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Risk adjustment uses information on an enrollee\u2019s medical conditions, as reported in claims data, to predict health care costs and adjust payments to MCOs. Risk adjustment helps ensure payments to MCOs are more equitable and mitigates the impact of selection bias, thus protecting MCO solvency and reducing incentives for plans to avoid high-risk individuals. Risk adjustment is designed to be budget neutral to the State. Routine Care \u2013 basic primary care services including the diagnosis and treatment of conditions to prevent deterioration to a more severe level, or minimize/reduce risk of development of chronic illness or the need for more complex treatment. Service Authorization \u2013 (also Prior Authorization); includes an enrollee\u2019s request for the provision of a service. Skilled Nursing Care \u2013 services from licensed nurses in a enrollee\u2019s own home or in a nursing home. Specialist \u2013 a provider who focuses on a specific kind of health care, such as a surgeon or a cardiologist. Start Date \u2013 the date the Contract for services becomes effective. Subcontract \u2013 any written agreement between the MCO and another party to fulfill any requirements of this Contract. Subcontractor \u2013 party contracting with the MCO to perform any services related to the requirements of this Contract. Subcontractors may include, without limitation, affiliates, subsidiaries, and affiliated and unaffiliated third parties. Subcontractor Monitoring Plan \u2013 a written plan describing how obligations, services, and functions performed by the MCO's Subcontractor will be reviewed to ensure that such obligations, services, and functions are performed to the same extent that they were performed by MCO. Supplemental Security Income (SSI) \u2013 a Federal income supplement program designed to help aged, blind, and disabled people with little or no income by providing cash to meet basic needs for food, clothing, and shelter. Systems Quality Assurance Plan \u2013 a written plan developed by the MCO that describes the processes, techniques, and tools that the MCO will use for assuring that the MCO information systems meet the Contract requirements. Temporary Assistance to Needy Families (TANF) \u2013 the federally funded program that provides assistance to single parent families with children who meet the categorical requirements for aid. Tertiary Services \u2013 highly specialized medical services administered in a specialized medical facility. Third Party \u2013 any individual entity or program which is or may be liable to pay all or part of the expenditures for Medicaid furnished under a State Plan. Title XIX \u2013 refers to Title XIX of the Social Security Act codified at 42 United States Code Annotated Section 1396 et. seq., including any amendments thereto (see Medicaid). Value-Added Services \u2013 services that include additional value benefits that are actual health care services, benefits, or positive incentives that will promote healthy lifestyles and improve health outcomes among enrollees. West Virginia Health Bridge (WVHB) \u2013 the name of West Virginia\u2019s mandatory managed care program for adults eligible for the Medicaid Alternative Benefit Plan (ABP). Withhold Arrangement \u2013 a payment mechanism under which a portion of a Capitation Payment is withheld from an MCO and a portion of or all of the withheld amount will be paid to the MCO for meeting measures specified in the Contract. The measures for a Withhold Arrangement are distinct from general operational requirements under the Contract. Arrangements that withhold a portion of a Capitation Payment for noncompliance with general operational requirements are contractual remedies and not a Withhold Arrangement.", "samples": [{"hash": "cv8T3qfpB9V", "uri": "/contracts/cv8T3qfpB9V#risk-adjustment", "label": "Purchase of Service Provider Agreement", "score": 23.798084259, "published": true}], "hash": "be5909d5c2781324af392c102a26bb3f", "id": 9}, {"snippet_links": [{"key": "defined-in-section", "type": "clause", "offset": [3, 21]}], "size": 1, "snippet": "as defined in Section 2.13.", "samples": [{"hash": "ffvm2eEDy5G", "uri": "/contracts/ffvm2eEDy5G#risk-adjustment", "label": "Credit Agreement (Phreesia, Inc.)", "score": 36.8631074606, "published": true}], "hash": "cf0766b1889ce41eab32dedbb3a0a754", "id": 10}], "next_curs": "ClwSVmoVc35sYXdpbnNpZGVyY29udHJhY3RzcjgLEhpEZWZpbml0aW9uU25pcHBldEdyb3VwX3Y1NiIYcmlzay1hZGp1c3RtZW50IzAwMDAwMDBhDKIBAmVuGAAgAA==", "definition": {"size": 36, "snippet": "means the process by which relative risk factors are assigned to individuals or groups based on expected resource use and by which those factors are taken into consideration and applied.", "title": "Risk adjustment", "id": "risk-adjustment", "examples": ["Notwithstanding the foregoing or anything herein to the contrary, no Reserve, adjustment of eligibility criteria, establishment of new eligibility criteria or adjustment of advance rates made under the Loan Documents (collectively, \u201c<strong>Risk Adjustments</strong>\u201d) shall be duplicative of any other <strong>Risk Adjustment</strong>."], "related": [["\u2587\u2587\u2587\u2587\u2587-adjustment", "\u2587\u2587\u2587\u2587\u2587 Adjustment", "\u2587\u2587\u2587\u2587\u2587 Adjustment"], ["true-up-adjustment", "True-Up Adjustment", "True-Up Adjustment"], ["isda-fallback-adjustment", "ISDA Fallback Adjustment", "ISDA Fallback Adjustment"], ["cpi-adjustment", "CPI Adjustment", "CPI Adjustment"], ["price-adjustment", "Price Adjustment", "Price Adjustment"]], "related_snippets": [], "updated": "2025-11-14T05:31:25+00:00"}, "json": true, "cursor": ""}}