DATA ADJUSTMENTS Sample Clauses

DATA ADJUSTMENTS. Capitation rates were developed from a blending of historical calendar year 2014 encounter and cost report data. Adjustments were made to the base experience for data credibility, completion, reimbursement changes, and other program adjustments. i. Credibility adjustment The base experience data was developed based on blending calendar year 2014 cost report and encounter data at the rate cell level using a 90% (cost report) / 10% (encounter) weighting. As discussed later in this section, known encounter data issues were addressed prior to blending the two data sources. Aggregate expenditures in the encounter data were approximately 10% less than those reported in the cost report data prior to addressing known encounter data issues. While the encounter data is underreported relative to cost reports, it is the only source of member and claim level experience. We believe it is an appropriate source of utilization and expenditures for the MMC program, which is why it is assigned a credibility of 10% after addressing known encounter data quality issues. It is our goal to increase the weighting of the encounter data in the development of capitation rates in rates periods after calendar year 2016 by addressing any data quality issues in conjunction with ODM. ii. Completion adjustment The capitation rates are based on calendar year 2014 experience. Encounter data is paid through June 30, 2015, while cost report data is paid through March 31, 2015. Separate sets of completion factors for the two data sources were developed by summarizing encounter data and applying traditional actuarial techniques to develop estimates of incurred but not paid (IBNP) liability. First, we stratified the data by category of service and population groupings. Claims for each of these population-service category stratifications were analyzed and formed into lag triangles by paid and incurred month. Claim completion factors were developed for each month of the base experience period, based on historical completion patterns. The monthly completion factors were applied to calendar year 2014 experience to estimate the remaining claims liability for the calendar year. Results were aggregated into annual completion factors for each calendar year. iii. Errors found in the data Through discussions with ODM and our independent review of the data, we were made aware and confirmed several encounter data quality concerns. After applying the adjustments, the aggregate encounter data expenditures were...

DATA ADJUSTMENTS. Should the MPF Provider make any adjustments to the data pertaining to any of the MPF Xtra Mortgages, such adjustments shall be the responsibility of the PFI just as the PFI would be responsible for adjustments made for Mortgages held by the Bank.

DATA ADJUSTMENTS. Capitation rates were developed from CY 2015 program-wide Opt-In and Opt-Out cost report data with claims runout through March 31, 2016. The base data year adjustments include claims completion adjustments, regional smoothing adjustments, opt-in/opt-out selection adjustments, retrospective program adjustments, and other program adjustments.

DATA ADJUSTMENTS. Capitation rates were developed from historical FFS data, incurred from May 1, 2013 to April 30, 2014, and paid through August 31, 2015. The primary base data year adjustments include completion adjustments, reimbursement adjustments, and other program adjustments. i. Credibility adjustment The MyCare eligible populations, in aggregate, were considered fully credible. No adjustments were made for credibility in the aggregate; however we did implement data smoothing among population groups and regions as discussed in a later section of this report. ii. Completion adjustment The base data year includes 12 months of incurred claims, with 16 additional months of claim payments. To develop the completion factors, we used an additional 16 months of earlier historical experience. This allowed us to analyze payment completion patterns in the earlier experience and apply it to the base year data. iii. Errors found in the data No material errors were found in the data. iv. Program change adjustments The base data year represents a historical time period from which projections were developed. We reviewed prior rate setting documentation and other materials from ODM to identify program changes that were implemented during the base data period. To the extent the program adjustments were estimated to have a material impact on MCOP service or administrative costs, an adjustment was considered for the calendar year 2016 rate development process. Adjustments were made to the portion of the base data prior to the implementation of each program change in order to ensure the entire base period was on a consistent basis. Relevant historical program changes are discussed below. Program changes have been grouped into three categories: nursing facility (NF), HCBS waivers, and other medical, as summarized below. Other base data year changes are also described.

DATA ADJUSTMENTS. Capitation rates were developed from a blending of historical CY 2015 encounter and cost report data. Adjustments were made to the base experience for data credibility, completion, reimbursement changes, and other program adjustments. i. Credibility adjustment The base experience data was primarily developed based on blending CY 2015 cost report and encounter data at the rate cell level using a 75% (cost report) / 25% (encounter) weighting. As discussed later in this section, known data issues were addressed prior to blending the two data sources. Aggregate expenditures in the encounter data were approximately 10% lower than those reported in the cost report data prior to addressing known data issues. After the application of the data adjustments, composite encounter claims were within 1% of aggregate cost report claims on a PMPM basis. We believe it is an appropriate source of utilization and expenditures for the MMC program, which is why it is assigned a credibility weighting of 25% after addressing known data quality issues. It is our goal to increase the weighting of the encounter data in the development of capitation rates in rates periods after CY 2017 by addressing any data quality issues in conjunction with ODM.

DATA ADJUSTMENTS. The CY 2019 Opt-In capitation rates were developed from the projected benefit expenses underlying the Opt-Out capitation rates (baseline Medicaid data). The baseline Medicaid data was adjusted for the following factors: • Selection adjustments • Application of non-benefit expenses • Application of 4% joint savings as required under demonstration year 5 Selection The baseline Medicaid data was adjusted using selection factors to reflect the estimated health status and corresponding utilization of the Opt-In population relative to the Opt-Out population. The selection factors are consistent with those used in the Original certification III. Non-Benefit Expenses Care management and administrative expenses have been calculated by rate cell and region for the baseline Medicaid data, and are applied as PMPMs consistent with the PMPMs associated with the baseline Medicaid data. Refer to the Opt-Out rate certification for additional information related to the development of the care management and administrative expenses. The provision for margin includes items such as cost of capital, risk mitigation, contingency, underwriting gain, and profit. Consistent with the Original certification, we applied a 3% margin to the Opt-In capitation rates.