Risk Adjustment. A methodology to account for the health status of Members via relative risk factors when predicting or explaining costs of services covered under the contract for defined populations or for evaluating retrospectively the experience of Contractor. Must be developed in a budget neutral manner consistent with generally accepted actuarial principles and practices.
Risk Adjustment. The MCO SNP will notify the STATE or its actuarial firm of its restated mid-year HCC risk adjustment score and additional HCC Frailty factor score for MSHO. Scores will be from restated data based upon the preceding calendar year as reported by CMS. The MCO SNP will send this information to the STATE, or its actuaries, within thirty (30) days of CMS making it available to the MCO. The actuarial firm may share information about the risk score with the STATE, but the STATE will not receive copies of this information. The MCO must identify this information as trade secret prior to, or at the time of its submission for the STATE to consider classifying it as non-public, as described in section 9.6. HOS Health Outcomes Survey. By October 15th of each Contract Year, or within thirty (30) days of availability, the MCO will provide the STATE the current HOS report for MSHO submitted to CMS. Quality Assurance Materials. Information as specified in Article 7 on Quality Assessment and Performance Improvement.
Risk Adjustment. An actuarial tool used to calibrate premiums paid to Health Benefits Plans or carriers based on geographical differences in the cost of health care and the relative differences in the health risk characteristics of Enrollees enrolled in each plan. Risk adjustment establishes premiums, in part, by assuming an equal distribution of health risk among Health Benefits Plans in order to avoid penalizing Enrollees for enrolling in a Health Benefits Plan with higher than average health risk characteristics.
Risk Adjustment. The STATE agrees to apply risk adjustment of capitation rates as follows using the Chronic Disability Payment System (CDPS; see xxxx://xxxx.xxxx.xxx/) and the Medicaid Rx risk adjustment model (collectively, “CDPS+Rx”) with Minnesota- specific custom weights to calculate risk scores.
Risk Adjustment. 7.4.1 Capitation rates calculated under this Agreement will be adjusted in accordance with the Chronic Illness and Disability Payment System (―CDPS‖) using the CDPS + Rx version 5.2 and standard weights. The version of the risk adjustment tool will not be modified during a calendar year, but will be updated annually with the most recent version publicly available. In order for an Enrollee’s individual claims data to be the basis for a risk adjustment score hereunder, such Enrollee must have been enrolled in the State Medicaid Program (i.e. either managed care or Fee- For-Service) for at least six (6) full months during the time period from which claims data are used to calculate the adjustment. In the event an Enrollee has not been enrolled in the State Medicaid Program for at least six (6) full months, then such Enrollee shall receive a risk score equal to Contractor’s average risk score. The risk scores shall be established for each MCO by rate cell. The risk scores will be established using a credibility formula for each MCO and rate cell. The credibility formula to be used will be determined by an independent actuary. All diagnoses codes submitted by Contractor shall be included in calculations of risk scoring irrespective of placement of such diagnoses codes in the encounter records. Encounter records may not be supplemented by medical record data. Diagnosis codes may only be recorded by the Provider at the time of the creation of the medical record and may not be retroactively adjusted except to correct errors. A significant increase in risk scores by an MCO may warrant an audit of the diagnosis collection and submission methods.
Risk Adjustment. Recipients must seek approval to commence specific tasks associated with risk adjustment. Recipients must submit plans to carry out tasks related to risk adjustment to your Project Officer for review and approval prior to commencing activities.
Risk Adjustment. The rates effective during the January through June 2022 rate period will initially be risk adjusted based on a methodology that utilizes the most recent available data and concurrent disease weights. The risk adjustment diagnosis data will exclude diagnosis codes associated with diagnostic testing and certain medical supply codes. The MMC program will be risk adjusted using CDPS+Rx risk scoring models. Risk adjustment is performed on a budget neutral basis at the region and rate cell level. Newborns, one-year-olds, and delivery kick payments will be excluded from the risk adjustment process. Along with HIC Franchise Fee and tax amounts, amounts attributable to CICIP and the Hospital Additional Payment will be excluded from the risk adjustment process. Risk scores will be applied to the capitation rates less these amounts. We will then apply CICIP amounts along with MCP-specific HIC Franchise Fee and tax amounts to the normalized rates on a budget neutral basis. HAP amounts will be paid on a separate payment term. Following the completion of the rating period, we anticipate revising the interim January through June 2022 risk adjusted rates to utilize relative risk scores derived from an updated concurrent risk adjustment analysis. We anticipate the January 1, 2021 through December 30, 2021 period to continue to be risk adjusted using an experience period concurrent with the rating period.
