441—92.9 (249A,249J) Claims and reimbursement methodologies.
	 92.9(1) Claims. Claims for Medicaid expansion services provided to IowaCare members shall be submitted to the Iowa Medicaid Enterprise, P.O. Box 150001, Des Moines, Iowa 50315, as required by 441—Chapter 80. To facilitate tracking of expenditures, clean claims for IowaCare services shall be submitted to the Iowa Medicaid enterprise within 20 days from ending date of service.
	 92.9(2) Payment for hospital services provided by IowaCare network. Effective July 1, 2010:
	  a.   	 Inpatient hospital services provided by University of Iowa Hospitals and Clinics will be paid based on 100 percent of reasonable and allowable costs.
	 (1) 	 An interim rate based on the Medicaid reimbursement rates and methodologies as of November 30, 2009, shall be used to price submitted claims.
	 (2) 	 At the end of the cost reporting period, a reconciliation will be performed based on the hospital’s CMS-2552 cost report as filed for the payment period and IowaCare claims data as extracted by the department from the Medicaid management information system. The aggregate payments under the interim methodology will be determined and compared to the IowaCare program costs as determined from the hospital’s cost report. For purposes of this rule, aggregate payments include amounts received for the IowaCare program, outlier payments, and patient and third-party payments up to the allowed amount.
	 (3) 	 If the aggregate payments exceed the hospital’s IowaCare costs, the amount by which payments exceed actual costs will be requested and collected from the hospitals.
	 (4) 	 If the aggregate payments are less than actual IowaCare costs, an additional payment equal to the difference will be made to the hospital.
	  b.   	 Inpatient hospital services provided by Broadlawns Medical Center shall be paid at the Medicaid reimbursement rates and methodologies in effect on November 30, 2009.
	  c.   	 Outpatient hospital services provided by University of Iowa Hospitals and Clinics or Broadlawns Medical Center shall be paid at the Medicaid reimbursement rates and methodologies in effect on November 30, 2009.
	 92.9(3) Payment for nonhospital services provided by IowaCare network. Effective July 1, 2010, IowaCare network providers shall be paid for nonhospital services at the Medicaid fee schedule amounts in effect on November 30, 2009, with the following exceptions:
	  a.   	 For preventive examination codes, the fee schedule amounts shall be based on the Medicaid physician fee schedule in effect on the date of service.
	  b.   	 Physician services provided to IowaCare members in a federally qualified health center shall be reimbursed based on the Medicaid physician fee schedule in effect on the date of service, limited to the amount appropriated for the fiscal year.
	  c.   	 Physician services provided by University of Iowa Hospitals and Clinics physicians to IowaCare members will be reimbursed based on the Medicaid physician fee schedule in effect on the date of service, limited to the amount appropriated for the fiscal year.
	 92.9(4) Medical home payments.
	  a.   	 In addition to any other IowaCare reimbursement, IowaCare providers that meet the medical home standards pursuant to subrule 92.8(6) and have contracted with the department shall receive a monthly medical home payment for each member assigned to the medical home by the department. The medical home payment shall begin the first day of the month following the member’s assignment to the medical home.
	 (1) 	 The medical home payment will be on a per-member, per-month basis in an amount determined by the department, but no more than $4 per member, per month.
	 (2) 	 Effective July 1, 2011, the department shall implement a tiered per-member, per-month payment method that is based on the medical home’s certification level as designated by a nationally recognized medical home accreditation organization.
	  b.   	 IowaCare medical homes shall be eligible for a performance payment for achieving medical home performance benchmarks designated by the department as specified in the provider’s contract with the department. The performance payment shall be paid by October 31 following the end of the state fiscal year and is in addition to any other IowaCare reimbursement.
	 92.9(5) Payment for services provided by nonparticipating hospitals. Nonparticipating hospitals shall be paid at the Medicaid reimbursement rates and methodologies in effect on December 1, 2009, up to the amount appropriated to the nonparticipating provider reimbursement fund created in 2009 Iowa Code Supplement section 249J.24A. No payment shall be made after appropriated funds are exhausted.
	 92.9(6) Payment for services provided by other nonparticipating providers. Nonparticipating providers other than hospitals shall be paid at the Medicaid reimbursement rates and methodologies in effect on the date of service.
[ARC 9135B, IAB 10/6/10, effective 10/1/10]