Risk Corridor. 1. The Parties agree that the ETCOC serves as the benchmark upon which the Risk Corridor is based.
2. Additionally, the Parties agree to a Risk Corridor arrangement as follows:
A. The Risk Corridor for the Traditional Attribution Cohort and Expanded Attribution Cohort will be 3% in aggregate.
B. The aggregate Risk Corridor for the Traditional Attribution Cohort and Expanded Attribution Cohort shall be applied as follows:
i. If, at the time of Year-End Reconciliation, the ATCOC is between 100% and 103% of the ETCOC amount for the two cohorts in aggregate, Contractor agrees it is liable for the costs between 100% and 103%. To the extent those costs are borne by DVHA during the year, Contractor shall be liable to DVHA. If the ATCOC is greater than 103% of the ETCOC amount for the two cohorts in aggregate, Contractor is liable for costs between 100% and 103%, and DVHA is liable for any costs exceeding 103%.
ii. Conversely, if the ATCOC is between 97% and 100% of the ETCOC amount for the two cohorts in aggregate, Contractor will be entitled to receive from DVHA payment of the full amount of the ETCOC. If the ATCOC is lower than 97% of the ETCOC amount for the two cohorts in aggregate, Contractor will be entitled to receive payment of the full value of the ETCOC less the difference between the ATCOC and 97% of the ETCOC.
3. If during the Contract, DVHA or Contractor determines that the Fee-for-Service Payments are 10% or more above the expected allocation of Fee-for-Service Payments multiplied by the number of member months or if the ATCOC is projecting to exceed the upper bound of the risk corridor, then the parties shall meet to discuss utilization or costs and potential remedies. Evaluations will occur no less frequently than quarterly within 60 days of the end of the quarter.
Risk Corridor. Funding from other sources or arrangements identified as funding formula, categorical, all fee-for-service, PECPM MIChild and Adults Benefits Waiver payments are completely excluded from the shared-risk arrangement, as the PIHP assumes full risk of operating within the boundaries of the approved expenditure and revenue budgets of each of these funding arrangements. The shared risk arrangements shall cover all Medicaid 1915, 1915(b)(3) capitation and 1915(c) Habilitation Supports Waiver payments. The risk corridor is administered across all services, with no separation for mental health and substance abuse funding A. The PIHP shall retain unexpended risk-corridor-related funds between 95% and 100% of said funds. The PIHP shall retain 50% of unexpended risk-corridor related funds between 90% and 95% of said funds. The PIHP shall return unexpended risk-corridor-related funds to the MDCH between 0% and 90% of said funds and 50% of the amount between 90% and 95%.
Risk Corridor. 1. The Parties agree that the ETCOC serves as the benchmark upon which the Risk Corridor is based.
2. Additionally, the Parties agree to a Risk Corridor arrangement as follows:
A. The Risk Corridor for the Traditional Attribution Cohort will be 2%.
B. The Risk Corridor for the Traditional Attribution Cohort shall be applied as follows:
i. If, at the time of Year-End Reconciliation, the ATCOC is between 100% and 102% of the ETCOC amount, Contractor agrees it is liable for the costs between 100% and 102%. To the extent those costs are borne by DVHA during the year, Contractor shall be liable to DVHA. If the ATCOC is greater than 102% of the ETCOC amount, Contractor is liable for costs between 100% and 102%, and DVHA is liable for any costs exceeding 102%.
ii. Conversely, if the ATCOC is between 98% and 100% of the ETCOC, Contractor will be entitled to receive from DVHA payment of the full amount of the ETCOC. If the ATCOC is lower than 98% of the ETCOC, Contractor will be entitled to receive payment of the full value of the ETCOC less the difference between the ATCOC and 98% of the ETCOC.
