State of New Hampshire Department of Health and Human … · 2018-06-26 · Milliman Client Report...

June 11, 2018

Milliman Client Report

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State of New Hampshire Department of Health and Human Services SFY 2019 Capitation Rate Development for

Medicaid Care Management Program

Prepared for: The State of New Hampshire Department of Health and Human Services

Prepared by: Milliman, Inc.

John D. Meerschaert, FSA, MAAA Principal and Consulting Actuary Mathieu Doucet, FSA, MAAA Consulting Actuary

Gregory J. Herrle, FSA, MAAA Consulting Actuary

Sarah Wunder, FSA, MAAA Actuary

Caroline Li, ASA, CERA, MAAA Associate Actuary


State of New Hampshire Department of Health and Human Services SFY 2019 Capitation Rate Development for Medicaid Care Management Program June 11, 2018 This report assumes that the reader is familiar with the State of New Hampshire’s Medicaid program, its benefits, and rate setting principles. This report was prepared solely to provide assistance to DHHS to set SFY 2019 capitation rates for the Medicaid Care Management program. It may not be appropriate for other purposes. Milliman does not intend to benefit and assumes no duty or liability to other parties who receive this work. This material should only be reviewed in its entirety.

TABLE OF CONTENTS I. EXECUTIVE SUMMARY ................................................................................................................. 1 II. METHODOLOGY OVERVIEW ........................................................................................................ 6 III. MEDICAL COST PROJECTIONS ................................................................................................. 10 IV. FINAL CAPITATION RATE ADJUSTMENTS............................................................................... 30 V. SERVICE CATEGORY ASSIGNMENT ......................................................................................... 36 VI. CMS RATE SETTING CHECKLIST ISSUES ................................................................................ 39 VII. RESPONSE TO 2018-2019 MEDICAID MANAGED CARE RATE DEVELOPMENT GUIDE

(MAY 2018) .................................................................................................................................... 45 APPENDICES Capitation Rate Development Exhibits: A1: SFY 2016 FFS Base Experience Data A2: SFY 2016 MCO Encounter Base Experience Data A3: SFY 2017 MCO Encounter Base Experience Data B1: Data Adjustments for SFY 2016 FFS Base Experience Data B2: Data Adjustments for SFY 2016 MCO Encounter Base Experience Data B3: Data Adjustments for SFY 2017 MCO Encounter Base Experience Data C1: Blended Projected SFY 2019 Medical Costs from SFY 2016 Experience C2: Blended Projected SFY 2019 Medical Costs from SFY 2017 Experience C3: Blended Projected SFY 2019 Medical Costs – Combined SFY 2016 and SFY 2017 D: Medicaid Care Management Benefit Add-Ons E: Final Base Capitation Rate Development F: Rate Comparison Fiscal Impact Exhibit: G: Estimated Fiscal Impact of Medicaid Care Management Program Other Supporting Exhibits: H: Community Mental Health Agreement Add-On Development I: Opioid Addiction Treatment Trend Adjustment Development J: National Drug Codes for Carved-Out Prescription Drugs K: Estimated MCM Enrollment by Fiscal Year Actuarial Certification: L: Actuarial Certification of SFY 2019 New Hampshire Medicaid Care Management Capitation Rates


State of New Hampshire Department of Health and Human Services Page 1 SFY 2019 Capitation Rate Development for Medicaid Care Management Program June 11, 2018 This report assumes that the reader is familiar with the State of New Hampshire’s Medicaid program, its benefits, and rate setting principles. This report was prepared solely to provide assistance to DHHS to set SFY 2019 capitation rates for the Medicaid Care Management program. It may not be appropriate for other purposes. Milliman does not intend to benefit, and assumes no duty or liability to, other parties who receive this work. This material should only be reviewed in its entirety.

I. EXECUTIVE SUMMARY This report documents the development of the SFY 2019 managed care organization (MCO) capitation rates for New Hampshire’s Medicaid Care Management (MCM) program. The New Hampshire Department of Health and Human Services (DHHS) retained Milliman to calculate, document, and certify its capitation rate development. We developed the capitation rates using the methodology described in this report. Our role is to certify that the SFY 2019 capitation rates produced by the rating methodology are actuarially sound to comply with Centers for Medicare and Medicaid Services (CMS) regulations. We developed actuarially sound capitation rates using published guidance from the American Academy of Actuaries (AAA), the Actuarial Standards Board (ASB), CMS, and federal regulations to ensure compliance with generally accepted actuarial practices and regulatory requirements. SFY 2019 CAPITATION RATE CHANGE Table 1 shows the details of the statewide rate change from the SFY 2018 capitation rates to the SFY 2019 MCM program capitation rates. Appendix F shows a summary of the rate change by rate cell.

Table 1 New Hampshire Department of Health and Human Services

Medicaid Care Management Program Capitation Rates Summary of SFY 2019 Capitation Rate Change Components Based on Projected SFY 2019 MCO Enrollment by Rate Cell

Rate Component Rate

Change Annualized

Dollar Impact Rate Change Prior to Program Changes 2.65% $13,935,000 SFY 2019 Program Changes: Opioid Addiction Treatment Cost Trend Adjustment 1.69% 8,871,000 CMHC Temporary Fee Schedule Increase 1.07% 5,606,000 Inclusion of ABA Services 0.74% 3,874,000 Sununu Youth Center Services 0.17% 897,000 Implementation of Behavioral Health Crisis Treatment Center Services 0.04% 230,000 White Mountain Community Center FQHC Lookalike Status 0.03% 147,000 CMHC Workforce Expansion Directed Payment -0.09% (469,000) Total Program Changes 3.65% 19,156,000 Total SFY 2018 - SFY 2019 Rate Change 6.30% $33,091,000

The majority of the 6.30% rate increase from SFY 2018 to SFY 2019 is related to program changes made by DHHS, such as changes in covered benefits and expansion of service availability. The combined impact of these program changes amounts to a 3.65% increase and results in a 2.65% rate increase excluding the impact of the SFY 2019 program changes. Table 2 shows the statewide rate change from the SFY 2018 capitation rates to the SFY 2019 MCM program capitation rates by major population.




SFY 2019 Capitation Rate Change Based on Projected SFY 2019 MCO Enrollment by Rate Cell

Population SFY 2018

Capitation Rate SFY 2019

Capitation Rate Percentage

Change Base Population Rate Cells $251.13 $269.78 7.43% NF Resident and Waiver Population Rate Cells 582.11 601.38 3.31% Behavioral Health Population Rate Cells 1,264.16 1,335.36 5.63% Grand Total $354.10 $376.41 6.30%

The SFY 2019 MCM capitation rates include a directed payment to community mental health centers (CMHCs) that is subject to CMS approval. While this amount is included in the MCO capitation rates, MCOs are not at risk for the amount of the payment. We project an overall MCO medical loss ratio (MLR) of 88.7% for the MCM program in SFY 2019, which includes:

An 8.0% administrative cost allowance and a 1.5% risk margin applied as a percentage of revenue prior to the CMHC directed payment and the premium tax allowance

A 2.0% allowance for New Hampshire’s premium tax The projected MLR excludes the impact of the CMHC directed payment in both the numerator and denominator of the MLR calculation, which is consistent with the treatment of directed payments in federal MLR calculations. The capitation rate composites shown above are based on our projections of the MCO enrollment for SFY 2019. We developed these membership projections from monthly enrollment trends observed after the mandatory enrollment provision took effect. We examined March 2017 to September 2017 enrollment data trends and smoothed out monthly trends for rate cells with more variation in monthly enrollment. Appendix K shows the results of our projections. SFY 2019 CAPITATION RATES Table 3 below shows the base population rates that DHHS will pay to MCOs for each member according to the rate cell definitions. Note that the base population rate cells exclude the behavioral health population, nursing facility (NF) residents, and waiver populations, which all have separate rate cells as shown in Tables 4 and 5. The rate changes by rate cell are shown in Appendix F.




Medicaid Care Management Program Capitation Rates SFY 2019 Base Population Capitation Rates1

Base Population Rate Cell Capitation Rates Low Income Children and Adults 2 – 11 months $223.43 1 – 18 139.77 19+ 477.56 Foster Care / Adoption 364.07 Breast and Cervical Cancer Program 1,822.10 Severely Disabled Children 1,055.54 Elderly and Disabled Adults 1,118.63 Dual Eligibles 242.77 Newborn Kick Payment 2,926.55 Neonatal Abstinence Syndrome Kick Payment 9,648.20 Maternity Kick Payment 2,838.56 1 Excludes the behavioral health population, NF residents, and waiver populations.

Table 4 shows the statewide capitation rates for NF residents and the waiver populations that DHHS will pay to the MCOs for each member.


Medicaid Care Management Program Capitation Rates SFY 2019 NF Resident and Waiver Populations Rates1

NF Resident and Waiver Rate Cell Capitation Rates Nursing Facility Residents – Medicaid Only – Under 65 $2,640.90 Nursing Facility Residents – Medicaid Only – 65+ 1,353.25 Nursing Facility Residents – Dual Eligibles – Under 65 278.52 Nursing Facility Residents – Dual Eligibles – 65+ 96.73 Community Residents – Medicaid Only – Under 65 3,118.44 Community Residents – Medicaid Only – 65+ 1,570.04 Community Residents – Dual Eligibles – Under 65 1,254.84 Community Residents – Dual Eligibles – 65+ 450.30 Developmentally Disabled Adults – Medicaid Only 842.80 Developmentally Disabled Adults – Dual Eligibles 252.23 Developmentally Disabled and IHS Children 1,215.75 Acquired Brain Disorder – Medicaid Only 1,488.03 Acquired Brain Disorder – Eligibles Dual 339.41 1 Excludes base population and behavioral health population.



Table 5 below shows the capitation rates for the behavioral health population that DHHS will pay to the MCOs for each member eligible for enhanced behavioral health services.


Medicaid Care Management Program Capitation Rates SFY 2019 Behavioral Health Population Rates1

Behavioral Health Population Rate Cells Capitation Rates Severe / Persistent Mental Illness – Medicaid Only $2,358.94 Severe / Persistent Mental Illness – Dual Eligibles 1,783.25 Severe Mental Illness – Medicaid Only 1,715.63 Severe Mental Illness – Dual Eligibles 1,057.24 Low Utilizer – Medicaid Only 1,480.45 Low Utilizer – Dual Eligibles 710.82 Serious Emotionally Disturbed Child 954.70 1 Excludes the base population, NF residents, and waiver populations.

It should be emphasized that capitation rates are a projection of future costs for an efficient MCO based on a set of assumptions. Actual MCO costs will be dependent on each MCO’s situation and the extent to which future experience conforms to the assumptions made in the capitation rate development calculations. REPORT STRUCTURE Appendices A – E document the development of the SFY 2019 capitation rates for all populations. Appendix F calculates the capitation rate change from the SFY 2018 rate period. Appendix G calculates the fiscal impact of the SFY 2019 capitation rates based on projected SFY 2019 member months. Appendices H – K provide additional supporting exhibits. The actuarial certification of the SFY 2019 New Hampshire MCM program capitation rates is included as Appendix L. Section II provides an overview of the methodology, including a summary of changes made to the SFY 2018 methodology. Section III documents the capitation rate base data and medical cost projections. Section IV summarizes final capitation rate adjustments for all rate cells, including various program adjustments and the administrative / margin allowance. Section V of the report provides information regarding the assignment of service categories. Section VI discusses issues related to the CMS rate setting checklist. Section VII includes comments on items related to the 2018-2019 Medicaid Managed Care Rate Development Guide. DATA RELIANCE AND IMPORTANT CAVEATS We used fee-for-service (FFS) and MCO encounter cost and eligibility data for July 2015 through December 2017, MCO financial data, historical reimbursement information, TPL recoveries, current fee schedules, and other DHHS and MCO information to calculate the New Hampshire MCM program capitation rates shown in this report. This data was provided by DHHS and participating MCOs. We did not audit this data and other information. If the underlying data or information is inaccurate or incomplete, the results of our analysis may likewise be inaccurate or incomplete. We performed a limited review of the data used directly in our analysis for reasonableness and consistency and did not find material defects in the data. If there are material defects in the data, it is possible they would be uncovered by a detailed, systematic review and comparison of the data to search for data values that are questionable or for relationships that are materially inconsistent. Such a review was beyond the scope of our assignment.



We constructed several projection models to develop the capitation rates shown in this report. Differences between the capitation rates and actual MCO experience will depend on the extent to which future experience conforms to the assumptions made in the capitation rate development calculations. It is certain that actual experience will not conform exactly to the assumptions used in the SFY 2019 capitation rates due to differences in health care trend, managed care efficiency, provider reimbursement levels, and many other factors. Actual amounts will differ from projected amounts to the extent that actual experience is higher or lower than expected. Milliman prepared this report for the specific purpose of developing SFY 2019 MCM program capitation rates. This report should not be used for any other purpose. This report has been prepared solely for the internal business use of, and is only to be relied upon by, the management of DHHS. We understand this report may be shared with participating MCOs, CMS, and other interested parties. Milliman does not intend to benefit or create a legal duty to any third party recipient of its work. This report should only be reviewed in its entirety. The results of this report are technical in nature and are dependent upon specific assumptions and methods. No party should rely on these results without a thorough understanding of those assumptions and methods. Such an understanding may require consultation with qualified professionals. The authors of this report are consulting actuaries for Milliman, members of the American Academy of Actuaries, and meet the Qualification Standards of the Academy to render the actuarial opinion contained herein. To the best of their knowledge and belief, this report is complete and accurate and has been prepared in accordance with generally recognized and accepted actuarial principles and practices. The terms of Milliman’s contract with the New Hampshire Department of Health and Human Services effective July 1, 2017 apply to this report and its use.



II. METHODOLOGY OVERVIEW This section of the report provides an overview of the SFY 2019 New Hampshire MCM program capitation rate methodology and highlights program changes effective for SFY 2019. BASE DATA We developed the SFY 2019 capitation rates using enrollment data, FFS claims, and MCO encounter claims from SFY 2016 and SFY 2017.

We used two years of base data to increase the credibility of the rate development calculation, particularly for smaller rate cells.

We obtained the FFS data through the Medicaid Management Information System (MMIS), supplemented by additional information from DHHS for services not included in the MMIS claims data (such as non-emergency transportation, hospice, and Stiripentol costs).

We obtained MCO encounter data and sub-capitated expenditures directly from the participating MCOs. The SFY 2019 capitation rates include sub-capitated expenditures for services not capitated through an affiliated organization. For related entities, the SFY 2019 rates include actual encounter payments to providers for those services, when available. We removed administrative payments made by the MCOs to related parties from the encounter data. The MCOs also provided summarized provider incentive payments and settlements made outside of the claims data and these items were included in the base data.

We obtained eligibility and MCM enrollment information from DHHS. We believe the encounter data is of appropriate quality and completeness to use as the primary basis for developing actuarially sound rates for the New Hampshire MCM program. We validated the MCO encounter data using the following process:

We compared the submitted encounter data to quarterly financial data summaries provided by the MCOs. The quarterly financial data summaries included FFS and sub-capitated payments made by the MCOs to providers by rate cell, broad service category, and quarter. The financial data was not audited, but is certified by the MCO as accurate and complete.

DHHS and Milliman provided an opportunity for MCOs to play a greater role in the base data validation for the SFY 2019 capitation rate development process. As we worked on the development of the SFY 2019 capitation rates, we provided MCOs with a series of detailed data summaries in order to further our understanding of the data, complete the validation process, and offer more transparency on the process leading to the capitation rates.