Risk Adjustment. Aged, Blind, and Disabled Risk adjustment will be applied to the ABD population using CDPS + Rx. Risk adjustment is performed on a budget neutral basis at the region level, separately between disabled children (under age 21) and adults (age 21+). The risk adjustment methodology is consistent with the January 1, 2016 through June 30, 2016 rate period. The July 1, 2016 through December 31, 2016 rate period will be risk adjusted based on a diagnosis and prescription drug collection period based on incurred (dispensed) dates from July 1, 2014 through June 30, 2015. Consistent with the January 1, 2016 through June 30, 2016 rate period, the risk adjustment diagnosis base will exclude diagnosis codes associated with diagnostic testing and certain medical supply codes. Extension Risk adjustment will be applied to the Extension population using CDPS + Rx. Risk adjustment is performed on a budget neutral basis at the region and rate cell level. The risk adjustment methodology will vary from the January 1, 2016 through June 30, 2016 rate period due to the usage of CDPS + Rx rather than Medicaid Rx. We believe that moving the diagnosis collection period forward six months will allow for a sufficient number of Extension beneficiaries to meet the requirements for being a ‘scored’ member (three months of Medicaid eligibility during the collection period). No other changes will be made to the risk adjustment methodology. The July 1, 2016 through December 31, 2016 rate period will be risk adjusted based on a diagnosis and prescription drug collection period based on incurred (dispensed) dates from July 1, 2014 through June 30, 2015. Consistent with the ABD risk adjustment methodology, the risk adjustment diagnosis base will exclude diagnosis codes associated with diagnostic testing and certain medical supply codes. CFC Historically, the CFC population has not been risk adjusted using a diagnosis or pharmaceutical-based methodology. The calendar year 2016 capitation rates for CFC will not be risk-adjusted beyond rate cell, Hepatitis C risk pool, and the maternity delivery kick payment.
Risk Adjustment. States must seek approval to commence specific tasks associated with risk adjustment. Please submit plans to carry out tasks related to risk adjustment to your Project Officer for review and approval prior to commencing activities.
Risk Adjustment. For the final payment rate, the county rate for the PO is multiplied by the individual participant risk score. Risk adjustment allows CMS to pay plans for the risk of the beneficiaries they enroll, instead of an average amount for Medicare beneficiaries. The individual participant risk score for Medicare Advantage and PACE is calculated using a CMS–HCC model (community, long-term institutionalized, End-Stage Renal Disease (ESRD) or new enrollee), which is published in the annual Announcement of Calendar Year Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter (Rate Announcement). Section 1894(d)(2) of the Act requires CMS to take into account the frailty of the PACE population when making payments to POs. Therefore, a frailty factor is added to each individual’s risk score for PACE payment. Risk adjustment predicts (or explains) the future Medicare expenditures of individuals based on diagnoses and demographics. Because risk adjustment may not explain all of the variation in expenditures for frail community populations, the frailty adjustment is used to predict the Medicare expenditures of community populations with functional impairments. The frailty score added to the beneficiary’s risk score is calculated at the contract-level, using the aggregate counts of ADLs among HOS-M survey respondents enrolled in a specific organization who responded to the survey the prior year. More information regarding the HOS-M can be found in section 10.30 in Chapter 10 of the PACE manual chapter, Quality Assessment and Performance Improvement, located online at: xxxxx://xxx.xxx.xxx/Regulations-and- Guidance/Guidance/Manuals/downloads/pace111c10.pdf Because the CMS-HCC model adequately predicts the costs of beneficiaries under age 55 or who are among the long-term institutionalized population, frailty adjustments are added to the risk scores for community-based and short-term institutionalized enrollees aged 55 and older. Updated frailty factors are published in the Rate Announcement for the payment year in which they are first used.
