Presenters: Zachary C. Aters, ASA, MAAA Sabrina H. Gibson, FSA, … · 2018-05-23 · Sabrina...
Transcript of Presenters: Zachary C. Aters, ASA, MAAA Sabrina H. Gibson, FSA, … · 2018-05-23 · Sabrina...
Session 75OF, Medicaid Hot Topics
Moderator/Presenter: Sabrina H. Gibson, FSA, MAAA
Presenters:
Zachary C. Aters, ASA, MAAA Sabrina H. Gibson, FSA, MAAA
Mary K. Hegemann, FSA, MAAA Chris Priest
Michelle L. Raleigh, ASA, FCA, MAAA
SOA Antitrust Disclaimer SOA Presentation Disclaimer
2018 SOA Health MeetingMedicaid Hot Topics Session 75Tuesday, 6/26/2018, 11:00 am - 12:15 pm
Sabrina Gibson, FSA, MAAA, ModeratorChristopher PriestMary Hegemann, FSA, MAAAMichelle Raleigh, ASA, MAAAZachary Aters, ASA, MAAA
• Work Requirements and Other New 1115 Waiver Topics
• Integration of Pass-Throughs into Risk Rates• Mega Rule Implementation Changes• Medicaid Expansion Member Durational Costs• Social Determinants Paper• Other Medicaid Hot Topics
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Planned Topics
We will use polling during this session.To participate in the polls, please navigate your smart phone to:
https://health.cnf.ioand select our session:
Session 75 - Medicaid Hot Topics
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Polling
Panel Bios
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• Vice President and Chief Medicaid Actuary for WellCareHealth Plans.
• Health care for 20+ years.• Medicaid for 12 years - mostly with a health plan but
also as a consulting actuary. • Experience with 26 Medicaid and CHIP programs in 16
states.• Active member of the American Academy of Actuaries
Medicaid workgroup and on the committee that developed the Actuarial Standard of Practice on Medicaid Managed Care Rate Setting – ASOP 49.
• Active with the Medicaid SOA committee as a presenter of current Medicaid topics at SOA meetings and webinars.
Sabrina Gibson, FSA, MAAA
• Principal at Wakely Consulting Group• Health care actuary for 20+ years, mostly in
consulting• Medicaid experience includes consulting for
Medicaid-focused MCO, association of Medicaid managed care plans, and certify Medicaid capitation rates
• Also consult for Medicare Advantage plans (especially dual-SNPs), ACA commercial lines of business, and non-profit organizations providing health care for homeless and indigent populations
Mary Hegemann, FSA, MAAA
• Vice President of Actuarial Services at Centene• Lead team of actuaries dedicated to Medicaid programs• 25 Medicaid health plans across the United States
• Focused career on Medicaid• 8 years with health plans• 17 years in consulting
• Co-authored the ASOP 49 on Medicaid Managed Care Rate Development
• Participate in various workgroups, co-author papers, and event speaker
Michelle Raleigh, ASA, MAAA
• Senior Actuary for Optumas Consulting• Health care for 19 years, including Commercial,
Medicare, and Medicaid• Medicaid focused for 11 years – Consulting• Recent programs include Oregon, Colorado,
Iowa, Nebraska, and Kansas• Active member of SOA, regularly presenting at
SOA meetings
Zachary Aters, ASA, MAAA
• Vice President, Medicaid Solutions at Centene• 25 Medicaid Health Plans across the United States
• Prior to coming to Centene was Michigan Medicaid Director and was elected to represent all Midwest Medicaid Directors on the board of the National Association of Medicaid Directors (NAMD)
• Secured multiple 1115 waivers and made reforms to the program in Michigan.
• Experience working for Governors of both political parties, working in Medicaid agencies in two states (e.g. IN and MI) and representing States in Washington DC.
Christopher Priest
32%
36%
0%
28%
4%
In what area do you work?