Through this detailed review process, Milliman, DHHS, and the MCOs validated the encounter data

for use in the capitation rate setting process. The FFS data utilized in the capitation rate development process represents approximately 3.1% of the total base experience data. We used the FFS data for the managed care eligible population that opted-out and remained in the FFS program during the July 2015 to January 2016 time period. Mandatory enrollment for those individuals began February 1, 2016. We excluded the FFS experience for other individuals eligible for the MCM program in July 2015 to January 2016, as this data corresponds to the MCO selection period for newly eligible individuals, which will continue in a similar fashion for SFY 2019. DHHS expects to



implement the “Next Day” enrollment process on January 1, 2019 in which a newly Medicaid eligible member will be enrolled in a MCO on the day following Medicaid eligibility confirmation. The capitation rates presented herein will be amended for this change when it goes into effect. We did not identify any material concerns with the quality or availability of the data with respect to total claims in aggregate or our ability to allocate encounter data to major service categories. Our data reconciliation efforts are consistent with Actuarial Standard of Practice #23. PROGRAM CHANGES FROM THE SFY 2018 CAPITATION RATE METHODOLOGY The SFY 2019 capitation rate methodology reflects several program changes from the SFY 2018 capitation rate methodology presented in our November 10, 2017 certification. The changes are as follows:

Inclusion of a specific trend adjustment to recognize an increase in the number of members treated for opioid addiction and their related treatment costs

Implementation of a temporary fee schedule increase for CMHC services

Inclusion of the applied behavior analysis (ABA) benefit as an at-risk services to the MCOs

Implementation of substance use disorder (SUD) services for adolescents at the Sununu Youth Center starting on August 15, 2018

Implementation of a Behavioral Health Crisis Treatment Center effective November 1, 2018

Implementation of a change for White Mountain Community Center to FQHC Look-Alike (LAL) status

Inclusion of a CMHC directed payment of $5 million across all programs (MCM and NHHPP) for SFY 2019 to support workforce development

Implementation of a neonatal abstinence syndrome (NAS) kick payment Any subsequent material program changes enacted by the legislature or DHHS would need to be factored into the SFY 2019 capitation rates as a rate adjustment. METHODOLOGY We used the following methodology to develop the New Hampshire MCM program capitation rates:

1. Summarize SFY 2016 and SFY 2017 encounter and FFS experience data for the MCM eligible population by eligibility category.

2. Calculate estimated statewide SFY 2019 MCM program medical costs for all covered services by

rate cell for the base population, individuals eligible for enhanced behavioral health services in community mental health centers (CMHCs), and individuals enrolled in the CFI, DD, IHS, and ABD waivers or residing in a nursing facility.

3. Adjust SFY 2019 projected medical costs for all rate cells for benefits not included in the base

experience data, expected administrative expenses, margin, and premium tax. Sections III and IV of this report document the rate setting methodology in detail.



ACA INSURER FEE The ACA places an annual fee on the health insurance industry. The fee is allocated to qualifying health insurers based on their respective market share of premium revenue in the previous year (e.g., the 2020 health insurer fee will be based on 2019 premium revenue). There is a moratorium on the health insurer fee for calendar year 2019. Market share is based on commercial, Medicare, and Medicaid revenue. CMS regulations require Medicaid managed care rates to include allowances for taxes like the ACA insurer fee because they are an unavoidable cost of doing business for Medicaid MCOs. DHHS recognizes the need to fund payments related to the ACA health insurer fee that will be paid by the MCOs. Taxes, such as the ACA health insurer fee and related income tax impacts, are widely recognized as a reasonable and unavoidable cost of doing business for Medicaid MCOs and should be considered by the Medicaid actuary for inclusion in Medicaid managed care payments. The MCO capitation rates documented in this report are actuarially sound prior to the application of the ACA health insurer fee provision. DHHS will recalculate capitation payments for each MCO based on the actual amount of the health insurer fee for each plan and make gross adjustment payments to the MCOs to appropriately fund the ACA health insurer tax and its related income tax impact. Although paid separately, the allocation for the ACA insurer fee is part of the actuarially sound MCO capitation rates. RISK ADJUSTMENT OF CAPITATION RATES The SFY 2019 capitation rates will continue to use the actuarially sound risk adjustment model currently in place to adjust the rates for each participating MCO. In continuation of the changes made to the January 2018 to June 2018 risk adjustment process, we will update the risk weight associated with “Substance abuse, low” to be used for the opioid addiction population using more recent data. We will publish the new risk weights once the results of our analysis are available. A brief description of the methodology is provided below. The current risk adjustment process uses the CDPS+Rx model to assign individuals to a demographic category and disease categories based on their medical claims and drug utilization during the study period. Only a single incidence of an International Classification of Disease Code (ICD) or drug is necessary to establish a CDPS+Rx disease category. We exclude diagnosis codes related to radiology and laboratory services to avoid including false positive diagnostic indicators for tests run on an individual. CDPS uses ICD-9 and ICD-10 diagnosis codes to assess risk and assigns each member to one or more of 58 possible medical condition categories from 19 major diagnostic categories. Each member is also assigned to one of 11 age / gender categories. All of the 19 major diagnostic categories are “hierarchical” categories in that only the single most severe diagnosis within the major category is counted. This counting rule simplifies the model and strengthens its resistance to additional coding. Single counting within major categories is intended to avoid encouraging a proliferation of different diagnoses reported for a single disease process just to increase payment. However, as with most models, CDPS considers not only a person’s single most serious diagnosis but also diagnoses from other major categories. The CDPS+Rx model includes the full set of diagnosis categories from the CDPS model, as well as 15 MRX categories from the Medicaid Rx model that are embedded within the CDPS hierarchy. The researchers at UCSD who developed the CDPS+Rx model decided to limit the MRX categories to the 15 that added predictive power to the diagnostic model (i.e., both relatively common and significant predictors of cost) and that were relatively less susceptible to variations in practice patterns.



We use version 6.3 of the risk weights to score individuals with at least six months of eligibility and claims experience in the base data. Each scored individual receives a demographic relative cost weight and can have multiple disease categories assigned depending on that individual’s health status. For each member, the weights for all of the disease categories assigned are combined with their demographic information to calculate a total individual risk score. Scored members are assigned to each MCO using enrollment data for the first month of each calendar quarter. For each MCO, the unadjusted plan factors are derived by performing a weighted average of the cost weights using the count of scored adults and children associated with each CDPS+Rx category. The unadjusted plan factor for the total population is the weighted average of each MCO’s unadjusted plan factor using total recipients, not scored recipients only. Using the total count of recipients rather than the count of scored recipients ensures that the budget neutral plan factors are indeed budget neutral. The budget neutral plan factor is calculated by dividing each individual MCO’s unadjusted plan factor by the total population’s unadjusted plan factor. For the SFY 2019 contract period, we will continue using a credibility threshold of 200 scored members (the total of scored members from both MCOs) to allow for enough volume to credibly measure differences in risk scores. Please note that only the following rates cells will be risk adjusted based on current membership levels.

Low Income Children and Adults 1 - 18 Low Income Children and Adults: 19+ Foster Care / Adoption Severely Disabled Children Elderly and Disabled Adults Dual Eligibles (opioid addiction adjustment only) Community Residents - Medicaid Only - Age 0 - 64 Developmentally Disabled Adults - Medicaid Only Developmentally Disabled and In-Home Supports Children Severe / Persistent Mental Illness – Medicaid Only Severe Mental Illness – Medicaid Only Serious Emotionally Disturbed Child

We do not anticipate risk adjusting the capitation rates for the following Medicaid only rate cells due to their small size.

Breast and Cervical Cancer Program Nursing Facility Residents – Medicaid Only – Under 65 Nursing Facility Residents – Medicaid Only – 65+ Community Residents - Medicaid Only - Age 0-64 Acquired Brain Disorder – Medicaid Only Low Utilizer – Medicaid Only All other dual eligible rate cells

The main Dual Eligible rate cell will continue to be risk adjusted to recognize the opioid addiction population as done for the January 2018 to June 2018 contract period. All other dual eligible rate cells will not be risk adjusted since most acute care costs are covered by Medicare, and diagnostic / pharmacy risk adjusters are not calibrated to adjust the Medicaid costs for dual eligibles.



III. MEDICAL COST PROJECTIONS This section of the report describes the projection of the FFS and MCO encounter data for all rate cells. We used the following methodology to project the FFS and encounter data used in the calculation of the medical component of the capitation rates:

1. Summarize SFY 2016 and SFY 2017 FFS and MCO encounter base experience data for the population eligible for and the services covered by the MCM program

2. Apply adjustments to the base data to project SFY 2019 medical costs

3. Blend the projected SFY 2016 and SFY 2017 FFS and encounter data

Each of the above steps is described in detail below. STEP 1: SUMMARIZE FFS AND MCO ENCOUNTER BASE EXPERIENCE DATA In this step, we summarize the FFS and encounter experience for SFY 2016 and SFY 2017 by rate cell and service category for the populations eligible to enroll in the MCM program. Effective February 1, 2016 individuals that previously opted out of the MCM program were mandatorily enrolled in the program. Due to this change, the FFS data only includes claims and enrollment prior to February 1, 2016. Appendix A1 shows the summarized SFY 2016 FFS base experience data for the opt-out rate cells only. Appendices A2 and A3 show the summarized SFY 2016 and SFY 2017 MCO encounter base experience data for every rate cell. Base Data We summarized detailed FFS and MCO encounter claims data with dates of service between July 2015 and June 2017 with dates of payment through December 2017 with the following specifications:

The cost and utilization data reflect the claim header information for claims paid at the header level and line item detail for claims paid at the detail level

Claims for FQHC and RHC providers reflect their normal prospective per encounter rates

Prescription drug claims reflect gross ingredient cost and dispensing fees prior to any pharmacy

rebates

We excluded all Part D covered drugs for dual eligibles

We excluded claims and eligibility data for the portion of any month when an individual had a stay longer than 15 days in an IMD

We excluded hepatitis C, hemophilia and other high cost drugs (Carbaglu and Ravicti) as they are carved out of the MCM program



Non-Covered Services Adjustment MCOs are allowed to provide services not explicitly covered under the MCM program to beneficiaries in-lieu of a covered service. As part of the capitation rate development process, the encounter data must be adjusted to remove any portion of the cost of in-lieu of services that exceeds the cost of the corresponding covered service. MCOs currently provide Medical Nutrition and Diabetes Self-Management services defined by Procedure Codes 97802, 97803 and G0108 with average unit cost of $19.20 per unit using staff nutritionists. Alternatively, these services would be provided as a covered service by a physician in an office setting at the cost of $20.16 per unit (based on the Medicaid fee for 99201 office visit). This comparison shows that Medical Nutrition and Diabetes Self-Management services are cost effective. Therefore, we did not make any adjustment to the base period data for non-covered services. Coordination of Benefits The amounts included in the SFY 2019 capitation rates presented herein are meant to be consistent with DHHS’ coordination of benefit (COB) methodology. As such, when Medicaid is not the primary payer and the primary insurance payment received is less than the applicable New Hampshire Medicaid program reimbursement level and a patient responsibility amount (deductible, copay, or coinsurance) is still outstanding, then a provider may submit a claim to New Hampshire Medicaid for the patient responsibility amount. Similarly, for Part A and Part B crossover claims billed on the UB-04 form, New Hampshire Medicaid will pay the patient responsibility amount (deductible and coinsurance). For Part B crossover claims billed on the CMS-1500 form, New Hampshire Medicaid will pay the lesser of (1) the patient responsibility amount (deductible and coinsurance), or (2) the difference between the amount paid by the primary payer and the Medicaid allowed amount. Please refer to the September 24, 2014 provider bulletin on this topic. It is our understanding that MCOs may not have followed the New Hampshire COB methodology for the entirety of the base experience period. Unfortunately, the details in the encounter claims data did not allow us to adjust the claims to reflect the prescribed methodology. We do not expect this issue to have a material impact on the SFY 2019 capitation rates. Retroactive Eligibility and Enrollment Lag Recipient enrollment in the FFS program can and does occur retroactively. When an individual applies and qualifies for Medicaid coverage, DHHS reimburses claims that occurred during the retroactive qualification period prior to their application. DHHS backdates the eligibility of the individual to accommodate the retroactive coverage. The MCOs do not cover these retroactive enrollment periods. Retroactive claims were included in the data provided by DHHS. The enrollment data provided by DHHS excluded retroactive enrollment periods, therefore a special adjustment was not necessary because we only summarized claims for individuals with non-retroactive enrollment records. As a result, the FFS claims included in this analysis are reflective of the claims and time period that would be covered by the MCO. Additionally, the encounter data already excludes the retroactive eligibility period and enrollment lag so no adjustments were needed.



Eligibility Category Assignment We grouped MCM enrollees into the SFY 2019 rate cell structure using the following hierarchy based on their eligibility status on the first of each month:

1. NF resident rate cells 2. Community resident and other waiver rate cells 3. Behavioral health population rate cells 4. Base population rate cells

We identified the NF resident population as those individuals with a Nursing Facility Level of Care or Placement Level of L2 / 020, L3 / 030, L4 / 040, L6 / 060 on the first of the month in any given month. We identified the CFI, DD, IHS and ABD Waiver populations using special eligibility codes as follows:

AC: Choices For Independence AD: Choices For Independence AA: Developmentally Disabled AB: Developmentally Disabled BB: Acquired Brain Disorder BC: Acquired Brain Disorder CC: In-Home Supports CI: In-Home Supports

All eligibility groups have separate rate cells based on Dual Status. The community and NF resident population are also split between under and over 65 years old. The behavioral health rate cells are structured around the target populations eligible for enhanced behavioral health services at the CMHCs. These individuals are identified through the following modifier codes found on CMHC FFS claims:

Modifier 1 is HW for all BBH eligible patients Modifier 2 is U1 for Severe / Persistent Mental Illness (SPMI) Modifier 2 is U2 for Severe Mental Illness (SMI) Modifier 2 is U5 for Low Utilizer Modifier 2 is U6 for Serious Emotionally Disturbed Child (SED) Modifier 2 is U7 for Serious Emotionally Disturbed Child, Interagency Involvement (SED-I)

To identify the behavioral health population enrolled in an MCO, we used a separate data file provided by DHHS that identified each individual for which a behavioral payment was made in the base experience period. We separated each group into rate cells based on Medicare eligibility as follows:

Severe / Persistent Mental Illness (SPMI) – Medicaid Only Severe / Persistent Mental Illness (SPMI) – Dual Eligibles Severe Mental Illness (SMI) – Medicaid Only Severe Mental Illness (SMI) – Dual Eligibles Low Utilizers – Medicaid Only Low Utilizers – Dual Eligibles Serious Emotionally Disturbed Child (SED) – Medicaid Only and Dual Eligibles



We identified and classified the base population using the eligibility codes found in the enrollment file. Table 6 below shows the definitions we used for the various rate cells. The various eligibility groups have been further segmented into rate cells based on analysis of the per capita costs of various population sub-groups. These sub-groups were defined by age and gender within the covered eligibility categories and grouped into rate cells based on similarities in average costs. There are a total of eight rate cells across several different eligibility categories. There are three additional kick payments made for maternity costs and newborn costs. All rate cell assignment is done on a first of the month basis, consistent with capitation rate payment from MMIS.


