1. Jeanne Lewer – HP Managed Care Director August 2011
HP Capitation Process
HHW/PE/NOP and HIP
Jeanne Lewer – HP Managed Care Director
August 2011
HP Confidential
31 December 2018

2. Presentation
Hoosier Healthwise (HHW)/Notification of Pregnancy (NOP)/Presumptive Eligibility (PE) capitation
HHW delivery capitation
Healthy Indiana Plan (HIP) capitation
Contact information
HP Confidential
31 December 2018

3. HHW/PE/NOP Capitation
Capitation rates vary by MCE and by Hoosier Healthwise (HHW) region.
Nine regions.
MCEs receive nine separate 820 files (one per region).
Region used to determine capitation rate is the region of the member’s home address as of the first of the month.
Member’s capitation payment appears on the 820 transaction for the region in which the member’s PMP practices.
Capitation rate for member who lives in region 5 is based on their residence. If the member’s PMP practices in region 6 the capitation payment appears on the plan’s region The region code for the county where the member resides was added to the 820 with the Rebid Project.
Capitation rate for member with no PMP assignment is based on their residence and is paid to the same plan region.
HP Confidential
31 December 2018

4. HHW/PE/NOP Capitation (cont’d.)
HHW pays full cap for members on the MCE roster for 18 days or more.
HHW pays half cap for members on the MCE roster for 17 days or less.
No individual MCE will receive more than one full cap payment for any single member for a given month.
Capitation runs the third Wednesday of each month for HHW, PE, and NOP.
Every HHW 820 includes the current month’s payment and adjustments covering up to the previous 13 months.
HP Confidential
31 December 2018

5. HHW/PE/NOP Capitation (cont’d.)
Capitation is paid based on the member’s last Indiana residence region code as long as the member has Medicaid eligibility and has an open MCE/PMP assignment.
Capitation is sometimes paid for members with an out-of-state address who have an in-state county code.
IndianaAIM system does not check street/state addresses against county codes to automatically close the MCE/PMP assignment.
Members with an out-of -state address appear on an Out-of-State Report worked by the HP Eligibility Unit.
HP Eligibility Unit refers members with out-of-state addresses to a caseworker who verifies and ends the Medicaid eligibility, if appropriate, which will also term the MCE/PMP assignment.
HP Confidential
31 December 2018

6. PE – Specific Capitation Information
PE capitation payment process runs on the HHW capitation cycle, third Wednesday of the month, and is included in the 820 MCE Capitation Payment Transaction.
PE member is identified with a RID beginning with 550.
Delivery capitation payments are not made when member delivers during PE period.
PE member must be determined Hoosier Healthwise eligible and a paid Hoosier Healthwise inpatient encounter claim with a 1099 RID must be on file for the delivery capitation payment to be issued.
HP Confidential
31 December 2018

7. NOP – Specific Capitation Information
NOP capitation payment process runs on the HHW capitation cycle, third Wednesday of the month, and is included in the 820 MCE Capitation Payment Transaction.
NOP capitation is a one-time payment; may be a 550 or 1099 RID.
NOP must be submitted by the qualified provider (QP) provider within five calendar days from the date of service.
NOP must be for a woman 29 weeks or less pregnant on the date of service.
NOP capitation payments are identified by the following codes:
NP (Package A/B).
UP (Package A, MA-U).
CP (Package C).
HP Confidential
31 December 2018

8. HHW Inpatient Delivery Capitation
A HHW delivery capitation payment is made to MCE in addition to the regular monthly capitation for the member to help offset delivery expenses.
Delivery capitation is generated from inpatient encounter data billed, according to established billing guidelines, that adjudicate through IndianaAIM with a paid status.
Paid inpatient claims automatically generate a delivery capitation payment as long as the inpatient encounter claim groups to the appropriate delivery diagnosis- related group (DRG).
When an inpatient encounter claim is voided and not replaced, HP will recoup the delivery capitation payment.
HP Confidential
31 December 2018

9. HHW Outpatient Delivery Capitation
Outpatient delivery claims require MCE to notify HP MCU analyst to generate manual payment following established guidelines.
After HP confirms payment is appropriate the manual process is executed to generate the delivery capitation. At times, OMPP may be asked to review and approve.
Delivery capitation payments are not made for Presumptive Eligibility or HIP members.
HP Confidential
31 December 2018

10. HHW/PE/NOP Capitation Adjustments
Most capitation adjustments are performed systematically.
OMPP may retroactively reset cap rates for MCEs.
Formal documentation from OMPP is required before HP can change cap rates.
HP sends verification documentation to OMPP for approval once changes are made and before the cap cycle runs.
If the retro rates are lower than the previous rate and the retro effective date is many months in arrears, it may take more than one capitation cycle to recoup the funds.
Date of death.
Retroactive eligibility changes (aid category/level of care, etc.).
Manual adjustments to monthly capitation payments are performed by HP as required.
Manual adjustments are placed on “hold” status until reviewed and approved by HP MCU.
Approved manual adjustments are activated prior to the capitation cycle.
HP Confidential
31 December 2018

11. HHW/PE/NOP Capitation Reconciliation
Regular cap cycle runs on third Wednesday, reconciliation cycle runs on Thursday, 820 FTP files are available on Saturday, and EFT occurs on following Tuesday.
Every 820 has the current month’s payments and adjustments covering up to the previous 13 months.
As an example: Capitation reconciliation runs a month behind, July adjustments are created in August and pay in September.
HP Confidential
31 December 2018

12. HIP Capitation
HIP capitation cycle runs the second Wednesday of every month.
Monthly cap cycle is for current month’s payments and adjustments covering up to the previous 37 months.
HIP capitation rate is the same throughout the State.
HIP capitation is paid for members with open Medicaid eligibility and an open MCE/PMP assignment.
HIP has no half capitation logic.
HP Confidential
31 December 2018

13. HIP Capitation Adjustments
Most capitation adjustments are performed systematically.
OMPP may retroactively reset cap rates for MCEs.
Formal documentation from OMPP is required before HP can change cap rates.
HP sends verification documentation to OMPP for approval once changes are made and before the cap cycle runs.
If the retro rates are lower than the previous rate and the retro effective date is many months in arrears, it may take more than one capitation cycle to recoup the funds.
Date of death.
Retroactive eligibility changes.
Manual adjustments to monthly capitation payments are performed by HP as required.
Manual adjustments placed on “hold” status until reviewed and approved by HP MCU.
Approved manual adjustments are activated prior to the capitation cycle.
HP Confidential
31 December 2018

14. HIP Capitation Reconciliation
HIP cap cycle runs on second Wednesday, reconciliation cycle runs on Thursday, 820 FTP files are available on Saturday, and EFT occurs on following Tuesday.
Every 820 has the current month’s payments and adjustments covering up to the previous 37 months.
Since capitation reconciliation runs a month behind, July adjustments are created in August and pay in September.
HP Confidential
31 December 2018

15. Contact Information for Questions
Please send capitation questions to:
Primary –
Secondary Back up –
Tertiary Back up –
HP Confidential
31 December 2018

16. Outcomes that matter.
HP Confidential
31 December 2018