Medicaid - MCO
Medicaid - Consulting
Medicaid – State Employee
Health – Not Medicaid
Other
Work Requirements and Other New 1115 Waiver Topics
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Work Requirements - Intro
• Per Kaiser Family Foundation as of 4/9/18:CMS has approved 1115 waivers in 3 states (KY, AR, and IN)
that include “work requirements” 7 other states have submitted proposals to CMS (AZ, KS, ME,
MS, NH, UT, and WI)
• These waivers require “work” as a condition of eligibilityBeneficiaries need to verify their participation in approved
activities (e.g., employment, job search, job training programs) for a certain number of hours per week Certain populations commonly exemptedAdministration complexities
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https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/?utm_source=web&utm_medium=trending&utm_campaign=waivers
41%
3%
50%
6%
0%
10%
20%
30%
40%
50%
60%
Caregivers Attending School Illness or Disability Other
What is the #1 reason that nonelderly non-SSI adult members are not working?
Work Requirements - Intro
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Per Kaiser Family Foundation (KFF), this new requirement may only impact 7% of the relevant population
Work Requirements - Intro
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Majority of public believes the main reason for imposing these work requirements is to reduce spending3
71%
41%
15%
3%
15%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Membership will drop Healthier membersdisenroll
Members will developskills that will movethem out of poverty
Members will becomemore engaged in their
healthcare
No Impact
What kind of impact do you think the work requirements will have on the Medicaid population?
Indiana’s Healthy Indiana Plan (HIP)• HIP – 1115 Waiver (2008) Goal: test consumer-driven model to low-income
beneficiaries Population: Caretakers of TANF kids and Childless adults
up to 150% FPL POWER Account:“Savings Account” pays for first $1,500 claims (jointly
funded by state and member)• Member Premiums (contributions to POWER
account)• Limited rollovers help fund future year premiums• Non-payment of premium lead to disenrollment
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Indiana’s HIP Program, cont.• HIP 2.0 - 1115 Waiver
(2015) Changes: All adults up to
138% FPL (including former TANF)POWER account
increased to $2,500Introduced
Basic/Plus Program distinction (see flowchart)
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Caretaker?
Yes: HIP State Plan
Paying premium?
Yes: Plus (additional benefits)
No: Basic (copays)
No: HIP Regular
Paying Premium?
No: Under 100% FPL?
Yes: HIP Basic (copays)
No: Lose Coverage
Yes: HIP Plus (additional benefits)
Indiana’s HIP Program, cont.• HIP - 1115 Waiver (2017) Changes:Work Requirement (next page)SUD Treatment expansion (ASAM criteria,
using IMDs)Changes in Open Enrollment Tobacco Surcharge (50% increase in
premium)Tiered Premium Structure More former TANF members (including
pregnant) moving into HIP
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Indiana’s HIP Program, cont.Work RequirementsAll HIP eligible members, not otherwise meeting an Exemption, will be required to:1. Work average 20 hours per week over 8 months during the
calendar year; or2. Be enrolled in full-time or part-time Education; or3. Participate in 1 of 16 activities defined by the state (e.g. Job
Training, Volunteer work, MCE Employment Initiatives, etc.) for 20 hours per week for 8 of 12 months.
• Compliance: members assessed at the end of each calendar year to determine if they met requirements.
• Approaching as a social determinant of health• Phased in approach – no expected eligibility changes until
January 2020 when a look back at 2019 activity occurs.
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Indiana’s HIP Program, cont.Work Requirements
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Not Working due to …
Not Working Due to …
Not Working Due to Homelessness,
Recent Incarceration or SUD Treatment
4%
Working >= 20 hours a week*
38%
Not Working Due to School Attendance
4%
Not Working …
Indiana Work Status and Reason for Not WorkingAmong Non-SSI Nonelderly Medicaid Adults
* Includes 25% of members covered by SNAP and TANF and therefore already subject to the work requirements of those programs
Estimated to be96k members to be subject to the requirements
Indiana’s HIP 2.0 Program, cont.
