Identifying Beneficiaries Eligible for Inclusion. Both the demonstration and comparison group will be identified using an intent-to-treat approach. The data used to identify demonstration and comparison beneficiaries will reflect eligibility on the Demonstration start date. The demonstration group will be identified retrospectively, after the Demonstration year has ended, to allow for additional data to become available.
i. Every beneficiary included in the first performance payment calculation must meet all of the following criteria to be included in the savings calculation:
1. Meet the Demonstration eligibility criteria for at least 3 months and have at least 3 months of baseline claims; and
2. Not be eligible for Medicaid by spend down.
ii. Individuals in an MA or PACE plan on the Demonstration start date will not be included in the base period. Unless such individuals disenroll from MA or PACE and become eligible for the Demonstration, their experience during the Demonstration will also be excluded from the savings calculation. For beneficiaries who disenroll from MA or PACE and become eligible for the Demonstration, the plan capitation payments will be used as the basis for their baseline Medicare and Medicaid costs if applicable, and their actual experience during the Demonstration will be included in the savings calculation.
iii. Only the member months during which a beneficiary was eligible for the demonstration or comparison group will be included in the calculation. Terminations in eligibility will result from moving out of area, death, loss of eligibility for Medicare Parts A and B, Medicare becoming a secondary payer, or loss of eligibility for full Medicaid benefits. The same rules for terminating eligibility for inclusion in the savings calculation will be applied to both the demonstration and comparison groups.
Identifying Beneficiaries Eligible for Inclusion. Both the demonstration and comparison group will be identified using an intent-to-treat approach. The data used to identify demonstration and comparison beneficiaries will reflect eligibility on the Demonstration start date. The demonstration group will be identified retrospectively, after the Demonstration Year has ended, to allow for additional data to become available.
I.2.a. i. Every beneficiary included in the first performance payment calculation must meet all of the following criteria to be included in the savings calculation:
Identifying Beneficiaries Eligible for Inclusion. Both the demonstration and comparison group will be identified using an intent-to-treat approach. The data used to identify demonstration and comparison beneficiaries will reflect eligibility on the Demonstration start date. The demonstration group will be identified retrospectively, after the Demonstration year has ended, to allow for additional data to become available.
i. Every beneficiary included in the first performance payment calculation must meet all of the following criteria to be included in the savings calculation:
1. Meet the Demonstration eligibility criteria for at least 3 months and have at least 3 months of baseline claims
ii. Individuals in an MA or PACE plan will not be included in the base period, and their experience during the Demonstration will also be excluded from the savings calculation.
iii. Only the member months during which a beneficiary was eligible for the demonstration or comparison group will be included in the calculation. Terminations in eligibility will result from moving out of area, death, loss of eligibility for Medicare Parts A and B, Medicare becoming a secondary payer, loss of eligibility for full Medicaid benefits, or receipt of Medicare or Medicaid hospice. The same rules for terminating eligibility for inclusion in the savings calculation will be applied to both the demonstration and comparison groups.
