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Virginia Administrative Code
Title 12. Health
Agency 30. Department of Medical Assistance Services
Chapter 50. Amount, Duration, and Scope of Medical and Remedial Care Services
12/26/2024

12VAC30-50-325. Rates and payments.

A. The Commonwealth assures that the capitated rates will be less than the cost to the agency of providing State Plan approved services to an equivalent nonenrolled population group.

B. To determine the amount that would otherwise have been paid (AWOP) under the State Plan for a comparable population, the Commonwealth uses base period encounter data adjusted for comparable populations and services to those provided by the Program of All-Inclusive Care for the Elderly (PACE) program, specifically individuals 55 years of age or older who historically receive services in an institutional setting or enrolled in a home and community-based services (HCBS) § 1915(c) waiver. The historical data is adjusted to reflect modifications of payment arrangements between the data period and the contract period as well as benefit or eligibility changes that occurred prior to the beginning of the contract period. The base period data is also updated to reflect expected increases in utilization and cost for the contract period covered by the rates. An allowance for administrative costs is added to the AWOPs along with a provision for underwriting gain.

C. The final capitation rates are determined as a percentage discount off of the amount that would otherwise have been paid for these populations.

D. The PACE capitation rates vary by region and by eligibility status (dual-eligible and non-dual-eligible).

E. The Commonwealth assures that the rates were set in a reasonable and predictable manner.

F. The Commonwealth will submit all capitated rates to the Centers for Medicare and Medicaid Services (CMS) regional office for prior approval.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.

Historical Notes

Derived from Virginia Register Volume 23, Issue 16, eff. July 1, 2007; amended, Virginia Register Volume 41, Issue 1, eff. October 10, 2024.

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