AZ
"37. COMPENSATION...
KidsCare Capitation: … KidsCare
capitation rates will be set by AHCCCSA in conjunction with an independent
actuary. Following CYE 99, AHCCCSA will review the assumptions made
in setting the capitation rates and may, at its option, reconcile and/or
adjust the rates." Arizona Contract, pages 39-40.
"64. KIDSCARE...
Capitation rates payable
to the Contractor for KidsCare members (age 18 and younger) will be set
by AHCCCSA in conjunction with an independent actuary." Arizona Contract,
page 54.
AZBH
"ADHS shall provide AHCCCSA with documentation relevant to the capitation rate calculation and is responsible for developing capitation rates to be paid by AHCCCSA for Title XIX and Title XXI members. ADHS must submit proposed capitation rates and supporting documentation to AHCCCSA no later than August 1 each year." Arizona Behavioral Health Contract, page 27.
"Prospective Capitation Adjustment
AHCCCSA reserves the right
to re-evaluate capitation rates up to four times per year. AHCCCSA
will review the capitation rates by subcontracted RBHA for the Title XIX
and Title XXI programs. AHCCCSA may make retrospective and prospective
adjustments to the capitation rates…and for the Title XXI program for a
gain or loss of more than 5% for the subcontracted RBHAs combined."
Arizona Behavioral Health Contract, Attachment E, page D-1.
CA
"5.4 CAPITATION RATES CONSTITUTE
PAYMENT IN FULL...
The actuarial basis for
the determination of the capitation payment rates is outlined in Attachment
I (consisting of ___ pages).
5.5 DETERMINATION OF RATES...
DHS reserves the right to
redetermine rates on an actuarial basis or move to a negotiated rate for
each rate year...
If DHS redetermines rates on an actuarial basis, DHS shall determine whether the rates shall be increased, decreased, or remain the same." California Contract, pages 62-63.
"ATTACHMENT 1
CAPITATION RATE DEVELOPMENT
PROCESS...
The rate development process
for this Contract consists of two separate calculations. First, a
Fee-For-Service equivalent (FFSE) is determined for the entire group of
Medi-Cal eligibles. Second, rates are calculated for each Contract
by beneficiary aid code using historical Medi-Cal managed care data.
The name given this latter method is an experienced based methodology.
Both the FFSE and experience based methodologies use factors which directly
influence the cost of providing health care to Medi-Cal beneficiaries.
These factors are age, sex, geographic area with price indices, Medi-Cal
aid code, and eligibility for Medicare. The rate methodologies also
employ adjustments for changes that are likely to occur during the term
of the Contract. These adjustments include fee, benefit, or policy
changes to reflect changes to the Medi-Cal program that are mandated each
year by the State Legislature and the use of a trend factor to project
costs to the term of the Contract.
Actuaries employed by the Department of Health Services conduct the rate development process for this Contract. This attachment presents the methodology and calculation of the capitation rates for this Contract." California Contract, page 144.
CO
"V. COSTS AND REIMBURSEMENT…"
Colorado Contract, page 20.
5. Rate Calculation
1. The Monthly Prepayment
Rates set forth in Exhibit B are calculated based on the following:
Step 1 The fee-for-service expenditures are accumulated through the Medicaid management information system (MMIS) by date of service and age and sex groupings by eligibility category for all fee-for-service Members. These expenditures are further separated by category of service, i.e., inpatient hospital, outpatient hospital...
Step 2 The fee-for-service expenditure base is inflated to adjust for the expected increase in cost and utilization between the base expenditure fiscal year and the next contract period fiscal year.
Step 3 The impact of any significant prospective financial event such as rate increases or lawsuits shall be calculated and applied to the fee-for-service expenditure base. If a Federally Qualified Health Center is a Participating Provider, then Projected expenditures for Federally Qualified Health Centers shall be included in the base to assure that the Contractor receives the reasonable costs for Clients who receive primary care services through the FQHC...
