Miscellaneous 4 Flashcards
(54 cards)
EPSDT (pediatric Medicaid benefit)
early & periodic screening, diagnostic, and treatment
Medicaid covers about ____% of the U.S. population
20%
flexible areas that vary by state for Medicaid
- eligibility
- benefits
- provider payment
- other aspects
Medicaid expansion benchmark plans must include
- EHBs
- family planning services
- prescription drugs
- meet Mental Health Parity requirements
Medicare & Medicaid Alignment
plans will receive separate capitation payments for Medicare Parts A & B, Medicaid, and Part D. Capitation rates for Medicare part A & B & Medicaid are calculated using the following process
- project baseline costs in absence of the demonstration
- apply savings %
- apply withhold %
- apply any prospective risk adjustment mechanisms
- apply an retrospective risks mitigation mechanisms (ex. risk corridors)
alignment of Medicaid & Medicare benefits will differ by states with respect to:
- target population
- all duals or subset - geographic area
- state wide or limited - capitated model enrollment process
- benefits covered
Duals compromise ___% of Medicaid population & account for ___% of expenditures
15%, 35%
section 1115 waivers allow changes to member cost sharing, such as:
- all waivers require some level of copayment
- Iowa & Michigan charge monthly premiums
- AR, IN, & MI use an approach similar to an HSA in which enrollees make monthly or quarterly contributions
Medicaid population
highest % of enrollees?
most expensive enrollees?
children & parents (75%)
elderly & disabled (65% of total spending)
ACA efforts to improve Medicaid
- increased payment rates to Medicare levels for PCPs in 2013-2014
- included various incentive and initiatives designed to promote more patient-centered, coordinated, & integrated care
- voluntary reporting of quality of care measure for adults
HEDIS
Healthcare Effectiveness Data & Information Set
-standardized data to measure the quality of care
MCCSR
Minimum Continuing Capital & Surplus Requirement
-amount of capital required by regulators, similar to risk-based capital in the U.S.
life & health insurers whose stock is publicly traded are required by the SEC to prepare financial reports on what basis?
GAAP
generally accepted accounting principles
ASOPs related to actuarial opinions for group insurance
- # 7 - considerations for liability & asset cash flows
- # 22 - cash flows under moderately adverse scenarios
- # 28 - consider specific policy & contract provisions affecting assets & liabilities
if a company grows faster than g*, it must do 1 of the following:
- improve operations by increasing
a. profit margin (P) or
b. asset turnover ratio (A) - alter financial policies by increasing
a. retention rate (R) or
b. financial leverage (T)
external funding required (for pro-forma method)
= total assets - (liabilities + owner’s equity)
Considerations during Risk adjustment implementation
- budget neutrality
- timing of the updates
- data testing & validation
- HIPAA considerations & controls
- Newborns
“Individual” approach to risk adjustment
transfer an individual’s risk score to a health plan when he/she moves
the capitation rate paid to the plan changes (monthly) based on the enrolled membership.
“aggregate” approach to risk adjustment
a composite risk score is calculated across all eligible members enrolled in the experience period. That risk score is used to determine the capitation rate for the entire rating period.
time period of prospective & concurrent risk scores
prospective - future period
concurrent - same time period as experience data
type of data needed for risk adjustment models
- age
- gender
- eligibility
- inpatient admissions diagnoses
- outpatient services
- pharmacy data
sustainable growth rate
limit on company’s growth if there is no external source of capital
adjustments in financial reports to reflect unusual or one time items
“normalization”
- items that qualify as extraordinary for accounting purposes
- disputed items resolved after the fact
- expenses discovered after the fact
- significant IBNR adjustments
- legal settlements
- start-up costs for new products
total leverage ratio
- “measure of how much debt the company has”
- most important liability is claims payable
- admin cost to process claims is typically included