Medicaid Care Management Program Rate Cell Definitions

Rate Cell Age / Gender Categories Eligibility Category

Dual Status Code* Other Criteria

Low Income Children and Adults

2 – 11 months** 1 – 18 19 +

MAEM, MAEN, MAER, MAES, MAEU, MAFR, MAFU, MCER, MCEU, MCFR, MCFU, MCIE, MCN, MCRA, MCRF, ME12, ME4, MMER, MMEU, MMFR, MMFU, MMRA, MMRF, MP C, MP P, MPQC, MPQP, MCIS, MGIC, MGIE, MGIN, MGIP, MGIW

N

Foster Care / Adoption All MCP1, MCP2, MCPI, MCPN, MMP2, MMPN, MGIF

N

Breast and Cervical Cancer Program (BCCP) All MBCC N

Severely Disabled Children All

MMHC, MCDC, MMDC, MCHC, MSPB, MSPP, MCAB, MAAB, MMAB

N Age <19 for category codes MSPB, MSPP, MCAB, MAAB, MMAB

Disabled Adults All

MAAB, MAAD, MCAB, MCAD, MEAD, MMAB, MMAD, MSPB, MSPP, MCAA, MAAA, MMAA

N

Age 19+ for category code MSPB, MSPP, MCAB, MAAB, MMAB (includes 18 year olds in other eligibility categories)

Dual Eligibles All Any Y Medicare coverage (excluding SLMB and QMB)

Newborn Kick Payment Any N

First two months of life within a single fiscal year (excluded babies with only one month from rate calculation)

Neonatal Abstinence Syndrome Any N Same as newborn criteria with

diagnosis code requirement Maternity Kick Payment Any N Service description below * Dual eligibility status determined by Dual Status indicator “Y” and the presence of a Medicaid Eligibility Category code. ** The Low Income Children and Adults – 2 - 11 Months old rate cell also includes the first month of life (excluding the birth month) for babies born prior to coming on Medicaid (and therefore excluded from the newborn kick payment).



We proactively assigned “Pending Duals” to their respective dual rate cell. Based on DHHS’ review of several cases, DHHS ultimately retroactively assigns a dual eligible status to these individuals in more than 90% of cases. Maternity Kick Payment Definition The maternity kick payment includes all facility and professional claims associated with deliveries. Maternity kick payment cases are counted as women who have either a maternity delivery DRG or a physician maternity delivery claim (or both). The maternity kick payment only includes women already enrolled in Medicaid at time of delivery. The maternity kick payment cases are distributed in the following manner:

Both a maternity delivery DRG and a physician claim = 80%

A maternity delivery physician claim only = 14%

A maternity delivery DRG only = 6% We used the following criteria to identify claims information to calculate the maternity kick payment.

Hospital inpatient services with DRG codes of 765 – 768, 774 – 775

Hospital outpatient and professional services with a primary diagnosis code of: ICD9: v27.0 – v27.9, 650, and 651.01 - 669.92 (with the 5th digit being 1 or 2) ICD10: O60 – O82, and Z37 This would include delivery related anesthesia services (CPT-4 codes 00850, 00857, 00946, 00955, 01960, 01961, 01967, 01968), as long as a relevant primary diagnosis code is present.

Delivery and post-partum care services (CPT-4 codes 59400, 59409, 59410, 59430, 59510, 59514,

59515, 59610, 59612, 59614, 59618, 59620, 59622) Prenatal and postpartum services are not included in the maternity kick payment. These services are included in the rate cell corresponding to the person receiving the services. For global reimbursement CPT-4 codes such as 59400, 59510, 59610, and 59618, we allocated the total allowed and paid amounts to prenatal and delivery services using RBRVS ratios corresponding to the codes without prenatal care: 59410, 59515, 59614, and 59622 respectively. The prenatal care allocation is then assigned to the corresponding monthly rate cell. Neonatal Abstinence Syndrome Kick Payment Definition The neonatal abstinence syndrome (NAS) kick payment is provided for babies who have a diagnosis code of P96.1 (ICD10) or 779.5 (ICD9) in their birth month on an inpatient claim. The regular newborn kick payment is provided for all other babies.



STEP 2: APPLY ADJUSTMENTS TO THE BASE EXPERIENCE DATA TO PROJECT SFY 2019 MEDICAL COSTS In this step, we apply adjustment factors to reflect differences between the base period data and the projected SFY 2019 MCM program medical costs. We explain each adjustment factor in detail below. Appendices B1-B3 show adjusted and trended values for each rate cell along with the detailed adjustment factors by service category. IBNR Adjustment We developed completion factors (CFs) by eligibility category and major service category for claims incurred in SFY 2016 and SFY 2017. Since we now have runout through December 2017, we determined that the SFY 2016 data was complete. We used Milliman’s Claim Reserve Estimation Workbook (CREW) to calculate the completion factors shown in Table 7 below. CREW calculates incurred but not reported (IBNR) reserve estimates by blending two different estimation methods: the lag completion method and the projection method. The lag method reflects the historical average lag between the time a claim is incurred and the time it is paid. In order to measure this average lag, claims are separated by month of incurral and month of payment. Using this data, historical lag relationships are used to estimate ultimate incurred claims (i.e., total claims for a given incurral month after all claims are paid) for a specific incurral month based on cumulative paid claims for each month. The projection method develops estimates for incurred claims in recent incurral months by trending an average base period incurred cost per unit to the midpoint of the incurred month at an assumed annual trend rate, and applying an additional factor to account for the seasonality of claim costs and the differing number of working days between months. The base period is chosen by selecting a group (usually 12) of recent consecutive months for which the lag completion method provides reasonable results. The lag completion and projection methods are combined to produce the final incurred claim estimate. Final incurred claim estimates are calculated as a weighted average of these two methods. We applied a 1.05 underreporting adjustment to the SFY 2016 and SFY 2017 MCO encounter base experience data for CMHC services only. We developed the underreporting adjustment in order to correct for data reporting issues between the CMHCs and MCOs as we understand there is not an actual reduction in services provided by the CMHCs. Table 7 below shows the IBNR adjustment factors applied to the SFY 2017 experience data.


Incurred But Not Reported Claims Adjustment

Eligibility Category

Hospital Inpatient Services

Hospital Outpatient Services

Mental Health Center

Services Prescription

Drugs

Professional and Other Services

SFY 2017 Encounter Data Low Income Children and Adults 1.009 1.007 1.052 1.000 1.005 Foster Care / Adoption 1.009 1.007 1.052 1.000 1.005 Breast and Cervical Cancer Program 1.008 1.008 1.051 1.000 1.005 Severely Disabled Children 1.008 1.008 1.051 1.000 1.005




Incurred But Not Reported Claims Adjustment


Hospital Inpatient Services

Hospital Outpatient Services

Mental Health Center

Services Prescription

Drugs

Professional and Other Services

Elderly and Disabled Adults 1.008 1.008 1.051 1.000 1.005 Dual Eligibles 1.013 1.029 1.051 1.000 1.014 Newborn Kick Payment 1.005 1.001 1.050 1.000 1.008 Maternity Kick Payment 1.005 1.001 1.050 1.000 1.008 Nursing Facility Residents 1.000 1.000 1.050 1.000 1.007 Community Residents 1.000 1.008 1.050 1.000 1.005 Developmentally Disabled / ABD 1.000 1.003 1.051 1.000 1.003 SPMI / SMI / LU 1.006 1.003 1.051 1.000 1.004 SED 1.001 1.003 1.052 1.000 1.005 Reimbursement Adjustment We reviewed the MCO provider reimbursement levels in the base experience period as a percentage of Medicaid fees to better understand MCO provider contracts and payment levels. We determined that payment levels in the base experience period were relatively consistent with previous assumptions except for hospital inpatient children’s specialty services. We maintained historical reimbursement levels compared to Medicaid fees for all services except hospital inpatient children’s specialty services where we adjusted the reimbursement level to 115% of expected FFS reimbursement. This higher reimbursement rate reflects contracting difficulties between the MCOs and specialty facilities. Table 8 below shows the aggregate results from our analysis compared to previous reimbursement level assumptions.


MCO Reimbursement Levels

Service Category Observed SFY 2017

Reimbursement Level Previously Assumed

Reimbursement Level Hospital Inpatient – Children’s Specialty Services 159% 115% Hospital Inpatient – Other Services 102% 102% Hospital Outpatient Services 102% 102% Professional Services 102% 101% Federally Qualified Health Center Services 100% 100% Community Mental Health Center Services 100% 100%

We applied an adjustment factor to reflect recent changes in FFS provider reimbursement to both the FFS and encounter data. Our adjustment factors are based on a comparison of the Medicaid fees effective during the SFY 2016 and SFY 2017 base period to the most recent fee schedules provided by DHHS. We used the DRG rate table effective October 2014 through October 2017 in conjunction with admit distributions by rate cell to develop reimbursement adjustment factors. Tables 9 and 10 show a summary of the impact of the hospital inpatient pricing adjustment. On average, the impact is an increase of 1.4% for SFY 2016 FFS claims, a 1.8% increase for SFY 2016 encounter claims, and a 1.4% increase for SFY 2017 encounter claims with variation by rate cell based on the services used by the population in each rate cell.




Impact of Repricing for Hospital Inpatient Services Average Impact for All Rate Cells Combined

Benefit Category

SFY 2016 FFS Data

SFY 2016 Encounter Data

Medical 1.004 1.006 Surgical 1.002 1.007 Maternity Delivery 1.057 1.067 Maternity Non-Delivery 1.049 1.064 Newborn 1.040 1.041 Psychiatric 1.113 1.010 Alcohol and Drug Abuse 1.123 1.086 Other 1.000 1.000 Total1 1.014 1.018 Total with Adjustment to Children’s Specialty Services 1.044 0.989

1Excludes the impact of decreasing reimbursement for children’s specialty services to 115%.


Impact of Repricing for Hospital Inpatient Services Average Impact for All Rate Cells Combined

Benefit Category

SFY 2017 Encounter Data

Medical 1.008 Surgical 1.001 Maternity Delivery 1.046 Maternity Non-Delivery 1.080 Newborn 1.029 Psychiatric 1.008 Alcohol and Drug Abuse 1.056 Other 1.000 Total1 1.014 Total with Adjustment to Children’s Specialty Services 0.979

1Excludes the impact of decreasing reimbursement for children’s specialty services to 115%. We did not apply a specific reimbursement adjustment for hospital outpatient services since MCOs will continue to pay most outpatient services on a cost basis consistent with FFS reimbursement. We address increases to cost-based reimbursement in the trend development section of this report. We also address cost-based settlements, including enhanced payments to Boston Children’s Hospital, in the hospital outpatient cost settlement adjustment section of this report. The reimbursement adjustment factors for professional and other services are based on a comparison of the Medicaid fees effective during the base period to the most recent fee schedules as of February 28, 2018 and change logs as of May 8, 2018. We also incorporated known fee changes not included in the current fee schedules. For each CPT and HCPCS code, we compared the current FFS amount to the corresponding amount in the fee schedules effective on the date of service. We then summarized the data by rate cell and service category to obtain the adjustment factors.



We adjusted claims for Federally Qualified Health Centers (FQHCs) and Rural Health Clinics (RHCs) to reflect the most recent per encounter rate at each facility. The SFY 2018 FQHC rates are 1.2% higher than the SFY 2017 rates. We assume an increase of 0.8% from SFY 2018 to SFY 2019, with the exception of Manchester Community Health Center (MCHC). MCHC recently filed a request for rate change due to two separate changes in their scope of services. Following approval by DHHS, the per encounter rate was increased to $195.08 for SFY 2019. The impact of the change in per encounter rate for MCHC is reflected in the reimbursement adjustment factors. Table 11 shows a summary of the impact of the reimbursement change for professional and other services. On average, we increased SFY 2016 FFS and encounter claims by 4.6% and 2.0%, respectively. We increased the SFY 2017 encounter claims by 1.1%. There is additional variation by rate cell based on the services used by the population in each rate cell.


Impact of Repricing for Professional and Other Services Average Impact for All Rate Cells Combined

Benefit Category

SFY 2016 FFS Data

SFY 2016 Encounter

Data

SFY 2017 Encounter

Data Ambulatory Surgery Center 1.000 1.002 1.003 Office Visits 1.000 1.000 1.000 Preventive Medicine 1.030 1.028 1.015 Maternity 1.000 1.000 1.000 Certified Midwife 1.000 1.000 1.000 PT / OT / ST 1.000 1.000 1.000 Psychiatric and Substance Abuse 1.000 1.000 1.004 Radiology and Pathology 1.000 1.000 1.000 Home Health and Private Duty Nursing 1.111 1.059 1.000 Ambulance 1.000 1.000 1.000 Non-Emergency Transportation 1.000 1.000 1.000 Opioid Treatment Program 1.000 1.000 1.000 Federally Qualified and Rural Health Clinics 1.063 1.060 1.050 Adult Medical Day Care 1.000 1.000 1.000 Personal Care 1.011 1.009 1.000 Durable Medical Equipment 1.007 1.002 1.002 Other 1.018 1.023 1.016 Total 1.046 1.020 1.011

DHHS is temporarily increasing reimbursement rates by 8.5% for select services provided by CMHCs during SFY 2019. Please see Section IV of this report for more details on the related adjustment for the SFY 2019 MCM capitation rates. Medical Trend from SFY 2016 and SFY 2017 to SFY 2019 We developed trend rates from SFY 2016 and SFY 2017 to SFY 2019 by type of service using our experience with similar populations in other states and CMS projected trends. Table 12 below summarizes the medical trend rate assumptions by major service category.



Table 12 New Hampshire Department of Health and Human Services Annual Trends from SFY 2016 and SFY 2017 to SFY 2019

Service Category Utilization Trend Unit Cost Trend Hospital Inpatient 0.00% 0.64%1 Hospital Outpatient 2.00% 1.20% Professional 1.00% 0.00% Community Mental Health Center 1.00% 0.00% Other Services 1.00% 0.00% 1 Unit cost trend for hospital inpatient services is applied as a one-time allowance for the expected 0.85% increase in

DRG reimbursement on October 1, 2018 (not as an annual trend rate). Although hospital inpatient, professional, and other services are repriced using the October 2017 DRG rate table and the 2018 fee schedule, we also made a trend adjustment to account for expected changes in reimbursement levels in SFY 2019. For hospital inpatient services, we estimated the expected October 2018 DRG weight update to be an increase of 0.85% based on our review of historical DRG weights. We applied the 0.85% DRG weight increase as a 0.64% adjustment since it impacts only the last nine months of SFY 2019. For professional and other services, we assumed no fee schedule changes would be implemented during SFY 2019. DHHS does not anticipate making mid-year capitation rate changes if mid-year FFS reimbursement changes do not vary materially from our assumptions. Hospital outpatient reimbursement changes are tied to changes in each hospital’s operating cost. We developed the 1.2% annual trend for hospital outpatient services by reviewing the average annual change in the Bureau of Labor Statistics (BLS) Producer Price Index (PPI) for hospital services from CY 2015 to CY 2017 (Series ID PCU622---622---). The Hospital PPI is a measure of hospital revenue changes that can also be used as a proxy for operating cost changes because the national average operating margins for hospitals are relatively stable from year to year. Note that the utilization and unit cost trends in Table 12 exclude trends related to the opioid addiction treatment population, which are shown as a separate adjustment and are described later in this report. Prescription Drug Trend from SFY 2016 and SFY 2017 to SFY 2019 Pharmacy trend assumptions are based on a combination of historical New Hampshire Medicaid data analysis, Milliman research on utilization and cost trends, and publicly available trend reports and forecasts. Our prescription drug trend model uses the most recent 12 months of available MCM program data with sufficient run out (December 2016 – November 2017) as the base period for our projections. Given the constantly changing prescription drug market, it is critical to project trends using the most current available data. The final trends are calculated as the ratio of the average drug costs in the projection period (SFY 2019) compared to the average drug costs in the rate setting base period (SFY 2016 and SFY 2017). Trends were calculated for brand, generic, and specialty drugs, separately for utilization and unit cost. Projected values are estimated using the prescription drug base period data (December 2016 – November 2017) as a starting point and applying anticipated shifts and trends. Each component of pharmacy trend is documented below. Since hepatitis C, hemophilia and other high cost drugs (Carbaglu and Ravicti) are carved out of the MCM program for SFY 2019, we excluded these drugs from our prescription drug trend development. Appendix J contains a list of NDCs for the excluded drugs.



