STATE OF TEXAS MEDICAID MANAGED CARE STAR …...Medicaid’s State of Texas Access Reform (STAR)...
Transcript of STATE OF TEXAS MEDICAID MANAGED CARE STAR …...Medicaid’s State of Texas Access Reform (STAR)...
Prepared for:
Texas Health and Human Services Commission
Uniform Managed Care Contract 529-12-0002 V2.16
Prepared by:
Evan L. Dial, F.S.A., M.A.A.A.
Rudd and Wisdom, Inc.
June 26, 2015
STATE OF TEXAS
MEDICAID MANAGED CARE
STAR PROGRAM RATE SETTING
STATE FISCAL YEAR 2016
TABLE OF CONTENTS
I. Introduction ........................................................................................................................1
II. Overview of Rate Setting Methodology ............................................................................3
III. Adjustment Factors ............................................................................................................6
IV. Administrative Fees, Taxes and Risk Margin ..................................................................11
V. Summary ..........................................................................................................................12
VI. Actuarial Certification .....................................................................................................16
VII. Attachments .....................................................................................................................17
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I. Introduction
Rudd and Wisdom, Inc. has been retained by the Texas Health and Human Services
Commission (HHSC) to develop the state fiscal year 2016 (FY2016, September 1, 2015
through August 31, 2016) premium rates for health plans participating in the Texas
Medicaid STAR program. This report presents the rating methodology and assumptions
used in developing the premium rates.
Medicaid’s State of Texas Access Reform (STAR) program provides primary, acute care, and
pharmacy services for low-income families, children, pregnant women, and some former foster
care youth. The program operates statewide with services delivered through managed care
organizations under contract with HHSC. There are thirteen STAR service delivery areas
(SDAs). STAR Medicaid members can select from at least two MCOs in each service delivery
area. There are a total of 18 MCOs serving different STAR SDAs throughout the state.
STAR is the program through which most people in Texas get their Medicaid coverage.
Rudd and Wisdom has provided actuarial services to the Texas Medicaid program for over
30 years. We have participated in the state’s managed care rating process since its inception
in 1993. This year, as in previous years, we have worked closely with HHSC in developing
the FY2016 health plan premium rates.
Rudd and Wisdom has relied on the following data sources as provided by HHSC, the
participating health plans and the agency’s External Quality Review Organization (EQRO):
Monthly enrollment by risk group and age group for each health plan. This includes
historical enrollment since September 2011 and a projection of future enrollment
through August 2016. These projections were prepared by HHS System Forecasting
staff.
Claim lag reports by risk group and age group for each health plan for the period
September 2011 through February 2015. These reports were prepared by the health
plans and include monthly paid claims by month of service.
Financial Statistical Reports (FSR) for each participating health plan for FY2013,
FY2014 and the first six months of FY2015. The FSR contains detailed information
regarding monthly enrollment, revenue, incurred claims and administrative expenses, as
reported by the health plan. These reports are prepared by the health plans and are
audited by an external audit organization.
Reports from the EQRO summarizing their analysis of the health plan’s encounter
claims data.
Reports from the health plans providing information on high volume claimants during
the experience period.
Current (FY2015) premium rates and Delivery Supplemental Payment rates by risk
group for each health plan.
The number of maternity deliveries by health plan and risk group for the period
September 2011 through November 2014.
Information from both HHSC and the health plans regarding recent changes in covered
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services and provider reimbursement under the Medicaid program.
Information from the health plans regarding current and projected payment rates for
certain capitated services, such as mental health and vision.
Information regarding FY2014 third party reimbursement from each of the health plans.
FY2014 acuity risk adjustment analysis provided by the EQRO for each participating
health plan.
Information from the health plans regarding current and projected reinsurance premium
rates.
Information provided by HHSC regarding FY2014 health plan claims cost by type of
service for certain services. This information was obtained from the encounter database.
Information provided by HHSC regarding proposed FY2016 Medicaid provider
reimbursement rates.
Information provided by HHSC regarding newly capitated services previously paid by
HHSC.
After accumulating all of the information to be used in the rate setting process, a comparison of
the various sources of claims data was performed to check for consistency. Information
submitted by the health plans was compared to information submitted in prior years, the audited
Financial Statistical Reports (FSRs) and the detailed encounter data. All comparisons were done
by risk group as well as in aggregate. In the case of inconsistent information, follow up inquiries
were made with each applicable health plan until all information was corrected and reconciled
with the other data sources. Ultimately there was satisfactory consistency between all data
sources. Although the above data was reviewed for reasonableness, Rudd and Wisdom did not
audit the data.
In addition, to the review for reasonableness performed by Rudd and Wisdom HHSC employs
the Institute for Child Health Policy (ICHP) as an External Quality Review Organization. ICHP
reviews the detail encounter data and provides certification of the data quality. Below is an
excerpt from their data certification report:
Based on an administrative review, the EQRO considers the required data elements for all
MCO/(R)SA combinations in STAR to be accurate, and complete, meeting the following
components of Texas Government Code § 533.0131 for data certification purposes:
1. The encounter data for the most recent measurement year are complete, accurate, and
reliable.
2. No statistically significant variability in the encounter data is attributable to
incompleteness, inaccuracy, or other deficiency as compared to equivalent data for
similar populations and when evaluated against professionally accepted standards.
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II. Overview of the Rate Setting Methodology
This report details the development of the medical component of the total premium rate.
Information regarding the carve-in of prescription drugs into the STAR program can be
found in the report titled State of Texas Medicaid Managed Care Rate Setting Pharmacy
Carve-in State Fiscal Year 2016.
The actuarial model used to derive the FY2016 STAR health plan premium rates relies
primarily on health plan financial experience. The historical claims experience for each
health plan (by area) was analyzed and estimates for the base period (FY2014) were
developed. These estimates were then projected forward to FY2016 using assumed trend
rates. Other plan expenditures such as capitated amounts, reinsurance costs and
administrative expenses were added to the claims component in order to project the total
FY2016 cost under the health plan. These projected total cost rates were determined
separately for each risk group for each health plan. The results of this analysis were then
combined for all health plans in a service area in order to develop a set of community rates
for each service area.
The managed care service areas used in the analysis were as follows:
• Bexar County Service Area (San Antonio)
• Dallas County Service Area (Dallas)
• El Paso County Service Area (El Paso)
• Harris County Service Area (Houston)
• Hidalgo County Service Area (Hidalgo)
• Jefferson County Service Area (Beaumont)
• Lubbock County Service Area (Lubbock)
• Nueces County Service Area (Corpus Christi)
• Tarrant County Service Area (Fort Worth)
• Travis County Service Area (Austin)
• Medicaid Rural Service Area - Central (MRSA Central)
• Medicaid Rural Service Area - Northeast (MRSA Northeast)
• Medicaid Rural Service Area - West (MRSA West)
The risk groups (or rating populations) used in the analysis are as follows:
• Children under Age One Year
• Children ages 1 - 5
• Children ages 6 - 14
• Children ages 15 - 18
• Children ages 19 - 20
• TANF Adults
• Pregnant Women
The services used in the analysis include the following:
• Inpatient Hospital
• Outpatient Hospital
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• Physician Services
• Other Professional Services
• Lab, X-ray and Radiology Services
• Medical Supplies
• Behavioral Health Services (except in the Dallas service area)
• EPSDT Medical Services
• Family Planning and Genetics Services
• Comprehensive Care Program Services
• Vision Services
• Hearing Services
• Home Health Services
• Emergency Room Services
• Ambulance Services
• Prescription Drugs
Services specifically excluded from the analysis include:
• Dental and Orthodontia Services
We projected the FY2016 cost for each individual health plan by estimating their base
period (FY2014) average claims cost and then applying trend and other adjustment factors.
These adjustment factors are described in Section III. We added capitation expenses for
services capitated by the health plan (such as vision and behavioral health), a net cost of
reinsurance, a reasonable provision for administrative expenses and a risk margin.
Attachment 2 presents a description and an example of the experience analysis for a sample
health plan. This type of analysis was conducted for each health plan.
The analysis of base period claims experience for each health plan attempted to identify and
adjust for any distortions in the data. Significant variations in experience, including the
impact from unusually large individual claims, were investigated however no adjustments
were deemed to be necessary.
HHSC utilized the combination of two rating methodologies in setting the FY2016 STAR
premium rates – individual plan experience rating and community rating. The individual
plan experience rating method is described above and documented in Attachment 2. The
community rates are developed by a weighted average of the projected FY2016 cost for
each health plan in the service area. The weights used in this formula are the projected
FY2016 number of clients enrolled in each health plan by risk group. Attachment 3
presents the summary community rating exhibit for each service area along with a
description of the analysis.
The projected FY2016 average total per-capita cost in a service area is called the unadjusted
premium rate. This rate includes provision for all health care and administrative services to
be provided by the health plan. This rate is then separated into two components – (i) non-
maternity related expenses and (ii) maternity expenses. The premium rate for non-maternity
expenses is called the adjusted premium rate. These are the monthly rates paid to the health
plan. The amount paid for maternity expenses is called the Delivery Supplemental
Payment. More information on this adjustment is provided in Section III below under Risk
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Risk Adjustment and in Attachment 8.
The base community rate in each service area was adjusted to reflect the health status, or
acuity, of the population enrolled in each health plan. The purpose of acuity risk adjustment
is to recognize the anticipated cost differential between multiple health plans in a service
area by analyzing the health status of their respective memberships. Additional information
regarding risk adjustment is included in Section III below under Risk Adjustment and in
Attachment 9.
The FY2016 STAR health plan premium rates were then defined as the following: the
minimum of (a) 110% of the rate developed using the individual experience of the plan and
(b) community rate with risk adjustment. This is the same methodology that was used
during the FY2015 STAR rate development and has been implemented in order to limit the
excessive profits achieved by health plans with significantly lower costs than the
community average. By limiting the final premium rates to no greater than 110% of the rate
developed using the individual experience of the plan, the STAR rates continue to
incentivize the efficient provision of services while limiting the ability of a relatively low
cost plan from benefiting from the higher community average premium rates.
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III. Adjustment Factors
This section contains a description of the adjustment factors used in the FY2016 STAR
rate setting process.
Trend Factors
The rating methodology uses assumed trend factors to adjust the base period claims cost to
the projection period. The cost trend factors used in this analysis are a combination of
utilization and inflation components. The projected trend rate assumptions were
developed by the actuary based on an analysis of recent experience under the various
health plans. Trend assumptions for FY2015 vary by service area are established on a
statewide basis for FY2016. All trend assumptions vary by risk group.
The trend analysis included a review of health plan claims experience data through
February 28, 2015. Based on this information, estimates of monthly incurred claims were
made through December 2014. The claims cost and trend experience was reviewed
separately by service area and risk group. The service area trends were then combined into
a statewide average using a weighted average formula with estimated incurred claims as
the weights. All historical trends have been calculated as the average cost per member per
month during a specified time period (monthly, quarterly or annually) compared to the
same time period from the prior year. For example the FY2014 trend has been calculated
as the change in average cost per member per month during the period September 1, 2013
through August 31, 2014 (FY2014) compared to the average cost per member per month
during the period September 1, 2012 through August 31, 2013 (FY2013). The experience
trends for all time periods were adjusted to remove the impact of various provider
reimbursement changes and other revisions that have impacted the cost of the program.
The FY2015 trend assumptions were developed from two components: (i) the actual
estimated trend by service area for the period September 2014 through December 2014
and (ii) the projected trend for the period January 2015 through August 2015. The actual
trends for the period September 2014 through December 2014 were calculated separately
for each service delivery area. The projected trend for the period January 2015 through
August 2015 were projected using experience data from FY2012 (3/10 weight), FY2013
(3/10 weight), FY2014 (3/10 weight) and the first four month of FY2015 (1/10 weight).
The weighting of each time period was based on the number of months within each time
period. All projected statewide trends were limited to no less than 0.0%
Blending the area specific trends for the period September 2014 through December 2014
with the statewide projected trend for the period January 2015 through August 2015 was
done via the following formula:
FY2015 SDA Trend = (9/14-12/14 actual SDA trend) x 4 + (1/15-8/15 Statewide) x 8
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The FY2016 trend assumptions were then developed on a statewide basis from a simple
average of the FY2012 trend, FY2013 trend, FY2014 trend and FY2015 trend.
The FY2015 and FY2016 trend assumptions were limited to no less than 0.0%.
Attachment 4 is a summary of the cost trend analysis. The chart below presents the
assumed annual trend rates for FY2015 and FY2016.
Under
Ages
Ages
Ages
Ages
TANF
Pregnant
Age 1
1-5
6-14
15-18
19-20
Adult
Women
FY2015
Bexar SDA
7.8%
5.7%
5.3%
1.0%
0.0%
0.0%
0.0%
Dallas SDA
0.0%
3.4%
7.5%
3.1%
0.0%
0.0%
1.5%
El Paso SDA
0.0%
2.8%
1.6%
2.2%
0.0%
0.0%
0.0%
Harris SDA
1.0%
5.2%
4.7%
0.8%
0.0%
0.0%
0.0%
Hidalgo SDA
0.0%
0.9%
3.4%
0.4%
0.0%
0.0%
0.0%
Jefferson SDA
0.0%
5.0%
5.8%
6.7%
0.0%
0.0%
0.0%
Lubbock SDA
0.3%
9.3%
5.2%
3.0%
0.0%
0.0%
0.0%
Nueces SDA
4.0%
4.6%
8.4%
0.0%
0.0%
0.0%
0.5%
Tarrant SDA
2.0%
4.8%
4.2%
4.5%
0.6%
0.0%
0.0%
Travis SDA
0.0%
4.6%
6.8%
1.9%
0.0%
0.0%
0.0%
MRSA Central SDA
9.2%
4.4%
6.2%
2.2%
0.0%
0.0%
0.0%
MRSA Northeast SDA
3.2%
5.1%
5.1%
4.4%
0.0%
0.0%
0.0%
MRSA West SDA
0.8%
3.3%
4.3%
0.0%
0.0%
0.0%
0.5%
FY2016
1.9%
3.9%
4.5%
2.2%
8.6%
0.0%
0.0%
Provider Reimbursement Adjustments
Medicaid provider reimbursement changes were recognized for the following services:
hospital inpatient reimbursement revisions, potentially preventable readmission
reimbursement reductions, potentially preventable complications reimbursement
reductions, rural hospital outpatient reimbursement revisions, and therapy reimbursement
reductions.
The rating adjustments for these provider reimbursement changes were calculated by
applying actual health plan encounter data to the old and new reimbursement basis and the
resulting impact determined. Attachment 5 presents a summary of the derivation of these
adjustment factors.
Newly Capitated Services
Effective September 1, 2014 mental health rehabilitation and targeted case management
services became capitated services under the STAR program. Previously these services
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were carved out of STAR and paid on a fee-for-service basis. Exhibit H of Attachment 5
presents a summary of the derivation of these adjustment factors.
Related Party Adjustments
Beginning in FY2011, HHSC revised the rating methodology to exclude from the base
period claims experience any amounts paid by a health plan to a related party in excess of
100% of Medicaid. HHSC discussed with the health plans individually to determine (i)
which providers had an owner-relationship to the health plan and (ii) the basis on which
the health plan reimbursed the provider. All health plans in the affected service areas were
impacted because the related party adjustment lowered the community rate applicable to
all of the plans in that area. Exhibit A of Attachment 5 presents a summary of the
derivation of these adjustment factors.
Makena Utilization Increase
During FY2016 it is expected that utilization of Makena will increase as the currently
available compound (17P) will be less readily available. Makena has a significantly higher
price than 17P and will result in increased medical cost because it is currently administered
by a physician. Exhibit I of Attachment 5 presents as summary of the derivation of this
adjustment factor.
Long Acting Reversible Contraceptive (LARC)
Although a current benefit under managed care, hospitals do not receive separate
compensation for LARC insertion other than their typical maternity related
reimbursement. Effective January 1, 2016 LARC’s will be subject to a separate, additional
reimbursement. This increase in reimbursement is expected to result in an increase in
utilization. Exhibit J of Attachment 5 presents as summary of the derivation of this
adjustment factor.
Family Planning Exclusion
One of the health plans that participates in the STAR program does not provide family
planning services. HHSC provided a listing of those services that will not be provided by
this health plan. Adjustment factors were determined through an evaluation of the base
period experience for the area in which this plan operates. The premium rates for this
health plan have been reduced to reflect the reduced level of services provided.
Attachment 6 provides additional information regarding this adjustment.
Third Party Recoveries
The rating methodology includes a factor to recognize those health plans that do not satisfy
a minimum level of recoveries for coordination of benefits. Any plan that did not recover
at least 2.0% of claims had its projected claims cost reduced by 2.0% less their actual
percentage of recoveries. For example, if a health plan has third party recoveries (TPR) of
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1.5% of claims, then their projected claims cost would be reduced by 0.5%. Any plan that
exceeded the minimum standard of 2.0% had no penalty applied. Additional information
regarding TPR is included in Attachment 7.
Risk Adjustment
Several risk adjustment techniques are employed in the rate setting methodology.
Premium rates are established separately by area of the state and risk group in order to
recognize the inherent geographical and demographical variation in the cost of delivering
care. In an attempt to treat the health plans more equitably regarding maternity expenses,
the methodology includes a separate rate for maternity services. In addition, the rating
methodology includes a health status adjustment.
The rate setting methodology incorporates a risk adjustment technique that is designed to
provide uniform treatment of the health plans for costs related to maternity services.
Maternity cases occur in several risk groups – Pregnant Women, TANF Adults, Ages 15-
18, and Ages 19-20. As a result, it is possible for one health plan to enroll a higher
percentage of TANF Adults, for example, who are pregnant and therefore generally more
expensive. In order to recognize the potential inequity that may arise between health
plans, HHSC developed this risk adjustment methodology. The goal is to reimburse the
plans uniformly for maternity delivery costs.
HHSC pays a delivery supplemental payment (DSP) for each delivery in a managed care
plan. The amount of the payment is a function of the average delivery cost in the service
area. Attachment 8 contains additional information regarding the DSP payment amounts.
In order to achieve cost neutrality, the projected cost of maternity expenses is subtracted
from the unadjusted premium rates. The resulting adjusted premium rates are the rates
actually paid to the health plans, in addition to any DSP amounts.
The base community rate in each service area was adjusted to reflect the health status, or
acuity, of the population enrolled in each health plan. The purpose of acuity risk
adjustment is to recognize the anticipated cost differential between multiple health plans in
a service area by analyzing the health status of their respective memberships. The risk
analysis was performed by the University of Florida’s Institute for Child Health Policy
(ICHP). The methodology used to calculate the acuity risk adjustment factors is the
Chronic Illness and Disability Payment System (CDPS). Additional information regarding
acuity risk adjustment is included in Attachment 9.
Although the results of the risk adjustment analysis were reviewed for reasonableness,
Rudd and Wisdom did not audit the risk adjustment data or the results of ICHP’s analysis.
Network Access Improvement Program (NAIP)
Effective March 1, 2015 several health plans implemented programs aimed at improving
network access for Medicaid members. The NAIP is designed to further the state's goal of
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increasing the availability and effectiveness of primary care for Medicaid beneficiaries by
incentivizing various institutions to provide high quality, well-coordinated, and continuous
care.
Attachment 10 presents the development of the NAIP add-on amounts to be included in
the capitation rates effective September 1, 2015 along with further information concerning
the NAIP program.
Pay-for-Quality Program (P4Q)
The STAR Program includes the Quality Challenge Program. It creates incentives and
penalties for all health plans based on their performance on certain quality measures.
Health plans that excel on meeting the measures are eligible for a bonus of up to 4 percent
of their capitation rate; health plans that don’t meet their measures can lose up to 4 percent
of their capitation rate. In aggregate all premium dollars recouped through penalties are
dispersed back to the health plans eligible for the quality bonus. In sum, this program is
budget neutral and does not result in an overall net gain or a net loss from the aggregate
premium rates certified in this report. We have reviewed the various measures and have
concluded that it is reasonable to expect the health plans to achieve the targeted quality
measures and no further adjustment to the premium rates are necessary. Attachment 11
presents further information regarding the P4Q Program and its measures.
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IV. Administrative Fees, Taxes and Risk Margin
The rating methodology includes an explicit provision for administrative services. The
amount allocated for administrative expenses is $8.00 pmpm plus 5.75% of gross
premium. This amount is intended to provide for all administrative-related services
performed by the health plan.
The administrative fee amounts were determined based on a review of (i) the
administrative fee provision included in Medicaid health plan premium rates in other
states, (ii) the reported administrative expenses of the STAR health plans and (iii) the
fees paid for similar services for other large Texas health plans.
The premium rates also include an amount for premium tax (1.75% of premium),
maintenance tax ($0.07 pmpm) and a risk margin (2.0% of premium).
The capitation rates included in this document do not include provision for the
Affordable Care Act (ACA) Health Insurance Providers Fee. HHSC will develop and
implement a procedure for reimbursing the health plans for (i) the ACA Health Insurance
Providers Fee, (ii) any applicable federal income tax impact resulting from payment of
the ACA Health Insurance Providers Fee and (iii) any applicable state premium tax
impact resulting from payment of the ACA Health Insurance Providers Fee. Such
reimbursement will be provided based on a CMS-approved methodology.
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V. Summary
The chart below presents the results of the FY2016 STAR rating analysis and includes all
components of the premium – medical, prescription drug and NAIP. This report details
the development of the medical and NAIP components of the premium. Further
information regarding the prescription drug component of the premium rate can be found
in the report titled State of Texas Medicaid Managed Care Rate Setting Pharmacy Carve-in
State Fiscal Year 2016.
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Under Ages Ages Ages Ages
Age 1 1-5 6-14 15-18 19-20
Monthly Adjusted Premium Rate
Aetna - Bexar 568.20 134.13 103.68 130.28 183.12
Amerigroup - Bexar 520.40 155.74 114.58 124.01 175.87
CFHP - Bexar 631.16 188.40 162.78 184.68 248.07
Superior - Bexar 643.32 185.94 157.80 173.25 239.54
Amerigroup - Dallas 471.12 182.69 151.11 173.20 232.85
Molina - Dallas 505.56 209.89 122.34 161.78 222.51
Parkland - Dallas 460.88 201.56 148.69 166.27 234.36
El Paso First - El Paso 542.90 183.49 163.87 181.37 181.42
Molina - El Paso 571.22 137.98 101.84 62.43 106.57
Superior - El Paso 605.54 180.09 157.54 196.85 198.72
Amerigroup - Harris 658.98 161.35 139.16 162.05 274.32
CHC - Harris 661.92 201.94 152.41 183.61 318.24
Molina - Harris 665.32 155.64 142.65 157.63 343.63
TCHP - Harris 523.35 164.46 143.18 182.72 303.61
United - Harris 722.98 221.80 178.77 232.86 416.49
Driscoll - Hidalgo 540.93 189.56 134.90 143.94 191.52
Molina - Hidalgo 492.42 170.42 141.58 147.15 204.80
Superior - Hidalgo 574.52 213.13 157.86 159.31 212.94
United - Hidalgo 576.19 205.10 152.96 152.19 232.05
Amerigroup - Jefferson 911.52 186.89 173.59 201.28 227.87
CHC - Jefferson 810.11 174.01 148.49 190.70 285.84
Molina - Jefferson 860.49 154.20 142.70 128.16 226.97
TCHP - Jefferson 708.81 149.53 146.62 176.23 293.69
United - Jefferson 758.59 203.04 173.25 221.09 233.63
Amerigroup - Lubbock 886.36 217.69 177.18 188.55 398.02
Firstcare - Lubbock 709.79 183.59 158.55 184.43 243.85
Superior - Lubbock 702.58 194.50 151.56 160.86 228.03
Christus - Nueces 881.92 216.71 164.97 193.98 218.54
Driscoll - Nueces 896.90 224.10 198.23 222.45 227.73
Superior - Nueces 809.63 232.62 200.47 192.53 159.56
Aetna - Tarrant 587.86 170.00 126.43 127.74 346.29
Amerigroup - Tarrant 553.32 164.56 143.71 165.01 314.62
Cook - Tarrant 557.65 182.91 160.25 182.06 317.31
Blue Cross - Travis 679.04 176.96 117.21 147.69 127.85
Sendero - Travis 691.29 193.36 132.29 178.63 204.82
Seton - Travis 563.75 162.51 116.92 159.71 173.12
Superior - Travis 669.91 162.76 136.60 170.54 199.63
Amerigroup - MRSA Central 580.81 122.30 108.97 113.60 184.56
Scott & White - MRSA Central 563.39 163.91 142.80 185.75 224.08
Superior - MRSA Central 557.03 140.86 125.49 150.02 199.97
Amerigroup - MRSA Northeast 661.48 148.58 130.48 154.29 345.05
Superior - MRSA Northeast 573.84 138.50 118.64 152.40 304.44
Amerigroup - MRSA West 617.17 184.35 165.62 197.62 354.10
Firstcare - MRSA West 585.19 179.45 157.70 199.60 279.58
Superior - MRSA West 545.89 147.38 139.56 171.64 242.43
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Delivery
TANF Pregnant Supplemental
Adults Women Payment
Monthly Adjusted Premium Rate
Aetna - Bexar 334.08 339.23 3,266.59
Amerigroup - Bexar 384.84 378.81 3,266.59
CFHP - Bexar 420.20 472.94 3,266.59
Superior - Bexar 436.28 472.16 3,266.59
Amerigroup - Dallas 343.93 476.93 3,537.13
Molina - Dallas 405.72 475.83 3,537.13
Parkland - Dallas 321.19 477.30 3,537.13
El Paso First - El Paso 353.29 421.62 3,443.04
Molina - El Paso 334.97 334.69 3,443.04
Superior - El Paso 355.75 414.49 3,443.04
Amerigroup - Harris 467.50 487.10 3,519.20
CHC - Harris 425.43 535.48 3,519.20
Molina - Harris 531.21 448.76 3,519.20
TCHP - Harris 347.35 491.01 3,519.20
United - Harris 610.44 473.17 3,519.20
Driscoll - Hidalgo 318.35 377.09 3,409.95
Molina - Hidalgo 458.73 363.73 3,409.95
Superior - Hidalgo 409.98 384.43 3,409.95
United - Hidalgo 418.39 377.89 3,409.95
Amerigroup - Jefferson 520.00 564.88 3,394.58
CHC - Jefferson 409.47 503.74 3,394.58
Molina - Jefferson 444.00 496.16 3,394.58
TCHP - Jefferson 381.97 508.49 3,394.58
United - Jefferson 503.65 506.86 3,394.58
Amerigroup - Lubbock 404.10 486.59 3,230.39
Firstcare - Lubbock 448.82 435.43 3,230.39
Superior - Lubbock 377.33 441.16 3,230.39
Christus - Nueces 314.23 399.60 3,203.82
Driscoll - Nueces 358.43 515.39 3,203.82
Superior - Nueces 467.72 530.61 3,203.82
Aetna - Tarrant 350.81 402.30 3,635.64
Amerigroup - Tarrant 433.31 391.24 3,635.64
Cook - Tarrant 321.51 374.24 3,635.64
Blue Cross - Travis 360.79 555.57 3,247.49
Sendero - Travis 285.88 545.70 3,247.49
Seton - Travis 332.57 523.40 3,247.49
Superior - Travis 403.33 557.39 3,247.49
Amerigroup - MRSA Central 304.95 430.89 3,035.27
Scott & White - MRSA Central 365.37 446.14 3,035.27
Superior - MRSA Central 368.09 439.40 3,035.27
Amerigroup - MRSA Northeast 391.22 446.02 3,160.40
Superior - MRSA Northeast 383.48 454.25 3,160.40
Amerigroup - MRSA West 443.45 525.87 3,204.07
Firstcare - MRSA West 445.40 485.72 3,204.07
Superior - MRSA West 407.69 465.14 3,204.07
15
The above premium rates include provision for 1915(b)(3) waiver services. The STAR
health plans cover adult inpatient hospital days in excess of thirty. The chart below
presents the amount included in the FY2016 STAR health plan premium rates for
1915(b)(3) waiver services.
TANF Pregnant
Health Plan Adults Women
Monthly Premium Rate for 1915(b)(3) Services
All Plans/All Areas $ 3.85 $ 2.56
Attachment 1 presents additional information regarding the FY2016 rates.
16
VI. Actuarial Certification of FY2016 STAR Health Plan Premium Rates
I, Evan L. Dial, am a principal with the firm of Rudd and Wisdom, Inc., Consulting
Actuaries (Rudd and Wisdom). I am a Fellow of the Society of Actuaries and a member of
the American Academy of Actuaries. I meet the Academy’s qualification standards for
rendering this opinion.
Rudd and Wisdom has been retained by the Texas Health and Human Services Commission
(HHSC) to assist in the development of their state fiscal year 2016 (FY2016) managed care
rate-setting methodology, assumptions and resulting premium rates and to provide the
actuarial certification required under Centers for Medicare and Medicaid Services (CMS)
requirements 42 CFR 438.6(c).
I certify that the FY2016 Health Plan premium rates developed by HHSC and Rudd and
Wisdom satisfy the following:
(a) The premium rates have been developed in accordance with generally accepted
actuarial principals and practices;
(b) The premium rates are appropriate for the populations and services covered under the
managed care contract; and
(c) The premium rates are actuarially sound as defined in the regulations.
We have relied on historical experience data and program information provided to us by
HHSC. We have reviewed the data for reasonableness but have not audited the data.
Please note that actual health plan contractor experience will differ from these projections.
Rudd and Wisdom has developed these rates on behalf of the State to demonstrate
compliance with the CMS requirements under 42 CFR 438.6(c). Any health plan
contracting with the State should analyze its own projected premium needs before deciding
whether to contract with the State.
Evan L. Dial, F.S.A., M.A.A.A.
17
VII. Attachments
18
Attachment 1
Summary of FY2016 STAR Rating Analysis
The attached exhibit presents summary information regarding the FY2016 rates. Included on the
exhibits are current (FY2015) premium rates split between medical, prescription drug, NAIP and
delivery supplemental payment (DSP) rates; FY2016 premium rates split between medical,
prescription drug, NAIP and DSP rates; and a comparison of FY2015 and FY2016 premium
rates.
