IHC Health Plans, Inc. - Page 25

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          provision of health services to Utah residents eligible for                 
          Medicaid benefits.10  Pursuant to the above-described contract,             
          the Department paid monthly premiums to petitioner based upon a             
          negotiated rate schedule under which premiums varied with the age           
          and sex of the enrollee.                                                    
          Petitioner offered Medicaid-eligible enrollees access to a                  
          large panel of PCPs and SCPs through its IHC Access plan.  IHC              
          Access enrollees were required to select a PCP for general                  
          medical care and for referral to a SCP.  As of January 1, 1999,             
          petitioner had nearly 36,000 Medicaid enrollees in its IHC Access           
          plan, almost half of the population of enrollees in managed                 
          Medicaid plans in Utah.                                                     
               Petitioner compensated IHC Access PCPs and SCPs on a                   
          discounted fee-for-service basis.  In addition, these physicians            
          were eligible for certain incentive payments, including an                  
          additional payment based on the number of newborn deliveries and            
          one-third of any budget surplus.  Petitioner applied discounts of           
          49 percent and 61 percent to estimated market rate fees for PCPs            
          and SCPs, respectively.                                                     

          10  42 U.S.C. sec. 1396 et seq. (1994), authorizes the use of               
          Federal funds (in conjunction with State funds) to supplement               
          State-administered medical assistance plans for families with               
          dependent children, and aged, blind, and disabled individuals               
          whose income and resources are insufficient to meet the costs of            
          necessary medical services.                                                 

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Last modified: May 25, 2011