Arizona Health Care Capitation Rate Updates
Discover the latest updates on capitation rates in Arizona, including timelines, budget items, and key takeaways for effective care management. Stay informed about changes effective from 10/1/17 to empower quality health care provision.
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Presentation Transcript
Rate Update Shelli Silver May 17, 2017
Capitation Rate Timeline CYE 18 10/1/17 rates due to CMS 7/1/17 Will include (not intended to be a complete list): o Historical encounter data through 9/30/16 o More current data for various analyses o FFS rate impacts completed by 6/1/17 o New reinsurance biologic drugs if any added Reaching across Arizona to provide comprehensive quality health care for those in need 2
Capitation Rate Timeline cont. o Budget items: Prop 206 (1/1/18 increase) Occupational Therapy benefit $1,000 Adult Emergency Dental o VBP Differential Payments (may require additional CMS approval under 438.6(c)) o Access to Professional Services Initiative (APSI) (does require additional CMS approval under 438.6(c)) Reaching across Arizona to provide comprehensive quality health care for those in need 3
Capitation Rate Timeline cont. 10/1/17 rates due to CMS 7/1/17 Won t include (not a complete list): o FFS rate impacts completed after 6/1/17 o DRG rebase impacts (?) o Recent Issues Raised by MCOs o Updated CYE 18 risk adjustment factors o Miscellaneous program changes Reaching across Arizona to provide comprehensive quality health care for those in need 4
Capitation Rate Timeline cont. Take-away: o 10/1/17 rates due to CMS 7/1/17 will necessitate amendment retroactive to 10/1/17 for all unknown impacts, incomplete analysis A number of Managed Care Regs are effective with this submission and research is ongoing New format for Actuarial Certifications Reaching across Arizona to provide comprehensive quality health care for those in need 5
VBP Differential Adjusted Rates Effective 10/1/17- 9/30/18: Hospitals (PT 02) inpatient and outpatient claims 0.5% Nursing Facilities (PT 22) all claims 1% or 2% Integrated Clinics (PT IC) select physical health claims 10% Reaching across Arizona to provide comprehensive quality health care for those in need 6
VBP Differential Adjusted Rates cont. Physicians, Physician Assistants, and Registered Nurse Practitioners (Provider Types 08, 31, 18, 19) all 1500 claims 1% Effective 1/1/18 - 9/30/18: Other Hospitals & Inpatient Facilities (PT 71; PT B5; PT C4) inpatient and outpatient claims 0.5% Reaching across Arizona to provide comprehensive quality health care for those in need 7
DRG Rebase Effective with discharges on & after 1/1/18 Stakeholder meeting 5/4/17 o Find meeting materials at https://www.azahcccs.gov/PlansProviders/Rate sAndBilling/FFS/APRDRGRebase.html Notice of Proposed Rule Making 6/12/17 Public comments through 7/11/17 Not finished but tentative info available Reaching across Arizona to provide comprehensive quality health care for those in need 8
DRG Rebase cont. 3M Version 34 of APR/DRG grouper V34 had almost no impact on case mix Adding projected $35 million in new spend o New Burn DRG policy adjuster of 2.700 ~$5M o New Other Adult policy adjuster of 1.025 to maintain current ~$13m o High-acuity pediatrics policy adjuster for SOI levels 3/4 increased to 2.300 ~$17M Reaching across Arizona to provide comprehensive quality health care for those in need 9
DRG Rebase cont. Considering addition of rural hospital provider adjustor to replace pass-through Solve for claims failing outlier due to member enrollment changes? No Documentation & Coding Improvement (DCI) adjustment No provider transitional adjustments Intend to update code mapper annually Reaching across Arizona to provide comprehensive quality health care for those in need 10
DRG Rebase cont. No sooner than 10/1/18, may implement new readmissions policy o No changes to existing readmissions policy prior to implementation of new policy o Considering a performance-based measurement consistent with Value-Based Purchasing differential adjusted payments More discussion with MCOs later Reaching across Arizona to provide comprehensive quality health care for those in need 11
Access to Professional Services Initiative (APSI) Workforce development critical to AZ Effective w/DOS on and after 10/1/17 for: o Acute Care o CRS 40% rate increase to practitioners affiliated with hospitals meeting specific criteria Expect to include a risk corridor utilizing a risk pool Reaching across Arizona to provide comprehensive quality health care for those in need 12
Access to Professional Services Initiative (APSI) cont. Hospital-affiliation criteria: o Facility with ACGME-accredited teaching program pursuant Title 48, Chapter 31 or o Facility with: ACGME-accredited teaching program with a state university, and AHCCCS discharge volume >/= 30% or, Freestanding children s hospital or pediatric unit of general acute care hospital > 100 licensed pediatric beds, excluding nursery beds Reaching across Arizona to provide comprehensive quality health care for those in need 13
Access to Professional Services Initiative (APSI) cont. Requires CMS prior approval under 438.6(c) before payments may be made Payment methodology is not renewed automatically o Requires CMS prior approval annually Reaching across Arizona to provide comprehensive quality health care for those in need 14
Cap Rate Risk Adjustment CYE 16 risk factors/risk adjustment to be completed this week or next MCOs given one week for review Payments/recoupments likely in mid/late July Payments/Recoupments computed from CYE 16 vs CYE 15 factors already in CYE 16 rates Reaching across Arizona to provide comprehensive quality health care for those in need 15
Cap Rate Risk Adjustment cont CYE 17 risk adjustment using CYE 16 factors, updated for budget neutrality factors CYE 17 accounts for MHP/United & PHP/Care1st mergers CYE 17 to be completed late-July CYE 18 risk adjustment use CYE 17 factors updated for BN or update base data Reaching across Arizona to provide comprehensive quality health care for those in need 16
Questions? Reaching across Arizona to provide comprehensive quality health care for those in need 17
Thank You. Reaching across Arizona to provide comprehensive quality health care for those in need 18