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
Current (3/1/2015-8/31/2015) Medical Premium Rates pmpm
Aetna - Bexar 605.40 126.66 82.67 110.85 362.25 294.63 404.62 3,266.59
Amerigroup - Bexar 468.42 155.38 56.39 79.78 268.45 217.96 334.56 3,266.59
CFHP - Bexar 529.42 135.65 88.63 116.39 298.46 334.26 383.34 3,266.59
Superior - Bexar 619.17 149.49 95.09 122.30 391.73 346.97 403.38 3,266.59
Amerigroup - Dallas 495.19 143.46 92.54 114.66 303.35 258.95 378.65 3,537.13
Molina - Dallas 524.74 168.73 74.74 87.59 253.18 252.29 363.39 3,537.13
Parkland - Dallas 521.56 155.98 95.49 117.42 304.90 243.84 383.97 3,537.13
El Paso First - El Paso 501.22 119.21 88.33 100.96 243.12 249.90 328.54 3,443.04
Molina - El Paso 506.69 145.75 53.93 67.21 161.33 186.86 295.09 3,443.04
Superior - El Paso 623.33 129.72 91.08 106.11 271.16 252.00 327.71 3,443.04
Amerigroup - Harris 577.31 114.19 70.49 96.03 337.98 335.69 381.82 3,519.20
CHC - Harris 597.87 135.67 84.46 111.20 380.77 331.32 430.83 3,519.20
Molina - Harris 585.65 153.87 88.30 114.82 297.01 309.15 388.13 3,519.20
TCHP - Harris 521.08 143.84 102.36 135.98 377.97 299.83 418.15 3,519.20
United - Harris 587.76 172.27 94.05 129.95 432.02 396.76 410.52 3,519.20
Driscoll - Hidalgo 436.31 152.77 87.90 103.11 240.41 191.05 314.74 3,409.95
Molina - Hidalgo 428.58 165.38 105.34 100.66 285.12 273.07 317.02 3,409.95
Superior - Hidalgo 487.05 185.67 110.27 113.23 278.17 293.09 323.24 3,409.95
United - Hidalgo 458.46 190.85 103.15 112.47 307.94 271.03 321.79 3,409.95
Amerigroup - Jefferson 623.70 123.63 71.10 87.48 378.57 349.01 371.91 3,394.58
CHC - Jefferson 648.06 109.08 81.86 100.66 301.24 293.34 407.22 3,394.58
Molina - Jefferson 552.80 132.47 96.06 93.87 325.75 336.63 399.85 3,394.58
TCHP - Jefferson 671.26 112.26 87.07 116.60 340.46 309.23 423.25 3,394.58
United - Jefferson 617.53 107.53 78.31 91.21 274.94 351.23 394.14 3,394.58
Amerigroup - Lubbock 558.43 115.68 68.84 99.75 355.97 202.08 375.03 3,230.39
Firstcare - Lubbock 590.35 120.82 78.91 116.74 293.52 312.58 381.29 3,230.39
Superior - Lubbock 670.75 110.37 78.01 122.64 242.11 287.41 385.39 3,230.39
Christus - Nueces 596.14 156.18 104.38 129.43 207.65 212.50 418.60 3,203.82
Driscoll - Nueces 696.50 179.33 125.71 181.49 327.34 278.45 417.95 3,203.82
Superior - Nueces 803.68 186.36 124.69 159.07 333.36 345.33 433.83 3,203.82
Aetna - Tarrant 500.59 104.57 70.56 92.49 276.12 296.81 311.61 3,635.64
Amerigroup - Tarrant 529.48 139.81 85.91 115.05 268.12 320.99 310.47 3,635.64
Cook - Tarrant 584.42 163.95 120.81 160.25 288.30 255.60 306.46 3,635.64
Blue Cross - Travis 571.72 122.59 76.80 84.71 242.83 277.09 515.23 3,247.49
Sendero - Travis 491.47 186.07 76.75 108.67 147.48 201.30 476.30 3,247.49
Seton - Travis 465.51 124.34 78.95 101.22 226.65 233.14 458.11 3,247.49
Superior - Travis 602.93 141.94 91.09 114.80 266.34 327.74 523.55 3,247.49
Amerigroup - MRSA Central 494.98 102.61 75.63 85.35 258.66 247.14 379.70 3,035.27
Scott & White - MRSA Central 561.54 141.21 89.57 125.23 284.03 267.36 380.19 3,035.27
Superior - MRSA Central 515.16 120.00 82.50 99.77 288.92 282.62 395.83 3,035.27
Amerigroup - MRSA Northeast 493.35 116.28 79.09 101.91 260.20 274.93 400.24 3,160.40
Superior - MRSA Northeast 506.83 115.64 79.46 99.59 302.88 283.71 392.48 3,160.40
Amerigroup - MRSA West 591.64 115.13 76.60 99.56 266.87 235.19 393.30 3,204.07
Firstcare - MRSA West 564.90 115.69 80.99 105.22 305.82 309.63 392.42 3,204.07
Superior - MRSA West 521.71 103.89 82.87 108.07 320.78 286.58 396.31 3,204.07
19
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
Current (3/1/2015-8/31/2015) Prescription Drug Premium Rates pmpm
Aetna - Bexar 22.03 19.61 38.28 33.67 31.44 103.75 48.20
Amerigroup - Bexar 19.16 27.04 29.34 27.23 26.19 86.25 44.79
CFHP - Bexar 19.26 21.00 41.03 35.35 25.91 117.70 45.66
Superior - Bexar 22.53 23.15 44.02 37.15 34.00 122.18 48.05
Amerigroup - Dallas 26.79 25.10 35.30 37.96 39.41 88.62 47.05
Molina - Dallas 28.39 29.52 28.51 29.00 32.89 86.34 45.16
Parkland - Dallas 28.22 27.29 36.42 38.87 39.61 83.45 47.71
El Paso First - El Paso 29.36 23.69 34.11 36.47 55.01 93.48 35.67
Molina - El Paso 29.68 28.97 20.83 24.28 36.50 69.90 32.04
Superior - El Paso 36.51 25.78 35.17 38.34 61.36 94.27 35.58
Amerigroup - Harris 32.34 22.96 28.21 28.75 34.28 124.31 52.82
CHC - Harris 29.98 24.43 30.26 29.81 34.58 109.86 53.37
Molina - Harris 29.37 27.70 31.64 30.78 26.97 102.50 48.08
TCHP - Harris 26.13 25.90 36.68 36.45 34.32 99.41 51.80
United - Harris 31.54 33.19 36.06 37.27 41.97 140.76 54.41
Driscoll - Hidalgo 49.78 40.13 37.65 41.19 33.99 90.92 47.58
Molina - Hidalgo 48.89 43.44 45.12 40.21 40.31 129.95 47.92
Superior - Hidalgo 55.56 48.77 47.23 45.23 39.32 139.48 48.86
United - Hidalgo 52.37 50.19 44.24 44.99 43.59 129.16 48.71
Amerigroup - Jefferson 37.66 35.89 45.04 39.93 59.88 140.51 43.40
CHC - Jefferson 37.18 30.09 49.26 43.66 45.27 112.21 45.15
Molina - Jefferson 31.72 36.54 57.81 40.71 48.96 128.76 44.33
TCHP - Jefferson 38.51 30.96 52.40 50.57 51.17 118.28 46.93
United - Jefferson 36.29 30.37 48.26 40.51 42.31 137.58 44.75
Amerigroup - Lubbock 24.10 23.29 30.76 28.98 85.80 83.25 37.90
Firstcare - Lubbock 25.48 24.33 35.26 33.91 70.75 128.78 38.53
Superior - Lubbock 29.02 22.28 34.95 35.72 58.51 118.72 39.05
Christus - Nueces 28.24 29.10 44.36 31.43 21.09 87.30 45.28
Driscoll - Nueces 32.99 33.41 53.45 44.61 32.71 113.45 45.08
Superior - Nueces 39.02 35.58 54.34 40.07 34.14 144.21 47.96
Aetna - Tarrant 21.09 15.00 25.17 27.11 56.70 110.33 51.92
Amerigroup - Tarrant 22.31 20.06 30.64 33.72 55.05 119.32 51.73
Cook - Tarrant 24.63 23.52 43.09 46.97 59.20 95.01 51.06
Blue Cross - Travis 23.08 15.84 24.91 25.11 25.83 95.28 43.76
Sendero - Travis 19.84 24.04 24.89 32.21 15.69 69.22 40.45
Seton - Travis 18.79 16.07 25.60 29.83 23.99 80.39 39.24
Superior - Travis 24.34 18.34 29.55 34.02 28.33 112.70 44.46
Amerigroup - MRSA Central 20.32 15.44 32.89 29.11 25.22 93.64 37.29
Scott & White - MRSA Central 23.39 21.55 39.51 43.32 28.09 102.75 37.87
Superior - MRSA Central 21.15 18.05 35.87 34.03 28.17 107.08 38.87
Amerigroup - MRSA Northeast 26.42 24.31 41.64 38.59 37.57 122.59 43.96
Superior - MRSA Northeast 27.14 24.18 41.83 37.71 43.73 126.50 43.11
Amerigroup - MRSA West 27.14 21.38 35.17 32.49 38.14 95.53 32.82
Firstcare - MRSA West 25.91 21.48 37.19 34.34 43.71 125.76 32.75
Superior - MRSA West 23.93 19.29 38.06 35.27 45.84 116.40 33.07
20
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
Current (3/1/2015-8/31/2015) NAIP Premium Rates pmpm
Aetna - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Bexar 1.78 1.78 1.78 1.78 1.78 1.78 1.78
CFHP - Bexar 22.29 22.29 22.29 22.29 22.29 22.29 22.29
Superior - Bexar 5.74 5.74 5.74 5.74 5.74 5.74 5.74
Amerigroup - Dallas 15.88 15.88 15.88 15.88 15.88 15.88 15.88
Molina - Dallas 16.80 16.80 16.80 16.80 16.80 16.80 16.80
Parkland - Dallas 13.51 13.51 13.51 13.51 13.51 13.51 13.51
El Paso First - El Paso 32.92 32.92 32.92 32.92 32.92 32.92 32.92
Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - El Paso 25.42 25.42 25.42 25.42 25.42 25.42 25.42
Amerigroup - Harris 30.56 30.56 30.56 30.56 30.56 30.56 30.56
CHC - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TCHP - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
United - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Driscoll - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Hidalgo 1.59 1.59 1.59 1.59 1.59 1.59 1.59
United - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Jefferson 1.78 1.78 1.78 1.78 1.78 1.78 1.78
CHC - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Molina - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TCHP - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
United - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Lubbock 11.40 11.40 11.40 11.40 11.40 11.40 11.40
Firstcare - Lubbock 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Lubbock 6.21 6.21 6.21 6.21 6.21 6.21 6.21
Christus - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Driscoll - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Aetna - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Tarrant 6.62 6.62 6.62 6.62 6.62 6.62 6.62
Cook - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Blue Cross - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Sendero - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Seton - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - MRSA Central 6.62 6.62 6.62 6.62 6.62 6.62 6.62
Scott & White - MRSA Central 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - MRSA Central 2.21 2.21 2.21 2.21 2.21 2.21 2.21
Amerigroup - MRSA Northeast 6.62 6.62 6.62 6.62 6.62 6.62 6.62
Superior - MRSA Northeast 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - MRSA West 16.24 16.24 16.24 16.24 16.24 16.24 16.24
Firstcare - MRSA West 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - MRSA West 0.00 0.00 0.00 0.00 0.00 0.00 0.00
21
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
Current (3/1/2015-8/31/2015) Total Premium Rates pmpm
Aetna - Bexar 627.43 146.27 120.95 144.52 393.69 398.38 452.82 3,266.59
Amerigroup - Bexar 489.36 184.20 87.51 108.79 296.42 305.99 381.13 3,266.59
CFHP - Bexar 570.97 178.94 151.95 174.03 346.66 474.25 451.29 3,266.59
Superior - Bexar 647.44 178.38 144.85 165.19 431.47 474.89 457.17 3,266.59
Amerigroup - Dallas 537.86 184.44 143.72 168.50 358.64 363.45 441.58 3,537.13
Molina - Dallas 569.93 215.05 120.05 133.39 302.87 355.43 425.35 3,537.13
Parkland - Dallas 563.29 196.78 145.42 169.80 358.02 340.80 445.19 3,537.13
El Paso First - El Paso 563.50 175.82 155.36 170.35 331.05 376.30 397.13 3,443.04
Molina - El Paso 536.37 174.72 74.76 91.49 197.83 256.76 327.13 3,443.04
Superior - El Paso 685.26 180.92 151.67 169.87 357.94 371.69 388.71 3,443.04
Amerigroup - Harris 640.21 167.71 129.26 155.34 402.82 490.56 465.20 3,519.20
CHC - Harris 627.85 160.10 114.72 141.01 415.35 441.18 484.20 3,519.20
Molina - Harris 615.02 181.57 119.94 145.60 323.98 411.65 436.21 3,519.20
TCHP - Harris 547.21 169.74 139.04 172.43 412.29 399.24 469.95 3,519.20
United - Harris 619.30 205.46 130.11 167.22 473.99 537.52 464.93 3,519.20
Driscoll - Hidalgo 486.09 192.90 125.55 144.30 274.40 281.97 362.32 3,409.95
Molina - Hidalgo 477.47 208.82 150.46 140.87 325.43 403.02 364.94 3,409.95
Superior - Hidalgo 544.20 236.03 159.09 160.05 319.08 434.16 373.69 3,409.95
United - Hidalgo 510.83 241.04 147.39 157.46 351.53 400.19 370.50 3,409.95
Amerigroup - Jefferson 663.14 161.30 117.92 129.19 440.23 491.30 417.09 3,394.58
CHC - Jefferson 685.24 139.17 131.12 144.32 346.51 405.55 452.37 3,394.58
Molina - Jefferson 584.52 169.01 153.87 134.58 374.71 465.39 444.18 3,394.58
TCHP - Jefferson 709.77 143.22 139.47 167.17 391.63 427.51 470.18 3,394.58
United - Jefferson 653.82 137.90 126.57 131.72 317.25 488.81 438.89 3,394.58
Amerigroup - Lubbock 593.93 150.37 111.00 140.13 453.17 296.73 424.33 3,230.39
Firstcare - Lubbock 615.83 145.15 114.17 150.65 364.27 441.36 419.82 3,230.39
Superior - Lubbock 705.98 138.86 119.17 164.57 306.83 412.34 430.65 3,230.39
Christus - Nueces 624.38 185.28 148.74 160.86 228.74 299.80 463.88 3,203.82
Driscoll - Nueces 729.49 212.74 179.16 226.10 360.05 391.90 463.03 3,203.82
Superior - Nueces 842.70 221.94 179.03 199.14 367.50 489.54 481.79 3,203.82
Aetna - Tarrant 521.68 119.57 95.73 119.60 332.82 407.14 363.53 3,635.64
Amerigroup - Tarrant 558.41 166.49 123.17 155.39 329.79 446.93 368.82 3,635.64
Cook - Tarrant 609.05 187.47 163.90 207.22 347.50 350.61 357.52 3,635.64
Blue Cross - Travis 594.80 138.43 101.71 109.82 268.66 372.37 558.99 3,247.49
Sendero - Travis 511.31 210.11 101.64 140.88 163.17 270.52 516.75 3,247.49
Seton - Travis 484.30 140.41 104.55 131.05 250.64 313.53 497.35 3,247.49
Superior - Travis 627.27 160.28 120.64 148.82 294.67 440.44 568.01 3,247.49
Amerigroup - MRSA Central 521.92 124.67 115.14 121.08 290.50 347.40 423.61 3,035.27
Scott & White - MRSA Central 584.93 162.76 129.08 168.55 312.12 370.11 418.06 3,035.27
Superior - MRSA Central 538.52 140.26 120.58 136.01 319.30 391.91 436.91 3,035.27
Amerigroup - MRSA Northeast 526.39 147.21 127.35 147.12 304.39 404.14 450.82 3,160.40
Superior - MRSA Northeast 533.97 139.82 121.29 137.30 346.61 410.21 435.59 3,160.40
Amerigroup - MRSA West 635.02 152.75 128.01 148.29 321.25 346.96 442.36 3,204.07
Firstcare - MRSA West 590.81 137.17 118.18 139.56 349.53 435.39 425.17 3,204.07
Superior - MRSA West 545.64 123.18 120.93 143.34 366.62 402.98 429.38 3,204.07
22
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Medical Premium Rates pmpm
Aetna - Bexar 549.14 111.08 70.40 94.14 150.64 242.69 289.31 3,266.59
Amerigroup - Bexar 499.84 130.85 81.60 96.22 148.79 283.18 325.73 3,266.59
CFHP - Bexar 582.74 136.62 92.79 116.22 183.59 285.51 392.02 3,266.59
Superior - Bexar 601.70 140.89 94.49 113.19 182.64 302.70 397.88 3,266.59
Amerigroup - Dallas 426.29 138.58 93.71 113.34 180.30 241.48 412.62 3,537.13
Molina - Dallas 460.75 163.28 75.05 106.63 173.48 288.85 413.62 3,537.13
Parkland - Dallas 418.96 156.48 93.72 110.07 183.61 226.45 415.14 3,537.13
El Paso First - El Paso 478.46 122.81 91.57 101.32 127.97 231.15 341.83 3,443.04
Molina - El Paso 538.86 114.66 72.76 43.42 93.59 243.80 296.45 3,443.04
Superior - El Paso 542.36 124.22 90.69 115.63 147.64 236.65 340.02 3,443.04
Amerigroup - Harris 597.63 106.49 75.27 98.02 196.70 318.54 401.21 3,519.20
CHC - Harris 606.98 146.37 90.57 122.10 244.52 300.95 452.59 3,519.20
Molina - Harris 637.90 131.62 104.56 124.37 290.35 403.12 400.89 3,519.20
TCHP - Harris 501.78 139.07 104.95 144.16 256.54 263.59 438.63 3,519.20
United - Harris 651.62 146.89 95.74 142.92 324.94 431.03 374.52 3,519.20
Driscoll - Hidalgo 494.53 144.17 90.18 100.02 149.52 216.71 327.37 3,409.95
Molina - Hidalgo 450.18 129.61 94.65 102.25 159.89 312.27 315.77 3,409.95
Superior - Hidalgo 520.73 158.35 102.24 107.27 162.39 275.73 329.46 3,409.95
United - Hidalgo 526.76 155.99 102.26 105.75 181.16 284.81 328.06 3,409.95
Amerigroup - Jefferson 835.63 112.18 80.37 113.91 153.69 318.17 474.73 3,394.58
CHC - Jefferson 752.68 118.27 75.17 121.63 224.27 270.36 434.77 3,394.58
Molina - Jefferson 825.11 122.51 86.97 94.16 195.26 312.34 450.73 3,394.58
TCHP - Jefferson 679.66 118.80 89.36 129.48 252.66 268.70 461.93 3,394.58
United - Jefferson 703.80 144.27 90.51 154.21 175.26 329.62 438.00 3,394.58
Amerigroup - Lubbock 804.16 136.74 85.33 99.88 292.96 240.99 390.58 3,230.39
Firstcare - Lubbock 664.74 135.15 94.71 120.68 189.19 293.89 373.47 3,230.39
Superior - Lubbock 652.46 139.66 86.08 99.15 171.05 240.94 373.68 3,230.39
Christus - Nueces 848.56 186.51 112.71 144.50 199.44 220.58 353.21 3,203.82
Driscoll - Nueces 865.28 189.92 140.31 173.49 206.39 260.27 468.76 3,203.82
Superior - Nueces 773.63 192.18 136.61 145.41 137.91 337.20 482.31 3,203.82
Aetna - Tarrant 561.41 146.46 93.01 98.13 228.02 249.92 348.33 3,635.64
Amerigroup - Tarrant 518.35 132.68 97.96 118.66 200.22 301.18 329.62 3,635.64
Cook - Tarrant 532.56 157.58 117.89 139.86 208.94 229.05 324.03 3,635.64
Blue Cross - Travis 658.05 157.79 88.37 113.74 109.57 265.18 508.48 3,247.49
Sendero - Travis 669.92 172.42 99.74 137.57 175.53 210.12 499.44 3,247.49
Seton - Travis 546.32 144.91 88.16 123.21 149.21 244.45 478.70 3,247.49
Superior - Travis 646.36 142.52 100.78 129.08 168.57 294.29 507.46 3,247.49
Amerigroup - MRSA Central 557.64 103.53 73.17 81.86 161.56 220.82 391.66 3,035.27
Scott & White - MRSA Central 542.61 140.84 97.51 136.02 198.10 266.15 407.23 3,035.27
Superior - MRSA Central 531.15 116.27 81.91 105.80 171.89 264.10 396.02 3,035.27
Amerigroup - MRSA Northeast 630.95 120.16 83.76 108.00 301.53 271.74 401.19 3,160.40
Superior - MRSA Northeast 548.86 113.39 77.23 107.94 267.45 267.60 410.26 3,160.40
Amerigroup - MRSA West 535.31 103.09 70.32 99.72 243.68 266.52 428.84 3,204.07
Firstcare - MRSA West 528.60 120.01 81.90 119.54 202.40 285.35 414.85 3,204.07
Superior - MRSA West 506.23 106.57 80.52 110.83 184.85 270.26 410.71 3,204.07
23
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Prescription Drug Premium Rates pmpm
Aetna - Bexar 19.06 23.05 33.28 36.14 32.48 91.39 49.92
Amerigroup - Bexar 18.75 23.08 31.17 25.98 25.27 99.85 51.27
CFHP - Bexar 18.24 21.60 39.81 38.28 34.30 104.51 50.74
Superior - Bexar 18.84 22.27 40.53 37.28 34.12 110.80 51.50
Amerigroup - Dallas 27.12 26.40 39.69 42.15 34.84 84.74 46.60
Molina - Dallas 29.31 31.11 31.79 39.65 33.53 101.37 46.71
Parkland - Dallas 26.65 29.81 39.70 40.93 35.48 79.47 46.89
El Paso First - El Paso 28.74 24.98 36.60 44.35 17.75 86.44 44.09
Molina - El Paso 32.36 23.32 29.08 19.01 12.98 91.17 38.24
Superior - El Paso 32.57 25.26 36.24 50.61 20.47 88.49 43.86
Amerigroup - Harris 28.66 22.17 31.20 31.34 44.93 116.27 53.20
CHC - Harris 26.09 26.72 32.99 32.66 44.87 95.63 54.04
Molina - Harris 27.42 24.02 38.09 33.26 53.28 128.09 47.87
TCHP - Harris 21.57 25.39 38.23 38.56 47.07 83.76 52.38
United - Harris 28.71 32.26 40.38 47.29 48.90 136.76 56.00
Driscoll - Hidalgo 46.40 45.39 44.72 43.92 42.00 101.64 49.72
Molina - Hidalgo 42.24 40.81 46.93 44.90 44.91 146.46 47.96
Superior - Hidalgo 48.86 49.85 50.69 47.11 45.62 129.32 50.04
United - Hidalgo 49.43 49.11 50.70 46.44 50.89 133.58 49.83
Amerigroup - Jefferson 33.77 32.59 51.10 45.25 32.06 159.71 48.03
CHC - Jefferson 32.28 30.59 48.17 43.92 36.42 113.96 43.82
Molina - Jefferson 35.38 31.69 55.73 34.00 31.71 131.66 45.43
TCHP - Jefferson 29.15 30.73 57.26 46.75 41.03 113.27 46.56
United - Jefferson 31.54 35.52 59.49 43.63 35.12 150.78 45.61
Amerigroup - Lubbock 28.51 27.26 38.16 34.98 51.37 109.42 42.32
Firstcare - Lubbock 23.56 26.95 42.35 42.26 33.17 133.44 40.47
Superior - Lubbock 23.13 27.85 38.49 34.72 29.99 109.40 40.49
Christus - Nueces 33.36 30.20 52.26 49.48 19.10 93.65 46.39
Driscoll - Nueces 31.62 34.18 57.92 48.96 21.34 98.16 46.63
Superior - Nueces 33.07 37.51 60.93 44.19 18.72 127.59 45.37
Aetna - Tarrant 26.45 23.54 33.42 29.61 118.27 100.89 53.97
Amerigroup - Tarrant 24.42 21.33 35.20 35.80 103.85 121.58 51.07
Cook - Tarrant 25.09 25.33 42.36 42.20 108.37 92.46 50.21
Blue Cross - Travis 20.99 19.17 28.84 33.95 18.28 95.61 47.09
Sendero - Travis 21.37 20.94 32.55 41.06 29.29 75.76 46.26
Seton - Travis 17.43 17.60 28.76 36.50 23.91 88.12 44.70
Superior - Travis 20.62 17.31 32.89 38.53 28.13 106.11 47.00
Amerigroup - MRSA Central 21.36 16.96 33.99 29.93 21.19 82.32 37.42
Scott & White - MRSA Central 20.78 23.07 45.29 49.73 25.98 99.22 38.91
Superior - MRSA Central 20.34 19.05 38.04 38.68 22.54 98.45 37.84
Amerigroup - MRSA Northeast 28.72 26.61 44.91 44.48 41.71 117.67 43.02
Superior - MRSA Northeast 24.98 25.11 41.41 44.46 36.99 115.88 43.99
Amerigroup - MRSA West 20.02 19.42 33.46 36.06 48.58 115.09 35.19
Firstcare - MRSA West 19.76 22.61 38.97 43.23 40.35 123.22 34.04
Superior - MRSA West 18.93 20.08 38.31 40.08 36.85 116.70 33.70
24
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 NAIP Premium Rates pmpm
Aetna - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Bexar 1.81 1.81 1.81 1.81 1.81 1.81 1.81
CFHP - Bexar 30.18 30.18 30.18 30.18 30.18 30.18 30.18
Superior - Bexar 22.78 22.78 22.78 22.78 22.78 22.78 22.78
Amerigroup - Dallas 17.71 17.71 17.71 17.71 17.71 17.71 17.71
Molina - Dallas 15.50 15.50 15.50 15.50 15.50 15.50 15.50
Parkland - Dallas 15.27 15.27 15.27 15.27 15.27 15.27 15.27
El Paso First - El Paso 35.70 35.70 35.70 35.70 35.70 35.70 35.70
Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - El Paso 30.61 30.61 30.61 30.61 30.61 30.61 30.61
Amerigroup - Harris 32.69 32.69 32.69 32.69 32.69 32.69 32.69
CHC - Harris 28.85 28.85 28.85 28.85 28.85 28.85 28.85
Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TCHP - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00
United - Harris 42.65 42.65 42.65 42.65 42.65 42.65 42.65
Driscoll - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Hidalgo 4.93 4.93 4.93 4.93 4.93 4.93 4.93
United - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Jefferson 42.12 42.12 42.12 42.12 42.12 42.12 42.12
CHC - Jefferson 25.15 25.15 25.15 25.15 25.15 25.15 25.15
Molina - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
TCHP - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00
United - Jefferson 23.25 23.25 23.25 23.25 23.25 23.25 23.25
Amerigroup - Lubbock 53.69 53.69 53.69 53.69 53.69 53.69 53.69
Firstcare - Lubbock 21.49 21.49 21.49 21.49 21.49 21.49 21.49
Superior - Lubbock 26.99 26.99 26.99 26.99 26.99 26.99 26.99
Christus - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Driscoll - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Nueces 2.93 2.93 2.93 2.93 2.93 2.93 2.93
Aetna - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - Tarrant 10.55 10.55 10.55 10.55 10.55 10.55 10.55
Cook - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Blue Cross - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Sendero - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Seton - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - Travis 2.93 2.93 2.93 2.93 2.93 2.93 2.93
Amerigroup - MRSA Central 1.81 1.81 1.81 1.81 1.81 1.81 1.81
Scott & White - MRSA Central 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Superior - MRSA Central 5.54 5.54 5.54 5.54 5.54 5.54 5.54
Amerigroup - MRSA Northeast 1.81 1.81 1.81 1.81 1.81 1.81 1.81
Superior - MRSA Northeast 0.00 0.00 0.00 0.00 0.00 0.00 0.00
Amerigroup - MRSA West 61.84 61.84 61.84 61.84 61.84 61.84 61.84
Firstcare - MRSA West 36.83 36.83 36.83 36.83 36.83 36.83 36.83
Superior - MRSA West 20.73 20.73 20.73 20.73 20.73 20.73 20.73
25
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Total Premium Rates pmpm
Aetna - Bexar 568.20 134.13 103.68 130.28 183.12 334.08 339.23 3,266.59
Amerigroup - Bexar 520.40 155.74 114.58 124.01 175.87 384.84 378.81 3,266.59
CFHP - Bexar 631.16 188.40 162.78 184.68 248.07 420.20 472.94 3,266.59
Superior - Bexar 643.32 185.94 157.80 173.25 239.54 436.28 472.16 3,266.59
Amerigroup - Dallas 471.12 182.69 151.11 173.20 232.85 343.93 476.93 3,537.13
Molina - Dallas 505.56 209.89 122.34 161.78 222.51 405.72 475.83 3,537.13
Parkland - Dallas 460.88 201.56 148.69 166.27 234.36 321.19 477.30 3,537.13
El Paso First - El Paso 542.90 183.49 163.87 181.37 181.42 353.29 421.62 3,443.04
Molina - El Paso 571.22 137.98 101.84 62.43 106.57 334.97 334.69 3,443.04
Superior - El Paso 605.54 180.09 157.54 196.85 198.72 355.75 414.49 3,443.04
Amerigroup - Harris 658.98 161.35 139.16 162.05 274.32 467.50 487.10 3,519.20
CHC - Harris 661.92 201.94 152.41 183.61 318.24 425.43 535.48 3,519.20
Molina - Harris 665.32 155.64 142.65 157.63 343.63 531.21 448.76 3,519.20
TCHP - Harris 523.35 164.46 143.18 182.72 303.61 347.35 491.01 3,519.20
United - Harris 722.98 221.80 178.77 232.86 416.49 610.44 473.17 3,519.20
Driscoll - Hidalgo 540.93 189.56 134.90 143.94 191.52 318.35 377.09 3,409.95
Molina - Hidalgo 492.42 170.42 141.58 147.15 204.80 458.73 363.73 3,409.95
Superior - Hidalgo 574.52 213.13 157.86 159.31 212.94 409.98 384.43 3,409.95
United - Hidalgo 576.19 205.10 152.96 152.19 232.05 418.39 377.89 3,409.95
Amerigroup - Jefferson 911.52 186.89 173.59 201.28 227.87 520.00 564.88 3,394.58
CHC - Jefferson 810.11 174.01 148.49 190.70 285.84 409.47 503.74 3,394.58
Molina - Jefferson 860.49 154.20 142.70 128.16 226.97 444.00 496.16 3,394.58
TCHP - Jefferson 708.81 149.53 146.62 176.23 293.69 381.97 508.49 3,394.58
United - Jefferson 758.59 203.04 173.25 221.09 233.63 503.65 506.86 3,394.58
Amerigroup - Lubbock 886.36 217.69 177.18 188.55 398.02 404.10 486.59 3,230.39
Firstcare - Lubbock 709.79 183.59 158.55 184.43 243.85 448.82 435.43 3,230.39
Superior - Lubbock 702.58 194.50 151.56 160.86 228.03 377.33 441.16 3,230.39
Christus - Nueces 881.92 216.71 164.97 193.98 218.54 314.23 399.60 3,203.82
Driscoll - Nueces 896.90 224.10 198.23 222.45 227.73 358.43 515.39 3,203.82
Superior - Nueces 809.63 232.62 200.47 192.53 159.56 467.72 530.61 3,203.82
Aetna - Tarrant 587.86 170.00 126.43 127.74 346.29 350.81 402.30 3,635.64
Amerigroup - Tarrant 553.32 164.56 143.71 165.01 314.62 433.31 391.24 3,635.64
Cook - Tarrant 557.65 182.91 160.25 182.06 317.31 321.51 374.24 3,635.64
Blue Cross - Travis 679.04 176.96 117.21 147.69 127.85 360.79 555.57 3,247.49
Sendero - Travis 691.29 193.36 132.29 178.63 204.82 285.88 545.70 3,247.49
Seton - Travis 563.75 162.51 116.92 159.71 173.12 332.57 523.40 3,247.49
Superior - Travis 669.91 162.76 136.60 170.54 199.63 403.33 557.39 3,247.49
Amerigroup - MRSA Central 580.81 122.30 108.97 113.60 184.56 304.95 430.89 3,035.27
Scott & White - MRSA Central 563.39 163.91 142.80 185.75 224.08 365.37 446.14 3,035.27
Superior - MRSA Central 557.03 140.86 125.49 150.02 199.97 368.09 439.40 3,035.27
Amerigroup - MRSA Northeast 661.48 148.58 130.48 154.29 345.05 391.22 446.02 3,160.40
Superior - MRSA Northeast 573.84 138.50 118.64 152.40 304.44 383.48 454.25 3,160.40
Amerigroup - MRSA West 617.17 184.35 165.62 197.62 354.10 443.45 525.87 3,204.07
Firstcare - MRSA West 585.19 179.45 157.70 199.60 279.58 445.40 485.72 3,204.07
Superior - MRSA West 545.89 147.38 139.56 171.64 242.43 407.69 465.14 3,204.07
26
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Medical Premium Rate Change
Aetna - Bexar -9.3% -12.3% -14.8% -15.1% -58.4% -17.6% -28.5% 0.0%
Amerigroup - Bexar 6.7% -15.8% 44.7% 20.6% -44.6% 29.9% -2.6% 0.0%
CFHP - Bexar 10.1% 0.7% 4.7% -0.1% -38.5% -14.6% 2.3% 0.0%
Superior - Bexar -2.8% -5.8% -0.6% -7.4% -53.4% -12.8% -1.4% 0.0%
Amerigroup - Dallas -13.9% -3.4% 1.3% -1.2% -40.6% -6.7% 9.0% 0.0%
Molina - Dallas -12.2% -3.2% 0.4% 21.7% -31.5% 14.5% 13.8% 0.0%
Parkland - Dallas -19.7% 0.3% -1.9% -6.3% -39.8% -7.1% 8.1% 0.0%
El Paso First - El Paso -4.5% 3.0% 3.7% 0.4% -47.4% -7.5% 4.0% 0.0%
Molina - El Paso 6.3% -21.3% 34.9% -35.4% -42.0% 30.5% 0.5% 0.0%
Superior - El Paso -13.0% -4.2% -0.4% 9.0% -45.6% -6.1% 3.8% 0.0%
Amerigroup - Harris 3.5% -6.7% 6.8% 2.1% -41.8% -5.1% 5.1% 0.0%