C. The Risk Corridor for the Expanded Attribution Cohort will be 1%.
D. The Risk Corridor for the Expanded Attribution Cohort shall be applied as follows:
i. If, at the time of Year-End Reconciliation, the ATCOC is between 100% and 101% of the ETCOC amount, Contractor agrees it is liable for the costs between 100% and 101%. To the extent those costs are borne by DVHA during the year, Contractor shall be liable to DVHA. If the ATCOC is greater than 101% of the ETCOC amount, Contractor is liable for costs between 100% and 101%, and DVHA is liable for any costs exceeding 101%.
ii. Conversely, if the ATCOC is between 99% and 100% of the ETCOC, Contractor will be entitled to receive from DVHA payment of the full amount of the ETCOC. If the ATCOC is lower than 99% of the ETCOC, Contractor will be entitled to receive payment of the full value of the ETCOC less the difference between the ATCOC and 99% of the ETCOC.
3. If during the Contract, DVHA or Contractor determines that the Fee-for-Service Payments are 10% or more above the expected allocation of Fee-for-Service Payments multiplied by the number of member months or if the ATCOC is projecting to exceed the upper bound of the risk corridor, then the parties shall meet to discuss utilization or costs and potential remedies. Evaluations will occur no less frequently than quarterly within 60 days of the end of the quarter.
Risk Corridor. Funding from other sources or arrangements identified as funding formula, categorical, all fee-for-service, PECPM MIChild and Adults Benefits Waiver payments are completely excluded from the shared-risk arrangement, as the PIHP assumes full risk of operating within the boundaries of the approved expenditure and
Risk Corridor. This Appendix establishes a risk corridor arrangement (Arrangement) between the Department and the PCO.
Risk Corridor. The APM PAYMENT in this contract is a risk sharing arrangement. In the pilot APM Year 1, Contractor shall be subject to the following risk corridor.
Risk Corridor. Agency shall include a risk corridor for the rate period beginning July 1, 2023 running through June 30, 2024. The Agency reserves the right to prospectively modify the terms of the risk corridor described though a contract amendment.
Risk Corridor a. A risk corridor arrangement between the PHP and the Department will apply to share in gains and losses of the PHP as defined in this section. The Risk Corridor payments to and recoupments from the PHP will be based on a comparison of the PHP’s reported Risk Corridor Services Ratio (“Reported Serves Ratio”) for the Risk Corridor Measurement Period as defined in this section, to the Target Services Ratio consistent with capitation rate setting and set forth in the Standard Plan Rate Book (“Target Services Ratio”).
i. The Risk Corridor Measurement Period is defined as July 1, 2021 to June 30, 2022.
ii. The risk corridor payments and recoupments will be based on a comparison of the PHP’s Reported Services Ratio for the measurement period to a Target Services Ratio derived from capitation rate-setting by the Department. The Target Services Ratio will be documented in the Standard Plan Rate Book by rate cell and may be revised concurrently with any amendments to the applicable Capitation Rates.
iii. The PHP Target Services Ratio shall be calculated using the Target Services Ratio for each rate cell documented in the Standard Plan Rate Book and weighted by the PHP’s capitation revenue for each rate cell (excluding revenue associated with additional utilization-based payments).
iv. The Reported Services Ratio numerator shall be the PHP’s expenses for the Risk Corridor Measurement Period specific to the North Carolina Medicaid and NC Health Choice managed care programs. The numerator shall be defined as the sum of:
a) Incurred claims as defined in 42 C.F.R. 438.8(e)(2)(i)-438.8(e)(2)(iii) for State Plan Services, approved In-Lieu of Services, and approved Value-Added Services not including additional utilization-based directed payments and COVID-19 vaccine and testing costs.
b) Advanced Medical Home Fees as defined in Section 4. Provider Payments including any uniform increases across all eligible providers above the defined floor and other increases with written approval from the Department
c) Performance Incentive Payments to Advanced Medical Homes as defined in Section 4. Provider Payments
d) Other quality-related incentive payments to NC Medicaid providers
e) Non-claims based provider stabilization payments to support provider sustainability and beneficiary access.
f) Contributions to community-based health-related resources and initiatives that advance Health Equity, subject to Department review and approval.
g) The final Risk Corridor Services Ratio report...