Brand Patent Loss:

When a brand drug loses patent, utilization shifts from the brand drug to new generic alternatives. In our analysis, we shifted utilization for brand drugs that recently lost patent or are expected to lose patent in the projection period. We included known patent expirations through the end of 2018 (later expirations were excluded due to the uncertainty of the timing of patent expirations further out in the future). Our utilization shift assumptions are based on Milliman research of how quickly historic brand utilization converts to generic in each month after a patent expires. Similarly, we used assumptions for what the cost of the new generic drug would be relative to the current brand drug price. Major brand drugs that have already lost or are expected to lose patent between the base period and the projection period include the following drugs:

Adcirca Byetta Lexiva Remicade Remodulin Rituxan Sensipar Treximet Viagra Viread Xolair

Cost per Script Trends:

Projected costs per script in December 2017 (the first month of the projection) are generally based on the average costs per script in the most recent three months of the experience data (September 2017 to November 2017), adjusted for any anomalies in the data. These costs are trended forward using separate cost trend assumptions for brand, generic, and specialty products, including class-specific trend assumptions for classes with demonstrably different trend patterns in recent months, based price history in New Hampshire claims experience data.

The cost per script trends are based on an analysis of historical average wholesale price (AWP) data. We mapped AWPs from Medi-Span by NDC and analyzed the annual trends over the past several quarters, using a fixed market basket of drugs from the MCM program’s pharmacy claims experience. We also used public industry trend reports, such as the “Express Scripts 2017 Drug Trend Report”, to validate these unit cost trends. Note that the overall average unit cost trend factor resulting from our trend analysis for certain rate cells and drug classes is above (or below) the targeted prospective unit cost trend used in our trend analysis to the extent that the September 2017 to November 2017 experience that we used as the starting point for the unit cost projections is above (or below) the SFY 2016 and SFY 2017 base period unit cost experience.

Brand Cost Trends

We analyzed AWP trends for the brand drugs used by MCM program members. Based on a combination of Milliman research, industry trend reports, such as the “Express Scripts 2017 Drug Trend Report”, and the historical AWP trends using MCM program data, we assumed a default brand annual unit cost trend of 8.0%. We varied trends from this default for several classes though, based on variations for classes with typically higher or lower than average trends. Table 13 shows the classes for which we used a unique trend value:




Annual Brand Unit Cost Trends for Specific Therapeutic Classes

Therapeutic Class

Annual Brand Unit Cost Trend

Acne Products 3.0% Anaphylaxis Therapy Agents 12.0% Anticonvulsants - Benzodiazepines 12.0% Antipsychotics - Misc. 18.0% Diagnostic Tests 3.0% Insulin - Long Acting 2.0% Insulin - Short / Intermediate Acting 12.0% Opioid Partial Agonists 6.0% Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 15.0% Combination Contraceptives - Oral 5.0% Sympathomimetics 5.0% Stimulants - Misc. 12.0% Antidementia Agents 15.0% Anticonvulsants - Misc. 12.0% Scabicides & Pediculicides 20.0%

Generic Cost Trends Generic drugs typically have only modest price increases. While generic trend increases were higher than usual during much of 2014 - 2016 due to ingredient shortages, changes to legislation, and consolidation of generic manufacturers resulting in reduced competition, this pattern has slowed, and generic trends have been returning to more typical levels in recent quarters. We expect this slowing of generic trends to continue in the near future. Based on a combination of Milliman research, industry trend reports, such as the “Express Scripts 2017 Drug Trend Report”, and the historical AWP trends using MCM program data, we assumed a default generic annual unit cost trend of 1.5%. Similar to brand unit cost trends, we varied trends from this default for several classes, based on variations in the data for classes with typically higher or lower than average trends. Table 14 shows the classes for which we used a unique trend value:


Annual Generic Unit Cost Trends for Specific Therapeutic Classes

Therapeutic Class Annual Generic Unit Cost Trend

Acne Products 3.0% HMG CoA Reductase Inhibitors 0.0% Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 0.0% Soluble Tumor Necrosis Factor Receptor Agents - Monoclonoal Antibodies 3.5% Stimulants - Misc. 10.0% Phenothiazines 8.0% Scabicides & Pediculicides 20.0%



Specialty Cost Trends

Specialty drugs continue to be a major contributor to overall pharmacy trends. There is an increase in overall average pharmacy costs due to an increased mix of specialty treatments - specialty drugs tend to be much higher cost than non-specialty medications, so as utilization of specialty products increases, the average price of all drugs increases. AWP trends for specialty drugs are also significant, and are currently expected to be somewhat higher than non-specialty brand cost trends.

Based on a combination of Milliman research, industry trend reports, such as the “Express Scripts 2017 Drug Trend Report”, and the historical AWP trends using New Hampshire data, we assumed a default specialty unit cost trend of 9.5%. While historical unit cost trends including high-cost pipeline drugs for the specialty category have been below 9.5%, this assumption includes an allowance for additional high-cost pipeline drugs above those reflected in the historical claims data used in the trend analysis. We varied unit cost trends from this default for several classes, based on variations in the data for classes with typically higher or lower than average trends. Table 15 shows the classes for which we used a unique trend value:

Table 15

New Hampshire Department of Health and Human Services Annual Specialty Unit Cost Trends for Specific Therapeutic Classes

Therapeutic Class Annual Specialty Unit Cost Trend

Cystic Fibrosis Agents 35.0% Soluble Tumor Necrosis Factor Receptor Agents / Anti-TNF-alpha - Monoclonoal Antibodies 17.0%

Changes in Utilization:

Utilization levels for each month in the projection period was based on the utilization level for the same month in our base period projected forward based on the utilization trend assigned to the therapeutic class. For example, December 2017 utilization was projected by trending December 2016 utilization using the applicable utilization trend assumptions, January 2018 utilization was projected by trending January 2017 utilization using the applicable utilization trend assumptions, and so on. This method accounts for seasonality differences in each month. Additionally, the most recent three to six months of the experience data were used to determine the appropriate brand / generic mix of utilization for each therapeutic class, adjusted for anomalies as needed. By using the most recent three to six months of data to set the brand / generic mix, the projection reflects the impact of the MCO management of the PDL.

Generally, we have observed very flat utilization trends among Medicaid populations. As such, we generally used 0.0% utilization trends for both brands and generics. There are a few specialty classes, however, that have been growing significantly and are expected to grow in the future based on our analysis. Therefore, we applied non-zero utilization trends to a few specialty classes, as seen in Table 16 below:




Specialty Utilization Trends for Specific Therapeutic Classes Therapeutic Class Specialty Trend Antineoplastic Enzyme Inhibitors 10.0% Antiretrovirals -5.0% Growth Hormones 5.0% Hematopoietic Growth Factors 5.0% Multiple Sclerosis Agents 3.0% Soluble Tumor Necrosis Factor Receptor Agents / Anti-TNF-alpha - Monoclonoal Antibodies 15.0% Pulmonary Hypertension – Endothelin Receptor Agonists 5.0%

Note that while flat or positive prospective utilization trends are used in our trend analysis in nearly all cases, the overall utilization trend factor resulting from our trend analysis for certain rate cells and drug classes is above (or below) the targeted prospective trend to the extent that the December 2016 to November 2017 utilization is above (or below) the SFY 2016 and SFY 2017 base data utilization.

Summary of Drug Trends by Eligibility Category: Tables 17 and 18 show a summary of the drugs trends by eligibility category for SFY 2016 and SFY 2017, respectively.


Annual Prescription Drug Trends from SFY 2016 to SFY 2019

Eligibility Category Utilization Trend Unit Cost Trend

PMPM Generic Brand Specialty Generic Brand Specialty Low Income Children -1.8% -7.8% 0.0% 2.1% 0.7% 12.8% 1.8% Low Income Adults -2.1% 0.1% -1.2% 0.2% 3.4% 22.1% 7.3% Foster Care / Adoption 1.3% -8.4% -7.3% -5.3% -3.4% 2.1% -7.0% Severely Disabled Children 0.8% -6.0% -2.6% -1.9% -7.5% -23.1% -19.0% Elderly and Disabled Adults -2.0% -3.1% -2.0% -2.0% 2.6% 12.6% 2.9% Dual Eligibles 2.3% -1.2% 25.6% -0.5% 3.2% -66.5% -1.6% Nursing Facility Residents -4.1% -11.3% -7.0% 6.9% 3.8% 21.4% 3.0% Community Residents -2.2% -4.3% -3.2% -0.5% 4.7% 12.8% 3.5% Developmentally Disabled / Acquired Brain Disorder -0.4% -8.6% -4.3% -3.2% 7.6% 9.3% -0.8%

SPMI / SMI / Low Utilizers -0.9% -3.6% 0.7% -2.6% 4.0% 9.8% 2.7% Serious Emotionally Disturbed Child -1.8% -11.0% -3.1% -3.5% -0.1% 8.3% -5.5%




Annual Prescription Drug Trends from SFY 2017 to SFY 2019

Eligibility Category Utilization Trend Unit Cost Trend

PMPM Generic Brand Specialty Generic Brand Specialty Low Income Children -1.3% -3.4% 0.3% 3.9% -1.1% 10.9% 3.4% Low Income Adults -1.4% 0.5% -0.9% 5.2% 2.8% 22.5% 9.2% Foster Care / Adoption -2.0% -2.1% 0.8% 0.5% -2.3% -15.4% -6.8% Severely Disabled Children 0.1% -5.8% 0.5% 1.9% 3.8% -18.3% -11.0% Elderly and Disabled Adults -1.6% -2.2% -1.4% 6.3% 3.2% 15.9% 6.8% Dual Eligibles 0.7% -2.0% 2.7% -1.1% 6.3% 2.0% 0.6% Nursing Facility Residents -2.1% -10.2% -2.2% 6.3% 6.5% 10.7% 3.3% Community Residents -1.1% -1.8% -2.2% 5.2% -3.2% 9.7% 1.6% Developmentally Disabled / Acquired Brain Disorder -0.2% -4.2% -1.0% 2.0% 7.8% 7.9% 3.7%

SPMI / SMI / Low Utilizers -0.8% -4.3% -1.2% 5.8% 2.1% 8.4% 2.6% Serious Emotionally Disturbed Child -1.4% -8.3% -0.3% 1.6% -0.2% 4.4% -2.2%

Aggregate pharmacy trends are lower than the trends included in in recent rate development years. This largely results from utilization levels that decreased 4.1% between SFY 2016 and SFY 2017 with these negative trends continuing through November 2017. The persistent negative trends in the recent data partially explains the current projected pharmacy trend levels since our projections start from a lower point than what is included in the base experience period underlying the capitation rates. It is also important to note that the shift to generic drugs further reduces the projected PMPM drug trends by 1.0%. Comparison to CMS Office of the Actuary Trends We did not rely on a strict trend calculation based on observed MCM program encounter data trends when developing trend assumptions for the SFY 2019 rate development. Instead, we developed the trend assumptions based on forward-looking considerations as described above. The SFY 2019 capitation rates are based on a blend of SFY 2016 and SFY 2017 base data. We also compared our overall trend assumptions to the national Medicaid benefit expenditures per enrollee estimates included in Table 19 of the 2016 Actuarial Report on the Financial Outlook for Medicaid published by the CMS Office of the Actuary. Table 19 summarizes federal fiscal year (FFY) 2016 to FFY 2019 expenditure projections and trends for the Child, Adult, Aged, and Disabled eligibility categories. This time period is generally consistent with the base data period and rate period used to calculate the SFY 2019 MCM program capitation rates. Note that the Aged and Disabled eligibility categories include a significant amount of costs related to long term services and supports (LTSS), therefore, the services included may not be as representative compared to current MCM covered services that exclude LTSS.



Table 19 Summary of National Medicaid Benefit Expenditures per Enrollee Estimates Table 19 of the 2016 Actuarial Report on the Financial Outlook for Medicaid

Published by the CMS Office of the Actuary

Federal Fiscal Year Non-Disabled

Children Non-Disabled

Adults Aged1 Disabled1 2016 $3,458 $5,215 $14,451 $20,082 2019 $3,939 $6,067 $16,294 $22,899

Average Annual Trend 4.4% 5.2% 4.1% 4.5% 1 Note that the Aged and Disabled eligibility categories include a significant amount of costs related to long term

services and supports (LTSS), therefore, the services included may not be as representative compared to current MCM covered services that exclude LTSS.

The combined annual trend rate applied from the SFY 2016 and SFY 2017 base period to the SFY 2019 rate period for all rate cells and services was roughly 3.0%. This trend includes utilization and unit cost trend across all services and also includes the impact of the repricing adjustments to hospital inpatient and professional services. The trend projections included in the report by CMS’ Office of the Actuary have not been updated since 2016 and are based on historical data through FFY 2015. Given the significant decrease in prescription drug trends in recent years, we believe that at a high level, the overall average annual trend rate we applied is generally consistent with CMS projections. MCO Reimbursement Adjustment We adjusted the base FFS data to reflect typical contractual arrangements between MCOs and providers. Based on our review of the encounter data, MCOs contract with providers at a rate greater than the FFS reimbursement for medical services to establish networks that provide adequate access to medical services for the Medicaid enrollees. However, MCO reimbursement levels generally appear reasonable and are relatively consistent with assumptions used in previous capitation rate development cycles, except for hospital inpatient children specialty services. Table 20 shows the MCO reimbursement adjustment by type of service.


MCO Reimbursement Adjustment Applied to July 2015 to January 2016 FFS Data Only

Service Category Reimbursement Adjustment (% FFS) Hospital Inpatient – Children’s Specialty Services 115% Hospital Inpatient – Other Services 102% Hospital Outpatient Services 102% Professional Services 101% Federally Qualified Health Center Services 100% Mental Health Center 100% Prescription Drugs 100% Other Services 101%



Managed Care Savings Adjustment The managed care savings adjustment reflects the medical cost savings generated through MCO care management activities. We developed the SFY 2019 managed care savings adjustments in two components. The first component puts the July 2015 to January 2016 FFS data for the opt-out rate cells on the same basis as the MCO encounter data. The component one managed care factors are shown in Table 21 and are consistent with the adjustments made in prior years. We initially developed this component of managed care savings adjustments based on our analysis of historical New Hampshire Medicaid utilization rates, medical cost savings achieved by similar programs in other states, and other information.


Medicaid Managed Care Savings Adjustment - Component One Service Category Applied to FFS Data Only Hospital Inpatient Services 17.5% Hospital Outpatient Services 17.5% Professional and Other State Plan Services 7.5% Community Mental Health Center 0.0% Prescription Drugs 10.0% (5.0% for behavioral health population)

The second component of the managed care savings adjustment reflects targeted initiatives for the MCM program in SFY 2019. Consistent with managed care adjustments in the SFY 2018 capitation rates, DHHS identified two priorities for MCO medical cost reductions in SFY 2019 compared to the SFY 2016 and SFY 2017 base periods:

1. Hospital unit cost reductions: We observed that, on average, the MCOs contract with hospitals at approximately 102% of the New Hampshire Medicaid fee schedule. We compared the observed hospital contracting level of each MCO and concluded it was attainable for the MCOs to reduce the average hospital contracting factor by 0.5%. Therefore, we applied a 0.5% managed care savings factor to all hospital inpatient and hospital outpatient costs in the MCO encounter data and the FFS data for the opt-out rate cells.

2. Medical cost savings from the integration of acute care and behavioral health care: The coordination of acute care and behavioral health care management has been fostered by the capitated arrangements between the CMHCs and the MCOs that were implemented in SFY 2017, the expansion of service capacity through the Community Mental Health Agreement, the expansion of SUD services through the Substance Use Disorder Treatment and Recovery Access 1115 Demonstration Waiver, and the delivery system reform activities that are part of New Hampshire’s Building Capacity for Transformation 1115 waiver. The expected impact of behavioral health integration is described in case studies cited in the Building Capacity for Transformation 1115 waiver application that show significant cost savings related to the integration of acute care and behavioral health care: “A variety of approaches to integrated medical-behavioral healthcare have been the focus of

cost effectiveness research over the past three decades, with most studies finding that integrated care can lead to reductions in total healthcare costs. Typical cost savings estimates range from 5% to 10% of total healthcare costs over a two to four year period for patients receiving collaborative care, although the most robust evidence is in the care of depression in older adults.”



The SFY 2019 capitation rates include the same level of targeted savings included in the SFY 2018 capitation rates. The following savings targets are applied to the MCO encounter data and the FFS data for the opt-out rate cells: Behavioral health population: total medical cost reduction of 2%. We do not expect savings to

be generated from CMHC services. Since CMHC services are approximately 50% of the total cost for the behavioral health population, we applied the overall 2% cost savings estimate as a 4% reduction to non-CMHC services.

All other populations: total medical cost reduction of 0.5%, applied only to non-CMHC services. The total impact of the managed care savings assumptions is a reduction of 0.9% to total medical costs. Pharmacy Rebate Adjustment The pharmacy rebate adjustment reflects a cost adjustment to prescription drugs to account for rebates the MCOs collect. The SFY 2016 and SFY 2017 encounter data does not reflect rebates the MCOs will collect outside of the claims payment system. As such, we include a reduction of 3.25% to estimate the amount of gross drug costs that will be collected in post-sale rebates. We based this estimate on a review of recent MCO prescription drug rebates after the MCOs started managing the PDL as reported in quarterly financial data. Private Duty Nursing Adjustments Effective April 1, 2016, DHHS implemented a reimbursement increase for private duty nursing (PDN) providers to meet the higher demand for nursing support for nights and weekends, as well as be competitive in the New Hampshire nursing marketplace. The Department’s intent was to improve nursing salary rates, with rate reimbursement increases depending on nursing level and time of day / acuity, for skilled nurses during the day, night, and weekends, as well as afford a competitive level of compensation for intensive nursing skills for members requiring acute care in the home. The reimbursement increase ranges from 25% for day services and 39% - 46% for nights, weekends and intensive nursing. We reviewed FFS claims and encounter data for SFY 2016 by rate cell and identified RNs and LPNs using the S9123 and S9124 CPT codes, respectively, as instructed by DHHS. We determined the MCM capitation rate impact using the proportion of PDN services for each rate cell. We included a 5% utilization adjustment for the expected increase in service hours provided. The impact of the reimbursement change is included in the reimbursement adjustment factors while the PDN specific adjustment includes the utilization component only. We applied the adjustment to the first nine months of the SFY 2016 data because the PDN changes were made on April 1, 2016. Non-Emergency Medical Transportation Claims Adjustments We adjusted historical non-emergency medical transportation (NEMT) services in the encounter data to reflect utilization increases beyond expected levels. Recent NEMT costs have increased significantly compared to the SFY 2016 and SFY 2017 base period. We developed the adjustment by reviewing more recent MCO cost experience for the non-opioid addiction treatment population and determined the impact on the base period experience. The NEMT cost adjustment related to the opioid addiction treatment population is discussed in the “Opioid Addiction Treatment Trend Adjustment” section later in this report. Table 22 shows the adjustments factors by eligibility category.




Medicaid Managed Care Program Non-Emergency Medical Transportation Adjustment

Eligibility Groupings SFY 2016 SFY 2017 Low Income Children and Adult, Foster Care 1.043 1.162 Disabled Children and Adults 1.415 1.316 Dual Eligibles 0.875 0.746 Nursing Facility Residents 0.450 0.353 Community Residents 1.122 0.915 Developmentally Disabled Children and Adults 5.888 5.280 Behavioral Health Populations 1.525 1.282

Cost Settlement Adjustment We included an allocation to reflect retroactive payments made to Boston Children’s Hospital under its FFS contract with DHHS starting April 2012. We added $640,000 to the hospital inpatient FFS data in SFY 2016 to account for retroactive inpatient facility payments for the opt-out population enrolled in FFS. We also added $435,000 to the hospital outpatient FFS data for SFY 2016 to account for retroactive payments related to outpatient, ancillary and professional services incurred 30 days prior to a related admission and up to 90 days post admission follow-up at Boston Children’s Hospital for the opt-out population enrolled in FFS. We allocated these additional expenses by rate cell based on actual hospital inpatient and outpatient expenditures for services incurred at Boston Children’s Hospital. High Cost Patient Stop-Loss Adjustment Effective September 1, 2015, DHHS implemented a stop-loss arrangement for high cost patients where DHHS will share 50% of the cost above $500,000 for members that have total expenses valued at Medicaid fee levels above that threshold. The resulting adjustment factors reduce the base experience data by about 0.2% to reflect the MCO liability under the stop-loss agreement. This program helps to reduce the variability of MCO financial results due to large cases. To evaluate the impact of this arrangement, we did not use claims re-priced at Medicaid fee levels since the majority of expenses leading to those large cases were for prescribed medicine.



STEP 3: BLEND THE PROJECTED SFY 2016 AND SFY 2017 DATA In this step, we blend the projected SFY 2019 medical cost using the SFY 2016 and SFY 2017 FFS and encounter base experience. We blend the data for each rate cell based on actual membership in the base experience period. Blending the two base year projections increases the credibility of the capitation rates, particularly for rate cells with low enrollment. Appendices C1 through C3 show the blending step for each rate cell. Opioid Addiction Treatment Trend Adjustment In Appendices C1 through C3, we also made a trend adjustment to the base experience data underlying the MCM capitation rates to account for the estimated increase in both prevalence and cost of treatment for the opioid addiction treatment population. The proposed adjustments result in increased opioid addiction funding of roughly $7.3 million in the MCM program in SFY 2019 compared to using the base experience data without any adjustment beyond standard trends. The base experience data underlying the SFY 2019 MCM capitation rates includes an average annual amount of about $15.0 million in SFY 2016 and SFY 2017 for opioid related addiction treatment services, which brings the total funding to $22.3M for the SFY 2019 contract period, before application of the normal utilization and cost trends. We believe the proposed adjustment factors properly address the funding of opioid addiction treatment in the SFY 2019 capitation rates based on available information. Table 23 below shows the adjustment factors for the rate cells most impacted by the adjustments.


Medicaid Care Management Program Total Opioid Addiction Treatment Cost Trend Adjustment

Rate Cell Cohort SFY 2016 SFY 2017 Low Income Adults 1.093 1.063 Elderly and Disabled Adults 1.037 1.023 Dual Eligibles 1.049 1.032 Severe / Persistent Mental Illness – Medicaid Only 1.014 1.008 Severe Mental Illness – Medicaid Only 1.067 1.037 Severe / Persistent Mental Illness – Duals 1.012 1.010 Severe Mental Illness – Duals 1.086 1.036 All Other 0.999 1.000



IV. FINAL CAPITATION RATE ADJUSTMENTS This section of the report describes the final adjustments to calculate the New Hampshire MCM program capitation rates from the projected SFY 2019 medical costs developed in Section III of this report. CALCULATE FINAL PROJECTED MEDICAL COSTS In this step, we use PMPM add-on adjustments for benefits not included in the base experience data. These benefits include:

Expanded mental health services under the Community Mental Health Agreement, Smoking cessation for pregnant women, IMD SUD services for adolescents, Temporary CMHC fee schedule increase, Gender dysphoria surgery benefit, Applied behavior analysis services, Facility specific FQHC adjustments, and Behavioral Health Crisis Treatment Center

Appendix D shows the details of our calculations. Expanded Mental Health Services DHHS is continuing its expansion of mental health service capacity consistent with the Community Mental Health Agreement (CMHA). New Hampshire’s SFY 2019 Medicaid budget includes approximately $18.0 million for additional Medicaid-funded services related to mobile crisis teams, crisis apartments, adult ACT teams, and supported employment. The SFY 2019 MCO capitation rates include a $12.4 million funding allowance to incorporate the expanded services expected to be delivered to the MCM population during the contract period. The SFY 2019 capitation rate funding is slightly lower than the amount included in the SFY 2018 capitation rates since the estimated managed care spend is spread across all managed care programs. The CMHA services are intended for all Medicaid beneficiaries in the adult behavioral health population (i.e., people identified as being in the Severe / Persistent Mental Illness, Serious Mental Illness, and Low Utilizer population). Accounting for the implementation of mandatory MCM enrollment under the 1915(b) waiver, approximately 25.6% of the CMHC expenditures for the adult behavioral health population will remain in the FFS program because they are not eligible to enroll in the MCM program due to retroactive eligibility, spenddown status, or Veteran’s Administration eligibility. Therefore, we allocated 74.4% of the $18.0 million in CMHA funding ($13.4 million) to the managed care populations (MCM and NHHPP). We developed the PMPM add-on by rate cell using the CMHC expenditures to allocate the CMHA funding. Note that some funding is allocated to members in the waiver population rate cells because there are some SPMI, SMI, and low utilizer members in the waiver rate cells. Appendix H shows the calculation of the PMPM add-on for expanded services under the CMHA. Smoking Cessation Adjustment The maternity kick payment includes a smoking cessation counseling program for pregnant women. DHHS estimated the annual cost of the program at about $135 per participant. We assumed that about 5% of pregnant women reportedly smoke and use the program based on a review of the encounter data and



discussions with the MCOs. As such, we included a $6.75 ($135 * 5%) per case add-on in the maternity kick payment. SUD IMD Services for Adolescents Consistent with the Substance Use Disorder Treatment and Recovery Access 1115 Demonstration Waiver, we included an allowance for substance use disorder (SUD) services provided in an institution for mental disease (IMD) for adolescents. Through this waiver application, DHHS can now expand the exception to the IMD exclusion in 42 CFR 441.11(c)(5) to the provider type Comprehensive SUD Treatment, as described in He-W 513.02 (c) to allow New Hampshire to claim federal financial participation (FFP) for individuals under 21 receiving residential substance use disorder treatment in these facilities for long as is medically necessary. The newly constructed Sununu Youth Services Center scheduled to open August 15, 2018 will have 36 beds, of which 75%, or 27 beds, are expected be occupied by Medicaid adolescent patients. Of the 36 beds, 16 are set to be operational on August 15, 2018, with the remaining 20 beds opening upon Federal Waiver approval. We assumed that the waiver would be approved prior to August 15, 2018 for all 36 beds to be available on implementation day. The allowance is based on per diem rates for low and medium intensity adolescent behavioral health; short-term residential of $128 and $170, respectively and an estimated average treatment length of 60 days. We also assumed that a member does not receive other services outside of the Sununu Youth Services Center while residing in the Sununu Youth Services Center. Temporary CMHC Fee Schedule Increase DHHS is temporarily increasing reimbursement rates by 8.5% for select services provided by CMHCs during SFY 2019 through a $3 million general fund investment. This investment will increase total CMHC revenue by approximately $5.6 million when matched with Federal funds across all Medicaid population and programs. The fee schedule increase applies to following twelve codes when the ‘HW’ modifier is present:

T1016 - Case management H2019 - Therapeutic behavioral services, per 15 minutes H2015 - Comprehensive community support services, per 15 minutes H2020 - Therapeutic behavioral services, per diem 90847 - Family psychotherapy (conjoint psychotherapy) (with patient present) H2023 - Supported employment, per 15 minutes T1027 - Family training and counseling for child development, per 15 minutes H2018 - Psychosocial rehabilitation services, per diem S9485 - Crisis intervention mental health services, per diem 90846 - Family psychotherapy (without the patient present) H0034 - Medication training and support, per 15 minutes 90832 - Psychotherapy, 30 minutes with patient and / or family member

These codes, when paired with the ‘HW’ modifier, accounted for over 80% of all CMHC payments during SFY 2016 and SFY 2017.



Implementation of Gender Dysphoria Surgery Benefit Effective July 1, 2017, DHHS implemented a gender dysphoria surgery benefit that covers male to female and female to male gender reassignment surgery. DHHS already covered psychotherapy and hormone treatment. We developed the expected cost of the gender dysphoria benefit using an estimated surgery cost of $50,000. We identified individuals with a gender dysphoria diagnosis in the MCO encounter data and assumed 10% would proceed with the surgery during SFY 2019. However, we assumed that individuals in a behavioral health population rate cell would not be candidates for surgery based on discussions with DHHS. We also assumed that cases for children aged 18 or younger would be reviewed on a case-by-case basis and therefore assumed 5% of these identified individuals would proceed with the surgery during SFY 2019. Based on the assumptions listed above, we estimate the cost of the gender dysphoria surgery benefit is $0.17 PMPM. Applied Behavior Analysis Effective July 1, 2018, Applied Behavior Analysis (ABA) will be an at-risk service for the MCOs participating in the MCM program. ABA services aim to produce observable changes in behavior for autistic children. ABA services have been covered under the New Hampshire Medicaid program and paid on a fee-for-service basis. We developed projected PMPM costs using available FFS data for members enrolled in the MCM program. We estimated the cost of those services to be $2.29 PMPM. Facility Specific FQHC Adjustments As of April 1, 2018, White Mountain Community Center is classified as a Federally Qualified Health Center Look-Alike (LAL) with a per encounter rate of $152.87 for SFY 2019. We estimated the impact of the change in classification by repricing all encounters at this facility at the per encounter rate. We only repriced services subject to the per encounter rate payment as defined in the FQHC provider manual, Volume II dated January 1, 2018. We estimate the impact of this change to be $0.09 PMPM. Behavioral Health Crisis Treatment Center On November 1, 2018, DHHS is implementing a Behavioral Health Crisis Treatment Center to serve any individuals in need of acute psychiatric treatment. The Behavioral Health Crisis Treatment Center is expected to provide services to adults ranging from crisis intervention, individual and group psychotherapy, and psychoeducational services. We used information provided by DHHS to estimate the cost of these services to the MCM population to be $206,667 or $0.14 PMPM. We allocated these costs by rate cell based on each rate cell’s use of CMHC services since the services will be analogous to services currently provided by CMHCs.



CALCULATE FINAL CAPITATION RATES BY RATE CELL In this step, we apply adjustment factors to reflect third party l iability recoveries, an allowance for MCO administration / margin, and an allowance for state premium tax. Appendix E shows the details of our calculations. Third Party Liability Recoveries and Other Transactional Adjustment MCOs are expected to pursue and collect third party liability (TPL) recoveries from other payers. DHHS provided a summary of actual DHHS recoveries and other transactional adjustments that are not already captured in the MMIS claims payment system for the FFS population and, therefore, are also not reflected in Appendix A1. The recoveries reflect both state and federal dollars. We used the information provided by DHHS to develop an appropriate adjustment factor for the FFS portion of the data underlying the SFY 2019 capitation rates. The aggregate adjustment factor for TPL and other transactional adjustments is 0.9994. MCO Administration / Margin Allowance Table 24 shows the MCO administration / margin allowance by eligibility category as a percentage of capitation revenue prior to the CMHC directed payment and the premium tax allowance. The total administration / margin allowance was set based on managed care industry experience and national MCO administrative cost data.




