Actuarial Soundness in Final Medicaid Managed Care Regulations November 1, 2016
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1 Actuarial Soundness in Final Medicaid Managed Care Regulations November 1, 2016 Brad Armstrong, FSA, MAAA Chris Pettit, FSA, MAAA Marlene Howard, FSA, MAAA
2 Webinar overview 1 Introduction 2 Rate ranges 3 Minimum MLR 4 Pass-through payments 5 Capitation Rate-Setting Process & CMS Review 2
3 Sections of Rule Relevant to Actuarially Sound Capitation Rates 438.4: Actuarial Soundness 438.5: Rate Development Standards 438.6: Special Contract Provisions Related to Payment 438.7: Rate Certification Submission 3
4 Actuarial Soundness Definition Actuarially sound capitation rates are projected to provide for all reasonable, appropriate, and attainable costs that are required under the terms of the contract and for the operation of the MCO, PIHP, or PAHP for the time period and the population covered under the terms of the contract ( 438.4(a)) 4
5 Rate Ranges
6 Rate ranges current practice Practical uses Flexibility Reduce interim modifications Concerns with ranges Size of range Reduced precision High End Actuarially sound Low End 6
7 Removal of Certified Rate Ranges Eliminate use of certified rate range Actuary must certify to payments for each rate cell under the contract ( 438.4(b)(4)) Certify final capitation rate for each risk contract ( 438.7(c)(1)) Enhance transparency and integrity CMS defines de minimis range of 1.5% 7
8 Action items Still able to develop Actuary can determine and share with State Establish range of appropriate payments Ability to utilize Choose rate within range Contract negotiations Has to meet requirements Timing Rating periods on or after 7/1/2018 8
9 Minimum MLR
10 Minimum MLR Consideration Develop rates with target Reasonably achievable 85% or higher Calculate in accordance with Claims + Quality Improvement + Fraud Prevention Premium Taxes and Fees + Credibility Adjustment Does not require state to employ MLR-based refund 10
11 Practical Use of MLR in Rate Development Rates are certified prospectively Composite of all assumptions don t always hit the mark Review of MLR can assist in future rate setting ( lookback study ) Codifies general practice already employed by many actuaries 11
12 Pass-through Payments
13 Pass-through payments current practice Typical provider classes Hospitals Nursing Facilities Physicians Practical uses Encourage provider access for Medicaid beneficiaries Retain critical funding stream to certain providers Avoid disruption of existing IGT or provider tax mechanisms Concerns with pass-through payments Diminished transparency in tracking payments from state to providers State-directed reimbursement to certain providers 13
14 Elimination of Pass-through Payments Varies by provider type 10-year phase-down for hospitals 5-year transition for physicians and nursing facilities July 1, 2017: Any pass-through payments that exceed maximum allowable amount ( 438.7(d)) Potential solutions Enhanced fee schedules for certain provider classes Value-based purchasing Adjustments to GME or DSH payments New pass-through payments during transition period July 29, 2016 CMCS Informational Bulletin 14
15 Capitation Rate-Setting Process & CMS Review
16 Capitation Rate-Setting Process Data Trend Non-Benefit Cost Adjustments MLR Risk Adjustment Types Age Historical Program Experience Actuarial Judgment Administrative expenses, Care coordination, Risk margin, Cost of capital, Taxes/Assessments/Fees, Other Program Changes Enrollee health status Past MLR; Projected MLR Prospective or retrospective Budget neutral 438.2: Rating period is a period of 12 months selected by the State for which the actuarially sound capitation rates are developed and documented in the rate certification submitted to CMS 16
17 Rate Development and Certification Standards Provides general guidance on how different components of rate should be developed and documented in certification Some aspects may be new or different than how components were developed in past: Base data requirements New requirements and documentation for risk adjustment processes Non-benefit costs may require additional detail Actuaries and states should review how current rate development and certification applies to new requirements 17
18 Actuarial Soundness CMS Review Developed in accordance with defined rate development standards and generally accepted actuarial principles and practices Appropriate for covered populations and services Adequate to meet requirements defined for MCOs Specific to payments for each rate cell under the contract No cross-subsidization between rate cells Certified on behalf of the state by a qualified actuary Meet any special contract provisions Appropriate submission of documentation to CMS Developed such that the MCO would reasonably achieve a medical loss ratio (MLR) of at least 85% 18
19 Evolution of Actuarial Soundness What s New What s New-ish What s Not Eliminate rate ranges and addition of +/-1.5% Use MLR in rate dev Phase out of passthrough payments Age of base data Prescribed methodology Documentation requirements CMS actuarial review Binding standards on actuaries (ASOP) Actuarial soundness Rate certification Generally accepted practice Actuarial judgment 19
20 Important Implementation Dates 60 days after publication of rule (now) Rating periods for contracts starting on or after July 1, 2017 Rating periods for contracts starting on or after July 1, 2018 Rating periods for contracts starting on or after July 1, 2019 Definitions of actuarial soundness and other rate components Appropriate for populations & services covered No crosssubsidization of rates Payments for plans for enrollees who are in IMDs Most rate development standards base data, trend, etc. Certification provided in format and timeframe required in Phase out of pass-through payments Certify to each rate per rate cell (no more ranges) Ability to change rate by 1.5% Adequate to meet new requirements on health plans in , , Rates should be developed so that plan can reasonably achieve an MLR of at least 85 percent 20
21 Additional Resources Medical loss ratio (MLR) in the Mega Reg Institution for Mental Disease (IMD) as an "in lieu of" service Encounter data standards: Implications for state Medicaid agencies and managed care entities from final Medicaid managed care rule Pass-through payment guidance in final Medicaid managed care regulations: Transitioning to value-based payments Overview of guidance related to actuarial soundness in final Medicaid managed care regulations 21
22 Thank you
23 Limitations This document is intended for informational purposes only, and opinions contained therein represent the opinions of the authors only. Milliman makes no representations or warranties regarding the contents of this document. Milliman does not intend to benefit or create a legal duty to any recipient of this document. Copyright 2016, Milliman, Inc. 23
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