principal health plan, the number of APM enrollees for each APM aid category in the plan each month. (d) The department shall pay each principal health plan its applicable APM supplemental capitation amount for the number of APM enrollees for each APM aid category reported by the principal health plan pursuant to subdivision (c), and shall appropriately fund each principal health plan to pay the per-visit rate for unassigned Medi-Cal beneficiaries described in subdivision (e) of Section 14138.13. (e) The department, in consultation with the principal health plans, shall develop methods to verify the information reported pursuant to subdivision (c), and may adjust the payments made pursuant to subdivision (d) as appropriate to reflect the verified number of APM enrollees for each APM aid category. (f) The department shall adjust the amounts in subdivision (b) as necessary to account for any change to the prospective payment system rate for participating FQHCs, including changes resulting from a change in the Medicare Economic Index pursuant to subdivision (d) of Section 14132.100, any changes in the FQHC’s scope of services pursuant to subdivision (e) of Section 14132.100, and changes in the projected mix of assigned members across applicable APM aid categories.