Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the baseline outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State law or policy; and changes in coding intensity.
Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Changes to the Medicare baselines (and therefore the corresponding payment rate) outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State determine the change is necessary to calculate accurate payment rates for the Demonstration. For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes may be based on the following factors: shifts in enrollment assumptions; major changes or discrepancies in Federal law and/or State policy compared to the assumptions about Federal law and/or State law or policy used in the development of baseline estimates; and changes in coding intensity. CMS and/or the State will make changes to baseline estimates after identification of the need for such changes, and changes will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month.
Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Updates to the Medicare portion of the capitated rate will take place on January 1st of each calendar year, while updates to the Medicaid portion of the rate will occur at the beginning of the state fiscal year, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates will take place at least once each Texas state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the THTQIP 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in the Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline (and therefore to the corresponding payment rate) outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. For changes solely affecting the Medicare program baseline, CMS will consult with the State prior to making any adjustment, but State concurrence will not be required. Changes outside the annual rate update process may be based on the following factors: shifts in enrollment assumptions, major changes in federal law and/or state law or policy compared to assumptions about federal law and/or state law or policy used in the development of baseline estimates, changes in coding intensity. CMS and/or the State will make changes to baseline estimates after the need for such change is identified, and changes will be applied, if necessary on a retrospective basis, to effectuate accurate payment rates for each month.
Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. Rate updates will take place on January 1st of each calendar year for the Medicare components of the rates, with changes to savings percentages applicable on a Demonstration Year basis. Rate updates for the Medicaid component of the rates will take place at least once each California state fiscal year and may be more often as necessary to match adjustments made to the Medicaid capitation rates in the contracts that support the 1115(a) demonstration program that would apply for beneficiaries in the target population who do not enroll in this Demonstration. Adjustments to the Medicaid component of the rates may be done retroactively, if necessary to match the Medicaid baseline rates. Changes to the baseline outside of the annual Medicare Advantage rate announcement and/or typical Medicaid rate adjustment process would occur only if and when CMS and the State jointly determine the change is necessary to calculate reasonable, appropriate, and attainable payment rates for the Demonstration. Such changes may be based on, the following factors: shifts in enrollment assumptions; changes due to litigation; changes in Federal law and/or State policy; changes in coding intensity, and other factors as determined appropriate and approved by CMS and the State.
Payments in Future Years and Mid-Year Rate Adjustments. A. Rates will be updated using a similar process for each calendar year. The Medicaid rate will be updated annually applying the risk adjustment methodology described in V to the most updated estimate of the enrolled population for a given year, and to apply that year’s savings and quality withhold percentages along with an updated estimate of Medicaid trend. The Medicare rate will be updated with the annual adjustments to Medicare baseline rates, yearly savings and quality withholds. Other changes to the Medicare and Medicaid baselines outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the State jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State policy; and changes in coding intensity.
Payments in Future Years and Mid-Year Rate Adjustments. Rates will be updated using a similar process for each calendar year. Changes to the Medicare and Medicaid baselines outside of the annual Medicare Advantage rate announcement would occur only if and when CMS and the Commonwealth jointly determine the change is necessary to calculate accurate payment rates for the Demonstration. Such changes may be based on the following factors: shifts in enrollment assumptions; major changes in Federal law and/or State policy; and changes in coding intensity. If Congress acts to delay or replace the Sustainable Growth Rate (SGR) formula used to adjust Medicare physician payment rates, CMS will adjust the Medicare baseline for beneficiaries who otherwise would have been enrolled in Original Fee-for-Service Medicare to reflect the revised current law physician payment rates. If Congress acts after the SGR cuts are scheduled to go in effect but applies changes retroactively, CMS will adjust the rates retroactively as well. If other statutory changes enacted after the annual baseline determination and rate development process are jointly determined by CMS and the Commonwealth to have a material change in baseline estimates for any given payment year, baseline estimates and corresponding standardized payment rates shall be updated outside of the annual rate development process.
