Reason for Acuity Adjustment Sample Clauses

Reason for Acuity Adjustment. ‌ The CYE 25 capitation rates use CYE 23 encounter data and enrollment information as the basis for the development of the capitation rates. The FFCRA included MOE requirements under which Arizona did not disenroll anyone who was eligible at the start of, or became eligible during, the PHE from AHCCCS programs, except in limited instances as allowed by the FFCRA. This growth in enrollment influenced the average PMPMs in each risk group in different ways. The CAA decoupled the MOE requirements from the end of the PHE, and Arizona began the process of redeterminations in February 2023, with the first disenrollments due to ineligibility happening in April 2023, as allowed under CAA. The acuity adjustment described here is intended to reverse some of the influence of the increased enrollment, account for changes in the average risk and health status of the members who will be enrolled during the rating period compared to those who were enrolled during the base period and reduce the likelihood of significant mismatches in projected medical expenses and actual medical expenses during the rating period. Over the course of the PHE, the AHCCCS DBF Actuarial Team reviewed the encounter data from multiple years with the expectation that the total average PMPMs would be lower when considering all members enrolled in a risk group than when considering members in the same risk group who were likely to still be enrolled after all redeterminations had been completed for the AHCCCS population, under the a priori assumption that members who may no longer be eligible for Medicaid had the potential to be otherwise insured, or healthier on average than an “ordinary” Medicaid member. Using information obtained from AHCCCS DMPS, described more in Section I.7.B.i.(b), the actuaries compared the base data for each risk group using all enrolled membership to a smaller subset of the base data which removed the enrollment and experience of potentially ineligible members and observed a lower PMPM average in the total set compared to the smaller subset. This was done both before redeterminations and disenrollments began, and after. After the MOE ended and disenrollments began, the a priori assumption that disenrolling members would have lower average PMPM expenses was confirmed through an additional review which looked at members who had already been disenrolled due to the redetermination process. Some level of uncertainty remains as to how the overall PMPMs will be impacted by further...

Reason for Acuity Adjustment. ‌ Please see the original capitation rate certification for documentation of the rationale for the acuity adjustments. The acuity adjustment factors in the original capitation rates projected an increase in the health needs of the population in a return towards pre-pandemic acuity levels due to less costly members on the COVID-19 override list being disenrolled. The revised acuity factors vary from the previous acuity factors both positively and negatively dependent on the actual disenrollment by risk group, and in aggregate, the total fiscal impact of the changes is a slight decrease from the previous projections. There are three risk groups (SSIWO, Expansion Adults, and members with SMI) in which the change in the acuity adjustment factors for the second half of the year causes the capitation rates in one or more GSAs to change by more than the +/-1.5% de minimis amounts allowable without an updated certification. The acuity factor update calculations were all performed in the same way using the same data sources, and differences in the results are due to actual experience during the base data period used for the capitation rate development of the disenrolled COVID-19 override members rather than the hypothetical average experience of expected disenrolled override members.