MCO Administration / Margin Allowance as a Percent of Revenue Rate Cell

MCO Administration

Allowance

Risk / Profit

Margin

Total Allowance

Base Capitation Rates Low Income Children and Adults 9.8% 1.5% 11.3% Foster Care / Adoption 9.8% 1.5% 11.3% Breast and Cervical Cancer Program 7.5% 1.5% 9.0% Severely Disabled Children 7.5% 1.5% 9.0% Elderly and Disabled Adults 7.5% 1.5% 9.0% Dual Eligibles 6.0% 1.5% 7.5% Newborn, NAS and Maternity Kick Payments 3.8% 1.5% 5.3%

NF Residents and Waiver Populations Nursing Facility Residents – Medicaid Only 7.5% 1.5% 9.0% Nursing Facility Residents – Dual Eligibles 6.0% 1.5% 7.5% Community Resident – Medicaid Only 7.5% 1.5% 9.0% Community Resident – Dual Eligibles 6.0% 1.5% 7.5% Developmentally Disabled – Medicaid Only 7.5% 1.5% 9.0% Developmentally Disabled – Dual Eligibles 6.0% 1.5% 7.5% Developmentally Disabled and In-Home Supports Children 7.5% 1.5% 9.0%

Acquired Brain Disorder – Medicaid Only 7.5% 1.5% 9.0% Acquired Brain Disorder – Dual Eligibles 6.0% 1.5% 7.5%

Behavioral Health Population SPMI – Medicaid Only 7.5% 1.5% 9.0% SPMI – Dual Eligibles 6.0% 1.5% 7.5% SMI – Medicaid Only 7.5% 1.5% 9.0% SMI – Dual Eligibles 6.0% 1.5% 7.5% Low Utilizers – Medicaid Only 7.5% 1.5% 9.0% Low Utilizers – Dual Eligibles 6.0% 1.5% 7.5% SED 7.5% 1.5% 9.0%

The composite MCO administration / margin allowance is $34.73 PMPM for the MCO-eligible population, which represents 9.5% of MCO revenue prior to the CMHC directed payment and the premium tax allowance. The administration / margin allowance provides for an 8.0% load for administrative expenses ($29.24 PMPM) and 1.5% for profit and risk margin ($5.48 PMPM). We used Milliman’s Medicaid risk-based managed care: Analysis of administrative costs for 20161 Research Report to benchmark the non-benefit cost allowance included in the SFY 2019 MCM capitation rates. We compared the SFY 2019 MCM administrative allowance to administrative costs reported by Medicaid MCOs in their 2016 financial statements, excluding amounts for taxes and fees.

1 http://us.milliman.com/insight/2017/Medicaid-risk-based-managed-care-Analysis-of-administrative-costs-for-2016/



The average PMPM load for administrative expenses across the MCM and New Hampshire Health Protection Program (NHHPP) programs is $31.20 PMPM. This average administrative load falls between the 25th and 50th percentile of the administrative costs reported by all MCOs after accounting for a 2% annual trend in administrative costs between calendar year 2016 and SFY 2019, and is at the 50th percentile for MCOs with revenue between $290 and $425 PMPM. CMHC Directed Payment The SFY 2019 MCM and NHHPP capitation rates include a directed payment of $5 million to the CMHCs across all programs and populations (MCM and NHHPP), pending approval by CMS. MCOs are required to pay these amounts directly to CMHCs according to criteria approved by CMS. The CMHC directed payment replaces the CMHC workforce expansion utilization adjustment that was included in the SFY 2017 and SFY 2018 MCM program capitation rates. The directed payment is targeted to all Medicaid beneficiaries in the behavioral health population (members identified as SPMI, SMI, low utilizer, and SED children). We developed the PMPM directed payment by rate cell using the CMHC expenditures to allocate the total directed payment amount. Since these amounts are to be paid directly to the providers by the MCOs, we did not include an additional allowance for administrative expense or risk margin. Premium Tax Allowance The capitation rates include an allowance for the 2.0% premium tax collected by the New Hampshire Insurance Department.



V. SERVICE CATEGORY ASSIGNMENT This section of the report provides information about the service category assignment used to create the cost models included in the New Hampshire MCM program capitation rate development. This information can be used by participating MCOs to monitor their experience in a format and detail similar to the rate development process. To prepare the attached cost models, we grouped claims into service categories. The service category assignment described below does not account for excluded or limited services. The next few paragraphs detail how the claim level detail is assigned to the service categories shown in Appendices A and B. HOSPITAL INPATIENT Hospital inpatient services are those items and services, provided under the direction of a physician, furnished to a patient who is admitted to a general acute care or psychiatric medical facility for facility and professional services on a continuous basis that is expected to last for a period greater than 24 hours. An admission occurs when the Severity of Illness / Intensity of Services criteria set forth by the review contractor and approved by DHHS is met. Among other services, hospital inpatient services encompass a full range of necessary diagnostic, therapeutic care including surgical, medical, general nursing, radiological, and rehabilitative services in emergency or non-emergency conditions. Additional hospital inpatient services would include miscellaneous hospital services, medical supplies, and equipment. The hospital inpatient claims are assigned a service category based on Diagnostic Related Group (DRG) codes. Milliman’s algorithm classifies hospital inpatient claims using the following groupings of CMS v24 DRG codes.


Hospital Inpatient Service Groupings by DRG Code Service Category Diagnosis Related Group

Medical

'052'-'103','121'-'125','146'-'159','175'-'208','280'-'316','368'-'395','432'-'446','533'-'566','592'-'607','637'-'645','682'-'700','722'-'730','754'-'761','789'-'794','808'-'816','834'-'849','862'-'872','913'-'923','933'-'935','945'-'951','963'-'965','974'-'977'

Surgical

'001'-'042','113'-'117','129'-'139','163'-'168','215'-'265','326'-'358','405'-'425','453'-'517','573'-'585','614'-'630','652'-'675','707'-'718','734'-'750','799'-'804','820'-'830','853'-'858','876'-'876','901'-'909','927'-'929','939'-'941','955'-'959','969'-'970','981'-'989'

Maternity Delivery '765'-'768', '774'-'775' Maternity Non-Delivery '769'-'770', '776'-'782' Newborn '795' Psychiatric '880'-'887' Alcohol and Drug Abuse '894'-'897' Other '998'-'999'



HOSPITAL OUTPATIENT Hospital outpatient services are defined as those preventive, diagnostic, therapeutic, rehabilitative, surgical, and emergency services received by a patient through an outpatient / ambulatory care facility for the treatment of a disease or injury for a period of time generally not exceeding 24 hours. Outpatient / ambulatory care facilities include hospital outpatient departments, diagnostic / treatment centers, ambulatory surgical centers, emergency rooms, end stage renal disease (ESRD) clinics, and outpatient pediatric AIDS clinics (OPAC). Costs include facility charges only and do not include professional charges unless performed by staff of the facility and billed on a UB-92 (hospital) claims form. All facility-billed items not part of an inpatient admission are considered hospital outpatient services. The hospital outpatient claims are assigned a service category based on revenue codes. Milliman’s algorithm classifies hospital outpatient claims using the following groupings of revenue codes.

Table 26 New Hampshire Department of Health and Human Services Hospital Outpatient Service Groupings by Revenue Code

Service Category Revenue Code Emergency Room '0450'-'0459' Surgery '0360'-'0369','0481','0490'-'0499','0750'-'0759','0790'-'0799'

Radiology '0320'-'0330','0333','0339'-'0349','0350'-'0359','0400'-'0403','0404','0409','0610'-'0619'

Pathology / Lab '0300'-'0319','0923','0925' Pharmacy '0250'-'0269','0331'-'0332','0335','0630'-'0637' Cardiovascular ‘0480','0482'-'0489','0730'-'0739' PT / OT / ST '0420'-'0449','0470'-'0479','0530'-'0539','0930'-'0932','0951'-'0952' Psychiatric '0513','0900'-'0905','0907'-'0919' Alcohol and Drug Abuse '0906', '0944'-'0945'

Other

'0001','0220'-'0249','0270'-'0279','0280'-'0289','0290'-'0299','0370'-'0379','0380'-'0399','0410'-'0419','0460'-'0469','0500'-'0509','0510'-'0512','0514'-'0521','0523','0526','0528','0529','0550'-'0569','0600'-'0609','0621'-'0624','0650','0655'-'0659','0670'-'0729','0740'-'0749','0760'-'0769','0770'-'0789','0800'-'0809','0810'-'0819','0820'-'0859','0860'-'0861','0880'-'0889','0920'-'0922','0924','0929','0940'-'0943','0946'-'0947','0948','0949','0990'-'0999','2100'-'3109'

PROFESSIONAL Professional services are assigned to a service category using a condensed version of Milliman’s Health Cost Guidelines (HCGs) grouping logic and other categories defined by DHHS. Professional services include the full range of preventive care services, primary care medical services, and physician specialty services. All services must be medically necessary and appropriate for the treatment of a specific diagnosis, as needed for the prevention, diagnostic, therapeutic care, and treatment of the specific condition. Physician services are performed at physician’s offices, patients’ homes, clinics, and skilled nursing facilities. Technical services performed in a physician’s office are considered part of the professional services delivered in an ambulatory setting unless designated as a separate service.



COMMUNITY MENTAL HEALTH CENTER Community Mental Health Center services are split into detailed service categories in order to provide more comprehensive medical cost information for the populations eligible for enhanced mental health services through the CMHCs. We reviewed the CMHC expenditures for those eligible for enhanced mental health services and developed the following service categories with the help of DHHS staff.


Community Mental Health Center Service Groupings by CPT Code Service Category CPT Code Case Management T1016 Long Term Support Service H0034, H2011, H2015, H2019, H2020, T1027 Partial Hospital H2001, H2018

Psychotherapy 90875, 90801, 90804, 90806, 90808, 90816, 90818, 90821, 90832, 90833, 90834, 90836, 90837, 90839, 90840, 90846, 90847, 90853

Evidence Based Practice H2027 Medication Management 90805, 90807, 90809, 90817, 90819, 90862, H2010, M0064, T1001 Emergency Service 24/7 S9484 APRTP S9485 Supported Employment H2023 Harbor Homes Provider NPI = 1699705079

PHARMACY The pharmacy category includes pharmaceuticals as ordered by licensed prescribers and obtained at an outpatient pharmacy. Prescription drugs are identified by the presence of a National Drug Code (NDC) in the claims file. We used Medi-Span information to separate prescription drug expenditures into generic, single source brand, multi-source brand, specialty, and other scripts. We used a definition of specialty drugs consistent with Milliman’s HCGs. OTHER The other service category includes the following services:

Home health services including intermittent skilled nursing, home health aide, physical,

occupational and speech therapy services, and physician ordered supplies

Emergency transportation or acute care situation where normal transportation would potentially endanger the life of the patient

Durable medical equipment that provides therapeutic benefits or enables a recipient to perform certain tasks that he or she would be unable to undertake otherwise due to certain medical conditions and / or illnesses

Other services are also assigned a service category using CPT codes. Other, unidentifiable services are assigned an “unknown” category of service.



VI. CMS RATE SETTING CHECKLIST ISSUES This section of the report lists each item in the November 10, 2014 CMS checklist and discusses how DHHS addresses each issue and / or directs the reader to other parts of this report. CMS uses the rate setting checklist to review and approve a state’s Medicaid capitation rates. AA.1.0 – Overview of Rates Being Paid Under the Contract The SFY 2019 managed care organization (MCO) capitation rates for the Medicaid Care Management program are developed using July 2015 – January 2016 FFS, and SFY 2016 and SFY 2017 MCO encounter data for the MCO eligible population, along with other information. DHHS sets rates by rate cell for all MCOs. Please refer to this report for background on the program and more details around the rate development. AA.1.1 – Actuarial Certification The Actuarial Certification of the SFY 2019 MCM capitation rates is shown in Appendix L. The SFY 2019 MCM capitation rates have been developed in accordance with generally accepted actuarial principles and practices and are appropriate for the populations to be covered and the services to be furnished under the contract. AA.1.2 – Projection of Expenditures Appendix G includes a projection of total expenditures based on estimated enrollment and SFY 2019 capitation rates. AA.1.3 – Risk Contracts The MCM program contract meets the criteria of a risk contract. AA.1.4 – Modifications The SFY 2019 rates documented in this report are the initial capitation rates for the MCM population for the SFY 2019 MCM contract period. Note: There is no AA.1.5 on the Rate Setting Checklist AA.1.6 – Limit on Payment to Other Providers It is our understanding no payment is made to a provider other than the participating MCOs for services available under the contract. AA.1.7 – Risk and Profit The SFY 2019 MCM capitation rates include a targeted margin of 1.5% for risk, profit, and contribution to reserves. We believe that this margin is appropriate given the variability of expenses under the program.



AA.1.8 – Family Planning Enhanced Match DHHS does not claim enhanced match for family planning services for the population covered under this program at this time. AA.1.9 – Indian Health Service (IHS) Facility Enhanced Match DHHS does not claim enhanced match for Indian Health Services for the population covered under this program. AA.1.10 – Newly Eligible Enhanced Match The MCM population is not part of the newly eligible Medicaid population. Therefore, the rates are not eligible for the enhanced Federal match under Section 1905(y). AA.1.11 – Retroactive Adjustments The SFY 2019 rates documented in this report are the initial capitation rates for the SFY 2019 MCM contracts and do not contain any retroactive adjustments. AA.2.0 – Based Only Upon Services Covered Under the State Plan The SFY 2016 and SFY 2017 MCO encounter base experience data includes a cost effective non-covered service that qualifies as an in-lieu of service and meets cost effectiveness requirements. Please see Section III of this report for more details. AA.2.1 – Provided Under the Contract to Medicaid-Eligible Individuals The SFY 2019 capitation rate development methodology primarily relies on MCO encounter data for all MCM eligible populations. FFS data is used for the populations that opted out of MCO enrollment during July 2015 – January 2016. AA.2.2 – Data Sources The SFY 2019 capitation rates are developed using July 2015 - January 2016 FFS, and SFY 2016 and SFY 2017 MCO encounter claims and eligibility data. Please refer to Sections II and III of this report for more details. AA.3.0 – Adjustments to Base Year Data All adjustments to the base year data are discussed in this report. In addition, each item in the checklist is addressed in items AA.3.1 – AA.3.17 below. AA.3.1 – Benefit Differences The base data used to calculate the capitation rates includes the services covered under the MCM contract. Section IV of this report documents the development of PMPM add-ons for substance use disorder treatment in an IMD for adolescents, Applied Behavioral Analysis (ABA) services, and gender dysphoria surgery services that were not offered under the MCM contract in the base period but are part of the MCM contract for SFY 2019.



AA.3.2 – Administrative Cost Allowance Calculations The capitation rates include explicit administrative allowances by rate cell. Please see Section IV in the report for more details regarding the administrative allowance calculation. AA.3.3 – Special Populations’ Adjustments The SFY 2019 capitation rates methodology does not include an adjustment for special populations as the base FFS and encounter data used to calculate the capitation rates is consistent with the eligible population. AA.3.4 – Eligibility Adjustments The base data only reflects experience for time periods where members were eligible to enroll in a MCO. AA.3.5 – Third Party Liability (TPL) The managed care organizations are responsible for the collection of any TPL recoveries. The capitation rates include an adjustment to reflect additional TPL recoveries that are not reflected in the base year FFS data portion. AA.3.6 – Indian Health Care Provider Payments The MCOs are responsible for the entirety of any IHC payments, which are fully reflected in the claims data. AA.3.7 – DSH Payments DSH payments are not included in the capitation rates. AA.3.8 – FQHC and RHC Reimbursement The MCOs are responsible for the entirety of the FQHC and RHC encounter payments, which are fully reflected in the claims data. AA.3.9 – Graduate Medical Education (GME) GME payments are not included as part of the capitation rates. AA.3.10 – Copayments, Coinsurance, and Deductibles in Capitated Rates The MCM population with an income over 100% of FPL must pay a $1 / $2 preferred / non-preferred copay for prescription drugs. The FFS and MCO encounter data reflect the copayment collection. AA.3.11 – Medical Cost / Trend Inflation Section III of this report documents the trend assumptions used to project the SFY 2016 and SFY 2017 base period costs to SFY 2019. AA.3.12 – Utilization Adjustments Utilization trend is included in AA.3.11.