Step 4 The fee-for-service eligibles are calculated by taking the total eligibles by demographic grouping for each category of assistance and subtracting the Medicaid Clients enrolled in managed care organizations. These numbers are then inflated for the expected case mix growth.
Step 5 The per capita fee-for-service expenditures by demographic grouping for each category of assistance is calculated by dividing the fee-for-service expenditures by the fee-for-service eligibles.
Step 6 The maximum allowable rate is calculated by multiplying the average adjusted fee-for-service per capita cost by ninety-five (95%) percent.
Step 7 The maximum allowable rate for each category of assistance may be inflated for administration.
B. Risk Adjustment
for Contractor’s Members
1.The Department shall utilize
a risk-adjustment payment mechanism for capitation payments to Contractors
for services provided to Members as described in Exhibit C. Capitation
payments may be adjusted during the performance period of this Contract
to reflect changes in the Contractor’s actual case mix, pursuant to an
executed bilateral change order, upon approval of the State Controller
or such assistant as he or she may designate." Colorado Contract,
pages 22-23.
FLMH
"4.11 Payment...
The rates to be paid under
the resulting contract shall not exceed Medicaid's upper payment limit
, which is that amount which would have been paid, on aggregate basis,
by Medicaid under fee-for-service for the same services to a demographically
similar population of recipients. The agency will ensure this by
setting the range of rates at which it will make payment at 92 to 98 percent
of the upper payment limit. The proposer, in its rate proposal, will
indicate the percent within this range that it will accept as its capitation
payment...
The capitation rates to be paid have been developed using historical rates paid by Medicaid fee-for-service for similar services in the same demographic area, adjusted for inflation, where applicable. Capitation rates will be banded for the AFDC population (including OBRA children and foster children) and, separately, for the SSI Without Medicare population. The capitation rate setting methodology and the capitation rates (the upper payment limits) applicable to each authorized eligibility group to be paid shall be based on actual monthly enrollment for each of the four eligibility categories as indicated in Attachment 14...
4.15 Rate Adjustments...
The agency shall retrospectively
adjust the capitation rates semi-annually for targeted case management
and OBRA children's services when the initial capitation payment is determined
by the agency to be unreasonably high or low when compared to more recent
fee-for-service utilization data in a demographically similar area
of the state.
The agency shall also adjust capitation rates to reflect budgetary changes in the Medicaid fee-for-service program..." Florida Mental Health RFP, pages 54-56.
HIBH
"SECTION 50 ACTUARIAL
ADJUSTMENTS
50.100 Data to be
Provided
Historical utilization data
and demographic data for the members in the existing
QUEST and ABD populations
shall be provided to the BHMC plan… Each offeror is solely responsible
for the research, preparation and documentation of its capitated rate calculations.
50.200 QUEST Rate Adjustments
The BHMC plan should make
at a minimum the following adjustments to the data to derive its capitated
rates:
• Aged, blind and
disabled
QUEST will specifically
include only select ABD members...
• Lack of Medicaid
Providers...
• Changes in Utilization
Under a Managed Care System
Because the historical utilization
data for the ABD is based on a fee-for-service system. the BHMC plan should
evaluate any changes in utilization of services that could occur under
its managed care system...
• Prescription Drugs
For purposes of the rate
calculation, the BHMC plan shall use the prescription drugs currently covered
by the Medicaid fee-for-service program.
• New Services
Some of the services are
not currently covered under the Medicaid Program and may not be reflected
in the utilization data provided. The plan shall estimate usage of the
services and note its assumptions on the Appendix M forms.
• State Hospital...
The plan shall estimate
usage under inpatient mental health services and note its assumptions on
the Appendix M forms." Hawaii Behavioral Health RFP, pages 64-65.
"90.200 Actuarial Data
Actuarial or other assumptions
used in the calculation of the capitated rates shall be described in this
section of the proposal. The utilization data should include information
on the average number of services provided, average number of members requiring
the services, and any other utilization data relied upon to calculate the
capitated rates. Examples include the average number of psychiatric inpatient
hospital days, average number of psychiatrist visits, average number of
members requiring detoxification services, etc..." Hawaii Behavioral
Health RFP, page 103.