Risk Corridor. Funding from other sources or arrangements identified as funding formula, categorical, all fee- for-service, PECPM MIChild and Adults Benefits Waiver payments are completely excluded from the shared-risk arrangement, as the PIHP assumes full risk of operating within the boundaries of the approved expenditure and revenue budgets of each of these funding arrangements. The shared risk arrangements shall cover all Medicaid 1915, 1915(b)(3) capitation and 1915(c) Habilitation Supports Waiver payments. The risk corridor is administered across all services, with no separation for mental health and substance abuse funding.
A. The PIHP shall retain unexpended risk-corridor-related funds between 95% and 100% of said funds. The PIHP shall retain 50% of unexpended risk-corridor related funds between 90% and 95% of said funds. The PIHP shall return unexpended risk-corridor-related funds to the MDCH between 0% and 90% of said funds and 50% of the amount between 90% and 95%.
B. The PIHP may retain funds noted in 7.7.1.A, except as specified in Part 1, section 13.0 “Closeout”
C. The PIHP shall be financially responsible for liabilities incurred above the risk corridor- related operating budget between 100% and 105% of said funds contracted.
D. The PIHP shall be responsible for 50% of the financial liabilities above the risk corridor- related operating budget between 105% and 110% of said funds contracted.
E. The PIHP shall not be financially responsible for liabilities incurred above the risk corridor-related operating budget over 110% of said funds contracted. The assumption of a shared-risk arrangement between the PIHP and the MDCH shall not permit the PIHP to overspend its total operating budget for any fiscal year. The PIHP shall not pass on, charge, or in any manner shift financial liabilities to Medicaid beneficiaries resulting from PIHP financial debt, loss and/or insolvency. The PIHP financial responsibility for liabilities for costs between 100% and 110% must first be paid from the PIHP’s ISF for risk funding or insurance for cost over-runs. If the PIHP’s liability exceeds the amount available from ISF and insurance, other funding available to the PIHP may be utilized in accordance with the terms of the PIHP’s Risk Management Strategy.
Risk Corridor. 4.2.4.1. As a result of the unknown risk level associated with the emerging MAGI childless adults population, the State has developed the following risk corridor as a risk- mitigation strategy: Min Max MCO Share Federal/State Share 0% 98% 50% 50% Min Max MCO Share Federal/State Share
4.2.4.2. The risk corridor percentage is calculated as total adjusted medical expenditures divided by the medical portion of the total capitation payment, for the same period.
4.2.4.3. Should the risk corridor percentage calculated as above, in the aggregate be greater than one hundred two percent (102%) the Department/Federal Government shall be responsible for fifty percent (50%) of the loss that is greater than one hundred two percent (102%) of the medical portion of the total capitation rate or the Department/Federal Government shall be responsible for fifty percent (50%) of the gain that is less than ninety-eight percent (98%) of the medical portion of the total capitation rate.
4.2.4.4. Should the risk corridor percentage in the aggregate be greater than or equal to ninety-eight percent (98%) or less than or equal to one hundred two percent (102%), the Department/Federal Government shall have no financial responsibility.
4.2.4.5. To the extent that the actual experience is below an eighty five percent (85%) medical loss ratio, the Federal Government will retain all profits below that threshold. On the top end of the corridor, the Federal Government will not provide financial participation above the fee-for-service-equivalent (FFSE), which will be calculated during the risk corridor process.
4.2.4.6. For the risk corridor calculations, the Department will use the encounter data priced at the Medicaid fee schedule for internal DH providers and will benchmark DH’s actual costs for external providers to the Medicaid fee schedule to ensure reasonable provider contracting.
4.2.4.7. MAGI childless adults settlement plan for the rate period from July 2015 to June 2016:
