Common use of Medicaid Managed Care Rates Clause in Contracts

Medicaid Managed Care Rates. 1. GENERAL INFORMATION This section provides information listed under the General Information section of the 2016 Managed Care Rate Setting Consultation Guide (2016 guide), Section I. The capitation rates provided with this certification are “actuarially sound” for purposes of 42 CFR 438.6(c), according to the following criteria:  The capitation rates have been developed in accordance with generally accepted actuarial principles and practices;  The capitation rates are appropriate for the Medicaid populations to be covered, and Medicaid services to be furnished under the contract; and,  The capitation rates meet the requirements of 42 CFR 438.6(c). To ensure compliance with generally accepted actuarial practices and regulatory requirements, we referred to published guidance from the American Academy of Actuaries (AAA), the Actuarial Standards Board, CMS, and federal regulations. Specifically, the following were referenced during the rate development:  Actuarial standards of practice applicable to Medicaid managed care rate setting which have been enacted as of the capitation rate certification date  Federal regulation 42 CFR §438.6(c).  2016 Medicaid Managed Care Rate Development Guide published by CMS on September 23, 2015.  Throughout this document, the term “actuarially sound” will be defined consistent with ASOP 49: “Medicaid capitation rates are “actuarially sound” if, for business for which the certification is being prepared and for the period covered by the certification, projected capitation rates and other revenue sources provide for all reasonable, appropriate, and attainable costs. For purposes of this definition, other revenue sources include, but are not limited to, expected reinsurance and governmental stop-loss cash flows, governmental risk-adjustment cash flows, and investment income. For purposes of this definition, costs include, but are not limited to, expected health benefits; health benefit settlement expenses; administrative expenses; the cost of capital, and government-mandated assessments, fees, and taxes.