Certification of Final Rates Sample Clauses

Certification of Final Rates. I. DATA BOOK The rate-setting process began with summarizing the FFS data from calendar years (CY) 1998-2000, which is contained in the Data Book dated March 29, 2002. This data was validated by the State as outlined in the Centers for Medicare and Medicaid Services' (CMS) Rate Checklist. During the time period of this base data, three significant expansions took place in Ohio that have an effect upon the 6-month and 12-month rates. These expansions increased eligibility [MMC LOGO] [XXXXXX LOGO] Government Human Services Consulting definitions for covered populations and included populations previously ineligible. These expansion populations are listed below: [XXXXXX LOGO] Government Human Services Consulting Page 3 November 11, 2003 Xx. Xxxxxx Xxxxxx Ohio Department of Job and Family Services

Certification of Final Rates. I. Data Book The rate-setting process began with summarizing the FFS data from calendar years (CY) 1998-2000, which is contained in the Data Book dated March 29, 2002. This data was validated by the State as outlined in the Centers for Medicare and Medicaid Services’ (CMS) Rate Checklist. During the time period of this base data, three significant expansions took place in Ohio that have an effect upon the 6-month and 12-month rates. These expansions increased eligibility definitions for covered populations and included populations previously ineligible. These expansion populations are listed below: ▪ January 1998 Child Expansion: Healthy Start – children < age 19 up to 150% federal poverty level (FPL), ▪ January 2000: Pregnant women up to 150% FPL, ▪ July 2000 Child Expansion: XXXX XX – children < age 19 up to 200% FPL, and ▪ July 2000 Parent Expansion: Parent Expansion up to 100% FPL. For July 1, 2003 through December 31, 2004 rate-setting purposes, historical experience was available in sufficient quantity only for the first expansion occurring in January 1998. Although the experience for the January and July 2000 expansions was reviewed, it was not used in rate setting since it was determined insufficiently credible. Instead, non-expansion and credible expansion data were blended together to account for the new populations. The FFS data are categorized by rate cohort. The basis of these rate cohorts is the demographics of the population and the treatment patterns and risks associated with each group. For this reason, newborns are isolated, males and females are separated where differences exist, maternity is separated from non-maternity, and ages are split into groupings based on levels of expenses. More detail regarding these breakdowns, services covered, and any adjustments made to this data are outlined in the Data Book. Some of the adjustments applied to the FFS data are: ▪ Incurred claims completion factors, ▪ Gross adjustments for payments not processed through MMIS, ▪ Third party liability, ▪ Hospital settlements, ▪ Pharmacy rebates, ▪ Third trimester enrollment, ▪ Retrospective eligibility costs, and ▪ Fraud and abuse. The data and corresponding adjustments are described in further detail in Sections 1 through 9 of the Data Book.

Certification of Final Rates