Risk Adjustment Methodology. To account for variation in risk for the costs of EW services among Enrollees, the STATE will calculate an MCO-specific risk score for the EW add-on rate in section 4.6 on an annual basis. The STATE agrees not to rebase the base rates for risk adjustment during the term of this Contract.
Risk Adjustment Methodology. The MEMA adjustment is applied by region for the NFLOC rate cell for each MCOP. Each population group within the NFLOC rate cell is given a weight based on its relative capitation rate compared to the composite NFLOC capitation rate. Each MCOP will receive a calculated MEMA score based on their enrollment of each population group within the NFLOC rate cell. To ensure budget neutrality, the MEMA scores will be normalized to 1.000 for each region. MEMA methodology uses generally accepted actuarial principles and practices.
Risk Adjustment Methodology. Medicare Parts A/B: The Medicare Parts A/B Component will be risk adjusted based on the risk profile of each Enrollee. Except as specified in Section 4.3.
Risk Adjustment Methodology. A. The Medicare A/B Demonstration county rate will be risk adjusted based on the risk profile of each enrolled beneficiary. Except as specified in section II.B.g, the existing CMS-HCC risk adjustment methodology will be utilized for the Demonstration.
B. The Medicare Part D national average bid will be risk-adjusted in accordance with existing Part D RxHCC methodology.
C. The Medicaid component will be risk adjusted based on a methodology as described in section I above.
Risk Adjustment Methodology. In order to account for variation in risk or health status across Enrollees, the STATE will calculate an MCO specific risk score for the Medicaid portion of the acute care rates on a quarterly basis using a capitation risk adjustment method based on disease categories assigned by the Chronic Illness and Disability Payment System (CDPS).
Risk Adjustment Methodology. A. The Medicare A/B Demonstration county rate will be risk adjusted based on the risk profile of each enrolled beneficiary. Except as specified in section II.B.g of this Appendix for calendar year 2013, the existing CMS-HCC risk adjustment methodology will be utilized for the Demonstration.
B. The Medicare Part D national average bid will be risk-adjusted in accordance with existing Part D RxHCC methodology.
C. The Medicaid component will be risk adjusted based on a methodology proposed by the Commonwealth and agreed to by CMS as described below: Under the Massachusetts Demonstration to Integrate Care for Dual Eligible Beneficiaries, the Commonwealth will rely on rating categories described in section I and use High Cost Risk Pools (HCRPs) for certain Rating Categories described in section IX to account for differences in risk among the eligible population.
D. The Commonwealth will be collecting functional data and will be working on the development of an enhanced risk adjustment methodology for the Medicaid component of the rate during the course of the Demonstration.
Risk Adjustment Methodology. The risk adjustment is designed to be cost neutral for each population. Relative risk scores will be normalized to result in a composite risk score of 1.000 for each population group, across all MCPs. The risk adjustment methodology uses generally accepted actuarial principles and practices.
Risk Adjustment Methodology. A. The Medicare Parts A/B FFS standardized county rate will be risk adjusted based on the risk profile of each enrollee. The existing CMS-HCC risk adjustment methodology will be utilized for the Demonstration.
B. The Medicare Part D NAMBA will be risk-adjusted in accordance with existing Part D RxHCC methodology.
C. The Medicaid component will employ the rating categories described in section I of this Appendix, above.
Risk Adjustment Methodology. A. The Medicare A/B Demonstration county rate will be risk adjusted based on the risk profile of each enrolled beneficiary. Except as specified in section I.B.7. , the existing CMS-HCC risk adjustment methodology will be utilized for the Demonstration.
