Retrospective Eligibility Periods. (a) MCOP responsibility
Retrospective Eligibility Periods. (a) MCOP responsibility
(b) Claims treatment
(c) Enrollment treatment
Retrospective Eligibility Periods i. Health plan responsibility Under the MyCare contract, the health plans are not responsible for retrospective eligibility periods. Services during retrospective eligibility periods are provided on a fee-for-service basis.
ii. Base data treatment The historical FFS data includes all eligibility spans for a MyCare eligible individual, including retrospective eligibility. We worked with ODM in an attempt to identify such eligibility spans but there was not an appropriate identification. We discussed the implications with ODM and determined that we could not make an explicit adjustment for this program item. We believe that through review of the emerging experience of the MCOPs that our base claim cost is appropriate without a material adjustment for this item.
iii. Enrollment treatment Enrollment is treated consistently with claims. We have not adjusted for retrospective eligibility.
Retrospective Eligibility Periods i. Health plan responsibility During the 2014 experience period, MCPs were not responsible for periods of retrospective eligibility. Under the ODM contract, beginning April 1, 2016, the MCPs will be responsible for retrospective eligibility periods when the beneficiary was previously enrolled with a MCP in the MMC program less than 90 days prior to re-enrolling with a MCP. ODM will provide capitation payments to the MCPs for beneficiaries meeting this criteria. We reviewed historical eligibility meeting the MCP retro-active eligibility criteria, as well as associated FFS expenses, and did not observe material or consistent cost differences between retro-active eligibility member months (meeting the specific 90 day criteria) and managed care member months. We have not adjusted the estimated benefit expense included in the rates for the retrospective eligibility policy change. Projected member months for calendar year 2016, with the exception of the HF/HST <1 M+F rate cell, were increased by 1.5% as a result of this policy change. FFS claims incurred during retrospective eligibility periods have been excluded from the base data.
ii. Enrollment treatment Enrollment is treated consistently with claims. We have not included retrospective eligibility in the base experience period.
Retrospective Eligibility Periods i. Health plan responsibility During the CY 2015 experience period, MCPs were not responsible for periods of retrospective eligibility. Under the ODM contract, beginning April 1, 2016, the MCPs became responsible for retrospective eligibility periods when the beneficiary was previously enrolled with an MCP in the MMC program less than 90 days prior to re-enrolling with an MCP. ODM will provide capitation payments to the MCPs for beneficiaries meeting this criteria. We reviewed historical eligibility meeting the MCP retro-active eligibility criteria, as well as associated FFS expenses, and did not observe material or consistent cost differences between retro-active eligibility member months (meeting the specific 90 day criteria) and managed care member months. We have not adjusted the estimated benefit expense included in the rates for the retrospective eligibility policy change. FFS claims incurred during retrospective eligibility periods have been excluded from the base data.
ii. Enrollment treatment Enrollment is treated consistently with claims. We have not included retrospective eligibility in the base experience period.
iii. Adjustments As previously mentioned, no explicit adjustment was applied to the CY 2017 rate setting as a result of the April 1, 2016 policy change, as we did not observe material or consistent cost differences between retro-active eligibility member months. In developing projected member months, we utilized enrollment data as of July 2016, and applied adjustments for population changes occurring after that point in time. This included population movements associated with the 1634 conversion, along with AFK, BCCP, and BCMH mandatory managed care enrollment.
Retrospective Eligibility Periods i. Health plan responsibility Under the MyCare contract, the health plans are not responsible for retrospective eligibility periods. Services during retrospective eligibility periods are provided on a fee-for-service basis.
ii. Base data treatment No base data adjustment was required for retroactive eligibility.
iii. Enrollment treatment Enrollment is treated consistently with claims. We have not adjusted for retrospective eligibility.
iv. Adjustments No adjustments to the rates for retrospective eligibility periods were applied.
Retrospective Eligibility Periods