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Member Engagement Basic Plus All
Enrollment mix 33% 67% 100%
Member Income less than 100% FPL (and therefore would maintain eligibility without paying premium)
100% 86%
Member Satisfaction Basic Plus All
Satisfaction with program 71% 86% 80%
Willing to pay more to participate 90% 80%
Would re-enroll again 93%
Members asked providers about the cost of care 1 in 4
Clinical Outcomes Basic Plus
Primary Care Visits 16% 31%
Preventive Care Visits 45% 64%
Drug Adherence 67% 84%
Missed Appointments 23% 18%
ER Utilization per Thousand 1,034 776
Kentucky ProgramDemonstration Goals Strengthen engagement in personal health care and
provide incentives for responsible decision making Requiring premiums will motivate beneficiaries to use
health services more efficiently Incentives to engage in healthy behaviors will result in
better health outcomes, lower overall costs, and improved socioeconomic conditions Community engagement requirements will help
beneficiaries obtain employment, transition to commercial health insurance, and achieve improved health outcomes
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Kentucky Program
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Medicaid Populations Not Included in Kentucky HEALTH
Medicaid Populations Included in Kentucky HEALTH
SSI AdultsNO CHANGE
Dual EligiblesNO CHANGE
SSI ChildrenNO CHANGE
Foster Care Children
NO CHANGE
Traditional Medicaid Parents and Caregivers
• Premiums or copays• No change in benefits
(Retain vision, dental, transportation)
• Community engagement required, unless primary caretaker of dependent
Medicaid Expansion Adults
• Premiums or copays• Alternative Benefit Plan • Vision and dental available through My Rewards Account• Community engagement required, unless primary caretaker
Pregnant Women & Children (Traditional
Medicaid and KCHIP) • No premiums • No change in benefits • Community engagement initiative not applicable
Medically Frail Adults and Former Foster
Children up to Age 26• No mandatory premiums or copayments• No change in benefits • Community engagement initiative not applicable
Grace periods
Re-entry if payment of past-due premiums within 6 months
Re-entry at 6 months with clean slate
6-month lockout at redetermination
Seasonal workers
Monthly entry of hours worked
Different options for <100% FPL and >100%
Rate Setting Considerations
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Morbidity
• Premium• Premium versus
Copay (risk adjustment)
• Work Requirement• Short duration (run-
on-the-bank and pent-up demand)
Other Fun Considerations
• Randomized Control Trial
• Outside payers• Risk mitigation
strategies
Phase-in Timing
• Medically Frail: enrollment, minimum length of enrollment
• RCT: closed block• Community
engagement: phase-in by geographic area
• Premium payments: delays and lockout periods
Medically Frail
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1 42 CFR 440.315(f)2 SSI program participants and Foster Care Children are excluded from Kentucky Health
Per regulations expanded in 2013, the medically frail program criteria must include, at a minimum1:
• Disabling mental disorders• Chronic substance abuse disorders• Serious and complex medical conditions• Physical, intellectual, or developmental disability that
impairs one of more activities of daily living (ADLs)• Disability determination (Social Security or state plan)• Supplemental Security Income (SSI) program
participants, disabled, and foster children2
Medically Frail Identification Process
The member enrolls in the MCO and is
assigned a COA of MAGI Adultor Parent and
Caregiver
At Enrollment
The member completes
the ‘Welcome to
Medicaid’ HRA
HRA returned; MCO reviews;
identifies member as potentially
Medically Frail; schedules
appointment with provider
Provider completes clinician
attestation; returns to the
MCO; MCO scores the attestation based on points
system
Total points lessthan threshold = not eligible
for MF
Total points more than threshold =
eligible for MF
Member remains in current COA
status
Member enrolled in Medically Frail
program; sent letter providing option to
opt-out
Through MCO Tool
MCO runs membership and claims
data through the MCO tool
MCO tool scores member using diagnosis
codes and other qualifying
claims criteria; returns
Medically Frail status
MCO tool identifies
member as automatic MF
MCO submits result to DMS; member enrolled
in MF program
Total points lessthan threshold = not eligible for
MF
Total points more than threshold =
eligible for MF
Member remains in
current COA status
Member enrolled in
Medically Frail program
MCO tool identifies
member as possible MF
MCO schedules appointment with
provider
Provider completes clinician
attestation; returns to the
MCO; MCO scores the attestation
based on points system
Medically Frail MCO Tool
Objectives
Meet CMS guidelines for defining Medically FrailAccurately identify Medically Frail membersSimple to understandMinimize gaming by any stakeholder
Inputs
Member eligibility fileEncounter claims data (medical and Rx)
SQL Code
FreeEditable
Outputs
Automatically qualifying membersPossibly qualifying members• Follow-up clinician
assessment required
Medically Frail Clinician Attestation
MCO applies the scoring algorithm, which includes scoring for different levels of severity, to determine each member’s eligibility
Clinicians also document non-claims information
Severity of mental health conditions Activities of daily living (ADLs) impairments
Accompanying instructions help clinicians list the member’s conditions
Clinician categorizes a member’s conditions
KY Flow Chart
The following page contains a flow chart of how the non-disabled adult members obtain or lose coverage in Kentucky under the new waiver.Red highlighted boxes are concerns about potentials for risk.
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Integrating Pass-Throughs in Risk Rates
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Illinois• Current: State pays MCOs a monthly lump sum and MCOs
wire the lump sum to the Illinois Hospital Association• Future (7/1/18?):
• Legislated – not yet approved by CMS• $3B of pass-throughs added to a $9B program = $12B
• Add a portion to the hospital fee schedules – 18% for 1st 2 years, 36% in next 2 years, then ???
• Remainder is an “access” payment• Funded through a hospital tax• No requirement in MCO/State contract to make
“access” payment – MCO and hospitals must agree to it
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IllinoisState pays MCO the
capitation rate
MCO calculates amount of “access” payment and pays the Illinois Hospital
Association
Illinois Hospital Association
distributes funds to the Hospitals
Hospitals pay the Hospital Tax
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MCO has contracts with the IHA and
each Hospital allows for the
payment of the “access” payment.
Capitation Rates include an
identified PMPM in each rate cell for
the “access” payment.
Hospitals do not pay the tax until they receive the funds from the
MCOs.
This is where the process can break down
Missouri• Technically not a pass-through:
• Increases hospital payments to UPL level• Payment structure is approved by CMS
• 23% increase to the risk rates• Paid to hospitals as a PMPM amount • Each hospital receives a portion• The hospitals “portion” is pre-determined based
on a prior year’s utilization• Funded as any other Medicaid amount• Requirement in MCO/State contract to make
payment
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MissouriState pays MCO the
capitation rate
MCO calculates amount of payment and pays the Hospital or the Missouri Hospital
Association
Missouri Hospital Association distributes funds to the Hospitals
that not are paid individually
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MCO has an agreement with
the MHA allows for the payment.
Capitation Rates include an
identified PMPM in each rate cell for
the payment.
Nebraska
• The University of Nebraska Medical Center (UNMC) providers are reimbursed at commercial fee levels.
• Since the MCOs contract at levels more commensurate with Medicaid reimbursement, a supplemental payment is required to be paid to UNMC by each MCO to make these providers whole.
• The State includes this supplemental payment as part of the capitation rates, which is then paid by the MCOs to UNMC.
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NebraskaState pays MCO the
capitation rate
MCO calculates amount of payment and pays
UNMC Providers
UNMC Providers receive payment from
MCO
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Capitation Rates include an
identified PMPM in each rate cell for
the payment.
NebraskaMethodology• Identify claims and services attributed to UNMC providers. • UNMC fee schedules are used to calculate the difference
between the UNMC fee schedule and the UNMC reimbursement inherent in the data.
• Difference is amount added into the rate development. • Per CMS regulations, pass-through payments cannot
increase in magnitude from the 7/5/16 value. To maintain consistency with this regulation, the UNMC fee schedule was reduced so the pass-through payment would remain smaller than the 7/5/16 value and the amount built into the previous rate cycle (7/1/17 – 12/31/17).
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Michigan Directed Payments• For fiscal year 2018, Michigan made changes to their Hospital Rate
Adjustment (HRA) that ensure compliance with the Medicaid managed care regulations by converting this pass-through into a directed payment.
• Major changes include:• Payments will be directly tied to actual hospital claims, not cost reports. MI Medicaid
will review hospital claims submitted by health plans and provide the supplemental HRA payments to hospitals on a quarterly basis.
• The distribution of HRA payments has been weighted more towards outpatient claims, which will provide rural hospitals, who tend to provide more outpatient services, a greater share of HRA revenue.
• Hospitals have agreed to be taxed more to provide an additional $190.0 million through this new arrangement.
• These adjustments to the HRA were approved in October by the federal government. The new HRA structure has been implemented for fiscal year 2018.
