Common use of PMPM Clause in Contracts

PMPM. An illustrative example of the calculation for (B) is shown below, with the “Hypothetical SFY20 MMs Estimate” being based on statewide SFY18 MMs for illustrative purposes: llustrative Example COA Hypothetica l SFY20 MMs NF CRR PMPM Estimate Total Expenditur e Estimate Custodial Care Nursing Facility <65 20,704 $40.77 $844,102 Custodial Care Nursing Facility 65+ 119,686 $40.77 $4,879,598 Non-Dual Skilled Nursing Facility 1,786 $40.77 $72,815 $5,796,516 In this example, (B) would be $5,796,516; this total dollar amount will vary depending upon the actual SFY20 MMs for these cohorts for each of the MCOs. The State will calculate a value (C) = (A) – (B), which represents how much more or less was paid for the NF CRR payments than originally estimated. If the amount (C) is within a +/-1% band of the original estimate (B) then no risk corridor payment will be made. In this example, the band for which (C) must fall in order for no risk corridor payment to take place is a value of (C) that is between -$57,965 and $57,965. MED-20-001 Any difference (C) in costs between actual utilization (A) and the original estimate (B) outside the 1% band would result in a payment to or from the State of the amount by which (C) exceeds 1% of (B) or falls below -1% of (B). The reconciliation will consist of the State paying the MCO a risk corridor settlement in the case of actual utilization (A) exceeding the original estimates

PMPM. An illustrative example of the calculation for (B) is shown below, with the “Hypothetical SFY20 MMs Estimate” being based on statewide SFY18 MMs for illustrative purposes: llustrative Example COA Hypothetica l Hypothetical SFY20 MMs Estimate NF CRR PMPM Estimate Total Expenditur e Expenditure Estimate Custodial Care Nursing Facility <65 20,704 $40.77 $844,102 Custodial Care Nursing Facility 65+ 119,686 $40.77 $4,879,598 Non-Dual Skilled Nursing Facility 1,786 $40.77 $72,815 $5,796,516 In this example, (B) would be $5,796,516; this total dollar amount will vary depending upon the actual SFY20 MMs for these cohorts for each of the MCOs. The State will calculate a value (C) = (A) – (B), which represents how much more or less was paid for the NF CRR payments than originally estimated. If the amount (C) is within a +/-1% band of the original estimate (B) then no risk corridor payment will be made. In this example, the band for which (C) must fall in order for no risk corridor payment to take place is a value of (C) that is between -$57,965 and $57,965. MED-20MED-16-001 018 Any difference (C) in costs between actual utilization (A) and the original estimate (B) outside the 1% band would result in a payment to or from the State of the amount by which (C) exceeds 1% of (B) or falls below -1% of (B). The reconciliation will consist of the State paying the MCO a risk corridor settlement in the case of actual utilization (A) exceeding the original estimates