Common use of STAR and STAR+PLUS Capitation Structure Clause in Contracts

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 Medicaid MCO Program and Service Area (e.g., Capitation Rates for the STAR Program will be based fee-for-service data in the Service Area). This 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. (3) Capitation Rates for subsequent Rate Periods 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 the Rate Periods following Rate Period 2 by analyzing the Medicaid MCO Program's historical Encounter Data and financial data for the Service Area. This 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. (d) Acuity adjustment. HHSC may evaluate and implement an acuity adjustment methodology, or alternative reasonable methodology, that appropriately reimburses the MCO for acuity and cost differences that deviate from that of the community average, if HHSC in its sole discretion determines that such a methodology is reasonable and appropriate. The community average is a uniform rate for all MCOs in a Service Area, and is determined by combining all the experience for all MCOs in a Service Area to get an average rate for the Service Area. (e) Value-added Services. Value-added Services will not be included in the rate-setting process. (f) Delay in Increased STAR+PLUS Capitation Level for Certain Members Receiving Waiver Services. Once a current STAR+PLUS MCO Member has been certified to receive STAR+PLUS Waiver (SPW) services, there is a two (2) month delay before the MCO will begin receiving the higher capitation payment. Non-Waiver Members who qualify for STAR+PLUS based on eligibility for SPW services and Waiver recipients who transfer from another region will not be subject to this two (2) month delay in the increased capitation payment. All SPW recipients will be registered into Service Authorization System Online (SASO). The Premium Payment System (PPS) will process data from the SASO system in establishing a Member's correct capitation payment.

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 Eligible (9) Individuals with Developmental Disabilities (IDD) - under age 21 (10) Individuals with Developmental Disabilities (IDD) - age 21 and older 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 Medicaid MCO Program and Service Area (e.g., Capitation Rates for the STAR Program will be based fee-for-service data in the Service Area). This 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. (3) Capitation Rates for subsequent Rate Periods 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 the Rate Periods following Rate Period 2 by analyzing the Medicaid MCO Program's historical Encounter Data and financial data for the Service Area. This 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. (d) Acuity adjustment. HHSC may evaluate and implement an acuity adjustment methodology, or alternative reasonable methodology, that appropriately reimburses the MCO for acuity and cost differences that deviate from that of the community average, if HHSC in its sole discretion determines that such a methodology is reasonable and appropriate. The community average is a uniform rate for all MCOs in a Service Area, and is determined by combining all the experience for all MCOs in a Service Area to get an average rate for the Service Area. (e) Value-added Services. Value-added Services will not be included in the rate-setting process. (f) Delay in Increased STAR+PLUS Capitation Level for Certain Members Receiving Waiver Services. Once a current STAR+PLUS MCO Member has been certified to receive STAR+PLUS Waiver (SPW) services, there is a two (2) month delay before the MCO will begin receiving the higher capitation payment. Non-Waiver Members who qualify for STAR+PLUS based on eligibility for SPW services and Waiver recipients who transfer from another region will not be subject to this two (2) month delay in the increased capitation payment. All SPW recipients will be registered into Service Authorization System Online (SASO). The Premium Payment System (PPS) will process data from the SASO system in establishing a Member's correct capitation payment.

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 ChildTANF adults; (2) Age 1-5 ChildTANF children over 12 months of age; (3) Age 6-14 ChildExpansion children over 12 months of age; (4) Age 15-18 ChildNewborns less than or equal to 12 months of age; (5) Age 19-20 ChildTANF children less than or equal to 12 months of age; (6) TANF adultsExpansion children less than or equal to 12 months of age; (7) Federal mandate children; (8) Pregnant women; and (8) 9) 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 1915 (c) Nursing Facility Waiver Rate - – Above Floor (3) Medicaid Only HCBS STAR+PLUS 1915 (c) Nursing Facility Waiver Rate - – Below Floor (4) Dual Eligible Standard Rate (5) Dual Eligible HCBS STAR+PLUS 1915(c) Nursing Facility Waiver Rate - – Above Floor (6) Dual Eligible HCBS STAR+PLUS 1915(c) Nursing Facility 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 ’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 Medicaid MCO Program and Service Area (e.g., Capitation Rates for the STAR Program will be based fee-for-service data in the Service Area). This 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. (3) Capitation Rates for subsequent Rate Periods 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 the Rate Periods following Rate Period 2 by analyzing the Medicaid MCO Program's ’s historical Encounter Data and financial data for the Service Area. This 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. (d) Acuity adjustment. HHSC may evaluate and implement an acuity adjustment methodology, or alternative reasonable methodology, that appropriately reimburses the MCO for acuity and cost differences that deviate from that of the community average, if HHSC in its sole discretion determines that such a methodology is reasonable and appropriate. The community average is a uniform rate for all MCOs in a Service Area, and is determined by combining all the experience for all MCOs in a Service Area to get an average rate for the Service Area. (e) Value-added Services. Value-added Services will not be included in the rate-setting process. (f) Delay in Increased STAR+PLUS Capitation Level for Certain Members Receiving Waiver Services. Services Once a current STAR+PLUS MCO Member has been certified to receive STAR+PLUS Waiver (SPW) services, there is a two (2) month delay before the MCO will begin receiving the higher capitation payment. Non-Waiver Members who qualify for STAR+PLUS based on eligibility for SPW services and Waiver recipients who transfer from another region will not be subject to this two (2) month delay in the increased capitation payment. All SPW recipients will be registered into Service Authorization System Online (SASO). The Premium Payment System (PPS) will process data from the SASO system in establishing a Member's ’s correct capitation payment.