Questions and Answers on Requests for Applications

The Actuarial Services Unit has sent these Responses to Requests for Information to the individual requesting the information. If you have any questions regarding the response to your request for information, please feel free to contact Susan Allen at susan.g.allen@state.or.us or 503.945.5898.   
 

RFA 2383—Jackson County

OregonHealth Plan

Methods for Developing Geographic and Risk Adjustments for Service Area Expansions

Q 1. If a health plan chooses to enter a new county within one of DMAP's defined rate regions in which the health plan currently participates, would DMAP offer a separate cap rate for enrollees in the new county rather than adjusting the current capitation rates to account for expected enrollment in that county? 

A 1. Response: DMAP plans to create a Jackson County rate. The Jackson County rate would be equivalent to the regional rate without any plan-specific adjustments for newly entering plans, be they from outside the region or within the region, but not considered Jackson County plans. This means the geographic factor would be for the region as a whole; the CD prevalence adjustment would be set to 1; the maternity case rate would be the regional rate without adjustment; the newborn prevalence rate would be set to 1; and the risk adjustment would be set to 1. The plans already considered Jackson County plans would keep their current rate adjustments. The plans already in the region, but not considered Jackson County plans, would keep their current rate adjustments for the other county(ies) and would get the new Jackson County rate for their enrollment considered to be Jackson County enrollees (excludes the contiguous zip enrollees that are currently considered part of their current non-Jackson County rates. Plans from outside the region would come in as new plans and would get the new Jackson County rate.

Q 2. How will DMAP calculate risk scores for the population in the expansion county situation described in Question #1? 

A 2. Response: The risk score for the new Jackson County rate will be 1.0 and will be updated after sufficient data has been submitted or at the time annual capitation rates are calculated. PHPs who currently have clients in contiguous zip codes of Jackson County will continue to receive their regional risk scores for those contiguous zip codes. 

Q 3. How will DMAP calculate newborn/maternity case rates for the expansion county situation described in Question #1?   

A 3. Response: For plans newly entering Jackson County (excluding contiguous zip codes), there will be a new Jackson County rate without plan-specific adjustments. This rate would apply only to the enrollment in Jackson County, not to existing enrollment in other county(ies) in the region. Please refer to the choices made in #1. 

Q 4. Can the state make available actual and/or projected fee for service utilization and cost data by service category for the expansion county? 

A 4. Response: The state can provide historical fee-for-service utilization, billed charges and payment data, however, no projections will be provided. 

Q 5. Please explain what is meant by the "Regional Rate." Since geographic factors are usually plan specific, I'm assuming that you would be replacing plan specific geographic factors with "regional" geographic factors. Then these "regional" geographic factors would be applied to statewide rates to arrive at plan specific rates. Can you provide us with these regional geographic factors for 2007? 

A 5. Response: We can calculate a regional geographic adjustment based on the enrollment distribution of all plans participating in that region. To calculate a Jackson County regional adjustment factor, we would need a reasonable estimate of the number of new enrollees in Jackson County. Given this estimate, we would calculate a new weighted average geographic adjustment for the region considering the new enrollees. Jackson County-specific inpatient and outpatient geographic factors could be developed, but this work has not been done.

Q 6. Also, with regard to risk scores, newborn and maternity adjustment factors, does this mean that a plan would receive 1.0 factors for new Jackson county enrollees or would these members be considered contiguous zip county enrollees and therefore receive the plans’ current JJD risk scores? I think you're saying that the newly eligible enrollees (outside of their current service area) would receive 1.0 risk scores (CDPS, newborn and maternity).

A 6. Response: New clients in the current coverage area (including any contiguous zip codes currently covered) would be capitated at current rates. New clients residing in zip codes that are not in the current coverage area would be capitated at the regional rate for the plan, as previously defined. This regional rate would include a regional (not plan-specific) geographic adjustment factor, and all other adjustment factors (including CDPS) would be set to 1.0.

Q 7. Does PWC or DMAP have any information regarding the average CDPS risk score for Jackson County FFS enrollees? Since Jackson County may become a mandated FCHP enrollment county, a plan entering into this county could take on a large amount of potential risk by being paid at a 1.0 risk score if the actual risk score for the potential population is different. If this hasn't been calculated, is this something PWC could calculate and provide?

A 7. Response: No, a CDPS score specific to Jackson County FFS clients has not been calculated, and it would not be particularly meaningful to do so. While it is true that managed care enrollees will be drawn from the FFS population, not all FFS clients will be enrolled in FCHPs even if there is mandatory enrollment. Past experience has been that FFS and managed care populations in a given region have different risk profiles.

Q 8. We would like to request actual FFS experience for both Jackson and Josephine counties. What time period of data will you provide and in what format? How much detail? 

A 8. Response: We would provide data with service dates from 7/1/2003 (the start of the data period for the current per capita cost report) through the latest available. It would be grouped by county, bucket, rate group, and month of service.  For each grouping, we would report number of claim detail lines, total billed amount, and total paid amount.  We can supply less detail or a shorter time period than this if you prefer.  County would be determined by zip code of residence, so there would be some imprecision in cases where zip codes spill over county lines. The output would be provided in a delimited text file unless you specify some other format.

Q 9. As far as FFS data goes, you stated that you would summarize a count of claim detail lines, billed charges and paid amounts by county, bucket, rate group and month of service. Would you be able to summarize utilization statistics by bucket?  Such as the number of days, admits, services, etc? Consistent with utilization counts in Exhibit 2 of the Per Capita Cost Report. Would you be able to provide the data in a format similar to Exhibits 3-B, 4-B and 5-B of the Per Capita Cost Report. Also, I'm assuming we will also be able to get the number of members by county, rate group and month of service. 

A 9. Response. We can provide FFS claims rolled up by month, bucket, and rate group for Jackson County (identified by zip code) and sum the Number of detail lines, AmtBilledDet, and AmtPaidDet. We can readily produce FFS member month data at this level of detail. As previously stated there would be some imprecision due to zip codes spilling over county lines.

Q 10. Would it be possible to obtain the average FFS risk scores by county, rate group, etc? I'm assuming this would not be available.  

A 10. Response. As previously stated, we cannot produce county-specific FFS CDPS risk scores, nor would it be particularly meaningful to do so.

Q 11. How soon would you anticipate calculating CDPS, maternity and newborn risk scores based on actual encounter and enrollment data for Jackson County? 

A 11. Response.  It is not our intention to permanently create a Jackson County rate region distinct from the current Jackson/Josephine/Douglas (J/J/D) region. When adjustments are calculated based on actual experience for newly-enrolled clients in Jackson County, they would be applied to the MCO’s entire population in the J/J/D region.

Risk adjustments based on actual data for the existing population could be applied to newly-enrolled population any time the contract is open.

Geographic adjustments can be calculated as soon as the enrollment is known.

CDPS adjustments for the newly-enrolled population could be calculated based on their FFS experience as soon as the enrollment is known.  Given the time lags involved in data collection, it is unlikely that managed care encounter data for the newly-enrolled population could be incorporated into the CDPS calculation prior to the 1/2009 capitation rates.

With the maternity case rate now implemented, there is no longer a maternity risk adjustment.

Given the time lags involved in data collection, it is unlikely that managed care encounter data for the newly-enrolled population could be incorporated into the newborn prevalence calculation prior to the 1/2009 capitation rates.