CHC - Harris 1.5% 7.9% 7.2% 9.8% -35.8% -9.2% 5.1% 0.0%
Molina - Harris 8.9% -14.5% 18.4% 8.3% -2.2% 30.4% 3.3% 0.0%
TCHP - Harris -3.7% -3.3% 2.5% 6.0% -32.1% -12.1% 4.9% 0.0%
United - Harris 10.9% -14.7% 1.8% 10.0% -24.8% 8.6% -8.8% 0.0%
Driscoll - Hidalgo 13.3% -5.6% 2.6% -3.0% -37.8% 13.4% 4.0% 0.0%
Molina - Hidalgo 5.0% -21.6% -10.1% 1.6% -43.9% 14.4% -0.4% 0.0%
Superior - Hidalgo 6.9% -14.7% -7.3% -5.3% -41.6% -5.9% 1.9% 0.0%
United - Hidalgo 14.9% -18.3% -0.9% -6.0% -41.2% 5.1% 1.9% 0.0%
Amerigroup - Jefferson 34.0% -9.3% 13.0% 30.2% -59.4% -8.8% 27.6% 0.0%
CHC - Jefferson 16.1% 8.4% -8.2% 20.8% -25.6% -7.8% 6.8% 0.0%
Molina - Jefferson 49.3% -7.5% -9.5% 0.3% -40.1% -7.2% 12.7% 0.0%
TCHP - Jefferson 1.3% 5.8% 2.6% 11.0% -25.8% -13.1% 9.1% 0.0%
United - Jefferson 14.0% 34.2% 15.6% 69.1% -36.3% -6.2% 11.1% 0.0%
Amerigroup - Lubbock 44.0% 18.2% 24.0% 0.1% -17.7% 19.3% 4.1% 0.0%
Firstcare - Lubbock 12.6% 11.9% 20.0% 3.4% -35.5% -6.0% -2.1% 0.0%
Superior - Lubbock -2.7% 26.5% 10.3% -19.2% -29.4% -16.2% -3.0% 0.0%
Christus - Nueces 42.3% 19.4% 8.0% 11.6% -4.0% 3.8% -15.6% 0.0%
Driscoll - Nueces 24.2% 5.9% 11.6% -4.4% -36.9% -6.5% 12.2% 0.0%
Superior - Nueces -3.7% 3.1% 9.6% -8.6% -58.6% -2.4% 11.2% 0.0%
Aetna - Tarrant 12.1% 40.1% 31.8% 6.1% -17.4% -15.8% 11.8% 0.0%
Amerigroup - Tarrant -2.1% -5.1% 14.0% 3.1% -25.3% -6.2% 6.2% 0.0%
Cook - Tarrant -8.9% -3.9% -2.4% -12.7% -27.5% -10.4% 5.7% 0.0%
Blue Cross - Travis 15.1% 28.7% 15.1% 34.3% -54.9% -4.3% -1.3% 0.0%
Sendero - Travis 36.3% -7.3% 30.0% 26.6% 19.0% 4.4% 4.9% 0.0%
Seton - Travis 17.4% 16.5% 11.7% 21.7% -34.2% 4.9% 4.5% 0.0%
Superior - Travis 7.2% 0.4% 10.6% 12.4% -36.7% -10.2% -3.1% 0.0%
Amerigroup - MRSA Central 12.7% 0.9% -3.3% -4.1% -37.5% -10.6% 3.1% 0.0%
Scott & White - MRSA Central -3.4% -0.3% 8.9% 8.6% -30.3% -0.5% 7.1% 0.0%
Superior - MRSA Central 3.1% -3.1% -0.7% 6.0% -40.5% -6.6% 0.0% 0.0%
Amerigroup - MRSA Northeast 27.9% 3.3% 5.9% 6.0% 15.9% -1.2% 0.2% 0.0%
Superior - MRSA Northeast 8.3% -1.9% -2.8% 8.4% -11.7% -5.7% 4.5% 0.0%
Amerigroup - MRSA West -9.5% -10.5% -8.2% 0.2% -8.7% 13.3% 9.0% 0.0%
Firstcare - MRSA West -6.4% 3.7% 1.1% 13.6% -33.8% -7.8% 5.7% 0.0%
Superior - MRSA West -3.0% 2.6% -2.8% 2.6% -42.4% -5.7% 3.6% 0.0%
27
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Prescription Drug Premium Rate Change
Aetna - Bexar -13.5% 17.5% -13.1% 7.3% 3.3% -11.9% 3.6%
Amerigroup - Bexar -2.1% -14.6% 6.2% -4.6% -3.5% 15.8% 14.5%
CFHP - Bexar -5.3% 2.9% -3.0% 8.3% 32.4% -11.2% 11.1%
Superior - Bexar -16.4% -3.8% -7.9% 0.3% 0.4% -9.3% 7.2%
Amerigroup - Dallas 1.2% 5.2% 12.4% 11.0% -11.6% -4.4% -1.0%
Molina - Dallas 3.2% 5.4% 11.5% 36.7% 1.9% 17.4% 3.4%
Parkland - Dallas -5.6% 9.2% 9.0% 5.3% -10.4% -4.8% -1.7%
El Paso First - El Paso -2.1% 5.4% 7.3% 21.6% -67.7% -7.5% 23.6%
Molina - El Paso 9.0% -19.5% 39.6% -21.7% -64.4% 30.4% 19.4%
Superior - El Paso -10.8% -2.0% 3.0% 32.0% -66.6% -6.1% 23.3%
Amerigroup - Harris -11.4% -3.4% 10.6% 9.0% 31.1% -6.5% 0.7%
CHC - Harris -13.0% 9.4% 9.0% 9.6% 29.8% -13.0% 1.3%
Molina - Harris -6.6% -13.3% 20.4% 8.1% 97.6% 25.0% -0.4%
TCHP - Harris -17.5% -2.0% 4.2% 5.8% 37.2% -15.7% 1.1%
United - Harris -9.0% -2.8% 12.0% 26.9% 16.5% -2.8% 2.9%
Driscoll - Hidalgo -6.8% 13.1% 18.8% 6.6% 23.6% 11.8% 4.5%
Molina - Hidalgo -13.6% -6.1% 4.0% 11.7% 11.4% 12.7% 0.1%
Superior - Hidalgo -12.1% 2.2% 7.3% 4.2% 16.0% -7.3% 2.4%
United - Hidalgo -5.6% -2.2% 14.6% 3.2% 16.7% 3.4% 2.3%
Amerigroup - Jefferson -10.3% -9.2% 13.5% 13.3% -46.5% 13.7% 10.7%
CHC - Jefferson -13.2% 1.7% -2.2% 0.6% -19.5% 1.6% -2.9%
Molina - Jefferson 11.5% -13.3% -3.6% -16.5% -35.2% 2.3% 2.5%
TCHP - Jefferson -24.3% -0.7% 9.3% -7.6% -19.8% -4.2% -0.8%
United - Jefferson -13.1% 17.0% 23.3% 7.7% -17.0% 9.6% 1.9%
Amerigroup - Lubbock 18.3% 17.0% 24.1% 20.7% -40.1% 31.4% 11.7%
Firstcare - Lubbock -7.5% 10.8% 20.1% 24.6% -53.1% 3.6% 5.0%
Superior - Lubbock -20.3% 25.0% 10.1% -2.8% -48.7% -7.9% 3.7%
Christus - Nueces 18.1% 3.8% 17.8% 57.4% -9.4% 7.3% 2.5%
Driscoll - Nueces -4.2% 2.3% 8.4% 9.8% -34.8% -13.5% 3.4%
Superior - Nueces -15.2% 5.4% 12.1% 10.3% -45.2% -11.5% -5.4%
Aetna - Tarrant 25.4% 56.9% 32.8% 9.2% 108.6% -8.6% 3.9%
Amerigroup - Tarrant 9.5% 6.3% 14.9% 6.2% 88.6% 1.9% -1.3%
Cook - Tarrant 1.9% 7.7% -1.7% -10.2% 83.1% -2.7% -1.7%
Blue Cross - Travis -9.1% 21.0% 15.8% 35.2% -29.2% 0.3% 7.6%
Sendero - Travis 7.7% -12.9% 30.8% 27.5% 86.7% 9.4% 14.4%
Seton - Travis -7.2% 9.5% 12.3% 22.4% -0.3% 9.6% 13.9%
Superior - Travis -15.3% -5.6% 11.3% 13.3% -0.7% -5.8% 5.7%
Amerigroup - MRSA Central 5.1% 9.8% 3.3% 2.8% -16.0% -12.1% 0.3%
Scott & White - MRSA Central -11.2% 7.1% 14.6% 14.8% -7.5% -3.4% 2.7%
Superior - MRSA Central -3.8% 5.5% 6.0% 13.7% -20.0% -8.1% -2.6%
Amerigroup - MRSA Northeast 8.7% 9.5% 7.9% 15.3% 11.0% -4.0% -2.1%
Superior - MRSA Northeast -8.0% 3.8% -1.0% 17.9% -15.4% -8.4% 2.0%
Amerigroup - MRSA West -26.2% -9.2% -4.9% 11.0% 27.4% 20.5% 7.2%
Firstcare - MRSA West -23.7% 5.3% 4.8% 25.9% -7.7% -2.0% 3.9%
Superior - MRSA West -20.9% 4.1% 0.7% 13.6% -19.6% 0.3% 1.9%
28
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 NAIP Premium Rate Change
Aetna - Bexar 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - Bexar 1.7% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7%
CFHP - Bexar 35.4% 35.4% 35.4% 35.4% 35.4% 35.4% 35.4%
Superior - Bexar 296.9% 296.9% 296.9% 296.9% 296.9% 296.9% 296.9%
Amerigroup - Dallas 11.5% 11.5% 11.5% 11.5% 11.5% 11.5% 11.5%
Molina - Dallas -7.7% -7.7% -7.7% -7.7% -7.7% -7.7% -7.7%
Parkland - Dallas 13.0% 13.0% 13.0% 13.0% 13.0% 13.0% 13.0%
El Paso First - El Paso 8.4% 8.4% 8.4% 8.4% 8.4% 8.4% 8.4%
Molina - El Paso 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - El Paso 20.4% 20.4% 20.4% 20.4% 20.4% 20.4% 20.4%
Amerigroup - Harris 7.0% 7.0% 7.0% 7.0% 7.0% 7.0% 7.0%
CHC - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Molina - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
TCHP - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
United - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Driscoll - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Molina - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - Hidalgo 210.1% 210.1% 210.1% 210.1% 210.1% 210.1% 210.1%
United - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - Jefferson 2266.3% 2266.3% 2266.3% 2266.3% 2266.3% 2266.3% 2266.3%
CHC - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Molina - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
TCHP - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
United - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - Lubbock 371.0% 371.0% 371.0% 371.0% 371.0% 371.0% 371.0%
Firstcare - Lubbock 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - Lubbock 334.6% 334.6% 334.6% 334.6% 334.6% 334.6% 334.6%
Christus - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Driscoll - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Aetna - Tarrant 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - Tarrant 59.4% 59.4% 59.4% 59.4% 59.4% 59.4% 59.4%
Cook - Tarrant 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Blue Cross - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Sendero - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Seton - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - MRSA Central -72.7% -72.7% -72.7% -72.7% -72.7% -72.7% -72.7%
Scott & White - MRSA Central 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - MRSA Central 150.7% 150.7% 150.7% 150.7% 150.7% 150.7% 150.7%
Amerigroup - MRSA Northeast -72.7% -72.7% -72.7% -72.7% -72.7% -72.7% -72.7%
Superior - MRSA Northeast 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Amerigroup - MRSA West 280.8% 280.8% 280.8% 280.8% 280.8% 280.8% 280.8%
Firstcare - MRSA West 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
Superior - MRSA West 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
29
Attachment 1
FY2016 STAR Rating Summary
Under Ages Ages Ages Ages TANF Pregnant
Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP
FY2016 Total Premium Rate Change
Aetna - Bexar -9.4% -8.3% -14.3% -9.9% -53.5% -16.1% -25.1% 0.0%
Amerigroup - Bexar 6.3% -15.5% 30.9% 14.0% -40.7% 25.8% -0.6% 0.0%
CFHP - Bexar 10.5% 5.3% 7.1% 6.1% -28.4% -11.4% 4.8% 0.0%
Superior - Bexar -0.6% 4.2% 8.9% 4.9% -44.5% -8.1% 3.3% 0.0%
Amerigroup - Dallas -12.4% -0.9% 5.1% 2.8% -35.1% -5.4% 8.0% 0.0%
Molina - Dallas -11.3% -2.4% 1.9% 21.3% -26.5% 14.1% 11.9% 0.0%
Parkland - Dallas -18.2% 2.4% 2.2% -2.1% -34.5% -5.8% 7.2% 0.0%
El Paso First - El Paso -3.7% 4.4% 5.5% 6.5% -45.2% -6.1% 6.2% 0.0%
Molina - El Paso 6.5% -21.0% 36.2% -31.8% -46.1% 30.5% 2.3% 0.0%
Superior - El Paso -11.6% -0.5% 3.9% 15.9% -44.5% -4.3% 6.6% 0.0%
Amerigroup - Harris 2.9% -3.8% 7.7% 4.3% -31.9% -4.7% 4.7% 0.0%
CHC - Harris 5.4% 26.1% 32.9% 30.2% -23.4% -3.6% 10.6% 0.0%
Molina - Harris 8.2% -14.3% 18.9% 8.3% 6.1% 29.0% 2.9% 0.0%
TCHP - Harris -4.4% -3.1% 3.0% 6.0% -26.4% -13.0% 4.5% 0.0%
United - Harris 16.7% 8.0% 37.4% 39.3% -12.1% 13.6% 1.8% 0.0%
Driscoll - Hidalgo 11.3% -1.7% 7.4% -0.2% -30.2% 12.9% 4.1% 0.0%
Molina - Hidalgo 3.1% -18.4% -5.9% 4.5% -37.1% 13.8% -0.3% 0.0%
Superior - Hidalgo 5.6% -9.7% -0.8% -0.5% -33.3% -5.6% 2.9% 0.0%
United - Hidalgo 12.8% -14.9% 3.8% -3.3% -34.0% 4.5% 2.0% 0.0%
Amerigroup - Jefferson 37.5% 15.9% 47.2% 55.8% -48.2% 5.8% 35.4% 0.0%
CHC - Jefferson 18.2% 25.0% 13.2% 32.1% -17.5% 1.0% 11.4% 0.0%
Molina - Jefferson 47.2% -8.8% -7.3% -4.8% -39.4% -4.6% 11.7% 0.0%
TCHP - Jefferson -0.1% 4.4% 5.1% 5.4% -25.0% -10.7% 8.1% 0.0%
United - Jefferson 16.0% 47.2% 36.9% 67.8% -26.4% 3.0% 15.5% 0.0%
Amerigroup - Lubbock 49.2% 44.8% 59.6% 34.6% -12.2% 36.2% 14.7% 0.0%
Firstcare - Lubbock 15.3% 26.5% 38.9% 22.4% -33.1% 1.7% 3.7% 0.0%
Superior - Lubbock -0.5% 40.1% 27.2% -2.3% -25.7% -8.5% 2.4% 0.0%
Christus - Nueces 41.2% 17.0% 10.9% 20.6% -4.5% 4.8% -13.9% 0.0%
Driscoll - Nueces 22.9% 5.3% 10.6% -1.6% -36.8% -8.5% 11.3% 0.0%
Superior - Nueces -3.9% 4.8% 12.0% -3.3% -56.6% -4.5% 10.1% 0.0%
Aetna - Tarrant 12.7% 42.2% 32.1% 6.8% 4.0% -13.8% 10.7% 0.0%
Amerigroup - Tarrant -0.9% -1.2% 16.7% 6.2% -4.6% -3.0% 6.1% 0.0%
Cook - Tarrant -8.4% -2.4% -2.2% -12.1% -8.7% -8.3% 4.7% 0.0%
Blue Cross - Travis 14.2% 27.8% 15.2% 34.5% -52.4% -3.1% -0.6% 0.0%
Sendero - Travis 35.2% -8.0% 30.2% 26.8% 25.5% 5.7% 5.6% 0.0%
Seton - Travis 16.4% 15.7% 11.8% 21.9% -30.9% 6.1% 5.2% 0.0%
Superior - Travis 6.8% 1.5% 13.2% 14.6% -32.3% -8.4% -1.9% 0.0%
Amerigroup - MRSA Central 11.3% -1.9% -5.4% -6.2% -36.5% -12.2% 1.7% 0.0%
Scott & White - MRSA Central -3.7% 0.7% 10.6% 10.2% -28.2% -1.3% 6.7% 0.0%
Superior - MRSA Central 3.4% 0.4% 4.1% 10.3% -37.4% -6.1% 0.6% 0.0%
Amerigroup - MRSA Northeast 25.7% 0.9% 2.5% 4.9% 13.4% -3.2% -1.1% 0.0%
Superior - MRSA Northeast 7.5% -0.9% -2.2% 11.0% -12.2% -6.5% 4.3% 0.0%
Amerigroup - MRSA West -2.8% 20.7% 29.4% 33.3% 10.2% 27.8% 18.9% 0.0%
Firstcare - MRSA West -1.0% 30.8% 33.4% 43.0% -20.0% 2.3% 14.2% 0.0%
Superior - MRSA West 0.0% 19.6% 15.4% 19.7% -33.9% 1.2% 8.3% 0.0%
30
31
Attachment 2
Individual Health Plan Experience Analysis
The following exhibits present a summary of the experience analysis performed for each health
plan. The exhibits in this section use hypothetical experience data from a sample health plan.
The actual analysis is based on experience data provided by each health plan. This data was
checked for reasonableness by comparing to other data sources provided by HHSC, the EQRO
and the health plan. Below is a brief description of each of the exhibits contained in this
attachment.
Exhibit A. This exhibit shows monthly enrollment and number of maternity deliveries by risk
group for the period September 2011 through February 2015. All of this information was
provided by HHSC.
Exhibit B. This exhibit shows a sample of a claim lag report for one risk group. This report
includes claim amounts by payment month and month of service. We analyzed claims
experience for the period September 2011 through February 2015.
Exhibit C. This exhibit shows the calculation of estimated monthly incurred claims for one risk
group. The report includes the following information: (i) monthly enrollment, (ii) claim amounts
incurred in that month and paid through February 28, 2015, (iii) estimated proportion of that
month’s incurred claims paid through February 28, 2015 (completion factor), (iv) estimated
incurred claims, (v) estimated incurred claims pmpm and (vi) the ratio of this month’s incurred
claims pmpm to the same statistic from one year ago (trend factor). The assumed completion
factors were derived based on the actual historical claims payment pattern of the health plan
using standard actuarial techniques. The claims payment patterns were analyzed by duration
since incurral to determine the average percentage of claims paid after each successive month.
Exhibit D. This exhibit is a summary of the sample health plan’s projected FY2016 cost based
on the health plan’s actual experience. The top of the exhibit shows summary base period
(FY2014) enrollment and claims experience. Next is projected FY2016 enrollment. Trend
assumptions for FY2015 and FY2016 are used to project the average base period claims cost to
FY2016. Adjustment factors are used to recognize the cost impact of benefit and provider
reimbursement changes. Combining these factors results in projected FY2016 incurred claims.
In addition to incurred claims, provision is also made for services that are capitated by the health
plan, such as vision and behavioral health services. The cost of reinsurance is also considered.
In developing the cost of reinsurance, an assumption is made regarding how much the health
plan is expected to receive in reinsurance recoveries (reimbursements from the reinsurance
company for large claims). We have assumed that the net cost of reinsurance (reinsurance
premium less reinsurance recoveries) is the minimum of (a) the actual reinsurance premium rate
and (b) $0.75 pmpm.
A provision for administrative expenses is included in the amount of $8.00 pmpm and 5.75% of
gross premium. Additional provisions are also included for premium tax (1.75% of premium),
maintenance tax ($0.07 pmpm) and risk margin (2.0% of premium).
32
At the bottom of Exhibit D is a summary of the projected FY2016 cost based on the above
assumptions. Cost projections are presented both with and without the inclusion of maternity
expenses.
Attachment 2 - Exhibit A
Sample HMO
Enrollment and Premium Experience
Number of Members
Age Age Age Age Age TANF Pregnant Total
Month <1 1-5 6-14 15-18 19-20 Adults Women Members
Sep-11 8,889 28,063 30,464 8,556 344 3,418 4,639 84,373
Oct-11 8,789 27,975 30,515 8,587 319 3,511 4,502 84,198
Nov-11 8,804 28,499 31,171 8,772 343 3,638 4,559 85,786
Dec-11 8,830 28,596 31,428 8,841 364 3,821 4,567 86,447
Jan-12 8,838 28,265 31,351 8,825 388 3,935 4,493 86,095
Feb-12 8,921 28,264 31,548 8,930 363 3,962 4,611 86,599
Mar-12 9,076 28,716 31,622 8,790 355 3,930 4,678 87,167
Apr-12 9,068 29,225 32,218 8,950 382 3,963 4,847 88,653
May-12 9,116 29,193 32,319 8,944 364 4,026 4,919 88,881
Jun-12 9,095 29,224 32,515 8,885 363 4,088 4,965 89,135
Jul-12 9,124 29,220 32,685 8,911 377 4,169 5,095 89,581
Aug-12 9,127 29,034 32,455 8,825 363 4,152 5,232 89,188
Sep-12 9,149 28,885 32,410 8,726 365 4,149 5,284 88,968
Oct-12 9,102 28,741 32,332 8,584 337 4,073 5,061 88,230
Nov-12 9,123 29,197 32,756 8,739 354 4,041 4,951 89,161
Dec-12 9,267 29,604 33,337 8,909 406 4,273 4,880 90,676
Jan-13 9,419 29,538 33,548 8,999 400 4,383 4,783 91,070
Feb-13 9,463 29,220 33,427 9,001 398 4,359 4,885 90,753
Mar-13 9,496 29,160 33,245 8,993 390 4,442 4,957 90,683
Apr-13 9,518 29,523 33,814 9,012 412 4,489 4,990 91,758
May-13 9,602 29,320 33,979 8,980 390 4,544 5,064 91,879
Jun-13 9,632 29,430 34,286 9,030 385 4,606 5,168 92,537
Jul-13 9,727 29,580 34,650 9,143 385 4,661 5,356 93,502
Aug-13 9,677 29,230 34,488 9,115 364 4,556 5,286 92,716
Sep-13 9,832 29,213 34,684 9,124 378 4,625 5,294 93,150
Oct-13 9,756 28,938 34,435 9,018 361 4,634 5,194 92,336
Nov-13 9,657 29,117 34,803 9,009 375 4,674 5,140 92,775
Dec-13 9,710 28,703 34,533 8,974 362 4,557 4,851 91,690
Jan-14 9,634 27,972 33,776 8,774 323 4,335 4,643 89,457
Feb-14 9,637 27,786 33,872 8,714 314 4,320 4,674 89,317
Mar-14 9,567 27,346 33,384 8,620 309 4,245 4,636 88,107
Apr-14 9,479 27,446 34,223 8,876 303 4,438 4,901 89,666
May-14 9,410 27,462 34,917 9,132 320 4,645 5,044 90,930
Jun-14 9,294 27,916 35,853 9,600 302 4,780 5,135 92,880
Jul-14 9,476 29,088 37,664 10,204 315 5,225 5,264 97,236
Aug-14 9,527 29,576 38,891 10,635 299 5,449 5,324 99,701
Sep-14 9,569 30,153 40,099 11,057 302 5,703 5,473 102,356
Oct-14 9,640 30,483 40,965 11,373 307 5,838 5,587 104,193
Nov-14 9,613 30,633 41,618 11,599 324 5,920 5,518 105,225
Dec-14 9,822 30,846 42,235 11,827 323 6,030 5,657 106,741
Jan-15 9,748 30,477 42,025 11,855 305 5,937 5,453 105,800
Feb-15 9,744 30,134 41,601 11,818 277 5,804 5,315 104,694
FY2012 107,677 344,274 380,291 105,816 4,325 46,613 57,107 1,046,103
FY2013 113,175 351,428 402,272 107,231 4,586 52,576 60,665 1,091,933
FY2014 114,979 340,563 421,035 110,680 3,961 55,927 60,100 1,107,245
9/14-2/15 58,137 182,726 248,543 69,529 1,838 35,233 33,002 629,008
33
Attachment 2 - Exhibit A
Sample HMO
Enrollment and Premium Experience
Number of Deliveries
Age Age Age Age Age TANF Pregnant Total
Month <1 1-5 6-14 15-18 19-20 Adults Women Deliveries
Sep-11 - - - 25 1 57 512 595
Oct-11 - - - 15 1 50 474 540
Nov-11 - - - 23 1 58 452 534
Dec-11 - - - 19 1 50 497 567
Jan-12 - - - 23 1 55 498 577
Feb-12 - - - 26 1 52 515 594
Mar-12 - - - 21 1 64 495 581
Apr-12 - - - 17 1 49 461 528
May-12 - - - 20 1 52 509 582
Jun-12 - - - 21 1 54 478 554
Jul-12 - - - 20 1 49 544 614
Aug-12 - - - 16 1 59 606 682
Sep-12 - - - 17 1 60 559 637
Oct-12 - - - 22 1 55 535 613
Nov-12 - - - 31 1 53 507 592
Dec-12 - - - 19 1 73 531 624
Jan-13 - - - 15 1 64 557 637
Feb-13 - - - 17 1 54 506 578
Mar-13 - - - 17 1 50 493 561
Apr-13 - - - 17 1 60 458 536
May-13 - - - 16 1 59 506 582
Jun-13 - - - 20 1 73 493 587
Jul-13 - - - 23 1 55 536 615
Aug-13 - - - 13 1 67 611 692
Sep-13 - - - 12 11 65 523 611
Oct-13 - - - 10 2 61 519 592
Nov-13 - - 2 4 6 57 528 597
Dec-13 - - - 9 10 67 581 667
Jan-14 - - 1 9 7 69 558 644
Feb-14 - - - 7 4 37 474 522
Mar-14 - - - 8 3 34 521 566
Apr-14 - - - 9 3 28 487 527
May-14 - - - 6 1 22 518 547
Jun-14 - - - 7 1 11 505 524
Jul-14 - - - 2 1 13 559 575
Aug-14 - - - 5 1 10 606 622
Sep-14 - - - 7 2 7 571 587
Oct-14 - - - 6 1 11 551 569
Nov-14 - - 0 11 5 63 551 631
Dec-14 - - 0 9 6 60 542 618
Jan-15 - - 0 8 6 56 529 600
Feb-15 - - 0 8 5 50 524 588
FY2012 - - - 248 10 649 6,041 6,948
FY2013 - - - 229 10 723 6,292 7,254
FY2014 - - 3 88 50 474 6,379 6,994
9/14-2/15 - - 2 50 25 248 3,268 3,593
34
Attachment 2 - Exhibit B
Sample HMO
Claims Lag Report
Month
Incurred Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
<1
Sep-12 27,104 -61,274 -73,775 -444 2,222 -21 -77 -15,685 187 -1,631 -7,959 -9,359 11,481 -3,650 52 -225
Oct-12 109,902 -346,955 305,432 -117,139 2,903 119,252 401 1,283 -12,167 -6,180 -2,452 -428 10,525 -23,215 8 -165
Nov-12 -3,425 -21,289 15,325 -179,883 1,721 613 1,134 1,368 -9,413 -1,002 -1,454 -131,257 133,702 -153 104 -23,600
Dec-12 4,097 -13,953 -33,061 -16,280 -36,520 -44 -294 838 0 -8,222 13,893 -225,015 229,131 -78 326 -3,010
Jan-13 -344 -10,070 5,174 -566 -380 125 -469 737 29,901 -2,251 -3,400 -134,818 146,825 -8 37 -5,934
Feb-13 61,202 71,223 266 -7,040 366 344 391 1,537 -1,140 -2,035 -744 -63,730 76,986 0 -58 -5,336
Mar-13 449,149 -3,716 -21,925 -6,655 -1,897 -188 0 1,013 2,463 -847 -8,502 -23,208 34,724 -233 25 -429
Apr-13 196,441 914,315 172,003 -6,024 52,496 85,968 -316 145 339 -200 -6,395 -125,764 130,731 -1,951 0 -4,923
May-13 656,672 348,616 335,058 21,087 2,970 2,227 1,436 -1,208 6 -1,002 -245,842 -35,395 40,273 -31 1,691 -2,458
Jun-13 329,142 308,437 373,833 498,735 157,891 7,136 -29,300 364,481 779 -1,795 30,845 -3,518 25,824 -41 -42 -1,012
Jul-13 930,867 381,551 735,516 52,924 14,373 3,660 -5,036 3,892 489,946 2,444 1,041 696,131 -9,009 -927 545 -1,022
Aug-13 1,746,823 1,440,946 628,898 696,679 208,441 129,009 159,862 11,552 62,141 31,943 -546 1,393 -12,408 -686 166,031 -16,811
Sep-13 694,272 1,796,894 875,425 679,579 46,613 584,820 2,457 7,931 9,940 -6,864 3,577 2,147 -9,382 -344,087 1,013 153,005
Oct-13 791,209 1,480,719 1,442,124 419,473 217,682 33,126 -46,994 74,696 48,296 76,065 -13,855 48,973 32,564 14,384 -101,849
Nov-13 643,860 2,340,712 746,521 317,296 76,205 -64,789 344,896 181,670 11,524 -26,552 160,767 -159,690 13,723 48,250
Dec-13 1,042,779 1,698,818 1,020,673 229,709 617,854 -8,054 147,321 367,168 -107,192 74,822 4,402 9,943 -9,490
Jan-14 1,054,658 1,920,639 1,450,271 604,314 963,190 30,529 19,717 452,188 -17,781 -11,466 76,541 125,199
Feb-14 1,022,753 1,715,783 859,037 612,429 -30,736 371,333 12,889 45,727 -28,132 27,913 -18,263
Mar-14 864,150 1,885,744 700,681 352,130 644,204 223,507 -2,792 1,971 -4,297 -1,098
Apr-14 990,514 1,513,321 686,604 180,770 364,393 317,704 -3,713 -7,210 461,245
May-14 920,695 1,366,809 1,146,683 555,341 497,558 13,678 38,753 227,444
Jun-14 857,937 1,554,631 978,790 589,471 56,424 101,366 27,531
Jul-14 978,040 1,667,947 798,993 933,737 709,346 313,506
Aug-14 845,257 1,706,414 1,046,569 356,589 670,464
Sep-14 1,088,149 2,272,327 966,321 513,580
Oct-14 979,169 1,560,357 1,113,265
Nov-14 810,005 1,974,429
Dec-14 1,089,659
Jan-15
Feb-15
4,708,646 6,295,856 5,743,475 6,337,121 4,370,536 5,435,348 4,499,433 5,223,564 5,694,836 3,642,918 5,122,197 4,899,892 6,117,408 4,762,780 4,843,466 6,521,952
35
Attachment 2 - Exhibit C
Sample HMO
Estimated Claims Experience
Inc & Pd Compl Est Inc Est Inc
Month Members Claims Factor Claims pmpm Trend
Sep-11 8,889 5,568,036 1.000 5,568,036 626.40
Oct-11 8,789 4,105,336 1.000 4,105,336 467.10
Nov-11 8,804 4,393,010 1.000 4,393,010 498.98
Dec-11 8,830 5,450,688 1.000 5,450,688 617.29
Jan-12 8,838 4,222,501 1.000 4,222,501 477.77
Feb-12 8,921 5,820,757 1.000 5,820,757 652.48
Mar-12 9,076 5,497,505 1.000 5,497,505 605.72
Apr-12 9,068 3,523,154 1.000 3,523,154 388.53
May-12 9,116 4,998,038 1.000 4,998,038 548.27
Jun-12 9,095 5,073,071 1.000 5,073,071 557.79
Jul-12 9,124 6,591,756 1.000 6,591,756 722.46
Aug-12 9,127 4,007,656 1.000 4,007,656 439.10
Sep-12 9,149 4,827,405 1.000 4,827,405 527.64 0.842
Oct-12 9,102 5,993,544 1.000 5,993,544 658.49 1.410
Nov-12 9,123 5,439,184 1.000 5,439,184 596.21 1.195
Dec-12 9,267 6,376,812 1.000 6,376,812 688.12 1.115
Jan-13 9,419 5,388,817 1.000 5,388,817 572.12 1.197
Feb-13 9,463 4,190,812 1.000 4,190,812 442.86 0.679
Mar-13 9,496 4,248,673 1.000 4,248,673 447.42 0.739
Apr-13 9,518 6,149,566 1.000 6,149,566 646.10 1.663
May-13 9,602 6,306,788 1.000 6,306,788 656.82 1.198
Jun-13 9,632 5,448,097 1.000 5,448,097 565.62 1.014
Jul-13 9,727 6,254,666 1.000 6,254,666 643.02 0.890
Aug-13 9,677 6,159,111 1.000 6,159,111 636.47 1.449
Sep-13 9,832 4,496,955 1.000 4,496,955 457.38 0.867
Oct-13 9,756 4,516,829 1.000 4,516,829 462.98 0.703
Nov-13 9,657 4,634,966 0.999 4,639,606 480.44 0.806
Dec-13 9,710 5,088,636 0.998 5,098,834 525.11 0.763
Jan-14 9,634 6,665,737 0.999 6,672,409 692.59 1.211
Feb-14 9,637 4,597,858 0.999 4,602,460 477.58 1.078
Mar-14 9,567 4,661,407 0.998 4,670,748 488.21 1.091
Apr-14 9,479 4,507,875 0.999 4,512,387 476.04 0.737
May-14 9,410 5,331,797 0.990 5,385,654 572.33 0.871
Jun-14 9,294 4,171,207 0.986 4,230,433 455.18 0.805
Jul-14 9,476 5,425,646 0.966 5,616,611 592.72 0.922
Aug-14 9,527 4,666,528 0.944 4,943,356 518.87 0.815
Sep-14 9,569 5,359,396 0.930 5,762,791 602.24 1.317
Oct-14 9,640 5,358,307 0.904 5,927,331 614.86 1.328
Nov-14 9,613 4,583,030 0.812 5,644,126 587.12 1.222
Dec-14 9,822 4,613,264 0.711 6,488,416 660.59 1.258
FY2012 107,677 59,251,507 550.27
FY2013 113,175 66,783,476 590.09 1.072
FY2014 114,979 59,386,282 516.50 0.875
9/13-12/13 38,955 18,752,223 481.38
9/14-12/14 38,645 23,822,664 616.46 1.281
Age <1
36
Attachment 2 - Exhibit D
Sample HMO
Rating Period: 9/1/2015 - 8/31/2016
Age <1 Age 1-5
Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 114,979 340,563
Estimated Incurred Claims 59,386,282 516.50 37,197,996 109.23
Projected FY2016 Member Months 119,554 373,675
Annual Cost Trend Assumptions
FY2015 7.8 % 5.7 %
FY2016 1.9 % 3.9 %
Provider Reimbursement Adjustment 0.9989 0.9489
Other Reimbursement Changes 1.0000 1.0005
Inpatient Reimbursement Changes 1.0178 1.0052
Out-of-Network Adjustment 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000
Projected FY2016 Incurred Claims 68,961,520 576.83 42,775,714 114.47
Capitation Expenses
Vision 209,219 1.75 653,932 1.75
Behavioral Health 239,107 2.00 747,350 2.00
PCP 358,661 3.00 1,121,026 3.00
Other 0 0.00 0 0.00
Total 806,986 6.75 2,522,308 6.75
Reinsurance Expenses
Gross Premium 4,782 0.04 14,947 0.04
Projected Reinsurance Recoveries 0 0.00 0 0.00
Net Reinsurance Cost 4,782 0.04 14,947 0.04
Administrative Expenses
Fixed Amount 956,428 8.00 2,989,402 8.00
Percentage of Premium 4,494,409 5.75% 3,070,597 5.75%
Total 5,450,837 45.59 6,059,999 16.22
Risk Margin 1,563,273 2.00% 1,068,034 2.00%
Premium Tax 1,367,864 1.75% 934,530 1.75%
Maintenance Tax 8,369 0.07 26,157 0.07
Projected Total Cost
With deliveries 78,163,630 653.80 53,401,688 142.91
Deliveries 0 0.00 0 0.00
Without deliveries 78,163,630 653.80 53,401,688 142.91
37
38
Attachment 3
Community Experience Analysis
The following exhibits present a summary of the experience analysis performed for each service
area. HHSC utilizes an adjusted community rating methodology in setting the STAR premium
rates. The base community rates by risk group vary by service area but are the same for each
health plan in a service area. The community rates are developed by a weighted average of the
projected FY2016 cost for each health plan in the service area. The weights used in this formula
are the projected number of FY2016 clients enrolled in each health plan.
