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COMMONWEALTH OF PENNSYLVANIA

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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 5598 (August 31, 2024).

55 Pa. Code § 1229.51. General payment policy.

PAYMENT FOR HEALTH MAINTENANCE ORGANIZATION
SERVICES


§ 1229.51. General payment policy.

 (a)  Payment for Health Maintenance Organization (HMO) services is made according to a capitation rate which is negotiated by the Department with each participating HMO. The Department will negotiate contracts with qualified HMOs in accordance with the established policy of the Commonwealth for competitive bidding and in accordance with applicable Federal regulations. A model contract shall be made available to a Federally qualified HMO that desires to provide services to Medical Assistance eligible recipients.

 (b)  No payment will be made to providers other than the HMO for services rendered to an enrolled recipient if the services were available to the recipient under the contract.

Source

   The provisions of this §  1229.51 adopted October 31, 1980, effective November 1, 1980, 10 Pa.B. 4255.


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