Common use of Reporting Requirements and Reporting Deliverables Clause in Contracts

Reporting Requirements and Reporting Deliverables. The contractor agrees to provide any information requested by the Department regarding expenditures related to this Contract. Including but not limited to any findings of the Medicaid Managed Care Operations Examination. APPENDICES Table of Contents APPENDIX A. CAPITATION PAYMENT RATES 2 APPENDIX B. MEDICAL LOSS RATIO CALCULATION 5 APPENDIX C. THIRD PARTY PAYMENTS/COORDINATION OF BENEFITS 7 APPENDIX D. MANAGEMENT INFORMATION SYSTEM REQUIREMENTS 9 APPENDIX E. BUSINESS ASSOCIATES AGREEMENT APPENDIX F. ENCOUNTER DATA SUBMISSION REQUIREMENTS AND QUALITY STANDARDS 00 XXXXXXXX X. XXXXX XXXXXXXX XXXXXXXXX PROGRAM 29 APPENDIX H. COVERED SERVICES APPENDIX I. TRANSITION/COORDINATION OF CARE PLANS 35 APPENDIX J. CREDENTIALING PROCESS 35 APPENDIX L. MCO PROVIDER NETWORK FILE LAYOUT (EFFECTIVE 11-07-12) 39 APPENDIX M. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM (EPSDT) 00 XXXXXXXX X. PROGRAM INTEGRITY REQUIREMENTS 57 APPENDIX O. PAID CLAIMS LISTING REQUIREMENTS 61 APPENDIX P. MCO CAPITATION RECONCILIATION INBOUND/OUTBOUND FILE LAYOUTS 62 APPENDIX A. CAPITATION PAYMENT RATES Capitation Rates Effective July 1, 2017 - December 31, 2017 Base Captiation Rates Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $571.58 $694.79 $801.42 $615.51 $779.93 $1,020.94 $734.68 $900.88 Child - Age 1 to 5 $126.16 $133.21 $148.33 $141.82 $140.45 $151.52 $152.24 $164.58 Child - Age 6 to 12 $145.08 $146.63 $181.87 $174.78 $150.19 $175.99 $193.87 $188.40 Child - Age 13 to 18 Female $238.23 $258.77 $265.58 $261.63 $256.43 $274.87 $269.29 $271.35 Child - Age 13 to 18 Male $219.92 $194.41 $243.73 $194.92 $191.57 $198.11 $196.67 $196.61 Adult - Age 19 to 24 Female $536.69 $502.27 $512.24 $472.49 $521.27 $494.55 $491.18 $506.29 Adult - Age 19 to 24 Male $173.50 $168.78 $170.33 $130.92 $194.19 $128.08 $169.05 $160.21 Adult - Age 25 to 39 Female $548.22 $498.00 $551.56 $489.68 $579.07 $528.93 $545.39 $558.28 Adult - Age 25 to 39 Male $314.91 $281.46 $325.73 $275.40 $367.55 $335.60 $323.13 $370.64 Adult - Age 40 or Older Female $571.94 $588.10 $648.86 $618.29 $695.08 $628.44 $656.59 $695.44 Adult - Age 40 or Older Male $601.76 $615.85 $563.07 $535.01 $614.69 $536.48 $527.93 $581.79 SSI Adults w ithout Medicare Age 19 to 24 Female $921.83 $853.17 $880.48 $1,336.15 $879.86 $816.02 $682.85 $741.11 Age 19 to 24 Male $902.16 $303.79 $513.11 $404.80 $700.59 $878.80 $714.28 $444.71 Age 25 to 44 Female $1,027.81 $1,116.13 $1,334.45 $1,009.85 $1,205.67 $1,086.71 $1,229.13 $1,157.63 Age 25 to 44 Male $1,029.09 $911.48 $1,249.76 $833.90 $1,019.24 $1,534.48 $887.10 $839.09 Age 45 or Older Female $1,663.54 $1,722.92 $1,874.25 $1,475.74 $1,592.06 $1,686.22 $1,605.95 $1,615.50 Age 45 or Older Male $1,395.16 $1,551.95 $1,830.27 $1,369.29 $1,589.53 $1,536.77 $1,333.28 $1,391.43 Dual Eligible Female $158.20 $163.83 $185.41 $163.54 $176.66 $214.96 $191.19 $188.11 Male $152.45 $142.29 $178.15 $190.32 $135.18 $147.90 $203.32 $179.60 SSI Child Age Under 1 $6,443.16 $6,343.66 $9,701.47 $5,700.46 $7,195.81 $11,489.31 $7,167.26 $4,730.10 Age 1 to 