IA
"II. OVERVIEW OF RATE
SETTING METHODOLOGY...
Calculation of the SFY 2000
HMO rate setting was based on program and policy adjustments and trend
adjustments applied to the analysis performed in setting the SFY 1999 rates.
The basis for the capitation rates is FFS experience from SFY 1995 with
the exception of the newborn population (Age 0-59 days) which is derived
from SFY 1997 FFS data.
Trend adjustments were applied based on research derived in the M&R Health Cost Index Database (HCID) and information supplied by DHS. Trend adjustments applied to the SFY 1997 Upper Payment Limit (UPL) and capitation rates are shown in Section IV of this report...
IV. DESCRIPTION OF
SFY 2000 HMO RATE CALCULATIONS
The following section describes
the steps used to calculate the SFY 2000 HMO capitation rates.
The Health Care Financing
Administration (HCFA) requires that capitation payments to HMOs for Medicaid
eligibles may not exceed the Upper Payment Limit (UPL), which represents
the cost of providing services to an actuarially equivalent population
in a FFS program.
1. Trend Adjustments
To calculate the SFY 2000
UPL, utilization and price trend adjustments were made to the SFY 1999
UPL. Utilization trend adjustments for adjusting the base data from
SFY 1999 to SFY 2000 were made based on reference to historical trends
and utilization trends as calculated by the M&R Health Cost Index Database
(HCID)...
2. Calculate SFY 2000
Capitation Rates
In order to ensure a savings
to the Medicaid program, the UPLs were reduced by 3.00%. Next, an
adjustment was made for practice pattern differences between fee-for-service
enrollees and HMO enrollees for mental health services. In recognition
of the additional screening and related services provided by HMOs, an adjustment
has been made..." Iowa Contract, Addendum XII, pages 2, 5-6.
IABH
"33.1 CAPITATION PAYMENT
FOR MEDICAID ENROLLEES...
Medicaid rates will be adjusted
on July 1, 1999, pursuant to attachments titled 'Distribution Medicaid
and Capitation Payment for Mental Health and Substance Abuse Services.'
Medicaid capitation rates will be actuarial adjusted by DHS if additional
services or populations are added by the DHS or if any services or populations
are excluded from the scope of services. DHS and the Contractor will
negotiate operational changes necessary to implement adjustments in services
or populations." Iowa Behavioral Health Contract, page 19.
KS
"KANSAS ADMINISTRATIVE REGULATIONS
Delivery of Managed Care
30-5-174. Delivery
of managed care...
(c) Each capitated
managed care contractor shall be reimbursed at a rate set by the secretary
on an actuarially sound basis..." Kansas Contract,
Appendix L.
KY
"ATTACHMENT B...
On or before December
3 1, 2000 the rate for KCHIP recipients will be retroactively adjusted
for the period January 31, 2000 through June 30, 2000 by DMS. The Department
shall recoup the difference between KCHIP capitation payments made and
the actual cost incurred by IJHC on behalf of these recipients. The actual
cost shall be determined by the Department's actuaries through analysis
of an extract of encounter records submitted by the contractor. This analysis
shall include consideration of such factors as IBNR's subcapitation and
proportionate administrative costs. In no event shall the Department pay
more than the rate in effect for the period. Any amount due to DMS shall
be paid in a lump sum no later than January 31, 2001..." Kentucky
Contract, Attachment B, pages 1-2.
"5.5.3 Rate Proposal Component
The rate proposal
component is negotiable rates subject to Commonwealth review and United
States Government approval.
There are both minimum
and maximum rates that have been actuarially determined to be reasonable,
within regulatory (HCFA) upper limits and sufficient to assure access and
quality. During negotiations, rates outside these bounds must be
resubmitted until they are within the acceptable price corridor."
Kentucky RFA, page 15.
