Common use of RATE DEVELOPMENT STANDARDS Clause in Contracts

RATE DEVELOPMENT STANDARDS. i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population. iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populations. iv. In Lieu Of Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers. v. Benefit expenses associated with members residing in an IMD Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an Institution for Mental Diseases (IMD) stay of more than 15 days in a month and any other MCP costs for services delivered in a month when an enrollee had an IMD stay of more than 15 days. These costs were identified and removed from the encounter data. In addition, as noted above we did not use the unit cost of the IMD as an in-lieu-of service, and instead utilized the unit cost for that of existing state plan providers.

RATE DEVELOPMENT STANDARDS. i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs MCOPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of “in lieu of” service for the 21 to 64-year-old population for up to 15 days per month. ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population. iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populations. iv. “In Lieu Of Of” Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of “in lieu of” service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers. v. Benefit expenses associated with members residing in an IMD Effective July 1, 2017, ODM began permitting the use of iv. IMDs as an in-lieu-of “in lieu of” service for the 21 to 64-year-old population for up to 15 days per month. provider We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an Institution for Mental Diseases (IMD) stay with a mental health primary diagnosis of more than 15 days in a month and any other MCP MCOP costs for services delivered in a month when an enrollee had an IMD stay of more than 15 days. These costs were identified and removed from the encounter data. In addition, as noted above we did not use the unit cost of the IMD as an in-lieu-of “in lieu of” service, and instead utilized the unit cost for that of existing state plan providers.

RATE DEVELOPMENT STANDARDS. i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population. iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populations. iv. In Lieu Of Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers. v. Benefit expenses associated with members residing in an IMD Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an a non-substance use disorder (SUD) Institution for Mental Diseases (IMD) stay of more than 15 days in a month and any other MCP costs for services delivered in a month when an enrollee had an a non-substance use disorder IMD stay of more than 15 days. These costs were identified and removed from the encounter data. We included costs and associated member months for members aged 21 to 64 with an SUD primary diagnosis who incurred IMD stays of more than 15 days, due to the presence of ODM’s 1115 SUD IMD waiver. In addition, as noted above we did not use the unit cost of the IMD as an in-lieu-of service, and instead utilized the unit cost for that of existing state plan providers.

RATE DEVELOPMENT STANDARDS. i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population. iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populations. iv. In Lieu Of Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers. v. Benefit expenses associated with members residing in an IMD Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an Institution for Mental Diseases (IMD) stay of more than 15 days in a month and any other MCP costs for services delivered in a month when an enrollee had an IMD stay of more than 15 days. These costs were identified and removed from the encounter data. In addition, as noted above we did not use the unit cost of the IMD as an in-in- lieu-of service, and instead utilized the unit cost for that of existing state plan providers. vi. IMDs as an in lieu of service provider Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month.

RATE DEVELOPMENT STANDARDS. i. Final Capitation Rate Compliance The final capitation rates are in compliance with 42 CFR 438.4(b)(6) and are only based on services outlined in 42 CFR 438.3(c)(1)(ii) and 438.3(e). Non-state plan services provided by the MCPs MCOPs have been excluded from the capitation rate development process. Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. ii. Basis for Variation in Assumptions Any assumption variation between covered populations is the result of program differences and is in no way based on the rate of federal financial participation associated with the population. iii. Benefit Cost Trend Assumptions Projected benefit cost trend assumptions are developed in accordance with generally accepted actuarial principles and practices. The primary data used to develop benefit cost trends is historical claims and enrollment from the covered populationspopulations as well as from the MyCare Opt-Out program. iv. In Lieu Of Services As noted earlier, ODM began permitting the use of IMDs as an in-lieu-of service effective July 1, 2017. Consistent with the rate-setting guidance published by CMS, in reviewing the impact of this program adjustment we did not use the unit cost of the IMD, and instead utilized the unit cost for that of existing state plan providers. v. Benefit expenses associated with members residing in an IMD Effective July 1, 2017, ODM began permitting the use of IMDs as an in-lieu-of service for the 21 to 64-year-old population for up to 15 days per month. We reviewed benefit costs for enrollees aged 21 to 64 during the base experience period to identify costs associated with an Institution for Mental Diseases (IMD) stay with a mental health primary diagnosis of more than 15 days in a month and any other MCP MCOP costs for services delivered in a month when an enrollee had an IMD stay of more than 15 days. These costs were identified and removed from the encounter data. In addition, as noted above we did not use the unit cost of the IMD as an in-lieu-of service, and instead utilized the unit cost for that of existing state plan providers.