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.
Retrospective Eligibility Periods. (a) MCOP responsibility The MCOPs are responsible for retrospective eligibility periods when the beneficiary was previously enrolled with an MCOP in the MyCare program less than 90 days prior to re-enrolling with an MCOP. ODM provides capitation payments to the MCOPs for beneficiaries meeting this criterion.
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.
Retrospective Eligibility Periods. (a) MCOP responsibility Under the ODM contract, beginning April 1, 2016, the MCOPs became responsible for retrospective eligibility periods when the beneficiary was previously enrolled with an MCOP in the MyCare program less than 90 days prior to re-enrolling with an MCOP. ODM will provide capitation payments to the MCOPs for beneficiaries meeting this criteria. Based on review of analyses performed for other Ohio Medicaid managed care programs, we do not consider this to be a material adjustment to the Opt-Out rates. We have not adjusted the estimated benefit expense included in the rates for the retrospective eligibility policy change.
Retrospective Eligibility Periods
