Credibility Adjustment. An adjustment to the Medical Loss Ratio (MLR) provided by the Contractor in accordance with 42 C.F.R. § 438.8 to account for a difference between the actual and target MLR that may be due to random statistical variation.
Credibility Adjustment. The MMC program, as represented in the base experience, was fully credible. No adjustments were made for credibility.
Credibility Adjustment. In total, the statewide MyCare Opt-In program experience was fully credible. While we did not apply an explicit credibility adjustment to the data, we did develop the Opt-In capitation rates at the region and rate cell level. To mitigate any credibility concerns at the regional level and to preserve potentially proprietary MCOP information in regions where only two MCOPs are present, we developed factors to stratify the statewide Opt-In experience into regional summaries. These factors were primarily informed by the combined CY 2019 Opt-Out and Opt-In encounter data.
Credibility Adjustment i. A PAHP may add a credibility adjustment to a calculated MLR if the MLR reporting year experience is partially credible. The credibility adjustment is added to the reported MLR calculation before calculating any remittances, if required by the State as described in paragraph (j) of this section.
Credibility Adjustment. Contractor may add a credibility adjustment to a calculated MLR if the MLR reporting year experience is partially credible. The credibility adjustment must be added to the reported MLR calculation before calculating any remittances. Contractor may not add a credibility adjustment to a calculated MLR if the MLR reporting year experience is fully credible. If Contractor’s experience is non-credible, it is presumed to meet or exceed the MLR calculation standards in this section. On an annual basis, CMS will publish base credibility factors for MCOs, PIHPs, and PAHPs that are developed according to the following methodology:
Credibility Adjustment. In total, the MyCare Opt-Out program experience was fully credible; however due to credibility concerns at the region and population level, we developed regional and population factors that were primarily informed by the CY 2016 encounter data. The base CY 2016 cost report data by major population grouping (Institutional, Community Waiver, and Community Well) was adjusted and stratified by population (including age ranges) based on observed relativities in the encounter data. On a program-wide basis, the application of the regional and population adjustment factors maintains budget neutrality of the base data experience.
Credibility Adjustment. If the contractor has few enrollees, there may not be complete confidence in the contractor's relative case mix produced by the limited number of enrollees. In this case, a credibility rating can be used to blend the contractor's case rate with the State's average case rate. For example, if the State assigns a contractor a case mix credibility of fifty (50) percent, the following formula is used to develop a case mix rate for the contractor:
Credibility Adjustment. Combining of Opt-In and Opt-Out cost report data and Selection Adjustments CY 2015 Opt-Out cost report data was combined with corresponding Opt-In MyCare Ohio Medicaid cost report data because the Opt-Out data alone was not fully credible for certain populations and most categories of service. Smoothing by region The CY 2015 cost report data was considered fully credible by population on a statewide basis following resolution of the data anomalies identified in Section 2.A.ii(c). However, regional adjustments were developed from aggregation of multiple data sources to improve credibility and to protect the proprietary nature of the cost report data due to the limited number of MCOPs which participate in each region. The application of the regional adjustments to the CY 2015 base experience data was normalized to a 1.000 statewide basis using August 2016 Opt-In and Opt-Out combined enrollment.
Credibility Adjustment. For each MLR calculation:
Credibility Adjustment. 7.10.6.1 Contractor may add a credibility adjustment, in accordance with 42 CFR 438.8(h), to a calculated MLR if the MLR reporting year experience is partially credible.
