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Technical Instructions History
| Date | Description of Change |
|---|---|
5/7/2018 |
Original technical instructions issued |
11/19/2024 |
Technical instructions updated to align with T-MSIS Data Dictionary V4.0.0
|
Brief Issue Description
This technical instructions document describes how to report individual capitation and sub-capitation payments in the T-MSIS Financial Transaction (FTX) file.
Background Discussion
Individual capitation payments and sub-capitation payments should be captured in the INDIVIDUAL-CAPITATION-PMPM-FTX00002 segment. Per 42 CFR ยง 438.2, capitation payment means a payment the State makes periodically to a contractor on behalf of each beneficiary enrolled under a contract and based on the actuarially sound capitation rate for the provision of services under the State plan.
The State makes the payment regardless of whether the beneficiary receives services during the period covered by the payment. Sub-capitation payments refer to a payment a Medicaid/CHIP managed care plan makes periodically to a sub-capitated entity or sub-capitated network provider. Capitation and sub-capitation payments do not include either partial or whole premium assistance payments for employer-sponsored insurance, marketplace qualified health plans, or other private commercial insurance at the market rate.
CMS Technical Instructions
- All capitation payments should be reported with valid date values in the PAYMENT-OR-RECOUPMENT-DATE, CAPITATION-PERIOD-START-DATE, and CAPITATION-PERIOD-END-DATE data elements.
- The PAYMENT-OR-RECOUPMENT-DATE should be reported with the date that the payment or recoupment was executed by the payer.
- The CAPITATION-PERIOD-START-DATE should be reported with the date representing the beginning of the period covered by the capitation or sub-capitation payment or recoupment; for example, the first day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month).
- Similarly, the CAPITATION-PERIOD-END-DATE should be reported with the date representing the end of the period covered by the capitation or sub-capitation payment or recoupment; for example, the last day of the calendar month of beneficiary enrollment in the managed care plan that the payment is intended to cover (whether or not the beneficiary actually receives services during that month)