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Michigan Directed Payments, cont.
Plans submit inpatient and outpatient encounters to State on quarterly basis
State analyzes encounters and makes gross
adjustment to health plans based on prescribed
methodology in preprint
State directs plans to pay specific amount to specific
hospital based on those encounters
Plans make payments to hospitals based on state
direction
Rinse and Repeat every quarter
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CMS Process to ApproveCMS will need to approve the new payment methodology, but the approval process can be quite different depending on a state’s approach. For example.
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Fee Schedule Change Directed Payment
State obtains authority to increase fee schedule/change current payment (if necessary); State prepares state plan amendment utilizing existing state process (e.g. tribal notice).
State obtains authority to change payment (if necessary); state submits preprint to CMS central office (payment must be tied to utilization or value, and must advanced state’s managed care quality strategy)
State Plan Amendment changes proposed to CMS followed by CMS approval.
Review and approval by CMS (OACT and CMCS Quality teams) – questions back and forth between State and CMS prior to approval. Formal letter notifies the state of approval process
New fee schedule taken into account during rate setting; MCO Contract changes, if necessary.
New methodology is factored into rate setting going forward; MCO contract changes, if necessary
Pass-Through Considerations• Moving to the hospital fee-schedule creates
variable income for hospitals• Being embedded in risk rates means it is subject
to:• Withholds• Risk adjustment
• FFS programs are not constrained by the mega-rule
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11%
89%
Will the mega-rule requirements kill the hospital tax pass-throughs?
Yes
No
Mega Rule Impacts to Rate Setting
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Selected Mega Rule Provisions by Effective Date
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Full schedule - https://www.medicaid.gov/medicaid/managed-care/downloads/implementation-dates.pdf
• MH parity | LTSS contract requirements | Actuarial soundness | IMD exclusionAlready in effect
• New OP Rx rules | Additional rate dev. requirements | Pass through payments | MLR standards | New state oversight regs.
July 1, 2017
• Certify by rate cell | +/- 1.5% rate adj. w/o re-certifying | Network adequacy standards | Provider screen / re-enroll
July 1, 2018
• Quality ratings system (a la Medicare STARS program)May 2019
• CMS rate review for 85% MLR floorJuly 1, 2019
35%
65%
0%
10%
20%
30%
40%
50%
60%
70%
Agree Disagree
More oversight enhances the process of rate development and results in more accurate capitation rates.
Transparency
• Mega Rule introduced a new level of review with respect to Medicaid capitation rate submissions/approval
• Similar to Medicare rate review process• Substantiation is required for all actuarial assumptions• This level of review has facilitated more transparency
between Optumas/MCOs/State/CMS(OACT), resulting in a more rigorous/collaborative process
• Discuss examples of transparency
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Minimum Loss Ratio (MLR) • States must monitor MLR on a regular basis• Actuaries are expected to consider historical MLRs when
developing capitation rates• Numerator: The numerator of an MCO’s MLR for a MLR
reporting year is the sum of the MCO’s incurred claims, expenditures for activities that improve health care quality, and fraud reduction
• Denominator: The denominator of an MCO’s MLR for a MLR reporting year must equal the adjusted premium revenue. The adjusted premium revenue is the MCO’s premium minus the MCO’s Federal, State, and local taxes and licensing and regulatory fees
• States are not required to implement rebates along with MLR
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36%
64%
0%
10%
20%
30%
40%
50%
60%
70%
Agree Disagree
The Mega Rule requires MCO specific rates to be actuarially sound.
Misconceptions Actuarial Sound Rate Requirement• Misconception: Mega Rule requires actuary to
develop actuarial sound rates for each participating MCO commensurate with MCOs business model (Plan Specific Rates)
• Intent: Mega Rule requires actuary to develop actuarial sound rates for the program that are shown to be:
• Reasonable and attainable• Encourage access to care
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53%
47%
46%
47%
48%
49%
50%
51%
52%
53%
54%
Agree Disagree
The Mega Rule allows states to adjust actuarially sound rates by 1.5% or less at their own discretion.
