RATE DEVELOPMENT STANDARDS i. Overview In accordance with 42 CFR §438.5(g), we will follow the rate development standards related to budget-neutral risk adjustment for the MMC program. The composite rates for the CFC, ABD, Extension, and AFK populations will be prospectively risk adjusted by MCP on a regional basis to reflect estimated prospective morbidity differences in the underlying population enrolling with each MCP.
ii. Risk adjustment model Risk adjustment will be performed using CDPS + Rx risk scoring models. Risk adjustment will be performed on a budget neutral basis at the region and rate cell level. Newborns, one-year-olds, and delivery kick payments will be excluded from the risk adjustment process.
iii. Acuity adjustments Acuity adjustments are not applicable to the CY 2020 capitation rates.
RATE DEVELOPMENT STANDARDS i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month.
ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population.
iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populations.
iv. In Lieu Of Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers.
v. Benefit expenses associated with members residing in an IMD We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an Institution for Mental Diseases (IMD) stay of more than 15 days in a month and any other MCP costs for services delivered in a month when an enrollee had an IMD stay of more than 15 days. These costs were identified and removed from the encounter data. In addition, as noted above we did not use the unit cost of the IMD as an in- lieu-of service, and instead utilized the unit cost for that of existing state plan providers.
vi. IMDs as an in lieu of service provider Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month.
RATE DEVELOPMENT STANDARDS i. Annual basis The capitation rates are for the one year rate period from January 1, 2018 through December 31, 2018.
ii. Differences among capitation rates Any proposed differences among capitation rates according to covered populations are based on valid rate development standards and are not based on the rate of federal financial participation associated with the covered populations.
iii. Cross-subsidization of rate cell payment The capitation rates were developed at the rate cell level and neither cross-subsidize nor are cross-subsidized by payments from any other rate cell.
RATE DEVELOPMENT STANDARDS i. Final Capitation Rate Compliance
RATE DEVELOPMENT STANDARDS i. Capitation rate structure The MyCare rate structure for CY 2022 did not change from the 2021 rate structure. Rates continue to vary by region consistent with current geographic definitions. The NFLOC rate cell continues to reflect a composite of the Institutional, Community Waiver 18 – 44, Community Waiver 45 – 64 and Community Waiver 65+ population groups. The NFLOC rate cell will be adjusted by the MEMA on a semi-annual basis. The Community Well population groups includes three separate rate cells: Community Well 18 – 44, Community Well 45 – 64, and Community Well 65+ for a total of four MyCare rate cells.
RATE DEVELOPMENT STANDARDS. Rate Ranges
RATE DEVELOPMENT STANDARDS. Rate Ranges The CY 2022 MyCare capitation rate development does not utilize rate ranges.
RATE DEVELOPMENT STANDARDS i. Annual basis The capitation rates are effective for the one year rate period from January 1, 2021 through December 31, 2021.
ii. Differences among capitation rates Any proposed differences among capitation rates according to covered populations are based on valid rate development standards and are not based on the rate of federal financial participation associated with the covered populations.
iii. Cross-subsidization of rate cell payment The capitation rates were developed at the rate cell level and neither cross-subsidize nor are cross-subsidized by payments from any other rate cell.
iv. Minimum medical loss ratio The capitation rates were developed such that the MCPs are reasonably expected to achieve a medical loss ratio greater than 85 percent, which includes provisions for non-benefit costs that are appropriate and attainable. ODM’s provider agreement indicates that ODM will perform medical loss ratio (MLR) calculations for the MMC program. ODM has implemented a minimum MLR requirement of 86% for the MMC program. ODM will require remittance in the event a MCP reports a MLR below 86%.
RATE DEVELOPMENT STANDARDS i. Capitation rate structure
RATE DEVELOPMENT STANDARDS i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs have been excluded from the capitation rate development process. During CY 2016, the MCPs did not provide any in-lieu-of services. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. We do not anticipate a material amount of additional expenditures due to this change, and have not projected any additional benefit costs.