B. The Medicare Part D national average bid will be risk-adjusted in accordance with existing Part D RxHCC methodology.
C. The Medicaid component will employ the rating categories described below: Community Well: age 21-64 Enrollees age 21-64 who do not meet a Nursing Facility Level of Care (NFLOC) standard Rates will vary for the five Demonstration regions Community Well: age 65+ Enrollees age 65 and older who do not meet a Nursing Facility Level of Care (NFLOC) standard Rates will vary for the five Demonstration regions Nursing Facility Level of Care: Single rate cell for all Enrollees age 21-64 meeting a NFLOC through waiver enrollment or currently in a nursing facility for 20 or more age 21-64 consecutive days. Note: An individual’s initial screening to determine NFLOC will be conducted by a state-reimbursed, external preadmission screening team. Annual reassessment screenings for NFLOC will be conducted by the Plan, but monitored by DMAS for quality assurance. There will be a member enrollment mix adjustment (MEMA) that will provide more revenue to Plans that have a greater proportion of high risk/cost individuals (e.g. nursing facility residents) compared to Plans with a lower proportion of high risk/cost individuals. Once a NFLOC recipient is determined to no longer need NFLOC services, either nursing facility or HCBS, the Plan continues to receive the higher NFLOC capitation rate for two full months following the change in determination. Beginning with the third month, the Plan would receive the Community Well capitation rate. Rates will vary for the five Demonstration regions Nursing Facility Level of Care: age 65+ Single rate cell for all Enrollees age 65 and over meeting a NFLOC through waiver enrollment or currently in a nursing facility for 20 or more consecutive days. Note: An individual’s initial screening to determine NFLOC will be conducted by a state-reimbursed, external preadmission screening team. Annual reassessment screenings for NFLOC will be conducted by the Plan, but monitored by DMAS for quality assurance. There will be a member enrollment mix adjustment (MEMA) that will provide more revenue to Plans that have a greater proportion of high risk/cost individuals (e...
Risk Adjustment Methodology. Medicare Parts A/B: The Medicare Parts A/B Component will be risk adjusted based on the risk profile of each Enrollee. Except as specified in Sections 4.6.7.5.1 through 4.6.7.5.4, the existing Medicare Advantage CMS-HCC and CMS-HCC ESRD risk adjustment methodology will be used for the Demonstration. In calendar year 2015, CMS will calculate and apply a coding intensity adjustment reflective of all Demonstration Enrollees. This will apply the prevailing Medicare Advantage coding intensity adjustment proportional to the anticipated proportion of Demonstration Enrollees in 2015 with Medicare Advantage experience in 2014, prior to the Demonstration. In calendar year 2016, CMS will apply an appropriate coding intensity adjustment reflective of all Demonstration Enrollees; this will apply the prevailing Medicare Advantage coding intensity adjustment proportional to the anticipated proportion of Demonstration Enrollees in CY 2016 with prior Medicare Advantage experience and/or Demonstration experience based on the Demonstration’s Enrollment phase-in as of September 30, 2015. (This may result in application of the full Medicare Advantage coding intensity adjustment for 2016.) After calendar year 2016, CMS will apply the prevailing Medicare Advantage coding intensity adjustment to all Demonstration Enrollees. The coding intensity adjustment factor will not be applied during the Demonstration to risk scores for Enrollees with an ESRD status of dialysis or transplant, consistent with Medicare Advantage policy. Medicare Part D: The Medicare Part D NAMBA will be risk adjusted in accordance with existing Part D RxHCC methodology. The estimated average monthly prospective payment amount for the low-income cost-sharing subsidy and federal reinsurance amounts will not be risk adjusted. Medicaid: The Medicaid component will employ rating categories described in Section 4.2.1. Risk Mitigation Approaches Risk Corridor Risk corridors will be established for Demonstration Year 1. Risk corridors will not be applied for Demonstration Years 2-10. The Demonstration will utilize a tiered ICO-level symmetrical risk corridor to include all Medicare A/B and Medicaid eligible costs. The risk corridors will be reconciled after application of any risk adjustment methodologies (e.g., CMS-HCC). Risk corridors will be reconciled as if all ICOs had received the full quality withhold payment. Process for collecting cost information CMS and MDHHS will evaluate Encounter Dat...