"8.0 Rate Component
8.1 Rate Proposals
The Partnership shall
submit rate proposals for each category of service, for each category of
eligible member.
8.2 Rate Methodology
Partnership's actuary
shall submit a narrative description of the rate methodology used in determining
the rate proposals. The narrative shall indicate the rates which
the actuary has high confidence of accuracy and those with lower confidence
of accuracy.
8.3 Actuarial Certification
The Partnership shall submit
an actuarial certification for all rate proposals." Kentucky RFA,
page 94.
ME
"V. PAYMENT FOR SERVICES...
4. Capitation Rates.
The methodology used by the Department's actuarial consultant to calculate
the capitation rates is explained and certified in Exhibit F, along with
a table of the capitation rates in effect for this Contract. If during
the course of this contract, the parties mutually agree that the data in
the data book is inaccurate and that the inaccuracy materially effects
the rates in Exhibit F, the parties agree that the Department's actuarial
consultant shall be instructed to recalculate the rates...
C. UPPER PAYMENT LIMIT
The capitation rates and
rate ranges specified in Exhibit F shall be effective throughout the term
of this Contract, unless otherwise amended and mutually agreed in the manner
prescribed herein. Notwithstanding anything herein to the contrary, in
no event may the aggregate payments made to HMOs under the Initiative exceed
the upper payment limit defined in 42 C.F.R.§ 447.361, as determined
by the Department's actuarial consultant." Maine Contract, pages
48-50.
MD
"10.09.65.19...
B. Capitation Rate-Setting
Methodology.
(1) Families and Children.
Capitation rates for enrollees who are waiver-eligible based upon receipt
of benefits through TCA or programs for medically needy families and children,
including PWC children, shall be established as follows:
(a) For enrollees
for whom the Department has sufficient clinical data, the Department shall:
(i) Determine
an ambulatory care group (ACG) assignment utilizing an enrollee's past
diagnostic record,
(ii) Utilizing
aggregated enrollee ACG data, on an annual basis define a limited number
of risk adjustment categories that reflect levels of relatively homogenous
resource utilization by ACG assignment, and
(iii) Assign
an enrollee to a risk adjustment category based upon the enrollee's ACG
assignment; and
(b) For enrollees
for whom the Department has insufficient data to generate an ACG assignment,
the Department shall assign the enrollee to a risk adjustment category
that reflects the enrollee's age, residence, and gender.
(2) Disabled.
Capitation rates for enrollees who are waiver-eligible based upon
receipt of benefits though SSI or as medically needy, aged, blind, or disabled
shall be established as follows:
(a) For enrollees
for whom the Department has sufficient clinical data, the Department shall:
(i) Determine
an ambulatory care group (ACG) assignment utilizing an enrollee's diagnostic
record,
(ii) Utilizing
aggregated enrollee ACG data, on an annual basis define a limited number
of risk adjustment categories that reflect levels of nearly homogenous
resource utilization by ACG assignment, and
(iii) Assign
an enrollee to a risk adjustment category (RAC) based upon the enrollee's
ACG assignment; and
(b) For enrollees
for whom the Department has insufficient data to generate and ACG assignment,
the Department shall assign the enrollee to a risk adjustment category
that reflects the enrollee's age, residence, and gender.
(3) Capitation Rate
Setting Methodology for Special Payment Categories.
(a) Unless §B(3)(b)
of this regulation applies, an MCO shall be paid a single supplemental
payment for maternity delivery costs for enrollees who are waiver-eligible.
(b) An MCO shall be
paid a monthly payment for mothers enrolled in the PWC program, supplemented
by the single maternity payment after the delivery of the child.
(c) An MCO shall be
paid a monthly payment for enrollees younger than 1 year old.
(d) An MCO shall be
paid a monthly payment for enrollees with AIDS…" Maryland COMAR 10.09.65.19.
