STAR and STAR+PLUS Capitation Structure Clause Samples

STAR and STAR+PLUS Capitation Structure. (a) STAR Rate Cells. STAR Capitation Rates are defined on a per Member per month basis by Rate Cells and Service Areas. STAR Rate Cells are: (1) Under Age 1 Child; (2) Age 1-5 Child; (3) Age 6-14 Child; (4) Age 15-18 Child; (5) Age 19-20 Child; (6) TANF adults; (7) Pregnant women; and (8) SSI (applies to the Medicaid Rural Service Area only). These Rate Cells are subject to change. (b) STAR+PLUS Rate Cells. STAR+PLUS Capitation Rates are defined on a per Member per month basis by Rate Cells. STAR+PLUS Rate Cells are based on client category as follows: (1) Medicaid Only Standard Rate (2) Medicaid Only HCBS STAR+PLUS Waiver Rate - Above Floor (3) Medicaid Only HCBS STAR+PLUS Waiver Rate - Below Floor (4) Dual Eligible Standard Rate (5) Dual Eligible HCBS STAR+PLUS Waiver Rate - Above Floor (6) Dual Eligible HCBS STAR+PLUS Waiver Rate - Below Floor (7) Nursing Facility - Medicaid only (8) Nursing Facility - Dual Eligible These Rate Cells are subject to change. (c) STAR and STAR+PLUS Capitation Rate development: (1) Capitation Rates for Service Areas with historical Medicaid MCO Program participation. For Service Areas where HHSC operated a Medicaid MCO Program prior to the Effective Date of this Contract, HHSC will develop base Capitation Rates by analyzing the Medicaid MCO Program's historical Encounter Data and financial data for the Service Area (e.g., Capitation Rates for the STAR Program will be based on STAR Program historical Encounter Data and financial data for the Service Area). This analysis will apply to all MCOs in the Service Area, including MCOs that have no historical participation in the Medicaid MCO Program in Service Area. The analysis will include a review of historical enrollment and claims experience information; any changes to Covered Services and covered populations; rate changes specified by the Texas Legislature; and any other relevant information. If the MCO participated in the Medicaid MCO Program in the Service Area prior to the Effective Date of this Contract, HHSC may modify the Service Area base Capitation Rates using diagnosis-based risk adjusters to yield the final Capitation Rates. (2) Capitation Rates for Rate Periods 1 and 2 for Service Areas with no historical STAR Program participation. For Service Areas where HHSC has not operated a Medicaid MCO Program prior to the Effective Date of this Contract, HHSC will establish base Capitation Rates for Rate Periods 1 and 2 by analyzing Fee-for-Service claims data for the Medica...