Common use of Risk Adjustment Clause in Contracts

Risk Adjustment. 7.4.1 Capitation rates calculated under this Agreement will be adjusted in accordance with the Chronic Illness and Disability Payment System (―CDPS‖) using the CDPS + Rx version 5.2 and standard weights. The version of the risk adjustment tool will not be modified during a calendar year, but will be updated annually with the most recent version publicly available. In order for an Enrollee’s individual claims data to be the basis for a risk adjustment score hereunder, such Enrollee must have been enrolled in the State Medicaid Program (i.e. either managed care or Fee- For-Service) for at least six (6) full months during the time period from which claims data are used to calculate the adjustment. In the event an Enrollee has not been enrolled in the State Medicaid Program for at least six (6) full months, then such Enrollee shall receive a risk score equal to Contractor’s average risk score. The risk scores shall be established for each MCO by rate cell. The risk scores will be established using a credibility formula for each MCO and rate cell. The credibility formula to be used will be determined by an independent actuary. All diagnoses codes submitted by Contractor shall be included in calculations of risk scoring irrespective of placement of such diagnoses codes in the encounter records. Encounter records may not be supplemented by medical record data. Diagnosis codes may only be recorded by the Provider at the time of the creation of the medical record and may not be retroactively adjusted except to correct errors. A significant increase in risk scores by an MCO may warrant an audit of the diagnosis collection and submission methods.

Risk Adjustment. 7.4.1 Capitation rates calculated under this Agreement will be adjusted in accordance with the Chronic Illness and Disability Payment System (―CDPS‖“CDPS”) using the CDPS + Rx version 5.2 and standard weights. The version of the risk adjustment tool will not be modified during a calendar year, but will be updated annually with the most recent version publicly available. In order for an Enrollee’s individual claims data to be the basis for a risk adjustment score hereunder, such Enrollee must have been enrolled in the State Medicaid Program (i.e. either managed care or Fee- For-Service) for at least six (6) full months during the time period from which claims data are used to calculate the adjustment. In the event an Enrollee has not been enrolled in the State Medicaid Program for at least six (6) full months, then such Enrollee shall receive a risk score equal to Contractor’s average risk score. The risk scores shall be established for each MCO by across all rate cellcells. The risk scores will be established using a credibility formula for each MCO and rate cell. The credibility formula to be used will be determined by an independent actuary. All diagnoses codes submitted by Contractor shall be included in calculations of risk scoring irrespective of placement of such diagnoses codes in the encounter records. Encounter records may not be supplemented by medical record data. Diagnosis codes may only be recorded by the Provider at the time of the creation of the medical record and may not be retroactively adjusted except to correct errors. A significant increase in risk scores by an MCO may warrant an audit of the diagnosis collection and submission methods.

Risk Adjustment. 7.4.1 Capitation rates calculated under this Agreement will be adjusted in accordance with the Chronic Illness and Disability Payment System (―CDPS‖“CDPS”) using the CDPS + Rx version 5.2 and standard weights. The version of the risk adjustment tool will not be modified during a calendar year, but will be updated annually with the most recent version publicly available. In order for an Enrollee’s individual claims data to be the basis for a risk adjustment score hereunder, such Enrollee must have been enrolled in the State Medicaid Program (i.e. either managed care or Fee- Fee-For-Service) for at least six (6) full months during the time period from which claims data are used to calculate the adjustment. In the event an Enrollee has not been enrolled in the State Medicaid Program for at least six (6) full months, then such Enrollee shall receive a risk score equal to Contractor’s average risk score. The risk scores shall be established for each MCO by across all rate cellcells. The risk scores will be established using a credibility formula for each MCO and rate cell. The credibility formula to be used will be determined by an independent actuary. All diagnoses codes submitted by Contractor shall be included in calculations of risk scoring irrespective of placement of such diagnoses codes in the encounter records. Encounter records may not be supplemented by medical record data. Diagnosis codes may only be recorded by the Provider at the time of the creation of the medical record and may not be retroactively adjusted except to correct errors. A significant increase in risk scores by an MCO may warrant an audit of the diagnosis collection and submission methods.