MABH
"SECTION 2: DEFINITIONS
The following term shall
have the meaning stated, as they appear hereunder, unless the context clearly
indicates otherwise…
Upper Payment Limit (UPL) - the maximum amount, calculated by the Commonwealth according to federal requirements under 42 CFR 447.361 which may be paid under the Contract. This amount shall not exceed the cost to the Division of providing the same services under this Contract, on a fee-for-service, to an actuarially equivalent non-enrolled population." Massachusetts MH/SAP Contract, Appendix A, pages 6, 16.
MN
"Section 4.2. Capitation Payment Rates. Monthly rates paid to the HEALTH PLAN shall be paid by the STATE according to the rates in Appendix A, which have an actuarial basis and which shall not exceed the payments limits set forth in 42 C.F.R. 447.361. The HEALTH PLAN shall receive for each Enrollee the rate of the county of service.
Section 4.2.1. Assignment of Rate Cells shall be made based on information on the STATE MMIS and information provided by the HEALTH PLAN to the STATE.
Section 4.2.2. The STATE will periodically review information in MMIS related to the assignment of Rate Cell categories to verify that appropriate rates are being paid." Minnesota Contract, pages 38-39.
MT
"SECTION 5 CONSIDERATION
AND PAYMENTS
C. In consideration
of the services provided through this contract, the DEPARTMENT shall reimburse
the CONTRACTOR as follows:
Specifics of Payment Mechanism:
The DEPARTMENT shall pay the CONTRACTOR monthly payments based on the capitation rates specified in Attachment 6...
The rates are set prospectively and actuarially by the DEPARTMENT at its discretion and are not subject to negotiation. The DEPARTMENT may adjust the rates for reasons including but not limited to: changes in the scope of covered services, changes in the design of the entire Medicaid managed care program, changes in the scope of administrative procedures, changes in the cost of alternative delivery models or changes in funding per Section 26…" Montana Contract, page 3.
NE
"8.28.2 Actuarial Basis: The capitation rate is calculated prospectively on an actuarial basis recognizing the payment limits set forth in 42 CFR 447.361, and based on geographic location, eligibility category, gender, age and type of services." Nebraska Contract, page 23.
"13.53 Payment for NHC Services:
...
The capitation rates in
Addendum B are actuarially determined and are based on geographic location,
eligibility category, gender, age and type of services. The Department
shall adjust rates, and complete all necessary contract amendments, when
it is determined appropriate, based on any changes in the Upper Payment
Limit, Medicaid fee-for-service (FFS) rates, or in instances where an error
or omission in the calculation of the rates has been identified…"
Nebraska Contract, pages 100-101.
NEBH
"8.28 Payment for Services
by the Department: The following provisions apply: ...
8.28.2 Actuarial Basis:
The capitation rate is calculated prospectively on an actuarial basis recognizing
the payment limit set forth in 42 CFR 447.361, and based on, eligibility
category, gender, age and type of services." Nebraska Behavioral
Health Contract, page 23.
NV
"1. General Terms,
Paragraph #4...
'Consideration shall
be paid on a capitated basis as set forth herein. The capitated rates
to be paid for the period of July 1, 1999 through September 30, 1999, are
delineated in Attachment E.3., Managed care Capitated Rates. The
methodology used to determine the rates has been certified to be actuarially
sound. DHCFP will review and revise the rates, in an actuarially
sound manner, to be effective for services dates of October 1, 1999, and
thereafter. Rates will be actuarially determined, in the aforementioned
manner, prior to any subsequent contract renewal period.'" Nevada
Amendment #1, page 2.
NH
"Exhibit B. ...
A. Capitation Rate
Development and Process
In determining Capitation
Payment rates for the managed care entities. the State shall:
(1) calculate the
fee-for-service upper limit , to comply with 42 CFR 447.361;
(2) compare the Contractor's
proposed Capitation Payment rates to the upper limit level; and,
(3) review and award
Agreements...
D. The development
of the rating methodology by the bidder shall be clearly illustrated to
include a detailed written description of the basis for Capitation request.
The methodology shall include:
(1) Actual claims
and Capitation paid under this Agreement;
(2) Administrative
costs charged under this Agreement..." New Hampshire General Service
Agreement, Exhibit B, pages 11-12.
NM
"ARTICLE 3 - LIMITATION OF
COST
The total amount payable
by HSD to all CONTRACTORS executing Agreements with HSD to perform services
shall be less than the upper payment limit established under the terms
of the 1915(b) waiver for Medicaid managed care. In no event shall
capitation fees or other payments provided for in the Agreement exceed
the payment limits set forth in 42 C.F.R. Section 447.361 and 447.362."
New Mexico Contract, page 70.
NC
"10.4 Calculation of
Rates...
Capitation rates have been
computed on an actuarially sound basis, and shall not exceed the upper
payment limit defined as the projected cost of providing the same services
covered under this Contract to a comparable Medicaid population on a fee-for-service
basis…
The upper payment limit for each group shall be calculated each year by determining the historical costs incurred by the Division in providing Covered Services… on a fee-for-service basis to nonenrolled Recipients in each eligibility group…" North Carolina Contract, page 19.
ND
"5 CONSIDERATION AND
PAYMENTS
A. In consideration
of the services provided through this contract, the Department shall pay
the Contractor monthly payments based on the capitation rates specified
in Attachment G...
The rates are set prospectively and actuarially by the Department and agreed to by the Contractor. The rates are not subject to further negotiation. The actuarial process incorporates Medicaid paid claims experience, eligible recipient months, cost-per-service trends, benefit adjustments, and utilization trends to formulate a fee-for-service per member per month rate. Managed care factors such as utilization and cost are introduced to create a managed care per member per month rate. The paid claims experience is net of third party liability payments. The Department practices cost aversion in its policy of TPL and claims payment...
The total amount paid to the Contractor cannot exceed the upper payment limit of what it would have cost the state to provide the same services under Fee for Service to an actuarially equivalent population." North Dakota Contract, page 2.
OH
"SECTION IV - RATES
Rates for reimbursing Managed
Care Plans (MCPs) have been developed by an actuary under contract to the
Ohio Department of Human Services, with review and comment by the Ohio
Association of Health Plans as well as Medicaid-contracting MCPs and others.
The complete methodology and the rates for January 1, 2000 through June
30, 2000 and July 1, 2000 through June 30, 2001 are located in RFP Appendix
B." Ohio RFP, page 35.
"5101:3-26-09 Managed
care plan: Reimbursement and financial responsibility.
(A) Reimbursement...
(2) The capitation
rates are prepared in accordance with 42 CFR 434. Capitation fees
will not exceed the cost of providing the same services on a fee-for-service
basis to an actuarially equivalent nonenrolled population. This rate
does not include any amount for risks assumed under any existing or any
previous agreement or contract. The capitation rate will be reviewed
at least annually and may be modified based on existing actuarial factors
and experience. Except as provided for in paragraph (D) of this rule,
any savings remaining after costs have been deducted from the capitation
will be wholly retained by the MCP." Ohio RFP, Appendix E, OAC 5101:3-26-09,
page 1.
ORMH
"VII. Consideration
A. Payment Types and
Rates...
Division shall provide upon
Contractor request and availability documents produced by the Actuarial
firm which document and describe the rate development process…
C. Changes in Payment
Rates
The Capitation Payment may
be changed by amendment to this Agreement pursuant to XXXI, Amendments
and Termination, of this Agreement, except that changes in Covered Services
in response to revisions in the Prioritized List of Health Services by
the HSC that would have an actuarial impact, as determined by Division,
on Contractors projected costs greater than 1% or in response to action
by the Oregon Legislative Assembly shall be made as follows…" Oregon Mental
Health Contract, pages 40-41.
PABH
"The first opportunity for contracting provision is contingent upon the counties agreement to enter into a full risk capitation contract at an actuarially sound rate as determined by the department, and demonstrated capacity to meet the program and fiscal requirements detailed in this RFP…" Pennsylvania Behavioral Health RFP, page 10.
