"Once the insurance company is paid its capitated rate
by the state, it's up the insurance company how it's going to make money.
You are going to be given a capitated rate
. The more you do, the less you'll make.
State lawmakers view Medicaid managed long-term care as a way to address the concerns over the increased enrollment and achieve budget stability over time through a capitated rate
The "capitated rate
"--the amount the companies would get per person for medical services alone--could vary from as much as $175 for a healthy Medicaid recipient to some $1,165 for an adult with developmental disabilities.
Medicare's revised end stage renal disease (ESRD) prospective payment system (PPS) is designed to broaden the scope of services covered under the dialysis capitated rate
, mitigate increases in expenditures, and improve patient quality of care.
When contracted services were used, 29 percent of the reporting systems based their payments on a capitated rate
Thus, payments will be 21.5 percent of the risk-adjusted capitated rate
when Medicare (i.e., the MA plan) is secondary.
Under the managed care model, the organization will be paid a capitated rate
to provide all Medicare-covered services to the beneficiary, including dialysis.
Some providers appear to have a strategy of recouping budgetary shortfalls by (a) selling employers a collateral product (such as coaching, training, or critical incident intervention) with a higher profit margin, (b) attempting to increase market share, or (c) tightly managing costs by providing fewer services within the capitated rate
For one thing, some HMOs that are paying physicians a capitated rate
have not been collecting detailed patient encounter data, so their risk adjustments may be off.
* renegotiated their pharmacy contract to set a capitated rate
for all Part A residents, complete with a drug formulary program, physician education and case-by-case utilization review - a renegotiation that was expedited, Mr.
Given the reputation of HMOs for skimping on medical care, some children's advocates object to the capitated rate
for child-welfare services.