5 $1,063.81 $1,047.38 $1,601.78 $941.18 $1,188.08 $1,896.97 $1,183.37 $780.97 Age 6 to 18 $652.77 $597.52 $925.60 $785.10 $644.63 $813.02 $722.90 $612.83 Xxxxxx Care Infant - Age Under 1 $716.14 $686.43 $1,293.89 $973.61 $892.51 $1,069.52 $935.86 $965.49 Age 1 to 5 $215.34 $206.41 $389.07 $292.77 $268.38 $321.60 $281.41 $290.32 Age 6 to 12 $326.42 $335.30 $564.98 $439.99 $353.12 $328.80 $393.31 $349.71 Age 13 or Older Female $303.55 $621.70 $749.05 $521.44 $478.12 $435.52 $380.87 $499.48 Age 13 or Older Male $339.78 $816.47 $674.05 $606.82 $436.11 $299.86 $797.40 $435.60 Former Xxxxxx Care Child Age 18 through 20 Female $494.79 $393.70 $507.20 $435.78 $466.49 $444.89 $602.32 $528.31 Age 18 through 20 Male $172.82 $156.78 $298.52 $203.94 $307.11 $273.25 $351.39 $243.23 Age 21 through 25 Female $494.79 $393.70 $507.20 $435.78 $466.49 $444.89 $602.32 $528.31 Age 21 through 25 Male $172.82 $156.78 $298.52 $203.94 $307.11 $273.25 $351.39 $243.23 MAGI Adult Age through 18 Female $274.11 $287.69 $316.01 $273.71 $297.17 $308.31 $289.74 $303.75 Age through 18 Male $187.27 $146.31 $239.80 $176.88 $211.03 $228.99 $173.10 $195.83 Age 19 through 24 Female $274.11 $287.69 $316.01 $273.71 $297.17 $308.31 $289.74 $303.75 Age 19 through 24 Male $187.27 $146.31 $239.80 $176.88 $211.03 $228.99 $173.10 $195.83 Age 25 through 39 Female $410.35 $391.33 $446.02 $364.97 $438.68 $446.82 $445.42 $484.65 Age 25 through 39 Male $325.93 $315.26 $392.17 $301.57 $382.81 $341.54 $356.84 $416.38 Age 40 or Older Female $710.45 $744.22 $820.58 $694.97 $769.66 $711.76 $753.14 $769.79 Age 40 or Older Male $695.91 $705.68 $774.82 $634.02 $739.36 $749.29 $653.83 $709.74 Capitation Rates Effective July 1, 2017 - December 31, 2017 Supplemental Payment PMPM Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $51.08 $37.63 $185.06 $67.91 $141.06 $5.71 $87.73 $118.26 Child - Age 1 to 5 $1.90 $2.42 $14.81 $4.79 $17.31 $0.39 $4.61 $6.60 Child - Age 6 to 12 $1.23 $1.76 $9.12 $2.98 $11.65 $0.37 $4.09 $4.57 Child - Age 13 to 18 Female $1.53 $2.45 $18.09 $6.32 $20.62 $1.66 $7.11 $9.82 Child - Age 13 to 18 Male $1.28 $4.73 $14.19 $5.73 $13.75 $0.50 $7.77 $5.09 Adult - Age 19 to 24 Female $2.22 $1.48 $54.24 $7.85 $43.00 $4.08 $34.23 $20.15 Adult - Age 19 to 24 Male $2.09 $0.14 $7.20 $1.56 $23.57 $0.00 $0.10 $8.70 Adult - Age 25 to 39 Female $0.87 $3.78 $42.63 $6.98 $43.28 $2.00 $19.06 $20.75 Adult - Age 25 to 39 Male $5.01 $2.17 $22.21 $9.19 $33.66 $1.88 $6.88 $11.77 Adult - Age 40 or Older Female $4.68 $8.27 $34.44 $7.65 $39.24 $2.17 $12.43 $22.71 Adult - Age 40 or Older Male $0.26 $7.76 $23.28 $33.61 $55.73 $3.71 $15.80 $22.74 SSI Adults w ithout Medicare Age 19 to 24 Female $6.00 $8.81 $109.40 $68.65 $80.33 $2.99 $36.25 $33.39 Age 19 to 24 Male $6.31 $0.84 $51.65 $8.63 $87.42 $2.08 $41.49 $20.98 Age 25 to 44 Female $7.29 $31.22 $126.65 $29.30 $100.96 $7.66 $47.97 $41.99 Age 25 to 44 Male $23.07 $7.96 $104.35 $31.86 $76.73 $6.47 $26.67 $34.96 Age 45 or Older Female $8.08 $10.42 $125.65 $25.53 $107.40 $11.14 $50.68 $50.20 Age 45 or Older Male $9.01 $26.53 $159.44 $30.83 $153.59 $12.53 $44.46 $43.37 Dual Eligible Female $0.16 $0.26 $7.67 $1.57 $15.97 $2.09 $2.14 $4.57 Male $0.17 $0.28 $11.55 $3.69 $11.35 $0.99 $4.22 $4.71 SSI Child Age Under 1 $421.08 $668.78 $1,623.63 $484.08 $1,213.30 $3.91 $429.24 $608.82 Age 1 to 5 $69.53 $110.42 $268.07 $79.92 $200.32 $0.64 $70.87 $100.52 Age 6 to 18 $6.28 $11.95 $60.74 $25.16 $54.14 $1.50 $31.37 $30.27 Xxxxxx Care Infant - Age Under 1 $19.93 $15.60 $133.78 $49.60 $91.92 $9.33 $59.34 $63.10 Age 1 to 5 $5.99 $4.69 $40.23 $14.91 $27.64 $2.80 $17.84 $18.97 Age 6 to 12 $3.76 $2.98 $11.91 $5.09 $14.33 $0.63 $5.13 $5.10 Age 13 or Older Female $1.07 $5.88 $26.28 $9.27 $22.26 $2.86 $7.68 $8.46 Age 13 or Older Male $6.44 $5.77 $18.59 $3.71 $14.78 $0.30 $6.83 $11.08 Former Xxxxxx Care Child Age 18 through 20 Female $2.47 $0.07 $66.58 $6.25 $48.96 $2.01 $40.05 $16.16 Age 18 through 20 Male $0.00 $0.00 $79.04 $2.08 $24.07 $0.00 $6.50 $4.52 Age 21 through 25 Female $2.47 $0.07 $66.58 $6.25 $48.96 $2.01 $40.05 $16.16 Age 21 through 25 Male $0.00 $0.00 $79.04 $2.08 $24.07 $0.00 $6.50 $4.52 MAGI Adult Age through 18 Female $1.49 $6.87 $28.47 $5.67 $20.73 $1.88 $11.03 $8.99 Age through 18 Male $0.76 $2.67 $31.94 $10.38 $22.03 $1.06 $6.97 $9.92 Age 19 through 24 Female $1.49 $6.87 $28.47 $5.67 $20.73 $1.88 $11.03 $8.99 Age 19 through 24 Male $0.76 $2.67 $31.94 $10.38 $22.03 $1.06 $6.97 $9.92 Age 25 through 39 Female $2.97 $4.04 $29.85 $6.75 $31.32 $3.35 $11.27 $15.41 Age 25 through 39 Male $2.44 $3.50 $46.62 $9.42 $31.46 $2.44 $10.56 $14.26 Age 40 or Older Female $3.51 $7.48 $49.04 $17.04 $49.12 $3.85 $20.43 $22.83 Age 40 or Older Male $6.92 $5.95 $75.22 $17.20 $62.05 $4.67 $22.44 $25.83 Capitation Rates Effective July 1, 2017 - December 31, 2017 HIF PMPM Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $19.61 $23.07 $31.07 $21.53 $29.01 $32.34 $25.91 $32.10 Child - Age 1 to 5 $4.03 $4.27 $5.14 $4.62 $4.97 $4.79 $4.94 $5.39 Child - Age 6 to 12 $4.61 $4.67 $6.02 $5.60 $5.10 $5.56 $6.24 $6.08 Child - Age 13 to 18 Female $7.55 $8.23 $8.94 $8.44 $8.73 $8.71 $8.71 $8.86 Child - Age 13 to 18 Male $6.97 $6.27 $8.12 $6.32 $6.47 $6.26 $6.44 $6.35 Adult - Age 19 to 24 Female $16.98 $15.87 $17.84 $15.13 $17.77 $15.71 $16.55 $16.58 Adult - Age 19 to 24 Male $5.53 $5.32 $5.59 $4.17 $6.86 $4.03 $5.33 $5.32 Adult - Age 25 to 39 Female $17.30 $15.81 $18.72 $15.64 $19.60 $16.72 $17.78 $18.24 Adult - Age 25 to 39 Male $10.08 $8.93 $10.96 $8.96 $12.64 $10.63 $10.40 $12.05 Adult - Age 40 or Older Female $18.16 $18.79 $21.52 $19.72 $23.13 $19.86 $21.07 $22.62 Adult - Age 40 or Older Male $18.96 $19.64 $18.47 $17.91 $21.12 $17.02 $17.13 $19.04 SSI Adults w ithout Medicare Age 19 to 24 Female $29.23 $27.15 $31.18 $44.25 $30.25 $25.80 $22.65 $24.40 Age 19 to 24 Male $28.62 $9.60 $17.79 $13.02 $24.82 $27.75 $23.81 $14.67 Age 25 to 44 Female $32.61 $36.14 $46.02 $32.73 $41.16 $34.47 $40.23 $37.79 Age 25 to 44 Male $33.14 $28.96 $42.65 $27.27 $34.52 $48.54 $28.78 $27.53 Age 45 or Older Female $52.66 $54.60 $63.00 $47.29 $53.53 $53.47 $52.18 $52.47 Age 45 or Older Male $44.23 $49.72 $62.68 $44.10 $54.91 $48.80 $43.40 $45.20 Dual Eligible Female $4.99 $5.17 $6.08 $5.20 $6.07 $6.84 $6.09 $6.07 Male $4.81 $4.49 $5.98 $6.11 $4.62 $4.69 $6.54 $5.81 SSI Child Age Under 1 $216.22 $220.89 $356.74 $194.81 $264.89 $362.04 $239.29 $168.18 Age 1 to 5 $35.70 $36.47 $58.90 $32.16 $43.73 $59.77 $39.51 $27.77 Age 6 to 18 $20.76 $19.20 $31.07 $25.52 $22.01 $25.66 $23.76 $20.26 Xxxxxx Care Infant - Age Under 1 $23.19 $22.11 $44.97 $32.23 $31.01 $33.98 $31.35 $32.40 Age 1 to 5 $6.97 $6.65 $13.52 $9.69 $9.32 $10.22 $9.43 $9.74 Age 6 to 12 $10.40 $10.66 $18.17 $14.02 $11.57 $10.38 $12.55 $11.18 Age 13 or Older Female $9.60 $19.77 $24.42 $16.72 $15.76 $13.81 $12.24 $16.00 Age 13 or Older Male $10.91 $25.90 $21.82 $19.23 $14.20 $9.46 $25.33 $14.07 Former Xxxxxx Care Child Age 18 through 20 Female $15.66 $12.40 $18.07 $13.92 $16.24 $14.08 $20.23 $17.15 Age 18 through 20 Male $5.44 $4.94 $11.89 $6.49 $10.43 $8.61 $11.27 $7.80 Age 21 through 25 Female $15.66 $12.40 $18.07 $13.92 $16.24 $14.08 $20.23 $17.15 Age 21 through 25 Male $5.44 $4.94 $11.89 $6.49 $10.43 $8.61 $11.27 $7.80 MAGI Adult Age through 18 Female $8.68 $9.28 $10.85 $8.80 $10.01 $9.77 $9.47 $9.85 Age through 18 Male $5.92 $4.69 $8.56 $5.90 $7.34 $7.25 $5.67 $6.48 Age 19 through 24 Female $8.68 $9.28 $10.85 $8.80 $10.01 $9.77 $9.47 $9.85 Age 19 through 24 Male $5.92 $4.69 $8.56 $5.90 $7.34 $7.25 $5.67 $6.48 Age 25 through 39 Female $13.02 $12.45 $14.99 $11.71 $14.81 $14.18 $14.39 $15.75 Age 25 through 39 Male $10.34 $10.04 $13.82 $9.80 $13.05 $10.84 $11.57 $13.57 Age 40 or Older Female $22.49 $23.68 $27.39 $22.43 $25.79 $22.54 $24.37 $24.97 Age 40 or Older Male $22.14 $22.42 $26.78 $20.51 $25.24 $23.75 $21.30 $23.17 APPENDIX B. MEDICAL LOSS RATIO CALCULATION Unless specifically addressed below, the Medical Loss Ratio (MLR) calculation shall follow guidelines described in the Affordable Care Act. The formula to be used for the MLR Calculation is as follows: Adjusted MLR = [(i + q – s + n - r)/{(p + s - n + r) - t – f - (s -n + r)}] + c Where,

Reporting Requirements and Reporting Deliverables. The contractor agrees to provide any information requested by the Department regarding expenditures related to this Contractcontract. Including but not limited to any findings of the Medicaid Managed Care Operations Examination. APPENDICES Table of Contents APPENDIX A. CAPITATION PAYMENT RATES 2 APPENDIX B. MEDICAL LOSS RATIO CALCULATION 5 4 APPENDIX C. THIRD PARTY PAYMENTS/COORDINATION OF BENEFITS 7 6 APPENDIX D. MANAGEMENT INFORMATION SYSTEM REQUIREMENTS 9 8 APPENDIX E. BUSINESS ASSOCIATES AGREEMENT 22 APPENDIX F. ENCOUNTER DATA SUBMISSION REQUIREMENTS AND QUALITY STANDARDS 00 XXXXXXXX X. XXXXX XXXXXXXX XXXXXXXXX PROGRAM 29 28 APPENDIX H. COVERED SERVICES 30 APPENDIX I. TRANSITION/COORDINATION OF CARE PLANS 35 APPENDIX J. CREDENTIALING PROCESS 35 36 APPENDIX K. REPORTING REQUIREMENTS AND REPORTING DELIVERABLES 39 APPENDIX L. MCO PROVIDER NETWORK FILE LAYOUT (EFFECTIVE 11-07-12) 39 181 APPENDIX M. EARLY AND PERIODIC SCREENING, DIAGNOSIS AND TREATMENT PROGRAM (EPSDT) 00 000 XXXXXXXX X. PROGRAM INTEGRITY REQUIREMENTS 57 199 APPENDIX O. PAID CLAIMS LISTING REQUIREMENTS 61 203 APPENDIX P. MCO CAPITATION RECONCILIATION INBOUND/OUTBOUND FILE LAYOUTS 62 204 APPENDIX A. CAPITATION PAYMENT RATES Capitation Rates Effective July 1, 2017 - December 31, 2017 Base Captiation