Risk Mitigation Strategies Sample Clauses

Risk Mitigation Strategies. ● The Commonwealth will establish High Cost Risk Pools (HCRP) to account for enrollment of high cost members, defined based on spending for select Medicaid long- term supports and services above a defined threshold within Medicaid rating categories across ICOs. For each rating category with a HCRP, a portion of the base Medicaid capitation rate will be withheld from all ICOs into a risk pool. The risk pool will be divided across ICOs based on their percent of total costs above the threshold amount associated with the high cost members. A. Applicable Medicaid rating categories: a. F1- Facility-based Care b. C3- Community Tier 3 - High Community Needs

Risk Mitigation Strategies. A. Description of Risk Mitigation Strategy ODM’s provider agreement indicates that ODM will perform MLR calculations for the MMC program. This includes the ABD, CFC, AFK, and Extension populations. Effective January 1, 2018, there are no financial consequences associated with MLR requirements. B. Changes to Risk Mitigation Strategy Relative to Prior Years Based on information provided by ODM, CY 2015 MLR calculations resulted in two MCPs having MLR below 85%. These MCPs were required to return the difference between 85% of net capitation and actual allowed medical expenses incurred. The MLR calculation for CY 2016 will be performed in January 2018; however, no MLR rebates are anticipated for CY 2016. Effective January 1, 2018, there will be no MLR rebate requirements for the Extension program.

Risk Mitigation Strategies. A. Cost reconciliation under Part D will continue as is under the Demonstration. CMS will monitor Part D costs closely on an on-going basis. Any material increase in Part D costs relative to the baseline may be factored into future Demonstration Year savings percentages. B. Rate Review Process: CMS and the State will review the Prime Contractor Plan financial reports, encounter data, and other information to assess the ongoing financial stability of the Prime Contractor Plans and the appropriateness of capitation payments. At any point, the State may request that CMS review documentation from specific plans to assess the appropriateness of capitation rates and identify any potential prospective adjustments that would ensure the rate-setting process is meeting the objective of Medicare and Medicaid jointly financing the costs and sharing in the savings. C. Limited Risk Corridors: Limited risk corridors will be established for all Demonstration Years in order to provide a level of protection to Prime Contractor Plans and payers against uncertainty in rate-setting that could result in either overpayment or underpayment. The Demonstration will utilize a limited down-side risk corridor and a limited up-side risk corridor to include all Medicare Parts A and B and Medicaid eligible costs. The corridors will be applied on a Prime contract specific basis and will be reconciled after application of any risk adjustment methodologies and any other adjustments. Risk corridors will be reconciled as if the Prime Contractor Plan had received the full quality withhold payment. The three-way contract will include further details on how risk corridors will be operationalized under this Demonstration. a. Process for collecting cost information. CMS and the State will evaluate encounter data, cost data, and Plan financial reports to determine Plan incurred costs. For the purposes of this risk corridor methodology, CMS and the State may make downward adjustments to Prime Contractor Plan costs for any excessive payments to Plan- affiliated providers. b. Limited down-side risk corridor: o To reflect the underlying characteristics of the eligible population and differences between counties, initial payments will be made on a county specific basis and reconciled based on plan costs within the limits specified below. o The application of county-specific interim savings percentages in Figure 6-5 establishes the initial capitation rates for purposes of this risk corridor calculation. ...

Risk Mitigation Strategies. Security Requirement to include OPSEC, facility clearances, and base access d. Data Transfer

Risk Mitigation Strategies. The certified rates reflect consideration of a minimum MLR requirement of 86% for the MMC program, which is consistent with the prior rating period. In addition, the rates include a risk pool arrangement between the MMC and OhioRISE programs.

Risk Mitigation Strategies. ‌ AHCCCS has a long-standing program policy of including risk corridors within the managed care programs to protect the State against excessive Contractor profits and to protect Contractors from excessive losses. This risk-sharing arrangement also contributes to Contractor sustainability and program continuity, which is an additional intangible benefit to the stability of the Medicaid member. The CYE 25 contracts will continue AHCCCS’ long-standing program policy and will include risk corridors. There are no risk mitigation strategies utilized specifically for COVID-19 costs for CYE 25. This is a change from previous contract years when COVID-19 vaccines and their administration costs were reimbursed through a cost settlement outside of the capitation rates on a non-risk basis. I.2. Data‌ This section provides documentation for the Data section of the 2025 Guide. I.2. A. Rate Development Standards‌ I.2.A.i. Compliance with 42 CFR § 438.5(c)‌ AHCCCS actuaries have followed the rate development standards related to base data in accordance with 42 CFR § 438.5(c). The data types, sources, validation methodologies, material adjustments, and other information related to the documentation standards required by CMS are documented in the subsections of I.2.B. I.2.B. Appropriate Documentation‌ I.2.B.i. Data Request‌ Since AHCCCS employs their own actuaries, a formal data request was not needed between the AHCCCS DBF Actuarial Team and the State. The AHCCCS DBF Actuarial Team worked with the appropriate teams at AHCCCS to obtain the primary sources of data in accordance with 42 CFR § 438.5(c). I.2.B.ii. Data Used for Rate Development‌ I.2.B.ii.(a) Description of Data I.2.B.ii.(a)(i) Types of Data Used‌‌‌ The primary data sources used or reviewed for the development of the CYE 25 capitation rates for the ACC and ACC-RBHA Program were: • Adjudicated and approved encounter data submitted by the ACC, ACC-RBHA, and prior RBHA Contractors and provided from the AHCCCS Prepaid Medical Management Information System (PMMIS) mainframe o Incurred from October 2019 through February 2024 o Adjudicated and approved through the second February 2024 encounter cycle • Reinsurance payments made to the ACC, ACC-RBHA, and prior RBHA Contractors for services o Incurred from October 2020 through September 2023 paid through April 2024 • Enrollment data for the ACC and ACC-RBHA Program as well as the prior RBHA Program from the AHCCCS PMMIS mainframe o October 2019 through February 2024 • Annual and ...

Risk Mitigation Strategies. The Offeror shall provide a plan of action to mitigate contract performance risks that could be encountered during the transition period.

Risk Mitigation Strategies. The Recipient will invest in state-of-the-art aviation-grade quality control measures; The Recipient will hire the necessary testing engineers to obtain the quickest testing results. • Anticipated performance goals: Test report that quantifies the performance of the films produced with each scalable method. The measurement of success will be against the criteria defined in Activity 1. • Milestones: N/A • Description: The large scale films will be tested in collaboration with AIRBUS and ESL for reliability in varying environmental conditions: temperature gradients, pressure variation, humidity control, UV resistance, heat, coloration effects. • Risks: Long lead time in environmental testing; not all environmental tests can be completed at a single location; material fails testing requirements. • Risk mitigation strategy: Engage early with environmental testing partners; utilize different materials for testing; test with raw materials quickly before fabricating the filters with them. • Anticipated performance goals: Environmental report characterizing the materials against the AIRBUS-approved specifications. •

Risk Mitigation Strategies. The Commonwealth will establish High Cost Risk Pools (HCRP) to account for enrollment of high cost members, defined based on spending for select Medicaid long-term supports and services above a defined threshold within Medicaid rating categories across ICOs. For each rating category with a HCRP, a portion of the base Medicaid capitation rate will be withheld from all ICOs into a risk pool. The risk pool will be divided across ICOs based on their percent of total costs above the threshold amount associated with the high cost members. Applicable Medicaid rating categories: F1- Facility-based Care C3- Community Tier 3 - High Community Needs Timing. HCRPs will be utilized until additional long-term care risk adjustment methodology is in place.