AA.3.13 – Utilization and Cost Assumptions The utilization and cost assumptions are appropriate for the population to be covered. AA.3.14 – Post-Eligibility Treatment of Income (PETI) Long term care services that are subject to patient liability are excluded from the MCM population capitation rates. AA.3.15 – Incomplete Data Adjustment The capitation rates include an adjustment to reflect IBNR claims and underreported CMHC claims. Please refer to Section III of this report for more information on the development of these adjustment factors. AA.3.16 – Primary Care Rate Enhancement The SFY 2019 capitation rates are priced at levels consistent with current MCO reimbursement levels with considerations for expected MCM fee schedule changes. AA.3.17 – Health Homes Not Applicable. AA.4.0 – Establish Rate Category Groupings The SFY 2019 capitation rates use several rate cells developed from Medicaid eligibility categories to designate the eligible population. Please see Section II of this report for more details. There are also separate maternity and newborn kick payments. AA.4.1 – Eligibility Categories The eligibility categories included in the SFY 2019 capitation rates are defined in Section II of this report. AA.4.2 – Age Age is used for certain rate category groupings. AA.4.3 – Gender Gender is not used for rate category groupings. AA.4.4 – Locality / Region Region is not used as a rating variable. AA.4.5 – Risk Adjustments The MCM population capitation rates will use an actuarially sound risk adjustment model to adjust the rates for each participating MCO. Section II of this report includes an overview of the risk adjustment methodology.



We will provide a separate report documenting the development of the MCO Adjusted Risk Factors that will be applied to the SFY 2019 capitation rates. AA.5.0 – Data Smoothing We did not perform any data smoothing. AA.5.1 – Cost-Neutral Data Smoothing Adjustment We did not perform any data smoothing. AA.5.2 – Data Distortion Assessment Our review of the base FFS and MCO encounter data did not detect any material distortions or outliers. AA.5.3 – Data Smoothing Techniques We determined that a data smoothing mechanism resulting from data distortions was not required. AA.5.4 – Risk Adjustments The MCM population capitation rates will use an actuarially sound risk adjustment model to adjust the rates for each participating MCO. Section II of this report includes an overview of the risk adjustment methodology. We will provide a separate report documenting the development of the MCO Adjusted Risk Factors that will be applied to the SFY 2019 capitation rates. AA.6.0 – Stop Loss, Reinsurance, or Risk Sharing Arrangements DHHS administers a stop-loss arrangement for high cost patients where DHHS will share 50% of the cost above $500,000 for member that have total expenses for capitated services valued at Medicaid fee levels above that threshold. The adjustment factors reduce the base experience data by about 0.2% to reflect the MCO liability under the stop-loss agreement. This change is intended to be budget neutral to DHHS and the MCOs since it is a program change. It helps to reduce the variability of MCO financial results due to large cases. AA.6.1 – Commercial Reinsurance DHHS does not require entities to purchase commercial reinsurance. AA.6.2 – Stop-Loss Program DHHS administers a stop-loss arrangement for high cost patients where DHHS will share 50% of the cost above $500,000 for member that have total expenses for capitated services valued at Medicaid fee levels above that threshold. The adjustment factors reduce the base experience data by about 0.2% to reflect the MCO liability under the stop-loss agreement. This change is intended to be budget neutral to DHHS and the MCOs since it is a program change. It helps to reduce the variability of MCO financial results due to large cases.



AA.6.3 – Risk Corridor Program None. AA.7.0 – Incentive Arrangements None. AA.7.1 – Electronic Health Records (EHR) Incentive Payments DHHS has not implemented incentive payments related to EHRs for the SFY 2019 contract period.



VII. RESPONSE TO 2018-2019 MEDICAID MANAGED CARE RATE DEVELOPMENT GUIDE (MAY 2018)

SECTION I. MEDICAID MANAGED CARE RATES 1. General Information

A. Rate Development Standards

i. The rate certification included herein is for the twelve-month SFY 2019 contract period. The previous certification was for the SFY 2018 contract period.

ii. This rate certification submission was prepared in accordance with 42 CFR §438.4, 438.5,

438.6, and 438.7.

a. The actuarial certification letter signed by John Meerschaert, FSA, MAAA certifies that the final capitation rates meet the standards in 42 CFR §438.3(c), 438.3(e), 438.4 (excluding paragraph (b)(9)), 438.5, 438.6, and 438.7. The certification can be found in Appendix L.

b. The final and certified capitation rates for all rate cells can be found in Appendix F. c. The items requested can be found in Sections I through IV of this report.

iii. Differences in capitation rates for covered populations are based on valid rate development

standards and are not based on the rate of federal financial participation associated with the covered population.

iv. Each rate cell is developed independently to be actuarially sound and does not cross-

subsidize payments for another rate cell.

v. The effective dates of changes to the Medicaid program are consistent with the assumptions used to develop the capitation rates.

vi. The rate certification submission demonstrates that the capitation rates were developed

using generally accepted actuarial practices and principles.

a. All adjustment to the capitation rates reflect reasonable, appropriate, and attainable costs.

b. No adjustments to the rates are performed outside of the initial rate setting process

beyond those outlined in Section III of the report. c. The final contracted rates in each cell match the capitation rates in the certification.

vii. The capitation rates included in this submission are certified for all time periods in which

they are effective. No rates for a previous time period are used for a future time period.

viii. This rate certification conforms to the procedure for rate certifications for rate and contract amendments. The SFY 2019 rates documented in this report are the initial capitation rates for the SFY 2019 Medicaid Care Management program contracts.



B. Appropriate Documentation

i. We believe the attached report properly documents all the elements included in the rate

certification and provides CMS enough detail to determine that regulation standards are met.

Please see Sections I through IV of this report for the following details:

a. Data used, including citations to studies, research papers, other states’ analyses, or

similar secondary data sources,

b. Assumptions made, including any basis or justification for the assumption; and

c. Methods for analyzing data and developing assumptions and adjustments.

ii. We detail within our responses in this guide the section of our report where each item described in the 2018 – 2019 Medicaid Managed Care Rate Development Guide can be found.

iii. All services and populations included in this rate certification are subject to the regular state

FMAP. DHHS does not claim enhanced match for family planning services for the population covered under this program at this time

iv. Please see Sections I and II of this report for the requested documentation.

2. Data


i. Our report includes a thorough description of the data used and shows compliance with 42 CFR §438.5(c).

a. DHHS provided Milliman with validated encounter data and financial reports for at least

the three most recent and complete years prior to the rating period.

b. The rate development methodology uses current MCO encounter data.

c. The data used is derived from the Medicaid population served under the Medicaid Care Management program.

d. The rate development methodology uses recent MCO encounter data.


i. Milliman requested and received a full claims and enrollment database from DHHS and

the MCOs. This information is summarized in Appendices A1-A3.

ii. A detailed description of the data used in the rate development methodology can be found in Section III of this report. Section III also includes comments on the availability and quality of the data used for rate development.



iii. The rate certification and attached report thoroughly describe any material adjustments, and the basis for the adjustments, that are made to the data. Please see Section III and IV of this report for more details.

3. Projected Benefit Costs


i. The final capitation rates shown in Appendix F are based only upon services described in 42 CFR 438.3(c)(1)(ii) and 438.3(e).

ii. Variations in assumptions used to develop the projected benefit costs for covered

populations are not based on the rate of federal financial participation associated with the covered population.

iii. Each projected benefit cost trend assumption is reasonable and developed in accordance

with generally accepted actuarial principles and practices using actual experience of the Medicaid population and consideration of other factors that may affect projected benefit cost trends through the rating period.

iv. Please refer to Section III of this report for the details related to the treatment of in lieu of

services.

v. The SFY 2019 capitation rates do not allow an institution for mental disease (IMD) to be used as an in lieu of service provider, therefore the cost of all psychiatric services provided in IMDs is excluded from the capitation rates. In addition, the SFY 2019 capitation rate methodology excludes all claims and eligibility data for the portion of any month when an individual age 21-64 had a psychiatric stay longer than 15 days in an IMD.

However, note that New Hampshire’s Substance Use Disorder Treatment and Recovery Access 1115 Demonstration Waiver allows for the coverage of substance use disorder (SUD) services provided in an IMD.

vi. The SFY 2019 capitation rates do not allow an IMD to be used as an in lieu of service

provider.


i. The various Exhibits included in this report document the final projected benefit costs by relevant level of detail and is consistent with how the State makes payments to the plans.

ii. Please refer to Section III of this report for the methodology and assumptions used to

project contract period benefit costs. Section II of the report highlights key methodological changes since the previous rate development.

iii. The rate certification includes a section on projected benefit cost trends in compliance with

42 CFR §438.7(b)(2). See Step 2 of Section III for details related to the development of projected benefit cost trends.

iv. This certification does not include additional services deemed by the state to be necessary

to comply with the parity standards of the Mental Health Parity and Addiction Equity Act.



v. Please refer to Section III of this report for the details related to the treatment of in lieu of services.

vi. Section III includes a description of how retrospective eligibility periods are accounted for

in rate development.

vii. Section I documents the impact on projected costs for all material changes to covered benefits or services since the last rate certification.

viii. The rate certification includes an estimated impact of each covered benefit or service

change on the amount of projected benefit costs and a description of the data, assumptions, and methodologies used to develop the adjustment for each change related to covered benefits or services.

4. Special Contract Provisions Related to Payment

A. Incentive Arrangements

i. Rate Development Standards

The SFY 2019 capitation rate methodology does not include any incentive arrangements.

ii. Appropriate Documentation

The SFY 2019 capitation rate methodology does not include any incentive arrangements.

B. Withhold Arrangements


The SFY 2019 capitation rate methodology does not include any withhold arrangements.


The SFY 2019 capitation rate methodology does not include any withhold arrangements.

C. Risk Sharing Mechanism


Section III of the report documents the High Cost Patient Stop-Loss Adjustment.


Section III of the report documents the High Cost Patient Stop-Loss Adjustment.

D. Delivery System and Provider Payment Initiatives


Section IV of the report documents the CMHC directed payment that is new for SFY 2019 and is pending CMS approval.




Section IV of the report documents the CMHC directed payment that is new for SFY 2019 and is pending CMS approval.

E. Pass-Through Payments


The SFY 2019 capitation rate methodology does not include any pass-through payments.


The SFY 2019 capitation rate methodology does not include any pass-through payments.

5. Projected Non-Benefit Costs


i. The development of the non-benefit component of the SFY 2019 rates is compliant with 42 CFR §438.5(e) and includes reasonable, appropriate, and attainable expenses related to MCO administration, taxes, licensing and regulatory fees, contribution to reserves, risk margin, and cost of capital.

ii. The non-benefit costs included in the SFY 2019 capitation rates are developed as a

percentage of projected benefit costs.

iii. Variations in assumptions used to develop the projected benefit costs for covered populations are not based on the rate of federal financial participation associated with the covered population.

iv. The Health Insurance Providers Fee (HIPF) is not included in the capitation rates

documented in this report. DHHS will recalculate capitation payments for each MCO based on the actual amount of the HIPF for each plan and make gross adjustment payments to the MCOs to appropriately fund the HIPF and its related income tax impact once appropriate documentation can be provided.


i. Please refer to Section IV of this report for a detailed description of the data and

methodology used to develop of the projected non-benefit costs included in the capitation rates. The report includes a description of changes made since the last rate development.

ii. The projected non-benefit costs include appropriate consideration for administrative costs,

taxes, licensing and regulatory fees, other assessments and fees, contribution to reserves, risk margin, and cost of capital.



iii. The Health Insurance Providers Fee (HIPF) is not included in the capitation rates documented in this report. DHHS will recalculate capitation payments for each MCO based on the actual amount of the HIPF for each plan and make gross adjustment payments to the MCOs to appropriately fund the HIPF and its related income tax impact once appropriate documentation can be provided. The MCO capitation rates documented in this report are actuarially sound prior to the application of the ACA health insurer fee provision.

6. Risk Adjustment and Acuity Adjustment


i. The SFY 2019 capitation rates will use the risk adjustment arrangement described in Section II of this report.

ii. The risk adjustment arrangement described in Section II has been developed in

accordance with generally accepted actuarial principles and practices and is budget neutral to the state in total.

iii. Section III of this report documents the trend adjustment for opioid addiction population

treatment costs to reflect the increased acuity of the covered population.


i. The SFY 2019 capitation rates will use the risk adjustment arrangement described in Section II of this report.

ii. The SFY 2019 capitation rate methodology does not include any retrospective risk

adjustment components.

iii. Proposed changes to the risk adjustment methodology will be documented in a separate correspondence. The risk adjustment process is and will remain budget neutral to the state in total.

iv. Please see Section III of this report for the requested documentation regarding the trend

adjustment for opioid addiction population treatment costs to reflect the increased acuity of the covered population.

SECTION II. MEDICAID MANAGED CARE RATES WITH LONG-TERM SERVICES AND SUPPORTS This certification does not include rates for managed long-term services and supports (MLTSS). SECTION III. NEW ADULT GROUP CAPITATION RATES This certification does not include rates for the new adult group under 1902(a)(10)(A)(i)(VIII) of the Social Security Act.


State of New Hampshire Department of Health and Human Services SFY 2019 Capitation Rate Development for Medicaid Care Management Program June 11, 2018 This report assumes that the reader is familiar with the State of New Hampshire’s Medicaid program, its benefits, and rate setting principles. This report was prepared solely to provide assistance to DHHS to set SFY 2019 capitation rates for the Medicaid Care Management program. It may not be appropriate for other purposes. Milliman does not intend to benefit, and assumes no duty or liability to, other parties who receive this work. This material should only be reviewed in its entirety.

