Credibility Adjustment. An adjustment to the Medical Loss Ratio (MLR) provided by the Contractor in accordance with 42 C.F.R. § 438.8 to account for a difference between the actual and target MLR that may be due to random statistical variation.
Credibility Adjustment. The MMC program, as represented in the base experience, was fully credible. No adjustments were made for credibility.
Credibility Adjustment. In total, the statewide MyCare Opt-In program experience was fully credible. While we did not apply an explicit credibility adjustment to the data, we did develop the Opt-In capitation rates at the region and rate cell level. To mitigate any credibility concerns at the regional level and to preserve potentially proprietary MCOP information in regions where only two MCOPs are present, we developed factors to stratify the statewide Opt-In experience into regional summaries. These factors were primarily informed by the combined CY 2019 Opt-Out and Opt-In encounter data.
Credibility Adjustment. The Contractor may add a Credibility Adjustment to a calculated MLR if the MLR Reporting Year experience is Partially Credible. The Credibility Adjustment is added to the reported MLR calculation before calculating any remittance due. The Contractor may not add a Credibility Adjustment to a calculated MLR if the MLR Reporting Year experience is fully credible. If the Contractor’s experience in “non-credible, the Contractor is presumed to meet or exceed the MLR calculation standards.
Credibility Adjustment. For each MLR calculation:
7.10.6.1 Contractor may add a credibility adjustment, in accordance with 42 CFR 438.8(h), to a calculated MLR if the MLR reporting year experience is partially credible.
7.10.6.2 Contractor shall add the credibility adjustment, if any, to the reported MLR calculation before calculating any remittances, if required.
7.10.6.3 Contractor may not add a credibility adjustment to a calculated MLR if the Coverage Year experience is fully credible.
7.10.6.4 If Contractor’s experience is non-credible, it is presumed to meet or exceed the MLR calculation standards.
Credibility Adjustment. In total, the MyCare Opt-Out program experience was fully credible; however due to credibility concerns at the region and population level, we developed regional and population factors that were primarily informed by the CY 2016 encounter data. The base CY 2016 cost report data by major population grouping (Institutional, Community Waiver, and Community Well) was adjusted and stratified by population (including age ranges) based on observed relativities in the encounter data. On a program-wide basis, the application of the regional and population adjustment factors maintains budget neutrality of the base data experience.
Credibility Adjustment. Contractor may add a credibility adjustment to a calculated MLR if the MLR reporting year experience is partially credible. The credibility adjustment must be added to the reported MLR calculation before calculating any remittances. Contractor may not add a credibility adjustment to a calculated MLR if the MLR reporting year experience is fully credible. If Contractor’s experience is non-credible, it is presumed to meet or exceed the MLR calculation standards in this section. On an annual basis, CMS will publish base credibility factors for MCOs, PIHPs, and PAHPs that are developed according to the following methodology:
Credibility Adjustment. An adjustment to the MLR for Partially Credible Contractor to account for a difference between the actual and target MLR that may be due to random statistical variation in accordance with 42 C.F.R. § 438.8.
Credibility Adjustment. Combining of Opt-In and Opt-Out cost report data and Selection Adjustments Smoothing by region
Credibility Adjustment i. A PAHP may add a credibility adjustment to a calculated MLR if the MLR reporting year experience is partially credible. The credibility adjustment is added to the reported MLR calculation before calculating any remittances, if required by the State as described in paragraph (j) of this section.
ii. A PAHP may not add a credibility adjustment to a calculated MLR if the MLR reporting year experience is fully credible.
iii. If a PAHP's experience is non-credible, it is presumed to meet or exceed the MLR calculation standards in this section.
iv. On an annual basis, CMS will publish base credibility factors for PAHPs that are developed according to the following methodology:
1. CMS will use the most recently available and complete managed care encounter
2. CMS will calculate the credibility adjustment so that a PAHP receiving a capitation payment that is estimated to have a medical loss ratio of 85 percent would be expected to experience a loss ratio less than 85 percent 1 out of every 4 years, or 25 percent of the time.
3. The minimum number of member months necessary for a PAHP's medical loss ratio to be determined at least partially credible will be set so that the credibility adjustment would not exceed 10 percent for any partially credible PAHP. Any PAHP with enrollment less than this number of member months will be determined non-credible.
4. The minimum number of member months necessary for a PAHP's medical loss ratio to be determined fully credible will be set so that the minimum credibility adjustment for any partially credible PAHP would be greater than 1 percent. Any PAHP with enrollment greater than this number of member months will be determined to be fully credible.
5. A PAHP with a number of enrollee member months between the levels established for non-credible and fully credible plans will be deemed partially credible, and CMS will develop adjustments, using linear interpolation, based on the number of enrollee member months.
6. CMS may adjust the number of enrollee member months necessary for a PAHP's experience to be non-credible, partially credible, or fully credible so that the standards are rounded for the purposes of administrative simplification. The number of member months will be rounded to 1,000 or a different degree of rounding as appropriate to ensure that the credibility thresholds are consistent with the objectives of this regulation.
i. PAHPs will aggregate data for all Medicaid eligibility groups covered under the contract wi...