Rates Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 $550.93 $549.63 $696.71 $566.48 $700.14 $809.52 $682.00 $712.83 $170.86 $172.89 $203.19 $173.93 $184.21 $175.48 $196.87 $198.10 $179.64 $182.27 $230.87 $210.17 $184.19 $186.87 $202.92 $215.60 $263.15 $278.21 $312.66 $292.14 $279.49 $340.00 $289.25 $298.14 $237.90 $219.25 $276.70 $226.01 $230.88 $219.57 $219.11 $223.03 $602.06 $548.61 $592.62 $581.48 $591.06 $551.43 $581.42 $566.09 $222.73 $180.14 $235.67 $202.05 $286.82 $230.71 $216.37 $217.08 $570.77 $545.83 $596.40 $520.36 $603.56 $556.65 $580.87 $590.49 $314.76 $341.11 $350.46 $330.98 $362.12 $377.01 $358.02 $406.38 $704.99 $555.11 $659.83 $640.53 $697.43 $573.14 $654.86 $686.21 $561.37 $556.34 $565.09 $527.39 $557.07 $550.59 $571.16 $594.10 $621.48 $854.76 $933.89 $1,136.82 $732.05 $712.21 $696.64 $686.56 $627.80 $388.31 $490.03 $345.58 $803.70 $406.50 $494.62 $517.56 $1,202.86 $1,021.86 $1,266.33 $934.26 $1,101.70 $993.08 $1,083.65 $1,089.77 $898.23 $731.79 $1,158.57 $800.45 $960.27 $1,143.65 $811.76 $782.62 $1,572.52 $1,625.34 $1,754.06 $1,403.45 $1,494.73 $1,523.30 $1,534.04 $1,526.80 $1,400.70 $1,315.13 $1,753.79 $1,259.35 $1,445.42 $1,481.62 $1,227.29 $1,254.59 $187.99 $192.36 $232.94 $181.29 $186.75 $183.90 $196.86 $202.96 $150.38 $166.46 $213.90 $168.69 $170.62 $163.03 $174.93 $186.05 $6,524.12 $5,487.17 $9,074.21 $5,286.73 $6,633.59 $9,660.66 $7,383.32 $5,031.29 $1,087.92 $915.02 $1,513.19 $881.59 $1,106.18 $1,610.94 $1,231.20 $839.00 $667.69 $672.67 $886.93 $767.27 $661.19 $781.24 $738.14 $617.87 $1,067.82 $1,005.85 $1,349.32 $1,316.83 $1,204.23 $1,185.01 $1,001.90 $1,443.32 $317.74 $299.30 $401.52 $391.82 $358.32 $352.60 $298.12 $429.46 $385.11 $390.88 $581.51 $534.31 $429.78 $358.94 $452.64 $420.77 $781.65 $714.53 $914.98 $597.11 $624.50 $649.32 $616.01 $616.55 $492.59 $932.66 $894.40 $683.22 $590.80 $529.13 $693.16 $510.46 $379.52 $478.59 $573.51 $419.55 $547.26 $458.29 $828.21 $590.30 $150.96 $163.36 $307.28 $266.77 $261.54 $180.01 $315.53 $269.58 $379.52 $478.59 $573.51 $419.55 $547.26 $458.29 $828.21 $590.30 $150.96 $163.36 $307.28 $266.77 $261.54 $180.01 $315.53 $269.58 $289.33 $303.85 $411.15 $286.68 $372.30 $314.06 $333.02 $338.12 $181.85 $204.04 $244.09 $203.88 $250.07 $246.83 $223.40 $230.62 $289.33 $303.85 $411.15 $286.68 $372.30 $314.06 $333.02 $338.12 $181.85 $204.04 $244.09 $203.88 $250.07 $246.83 $223.40 $230.62 $433.87 $402.57 $500.23 $384.27 $500.14 $419.59 $469.64 $507.63 $335.65 $330.35 $406.55 $335.42 $413.19 $333.38 $370.54 $439.77 $678.52 $731.83 $787.65 $664.46 $760.79 $673.75 $736.45 $736.47 $645.87 $692.92 $797.19 $621.82 $808.86 $679.80 $698.67 $684.61 Families & Children Infant - Age Under 1 $571.58 $694.79 $801.42 $615.51 $779.93 $1,020.94 $734.68 $900.88 Child - Age 1 to 5 $126.16 $133.21 $148.33 $141.82 $140.45 $151.52 $152.24 $164.58 Child - Age 6 to 12 $145.08 $146.63 $181.87 $174.78 $150.19 $175.99 $193.87 $188.40 Child - Age 13 to 18 Female $238.23 $258.77 $265.58 $261.63 $256.43 $274.87 $269.29 $271.35 Child - Age 13 to 18 Male $219.92 $194.41 $243.73 $194.92 $191.57 $198.11 $196.67 $196.61 Adult - Age 19 to 24 Female $536.69 $502.27 $512.24 $472.49 $521.27 $494.55 $491.18 $506.29 Adult - Age 19 