Below is a brief description of the exhibits contained in this attachment. The exhibits present the
derivation of the FY2016 STAR community rates for the following service areas:
Exhibit A – Bexar Service Area
Exhibit B – Dallas Service Area
Exhibit C – El Paso Service Area
Exhibit D – Harris Service Area
Exhibit E – Hidalgo Service Area
Exhibit F – Jefferson Service Area
Exhibit G – Lubbock Service Area
Exhibit H – Nueces Service Area
Exhibit I – Tarrant Service Area
Exhibit J – Travis Service Area
Exhibit K – MRSA Central Service Area
Exhibit L – MRSA Northeast Service Area
Exhibit M – MRSA West Service Area
These exhibits show projected FY2016 experience for each of the service areas. These amounts
were derived by summing amounts from each individual health plan in the service area. The
experience analysis for individual health plans is described in Attachment 2. The top portion of
the exhibit shows summary base period (FY2014) experience and projected FY2016 enrollment
and incurred claims experience.
In addition to incurred claims, provision is also made for services that are capitated by the health
plans, such as vision and behavioral health services. The cost of reinsurance is also considered.
In developing the cost of reinsurance we make an assumption regarding how much the health
plan is expected to receive in reinsurance recoveries (reimbursements from the reinsurance
company for large claims). We have assumed that the net cost of reinsurance (reinsurance
premium less reinsurance recoveries) is the minimum of (a) the actual reinsurance premium rate
and (b) $0.75 pmpm.
A provision for administrative expenses is included in the amount of $8.00 pmpm and 5.75% of
gross premium. Additional provisions are also included for premium tax (1.75% of premium),
maintenance tax ($0.07 pmpm) and risk margin (2.0% of premium).
The bottom of the exhibit shows a summary of the projected FY2016 cost based on these
assumptions. Cost projections are presented both with and without the inclusion of maternity
expenses
Attachment 3 - Exhibit A
FY2016 STAR Rating Summary
Bexar SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 237,121 769,863 1,017,719 284,175
Estimated Incurred Claims 112,385,447 473.96 85,099,137 110.54 66,532,883 65.37 25,262,196 88.90
Projected FY2016 Member Months 256,366 859,698 1,320,448 397,235
Annual Cost Trend Assumptions
FY2015 7.8 % 5.7 % 5.3 % 1.0 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9989 0.9489 0.9864 1.0017
Other Reimbursement Changes 1.0000 1.0005 1.0083 1.0083
Inpatient Reimbursement Changes 1.0156 1.0049 1.0053 1.0072
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 135,408,281 528.18 99,563,965 115.81 94,974,917 71.93 37,079,346 93.34
Capitation & Other Expenses/Refunds 481,875 1.88 2,043,564 2.38 2,944,027 2.23 813,455 2.05
Net Reinsurance Cost 100,867 0.39 350,644 0.41 585,350 0.44 182,160 0.46
Administrative Expenses
Fixed Amount 2,050,929 8.00 6,877,584 8.00 10,563,583 8.00 3,177,883 8.00
Percentage of Premium 8,771,761 5.75% 6,918,803 5.75% 6,935,600 5.75% 2,622,804 5.75%
Total 10,822,691 42.22 13,796,387 16.05 17,499,183 13.25 5,800,686 14.60
Risk Margin 3,051,047 2.00% 2,406,540 2.00% 2,412,383 2.00% 912,280 2.00%
Premium Tax 2,669,667 1.75% 2,105,723 1.75% 2,110,835 1.75% 798,245 1.75%
Maintenance Tax 17,946 0.07 60,179 0.07 92,431 0.07 27,806 0.07
Projected Total Cost
With deliveries (Unadjusted) 152,552,373 595.06 120,327,001 139.96 120,619,125 91.35 45,613,978 114.83
Deliveries 0 0.00 0 0.00 0 0.00 755,888 1.90
Without deliveries (Adjusted) 152,552,373 595.06 120,327,001 139.96 120,619,125 91.35 44,858,090 112.93
39
Attachment 3 - Exhibit A
FY2016 STAR Rating Summary
Bexar SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
8,664 128,319 126,291 2,572,152
1,498,241 172.93 33,803,496 263.43 79,435,278 628.98 404,016,678 157.07
8,456 173,061 144,290 3,159,554
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0006 1.0017 1.0011
1.0023 1.0058 1.0089
1.0115 1.0118 1.0188
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
1,611,004 190.52 46,475,163 268.55 93,391,668 647.25 508,504,345 160.94
20,605 2.44 408,897 2.36 249,588 1.73 6,962,010 2.20
3,443 0.41 72,510 0.42 54,206 0.38 1,349,180 0.43
67,646 8.00 1,384,486 8.00 1,154,319 8.00 25,276,430 8.00
108,220 5.75% 3,072,163 5.75% 6,027,009 5.75% 34,456,359 5.75%
175,866 20.80 4,456,649 25.75 7,181,328 49.77 59,732,789 18.91
37,642 2.00% 1,068,578 2.00% 2,096,351 2.00% 11,984,821 2.00%
32,937 1.75% 935,006 1.75% 1,834,307 1.75% 10,486,718 1.75%
592 0.07 12,114 0.07 10,100 0.07 221,169 0.07
1,882,088 222.58 53,428,919 308.73 104,817,548 726.44 599,241,031 189.66
355,559 42.05 3,718,101 21.48 47,912,428 332.06 52,741,975 16.69
1,526,529 180.53 49,710,818 287.24 56,905,120 394.38 546,499,056 172.97
40
Attachment 3 - Exhibit B
FY2016 STAR Rating Summary
Dallas SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 349,925 1,338,586 1,777,386 449,147
Estimated Incurred Claims 128,740,912 367.91 160,489,009 119.89 119,088,760 67.00 40,125,353 89.34
Projected FY2016 Member Months 350,797 1,496,884 2,352,061 643,019
Annual Cost Trend Assumptions
FY2015 0.0 % 3.4 % 7.5 % 3.1 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9993 0.9712 0.9923 0.9998
Other Reimbursement Changes 1.0000 1.0000 1.0001 1.0001
Inpatient Reimbursement Changes 1.0026 0.9935 0.9942 0.9928
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 131,758,932 375.60 186,038,758 124.28 174,663,140 74.26 60,090,084 93.45
Capitation & Other Expenses/Refunds 415,514 1.18 2,076,173 1.39 3,453,300 1.47 908,565 1.41
Net Reinsurance Cost 138,699 0.40 622,385 0.42 933,063 0.40 239,401 0.37
Administrative Expenses
Fixed Amount 2,806,374 8.00 11,975,075 8.00 18,816,490 8.00 5,144,150 8.00
Percentage of Premium 8,586,502 5.75% 12,759,102 5.75% 12,582,057 5.75% 4,220,513 5.75%
Total 11,392,876 32.48 24,734,177 16.52 31,398,547 13.35 9,364,664 14.56
Risk Margin 2,986,609 2.00% 4,437,949 2.00% 4,376,368 2.00% 1,468,005 2.00%
Premium Tax 2,613,283 1.75% 3,883,205 1.75% 3,829,322 1.75% 1,284,504 1.75%
Maintenance Tax 24,556 0.07 104,782 0.07 164,644 0.07 45,011 0.07
Projected Total Cost
With deliveries (Unadjusted) 149,330,468 425.69 221,897,428 148.24 218,818,385 93.03 73,400,234 114.15
Deliveries 0 0.00 0 0.00 0 0.00 1,583,186 2.46
Without deliveries (Adjusted) 149,330,468 425.69 221,897,428 148.24 218,818,385 93.03 71,817,048 111.69
41
Attachment 3 - Exhibit B
FY2016 STAR Rating Summary
Dallas SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
9,144 124,349 153,596 4,202,134
1,732,121 189.42 29,877,775 240.27 103,273,925 672.38 583,327,856 138.82
8,983 167,055 180,521 5,199,319
0.0 % 0.0 % 1.5 %
8.6 % 0.0 % 0.0 %
1.0007 1.0010 1.0003
1.0000 1.0000 1.0090
1.0056 0.9815 1.0159
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
1,859,471 207.01 39,435,767 236.07 126,319,294 699.75 720,165,446 138.51
3,574 0.40 174,757 1.05 -401,026 -2.22 6,630,858 1.28
3,519 0.39 61,544 0.37 72,707 0.40 2,071,318 0.40
71,861 8.00 1,336,437 8.00 1,444,165 8.00 41,594,551 8.00
123,200 5.75% 2,606,256 5.75% 8,097,511 5.75% 48,975,141 5.75%
195,060 21.72 3,942,693 23.60 9,541,676 52.86 90,569,692 17.42
42,852 2.00% 906,524 2.00% 2,816,525 2.00% 17,034,832 2.00%
37,496 1.75% 793,208 1.75% 2,464,460 1.75% 14,905,478 1.75%
629 0.07 11,694 0.07 12,636 0.07 363,952 0.07
2,142,600 238.53 45,326,187 271.33 140,826,272 780.11 851,741,576 163.82
512,834 57.09 4,783,326 28.63 66,123,119 366.29 73,002,464 14.04
1,629,766 181.44 40,542,862 242.69 74,703,153 413.82 778,739,112 149.78
42
Attachment 3 - Exhibit C
FY2016 STAR Rating Summary
El Paso SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 110,945 382,824 564,845 192,119
Estimated Incurred Claims 44,769,271 403.53 35,347,260 92.33 35,144,481 62.22 14,829,289 77.19
Projected FY2016 Member Months 113,285 419,128 696,318 247,776
Annual Cost Trend Assumptions
FY2015 0.0 % 2.8 % 1.6 % 2.2 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9989 0.9701 0.9909 0.9969
Other Reimbursement Changes 1.0000 1.0000 1.0075 1.0096
Inpatient Reimbursement Changes 1.0960 1.0530 1.0768 1.0761
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 0.9927 0.9931 0.9935 0.9935
Projected FY2016 Incurred Claims 50,627,589 446.90 41,930,954 100.04 49,128,247 70.55 21,495,193 86.75
Capitation & Other Expenses/Refunds 339,328 3.00 1,251,814 2.99 2,111,025 3.03 732,160 2.95
Net Reinsurance Cost 50,349 0.44 168,264 0.40 279,660 0.40 101,667 0.41
Administrative Expenses
Fixed Amount 906,281 8.00 3,353,025 8.00 5,570,546 8.00 1,982,207 8.00
Percentage of Premium 3,299,514 5.75% 2,969,249 5.75% 3,630,329 5.75% 1,545,738 5.75%
Total 4,205,795 37.13 6,322,274 15.08 9,200,875 13.21 3,527,945 14.24
Risk Margin 1,147,657 2.00% 1,032,782 2.00% 1,262,723 2.00% 537,648 2.00%
Premium Tax 1,004,200 1.75% 903,684 1.75% 1,104,883 1.75% 470,442 1.75%
Maintenance Tax 7,930 0.07 29,339 0.07 48,742 0.07 17,344 0.07
Projected Total Cost
With deliveries (Unadjusted) 57,382,848 506.53 51,639,111 123.21 63,136,155 90.67 26,882,400 108.49
Deliveries 0 0.00 0 0.00 0 0.00 509,636 2.06
Without deliveries (Adjusted) 57,382,848 506.53 51,639,111 123.21 63,136,155 90.67 26,372,764 106.44
43
Attachment 3 - Exhibit C
FY2016 STAR Rating Summary
El Paso SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
4,329 53,480 54,454 1,362,995
575,941 133.04 11,109,263 207.73 31,184,583 572.68 172,960,089 126.90
3,977 67,479 60,181 1,608,144
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0000 0.9993 1.0000
1.0064 1.0196 1.0157
1.0331 1.0342 1.0551
1.0000 1.0000 1.0000
0.9936 0.9936 0.9931
593,629 149.26 14,676,043 217.49 36,678,361 609.47 215,130,016 133.78
6,220 1.56 189,095 2.80 27,085 0.45 4,656,727 2.90
1,515 0.38 29,678 0.44 27,129 0.45 658,262 0.41
31,816 8.00 539,831 8.00 481,446 8.00 12,865,152 8.00
40,247 5.75% 980,954 5.75% 2,364,694 5.75% 14,830,726 5.75%
72,064 18.12 1,520,785 22.54 2,846,140 47.29 27,695,878 17.22
13,999 2.00% 341,202 2.00% 822,502 2.00% 5,158,513 2.00%
12,249 1.75% 298,551 1.75% 719,690 1.75% 4,513,699 1.75%
278 0.07 4,724 0.07 4,213 0.07 112,570 0.07
699,954 176.00 17,060,078 252.82 41,125,120 683.36 257,925,666 160.39
157,344 39.56 1,257,866 18.64 20,667,495 343.42 22,592,342 14.05
542,610 136.43 15,802,211 234.18 20,457,625 339.94 235,333,324 146.34
44
Attachment 3 - Exhibit D
FY2016 STAR Rating Summary
Harris SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 661,356 2,228,877 2,803,053 735,628
Estimated Incurred Claims 325,207,854 491.73 243,226,989 109.13 197,305,215 70.39 79,942,248 108.67
Projected FY2016 Member Months 697,210 2,516,076 3,750,190 1,058,737
Annual Cost Trend Assumptions
FY2015 1.0 % 5.2 % 4.7 % 0.8 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9997 0.9680 0.9918 0.9999
Other Reimbursement Changes 1.0000 1.0005 1.0085 1.0096
Inpatient Reimbursement Changes 1.0279 1.0005 0.9991 0.9988
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 362,596,203 520.07 290,785,165 115.57 288,617,314 76.96 119,508,090 112.88
Capitation & Other Expenses/Refunds -2,565,316 -3.68 7,714,603 3.07 11,928,758 3.18 3,103,576 2.93
Net Reinsurance Cost 323,075 0.46 1,101,871 0.44 1,560,347 0.42 427,723 0.40
Administrative Expenses
Fixed Amount 5,577,680 8.00 20,128,612 8.00 30,001,519 8.00 8,469,893 8.00
Percentage of Premium 23,252,901 5.75% 20,325,543 5.75% 21,117,460 5.75% 8,360,271 5.75%
Total 28,830,581 41.35 40,454,155 16.08 51,118,978 13.63 16,830,164 15.90
Risk Margin 8,087,966 2.00% 7,069,754 2.00% 7,345,203 2.00% 2,907,920 2.00%
Premium Tax 7,076,970 1.75% 6,186,035 1.75% 6,427,053 1.75% 2,544,430 1.75%
Maintenance Tax 48,805 0.07 176,125 0.07 262,513 0.07 74,112 0.07
Projected Total Cost
With deliveries (Unadjusted) 404,398,282 580.02 353,487,709 140.49 367,260,166 97.93 145,396,016 137.33
Deliveries 0 0.00 0 0.00 0 0.00 2,395,875 2.26
Without deliveries (Adjusted) 404,398,282 580.02 353,487,709 140.49 367,260,166 97.93 143,000,141 135.07
45
Attachment 3 - Exhibit D
FY2016 STAR Rating Summary
Harris SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
16,409 221,246 276,831 6,943,400
3,888,407 236.97 68,561,587 309.89 198,369,098 716.57 1,116,501,398 160.80
15,981 311,080 322,651 8,671,925
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0005 1.0008 1.0007
1.0012 1.0043 1.0089
1.0171 1.0133 1.0226
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
4,189,905 262.19 98,184,797 315.63 238,694,521 739.79 1,402,575,995 161.74
19,207 1.20 123,056 0.40 -389,571 -1.21 19,934,311 2.30
6,960 0.44 123,690 0.40 154,583 0.48 3,698,250 0.43
127,845 8.00 2,488,643 8.00 2,581,211 8.00 69,375,402 8.00
276,066 5.75% 6,413,440 5.75% 15,316,178 5.75% 95,061,859 5.75%
403,910 25.28 8,902,083 28.62 17,897,390 55.47 164,437,261 18.96
96,023 2.00% 2,230,762 2.00% 5,327,366 2.00% 33,064,994 2.00%
84,020 1.75% 1,951,916 1.75% 4,661,446 1.75% 28,931,870 1.75%
1,119 0.07 21,776 0.07 22,586 0.07 607,035 0.07
4,801,144 300.44 111,538,079 358.55 266,368,320 825.56 1,653,249,716 190.64
791,566 49.53 8,900,538 28.61 121,690,945 377.16 133,778,924 15.43
4,009,578 250.90 102,637,541 329.94 144,677,375 448.40 1,519,470,792 175.22
46
Attachment 3 - Exhibit E
FY2016 STAR Rating Summary
Hidalgo SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 315,311 1,167,574 1,680,615 505,565
Estimated Incurred Claims 131,121,839 415.85 143,340,689 122.77 120,160,344 71.50 41,381,261 81.85
Projected FY2016 Member Months 325,452 1,250,782 2,006,062 642,942
Annual Cost Trend Assumptions
FY2015 0.0 % 0.9 % 3.4 % 0.4 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9996 0.9606 0.9807 0.9979
Other Reimbursement Changes 1.0000 1.0029 1.0250 1.0227
Inpatient Reimbursement Changes 1.0196 1.0047 1.0062 1.0112
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 0.9989 0.9985 0.9987 0.9986
Projected FY2016 Incurred Claims 140,407,620 431.42 155,580,657 124.39 156,547,647 78.04 55,647,047 86.55
Capitation & Other Expenses/Refunds 5,188,736 15.94 3,910,233 3.13 5,762,764 2.87 1,839,837 2.86
Net Reinsurance Cost 91,331 0.28 269,957 0.22 424,835 0.21 133,401 0.21
Administrative Expenses
Fixed Amount 2,603,618 8.00 10,006,259 8.00 16,048,493 8.00 5,143,532 8.00
Percentage of Premium 9,423,271 5.75% 10,791,871 5.75% 11,368,110 5.75% 3,990,616 5.75%
Total 12,026,889 36.95 20,798,130 16.63 27,416,603 13.67 9,134,148 14.21
Risk Margin 3,277,659 2.00% 3,753,694 2.00% 3,954,125 2.00% 1,388,040 2.00%
Premium Tax 2,867,952 1.75% 3,284,482 1.75% 3,459,860 1.75% 1,214,535 1.75%
Maintenance Tax 22,782 0.07 87,555 0.07 140,424 0.07 45,006 0.07
Projected Total Cost
With deliveries (Unadjusted) 163,882,968 503.55 187,684,708 150.05 197,706,258 98.55 69,402,015 107.94
Deliveries 0 0.00 0 0.00 0 0.00 2,068,354 3.22
Without deliveries (Adjusted) 163,882,968 503.55 187,684,708 150.05 197,706,258 98.55 67,333,661 104.73
47
Attachment 3 - Exhibit E
FY2016 STAR Rating Summary
Hidalgo SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
11,676 132,276 135,406 3,948,423
1,852,849 158.69 33,211,163 251.07 75,923,041 560.70 546,991,186 138.53
10,207 155,852 152,913 4,544,210
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0019 0.9993 1.0010
1.0090 1.0108 1.0109
1.0166 1.0211 1.0310
1.0000 1.0000 1.0000
0.9982 0.9981 0.9989
1,804,437 176.78 40,281,452 258.46 89,349,027 584.31 639,617,887 140.75
33,227 3.26 483,585 3.10 2,934,153 19.19 20,152,535 4.43
2,253 0.22 31,169 0.20 48,417 0.32 1,001,363 0.22
81,656 8.00 1,246,814 8.00 1,223,306 8.00 36,353,679 8.00
122,134 5.75% 2,671,935 5.75% 5,944,776 5.75% 44,312,712 5.75%
203,790 19.97 3,918,749 25.14 7,168,083 46.88 80,666,391 17.75
42,482 2.00% 929,369 2.00% 2,067,748 2.00% 15,413,117 2.00%
37,171 1.75% 813,198 1.75% 1,809,280 1.75% 13,486,478 1.75%
714 0.07 10,910 0.07 10,704 0.07 318,095 0.07
2,124,075 208.10 46,468,431 298.16 103,387,412 676.12 770,655,866 169.59
458,253 44.90 3,835,477 24.61 53,414,562 349.31 59,776,645 13.15
1,665,822 163.20 42,632,954 273.55 49,972,850 326.81 710,879,221 156.44
48
Attachment 3 - Exhibit F
FY2016 STAR Rating Summary
Jefferson SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 76,089 237,907 300,396 85,620
Estimated Incurred Claims 47,842,256 628.77 22,063,262 92.74 17,284,309 57.54 7,820,574 91.34
Projected FY2016 Member Months 79,757 265,106 377,362 114,413
Annual Cost Trend Assumptions
FY2015 0.0 % 5.0 % 5.8 % 6.7 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 1.0002 0.9829 0.9987 1.0036
Other Reimbursement Changes 1.0000 1.0042 1.0449 1.0266
Inpatient Reimbursement Changes 1.0233 1.0047 1.0020 1.0081
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 52,305,403 655.81 26,598,333 100.33 25,101,017 66.52 11,837,000 103.46
Capitation & Other Expenses/Refunds -4,856 -0.06 477,967 1.80 679,280 1.80 176,624 1.54
Net Reinsurance Cost 32,671 0.41 110,070 0.42 151,017 0.40 44,514 0.39
Administrative Expenses
Fixed Amount 638,059 8.00 2,120,851 8.00 3,018,899 8.00 915,306 8.00
Percentage of Premium 3,365,933 5.75% 1,863,240 5.75% 1,841,057 5.75% 824,788 5.75%
Total 4,003,992 50.20 3,984,091 15.03 4,859,956 12.88 1,740,095 15.21
Risk Margin 1,170,759 2.00% 648,083 2.00% 640,367 2.00% 286,883 2.00%
Premium Tax 1,024,414 1.75% 567,073 1.75% 560,322 1.75% 251,023 1.75%
Maintenance Tax 5,583 0.07 18,557 0.07 26,415 0.07 8,009 0.07
Projected Total Cost
With deliveries (Unadjusted) 58,537,967 733.95 32,404,174 122.23 32,018,375 84.85 14,344,146 125.37
Deliveries 0 0.00 0 0.00 0 0.00 260,348 2.28
Without deliveries (Adjusted) 58,537,967 733.95 32,404,174 122.23 32,018,375 84.85 14,083,798 123.10
49
Attachment 3 - Exhibit F
FY2016 STAR Rating Summary
Jefferson SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
2,940 43,769 40,491 787,211
615,318 209.29 12,416,041 283.67 27,798,300 686.53 135,840,061 172.56
2,348 55,954 47,176 942,118
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0109 1.0045 1.0025
1.0023 1.0051 1.0104
1.0147 1.0122 1.0175
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
548,727 233.68 16,220,468 289.89 33,381,010 707.59 165,991,958 176.19
3,743 1.59 23,879 0.43 -43,339 -0.92 1,313,297 1.39
968 0.41 20,840 0.37 18,687 0.40 378,768 0.40
18,785 8.00 447,634 8.00 377,407 8.00 7,536,942 8.00
36,367 5.75% 1,062,113 5.75% 2,143,515 5.75% 11,137,014 5.75%
55,153 23.49 1,509,747 26.98 2,520,923 53.44 18,673,956 19.82
12,649 2.00% 369,431 2.00% 745,571 2.00% 3,873,744 2.00%
11,068 1.75% 323,252 1.75% 652,374 1.75% 3,389,526 1.75%
164 0.07 3,917 0.07 3,302 0.07 65,948 0.07
632,473 269.35 18,471,533 330.12 37,278,528 790.20 193,687,197 205.59
103,046 43.88 1,274,069 22.77 15,983,438 338.80 17,620,901 18.70
529,426 225.46 17,197,465 307.35 21,295,090 451.40 176,066,296 186.88
50
Attachment 3 - Exhibit G
FY2016 STAR Rating Summary
Lubbock SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 80,179 237,421 305,327 79,332
Estimated Incurred Claims 44,607,773 556.35 24,173,082 101.82 19,509,902 63.90 6,666,644 84.03
Projected FY2016 Member Months 84,206 263,291 392,732 108,915
Annual Cost Trend Assumptions
FY2015 0.3 % 9.3 % 5.2 % 3.0 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9997 0.9755 0.9987 1.0095
Other Reimbursement Changes 1.0000 1.0017 1.0190 1.0174
Inpatient Reimbursement Changes 1.0613 1.0145 1.0187 1.0161
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 50,801,116 603.30 30,178,747 114.62 28,600,432 72.82 10,054,706 92.32
Capitation & Other Expenses/Refunds 64,412 0.76 203,761 0.77 294,765 0.75 82,772 0.76
Net Reinsurance Cost 35,771 0.42 111,215 0.42 169,172 0.43 46,389 0.43
Administrative Expenses
Fixed Amount 673,646 8.00 2,106,330 8.00 3,141,852 8.00 871,318 8.00
Percentage of Premium 3,277,236 5.75% 2,072,445 5.75% 2,047,998 5.75% 702,886 5.75%
Total 3,950,882 46.92 4,178,775 15.87 5,189,851 13.21 1,574,204 14.45
Risk Margin 1,139,908 2.00% 720,850 2.00% 712,347 2.00% 244,482 2.00%
Premium Tax 997,420 1.75% 630,744 1.75% 623,304 1.75% 213,922 1.75%
Maintenance Tax 5,894 0.07 18,430 0.07 27,491 0.07 7,624 0.07
Projected Total Cost
With deliveries (Unadjusted) 56,995,403 676.86 36,042,524 136.89 35,617,363 90.69 12,224,099 112.24
Deliveries 0 0.00 0 0.00 0 0.00 160,149 1.47
Without deliveries (Adjusted) 56,995,403 676.86 36,042,524 136.89 35,617,363 90.69 12,063,950 110.77
51
Attachment 3 - Exhibit G
FY2016 STAR Rating Summary
Lubbock SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
2,416 36,746 45,759 787,181
410,641 169.97 8,885,716 241.81 27,042,360 590.98 131,296,118 166.79
2,549 48,240 47,961 947,893
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0126 1.0118 1.0062
1.0012 1.0058 1.0085
1.0118 1.0180 1.0275
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
482,604 189.34 12,084,749 250.51 29,553,081 616.19 161,755,434 170.65
1,896 0.74 41,475 0.86 35,073 0.73 724,155 0.76
1,118 0.44 17,992 0.37 21,179 0.44 402,837 0.42
20,391 8.00 385,920 8.00 383,689 8.00 7,583,146 8.00
32,161 5.75% 796,328 5.75% 1,905,847 5.75% 10,834,901 5.75%
52,552 20.62 1,182,248 24.51 2,289,536 47.74 18,418,047 19.43
11,186 2.00% 276,984 2.00% 662,903 2.00% 3,768,661 2.00%
9,788 1.75% 242,361 1.75% 580,040 1.75% 3,297,579 1.75%
178 0.07 3,377 0.07 3,357 0.07 66,353 0.07
559,322 219.44 13,849,185 287.09 33,145,170 691.08 188,433,066 198.79
61,854 24.27 1,057,319 21.92 15,151,255 315.91 16,430,577 17.33
497,468 195.17 12,791,867 265.17 17,993,914 375.18 172,002,489 181.46
52
Attachment 3 - Exhibit H
FY2016 STAR Rating Summary
Nueces SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 85,323 254,654 340,305 94,635
Estimated Incurred Claims 58,210,270 682.24 33,874,731 133.02 28,886,669 84.88 11,408,447 120.55
Projected FY2016 Member Months 90,951 283,045 432,990 128,089
Annual Cost Trend Assumptions
FY2015 4.0 % 4.6 % 8.4 % 0.0 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 1.0010 0.9972 1.0037 1.0075
Other Reimbursement Changes 1.0000 1.0012 1.0141 1.0107
Inpatient Reimbursement Changes 0.9962 1.0050 1.0068 1.0118
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 65,573,015 720.97 41,059,929 145.06 42,664,555 98.53 16,259,342 126.94
Capitation & Other Expenses/Refunds 5,484,314 60.30 5,782,762 20.43 8,758,535 20.23 2,587,728 20.20
Net Reinsurance Cost 56,355 0.62 155,211 0.55 237,639 0.55 70,045 0.55
Administrative Expenses
Fixed Amount 727,604 8.00 2,264,362 8.00 3,463,922 8.00 1,024,711 8.00
Percentage of Premium 4,564,906 5.75% 3,131,182 5.75% 3,504,321 5.75% 1,267,592 5.75%
Total 5,292,511 58.19 5,395,544 19.06 6,968,243 16.09 2,292,303 17.90
Risk Margin 1,587,793 2.00% 1,089,107 2.00% 1,218,894 2.00% 440,901 2.00%
Premium Tax 1,389,319 1.75% 952,968 1.75% 1,066,532 1.75% 385,789 1.75%
Maintenance Tax 6,367 0.07 19,813 0.07 30,309 0.07 8,966 0.07
Projected Total Cost
With deliveries (Unadjusted) 79,389,674 872.89 54,455,334 192.39 60,944,706 140.75 22,045,074 172.11
Deliveries 0 0.00 0 0.00 0 0.00 319,110 2.49
Without deliveries (Adjusted) 79,389,674 872.89 54,455,334 192.39 60,944,706 140.75 21,725,964 169.62
53
Attachment 3 - Exhibit H
FY2016 STAR Rating Summary
Nueces SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
3,132 40,787 49,091 867,926
562,626 179.64 9,952,067 244.00 29,554,157 602.03 172,448,965 198.69
2,888 53,905 54,135 1,046,003
0.0 % 0.0 % 0.5 %
8.6 % 0.0 % 0.0 %
1.0074 1.0140 1.0045
1.0081 1.0108 1.0141
1.0210 1.0226 1.0355
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
584,179 202.28 13,785,731 255.74 34,549,612 638.21 214,476,362 205.04
63,971 22.15 939,085 17.42 3,410,684 63.00 27,027,080 25.84
1,618 0.56 27,613 0.51 34,462 0.64 582,942 0.56
23,103 8.00 431,239 8.00 433,080 8.00 8,368,022 8.00
42,764 5.75% 964,948 5.75% 2,441,788 5.75% 15,917,501 5.75%
65,868 22.81 1,396,187 25.90 2,874,868 53.11 24,285,523 23.22
14,875 2.00% 335,634 2.00% 849,318 2.00% 5,536,522 2.00%
13,015 1.75% 293,680 1.75% 743,153 1.75% 4,844,457 1.75%
202 0.07 3,773 0.07 3,789 0.07 73,220 0.07
743,727 257.53 16,781,703 311.32 42,465,886 784.44 276,826,105 264.65
166,350 57.60 1,599,173 29.67 17,166,254 317.10 19,250,887 18.40
577,377 199.93 15,182,530 281.65 25,299,632 467.34 257,575,218 246.25
54
Attachment 3 - Exhibit I
FY2016 STAR Rating Summary
