Common use of Program Adjustments Clause in Contracts

Program Adjustments. Adjustment factors for the rate amendment were developed for the following policy and program changes, known as of the date of this report, that affect the MyCare Opt-In program during January through December 2021. With the exception of nursing facility (NF) and other select services subject to 438.6(c) preprints approved by CMS, MCOP provider contracts are not required to equal the Medicaid fee schedule. However, data available in MCOP surveys indicate that a large portion of reimbursement is tied to Medicaid fee-for-service (FFS). MCOPs are notified of program and reimbursement changes that will be reflected in future rate setting activities and are provided the opportunity to share comments and feedback. The reimbursement changes reflected in the amended CY 2021 capitation rates were determined to be reasonably achievable by the MCOPs. Incarcerated Members We were informed of the presence of Ohio Department of Rehabilitation and Correction (ODRC) incarcerated members that were inadvertently assigned to MyCare Opt-In eligibility spans in the data used to develop the CY 2019 base data underlying the Original certification. We anticipate these members will no longer be enrolled during the January 1, 2021 to December 31, 2021 rating period. Using data received from ODM, we estimated the impact to projected benefit expense of removing these members from the baseline experience. Enrollment Backlog ODM identified a backlog of approximately 12,000 individuals eligible for the MyCare program that were enrolled in the fee-for-service (FFS) Medicaid program. We received a listing of the enrollment backlog recipient IDs from ODM and utilized this information to develop the estimated impact associated with the introduction of this population. Based on discussions with ODM, these individuals were evenly phased-in to the MyCare program over a 3-month period, starting in May 2021, and were assigned to rate cells based on the available FFS demographic information. We anticipate that the morbidity of this population will be consistent with the morbidity of the existing MyCare program and will continue to monitor this population as emerging experience becomes available. Non-Facility Reimbursement Changes We reviewed and analyzed the impact of other non-facility reimbursement changes with effective start dates between January 1, 2021 and June 30, 2021 that were not already incorporated into the Original certification. This included 2 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇.▇▇▇▇.▇▇▇/wps/portal/gov/covid-19/dashboards reimbursement changes to durable medical equipment (DME), laboratory, and physician administered drugs. We estimated the impact of these fee schedule changes and applied rating adjustments to impacted categories of service. Nursing Facility Reimbursement Changes ODM updates nursing facility payment rates and acuity scores on a semi-annual basis. We applied adjustments to reflect the impact of the semi-annual per diem updates, which were effective July 1, 2021. Adjustments were applied to the nursing facility and hospice room and board categories of service and vary based on differences in base nursing facility experience by rate cell and region. Non-Facility Reimbursement Changes We reviewed and analyzed the impact of other non-facility reimbursement changes effective on or after July 1, 2021 that were not already incorporated into the Original certification. This included reimbursement changes to DME and physician administered drugs. We estimated the impact of these fee schedule changes and applied rating adjustments to impacted categories of service.

Program Adjustments. Adjustment factors for the rate amendment were developed for the following policy and program changes, known as of the date of this report, that affect the MyCare Opt-In Out program during January through December 2021. With the exception of nursing facility (NF) and other select services subject to 438.6(c) preprints approved by CMS, MCOP provider contracts are not required to equal the Medicaid fee schedule. However, data available in MCOP surveys indicate that a large portion of reimbursement is tied to Medicaid fee-for-service (FFS). MCOPs are notified of program and reimbursement changes that will be reflected in future rate setting activities and are provided the opportunity to share comments and feedback. The reimbursement changes reflected in the amended CY 2021 capitation rates were determined to be reasonably achievable by the MCOPs. Incarcerated Members We were informed of the presence of Ohio Department of Rehabilitation and Correction (ODRC) incarcerated members that were inadvertently assigned to MyCare Opt-In Out eligibility spans in the data used to develop the CY 2019 base data underlying the Original certification. We anticipate these members will no longer be enrolled during the January 1, 2021 to December 31, 2021 rating period. Using data received from ODM, we estimated the impact to projected benefit expense of removing these members from the baseline experience. Enrollment Backlog ODM identified a backlog of approximately 12,000 individuals eligible for the MyCare program that were enrolled in the fee-for-service (FFS) Medicaid program. We received a listing of the enrollment backlog recipient IDs from ODM and utilized this information to develop the estimated impact associated with the introduction of this population. Based on discussions with ODM, these individuals were evenly phased-in to the MyCare program over a 3-month period, starting in May 2021, and were assigned to rate cells based on the available FFS demographic information. We anticipate that the morbidity of this population will be consistent with the morbidity of the existing MyCare program and will continue to monitor this population as emerging experience becomes available. 2 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇.▇▇▇▇.▇▇▇/wps/portal/gov/covid-19/dashboards Non-Facility Reimbursement Changes We reviewed and analyzed the impact of other non-facility reimbursement changes with effective start dates between January 1, 2021 and June 30, 2021 that were not already incorporated into the Original certification. This included 2 ▇▇▇▇▇://▇▇▇▇▇▇▇▇▇▇▇.▇▇▇▇.▇▇▇/wps/portal/gov/covid-19/dashboards reimbursement changes to durable medical equipment (DME), laboratory, and physician administered drugs. We estimated the impact of these fee schedule changes and applied rating adjustments to impacted categories of service. Nursing Facility Reimbursement Changes ODM updates nursing facility payment rates and acuity scores on a semi-annual basis. We applied adjustments to reflect the impact of the semi-annual per diem updates, which were effective July 1, 2021. Adjustments were applied to the nursing facility and hospice room and board categories of service and vary based on differences in base nursing facility experience by rate cell and region. Non-Facility Reimbursement Changes We reviewed and analyzed the impact of other non-facility reimbursement changes effective on or after July 1, 2021 that were not already incorporated into the Original certification. This included reimbursement changes to DME and physician administered drugs. We estimated the impact of these fee schedule changes and applied rating adjustments to impacted categories of service. Adjustment factors were developed for policy and program changes estimated to materially affect the MyCare program during January through December 2021 that were not reflected in the Original Certification. Program adjustments were applied in the rate development process to the extent a policy or reimbursement change is deemed to have a material cost impact to the MCOPs. We defined a program adjustment to be ‘material’ if the total benefit expense for any individual rate cell is impacted by more than 0.1%, or if the program adjustment was considered ‘material’ for the Medicaid Managed Care (MMC) program. The following is a list of program adjustments deemed immaterial based on our review of the experience data and policy change.