Long-Term Care Functional Status Sample Clauses

Long-Term Care Functional Status. In new service regions for a program (i.e., regions or target groups in which the program has not previously provided services) the long-term care component of the capitation rate may be adjusted for the actual acuity of an MCO’s membership, as measured by the long-term care functional screen, relative to the acuity assumed in the prospective actuarial rate calculations. The intent of this adjustment is to better reflect within the long-term care component of the capitation rate method a significant acuity change between the base population assumed in the calculation of the prospective capitation rate and the population enrolled in the program during the contract period. This adjustment will be implemented for the first three years the program covers a new service region. However, this adjustment pertains only to the current contract period and shall not be interpreted to apply to any other contract periods. The method for this adjustment is as follows: a. The long-term care component of the capitation rate will be re-calculated quarterly and at the end of the contract period, using the same actuarial rate setting method as outlined above, to account for actual enrolled members’ functional status as determined through the long-term care functional screen. Specifically, the case mix assumptions used to develop the long-term care component of the prospective capitation rate will be updated to account for the actual enrolled case mix. b. This rate, recalculated to reflect actual enrolled members’ functional status, will replace the capitation rate that is based on the assumed values at the end of the contract period through a retrospective rate adjustment. c. In addition, a retrospective rate payment adjustment may be provided on a quarterly basis if the following calculation results in a 10% difference in total revenue during the retrospective period: d. The capitation rate, updated for actual enrolled members’ functional status during the retrospective period, multiplied by actual enrollment during the retrospective period. e. The MCO and the Department may waive the quarterly payment adjustment if it is jointly determined that such an adjustment is administratively burdensome. However, the payment adjustment calculated at the end of the contract period may not be waived and shall be the final capitation rate for the contract period.
Sample 1
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