to 24 Male $173.50 $168.78 $170.33 $130.92 $194.19 $128.08 $169.05 $160.21 Adult - Age 25 to 39 Female $548.22 $498.00 $551.56 $489.68 $579.07 $528.93 $545.39 $558.28 Adult - Age 25 to 39 Male $314.91 $281.46 $325.73 $275.40 $367.55 $335.60 $323.13 $370.64 Adult - Age 40 or Older Female $571.94 $588.10 $648.86 $618.29 $695.08 $628.44 $656.59 $695.44 Adult - Age 40 or Older Male $601.76 $615.85 $563.07 $535.01 $614.69 $536.48 $527.93 $581.79 SSI Adults w ithout without Medicare Age 19 to 24 Female $921.83 $853.17 $880.48 $1,336.15 $879.86 $816.02 $682.85 $741.11 Age 19 to 24 Male $902.16 $303.79 $513.11 $404.80 $700.59 $878.80 $714.28 $444.71 Age 25 to 44 Female $1,027.81 $1,116.13 $1,334.45 $1,009.85 $1,205.67 $1,086.71 $1,229.13 $1,157.63 Age 25 to 44 Male $1,029.09 $911.48 $1,249.76 $833.90 $1,019.24 $1,534.48 $887.10 $839.09 Age 45 or Older Female $1,663.54 $1,722.92 $1,874.25 $1,475.74 $1,592.06 $1,686.22 $1,605.95 $1,615.50 Age 45 or Older Male $1,395.16 $1,551.95 $1,830.27 $1,369.29 $1,589.53 $1,536.77 $1,333.28 $1,391.43 Dual Eligible Female $158.20 $163.83 $185.41 $163.54 $176.66 $214.96 $191.19 $188.11 Male $152.45 $142.29 $178.15 $190.32 $135.18 $147.90 $203.32 $179.60 SSI Child Age Under 1 $6,443.16 $6,343.66 $9,701.47 $5,700.46 $7,195.81 $11,489.31 $7,167.26 $4,730.10 Age 1 to 5 $1,063.81 $1,047.38 $1,601.78 $941.18 $1,188.08 $1,896.97 $1,183.37 $780.97 Age 6 to 18 $652.77 $597.52 $925.60 $785.10 $644.63 $813.02 $722.90 $612.83 Xxxxxx Care Infant - Age Under 1 $716.14 $686.43 $1,293.89 $973.61 $892.51 $1,069.52 $935.86 $965.49 Age 1 to 5 $215.34 $206.41 $389.07 $292.77 $268.38 $321.60 $281.41 $290.32 Age 6 to 12 $326.42 $335.30 $564.98 $439.99 $353.12 $328.80 $393.31 $349.71 Age 13 or Older Female $303.55 $621.70 $749.05 $521.44 $478.12 $435.52 $380.87 $499.48 Age 13 or Older Male $339.78 $816.47 $674.05 $606.82 $436.11 $299.86 $797.40 $435.60 Former Xxxxxx Care Child Age 18 through 20 Female $494.79 $393.70 $507.20 $435.78 $466.49 $444.89 $602.32 $528.31 Age 18 through 20 Male $172.82 $156.78 $298.52 $203.94 $307.11 $273.25 $351.39 $243.23 Age 21 through 25 Female $494.79 $393.70 $507.20 $435.78 $466.49 $444.89 $602.32 $528.31 Age 21 through 25 Male $172.82 $156.78 $298.52 $203.94 $307.11 $273.25 $351.39 $243.23 MAGI Adult Age through 18 Female $274.11 $287.69 $316.01 $273.71 $297.17 $308.31 $289.74 $303.75 Age through 18 Male $187.27 $146.31 $239.80 $176.88 $211.03 $228.99 $173.10 $195.83 Age 19 through 24 Female $274.11 $287.69 $316.01 $273.71 $297.17 $308.31 $289.74 $303.75 Age 19 through 24 Male $187.27 $146.31 $239.80 $176.88 $211.03 $228.99 $173.10 $195.83 Age 25 through 39 Female $410.35 $391.33 $446.02 $364.97 $438.68 $446.82 $445.42 $484.65 Age 25 through 39 Male $325.93 $315.26 $392.17 $301.57 $382.81 $341.54 $356.84 $416.38 Age 40 or Older Female $710.45 $744.22 $820.58 $694.97 $769.66 $711.76 $753.14 $769.79 Age 40 or Older Male $695.91 $705.68 $774.82 $634.02 $739.36 $749.29 $653.83 $709.74 Capitation Rates Effective July 1, 2017 - December 31, 2017 Supplemental Payment PMPM Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $51.08 $37.63 $185.06 $67.91 $141.06 $5.71 $87.73 $118.26 Child - Age 1 