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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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