Misconceptions 1.5% rate adjustment without rate certification• Misconception: States have the autonomy to adjust
actuarially sound rates up or down by 1.5%• Intent: (Mitigate administrative burden) Medicaid
programs are constantly changing due to policy changes, changes in economy, or changes within the provider community. These changes may result in rates not aligning with risk of the program. States may adjust actuarial sound rates within the 1.5% variance without submitting an actuarial certification, but still must submit substantiation surrounding the cause of the rate adjustment to CMS/OACT
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11%
89%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Agree Disagree
An 85% MLR requirement implies a non-medical load of 15% must be used within the rate development.
Misconceptions
85% MLR requirement• Misconception: States must align non-medical load
assumptions with MLR requirement of 85%, implying a 15% NML.
• Intent: Rates should be set such that there is not high probability of projection error resulting in MLRs that are unpredictable.
• MLR calculation is more complex than just taking traditional medical expenditures and dividing by revenue
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94%
6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Agree Disagree
The certifying actuary can use less than 3-years of historical base data to develop capitation rates.
Misconceptions
Encounter Data• Misconception: States must use three years of
historical data as base data to develop capitation rates
• Intent: Ideally, three years of data is used as base data, however, there are unique situations that do not allow the actuary to comply. In these cases, the actuary should include substantiation related to the unique situation.
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Medicaid Expansion Member Durational Costs
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Medicaid Expansion Member Durational Results
• Avalere published a paper in January 2018• Analysis of how enrollment, utilization, and cost patterns
for newly eligible Medicaid Expansion enrollees change over time and whether spending patterns differed for earlier versus later expansion enrollees
• Used experience from three MCOs• Paper located here:
http://go.avalere.com/acton/attachment/12909/f-0517/1/-/-/-/-/Avalere%20Medicaid%20Expansion%20Analysis.pdf
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Enrollment Composition by Age Group Over Time, First Half 2014 Enrollment Group
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Average Per Member Per Month Costs for Medicaid Expansion Beneficiaries Who Enrolled in 2014, by Length of Enrollment
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Percentage of Healthcare Costs by Type over Time, First Half 2014 Enrollment Group
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Study Conclusions• Across plans and states, the expansion population
experienced high disenrollment rates – substantial churn in this population.
• Even after adjusting for age and gender, claims costs increased steadily over time, suggesting that expansion enrollees have complex and/or chronic conditions.
• For some enrollment cohorts, average claims costs decreased modestly in the second half of the first year of enrollment, suggesting some initial pent-up demand for services, though claims costs increased steadily from that point forward.
• Across enrollment groups, per member per month spending on prescription drugs increased with enrollment duration.
• Among enrollees who remained enrolled the longest, inpatient claims initially made up the largest share of claims costs, but were surpassed by prescription drug claims by month 8 of enrollment, on average.
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Social Determinants
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Social Determinants of Health per Healthy People 2020
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https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
Social Determinants & Rate Development• The Commonwealth Fund’s report “Enabling
Sustainable Investment in Social Interventions: A Review of Medicaid Managed Care Rate-Setting Tools” was issued in JanuarySummary of a literature review and interviews with state
officials, health plan leaders, actuarial experts, and other stakeholdersDiscussed ways rates could be developed so MCOs are
incentivized, required and/or have the resources to address social issues6 strategies states can employ to support MCOs in
addressing social issues
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http://www.commonwealthfund.org/publications/fund-reports/2018/jan/social-inteventions-medicaid-managed-care-rate-setting
Social Determinants & Rate Development, cont.
Modify state plan to include social benefits
Explore flexibility of 1115 waivers
Require value-based payment and other delivery system reforms
Include incentives and/or withholds to drive coverage
Explore whether social benefits can count as quality improvement initiatives
Reflect/reward plans with higher rates to prevent premium slide
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Other Quick Topics
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• Medically Frail - . https://www.wakely.com/blog/identifying-medically-frail-individuals-kentucky-medicaid-case-study
• Medicaid Expansion Study -http://go.avalere.com/acton/attachment/12909/f-0517/1/-/-/-/-/Avalere%20Medicaid%20Expansion%20Analysis.pdf
• Social Determinants -https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-healthhttp://www.commonwealthfund.org/publications/fund-reports/2018/jan/social-inteventions-medicaid-managed-care-rate-setting
Recommended Resources