to 5 $1.90 $2.42 $14.81 $4.79 $17.31 $0.39 $4.61 $6.60 Child - Age 6 to 12 $1.23 $1.76 $9.12 $2.98 $11.65 $0.37 $4.09 $4.57 Child - Age 13 to 18 Female $1.53 $2.45 $18.09 $6.32 $20.62 $1.66 $7.11 $9.82 Child - Age 13 to 18 Male $1.28 $4.73 $14.19 $5.73 $13.75 $0.50 $7.77 $5.09 Adult - Age 19 to 24 Female $2.22 $1.48 $54.24 $7.85 $43.00 $4.08 $34.23 $20.15 Adult - Age 19 to 24 Male $2.09 $0.14 $7.20 $1.56 $23.57 $0.00 $0.10 $8.70 Adult - Age 25 to 39 Female $0.87 $3.78 $42.63 $6.98 $43.28 $2.00 $19.06 $20.75 Adult - Age 25 to 39 Male $5.01 $2.17 $22.21 $9.19 $33.66 $1.88 $6.88 $11.77 Adult - Age 40 or Older Female $4.68 $8.27 $34.44 $7.65 $39.24 $2.17 $12.43 $22.71 Adult - Age 40 or Older Male $0.26 $7.76 $23.28 $33.61 $55.73 $3.71 $15.80 $22.74 SSI Adults w ithout Medicare Age 19 to 24 Female $6.00 $8.81 $109.40 $68.65 $80.33 $2.99 $36.25 $33.39 Age 19 to 24 Male $6.31 $0.84 $51.65 $8.63 $87.42 $2.08 $41.49 $20.98 Age 25 to 44 Female $7.29 $31.22 $126.65 $29.30 $100.96 $7.66 $47.97 $41.99 Age 25 to 44 Male $23.07 $7.96 $104.35 $31.86 $76.73 $6.47 $26.67 $34.96 Age 45 or Older Female $8.08 $10.42 $125.65 $25.53 $107.40 $11.14 $50.68 $50.20 Age 45 or Older Male $9.01 $26.53 $159.44 $30.83 $153.59 $12.53 $44.46 $43.37 Dual Eligible Female $0.16 $0.26 $7.67 $1.57 $15.97 $2.09 $2.14 $4.57 Male $0.17 $0.28 $11.55 $3.69 $11.35 $0.99 $4.22 $4.71 SSI Child Age Under 1 $421.08 $668.78 $1,623.63 $484.08 $1,213.30 $3.91 $429.24 $608.82 Age 1 to 5 $69.53 $110.42 $268.07 $79.92 $200.32 $0.64 $70.87 $100.52 Age 6 to 18 $6.28 $11.95 $60.74 $25.16 $54.14 $1.50 $31.37 $30.27 Xxxxxx Care Infant - Age Under 1 $19.93 $15.60 $133.78 $49.60 $91.92 $9.33 $59.34 $63.10 Age 1 to 5 $5.99 $4.69 $40.23 $14.91 $27.64 $2.80 $17.84 $18.97 Age 6 to 12 $3.76 $2.98 $11.91 $5.09 $14.33 $0.63 $5.13 $5.10 Age 13 or Older Female $1.07 $5.88 $26.28 $9.27 $22.26 $2.86 $7.68 $8.46 Age 13 or Older Male $6.44 $5.77 $18.59 $3.71 $14.78 $0.30 $6.83 $11.08 Former Xxxxxx Care Child Age 18 through 20 Female $2.47 $0.07 $66.58 $6.25 $48.96 $2.01 $40.05 $16.16 Age 18 through 20 Male $0.00 $0.00 $79.04 $2.08 $24.07 $0.00 $6.50 $4.52 Age 21 through 25 Female $2.47 $0.07 $66.58 $6.25 $48.96 $2.01 $40.05 $16.16 Age 21 through 25 Male $0.00 $0.00 $79.04 $2.08 $24.07 $0.00 $6.50 $4.52 MAGI Adult Age through 18 Female $1.49 $6.87 $28.47 $5.67 $20.73 $1.88 $11.03 $8.99 Age through 18 Male $0.76 $2.67 $31.94 $10.38 $22.03 $1.06 $6.97 $9.92 Age 19 through 24 Female $1.49 $6.87 $28.47 $5.67 $20.73 $1.88 $11.03 $8.99 Age 19 through 24 Male $0.76 $2.67 $31.94 $10.38 $22.03 $1.06 $6.97 $9.92 Age 25 through 39 Female $2.97 $4.04 $29.85 $6.75 $31.32 $3.35 $11.27 $15.41 Age 25 through 39 Male $2.44 $3.50 $46.62 $9.42 $31.46 $2.44 $10.56 $14.26 Age 40 or Older Female $3.51 $7.48 $49.04 $17.04 $49.12 $3.85 $20.43 $22.83 Age 40 or Older Male $6.92 $5.95 $75.22 $17.20 $62.05 $4.67 $22.44 $25.83 Capitation Rates Effective July 1, 2017 - December 31, 2017 HIF PMPM Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7 Region 8 Families & Children Infant - Age Under 1 $19.61 $23.07 $31.07 $21.53 $29.01 $32.34 $25.91 $32.10 Child - Age 1 to 5 $4.03 $4.27 $5.14 $4.62 $4.97 $4.79 $4.94 $5.39 Child - Age 6 to 12 $4.61 $4.67 $6.02 $5.60 $5.10 $5.56 $6.24 $6.08 Child - Age 13 to 18 Female $7.55 $8.23 $8.94 $8.44 $8.73 $8.71 $8.71 $8.86 Child - Age 13 to 18 Male $6.97 $6.27 $8.12 $6.32 $6.47 $6.26 $6.44 $6.35 Adult - Age 19 to 24 Female $16.98 $15.87 $17.84 $15.13 $17.77 $15.71 $16.55 $16.58 Adult - Age 19 to 24 Male $5.53 $5.32 $5.59 $4.17 $6.86 $4.03 $5.33 $5.32 Adult - Age 25 to 39 Female $17.30 $15.81 $18.72 $15.64 $19.60 $16.72 $17.78 $18.24 Adult - Age 25 to 39 Male $10.08 $8.93 $10.96 $8.96 $12.64 $10.63 $10.40 $12.05 Adult - Age 40 or Older Female $18.16 $18.79 $21.52 $19.72 $23.13 $19.86 $21.07 $22.62 Adult - Age 40 or Older Male $18.96 $19.64 $18.47 $17.91 $21.12 $17.02 $17.13 $19.04 SSI Adults w ithout Medicare Age 19 to 24 Female $29.23 $27.15 $31.18 $44.25 $30.25 $25.80 $22.65 $24.40 Age 19 to 24 Male $28.62 $9.60 $17.79 $13.02 $24.82 $27.75 $23.81 $14.67 Age 25 to 44 Female $32.61 $36.14 $46.02 $32.73 $41.16 $34.47 $40.23 $37.79 Age 25 to 44 Male $33.14 $28.96 $42.65 $27.27 $34.52 $48.54 $28.78 $27.53 Age 45 or Older Female $52.66 $54.60 $63.00 $47.29 $53.53 $53.47 $52.18 $52.47 Age 45 or Older Male $44.23 $49.72 $62.68 $44.10 $54.91 $48.80 $43.40 $45.20 Dual Eligible Female $4.99 $5.17 $6.08 $5.20 $6.07 $6.84 $6.09 $6.07 Male $4.81 $4.49 $5.98 $6.11 $4.62 $4.69 $6.54 $5.81 SSI Child Age Under 1 $216.22 $220.89 $356.74 $194.81 $264.89 $362.04 $239.29 $168.18 Age 1 to 5 $35.70 $36.47 $58.90 $32.16 $43.73 $59.77 $39.51 $27.77 Age 6 to 18 $20.76 $19.20 $31.07 $25.52 $22.01 $25.66 $23.76 $20.26 Xxxxxx Care Infant - Age Under 1 $23.19 $22.11 $44.97 $32.23 $31.01 $33.98 $31.35 $32.40 Age 1 to 5 $6.97 $6.65 $13.52 $9.69 $9.32 $10.22 $9.43 $9.74 Age 6 to 12 $10.40 $10.66 $18.17 $14.02 $11.57 $10.38 $12.55 $11.18 Age 13 or Older Female $9.60 $19.77 $24.42 $16.72 $15.76 $13.81 $12.24 $16.00 Age 13 or Older Male $10.91 $25.90 $21.82 $19.23 $14.20 $9.46 $25.33 $14.07 Former Xxxxxx Care Child Age 18 through 20 Female $15.66 $12.40 $18.07 $13.92 $16.24 $14.08 $20.23 $17.15 Age 18 through 20 Male $5.44 $4.94 $11.89 $6.49 $10.43 $8.61 $11.27 $7.80 Age 21 through 25 Female $15.66 $12.40 $18.07 $13.92 $16.24 $14.08 $20.23 $17.15 Age 21 through 25 Male $5.44 $4.94 $11.89 $6.49 $10.43 $8.61 $11.27 $7.80 MAGI Adult Age through 18 Female $8.68 $9.28 $10.85 $8.80 $10.01 $9.77 $9.47 $9.85 Age through 18 Male $5.92 $4.69 $8.56 $5.90 $7.34 $7.25 $5.67 $6.48 Age 19 through 24 Female $8.68 $9.28 $10.85 $8.80 $10.01 $9.77 $9.47 $9.85 Age 19 through 24 Male $5.92 $4.69 $8.56 $5.90 $7.34 $7.25 $5.67 $6.48 Age 25 through 39 Female $13.02 $12.45 $14.99 $11.71 $14.81 $14.18 $14.39 $15.75 Age 25 through 39 Male $10.34 $10.04 $13.82 $9.80 $13.05 $10.84 $11.57 $13.57 Age 40 or Older Female $22.49 $23.68 $27.39 $22.43 $25.79 $22.54 $24.37 $24.97 Age 40 or Older Male $22.14 $22.42 $26.78 $20.51 $25.24 $23.75 $21.30 $23.17 APPENDIX B. MEDICAL LOSS RATIO CALCULATION Unless specifically addressed below, the Medical Loss Ratio (MLR) calculation shall follow guidelines described in the Affordable Care Act. The formula to be used for the MLR Calculation is as follows: Adjusted MLR = [(i + q – s + n - r)/{(p + s - n + r) - t – f - (s -n + r)}] + c Where,5