Tarrant SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 267,380 832,870 1,075,715 271,619
Estimated Incurred Claims 120,482,798 450.61 96,523,123 115.89 83,881,629 77.98 25,956,798 95.56
Projected FY2016 Member Months 285,868 963,314 1,468,940 398,426
Annual Cost Trend Assumptions
FY2015 2.0 % 4.8 % 4.2 % 4.5 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9997 0.9577 0.9910 1.0002
Other Reimbursement Changes 1.0000 1.0010 1.0066 1.0050
Inpatient Reimbursement Changes 1.0165 1.0014 1.0026 1.0111
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 136,054,877 475.94 116,699,813 121.14 124,742,938 84.92 41,328,831 103.73
Capitation & Other Expenses/Refunds 247,256 0.86 1,418,769 1.47 2,337,607 1.59 605,215 1.52
Net Reinsurance Cost 148,746 0.52 453,117 0.47 623,821 0.42 176,159 0.44
Administrative Expenses
Fixed Amount 2,286,948 8.00 7,706,514 8.00 11,751,518 8.00 3,187,407 8.00
Percentage of Premium 8,816,106 5.75% 8,027,486 5.75% 8,866,990 5.75% 2,879,797 5.75%
Total 11,103,054 38.84 15,733,999 16.33 20,618,508 14.04 6,067,204 15.23
Risk Margin 3,066,472 2.00% 2,792,169 2.00% 3,084,170 2.00% 1,001,669 2.00%
Premium Tax 2,683,163 1.75% 2,443,148 1.75% 2,698,649 1.75% 876,460 1.75%
Maintenance Tax 20,011 0.07 67,432 0.07 102,826 0.07 27,890 0.07
Projected Total Cost
With deliveries (Unadjusted) 153,323,578 536.34 139,608,447 144.93 154,208,519 104.98 50,083,427 125.70
Deliveries 0 0.00 0 0.00 0 0.00 868,724 2.18
Without deliveries (Adjusted) 153,323,578 536.34 139,608,447 144.93 154,208,519 104.98 49,214,703 123.52
55
Attachment 3 - Exhibit I
FY2016 STAR Rating Summary
Tarrant SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
6,224 104,169 122,772 2,680,749
1,236,185 198.62 25,863,582 248.28 74,025,539 602.95 427,969,653 159.65
6,329 144,201 142,947 3,410,025
0.6 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0006 1.0017 1.0007
1.0003 1.0041 1.0095
1.0116 1.0192 1.0317
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
1,390,461 219.71 36,702,072 254.52 89,829,712 628.41 546,748,704 160.34
-2,049 -0.32 209,834 1.46 -299,166 -2.09 4,517,467 1.32
2,922 0.46 68,917 0.48 75,653 0.53 1,549,334 0.45
50,630 8.00 1,153,607 8.00 1,143,575 8.00 27,280,199 8.00
91,645 5.75% 2,423,547 5.75% 5,766,505 5.75% 36,872,076 5.75%
142,275 22.48 3,577,154 24.81 6,910,081 48.34 64,152,275 18.81
31,876 2.00% 842,973 2.00% 2,005,741 2.00% 12,825,070 2.00%
27,892 1.75% 737,601 1.75% 1,755,023 1.75% 11,221,936 1.75%
443 0.07 10,094 0.07 10,006 0.07 238,702 0.07
1,593,820 251.84 42,148,645 292.29 100,287,051 701.57 641,253,488 188.05
265,304 41.92 3,708,550 25.72 52,429,837 366.78 57,272,414 16.80
1,328,516 209.92 38,440,095 266.57 47,857,214 334.79 583,981,073 171.25
56
Attachment 3 - Exhibit J
FY2016 STAR Rating Summary
Travis SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 148,868 480,631 605,230 147,252
Estimated Incurred Claims 81,476,212 547.30 56,045,282 116.61 41,467,431 68.52 14,380,138 97.66
Projected FY2016 Member Months 159,375 541,945 813,053 215,951
Annual Cost Trend Assumptions
FY2015 0.0 % 4.6 % 6.8 % 1.9 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 0.9997 0.9660 0.9919 1.0030
Other Reimbursement Changes 1.0000 1.0007 1.0163 1.0203
Inpatient Reimbursement Changes 1.0202 1.0030 1.0038 1.0102
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 90,651,983 568.80 66,590,323 122.87 62,911,494 77.38 22,704,795 105.14
Capitation & Other Expenses/Refunds 444,798 2.79 1,386,069 2.56 2,169,824 2.67 576,505 2.67
Net Reinsurance Cost 32,545 0.20 99,437 0.18 123,861 0.15 37,698 0.17
Administrative Expenses
Fixed Amount 1,274,996 8.00 4,335,559 8.00 6,504,428 8.00 1,727,611 8.00
Percentage of Premium 5,871,702 5.75% 4,603,134 5.75% 4,559,751 5.75% 1,592,319 5.75%
Total 7,146,698 44.84 8,938,692 16.49 11,064,179 13.61 3,319,930 15.37
Risk Margin 2,042,331 2.00% 1,601,090 2.00% 1,586,000 2.00% 553,850 2.00%
Premium Tax 1,787,040 1.75% 1,400,954 1.75% 1,387,750 1.75% 484,619 1.75%
Maintenance Tax 11,156 0.07 37,936 0.07 56,914 0.07 15,117 0.07
Projected Total Cost
With deliveries (Unadjusted) 102,116,550 640.73 80,054,501 147.72 79,300,023 97.53 27,692,513 128.23
Deliveries 0 0.00 0 0.00 0 0.00 413,963 1.92
Without deliveries (Adjusted) 102,116,550 640.73 80,054,501 147.72 79,300,023 97.53 27,278,550 126.32
57
Attachment 3 - Exhibit J
FY2016 STAR Rating Summary
Travis SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
4,064 69,820 64,588 1,520,455
634,439 156.11 17,341,173 248.37 45,683,524 707.31 257,028,199 169.05
3,477 87,286 72,918 1,894,005
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0024 1.0046 1.0017
1.0005 1.0068 1.0097
1.0157 1.0140 1.0247
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
600,436 172.70 22,233,907 254.72 53,453,027 733.06 319,145,964 168.50
9,307 2.68 229,845 2.63 195,297 2.68 5,011,644 2.65
586 0.17 17,170 0.20 14,109 0.19 325,407 0.17
27,814 8.00 698,289 8.00 583,345 8.00 15,152,041 8.00
40,560 5.75% 1,473,100 5.75% 3,446,879 5.75% 21,587,446 5.75%
68,375 19.67 2,171,389 24.88 4,030,224 55.27 36,739,488 19.40
14,108 2.00% 512,383 2.00% 1,198,915 2.00% 7,508,677 2.00%
12,344 1.75% 448,335 1.75% 1,049,050 1.75% 6,570,092 1.75%
243 0.07 6,110 0.07 5,104 0.07 132,580 0.07
705,399 202.89 25,619,139 293.51 59,945,727 822.10 375,433,852 198.22
155,814 44.82 1,782,249 20.42 23,146,703 317.43 25,498,730 13.46
549,585 158.07 23,836,889 273.09 36,799,023 504.66 349,935,122 184.76
58
Attachment 3 - Exhibit K
FY2016 STAR Rating Summary
MRSA Central SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 128,035 404,809 503,221 134,142
Estimated Incurred Claims 52,895,552 413.13 38,033,104 93.95 29,528,942 58.68 11,415,848 85.10
Projected FY2016 Member Months 139,370 460,690 670,635 188,948
Annual Cost Trend Assumptions
FY2015 9.2 % 4.4 % 6.2 % 2.2 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 1.0020 0.9764 1.0052 1.0171
Other Reimbursement Changes 1.0000 1.0017 1.0167 1.0154
Inpatient Reimbursement Changes 1.0386 1.0082 1.0098 1.0163
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 66,676,574 478.41 46,296,562 100.49 45,070,960 67.21 17,628,247 93.30
Capitation & Other Expenses/Refunds 153,390 1.10 543,941 1.18 810,424 1.21 223,560 1.18
Net Reinsurance Cost 43,678 0.31 125,091 0.27 172,441 0.26 51,079 0.27
Administrative Expenses
Fixed Amount 1,114,960 8.00 3,685,522 8.00 5,365,078 8.00 1,511,585 8.00
Percentage of Premium 4,320,338 5.75% 3,220,214 5.75% 3,269,930 5.75% 1,234,356 5.75%
Total 5,435,298 39.00 6,905,735 14.99 8,635,007 12.88 2,745,941 14.53
Risk Margin 1,502,726 2.00% 1,120,074 2.00% 1,137,367 2.00% 429,341 2.00%
Premium Tax 1,314,885 1.75% 980,065 1.75% 995,196 1.75% 375,674 1.75%
Maintenance Tax 9,756 0.07 32,248 0.07 46,944 0.07 13,226 0.07
Projected Total Cost
With deliveries (Unadjusted) 75,136,307 539.11 56,003,716 121.56 56,868,339 84.80 21,467,068 113.61
Deliveries 0 0.00 0 0.00 0 0.00 489,047 2.59
Without deliveries (Adjusted) 75,136,307 539.11 56,003,716 121.56 56,868,339 84.80 20,978,021 111.03
59
Attachment 3 - Exhibit K
FY2016 STAR Rating Summary
MRSA Central SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
4,276 67,226 66,065 1,307,774
764,793 178.86 15,582,160 231.79 39,012,613 590.52 187,233,012 143.17
3,793 84,089 74,848 1,622,374
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0187 1.0188 1.0069
1.0008 1.0060 1.0092
1.0224 1.0261 1.0400
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
767,963 202.47 20,497,823 243.76 46,710,073 624.06 243,648,202 150.18
4,205 1.11 86,950 1.03 81,817 1.09 1,904,286 1.17
1,172 0.31 29,245 0.35 23,757 0.32 446,462 0.28
30,343 8.00 672,714 8.00 598,787 8.00 12,978,988 8.00
51,080 5.75% 1,352,846 5.75% 3,012,852 5.75% 16,461,615 5.75%
81,423 21.47 2,025,560 24.09 3,611,639 48.25 29,440,603 18.15
17,767 2.00% 470,555 2.00% 1,047,949 2.00% 5,725,779 2.00%
15,546 1.75% 411,736 1.75% 916,955 1.75% 5,010,057 1.75%
266 0.07 5,886 0.07 5,239 0.07 113,566 0.07
888,341 234.21 23,527,754 279.80 52,397,429 700.05 286,288,955 176.46
206,179 54.36 1,811,050 21.54 22,474,828 300.27 24,981,103 15.40
682,162 179.85 21,716,705 258.26 29,922,601 399.78 261,307,851 161.07
60
Attachment 3 - Exhibit L
FY2016 STAR Rating Summary
MRSA Northeast SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 166,748 534,431 680,355 184,371
Estimated Incurred Claims 79,128,796 474.54 46,450,515 86.92 36,840,954 54.15 14,863,306 80.62
Projected FY2016 Member Months 168,834 595,499 878,407 252,209
Annual Cost Trend Assumptions
FY2015 3.2 % 5.1 % 5.1 % 4.4 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 1.0020 0.9947 1.0076 1.0153
Other Reimbursement Changes 1.0000 1.0030 1.0337 1.0189
Inpatient Reimbursement Changes 1.0194 1.0018 1.0032 1.0097
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 86,059,780 509.73 56,490,051 94.86 54,585,928 62.14 22,659,628 89.84
Capitation & Other Expenses/Refunds 295,697 1.75 1,036,068 1.74 1,524,604 1.74 438,222 1.74
Net Reinsurance Cost 9,354 0.06 34,071 0.06 50,832 0.06 14,520 0.06
Administrative Expenses
Fixed Amount 1,350,672 8.00 4,763,988 8.00 7,027,259 8.00 2,017,674 8.00
Percentage of Premium 5,573,835 5.75% 3,962,472 5.75% 4,018,653 5.75% 1,597,782 5.75%
Total 6,924,507 41.01 8,726,460 14.65 11,045,913 12.57 3,615,456 14.34
Risk Margin 1,938,725 2.00% 1,378,251 2.00% 1,397,793 2.00% 555,750 2.00%
Premium Tax 1,696,385 1.75% 1,205,970 1.75% 1,223,068 1.75% 486,281 1.75%
Maintenance Tax 11,818 0.07 41,685 0.07 61,489 0.07 17,655 0.07
Projected Total Cost
With deliveries (Unadjusted) 96,936,267 574.15 68,912,555 115.72 69,889,625 79.56 27,787,513 110.18
Deliveries 0 0.00 0 0.00 0 0.00 557,958 2.21
Without deliveries (Adjusted) 96,936,267 574.15 68,912,555 115.72 69,889,625 79.56 27,229,556 107.96
61
Attachment 3 - Exhibit L
FY2016 STAR Rating Summary
MRSA Northeast SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
5,145 80,422 84,718 1,736,190
1,354,053 263.18 19,462,109 242.00 53,768,469 634.68 251,868,202 145.07
4,681 97,743 96,710 2,094,084
0.0 % 0.0 % 0.0 %
8.6 % 0.0 % 0.0 %
1.0112 1.0181 1.0079
1.0011 1.0065 1.0102
1.0032 1.0198 1.0198
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
1,358,800 290.26 24,718,428 252.89 63,733,013 659.01 309,605,627 147.85
8,130 1.74 169,481 1.73 169,529 1.75 3,641,731 1.74
270 0.06 5,682 0.06 5,335 0.06 120,064 0.06
37,451 8.00 781,943 8.00 773,682 8.00 16,752,669 8.00
89,267 5.75% 1,631,753 5.75% 4,110,032 5.75% 20,983,794 5.75%
126,717 27.07 2,413,696 24.69 4,883,714 50.50 37,736,464 18.02
31,049 2.00% 567,566 2.00% 1,429,576 2.00% 7,298,711 2.00%
27,168 1.75% 496,621 1.75% 1,250,879 1.75% 6,386,372 1.75%
328 0.07 6,842 0.07 6,770 0.07 146,586 0.07
1,552,463 331.63 28,378,315 290.34 71,478,817 739.10 364,935,555 174.27
243,932 52.11 2,075,764 21.24 32,068,248 331.59 34,945,902 16.69
1,308,530 279.52 26,302,551 269.10 39,410,569 407.51 329,989,653 157.58
62
Attachment 3 - Exhibit M
FY2016 STAR Rating Summary
MRSA West SDA Total
Age <1 Age 1-5 Age 6-14 Age 15-18
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
FY2014 Experience Period
Member Months 168,507 446,109 575,394 152,831
Estimated Incurred Claims 73,835,336 438.17 37,159,255 83.30 31,017,683 53.91 13,243,020 86.65
Projected FY2016 Member Months 175,451 506,744 755,961 215,279
Annual Cost Trend Assumptions
FY2015 0.8 % 3.3 % 4.3 % 0.0 %
FY2016 1.9 % 3.9 % 4.5 % 2.2 %
Provider Reimbursement Adjustment 1.0024 1.0060 1.0135 1.0237
Other Reimbursement Changes 1.0000 1.0019 1.0294 1.0210
Inpatient Reimbursement Changes 1.0248 1.0090 1.0106 1.0071
Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000
Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000
Projected FY2016 Incurred Claims 81,117,802 462.34 46,072,747 90.92 46,830,754 61.95 20,067,725 93.22
Capitation & Other Expenses/Refunds 175,387 1.00 573,719 1.13 890,828 1.18 248,154 1.15
Net Reinsurance Cost 67,456 0.38 159,299 0.31 218,996 0.29 65,323 0.30
Administrative Expenses
Fixed Amount 1,403,609 8.00 4,053,952 8.00 6,047,690 8.00 1,722,230 8.00
Percentage of Premium 5,259,283 5.75% 3,233,672 5.75% 3,433,556 5.75% 1,405,319 5.75%
Total 6,662,892 37.98 7,287,624 14.38 9,481,246 12.54 3,127,549 14.53
Risk Margin 1,829,316 2.00% 1,124,756 2.00% 1,194,280 2.00% 488,807 2.00%
Premium Tax 1,600,651 1.75% 984,161 1.75% 1,044,995 1.75% 427,706 1.75%
Maintenance Tax 12,282 0.07 35,472 0.07 52,917 0.07 15,070 0.07
Projected Total Cost
With deliveries (Unadjusted) 91,465,786 521.32 56,237,778 110.98 59,714,016 78.99 24,440,334 113.53
Deliveries 0 0.00 0 0.00 0 0.00 347,224 1.61
Without deliveries (Adjusted) 91,465,786 521.32 56,237,778 110.98 59,714,016 78.99 24,093,110 111.92
63
Attachment 3 - Exhibit M
FY2016 STAR Rating Summary
MRSA West SDA Total
FY2014 Experience Period
Member Months
Estimated Incurred Claims
Projected FY2016 Member Months
Annual Cost Trend Assumptions
FY2015
FY2016
Provider Reimbursement Adjustment
Other Reimbursement Changes
Inpatient Reimbursement Changes
Out-of-Network Adjustment
Third Party Recovery Adjustment
Projected FY2016 Incurred Claims
Capitation & Other Expenses/Refunds
Net Reinsurance Cost
Administrative Expenses
Fixed Amount
Percentage of Premium
Total
Risk Margin
Premium Tax
Maintenance Tax
Projected Total Cost
With deliveries (Unadjusted)
Deliveries
Without deliveries (Adjusted)
Age 19-20 TANF Adults Pregnant Women Total
Amount pmpm Amount pmpm Amount pmpm Amount pmpm
4,914 63,863 90,585 1,502,204
879,592 179.00 15,903,540 249.03 57,207,454 631.53 229,245,879 152.61
5,038 80,727 101,475 1,840,675
0.0 % 0.0 % 0.5 %
8.6 % 0.0 % 0.0 %
1.0188 1.0230 1.0114
1.0005 1.0067 1.0091
1.0085 1.0132 1.0146
1.0000 1.0000 1.0000
1.0000 1.0000 1.0000
1,006,663 199.83 20,976,557 259.85 66,691,803 657.22 282,764,051 153.62
5,391 1.07 92,196 1.14 95,430 0.94 2,081,106 1.13
1,746 0.35 24,925 0.31 42,223 0.42 579,968 0.32
40,301 8.00 645,817 8.00 811,801 8.00 14,725,400 8.00
66,996 5.75% 1,381,598 5.75% 4,298,100 5.75% 19,078,524 5.75%
107,297 21.30 2,027,415 25.11 5,109,901 50.36 33,803,924 18.36
23,303 2.00% 480,556 2.00% 1,494,991 2.00% 6,636,008 2.00%
20,390 1.75% 420,486 1.75% 1,308,117 1.75% 5,806,507 1.75%
353 0.07 5,651 0.07 7,103 0.07 128,847 0.07
1,165,142 231.29 24,027,785 297.64 74,749,570 736.63 331,800,410 180.26
137,351 27.27 1,826,375 22.62 32,618,830 321.45 34,929,780 18.98
1,027,790 204.02 22,201,410 275.02 42,130,740 415.18 296,870,630 161.28
64
65
Attachment 4
Trend Analysis
The FY2016 rating methodology uses assumed trend factors to adjust the base period claims cost
to the projection period. The cost trend factors used in this analysis are a combination of
utilization and inflation components. The projected trend rate assumptions were developed by
the actuary based on an analysis of recent experience under the various health plans. Trend
assumptions vary by service area for FY2015 and are established on a statewide basis for
FY2016. All trend assumptions vary by risk group.
The trend analysis included a review of health plan claims experience data through February 28,
2015. Based on this information, estimates of monthly incurred claims were made through
December 2014. The claims cost and trend experience was reviewed separately by service area
and risk group.
Exhibit A provides a summary of the FY2012, FY2013, FY2014 and FY2015 trends by service
area and risk group. The FY2015 trend represents the trend during the period September 2014
through December 2014. All trends have been calculated as the average cost per member per
month during the specified time period compared to the same time period during the prior fiscal
year. For example, the FY2014 trend is calculated as the average cost per member per month
during FY2014 divided by the average cost per member per month during FY2013. All trends
have been adjusted to remove the impact of the various provider reimbursement changes that
have impacted the program.
On Exhibit A, the service area trends have been combined into a statewide weighted average by
weighting the service area specific trends by each area’s proportion of the total incurred claims.
The Hidalgo service area has been excluded from the statewide weighted average because this
area has experienced significant managed care savings resulting in reductions in the average cost
since it effective date of March 1, 2012. Due to these managed care reductions, the Hidalgo
service area experience is not indicative of the underlying statewide trend and has therefore been
excluded.
The FY2015 trend assumptions were developed from two components: (i) the actual service area
specific estimated trend for the period September 2014 through December 2014 and (ii) the
statewide projected trend for the period January 2015 through August 2015. The trends for the
final eight months of FY2015 were projected using statewide experience from FY2012 (3/10
weight), FY2013 (3/10 weight), FY2014 (3/10 weight) and 9/2014-12/2014 (1/10 weight). The
weighting of each time period was based on the number of months within each time period. All
projected statewide trends were limited to no less than 0.0%
Blending the area specific trends for the period September 2014 through December 2014 with
the statewide projected trend for the period January 2015 through August 2015 was done via the
following formula:
FY2015 SDA Trend = (9/14-12/14 actual SDA trend) x 4 + (1/15-8/15 Statewide) x 8
12
66
Exhibit B provides a summary of the derivation of the FY2015 service area and statewide trend
components.
The FY2016 trend assumptions were then developed from a simple average of the FY2012 trend,
FY2013 trend, FY2014 trend and FY2015 trend.
Exhibit C provides a summary of the final FY2015 and FY2016 trend assumptions.
Attachment 4 - Exhibit A
FY2016 STAR Rating
Analysis of STAR HMO Cost Trend Factors
Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis
Age <1
FY2012 1.057 1.022 1.066 1.089 0.943 0.957 1.073 0.930
FY2013 0.947 1.005 1.158 1.002 1.109 1.034 1.106 1.134 1.060 1.001
FY2014 0.941 0.849 0.868 0.988 1.076 1.120 1.100 1.174 0.962 1.138
FY2015 1.197 0.744 0.926 0.994 0.904 0.861 0.971 1.083 1.022 0.897
Age 1-5
FY2012 1.055 1.028 0.973 1.057 1.017 1.052 1.145 1.022
FY2013 1.007 1.053 1.094 1.097 0.839 1.027 1.078 1.038 0.972 1.011
FY2014 0.988 0.996 1.000 0.996 0.876 1.060 1.105 1.059 1.028 1.041
FY2015 1.093 1.024 1.007 1.077 0.950 1.073 1.201 1.060 1.068 1.061
Age 6-14
FY2012 1.091 1.042 1.037 1.041 0.978 1.008 1.138 1.096
FY2013 0.982 1.048 1.134 1.076 0.829 1.040 1.082 1.046 0.993 1.002
FY2014 0.988 0.955 1.041 1.042 0.929 0.969 1.133 1.121 1.083 1.072
FY2015 1.069 1.136 0.957 1.049 1.011 1.084 1.066 1.161 1.037 1.113
Age 15-18
FY2012 1.047 1.028 1.030 1.019 0.942 1.074 1.112 0.918
FY2013 0.989 1.056 1.067 1.023 0.948 0.912 1.078 1.054 1.099 0.993
FY2014 0.923 0.947 1.002 1.093 0.929 1.095 0.879 0.973 0.917 1.103
FY2015 0.986 1.049 1.022 0.978 0.968 1.155 1.044 0.922 1.091 1.013
Age 19-20
FY2012 1.320 1.772 1.086 1.596 1.509 1.243 1.656 1.203
FY2013 0.931 0.963 0.878 0.927 1.045 0.977 0.830 0.958 0.831 1.021
FY2014 0.701 0.859 0.730 0.914 0.752 0.892 0.837 0.860 1.001 0.864
FY2015 0.700 0.668 0.828 0.748 0.619 0.639 0.448 0.639 0.866 0.728
67
Attachment 4 - Exhibit A
FY2016 STAR Rating
Analysis of STAR HMO Cost Trend Factors
Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis
TANF Adult
FY2012 1.000 1.077 0.953 1.042 0.873 0.984 1.108 1.124
FY2013 0.863 0.970 1.004 0.946 1.021 1.075 1.013 0.942 0.910 1.027
FY2014 0.892 0.923 0.972 0.941 0.999 0.944 0.975 0.908 0.883 0.932
FY2015 0.806 0.821 0.972 0.803 0.879 0.824 0.944 0.736 0.798 0.821
Pregnant Women
FY2012 1.053 1.001 0.998 1.007 0.994 0.975 0.981 0.966
FY2013 0.880 0.979 1.062 0.999 0.992 1.020 0.995 0.955 0.949 1.003
FY2014 0.979 1.010 0.962 1.022 0.988 1.047 0.976 0.986 1.011 0.963
FY2015 0.994 1.046 0.946 0.975 0.977 0.970 0.994 1.016 0.977 0.973
Footnotes
(1) Hidalgo SDA excluded from the statewide weighted average trend calculation due to significant managed care savings that have resulted from
STAR expansion into the Hidalgo SDA effective March 1, 2012.
68
Attachment 4 - Exhibit A
FY2016 STAR Rating
Analysis of STAR HMO Cost Trend Factors
MRSA MRSA MRSA Weighted
Central Northeast West Average (1)
Age <1
FY2012 1.047
FY2013 1.068 0.975 0.933 1.020
FY2014 0.914 1.133 0.946 0.994
FY2015 1.238 1.060 0.987 1.002
Age 1-5
FY2012 1.054
FY2013 1.049 0.967 0.984 1.046
FY2014 0.994 0.982 0.989 1.007
FY2015 1.054 1.075 1.020 1.064
Age 6-14
FY2012 1.061
FY2013 1.044 1.075 1.000 1.044
FY2014 0.977 0.964 0.929 1.021
FY2015 1.095 1.061 1.039 1.073
Age 15-18
FY2012 1.031
FY2013 0.875 0.938 1.030 1.030
FY2014 1.015 1.004 1.017 1.009
FY2015 1.020 1.088 0.873 1.014
Age 19-20
FY2012 1.492
FY2013 1.228 0.960 1.040 0.943
FY2014 0.884 1.323 0.828 0.910
FY2015 0.697 0.586 0.843 0.724
69
Attachment 4 - Exhibit A
FY2016 STAR Rating
Analysis of STAR HMO Cost Trend Factors
MRSA MRSA MRSA Weighted
Central Northeast West Average (1)
TANF Adult
FY2012 1.040
FY2013 1.211 0.993 1.051 0.967
FY2014 0.932 0.951 0.948 0.929
FY2015 0.878 0.888 0.816 0.828
Pregnant Women
FY2012 1.004
FY2013 1.076 1.022 0.973 0.982
FY2014 0.976 1.008 1.020 1.003
FY2015 1.001 0.981 1.016 0.993
Footnotes
(1) Hidalgo SDA excluded from the statewide weighted average trend calculation due to significant managed care savings that have resulted from
STAR expansion into the Hidalgo SDA effective March 1, 2012.
70
Attachment 4 - Exhibit B
FY2016 STAR Rating
Average Historical Trends
FY2012 FY2013 FY2014 9/14-12/14 (2)
Statewide Average Trend (1)
Age <1 4.7 % 2.0 % -0.6 % 0.2 %
Age 1-5 5.4 % 4.6 % 0.7 % 6.4 %
Age 6-14 6.1 % 4.4 % 2.1 % 7.3 %
Age 15-18 3.1 % 3.0 % 0.9 % 1.4 %
Age 19-20 49.2 % -5.7 % -9.0 % -27.6 %
TANF - Adults 4.0 % -3.3 % -7.1 % -17.2 %
Pregnant Women 0.4 % -1.8 % 0.3 % -0.7 %
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women
9/2014-12/2014 (2)
Bexar 19.7 % 9.3 % 6.9 % -1.4 % -30.0 % -19.4 % -0.6 %
Dallas -25.6 % 2.4 % 13.6 % 4.9 % -33.2 % -17.9 % 4.6 %
El Paso -7.4 % 0.7 % -4.3 % 2.2 % -17.2 % -2.8 % -5.4 %
Harris -0.6 % 7.7 % 4.9 % -2.2 % -25.2 % -19.7 % -2.5 %
Hidalgo -9.6 % -5.0 % 1.1 % -3.2 % -38.1 % -12.1 % -2.3 %
Jefferson -13.9 % 7.3 % 8.4 % 15.5 % -36.1 % -17.6 % -3.0 %
Lubbock -2.9 % 20.1 % 6.6 % 4.4 % -55.2 % -5.6 % -0.6 %
Nueces 8.3 % 6.0 % 16.1 % -7.8 % -36.1 % -26.4 % 1.6 %
Tarrant 2.2 % 6.8 % 3.7 % 9.1 % -13.4 % -20.2 % -2.3 %
Travis -10.3 % 6.1 % 11.3 % 1.3 % -27.2 % -17.9 % -2.7 %
MRSA Central 23.8 % 5.4 % 9.5 % 2.0 % -30.3 % -12.2 % 0.1 %
MRSA Northeast 6.0 % 7.5 % 6.1 % 8.8 % -41.4 % -11.2 % -1.9 %
MRSA West -1.3 % 2.0 % 3.9 % -12.7 % -15.7 % -18.4 % 1.6 %
Statewide Average 0.2 % 6.4 % 7.3 % 1.4 % -27.6 % -17.2 % -0.7 %
1/2015-8/2015 (3) 1.9 % 3.9 % 4.5 % 2.2 % 7.6 % 0.0 % 0.0 %
Footnotes
(1) All trends are net of reimbursement changes.
(2) Average trend during the period 9/1/2014-12/31/2014.
(3) Assumed trend during the period 1/1/2015-8/31/2015. Equals weighted average of the Statewide FY2012, FY2013, FY2014 and 9/14-12/14 trends.
Weighted based on number of months. Limited to no less than 0.0%.
71
Attachment 4 - Exhibit C
FY2016 STAR Rating
Trend Assumptions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women
FY2015 (1)
Bexar 7.8 % 5.7 % 5.3 % 1.0 % 0.0 % 0.0 % 0.0 %
Dallas 0.0 % 3.4 % 7.5 % 3.1 % 0.0 % 0.0 % 1.5 %
El Paso 0.0 % 2.8 % 1.6 % 2.2 % 0.0 % 0.0 % 0.0 %
Harris 1.0 % 5.2 % 4.7 % 0.8 % 0.0 % 0.0 % 0.0 %
Hidalgo 0.0 % 0.9 % 3.4 % 0.4 % 0.0 % 0.0 % 0.0 %
Jefferson 0.0 % 5.0 % 5.8 % 6.7 % 0.0 % 0.0 % 0.0 %
Lubbock 0.3 % 9.3 % 5.2 % 3.0 % 0.0 % 0.0 % 0.0 %
Nueces 4.0 % 4.6 % 8.4 % 0.0 % 0.0 % 0.0 % 0.5 %
Tarrant 2.0 % 4.8 % 4.2 % 4.5 % 0.6 % 0.0 % 0.0 %
Travis 0.0 % 4.6 % 6.8 % 1.9 % 0.0 % 0.0 % 0.0 %
MRSA Central 9.2 % 4.4 % 6.2 % 2.2 % 0.0 % 0.0 % 0.0 %
MRSA Northeast 3.2 % 5.1 % 5.1 % 4.4 % 0.0 % 0.0 % 0.0 %
MRSA West 0.8 % 3.3 % 4.3 % 0.0 % 0.0 % 0.0 % 0.5 %
Statewide Average 1.3 % 4.7 % 5.4 % 2.0 % 0.0 % 0.0 % 0.0 %
FY2016 (2) 1.9 % 3.9 % 4.5 % 2.2 % 8.6 % 0.0 % 0.0 %
Footnotes
(1) Weighted Average trend based on SDA specific actual (9/14-12/14) and statewide projected (1/15-8/15) trends. Weighted based on number of months.