"D. Cost and Price
Analysis; Tab 8
1. General...
Capitation is designed
to provide the bidder with a prospectively determined monthly amount sufficient
to meet the program standards described in Part IV. The bidder in
this proposal must in fact demonstrate that its proposed capitation rates
are actuarially sound. The basis of all financial projections must
be linked to the capitation proposal. The bidder may require assistance
from an actuary to develop some of the fundamental assumptions for meeting
the criteria defined below...
3. Instruction
for Completing CRCS Forms
a. Utilization
Estimates
1) General
Bidders should begin
development of their cost proposals by estimating utilization for each
rate category within the categories of service described below and presenting
these estimates along with their underlying assumptions. The categories
of service represent the major areas of utilization for program members...
2) Service Categories
for Rate Categories 1-7
For rate categories
1 through 7, there are 11 categories of service for which annualized utilization
frequencies must be estimated...
For each of the 11 categories of service, the bidder should describe cost per unit by rate group and provide supporting evidence for its estimates. The supporting documentation must be consistent with the bidder's financial plan and cash flow statement.
c. Adjustment
to Capitation Rate
Bidders should document
adjustments being made to their capitation bids to account for RPL; administrative
charges; reinvestment requirements, profit charges for non-county bidders;
the risk and contingency charges. The underlying assumptions for
each of these adjustments also should be described…" Pennsylvania
Behavioral Health RFP, pages 31-36.
"5. Rating Period
MCOs are to submit
capitation bids that will apply to the initial rating period stated below.
Note that these periods will vary by category of aid as follows: ...
The capitation bids that apply to the SSI, GA, and Health Horizons categories of aid also apply to the '11/01/96 to 06/30/97' rating period, after an actuarial reduction percentage is applied to the rates. The Department will supply the actuarial reduction percentage at a Technical Assistance Session (see the cover letter to this RFP for date/locations of the sessions). This rating period includes only voluntary MCO enrollments for those recipients.
For the second rating
period, the Capitation rates may be subject to adjustments, in an actuarially-sound
manner, prior to the start of the second period, to reflect either or both
of the following:
Inflation Adjustment:
to reflect changes in medical costs
Programmatic Adjustment:
to reflect any changes that affect the MCO's delivery or coverage of benefits.
The Department intends
to determine adjustments for the third rating period." Pennsylvania
Behavioral Health RFP, page 46.
SC
"13.30 Annual Rate Adjustment
The Contractor and SCDHHS
both agree that the capitation rates identified in Appendix K of this Contract
shall remain in effect through the first year of the Contract. Rates may
be adjusted in future years based on SCDHHS and actuarial analysis."
South Carolina Contract, page 78.
UTMH
"Article I
DEFINITIONS
'Upper Payment Limit' means
the cost to Medicaid providing the same services on a fee-for-service basis
to an actuarially equivalent non-enrolled population as pursuant to 42
CFR 447.361." Utah Mental Health Contract, page 2.
"Article IX
PAYMENT
A. Rate Cells
The DEPARTMENT agrees
to pay the CONTRACTOR monthly a negotiated rate for each Medicaid eligible
group for all Medicaid eligible persons enrolled in the CONTRACTOR's enrollment
area up to 12-month retroactive period (see Article II (enrollment) SectionC.1),
whether or not the Enrollee receives a Covered Service during that month…
E. Rate-setting
The DEPARTMENT will
negotiate a single set of rates for risk-based premiums. The rates
will cover the combined outpatient mental health services and inpatient
psychiatric including related physician services.
Negotiated
rates for risk-based services may not exceed the cost to the DEPARTMENT
of providing these same services on a fee-for-service basis to an actuarially
equivalent non-enrolled population group (42 CFR 447.361).
1. The DEPARTMENT
will use an inflationary increase negotiated between the DEPARTMENT
and the CONTRACTOR to inflate rates from the previous Contract year plus
and 'equalizer' percentage and an adjuster for any changes in the scope
of Covered Services.
