Per Capita Capitation Benchmark (PCCB) Clause Samples

Per Capita Capitation Benchmark (PCCB). The Agency shall establish a PCCB for each service area in which the Health Plan provides services and for those services the Health Plan provides (including primary care case management fees). The PCCB is an Agency- established PMPM and, for purposes of this section, is considered to be the capitation rate that the Agency would have paid the Health Plan if the Health Plan had been capitated except the pharmacy rebate adjustment performed for the capitated health plans is not included in the PCCB. a. Pursuant to s. 409.912, F.S., the PCCB is a rate that includes covered services consistent with Medicaid HMO capitation rate methodology. For PSNs serving Reform populations, the PCCB is consistent with capitation rate methodology pursuant to s. 409.91211, F.S., and includes the application of the monthly plan factor for risk adjustment. b. The Medicaid Reform HMO capitation rate methodology does not include services paid by the Agency to the capitated health plan through kick payments. Kick payments are a method the Agency uses to reimburse capitated health plans in the form of a separate one-time fixed payment for specific services. Obstetrical deliveries and transplant services are kick payment services and as such are not included in the Reform PCCB. c. For a Health Plan that receives a capitated payment for transportation for its Reform population, an adjustment will be made to the PCCB to account for the capitation payment received by the Health Plan from the Agency for transportation services. d. The PCCB is calculated by the enrollees’ Medicaid eligibility groups (MEG). If an enrollee changes eligibility groups and the change is identified in the system, then the enrollee’s final eligibility group will be used by the Agency in establishing the PCCB. However, the Agency shall use the enrollee’s age group at the time of each month’s Health Plan payment when establishing the PCCB. e. The aggregate PCCB is the total sum of all PCCBs for all enrollees as calculated by the Agency.