(2) Statewide projected trends based on FY2012-FY2015 average trends weighted equally.
72
73
Attachment 5
Provider Reimbursement and Benefit Revisions Effective During FY2014, FY2015 and FY2016
This attachment presents information regarding rating adjustments for the various provider
reimbursement and benefit revisions that became effective (or will become effective) after the
base period used in rate setting (FY2014) and before the end of FY2016.
All adjustments have been calculated through an analysis of health plan encounter data repriced
using the old and new reimbursement terms and the impact determined as the relative change in
cost.
Effective September 1, 2010, HHSC revised the rating methodology to exclude from the claims
experience base any amounts paid by a health plan to a related party in excess of 100% of
Medicaid. Attached Exhibit A presents a summary of the derivation of the rating adjustment
factors.
Effective September 1, 2014 and again on September 1, 2015 HHSC revised the standard dollar
amounts applied to the inpatient reimbursement for certain children’s, safety net and trauma
hospitals. Exhibit B presents a summary of the derivation of the rating adjustment factors.
Effective May 1, 2013 HHSC implemented revisions to hospital reimbursement to account for
Potentially Preventable Readmissions (PPR). The reimbursement reductions amount to 1-2%
depending on a hospitals performance during the evaluation time period. New PPR lists will
become effective September 1, 2015. Exhibit C presents a summary of the derivation of the
rating adjustment factors.
Effective March 1, 2014 HHSC implemented revisions to hospital reimbursement to account for
Potentially Preventable Complications (PPC). The reimbursement reductions amount to 2-2.5%
depending on a hospitals performance during the evaluation time period. New PPC lists will
become effective September 1, 2015. Exhibit D presents a summary of the derivation of the
rating adjustment factors.
Effective September 1, 2015 HHSC will implement revisions to outpatient rural hospital
reimbursement. Exhibits E and F present the rating adjustment factors for non-imaging services
and imaging services, respectively.
Effective September 1, 2015 HHSC will implement revisions to the reimbursement for therapy
services. Exhibit G presents a summary of the derivation of the rating adjustment factors
Effective September 1, 2014 mental health rehabilitation and targeted case management services
became capitated under the program. Prior to this time these services were paid on a fee-for-
service basis. Exhibit H presents a summary of the derivation of the rating adjustment factors.
Effective June 15, 2015 HHSC has placed Makena on the preferred drug list (PDL) which is
expected to increase the utilization of the physician administered drug amongst pregnant women.
Exhibit I presents a summary of the derivation of the rating adjustment factors.
74
Effective January 1, 2016 HHSC will increase the reimbursement for Long Acting Reversible
Contraceptives (LARCs). As a result of the increased reimbursement it is expected that
utilization will increase. Exhibit J presents a summary of the derivation of the rating adjustment
factor for pregnant women.
For ease of reporting purposes, the numerous provider reimbursement adjustments described
above have been consolidated in the community rating exhibits included in Attachment 3. The
key below includes a description of where each adjustment has been included in Attachment 3.
Attachment 3 Heading Attachment 5 Exhibits
Provider Reimbursement Adjustment
Exhibits E, F and G
Other Reimbursement Changes Exhibits H, I and J
Inpatient Reimbursement Changes Exhibits A, B, C and D
Attachment 5 - Exhibit A
FY2016 STAR Rating
Provider Reimbursement Adjustments
Limit Reimbursement to Related Parties
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact (1)
CFHP -202,720 -26,220 -18,993 -31,460 -474 -11,453 -65,004 0 -356,324
Driscoll - Hid -678,933 -21,548 -31,730 -6,662 0 0 0 0 -738,873
Driscoll - Nue -1,449,265 -139,327 -118,052 -36,687 0 0 0 0 -1,743,331
Parkland -333,771 -694,217 -478,859 -405,791 -30,317 -1,162,493 -1,355,377 0 -4,460,824
TCHP-Harris -606,613 -1,770,185 -1,868,479 -886,613 -3,507 -16,450 -187,607 0 -5,339,453
TCHP-Jeff -30,569 -67,444 -47,474 -32,712 0 -292 -4,813 0 -183,304
All Other 0 0 0 0 0 0 0 0 0
Total -3,301,870 -2,718,940 -2,563,587 -1,399,924 -34,298 -1,190,688 -1,612,802 0 -12,822,109
FY2014 Total Incurred Claims (2)
CFHP 34,895,067 37,069,194 32,170,050 12,686,953 666,865 12,605,706 26,073,716 0 156,167,550
Driscoll - Hid 31,940,434 17,356,369 15,444,875 6,367,444 371,944 3,826,600 21,176,104 0 96,483,770
Driscoll - Nue 41,734,914 21,466,012 18,612,611 7,676,600 404,240 4,667,270 23,593,434 0 118,155,080
Parkland 57,778,068 84,987,269 57,439,412 18,461,818 832,841 13,675,075 48,758,063 0 281,932,545
TCHP-Harris 92,366,136 120,867,418 109,393,551 42,472,535 1,098,281 14,596,048 53,462,935 0 434,256,904
TCHP-Jeff 11,238,716 8,744,062 6,757,059 2,439,540 196,863 2,742,428 6,552,480 0 38,671,148
All Other 948,518,313 704,460,115 546,292,964 200,015,186 11,574,614 251,421,659 633,489,445 285,145,235 3,580,917,531
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
Rate Adjustment - by Plan (3)
CFHP -0.58 % -0.07 % -0.06 % -0.25 % -0.07 % -0.09 % -0.25 % -0.23 %
Driscoll - Hid -2.13 % -0.12 % -0.21 % -0.10 % 0.00 % 0.00 % 0.00 % -0.77 %
Driscoll - Nue -3.47 % -0.65 % -0.63 % -0.48 % 0.00 % 0.00 % 0.00 % -1.48 %
Parkland -0.58 % -0.82 % -0.83 % -2.20 % -3.64 % -8.50 % -2.78 % -1.58 %
TCHP-Harris -0.66 % -1.46 % -1.71 % -2.09 % -0.32 % -0.11 % -0.35 % -1.23 %
TCHP-Jeff -0.27 % -0.77 % -0.70 % -1.34 % 0.00 % -0.01 % -0.07 % -0.47 %
All Other 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Total -0.27 % -0.27 % -0.33 % -0.48 % -0.23 % -0.39 % -0.20 % 0.00 % -0.27 %
75
Attachment 5 - Exhibit A
FY2016 STAR Rating
Provider Reimbursement Adjustments
Limit Reimbursement to Related Parties
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment - by SDA (3)
Bexar -0.21 % -0.03 % -0.03 % -0.13 % -0.04 % -0.04 % -0.09 %
Dallas -0.26 % -0.43 % -0.40 % -0.98 % -1.61 % -3.53 % -1.27 %
El Paso 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Harris -0.21 % -0.76 % -1.00 % -1.18 % -0.13 % -0.03 % -0.11 %
Hidalgo -0.70 % -0.02 % -0.03 % -0.02 % 0.00 % 0.00 % 0.00 %
Jefferson -0.08 % -0.32 % -0.29 % -0.46 % 0.00 % 0.00 % -0.02 %
Lubbock 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Nueces -2.92 % -0.44 % -0.43 % -0.34 % 0.00 % 0.00 % 0.00 %
Tarrant 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Travis 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
MRSA Central 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
MRSA Northeast 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
MRSA West 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Footnotes:
(1) Equals the cost impact from limiting reimbursement to a related party to 100% of Medicaid.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
(4) Adjustment factor applied by service delivery area.
76
Attachment 5 - Exhibit B
FY2016 STAR Rating
Provider Reimbursement Adjustments
Hospital Reimbursement Changes - Standard Dollar Amount
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of SDA Changes (1)
Bexar 2,632,249 500,805 404,965 247,052 23,309 533,128 1,969,343 0 6,310,851
Dallas 711,891 -347,410 -224,776 116,592 39,018 597,838 3,139,053 0 4,032,206
El Paso 4,349,948 1,900,446 2,560,011 1,073,821 19,923 381,624 1,613,285 0 11,899,058
Harris 9,017,034 1,928,018 1,810,523 866,802 64,751 962,169 4,658,892 0 19,308,189
Hidalgo 4,112,268 749,945 789,257 463,816 34,738 776,440 2,496,188 0 9,422,652
Jefferson 1,086,311 170,480 87,122 99,831 8,915 167,252 501,461 0 2,121,370
Lubbock 2,958,418 362,818 371,016 110,116 6,305 201,866 922,080 0 4,932,618
Nueces 1,977,222 382,935 362,984 194,083 12,992 243,939 1,099,226 0 4,273,379
Tarrant 1,886,793 130,066 228,128 279,498 16,084 515,943 2,233,951 0 5,290,463
Travis 2,023,824 280,088 285,645 179,941 11,578 274,036 1,097,811 0 4,152,924
MRSA Central 1,777,919 302,683 264,905 160,387 16,217 370,720 1,339,287 2,976,129 7,208,247
MRSA Northeast 1,373,269 86,470 114,889 144,936 17,960 432,757 1,158,624 3,522,293 6,851,198
MRSA West 2,211,688 365,343 332,069 111,028 11,623 311,119 1,268,117 2,109,659 6,720,646
Total 36,118,833 6,812,686 7,386,737 4,047,903 283,413 5,768,831 23,497,317 8,608,081 92,523,801
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
77
Attachment 5 - Exhibit B
FY2016 STAR Rating
Provider Reimbursement Adjustments
Hospital Reimbursement Changes - Standard Dollar Amount
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 2.50 % 0.60 % 0.66 % 1.03 % 1.54 % 1.57 % 2.60 % 1.64 %
Dallas 0.62 % -0.22 % -0.19 % 0.29 % 2.36 % 1.91 % 3.09 % 0.71 %
El Paso 10.08 % 5.50 % 7.91 % 7.77 % 3.36 % 3.34 % 5.37 % 7.17 %
Harris 2.95 % 0.82 % 0.95 % 1.14 % 1.97 % 1.43 % 2.40 % 1.80 %
Hidalgo 3.28 % 0.53 % 0.70 % 1.24 % 1.97 % 2.34 % 3.41 % 1.79 %
Jefferson 2.51 % 0.81 % 0.52 % 1.33 % 1.67 % 1.36 % 1.83 % 1.65 %
Lubbock 6.78 % 1.55 % 2.02 % 1.74 % 1.55 % 2.26 % 3.51 % 3.87 %
Nueces 3.64 % 1.14 % 1.30 % 1.77 % 2.31 % 2.54 % 3.77 % 2.57 %
Tarrant 1.64 % 0.14 % 0.28 % 1.10 % 1.32 % 1.93 % 3.14 % 1.28 %
Travis 2.64 % 0.51 % 0.75 % 1.45 % 1.69 % 1.53 % 2.49 % 1.70 %
MRSA Central 3.92 % 0.86 % 1.05 % 1.64 % 2.29 % 2.66 % 4.03 % 4.31 % 3.10 %
MRSA Northeast 1.86 % 0.19 % 0.34 % 1.03 % 1.34 % 2.11 % 2.25 % 2.78 % 1.87 %
MRSA West 3.07 % 1.02 % 1.14 % 0.91 % 1.32 % 1.89 % 2.28 % 2.36 % 2.16 %
Total 2.96 % 0.68 % 0.94 % 1.40 % 1.87 % 1.90 % 2.89 % 3.02 % 1.97 %
Footnotes:
(1) Equals the cost impact from application of the revised hospital Standard Dollar Amounts effective 9/1/2015.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
78
Attachment 5 - Exhibit C
FY2016 STAR Rating
Provider Reimbursement Adjustments
Potentially Preventable Readmission (PPR) Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of PPR Revisions (1)
Bexar 2,585 578 -4,632 -586 157 1,827 5,752 0 5,679
Dallas -12,493 247 -146 -2,572 -918 -19,206 -96,024 0 -131,111
El Paso -105,488 -32,687 -28,446 -9,156 -341 3,995 3,039 0 -169,083
Harris 383,033 16,559 13,006 5,162 900 19,599 122,426 0 560,684
Hidalgo -30,675 -4,165 -1,953 -4,967 -1,760 -26,604 -77,277 0 -147,402
Jefferson 75,112 746 1,155 634 -137 3,333 26,537 0 107,381
Lubbock -31,421 -1,292 -2,911 -216 -115 -3,094 -15,056 0 -54,104
Nueces 104,950 10,243 8,862 3,801 129 2,109 25,984 0 156,078
Tarrant 47,642 209 -5,271 -3,825 1,958 8,950 36,101 0 85,764
Travis 55,378 19,962 15,834 3,572 -598 -6,768 -3,756 0 83,625
MRSA Central 38,415 1,726 1,515 1,326 104 452 3,065 10,744 57,347
MRSA Northeast 69,031 -958 6 1,525 -3,902 -3,565 9,816 -33,681 38,272
MRSA West 6,713 837 1,844 777 -68 -2,238 8,830 -18,605 -1,910
Total 602,782 12,004 -1,137 -4,524 -4,591 -21,210 49,437 -41,542 591,220
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
79
Attachment 5 - Exhibit C
FY2016 STAR Rating
Provider Reimbursement Adjustments
Potentially Preventable Readmission (PPR) Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 0.00 % 0.00 % -0.01 % 0.00 % 0.01 % 0.01 % 0.01 % 0.00 %
Dallas -0.01 % 0.00 % 0.00 % -0.01 % -0.06 % -0.06 % -0.09 % -0.02 %
El Paso -0.24 % -0.09 % -0.09 % -0.07 % -0.06 % 0.03 % 0.01 % -0.10 %
Harris 0.13 % 0.01 % 0.01 % 0.01 % 0.03 % 0.03 % 0.06 % 0.05 %
Hidalgo -0.02 % 0.00 % 0.00 % -0.01 % -0.10 % -0.08 % -0.11 % -0.03 %
Jefferson 0.17 % 0.00 % 0.01 % 0.01 % -0.03 % 0.03 % 0.10 % 0.08 %
Lubbock -0.07 % -0.01 % -0.02 % 0.00 % -0.03 % -0.03 % -0.06 % -0.04 %
Nueces 0.19 % 0.03 % 0.03 % 0.03 % 0.02 % 0.02 % 0.09 % 0.09 %
Tarrant 0.04 % 0.00 % -0.01 % -0.02 % 0.16 % 0.03 % 0.05 % 0.02 %
Travis 0.07 % 0.04 % 0.04 % 0.03 % -0.09 % -0.04 % -0.01 % 0.03 %
MRSA Central 0.08 % 0.00 % 0.01 % 0.01 % 0.01 % 0.00 % 0.01 % 0.02 % 0.02 %
MRSA Northeast 0.09 % 0.00 % 0.00 % 0.01 % -0.29 % -0.02 % 0.02 % -0.03 % 0.01 %
MRSA West 0.01 % 0.00 % 0.01 % 0.01 % -0.01 % -0.01 % 0.02 % -0.02 % 0.00 %
Total 0.05 % 0.00 % 0.00 % 0.00 % -0.03 % -0.01 % 0.01 % -0.01 % 0.01 %
Footnotes:
(1) Equals the net cost/savings resulting from PPR reductions that will become effective 9/1/2015 versus those effective during FY2014.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
80
Attachment 5 - Exhibit D
FY2016 STAR Rating
Provider Reimbursement Adjustments
Potentially Preventable Complications (PPC) Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of PPC Revisions (1)
Bexar -741,298 -66,045 -54,936 -42,455 -5,369 -119,162 -466,249 0 -1,495,515
Dallas -103,378 3,085 4,892 -5,502 -1,647 -35,162 -98,977 0 -236,689
El Paso -86,819 -34,391 -38,453 -11,315 51 5,731 37,013 0 -128,184
Harris -208,999 -41,899 -71,077 -60,053 -5,219 -64,990 -169,408 0 -621,644
Hidalgo -704,976 -59,257 -60,256 -33,618 -3,500 -45,782 -137,039 0 -1,044,428
Jefferson -112,689 -3,837 -6,639 -4,303 -888 -20,988 -43,819 0 -193,162
Lubbock -233,677 -21,045 -23,884 -8,266 -1,348 -37,183 -177,182 0 -502,586
Nueces -632,842 -73,849 -62,060 -29,986 -1,291 -28,192 -87,717 0 -915,937
Tarrant -40,145 -988 -5,019 7,083 -3,926 -10,158 -14,060 0 -67,212
Travis -511,931 -139,279 -155,959 -55,779 -208 -15,871 -2,920 0 -881,947
MRSA Central -62,154 -14,068 -20,459 -2,173 -439 -6,493 -12,714 -79,720 -198,219
MRSA Northeast -6,708 -5,659 -6,742 -10,283 -9,584 -23,578 -145,978 -314,389 -522,920
MRSA West -418,886 -44,335 -27,010 -26,216 -4,006 -89,728 -457,067 -562,409 -1,629,656
Total -3,864,502 -501,567 -527,602 -282,865 -37,374 -491,555 -1,776,117 -956,517 -8,438,099
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
81
Attachment 5 - Exhibit D
FY2016 STAR Rating
Provider Reimbursement Adjustments
Potentially Preventable Complications (PPC) Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar -0.70 % -0.08 % -0.09 % -0.18 % -0.35 % -0.35 % -0.62 % -0.39 %
Dallas -0.09 % 0.00 % 0.00 % -0.01 % -0.10 % -0.11 % -0.10 % -0.04 %
El Paso -0.20 % -0.10 % -0.12 % -0.08 % 0.01 % 0.05 % 0.12 % -0.08 %
Harris -0.07 % -0.02 % -0.04 % -0.08 % -0.16 % -0.10 % -0.09 % -0.06 %
Hidalgo -0.56 % -0.04 % -0.05 % -0.09 % -0.20 % -0.14 % -0.19 % -0.20 %
Jefferson -0.26 % -0.02 % -0.04 % -0.06 % -0.17 % -0.17 % -0.16 % -0.15 %
Lubbock -0.54 % -0.09 % -0.13 % -0.13 % -0.33 % -0.42 % -0.67 % -0.39 %
Nueces -1.17 % -0.22 % -0.22 % -0.27 % -0.23 % -0.29 % -0.30 % -0.55 %
Tarrant -0.03 % 0.00 % -0.01 % 0.03 % -0.32 % -0.04 % -0.02 % -0.02 %
Travis -0.67 % -0.25 % -0.41 % -0.45 % -0.03 % -0.09 % -0.01 % -0.36 %
MRSA Central -0.14 % -0.04 % -0.08 % -0.02 % -0.06 % -0.05 % -0.04 % -0.12 % -0.09 %
MRSA Northeast -0.01 % -0.01 % -0.02 % -0.07 % -0.72 % -0.11 % -0.28 % -0.25 % -0.14 %
MRSA West -0.58 % -0.12 % -0.09 % -0.21 % -0.45 % -0.55 % -0.82 % -0.63 % -0.52 %
Total -0.32 % -0.05 % -0.07 % -0.10 % -0.25 % -0.16 % -0.22 % -0.34 % -0.18 %
Footnotes:
(1) Equals the net cost/savings resulting from PPC reductions that will become effective 9/1/2015 versus those effective during FY2014.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
82
Attachment 5 - Exhibit E
FY2016 STAR Rating
Provider Reimbursement Adjustments
Outpatient Rural Hospital Reimbursement Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of Reimbursement Increase (1)
Bexar 24,173 68,753 102,739 71,407 857 79,593 82,575 0 430,098
Dallas 20,168 59,444 43,591 19,832 1,176 33,155 29,548 0 206,914
El Paso 1,271 685 2,211 2,104 119 582 277 0 7,247
Harris 33,144 104,603 151,435 56,854 2,168 97,963 131,790 0 577,956
Hidalgo 36,819 105,202 81,746 52,744 3,632 39,639 73,629 0 393,412
Jefferson 18,231 50,441 45,542 28,999 5,504 62,770 63,460 0 274,947
Lubbock 28,404 65,244 80,772 55,706 4,923 101,320 151,783 0 488,152
Nueces 69,106 142,531 144,185 83,452 4,007 132,577 126,024 0 701,881
Tarrant 19,559 45,009 51,495 32,124 681 61,792 40,042 0 250,702
Travis 30,877 67,617 72,282 43,322 1,551 82,493 69,335 0 367,478
MRSA Central 102,597 280,930 255,029 156,371 12,704 247,031 210,020 763,312 2,027,994
MRSA Northeast 161,757 464,610 351,424 199,541 13,934 340,780 367,057 1,318,965 3,218,068
MRSA West 226,405 595,744 446,180 271,245 15,577 354,133 596,892 1,292,634 3,798,809
Total 772,511 2,050,812 1,828,629 1,073,701 66,832 1,633,829 1,942,433 3,374,911 12,743,658
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
83
Attachment 5 - Exhibit E
FY2016 STAR Rating
Provider Reimbursement Adjustments
Outpatient Rural Hospital Reimbursement Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 0.02 % 0.08 % 0.17 % 0.30 % 0.06 % 0.23 % 0.11 % 0.11 %
Dallas 0.02 % 0.04 % 0.04 % 0.05 % 0.07 % 0.11 % 0.03 % 0.04 %
El Paso 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.01 % 0.00 % 0.00 %
Harris 0.01 % 0.04 % 0.08 % 0.07 % 0.07 % 0.15 % 0.07 % 0.05 %
Hidalgo 0.03 % 0.07 % 0.07 % 0.14 % 0.21 % 0.12 % 0.10 % 0.07 %
Jefferson 0.04 % 0.24 % 0.27 % 0.39 % 1.03 % 0.51 % 0.23 % 0.21 %
Lubbock 0.07 % 0.28 % 0.44 % 0.88 % 1.21 % 1.13 % 0.58 % 0.38 %
Nueces 0.13 % 0.42 % 0.52 % 0.76 % 0.71 % 1.38 % 0.43 % 0.42 %
Tarrant 0.02 % 0.05 % 0.06 % 0.13 % 0.06 % 0.23 % 0.06 % 0.06 %
Travis 0.04 % 0.12 % 0.19 % 0.35 % 0.23 % 0.46 % 0.16 % 0.15 %
MRSA Central 0.23 % 0.80 % 1.01 % 1.60 % 1.79 % 1.77 % 0.63 % 1.11 % 0.87 %
MRSA Northeast 0.22 % 1.02 % 1.04 % 1.42 % 1.04 % 1.66 % 0.71 % 1.04 % 0.88 %
MRSA West 0.31 % 1.66 % 1.53 % 2.22 % 1.77 % 2.15 % 1.07 % 1.45 % 1.22 %
Total 0.06 % 0.21 % 0.23 % 0.37 % 0.44 % 0.54 % 0.24 % 1.18 % 0.27 %
Footnotes:
(1) Equals the increased cost due to revised outpatient rural hospital reimbursement effective 9/1/2015. Excludes imaging reimbursement increase.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
84
Attachment 5 - Exhibit F
FY2016 STAR Rating
Provider Reimbursement Adjustments
Outpatient Rural Hospital Imaging Reimbursement Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of Reimbursement Increase (1)
Bexar 1,045 2,319 5,901 3,653 89 4,846 3,639 0 21,492
Dallas 986 2,184 2,962 1,831 82 2,629 1,744 0 12,418
El Paso 76 30 84 116 6 78 47 0 437
Harris 1,870 4,254 6,880 3,635 134 4,181 3,382 0 24,336
Hidalgo 2,900 6,334 11,293 7,241 343 4,149 7,804 0 40,064
Jefferson 1,422 3,430 5,762 3,950 298 6,423 4,234 0 25,519
Lubbock 1,889 4,584 9,799 5,295 229 5,130 9,808 0 36,734
Nueces 2,386 5,128 11,025 6,552 253 7,226 9,429 0 41,999
Tarrant 1,298 2,306 6,018 4,154 205 9,038 8,220 0 31,239
Travis 1,152 2,721 5,951 3,181 137 4,597 3,028 0 20,767
MRSA Central 4,671 10,906 20,600 14,149 650 18,168 18,529 48,147 135,820
MRSA Northeast 13,212 25,963 41,100 26,808 1,122 33,928 38,708 112,042 292,883
MRSA West 10,151 20,109 40,405 26,826 1,190 29,151 39,202 85,867 252,901
Total 43,058 90,268 167,780 107,391 4,738 129,544 147,774 246,056 936,609
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
85
Attachment 5 - Exhibit F
FY2016 STAR Rating
Provider Reimbursement Adjustments
Outpatient Rural Hospital Imaging Reimbursement Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 0.00 % 0.00 % 0.01 % 0.02 % 0.01 % 0.01 % 0.00 % 0.01 %
Dallas 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.00 %
El Paso 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %
Harris 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.00 %
Hidalgo 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.01 % 0.01 % 0.01 %
Jefferson 0.00 % 0.02 % 0.03 % 0.05 % 0.06 % 0.05 % 0.02 % 0.02 %
Lubbock 0.00 % 0.02 % 0.05 % 0.08 % 0.06 % 0.06 % 0.04 % 0.03 %
Nueces 0.00 % 0.02 % 0.04 % 0.06 % 0.04 % 0.08 % 0.03 % 0.03 %
Tarrant 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.03 % 0.01 % 0.01 %
Travis 0.00 % 0.00 % 0.02 % 0.03 % 0.02 % 0.03 % 0.01 % 0.01 %
MRSA Central 0.01 % 0.03 % 0.08 % 0.14 % 0.09 % 0.13 % 0.06 % 0.07 % 0.06 %
MRSA Northeast 0.02 % 0.06 % 0.12 % 0.19 % 0.08 % 0.17 % 0.08 % 0.09 % 0.08 %
MRSA West 0.01 % 0.06 % 0.14 % 0.22 % 0.14 % 0.18 % 0.07 % 0.10 % 0.08 %
Total 0.00 % 0.01 % 0.02 % 0.04 % 0.03 % 0.04 % 0.02 % 0.09 % 0.02 %
Footnotes:
(1) Equals the increased cost due to revised outpatient rural hospital imaging reimbursement effective 9/1/2015.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
86
Attachment 5 - Exhibit G
FY2016 STAR Rating
Provider Reimbursement Adjustments
Therapy Reimbursement Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Impact of Reimbursement Reduction (1)
Bexar -138,070 -4,335,484 -947,597 -36,397 -217 -22,087 -3,045 0 -5,482,897
Dallas -104,843 -4,614,893 -964,137 -26,264 -20 -7,793 -925 0 -5,718,876
El Paso -47,533 -1,031,467 -297,133 -45,188 -119 -8,786 -957 0 -1,431,184
Harris -112,112 -7,621,844 -1,721,403 -58,713 -789 -52,348 -7,796 0 -9,575,004
Hidalgo -93,427 -5,672,282 -2,269,573 -137,646 -626 -66,905 -3,853 0 -8,244,310
Jefferson -6,675 -413,410 -72,307 -5,884 0 -13,363 -592 0 -512,231
Lubbock -42,051 -641,765 -113,447 -842 -26 -850 0 0 -798,982
Nueces -16,009 -240,452 -52,366 -7,831 -43 -5,683 -2,873 0 -325,257
Tarrant -62,175 -3,974,887 -790,259 -32,645 -206 -25,259 -2,525 0 -4,887,955
Travis -52,276 -1,930,427 -387,801 -9,772 -52 -6,125 -663 0 -2,387,116
MRSA Central -20,082 -1,112,511 -140,032 -3,379 -80 -2,575 -71 -278,291 -1,557,020
MRSA Northeast -32,996 -724,082 -135,474 -11,217 0 -4,325 -126 -264,868 -1,173,086
MRSA West -56,867 -395,743 -93,620 -8,433 -225 -5,229 -1,247 -95,093 -656,457
Total -785,115 -32,709,245 -7,985,150 -384,212 -2,403 -221,328 -24,672 -638,251 -42,750,376
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
87
Attachment 5 - Exhibit G
FY2016 STAR Rating
Provider Reimbursement Adjustments
Therapy Reimbursement Reductions
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar -0.13 % -5.19 % -1.54 % -0.15 % -0.01 % -0.07 % 0.00 % -1.42 %
Dallas -0.09 % -2.92 % -0.81 % -0.07 % 0.00 % -0.02 % 0.00 % -1.01 %
El Paso -0.11 % -2.99 % -0.92 % -0.33 % -0.02 % -0.08 % 0.00 % -0.86 %
Harris -0.04 % -3.24 % -0.90 % -0.08 % -0.02 % -0.08 % 0.00 % -0.89 %
Hidalgo -0.07 % -4.01 % -2.01 % -0.37 % -0.04 % -0.20 % -0.01 % -1.57 %
Jefferson -0.02 % -1.96 % -0.43 % -0.08 % 0.00 % -0.11 % 0.00 % -0.40 %
Lubbock -0.10 % -2.74 % -0.62 % -0.01 % -0.01 % -0.01 % 0.00 % -0.63 %
Nueces -0.03 % -0.72 % -0.19 % -0.07 % -0.01 % -0.06 % -0.01 % -0.20 %
Tarrant -0.05 % -4.28 % -0.97 % -0.13 % -0.02 % -0.09 % 0.00 % -1.18 %
Travis -0.07 % -3.52 % -1.02 % -0.08 % -0.01 % -0.03 % 0.00 % -0.98 %
MRSA Central -0.04 % -3.16 % -0.56 % -0.03 % -0.01 % -0.02 % 0.00 % -0.40 % -0.67 %
MRSA Northeast -0.04 % -1.59 % -0.40 % -0.08 % 0.00 % -0.02 % 0.00 % -0.21 % -0.32 %
MRSA West -0.08 % -1.10 % -0.32 % -0.07 % -0.03 % -0.03 % 0.00 % -0.11 % -0.21 %
Total -0.06 % -3.29 % -1.02 % -0.13 % -0.02 % -0.07 % 0.00 % -0.22 % -0.91 %
Footnotes:
(1) Equals the cost reduction resulting from the therapy reimbursement changes effective 9/1/2015.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
88
Attachment 5 - Exhibit H
FY2016 STAR Rating
Provider Reimbursement Adjustments
Mental Health Rehab Carve-In
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Estimated Cost Impact of Newly Capitated Services (1)
Bexar 0 42,123 511,307 198,296 3,514 197,855 47,179 0 1,000,274
Dallas 0 2,429 7,247 3,734 0 865 1,149 0 15,423
El Paso 0 1,310 241,171 131,899 3,793 212,673 27,170 0 618,016
Harris 0 124,440 1,622,010 726,236 3,933 286,592 78,179 0 2,841,391
Hidalgo 0 406,267 2,817,452 832,256 10,261 357,710 72,651 0 4,496,597
Jefferson 0 87,863 751,627 199,419 1,204 63,078 20,387 0 1,123,578
Lubbock 0 40,355 348,416 109,909 496 48,190 11,948 0 559,314
Nueces 0 41,557 394,527 117,590 1,186 89,381 11,737 0 655,979
Tarrant 0 93,393 538,749 127,015 332 99,325 31,042 0 889,857
Travis 0 40,358 619,232 251,583 310 119,672 16,226 0 1,047,380
MRSA Central 0 58,561 421,190 150,913 556 76,336 12,408 1,656,996 2,376,960
MRSA Northeast 0 137,096 1,137,179 266,200 1,537 127,045 37,703 3,174,204 4,880,964
MRSA West 0 66,985 857,390 256,352 442 106,706 34,916 3,291,329 4,614,121
Total 0 1,142,737 10,267,497 3,371,403 27,564 1,785,428 402,694 8,122,530 25,119,853
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
89
Attachment 5 - Exhibit H
FY2016 STAR Rating
Provider Reimbursement Adjustments
Mental Health Rehab Carve-In
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 0.00 % 0.05 % 0.83 % 0.83 % 0.23 % 0.58 % 0.06 % 0.26 %
Dallas 0.00 % 0.00 % 0.01 % 0.01 % 0.00 % 0.00 % 0.00 % 0.00 %
El Paso 0.00 % 0.00 % 0.75 % 0.95 % 0.64 % 1.86 % 0.09 % 0.37 %
Harris 0.00 % 0.05 % 0.85 % 0.96 % 0.12 % 0.43 % 0.04 % 0.27 %
Hidalgo 0.00 % 0.29 % 2.50 % 2.23 % 0.58 % 1.08 % 0.10 % 0.86 %
Jefferson 0.00 % 0.42 % 4.49 % 2.66 % 0.23 % 0.51 % 0.07 % 0.87 %
Lubbock 0.00 % 0.17 % 1.90 % 1.74 % 0.12 % 0.54 % 0.05 % 0.44 %
Nueces 0.00 % 0.12 % 1.41 % 1.07 % 0.21 % 0.93 % 0.04 % 0.39 %
Tarrant 0.00 % 0.10 % 0.66 % 0.50 % 0.03 % 0.37 % 0.04 % 0.21 %
Travis 0.00 % 0.07 % 1.63 % 2.03 % 0.05 % 0.67 % 0.04 % 0.43 %
MRSA Central 0.00 % 0.17 % 1.67 % 1.54 % 0.08 % 0.55 % 0.04 % 2.40 % 1.02 %
MRSA Northeast 0.00 % 0.30 % 3.37 % 1.89 % 0.11 % 0.62 % 0.07 % 2.51 % 1.33 %
MRSA West 0.00 % 0.19 % 2.94 % 2.10 % 0.05 % 0.65 % 0.06 % 3.68 % 1.48 %
Total 0.00 % 0.11 % 1.31 % 1.16 % 0.18 % 0.59 % 0.05 % 2.85 % 0.53 %
Footnotes:
(1) Equals the cost resulting from capitating these services into the STAR program.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
90
Attachment 5 - Exhibit I
FY2016 STAR Rating
Provider Reimbursement Adjustments
Makena Utilization Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Impact of Utilization Increase (1)
Bexar 0 0 0 0 0 0 43,098 0 43,098
Dallas 0 0 0 0 0 4 131,434 0 131,438
El Paso 0 0 0 1,400 0 11,201 210,392 0 222,993
Harris 0 0 0 0 0 0 147,561 0 147,561
Hidalgo 0 0 0 14,001 5,602 83 163,870 0 183,556
Jefferson 0 0 0 0 0 0 55,287 0 55,287
Lubbock 0 0 0 0 0 3,775 7,003 0 10,778
Nueces 0 0 0 7 3,360 14,711 172,763 0 190,841
Tarrant 0 0 0 0 0 10,038 97,113 0 107,151
Travis 0 0 0 0 0 2,391 69,468 0 71,858
MRSA Central 0 0 0 0 0 7,001 36,954 0 43,955
MRSA Northeast 0 0 0 0 0 7,001 92,437 43 99,481
MRSA West 0 0 0 0 0 3,500 46,620 0 50,120
Total 0 0 0 15,408 8,962 59,705 1,273,998 43 1,358,116
FY2014 Total Incurred Claims (2)
Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126
Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386
El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500
Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841
Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142
Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392
Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677
Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479
Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017
Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805
MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195
MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992
MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978
Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528
91
Attachment 5 - Exhibit I
FY2016 STAR Rating
Provider Reimbursement Adjustments
Makena Utilization Increase
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women SSI Total
Rate Adjustment (3)
Bexar 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.06 % 0.01 %
Dallas 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.13 % 0.02 %
El Paso 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.10 % 0.70 % 0.13 %
Harris 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.08 % 0.01 %
Hidalgo 0.00 % 0.00 % 0.00 % 0.04 % 0.32 % 0.00 % 0.22 % 0.03 %
Jefferson 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.20 % 0.04 %
Lubbock 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.04 % 0.03 % 0.01 %
Nueces 0.00 % 0.00 % 0.00 % 0.00 % 0.60 % 0.15 % 0.59 % 0.11 %
Tarrant 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.04 % 0.14 % 0.03 %
Travis 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.16 % 0.03 %
MRSA Central 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.05 % 0.11 % 0.00 % 0.02 %
MRSA Northeast 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.03 % 0.18 % 0.00 % 0.03 %
MRSA West 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.02 % 0.08 % 0.00 % 0.02 %
Total 0.00 % 0.00 % 0.00 % 0.01 % 0.06 % 0.02 % 0.16 % 0.00 % 0.03 %
Footnotes:
(1) Equals the unit cost difference between Makena and Compound 17P. Assumes Makena utilization will increase by 50%.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
92
Attachment 5 - Exhibit J
FY2016 STAR Rating
Provider Reimbursement Adjustments
Increased LARC Utilization
Pregnant
Women
Projected Cost Increase (1) 6,234,000
FY2014 Total Incurred Claims (2) 813,106,177
Rate Adjustment (3) 0.77%
Footnotes:
(1) Equals the projected cost resulting from increased utilization. Estimate provided by HHSC.