2. Medicaid
expenditures for Medicare crossover claims will not be included in the
negotiated rate. The CONTRACTOR may collect such portion through
the crossover system.
3. The monthly
capitation rates (premiums) set forth in Attachment C of this Contract
may be renegotiated annually. Renegotiations may also occur if there
is a change in state or federal policy or practice that may impact the
utilization of or access to Covered Services by Medicaid Enrollees."
Utah Mental Health Contract, pages 22-24.
VA
"ARTICLE I - DEFINITIONS...
Capitation Rate - The monthly
rate, payable to the Contractor, per enrollee, for all expenses incurred
by the Contractor in the provision of contract services as defined herein.
This rate shall not exceed the upper payment limit set forth in 42 C.F.R.
447.361, as amended." Virginia Contract, page 7.
WA
"3.1 Rates/Premiums:
… The monthly payment for each member will be the Contractor's base
rate, age/sex adjusted based on the member's age on the first of the payment
month.
a. The Contractor's
statewide base rate is $______.
b. The following
age/sex factors will be multiplied by the Contractor's base rate to determine
the monthly payment rate for the member:
[age]...Males...Females
Under age 1... 2.687...2.687
Ages 1-5...0.664...0.664
Ages 6-18...0.477...0.712
Ages 19-34... 0.819...2.238
Ages 35-64...1.585...1.989
Age 65 and over...4.107...4.107"
Washington General Service, page 10.
"AMENDMENT 1
1. The purpose of
this amendment is to add coverage for Children's Health Insurance Program
(CHIP) clients...
5. The following terms
and conditions of this contract are modified as follows for CHIP enrollees:
...
b. Section 3.1, Rates.
For CHIP enrollees:
(1) The base rate
is $___________
(2) The age sex factors
are:
(a) 4.208 for
males and females under age 1;
(b) 1.010 for
males and females age 1-5;
(c) .0724 for
males age 6-18;
(d) 1.093 for
females age 6-18.
(3) The delivery case
rate is $__________" Washington Contract, Amendment 1, pages 1-2.
WV
"4.4 Capitation Payment to
Managed Care Plan...
The capitation payment amounts
will reflect 95 percent of the Department's estimate of the monthly per
capita medical cost that would otherwise occur in the fee-for-service setting
to an actuarially equivalent non enrolled population group. These capitation
rates will not exceed the Upper Payment Limit (UPL) as set forth in 42
CFR 447.361…" West Virginia Contract, page 30.
"CAPITATION RATE METHODOLOGY
FOR THE WEST VIRGINIA MEDICAID MANAGED CARE INITIATIVE...
The methodology below describes
the derivation of eligibility levels and per capita costs, and details
the trend factors, savings factor, and administrative costs to be applied
to the base period data.
The proposed initiative targets most non-Medicare, categorically-eligible AFDC and SSI recipients. Medicaid-Medicare dual eligibles and institutionalized beneficiaries will not be part or the HMO program and accordingly have been excluded from the capitation rate development.
The basic steps for developing
UPLs for these populations were to:
1. Collect historical claims
data from the State's fiscal agent, Consulted, for state fiscal years 1993
through 1994;
2. Calculate the medical
costs of those services incurred for which the contractor would be responsible
under the new program;
3. Adjust base line expenditures
for program/policy changes;
4. Tabulate the number or
Medicaid eligible beneficiary months for those categories of beneficiaries
included in the program;
5. Calculate per capita
costs for the AFDC and SSI groups, by age and sex;
6. Trend fee-for-service
per capita costs forward to the first operational year;
7. Trend Year 1 upper payment
limits forward to Year 2; and
8. Calculate capital rates
equal to 95 percent of fee-for-service costs for Years 1 and 2."
West Virginia RFA, Appendix K, page H2.
WI
"V. PAYMENT TO THE
HMO...
B. ACTUARIAL BASIS
- The capitation rate is calculated on an actuarial basis (specified in
Addendum VII) recognizing the payment limits set forth in 42 CFR 447.361."
Wisconsin Contract, page 44.