(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).
(3) Additional cost divided by FY2014 Total Incurred Claims.
93
94
Attachment 6
Family Planning Adjustment
One of the health plans that participates in the STAR program does not provide family planning
services. For this health plan, family planning services will be provided through FFS. HHSC
provided a listing of those services that will not be provided by this health plan. Using base
period claims experience, we determined the per member per month cost expected to be
represented by these family planning services. The premium rates for the health plan that does
not provide family planning services have been reduced accordingly. The attached exhibit
presents a summary of the family planning reduction factors associated with the applicable
health plan.
Attachment 6
FY2016 STAR Rating
Projected FY2016 Family Planning Cost PMPM
Risk Group Travis
Age <1 $ 0.00
Age 1-5 0.00
Age 6-14 0.00
Age 15-18 0.33
Age 19-20 1.65
TANF Adults 2.25
Pregnant Women 6.95
95
96
Attachment 7
Third Party Recoveries
The rating methodology includes a factor to recognize those health plans that do not satisfy a
minimum level of recoveries for coordination of benefits. Any plan that did not recover at least
2.0% of claims had its projected claims cost reduced by 2.0% less their actual percentage of
recoveries. For example, if a specific health plan has third party recoveries (TPR) of 1.5% of
claims, then their projected claims cost would be reduced by 0.5%. Any plan that exceeded the
minimum TPR standard of 2.0% had no penalty applied.
The attached chart presents a summary of TPR experience for FY2014.
Attachment 7
FY2016 STAR Rating
Analysis of Third Party Recovery (TPR) Experience
FY2014 FY2014 Inc. Adjustment
Health Plan TPR Claims TPR/Claims Factor
Aetna - Bexar 1,075,168 31,025,956 3.5 % 1.0000
Amerigroup - Bexar 793,185 16,109,184 4.9 % 1.0000
CFHP - Bexar 9,698,473 141,605,114 6.8 % 1.0000
Superior - Bexar 16,898,845 170,476,799 9.9 % 1.0000
Amerigroup - Dallas 7,223,805 243,448,320 3.0 % 1.0000
Molina - Dallas 2,089,850 31,359,065 6.7 % 1.0000
Parkland - Dallas 11,100,684 266,888,564 4.2 % 1.0000
El Paso First - El Paso 499,977 72,929,071 0.7 % 0.9869
Molina - El Paso 205,737 7,332,336 2.8 % 1.0000
Superior - El Paso 7,723,391 76,619,377 10.1 % 1.0000
Amerigroup - Harris 3,975,829 128,859,259 3.1 % 1.0000
CHC - Harris 23,257,848 379,366,032 6.1 % 1.0000
Molina - Harris 925,047 19,796,607 4.7 % 1.0000
TCHP - Harris 19,559,281 396,441,408 4.9 % 1.0000
United - Harris 1,386,412 66,775,773 2.1 % 1.0000
Driscoll - Hidalgo 3,639,480 88,895,621 4.1 % 1.0000
Molina - Hidalgo 2,081,584 74,014,302 2.8 % 1.0000
Superior - Hidalgo 13,580,118 248,047,036 5.5 % 1.0000
United - Hidalgo 1,131,050 90,923,415 1.2 % 0.9924
Amerigroup - Jefferson 231,130 10,449,655 2.2 % 1.0000
CHC - Jefferson 3,502,870 42,608,658 8.2 % 1.0000
Molina - Jefferson 396,748 9,905,699 4.0 % 1.0000
TCHP - Jefferson 3,226,384 36,210,318 8.9 % 1.0000
United - Jefferson 412,688 20,611,408 2.0 % 1.0000
Amerigroup - Lubbock 872,133 19,319,776 4.5 % 1.0000
Firstcare - Lubbock 2,152,292 60,821,610 3.5 % 1.0000
Superior - Lubbock 4,007,391 39,147,215 10.2 % 1.0000
Christus - Nueces 950,170 12,551,789 7.6 % 1.0000
Driscoll - Nueces 6,699,053 107,799,552 6.2 % 1.0000
Superior - Nueces 3,236,145 33,790,624 9.6 % 1.0000
Aetna - Tarrant 2,701,963 94,335,648 2.9 % 1.0000
Amerigroup - Tarrant 3,523,720 149,783,941 2.4 % 1.0000
Cook - Tarrant 11,459,271 146,909,029 7.8 % 1.0000
BCBS - Travis 4,501,996 34,139,828 13.2 % 1.0000
Sendero - Travis 1,066,610 28,930,088 3.7 % 1.0000
Seton - Travis 1,139,025 18,504,558 6.2 % 1.0000
Superior - Travis 13,023,780 149,860,921 8.7 % 1.0000
Amerigroup - MRSA Central 1,678,997 32,375,779 5.2 % 1.0000
Scott & White - MRSA Central 2,963,878 33,558,216 8.8 % 1.0000
Superior - MRSA Central 8,853,537 86,153,032 10.3 % 1.0000
Amerigroup - MRSA Northeast 4,716,097 78,118,954 6.0 % 1.0000
Superior - MRSA Northeast 12,084,662 151,025,993 8.0 % 1.0000
Amerigroup - MRSA West 2,038,635 34,899,549 5.8 % 1.0000
Firstcare - MRSA West 3,059,012 93,794,719 3.3 % 1.0000
Superior - MRSA West 5,423,336 79,745,698 6.8 % 1.0000
Total 230,767,287 4,156,265,497 5.6 %
97
98
Attachment 8
Delivery Supplemental Payment
The rate setting methodology incorporates a risk adjustment technique that is designed to provide
uniform treatment of the health plans for costs related to maternity delivery services. Maternity
cases occur in several risk groups – Pregnant Women, TANF Adults, and various children age
groups. As a result, it is possible for one health plan to enroll a higher percentage of TANF
Adults who are pregnant and therefore generally more expensive. In order to recognize the
potential inequity that might arise between health plans, HHSC developed this risk adjustment
methodology. The goal is to reimburse the plans uniformly for maternity expenses.
The State pays a delivery supplemental payment (DSP) for each delivery in a managed care plan.
The amount of the payment is a function of the average delivery cost in the area. The attached
exhibit presents the FY2016 DSP payment rates by area.
In order to achieve cost neutrality, the projected cost of maternity expenses is subtracted from the
unadjusted premium rates. The resulting adjusted premium rates are the rates actually paid to the
health plans in addition to any DSP amounts.
Attachment 8
FY2016 STAR Rating
Delivery Supplemental Payment (DSP) Rates per Delivery
Service DSP Amount
Delivery Area FY2015 FY2016
Bexar SDA $ 3,266.59 $ 3,266.59
Dallas SDA 3,537.13 3,537.13
El Paso SDA 3,443.04 3,443.04
Harris SDA 3,519.20 3,519.20
Hidalgo SDA 3,409.95 3,409.95
Jefferson SDA 3,394.58 3,394.58
Lubbock SDA 3,230.39 3,230.39
Nueces SDA 3,203.82 3,203.82
Tarrant SDA 3,635.64 3,635.64
Travis SDA 3,247.49 3,247.49
MRSA Central SDA 3,035.27 3,035.27
MRSA Northeast SDA 3,160.40 3,160.40
MRSA West SDA 3,204.07 3,204.07
99
100
Attachment 9
Acuity Risk Adjustment
The rate setting methodology incorporates a risk adjustment technique that is designed to adjust
the base community rate in each service area to reflect the health status, or acuity, of the
population enrolled in each health plan. The purpose of acuity risk adjustment is to recognize
the anticipated cost differential between multiple health plans in a service area by analyzing the
health status of their respective memberships. The risk analysis was performed by the University
of Florida’s Institute for Child Health Policy (ICHP). The methodology used to calculate the risk
adjustment is the Chronic Illness and Disability Payment System (CDPS). The attached exhibits
(provided by ICHP) present a summary of the risk adjustment analysis. There is a separate
exhibit for each risk group (Exhibits A-G).
The column titled Case Mix on the chart is the risk adjustment factor. It is the ratio of the
predicted average cost of the individual health plan’s membership divided by the predicted
average cost of the entire service area’s membership.
If necessary, an additional adjustment was made to the risk adjustment factors to ensure that, in
total, they produce the same premium as the community rates (budget neutral). Exhibit H
summarizes the raw, unadjusted risk adjustment factors (case-mix), the budget neutral
adjustment applied equally to each risk group within each service area along with the resulting
adjusted risk adjustment factors.
The adjusted risk adjustment factor is applied to the community rate for each health plan and risk
group.
Attachment 9 - Exhibit A
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (<1 Year of Age) 228,082 100.00 714.73 714.73 1.00 1.00
Bexar 19,755 100.00 732.88 759.95 1.00 0.96
Aetna 2,326 11.77 557.51 777.12 1.02 0.72
Amerigroup 861 4.36 725.08 764.50 1.01 0.95
Community First Health Plan (CFHP) 7,468 37.80 658.22 743.84 0.98 0.88
Superior 9,100 46.06 835.85 768.04 1.01 1.09
Dallas 27,082 100.00 497.18 585.37 1.00 0.85
Amerigroup 12,698 46.89 457.20 586.88 1.00 0.78
Molina 2,004 7.40 602.28 634.32 1.08 0.95
Parkland 12,380 45.71 520.49 576.80 0.99 0.90
El Paso 9,024 100.00 650.84 683.17 1.00 0.95
El Paso First Health Plan 4,819 53.40 606.54 641.48 0.94 0.95
Molina 281 3.11 1,061.54 722.47 1.06 1.47
Superior 3,924 43.48 674.77 727.16 1.06 0.93
Harris 54,019 100.00 753.60 677.59 1.00 1.11
Amerigroup 7,021 13.00 726.62 772.33 1.14 0.94
Community Health Choice (CHC) 22,419 41.50 806.87 703.25 1.04 1.15
Molina 877 1.62 937.98 739.08 1.09 1.27
Texas Children's Health Plan (TCHP) 19,187 35.52 682.10 581.37 0.86 1.17
United Health Care (United) 4,515 8.36 776.40 773.66 1.14 1.00
Hidalgo 25,423 100.00 646.54 747.18 1.00 0.87
Driscoll Health Plan 7,388 29.06 668.57 731.82 0.98 0.91
Molina 3,619 14.24 650.59 666.19 0.89 0.98
Superior 9,911 38.98 682.24 770.60 1.03 0.89
United Health Care (United) 4,505 17.72 532.97 779.52 1.04 0.68
Jefferson 6,219 100.00 966.02 847.80 1.00 1.14
Amerigroup 532 8.55 1,053.93 907.28 1.07 1.16
Community Health Choice (CHC) 2,249 36.16 1,078.17 867.11 1.02 1.24
Molina 403 6.48 1,399.41 950.56 1.12 1.47
Texas Children's Health Plan (TCHP) 1,863 29.96 818.22 783.00 0.92 1.04
United Health Care (United) 1,172 18.85 776.79 847.23 1.00 0.92
Lubbock 6,772 100.00 928.62 910.63 1.00 1.02
Amerigroup 953 14.07 1,417.48 1,074.30 1.18 1.32
Firstcare 3,386 50.00 778.25 888.05 0.98 0.88
Sueprior 2,433 35.93 926.04 871.64 0.96 1.06
MRSA Central 10,802 100.00 595.55 777.97 1.00 0.77
Amerigroup 1,619 14.99 769.29 804.36 1.03 0.96
Scott & White 4,010 37.12 496.19 782.68 1.01 0.63
Superior 5,173 47.89 614.45 766.15 0.98 0.80
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
101
Attachment 9 - Exhibit A
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 13,546 100.00 762.31 767.60 1.00 0.99
Amerigroup 4,218 31.14 735.86 843.73 1.10 0.87
Superior 9,328 68.86 774.00 733.95 0.96 1.05
MRSA West 13,864 100.00 674.73 663.50 1.00 1.02
Amerigroup 2,194 15.83 774.60 681.05 1.03 1.14
Firstcare 6,522 47.04 684.54 672.51 1.01 1.02
Superior 5,148 37.13 618.11 644.05 0.97 0.96
Nueces 7,013 100.00 1,048.06 865.65 1.00 1.21
Christus 397 5.66 917.46 904.47 1.04 1.01
Driscoll 5,658 80.68 1,065.62 857.34 0.99 1.24
Superior 958 13.66 1,000.82 896.75 1.04 1.12
Tarrant 22,161 100.00 708.87 719.03 1.00 0.99
Aetna 6,861 30.96 741.87 751.40 1.05 0.99
Amerigroup 7,435 33.55 675.58 693.78 0.96 0.97
Cook 7,865 35.49 709.46 712.80 0.99 1.00
Travis 12,402 100.00 812.54 693.67 1.00 1.17
Blue Cross Blue Shield (BCBS) 2,717 21.91 696.57 711.70 1.03 0.98
Sendero 1,554 12.53 1,035.30 724.55 1.04 1.43
Seton 1,360 10.97 585.22 590.87 0.85 0.99
Superior 6,771 54.60 849.76 699.07 1.01 1.22
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
102
Attachment 9 - Exhibit B
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (Age 1 to 5) 800,695 100.00 150.29 150.29 1.00 1.00
Bexar 66,321 100.00 147.59 152.36 1.00 0.97
Aetna 7,477 11.27 114.91 158.67 1.04 0.72
Amerigroup 3,365 5.07 117.13 158.85 1.04 0.74
Community First Health Plan (CFHP) 25,925 39.09 158.17 148.65 0.98 1.06
Superior 29,554 44.56 149.95 153.30 1.01 0.98
Dallas 113,569 100.00 164.40 153.14 1.00 1.07
Amerigroup 52,936 46.61 153.65 142.97 0.93 1.07
Molina 4,727 4.16 154.31 168.45 1.10 0.92
Parkland 55,906 49.23 175.33 161.43 1.05 1.09
El Paso 32,704 100.00 132.36 142.93 1.00 0.93
El Paso First Health Plan 15,555 47.56 142.04 142.44 1.00 1.00
Molina 1,120 3.42 126.36 133.00 0.93 0.95
Superior 16,029 49.01 123.35 144.09 1.01 0.86
Harris 190,823 100.00 147.73 130.41 1.00 1.13
Amerigroup 32,132 16.84 100.16 112.98 0.87 0.89
Community Health Choice (CHC) 63,999 33.54 151.62 136.15 1.04 1.11
Molina 3,560 1.87 102.42 122.43 0.94 0.84
Texas Children's Health Plan (TCHP) 81,874 42.91 164.15 129.37 0.99 1.27
United Health Care (United) 9,258 4.85 159.17 164.39 1.26 0.97
Hidalgo 100,412 100.00 169.39 191.78 1.00 0.88
Driscoll Health Plan 18,842 18.76 138.69 184.14 0.96 0.75
Molina 17,900 17.83 129.47 165.54 0.86 0.78
Superior 44,949 44.76 195.47 202.25 1.05 0.97
United Health Care (United) 18,721 18.64 175.32 199.24 1.04 0.88
Jefferson 20,765 100.00 138.11 164.90 1.00 0.84
Amerigroup 1,627 7.84 118.57 170.14 1.03 0.70
Community Health Choice (CHC) 6,684 32.19 125.01 159.69 0.97 0.78
Molina 1,141 5.49 119.55 165.41 1.00 0.72
Texas Children's Health Plan (TCHP) 8,213 39.55 149.75 160.40 0.97 0.93
United Health Care (United) 3,100 14.93 152.48 185.43 1.12 0.82
Lubbock 20,506 100.00 137.21 148.78 1.00 0.92
Amerigroup 2,688 13.11 123.65 148.62 1.00 0.83
Firstcare 10,845 52.89 146.52 146.89 0.99 1.00
Sueprior 6,973 34.00 127.79 151.79 1.02 0.84
MRSA Central 34,748 100.00 128.42 142.69 1.00 0.90
Amerigroup 6,845 19.70 130.18 122.42 0.86 1.06
Scott & White 9,875 28.42 138.08 166.53 1.17 0.83
Superior 18,028 51.88 122.56 137.47 0.96 0.89
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
103
Attachment 9 - Exhibit B
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 46,264 100.00 131.80 136.16 1.00 0.97
Amerigroup 15,689 33.91 134.18 141.43 1.04 0.95
Superior 30,575 66.09 130.58 133.47 0.98 0.98
MRSA West 39,389 100.00 122.11 139.75 1.00 0.87
Amerigroup 6,593 16.74 108.38 129.57 0.93 0.84
Firstcare 15,235 38.68 138.41 150.83 1.08 0.92
Superior 17,561 44.58 113.11 133.94 0.96 0.84
Nueces 22,196 100.00 186.41 167.32 1.00 1.11
Christus 2,019 9.10 191.03 145.73 0.87 1.31
Driscoll 14,548 65.54 184.21 164.96 0.99 1.12
Superior 5,629 25.36 190.48 181.02 1.08 1.05
Tarrant 71,800 100.00 148.09 154.17 1.00 0.96
Aetna 13,764 19.17 134.60 156.08 1.01 0.86
Amerigroup 30,946 43.10 128.30 141.39 0.92 0.91
Cook 27,090 37.73 177.73 167.93 1.09 1.06
Travis 41,198 100.00 156.63 143.13 1.00 1.09
Blue Cross Blue Shield (BCBS) 4,143 10.06 159.12 153.56 1.07 1.04
Sendero 3,942 9.57 202.97 167.80 1.17 1.21
Seton 4,145 10.06 142.25 141.03 0.99 1.01
Superior 28,968 70.31 152.12 138.70 0.97 1.10
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
104
Attachment 9 - Exhibit C
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (Age 6 to 14) 1,012,913 100.00 99.83 99.83 1.00 1.00
Bexar 84,759 100.00 99.18 99.75 1.00 0.99
Aetna 7,366 8.69 75.24 84.61 0.85 0.89
Amerigroup 3,150 3.72 68.94 79.25 0.79 0.87
Community First Health Plan (CFHP) 39,168 46.21 108.23 101.19 1.01 1.07
Superior 35,075 41.38 96.69 103.04 1.03 0.94
Dallas 146,779 100.00 98.31 92.11 1.00 1.07
Amerigroup 73,471 50.06 95.81 92.68 1.01 1.03
Molina 4,712 3.21 73.75 74.23 0.81 0.99
Parkland 68,596 46.73 102.59 92.69 1.01 1.11
El Paso 46,626 100.00 91.36 102.62 1.00 0.89
El Paso First Health Plan 22,383 48.01 95.41 103.67 1.01 0.92
Molina 1,251 2.68 65.88 82.37 0.80 0.80
Superior 22,992 49.31 88.76 102.67 1.00 0.86
Harris 231,671 100.00 97.71 86.72 1.00 1.13
Amerigroup 44,647 19.27 67.79 76.23 0.88 0.89
Community Health Choice (CHC) 63,977 27.62 87.15 80.61 0.93 1.08
Molina 4,316 1.86 102.13 93.06 1.07 1.10
Texas Children's Health Plan (TCHP) 109,870 47.43 116.37 93.41 1.08 1.25
United Health Care (United) 8,861 3.82 92.13 98.66 1.14 0.93
Hidalgo 141,248 100.00 110.85 137.57 1.00 0.81
Driscoll Health Plan 24,422 17.29 90.97 125.63 0.91 0.72
Molina 26,442 18.72 94.21 131.85 0.96 0.71
Superior 65,835 46.61 122.37 142.42 1.04 0.86
United Health Care (United) 24,549 17.38 117.32 142.45 1.04 0.82
Jefferson 25,119 100.00 102.46 106.57 1.00 0.96
Amerigroup 2,406 9.58 96.34 100.46 0.94 0.96
Community Health Choice (CHC) 7,544 30.03 96.70 94.69 0.89 1.02
Molina 1,369 5.45 110.15 109.56 1.03 1.01
Texas Children's Health Plan (TCHP) 9,864 39.27 108.25 112.57 1.06 0.96
United Health Care (United) 3,936 15.67 99.91 116.96 1.10 0.85
Lubbock 25,293 100.00 93.34 89.71 1.00 1.04
Amerigroup 2,610 10.32 70.89 84.33 0.94 0.84
Firstcare 13,856 54.78 103.54 93.61 1.04 1.11
Sueprior 8,827 34.90 83.66 85.08 0.95 0.98
MRSA Central 41,779 100.00 92.74 96.84 1.00 0.96
Amerigroup 8,469 20.27 87.18 84.21 0.87 1.04
Scott & White 10,864 26.00 93.92 112.22 1.16 0.84
Superior 22,446 53.73 94.26 94.26 0.97 1.00
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
105
Attachment 9 - Exhibit C
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 56,546 100.00 91.73 90.51 1.00 1.01
Amerigroup 19,986 35.34 100.06 95.33 1.05 1.05
Superior 36,560 64.66 87.20 87.89 0.97 0.99
MRSA West 47,169 100.00 86.38 88.87 1.00 0.97
Amerigroup 9,000 19.08 78.50 79.03 0.89 0.99
Firstcare 16,482 34.94 91.44 92.05 1.04 0.99
Superior 21,687 45.98 85.76 90.49 1.02 0.95
Nueces 28,333 100.00 130.81 109.18 1.00 1.20
Christus 2,866 10.12 109.23 98.19 0.90 1.11
Driscoll 18,533 65.41 130.89 108.84 1.00 1.20
Superior 6,934 24.47 139.21 114.49 1.05 1.22
Tarrant 87,931 100.00 105.45 100.85 1.00 1.05
Aetna 9,726 11.06 87.35 89.61 0.89 0.97
Amerigroup 45,983 52.29 93.89 94.38 0.94 0.99
Cook 32,222 36.64 127.63 113.58 1.13 1.12
Travis 49,660 100.00 93.39 88.65 1.00 1.05
Blue Cross Blue Shield (BCBS) 6,331 12.75 85.58 79.78 0.90 1.07
Sendero 2,459 4.95 104.38 90.04 1.02 1.16
Seton 4,077 8.21 93.02 79.59 0.90 1.17
Superior 36,793 74.09 94.03 90.98 1.03 1.03
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
106
Attachment 9 - Exhibit D
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (Age 15 to 18) 272,552 100.00 122.44 122.44 1.00 1.00
Bexar 23,372 100.00 121.88 122.77 1.00 0.99
Aetna 2,395 10.25 81.76 119.31 0.97 0.69
Amerigroup 940 4.02 92.78 85.76 0.70 1.08
Community First Health Plan (CFHP) 10,913 46.69 142.29 126.37 1.03 1.13
Superior 9,124 39.04 111.00 123.07 1.00 0.90
Dallas 36,817 100.00 120.97 105.90 1.00 1.14
Amerigroup 19,678 53.45 121.67 107.48 1.01 1.13
Molina 1,430 3.88 126.31 101.11 0.95 1.25
Parkland 15,709 42.67 119.62 104.37 0.99 1.15
El Paso 15,666 100.00 111.18 131.73 1.00 0.84
El Paso First Health Plan 7,542 48.14 117.31 125.09 0.95 0.94
Molina 459 2.93 55.83 53.61 0.41 1.04
Superior 7,665 48.93 108.45 142.75 1.08 0.76
Harris 59,912 100.00 129.42 107.08 1.00 1.21
Amerigroup 12,195 20.35 85.34 93.76 0.88 0.91
Community Health Choice (CHC) 16,478 27.50 112.38 97.71 0.91 1.15
Molina 1,371 2.29 88.18 99.52 0.93 0.89
Texas Children's Health Plan (TCHP) 26,628 44.45 160.40 115.36 1.08 1.39
United Health Care (United) 3,240 5.41 146.20 141.48 1.32 1.03
Hidalgo 42,235 100.00 112.53 156.20 1.00 0.72
Driscoll Health Plan 7,230 17.12 107.47 149.01 0.95 0.72
Molina 7,507 17.77 107.38 152.34 0.98 0.70
Superior 19,096 45.21 114.50 159.81 1.02 0.72
United Health Care (United) 8,402 19.89 116.94 157.54 1.01 0.74
Jefferson 7,069 100.00 124.14 125.60 1.00 0.99
Amerigroup 770 10.89 88.49 127.96 1.02 0.69
Community Health Choice (CHC) 2,198 31.09 114.94 124.19 0.99 0.93
Molina 408 5.77 106.32 96.14 0.77 1.11
Texas Children's Health Plan (TCHP) 2,460 34.80 147.36 132.20 1.05 1.11
United Health Care (United) 1,233 17.44 122.41 123.37 0.98 0.99
Lubbock 6,619 100.00 114.15 111.97 1.00 1.02
Amerigroup 734 11.09 99.94 101.10 0.90 0.99
Firstcare 3,483 52.62 121.39 122.15 1.09 0.99
Sueprior 2,402 36.29 107.78 100.36 0.90 1.07
MRSA Central 11,070 100.00 111.95 124.73 1.00 0.90
Amerigroup 2,128 19.22 111.31 93.34 0.75 1.19
Scott & White 3,038 27.44 117.78 155.09 1.24 0.76
Superior 5,904 53.33 109.24 120.64 0.97 0.91
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
107
Attachment 9 - Exhibit D
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 15,306 100.00 112.32 111.43 1.00 1.01
Amerigroup 5,437 35.52 106.58 111.47 1.00 0.96
Superior 9,869 64.48 115.47 111.41 1.00 1.04
MRSA West 12,658 100.00 118.15 120.88 1.00 0.98
Amerigroup 2,272 17.95 99.14 107.51 0.89 0.92
Firstcare 4,722 37.30 119.66 128.88 1.07 0.93
Superior 5,664 44.75 124.43 119.49 0.99 1.04
Nueces 7,734 100.00 159.00 141.10 1.00 1.13
Christus 749 9.68 130.10 146.10 1.04 0.89
Driscoll 5,029 65.02 165.96 144.55 1.02 1.15
Superior 1,956 25.29 151.90 130.46 0.92 1.16
Tarrant 22,071 100.00 132.76 127.67 1.00 1.04
Aetna 3,006 13.62 93.10 101.42 0.79 0.92
Amerigroup 11,116 50.36 125.71 122.64 0.96 1.03
Cook 7,949 36.02 157.47 144.55 1.13 1.09
Travis 12,023 100.00 132.41 110.04 1.00 1.20
Blue Cross Blue Shield (BCBS) 1,610 13.39 108.05 98.57 0.90 1.10
Sendero 637 5.30 335.67 119.22 1.08 2.82
Seton 1,231 10.24 132.19 107.06 0.97 1.23
Superior 8,545 71.07 122.48 111.86 1.02 1.09
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
108
Attachment 9 - Exhibit E
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (Age 19 to 20) 26,406 100.00 116.24 116.24 1.00 1.00
Bexar 2,406 100.00 119.85 124.56 1.00 0.96
Aetna 282 11.72 119.51 120.56 0.97 0.99
Amerigroup 128 5.32 88.82 93.82 0.75 0.95
Community First Health Plan (CFHP) 1,016 42.23 129.81 127.33 1.02 1.02
Superior 980 40.73 113.65 126.67 1.02 0.90
Dallas 3,481 100.00 104.09 106.57 1.00 0.98
Amerigroup 1,839 52.83 97.95 105.92 0.99 0.92
Molina 157 4.51 123.38 101.92 0.96 1.21
Parkland 1,485 42.66 109.53 107.87 1.01 1.02
El Paso 1,832 100.00 93.61 113.64 1.00 0.82
El Paso First Health Plan 888 48.47 87.42 106.55 0.94 0.82
Molina 53 2.89 71.64 77.92 0.69 0.92
Superior 891 48.64 101.15 122.92 1.08 0.82
Harris 5,624 100.00 134.52 104.36 1.00 1.29
Amerigroup 1,253 22.28 92.99 101.47 0.97 0.92
Community Health Choice (CHC) 1,647 29.29 114.50 101.31 0.97 1.13
Molina 149 2.65 157.61 120.31 1.15 1.31
Texas Children's Health Plan (TCHP) 2,229 39.63 171.26 106.29 1.02 1.61
United Health Care (United) 346 6.15 138.11 110.43 1.06 1.25
Hidalgo 4,450 100.00 103.87 127.00 1.00 0.82
Driscoll Health Plan 692 15.55 94.69 115.74 0.91 0.82
Molina 798 17.93 118.63 123.76 0.97 0.96
Superior 1,971 44.29 103.08 125.70 0.99 0.82
United Health Care (United) 989 22.22 99.96 140.23 1.10 0.71
Jefferson 711 100.00 112.09 121.99 1.00 0.92
Amerigroup 91 12.80 83.43 106.87 0.88 0.78
Community Health Choice (CHC) 240 33.76 106.42 121.42 1.00 0.88
Molina 40 5.63 123.23 105.72 0.87 1.17
Texas Children's Health Plan (TCHP) 199 27.99 131.03 136.79 1.12 0.96
United Health Care (United) 141 19.83 111.31 117.08 0.96 0.95
Lubbock 514 100.00 120.22 126.42 1.00 0.95
Amerigroup 67 13.04 135.09 188.23 1.49 0.72
Firstcare 272 52.92 127.51 121.56 0.96 1.05
Sueprior 175 34.05 103.18 109.90 0.87 0.94
MRSA Central 1,032 100.00 99.67 129.33 1.00 0.77
Amerigroup 223 21.61 102.25 118.11 0.91 0.87
Scott & White 288 27.91 92.96 144.83 1.12 0.64
Superior 521 50.48 102.20 125.67 0.97 0.81
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
109
Attachment 9 - Exhibit E
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 1,407 100.00 148.73 132.71 1.00 1.12
Amerigroup 528 37.53 202.29 142.86 1.08 1.42
Superior 879 62.47 117.09 126.72 0.95 0.92
MRSA West 1,075 100.00 118.13 125.07 1.00 0.94
Amerigroup 213 19.81 135.15 149.85 1.20 0.90
Firstcare 408 37.95 108.78 124.47 1.00 0.87
Superior 454 42.23 118.32 113.68 0.91 1.04
Nueces 769 100.00 128.93 115.49 1.00 1.12
Christus 83 10.79 84.77 108.00 0.94 0.78
Driscoll 485 63.07 126.00 120.70 1.05 1.04
Superior 201 26.14 153.27 105.89 0.92 1.45
Tarrant 1,981 100.00 119.64 114.33 1.00 1.05
Aetna 346 17.47 80.80 125.41 1.10 0.64
Amerigroup 995 50.23 142.98 110.12 0.96 1.30
Cook 640 32.31 104.20 114.92 1.01 0.91
Travis 1,124 100.00 100.33 102.65 1.00 0.98
Blue Cross Blue Shield (BCBS) 130 11.57 62.27 70.12 0.68 0.89
Sendero 68 6.05 106.16 112.32 1.09 0.95
Seton 116 10.32 92.36 96.54 0.94 0.96
Superior 810 72.06 107.01 107.87 1.05 0.99
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
110
Attachment 9 - Exhibit F
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (AFDC Adults) 73,093 100.00 352.49 352.49 1.00 1.00
Bexar 8,134 100.00 356.85 353.13 1.00 1.01
Aetna 917 11.27 258.51 306.10 0.87 0.84
Amerigroup 766 9.42 317.85 334.43 0.95 0.95
Community First Health Plan (CFHP) 2,840 34.92 370.30 350.03 0.99 1.06
Superior 3,611 44.39 379.06 371.10 1.05 1.02
Dallas 7,448 100.00 308.53 311.44 1.00 0.99
Amerigroup 3,774 50.67 291.94 311.86 1.00 0.94
Molina 849 11.40 367.36 373.05 1.20 0.98
Parkland 2,825 37.93 313.28 292.45 0.94 1.07
El Paso 3,550 100.00 283.13 318.36 1.00 0.89
El Paso First Health Plan 1,702 47.94 249.93 313.54 0.98 0.80
Molina 350 9.86 423.01 330.70 1.04 1.28
Superior 1,498 42.20 288.65 321.00 1.01 0.90
Harris 13,331 100.00 387.27 351.15 1.00 1.10
Amerigroup 2,891 21.69 389.88 387.71 1.10 1.01
Community Health Choice (CHC) 5,050 37.88 366.58 318.87 0.91 1.15
Molina 467 3.50 430.23 427.11 1.22 1.01
Texas Children's Health Plan (TCHP) 2,810 21.08 332.18 279.28 0.80 1.19
United Health Care (United) 2,113 15.85 496.73 456.00 1.30 1.09
Hidalgo 9,095 100.00 355.68 378.78 1.00 0.94
Driscoll Health Plan 1,018 11.19 251.03 294.19 0.78 0.85
Molina 1,856 20.41 451.27 423.92 1.12 1.06
Superior 4,049 44.52 329.91 374.31 0.99 0.88
United Health Care (United) 2,172 23.88 369.26 386.64 1.02 0.96
Jefferson 2,768 100.00 393.95 377.98 1.00 1.04
Amerigroup 298 10.77 448.22 468.83 1.24 0.96
Community Health Choice (CHC) 1,044 37.72 321.49 334.54 0.89 0.96
Molina 247 8.92 478.38 386.48 1.02 1.24
Texas Children's Health Plan (TCHP) 558 20.16 369.42 332.48 0.88 1.11
United Health Care (United) 621 22.43 475.59 442.62 1.17 1.07
Lubbock 2,298 100.00 350.35 360.11 1.00 0.97
Amerigroup 564 24.54 327.83 331.82 0.92 0.99
Firstcare 893 38.86 422.94 404.66 1.12 1.05
Sueprior 841 36.60 288.36 331.75 0.92 0.87
MRSA Central 4,234 100.00 314.69 341.02 1.00 0.92
Amerigroup 799 18.87 312.16 293.44 0.86 1.06
Scott & White 1,513 35.73 300.40 353.67 1.04 0.85
Superior 1,922 45.39 327.01 350.95 1.03 0.93
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
111
Attachment 9 - Exhibit F
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 5,089 100.00 375.50 390.04 1.00 0.96
Amerigroup 2,020 39.69 414.17 393.66 1.01 1.05
Superior 3,069 60.31 350.04 387.67 0.99 0.90
MRSA West 3,895 100.00 366.30 357.47 1.00 1.02
Amerigroup 753 19.33 337.79 345.93 0.97 0.98
Firstcare 1,514 38.87 368.20 370.36 1.04 0.99
Superior 1,628 41.80 377.65 350.77 0.98 1.08
Nueces 2,647 100.00 323.15 358.80 1.00 0.90
Christus 520 19.64 247.48 310.19 0.86 0.80
Driscoll 1,140 43.07 292.25 325.14 0.91 0.90
Superior 987 37.29 398.21 422.63 1.18 0.94
Tarrant 6,328 100.00 369.96 379.45 1.00 0.97
Aetna 2,147 33.93 309.77 351.26 0.93 0.88
Amerigroup 2,930 46.30 452.93 423.30 1.12 1.07
Cook 1,251 19.77 272.93 321.93 0.85 0.85
Travis 4,276 100.00 328.10 295.98 1.00 1.11
Blue Cross Blue Shield (BCBS) 706 16.51 297.89 285.28 0.96 1.04
Sendero 444 10.38 276.18 226.04 0.76 1.22
Seton 533 12.46 328.89 265.40 0.90 1.24
Superior 2,593 60.64 344.68 316.59 1.07 1.09
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
112
Attachment 9 - Exhibit G
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO (Pregnant Woman) 122,637 100.00 545.34 545.34 1.00 1.00
Bexar 12,017 100.00 538.66 543.75 1.00 0.99
Aetna 1,274 10.60 417.02 531.72 0.98 0.78
Amerigroup 532 4.43 453.98 546.17 1.00 0.83
Community First Health Plan (CFHP) 4,352 36.22 514.95 540.47 0.99 0.95
Superior 5,859 48.76 590.38 548.55 1.01 1.08
Dallas 14,287 100.00 571.99 550.24 1.00 1.04
Amerigroup 6,439 45.07 565.83 548.55 1.00 1.03
Molina 1,086 7.60 610.39 549.88 1.00 1.11
Parkland 6,762 47.33 571.68 551.90 1.00 1.04
El Paso 5,173 100.00 485.33 522.75 1.00 0.93
El Paso First Health Plan 2,744 53.04 456.94 525.62 1.01 0.87
Molina 119 2.30 515.42 455.84 0.87 1.13
Superior 2,310 44.65 517.07 522.85 1.00 0.99
Harris 25,508 100.00 605.68 547.54 1.00 1.11
Amerigroup 3,809 14.93 528.87 543.86 0.99 0.97
Community Health Choice (CHC) 12,432 48.74 619.27 552.50 1.01 1.12
Molina 372 1.46 579.01 489.38 0.89 1.18
Texas Children's Health Plan (TCHP) 6,654 26.09 639.71 535.45 0.98 1.19
United Health Care (United) 2,241 8.79 565.57 572.52 1.05 0.99
Hidalgo 13,188 100.00 459.41 515.31 1.00 0.89
Driscoll Health Plan 3,953 29.97 433.39 516.29 1.00 0.84
Molina 1,749 13.26 473.61 497.98 0.97 0.95
Superior 5,119 38.82 471.36 519.58 1.01 0.91
United Health Care (United) 2,367 17.95 465.41 517.37 1.00 0.90
Jefferson 3,871 100.00 588.94 562.70 1.00 1.05
Amerigroup 343 8.86 582.12 595.83 1.06 0.98
Community Health Choice (CHC) 1,539 39.76 571.42 543.63 0.97 1.05
Molina 282 7.28 634.10 563.57 1.00 1.13
Texas Children's Health Plan (TCHP) 965 24.93 625.80 577.58 1.03 1.08
United Health Care (United) 742 19.17 561.92 565.84 1.01 0.99
Lubbock 4,259 100.00 502.61 551.29 1.00 0.91
Amerigroup 554 13.01 503.81 573.01 1.04 0.88
Firstcare 2,234 52.45 487.37 547.90 0.99 0.89
Sueprior 1,471 34.54 525.21 548.20 0.99 0.96
MRSA Central 6,224 100.00 515.64 571.89 1.00 0.90
Amerigroup 989 15.89 536.08 560.99 0.98 0.96
Scott & White 2,204 35.41 468.95 583.28 1.02 0.80
Superior 3,031 48.70 542.64 567.23 0.99 0.96
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
113
Attachment 9 - Exhibit G
Reporting Period: Sep 1, 2013 to Aug 31, 2014
SDA/Health Plan
Number of
Enrollees
Percent
Affected
Actual
PMPM
Expenditures
Based on Paid
Amounts
Predicted
PMPM
Payment Case Mix Spend Ratio
CDPS
TEXAS STAR MCO CDPS SA/Health Plan Risk
STAR MCO
MRSA Northeast 7,975 100.00 548.18 564.92 1.00 0.97
Amerigroup 2,434 30.52 513.17 556.18 0.98 0.92
Superior 5,541 69.48 563.62 568.77 1.01 0.99
MRSA West 8,402 100.00 536.86 536.20 1.00 1.00
Amerigroup 1,180 14.04 545.99 553.70 1.03 0.99
Firstcare 4,203 50.02 523.05 535.63 1.00 0.98
Superior 3,019 35.93 552.33 530.28 0.99 1.04
Nueces 4,682 100.00 509.64 527.24 1.00 0.97
Christus 272 5.81 461.46 526.41 1.00 0.88
Driscoll 3,828 81.76 511.10 529.21 1.00 0.97
Superior 582 12.43 523.13 514.83 0.98 1.02
Tarrant 11,118 100.00 504.24 566.05 1.00 0.89
Aetna 4,035 36.29 507.02 589.31 1.04 0.86
Amerigroup 3,536 31.80 514.62 557.66 0.99 0.92
Cook 3,547 31.90 490.55 548.20 0.97 0.89
Travis 5,933 100.00 630.59 534.14 1.00 1.18
Blue Cross Blue Shield (BCBS) 1,260 21.24 559.34 537.65 1.01 1.04
Sendero 690 11.63 729.62 528.09 0.99 1.38
Seton 437 7.37 505.75 513.51 0.96 0.98
Superior 3,546 59.77 651.62 536.57 1.00 1.21
Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who
had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)
(permitting one month lapse in enrollment within the 6 months period).
114
Attachment 9 - Exhibit H
FY2016 STAR Rating
Adjusted Acuity Scores
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women
Unadjusted Acuity Scores (1)
Aetna - Bexar 1.0226 1.0414 0.8483 0.9717 0.9679 0.8668 0.9779
Amerigroup - Bexar 1.0060 1.0426 0.7945 0.6985 0.7532 0.9470 1.0044
CFHP - Bexar 0.9788 0.9756 1.0144 1.0293 1.0222 0.9912 0.9940
Superior - Bexar 1.0106 1.0061 1.0330 1.0024 1.0169 1.0509 1.0088
Amerigroup - Dallas 1.0026 0.9336 1.0062 1.0148 0.9939 1.0014 0.9969
Molina - Dallas 1.0836 1.1000 0.8058 0.9547 0.9564 1.1978 0.9993
Parkland - Dallas 0.9854 1.0541 1.0063 0.9855 1.0122 0.9390 1.0030
El Paso First - El Paso 0.9390 0.9966 1.0102 0.9495 0.9376 0.9849 1.0055
Molina - El Paso 1.0575 0.9305 0.8026 0.4069 0.6857 1.0388 0.8720
Superior - El Paso 1.0644 1.0081 1.0004 1.0836 1.0816 1.0083 1.0002
Amerigroup - Harris 1.1398 0.8664 0.8790 0.8756 0.9723 1.1041 0.9933
CHC - Harris 1.0379 1.0441 0.9295 0.9125 0.9708 0.9081 1.0091
Molina - Harris 1.0907 0.9389 1.0731 0.9294 1.1528 1.2163 0.8938
TCHP - Harris 0.8580 0.9920 1.0770 1.0773 1.0185 0.7953 0.9779
United - Harris 1.1418 1.2606 1.1377 1.3212 1.0582 1.2986 1.0456
Driscoll - Hidalgo 0.9794 0.9602 0.9132 0.9540 0.9113 0.7767 1.0019
Molina - Hidalgo 0.8916 0.8632 0.9584 0.9753 0.9745 1.1192 0.9664
Superior - Hidalgo 1.0313 1.0546 1.0352 1.0231 0.9897 0.9882 1.0083
United - Hidalgo 1.0433 1.0389 1.0355 1.0086 1.1041 1.0207 1.0040
Amerigroup - Jefferson 1.0702 1.0318 0.9426 1.0188 0.8761 1.2404 1.0589
CHC - Jefferson 1.0228 0.9684 0.8885 0.9888 0.9953 0.8851 0.9661
Molina - Jefferson 1.1212 1.0031 1.0280 0.7655 0.8666 1.0225 1.0016
TCHP - Jefferson 0.9236 0.9727 1.0563 1.0526 1.1213 0.8796 1.0264
United - Jefferson 0.9993 1.1245 1.0975 0.9823 0.9597 1.1710 1.0056
Amerigroup - Lubbock 1.1797 0.9989 0.9401 0.9029 1.4888 0.9215 1.0394
Firstcare - Lubbock 0.9752 0.9873 1.0435 1.0909 0.9615 1.1237 0.9939
Superior - Lubbock 0.9572 1.0202 0.9485 0.8963 0.8693 0.9213 0.9944
Christus - Nueces 1.0448 0.8710 0.8993 1.0354 0.9352 0.8645 0.9984
Driscoll - Nueces 0.9904 0.9859 0.9968 1.0244 1.0451 0.9062 1.0037
Superior - Nueces 1.0359 1.0819 1.0486 0.9246 0.9169 1.1779 0.9765
Aetna - Tarrant 1.0450 1.0124 0.8886 0.7944 1.0969 0.9257 1.0411
Amerigroup - Tarrant 0.9649 0.9171 0.9359 0.9606 0.9632 1.1156 0.9852
Cook - Tarrant 0.9913 1.0893 1.1263 1.1322 1.0052 0.8484 0.9685
Blue Cross - Travis 1.0260 1.0729 0.8999 0.8957 0.6831 0.9638 1.0066
Sendero - Travis 1.0445 1.1724 1.0157 1.0834 1.0942 0.7637 0.9887
Seton - Travis 0.8518 0.9853 0.8978 0.9729 0.9404 0.8967 0.9614
Superior - Travis 1.0078 0.9691 1.0263 1.0165 1.0509 1.0697 1.0045
Amerigroup - MRSA Central 1.0339 0.8579 0.8696 0.7484 0.9133 0.8605 0.9809
Scott & White - MRSA Central 1.0060 1.1671 1.1588 1.2435 1.1199 1.0371 1.0199
Superior - MRSA Central 0.9848 0.9635 0.9734 0.9672 0.9717 1.0291 0.9918
Amerigroup - MRSA Northeast 1.0992 1.0387 1.0532 1.0003 1.0765 1.0093 0.9845
Superior - MRSA Northeast 0.9562 0.9802 0.9711 0.9998 0.9548 0.9939 1.0068
Amerigroup - MRSA West 1.0265 0.9272 0.8892 0.8894 1.1981 0.9677 1.0326
Firstcare - MRSA West 1.0136 1.0793 1.0357 1.0662 0.9951 1.0361 0.9989
Superior - MRSA West 0.9707 0.9584 1.0182 0.9885 0.9089 0.9813 0.9890
115
Attachment 9 - Exhibit H
FY2016 STAR Rating
Adjusted Acuity Scores
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women
Budget Neutrality Adjustment (2)
Aetna - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000
Amerigroup - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000
CFHP - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000
Superior - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000
Amerigroup - Dallas 0.9988 1.0014 1.0011 1.0000 0.9998 0.9936 1.0002
Molina - Dallas 0.9988 1.0014 1.0011 1.0000 0.9998 0.9936 1.0002
Parkland - Dallas 0.9988 1.0014 1.0011 1.0000 0.9998 0.9936 1.0002
El Paso First - El Paso 1.0060 1.0002 0.9997 1.0025 1.0004 1.0022 1.0001
Molina - El Paso 1.0060 1.0002 0.9997 1.0025 1.0004 1.0022 1.0001
Superior - El Paso 1.0060 1.0002 0.9997 1.0025 1.0004 1.0022 1.0001
Amerigroup - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003
CHC - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003
Molina - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003
TCHP - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003
United - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003
Driscoll - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999
Molina - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999
Superior - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999
United - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999
Amerigroup - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970
CHC - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970
Molina - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970
TCHP - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970
United - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970
Amerigroup - Lubbock 1.0071 1.0000 1.0008 0.9987 1.0082 0.9863 1.0016
Firstcare - Lubbock 1.0071 1.0000 1.0008 0.9987 1.0082 0.9863 1.0016
Superior - Lubbock 1.0071 1.0000 1.0008 0.9987 1.0082 0.9863 1.0016
Christus - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993
Driscoll - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993
Superior - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993
Aetna - Tarrant 1.0016 0.9982 0.9970 1.0001 0.9902 1.0128 0.9994
Amerigroup - Tarrant 1.0016 0.9982 0.9970 1.0001 0.9902 1.0128 0.9994
Cook - Tarrant 1.0016 0.9982 0.9970 1.0001 0.9902 1.0128 0.9994
Blue Cross - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010
Sendero - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010
Seton - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010
Superior - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010
Amerigroup - MRSA Central 1.0004 0.9927 0.9923 0.9853 0.9836 0.9937 0.9987
Scott & White - MRSA Central 1.0004 0.9927 0.9923 0.9853 0.9836 0.9937 0.9987
Superior - MRSA Central 1.0004 0.9927 0.9923 0.9853 0.9836 0.9937 0.9987
Amerigroup - MRSA Northeast 0.9998 0.9996 0.9996 1.0000 1.0021 1.0005 0.9999
Superior - MRSA Northeast 0.9998 0.9996 0.9996 1.0000 1.0021 1.0005 0.9999
Amerigroup - MRSA West 1.0004 1.0019 1.0011 1.0018 0.9969 1.0015 1.0003
Firstcare - MRSA West 1.0004 1.0019 1.0011 1.0018 0.9969 1.0015 1.0003
Superior - MRSA West 1.0004 1.0019 1.0011 1.0018 0.9969 1.0015 1.0003
116
Attachment 9 - Exhibit H
FY2016 STAR Rating
Adjusted Acuity Scores
Age Age Age Age Age TANF Pregnant
<1 1-5 6-14 15-18 19-20 Adult Women
Budget Neutral Acuity Scores (3)
Aetna - Bexar 1.0231 1.0419 0.8494 0.9716 0.9629 0.8692 0.9779
Amerigroup - Bexar 1.0065 1.0431 0.7956 0.6985 0.7493 0.9497 1.0045
CFHP - Bexar 0.9793 0.9761 1.0158 1.0292 1.0170 0.9940 0.9940
Superior - Bexar 1.0112 1.0066 1.0344 1.0023 1.0117 1.0538 1.0089
Amerigroup - Dallas 1.0014 0.9348 1.0073 1.0148 0.9937 0.9950 0.9971
Molina - Dallas 1.0824 1.1015 0.8067 0.9547 0.9562 1.1902 0.9995
Parkland - Dallas 0.9842 1.0556 1.0074 0.9855 1.0120 0.9331 1.0032
El Paso First - El Paso 0.9446 0.9968 1.0099 0.9520 0.9380 0.9871 1.0056
Molina - El Paso 1.0638 0.9307 0.8024 0.4080 0.6859 1.0411 0.8721
Superior - El Paso 1.0707 1.0082 1.0002 1.0864 1.0821 1.0105 1.0003
Amerigroup - Harris 1.1493 0.8645 0.8746 0.8675 0.9760 1.1091 0.9936
CHC - Harris 1.0465 1.0418 0.9248 0.9040 0.9746 0.9122 1.0093
Molina - Harris 1.0998 0.9368 1.0677 0.9208 1.1572 1.2218 0.8940
TCHP - Harris 0.8651 0.9899 1.0717 1.0673 1.0225 0.7989 0.9782
United - Harris 1.1512 1.2579 1.1320 1.3090 1.0622 1.3044 1.0459
Driscoll - Hidalgo 0.9821 0.9608 0.9151 0.9550 0.9162 0.7922 1.0017
Molina - Hidalgo 0.8940 0.8638 0.9604 0.9764 0.9797 1.1415 0.9662
Superior - Hidalgo 1.0341 1.0553 1.0374 1.0242 0.9950 1.0080 1.0081
United - Hidalgo 1.0461 1.0396 1.0376 1.0097 1.1100 1.0412 1.0039
Amerigroup - Jefferson 1.0730 1.0309 0.9398 1.0181 0.8755 1.2328 1.0557
CHC - Jefferson 1.0255 0.9676 0.8859 0.9881 0.9947 0.8796 0.9632
Molina - Jefferson 1.1242 1.0023 1.0250 0.7649 0.8661 1.0162 0.9985
TCHP - Jefferson 0.9260 0.9719 1.0531 1.0518 1.1206 0.8743 1.0233
United - Jefferson 1.0020 1.1236 1.0942 0.9816 0.9591 1.1639 1.0025
Amerigroup - Lubbock 1.1881 0.9989 0.9408 0.9017 1.5010 0.9088 1.0411
Firstcare - Lubbock 0.9821 0.9873 1.0444 1.0895 0.9693 1.1083 0.9954
Superior - Lubbock 0.9640 1.0202 0.9492 0.8952 0.8764 0.9086 0.9960
Christus - Nueces 1.0458 0.8721 0.8993 1.0338 0.9238 0.8816 0.9977
Driscoll - Nueces 0.9913 0.9871 0.9968 1.0228 1.0323 0.9241 1.0030
Superior - Nueces 1.0368 1.0833 1.0486 0.9231 0.9057 1.2011 0.9758
Aetna - Tarrant 1.0467 1.0106 0.8860 0.7945 1.0862 0.9375 1.0404
Amerigroup - Tarrant 0.9665 0.9155 0.9331 0.9606 0.9538 1.1298 0.9846
Cook - Tarrant 0.9930 1.0873 1.1230 1.1323 0.9953 0.8592 0.9679
Blue Cross - Travis 1.0270 1.0682 0.9061 0.9004 0.6932 0.9710 1.0076
Sendero - Travis 1.0456 1.1672 1.0226 1.0891 1.1104 0.7694 0.9896
Seton - Travis 0.8526 0.9810 0.9039 0.9780 0.9544 0.9034 0.9623
Superior - Travis 1.0088 0.9648 1.0332 1.0219 1.0664 1.0776 1.0055
Amerigroup - MRSA Central 1.0344 0.8517 0.8629 0.7373 0.8983 0.8550 0.9797
Scott & White - MRSA Central 1.0065 1.1586 1.1499 1.2252 1.1015 1.0305 1.0186
Superior - MRSA Central 0.9852 0.9564 0.9659 0.9530 0.9557 1.0226 0.9906
Amerigroup - MRSA Northeast 1.0989 1.0383 1.0527 1.0003 1.0787 1.0098 0.9845
Superior - MRSA Northeast 0.9559 0.9799 0.9707 0.9998 0.9568 0.9944 1.0068
Amerigroup - MRSA West 1.0268 0.9289 0.8902 0.8910 1.1944 0.9691 1.0329
Firstcare - MRSA West 1.0140 1.0813 1.0369 1.0681 0.9920 1.0376 0.9992
Superior - MRSA West 0.9711 0.9602 1.0193 0.9903 0.9060 0.9827 0.9892
Footnotes:
(1) Raw acuity scores as developed by ICHP. Equals the case mix factors from Exhibits A-G.
(2) Budget neutral adjustment applied uniformly within each service area to ensure acuity adjustment is budget neutral in total.
(3) Adjusted acuity scores applied to FY2016 Community Rates.
117
118
Attachment 10
Network Access Improvement Program (NAIP)
Effective March 1, 2015 several health plans implemented programs aimed at improving
network access for Medicaid members. The NAIP is designed to further the state's goal of
increasing the availability and effectiveness of primary care for Medicaid beneficiaries by
incentivizing various institutions to provide quality, well-coordinated, and continuous care. The
NAIP is intended to achieve the following objectives regarding health-related institutions (HRI):
Improve the availability of and Medicaid access to primary care physicians. This
program may also target specialist physicians willing to provide a medical home to
managed care members with special needs and conditions, and advanced practice
registered nurses (APRNs) and physician assistants (PAs) practicing under the
supervision of an HRI staff provider.
Enhance the coordination and continuity of services and quality of care of Medicaid
managed care members who receive primary care services through those physician
practices.
Increase access to primary care in these settings, underscoring the importance of primary
care residency programs and influencing future physician participation.
Promote provider education on Medicaid program requirements and the specialized needs
of Medicaid recipients.
Measure progress through increased primary care access and physician compliance with
selected quality objectives, to be determined later.
Similarly, the NAIP is intended to achieve the following objectives relating to public hospitals:
Improve the availability, quality and coordination of primary and specialty care services
provided by public hospitals;
Promote provider education on Medicaid program requirements and the specialized needs
of Medicaid recipients;
Measure progress through increased care access and physician compliance with quality
objectives.
The above-stated objectives will lead to better health outcomes for Medicaid beneficiaries and
decreased overall healthcare costs for the Medicaid program.
The NAIPs were developed independently by various managed care organizations and providers.
The NAIPs outline the services to be provided by the providers, measurements to evaluate their
effectiveness and the cost to be paid by the managed care organizations. The NAIP amounts
impact all STAR risk groups.
The attached exhibit summarizes each of the NAIPs by health plan, service area and program.
The participating provider has been removed from the exhibit in order to maintain the privacy of
these negotiated arrangements.
Attachment 10
FY2016 STAR Rating
Network Access Improvement Program (NAIP) Summary
MCO (1) Impacted Programs SDAs Impacted
Contracted
Cost (2)
Projected Member
Months (3) PMPM Impact
Amerigroup STAR, STAR+PLUS Lubbock, MRSA West 7,522,250 531,315 14.16
Amerigroup STAR, STAR+PLUS Lubbock, MRSA West 2,189,980 531,315 4.12
Amerigroup STAR, STAR+PLUS Tarrant, MRSA West 4,782,360 2,085,291 2.29
Amerigroup STAR Dallas 22,780,000 2,557,783 8.91
Amerigroup STAR, STAR+PLUS Lubbock, MRSA West 11,525,954 531,315 21.69
Amerigroup STAR, STAR+PLUS El Paso, MRSA West 2,663,700 454,522 5.86
Amerigroup STAR, STAR+PLUS Lubbock, MRSA West 6,323,987 531,315 11.90
Amerigroup STAR, STAR+PLUS Harris 45,553,955 1,699,281 26.81
Amerigroup STAR, STAR+PLUS Jefferson 4,835,250 133,437 36.24
Amerigroup STAR, STAR+PLUS Harris, Jefferson 7,456,009 1,832,718 4.07
Amerigroup STAR, STAR+PLUS Dallas 1,400,000 2,557,783 0.55
Amerigroup STAR, STAR+PLUS Dallas, Tarrant 27,400,000 4,249,288 6.45
Amerigroup STAR, STAR+PLUS
Bexar, Dallas, El Paso, Harris,
Jefferson, Lubbock, Tarrant, Travis,
MRSAs 14,400,000 7,945,331 1.81
CFHP STAR Bexar 41,828,301 1,385,796 30.18
CHC STAR Harris 36,600,000 2,650,907 13.81
CHC STAR Harris 28,479,891 2,650,907 10.74
CHC STAR Jefferson 6,015,781 288,546 20.85
CHC STAR Harris, Jefferson 12,631,735 2,939,453 4.30
El Paso First STAR El Paso 27,000,000 806,632 33.47
El Paso First STAR El Paso 1,800,000 806,632 2.23
FirstCare STAR MRSA West 10,600,000 691,360 15.33
FirstCare STAR Lubbock, MRSA West 25,796,182 1,200,195 21.49
Molina STAR Dallas 3,779,681 243,865 15.50
Parkland STAR Dallas 34,990,000 2,291,169 15.27
Superior STAR, STAR+PLUS Bexar 27,286,963 1,528,854 17.85
Superior STAR, STAR+PLUS Bexar, Hidalgo, MRSA Central 22,488,634 4,563,659 4.93
Superior STAR, STAR+PLUS Travis, Nueces, MRSA West 7,184,766 2,449,044 2.93
Superior STAR El Paso 20,250,014 733,403 27.61
Superior STAR, STAR+PLUS Lubbock, MRSA West 23,326,336 1,310,818 17.80
Superior STAR El Paso 2,200,140 733,403 3.00
Superior STAR, STAR+PLUS Lubbock 3,498,950 380,567 9.19
Superior STAR, STAR+PLUS MRSA Central 559,832 912,213 0.61
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Attachment 10
FY2016 STAR Rating
Network Access Improvement Program (NAIP) Summary
MCO (1) Impacted Programs SDAs Impacted
Contracted
Cost (2)
Projected Member
Months (3) PMPM Impact
United STAR Harris 13,369,339 522,090 25.61
United STAR, STAR+PLUS Harris 10,299,178 804,544 12.80
United STAR, STAR+PLUS Jefferson 3,724,540 195,895 19.01
United STAR, STAR+PLUS Harris, Jefferson 4,239,824 1,000,439 4.24
Foootnotes:
(1) MCOs may have NAIP arrangements with multiple providers.
(2) Based on contracted amounts between MCOs and providers.
(3) Based on HHSC most recent caseload forecast. Includes all (i) all STAR Risk Groups, (ii) STAR+PLUS Medicaid Only OCC,
(iii) STAR+PLUS Medicaid Only HCBS and (iv) IDD <21 and >21.
120
121
Attachment 11
Pay-for-Quality Program (P4Q)
The Texas P4Q Program is based on the concept of incremental improvement where each health
plan is (1) incentivized to improve its own quality performance each year and (2) evaluated
based on its success in achieving such improvement. A gap closure approach to each P4Q quality
measure is used where a minimum threshold is set, establishing a minimum quality score at
which health plans become eligible to earn positive quality points. Health plans with scores
below the minimum threshold for a measure will not be eligible to earn positive points for
incremental improvement, but will not be penalized as long as they show year-to-year
improvement in the measure. An attainment goal is specified which represents a recognized level
of excellence for the specific quality measure. Both minimum thresholds and attainment goals
are determined at the discretion of HHSC.
The P4Q measures include:
1. Healthcare effectiveness data information set Quality of Care Measures
o Well-child visits for 3, 4, 5, and 6 year olds
o Adolescent well care
o Prenatal and postpartum care
2. Potentially Preventable Events
o Potentially Preventable Admissions
o Potentially Preventable Readmissions
o Potentially Preventable Emergency Department Visits
o Potentially Preventable Complications
Each health plan is expected to close the gap between the attainment goal and the health plan's
baseline performance by 15 percent each year. This 15 percent annual gap closure target is not
referring to a 15 percentage point annual increase in the measure, but is 15 percent of the
difference between the attainment goal and the health plan’s 2013 (baseline) performance. For
example, if a health plan’s current performance is 60 percent for the measure and the attainment
goal is 70 percent, the gap is 70 percent - 60 percent or 10 percentage points. Correspondingly,
15 percent of the gap equals 0.15 x 10 percentage points or 1.5 percentage points. The 15 percent
annual gap closure target will be achieved if the health plan improves from 60 percent to 61.5
percent on the measure. Higher scores on the Healthcare Effectiveness Data Information Set
(HEDIS®) measures correspond to higher quality. However, lower Potentially Preventable Event
(PPE) expenditures are indicative of higher quality. For this reason, improvement for the PPE
measures is defined by a reduction in PPE expenditures. PPE expenditures are calculated using
standardized resource units rather than paid amounts to eliminate any extraneous market-based
variation that is present in the paid amounts.