APPENDICES



APPENDICES A ‒ E State of New Hampshire

Department of Health and Human Services Medicaid Care Management Program

SFY 2019 Capitation Rate Development

6/11/2018 Milliman Page 1

Appendix A1New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2016 FFS Base Experience Data

Eligibility Category: Foster Care / Adoption

Member Months: 2,528

BenefitsTotal Paid

DollarsTotal Paid

AdmitsTotal Paid Services

Admits Per 1,000

Utilization Per 1,000

Average Paid Charge

Per Capita Monthly Paid

CostHospital InpatientMedical $18,034 5 9 23.7 42.7 $3,606.79 $7.13Surgical 3,013 1 2 4.7 9.5 3,012.74 1.19Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 87,130 7 64 33.2 303.8 12,447.20 34.46Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$108,177 13 75 61.7 356.0 $8,321.31 $42.79Hospital OutpatientEmergency Room $36,436 82 389.2 $444.34 $14.41Surgery 785 2 9.5 392.54 0.31Radiology 6,106 45 213.6 135.69 2.42Pathology 3,982 84 398.7 47.41 1.58Pharmacy 13,233 328 1,556.8 40.35 5.23Cardiovascular 309 4 19.0 77.13 0.12PT/OT/ST 12,458 359 1,703.9 34.70 4.93Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 19,619 107 507.9 183.36 7.76

$92,928 1,011 4,798.6 $91.92 $36.76Professional and Other State Plan ServicesAmbulatory Surgery Center $2,033 1 4.7 $2,032.74 $0.80Office Visits 25,995 489 2,321.0 53.16 10.28Preventive Medicine 10,322 434 2,059.9 23.78 4.08Maternity 250 1 4.7 250.00 0.10Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 11,765 412 1,955.5 28.55 4.65Psychiatric and Substance Abuse 24,371 375 1,779.9 64.99 9.64Radiology and Pathology 8,097 567 2,691.2 14.28 3.20Home Health and Private Duty Nursing 133,472 9,242 43,865.9 14.44 52.79Ambulance 1,777 240 1,139.1 7.41 0.70Non-Emergency Transportation 1,596 0 0.0 0.00 0.63Opioid Treatment Program 1,247 122 579.1 10.22 0.49Federally Qualified and Rural Health Clinics 6,832 75 356.0 91.09 2.70Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 73,439 19,265 91,438.7 3.81 29.05Other 21,077 865 4,105.6 24.37 8.34

$322,273 32,088 152,301.3 $10.04 $127.47Prescription DrugsGeneric Scripts $54,308 1,457 6,915.5 $37.27 $21.48Single-Source Brand 36,240 223 1,058.4 162.51 14.33Multi-Source Brand 88,583 278 1,319.5 318.65 35.04Specialty 9,162 12 57.0 763.54 3.62Other 0 0 0.0 0.00 0.00

$188,294 1,970 9,350.3 $95.58 $74.48Mental Health CenterCase Management $6,805 19 90.2 $358.14 $2.69Long Term Support Service 3,310 87 412.9 38.05 1.31Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 4,914 83 393.9 59.20 1.94Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 5,614 46 218.3 122.04 2.22

$20,643 235 1,115.4 $87.84 $8.16All Services $732,315 13 35,379 61.7 167,921.6 $20.70 $289.65




Eligibility Category: Severely Disabled Children


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$147,979 20 162 83.8 678.9 $7,398.93 $51.68Hospital OutpatientEmergency Room $14,228 58 243.1 $245.32 $4.97Surgery 300 1 4.2 300.01 0.10Radiology 16,502 49 205.4 336.78 5.76Pathology 17,202 173 725.0 99.43 6.01Pharmacy 56,640 125 523.9 453.12 19.78Cardiovascular 5,503 13 54.5 423.33 1.92PT/OT/ST 42,007 971 4,069.4 43.26 14.67Psychiatric 2,518 10 41.9 251.80 0.88Substance Abuse 0 0 0.0 0.00 0.00Other 19,422 56 234.7 346.83 6.78

$174,324 1,456 6,102.1 $119.73 $60.88Professional and Other State Plan ServicesAmbulatory Surgery Center $2,323 7 29.3 $331.83 $0.81Office Visits 33,516 612 2,564.9 54.76 11.71Preventive Medicine 3,981 174 729.2 22.88 1.39Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 88,584 3,636 15,238.4 24.36 30.94Psychiatric and Substance Abuse 10,207 160 670.6 63.80 3.56Radiology and Pathology 6,641 378 1,584.2 17.57 2.32Home Health and Private Duty Nursing 1,226,401 126,621 530,666.2 9.69 428.32Ambulance 5,256 548 2,296.7 9.59 1.84Non-Emergency Transportation 8,550 25 104.8 341.98 2.99Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 2,515 22 92.2 114.31 0.88Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 526,484 216,783 908,533.4 2.43 183.87Other 64,612 2,532 10,611.6 25.52 22.57

$1,979,070 351,498 1,473,121.5 $5.63 $691.19Prescription DrugsGeneric Scripts $80,255 2,572 10,779.2 $31.20 $28.03Single-Source Brand 232,431 490 2,053.6 474.35 81.18Multi-Source Brand 87,705 251 1,051.9 349.42 30.63Specialty 920,637 155 649.6 5,939.59 321.53Other 19 6 25.1 3.22 0.01

$1,321,048 3,474 14,559.5 $380.27 $461.37Mental Health CenterCase Management $5,014 14 58.7 $358.14 $1.75Long Term Support Service 2,709 100 419.1 27.09 0.95Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 2,591 63 264.0 41.12 0.90Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 3,276 26 109.0 126.01 1.14

$13,590 203 850.8 $66.94 $4.75All Services $3,636,010 20 356,793 83.8 1,495,312.7 $10.19 $1,269.87




Eligibility Category: Dual Eligibles


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $473,413 216 1,648 187.7 1,432.2 $2,191.73 $34.28Surgical 109,157 67 517 58.2 449.3 1,629.20 7.91Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 2,520 2 7 1.7 6.1 1,260.00 0.18Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 26,816 18 149 15.6 129.5 1,489.75 1.94Alcohol and Drug Abuse 5,040 4 11 3.5 9.6 1,260.00 0.37Other 3,623 1 38 0.9 33.0 3,622.50 0.26

$620,568 308 2,370 267.7 2,059.6 $2,014.83 $44.94Hospital OutpatientEmergency Room $318,177 1,240 1,077.6 $256.59 $23.04Surgery 6,795 49 42.6 138.68 0.49Radiology 98,764 766 665.7 128.93 7.15Pathology 60,893 1,083 941.2 56.23 4.41Pharmacy 427,009 2,172 1,887.6 196.60 30.92Cardiovascular 9,149 105 91.3 87.13 0.66PT/OT/ST 23,149 388 337.2 59.66 1.68Psychiatric 2,317 77 66.9 30.09 0.17Substance Abuse 0 0 0.0 0.00 0.00Other 188,391 3,384 2,940.9 55.67 13.64

$1,134,644 9,264 8,050.9 $122.48 $82.17Professional and Other State Plan ServicesAmbulatory Surgery Center $2,521 28 24.3 $90.02 $0.18Office Visits 61,175 2,653 2,305.6 23.06 4.43Preventive Medicine 6,588 223 193.8 29.54 0.48Maternity 764 13 11.3 58.76 0.06Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,643 554 481.5 6.58 0.26Psychiatric and Substance Abuse 42,454 437 379.8 97.15 3.07Radiology and Pathology 19,950 999 868.2 19.97 1.44Home Health and Private Duty Nursing 36,052 1,822 1,583.4 19.79 2.61Ambulance 17,928 1,034 898.6 17.34 1.30Non-Emergency Transportation 93,097 1,468 1,275.8 63.42 6.74Opioid Treatment Program 63,921 6,255 5,435.9 10.22 4.63Federally Qualified and Rural Health Clinics 16,159 126 109.5 128.25 1.17Adult Medical Day Care 9,416 255 221.6 36.92 0.68Personal Care 47,996 9,073 7,884.9 5.29 3.48Durable Medical Equipment 98,512 34,590 30,060.4 2.85 7.13Other 133,152 33,742 29,323.5 3.95 9.64

$653,327 93,272 81,058.0 $7.00 $47.31Prescription DrugsGeneric Scripts $5,052 998 867.3 $5.06 $0.37Single-Source Brand 44 4 3.5 10.94 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$5,096 1,002 870.8 $5.09 $0.37Mental Health CenterCase Management $21,847 61 53.0 $358.14 $1.58Long Term Support Service 25,275 629 546.6 40.18 1.83Partial Hospital 200 2 1.7 99.90 0.01Psychotherapy 7,888 326 283.3 24.20 0.57Evidence Based Practice 147 16 13.9 9.19 0.01Medication Management 367 17 14.8 21.60 0.03Emergency Service 24/7 352 15 13.0 23.46 0.03APRTP 7,686 14 12.2 549.00 0.56Supported Employment Services 1,274 48 41.7 26.54 0.09Harbor Homes 2,846 49 42.6 58.08 0.21Other 20,391 766 665.7 26.62 1.48

$88,272 1,943 1,688.6 $45.43 $6.39All Services $2,501,908 308 107,851 267.7 93,727.9 $23.20 $181.19




Eligibility Category: Nursing Facility Residents - Dual Eligibles - Age 0-64


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $40,089 29 119 224.0 919.0 $1,382.38 $25.80Surgical 8,848 7 94 54.1 725.9 1,264.00 5.69Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$48,937 36 213 278.0 1,644.9 $1,359.36 $31.49Hospital OutpatientEmergency Room $29,904 95 733.7 $314.78 $19.24Surgery 852 11 85.0 77.45 0.55Radiology 6,736 54 417.0 124.73 4.33Pathology 3,111 37 285.7 84.09 2.00Pharmacy 73,279 411 3,174.0 178.30 47.16Cardiovascular 390 9 69.5 43.36 0.25PT/OT/ST 1,184 7 54.1 169.14 0.76Psychiatric 55 2 15.4 27.60 0.04Substance Abuse 0 0 0.0 0.00 0.00Other 20,353 209 1,614.1 97.38 13.10

$135,864 835 6,448.5 $162.71 $87.44Professional and Other State Plan ServicesAmbulatory Surgery Center $33 1 7.7 $32.63 $0.02Office Visits 8,148 317 2,448.1 25.70 5.24Preventive Medicine 277 13 100.4 21.31 0.18Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 278 42 324.4 6.61 0.18Psychiatric and Substance Abuse 2,255 99 764.6 22.77 1.45Radiology and Pathology 673 58 447.9 11.60 0.43Home Health and Private Duty Nursing 384 8 61.8 48.05 0.25Ambulance 4,994 381 2,942.4 13.11 3.21Non-Emergency Transportation 51,057 939 7,251.6 54.37 32.86Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 1,851 12 92.7 154.25 1.19Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 159 30 231.7 5.29 0.10Durable Medical Equipment 43,245 2,911 22,480.9 14.86 27.83Other 16,554 992 7,660.9 16.69 10.65

$129,906 5,803 44,815.0 $22.39 $83.60Prescription DrugsGeneric Scripts $5,282 1,449 11,190.2 $3.65 $3.40Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$5,282 1,449 11,190.2 $3.65 $3.40Mental Health CenterCase Management $3,581 10 77.2 $358.14 $2.30Long Term Support Service 1,865 46 355.2 40.54 1.20Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 2,120 29 224.0 73.11 1.36Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 375 16 123.6 23.46 0.24APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 2,160 18 139.0 120.00 1.39Other 537 17 131.3 31.61 0.35

$10,639 136 1,050.3 $78.23 $6.85All Services $330,629 36 8,436 278.0 65,148.9 $39.19 $212.78




Eligibility Category: Nursing Facility Residents - Dual Eligibles - Age 65+


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $387,574 226 1,133 139.9 701.1 $1,714.93 $19.99Surgical 30,324 24 124 14.9 76.7 1,263.50 1.56Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 19,050 9 121 5.6 74.9 2,116.67 0.98Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$436,948 259 1,378 160.3 852.7 $1,687.06 $22.53Hospital OutpatientEmergency Room $138,695 442 273.5 $313.79 $7.15Surgery 2,510 25 15.5 100.41 0.13Radiology 31,921 331 204.8 96.44 1.65Pathology 17,977 207 128.1 86.85 0.93Pharmacy 76,470 232 143.6 329.61 3.94Cardiovascular 2,451 77 47.6 31.83 0.13PT/OT/ST 11,667 75 46.4 155.56 0.60Psychiatric 102 1 0.6 101.54 0.01Substance Abuse 0 0 0.0 0.00 0.00Other 74,172 995 615.7 74.54 3.82

$355,966 2,385 1,475.9 $149.25 $18.36Professional and Other State Plan ServicesAmbulatory Surgery Center $1,715 44 27.2 $38.97 $0.09Office Visits 26,990 985 609.5 27.40 1.39Preventive Medicine 8,060 467 289.0 17.26 0.42Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 62 3 1.9 20.75 0.00Psychiatric and Substance Abuse 5,558 214 132.4 25.97 0.29Radiology and Pathology 3,873 333 206.1 11.63 0.20Home Health and Private Duty Nursing 12,063 0 0.0 0.00 0.62Ambulance 16,346 974 602.7 16.78 0.84Non-Emergency Transportation 237,799 4,940 3,057.0 48.14 12.26Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 2,725 19 11.8 143.40 0.14Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 112,896 6,578 4,070.6 17.16 5.82Other 196,831 11,654 7,211.8 16.89 10.15


$40,919 13,201 8,169.1 $3.10 $2.11Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 1,426 17 10.5 83.91 0.07Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 653 8 5.0 81.65 0.03Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 1,331 78 48.3 17.07 0.07

$3,411 103 63.7 $33.12 $0.18All Services $1,462,161 259 43,278 160.3 26,781.4 $33.79 $75.40




Eligibility Category: Community Residents - Dual Eligibles - Age 0-64


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $99,316 78 391 295.6 1,481.8 $1,273.28 $31.37Surgical 31,556 21 227 79.6 860.3 1,502.67 9.97Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 3,780 3 18 11.4 68.2 1,260.00 1.19Alcohol and Drug Abuse 2,520 2 11 7.6 41.7 1,260.00 0.80Other 0 0 0 0.0 0.0 0.00 0.00

$137,172 104 647 394.1 2,452.0 $1,318.96 $43.32Hospital OutpatientEmergency Room $84,198 397 1,504.5 $212.08 $26.59Surgery 5,970 59 223.6 101.19 1.89Radiology 25,531 223 845.1 114.49 8.06Pathology 22,338 397 1,504.5 56.27 7.05Pharmacy 143,723 495 1,875.9 290.35 45.39Cardiovascular 1,469 24 91.0 61.20 0.46PT/OT/ST 10,901 171 648.1 63.75 3.44Psychiatric 1,570 49 185.7 32.04 0.50Substance Abuse 0 0 0.0 0.00 0.00Other 76,074 1,348 5,108.6 56.43 24.03

$371,774 3,163 11,987.1 $117.54 $117.41Professional and Other State Plan ServicesAmbulatory Surgery Center $627 3 11.4 $209.07 $0.20Office Visits 16,197 998 3,782.2 16.23 5.12Preventive Medicine 1,068 25 94.7 42.72 0.34Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,226 213 807.2 5.76 0.39Psychiatric and Substance Abuse 2,838 47 178.1 60.39 0.90Radiology and Pathology 2,897 158 598.8 18.33 0.91Home Health and Private Duty Nursing 95,763 2,248 8,519.4 42.60 30.24Ambulance 10,300 1,205 4,566.7 8.55 3.25Non-Emergency Transportation 267,825 4,357 16,512.1 61.47 84.58Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 1,247 11 41.7 113.40 0.39Adult Medical Day Care 12,248 829 3,141.7 14.77 3.87Personal Care 1,833,662 346,628 1,313,645.6 5.29 579.10Durable Medical Equipment 227,052 154,296 584,748.7 1.47 71.71Other 20,096 19,257 72,979.9 1.04 6.35

$2,493,049 530,275 2,009,628.3 $4.70 $787.34Prescription DrugsGeneric Scripts $4,264 759 2,876.4 $5.62 $1.35Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 233 5 18.9 46.69 0.07Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$4,498 764 2,895.4 $5.89 $1.42Mental Health CenterCase Management $159,372 445 1,686.5 $358.14 $50.33Long Term Support Service 200,543 8,651 32,785.4 23.18 63.33Partial Hospital 4,995 50 189.5 99.90 1.58Psychotherapy 12,815 370 1,402.2 34.64 4.05Evidence Based Practice 902 51 193.3 17.69 0.29Medication Management 4,229 143 541.9 29.57 1.34Emergency Service 24/7 12,012 512 1,940.4 23.46 3.79APRTP 18,666 34 128.9 549.00 5.90Supported Employment Services 20,091 757 2,868.9 26.54 6.34Harbor Homes 25,800 215 814.8 120.00 8.15Other 5,767 290 1,099.0 19.89 1.82

$465,192 11,518 43,650.7 $40.39 $146.91All Services $3,471,684 104 546,367 394.1 2,070,613.5 $6.35 $1,096.41




Eligibility Category: Community Residents - Dual Eligibles - Age 65+


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $312,261 232 1,201 393.0 2,034.4 $1,345.95 $44.08Surgical 41,608 33 211 55.9 357.4 1,260.85 5.87Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 17,832 10 208 16.9 352.3 1,783.20 2.52Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$371,701 275 1,620 465.8 2,744.2 $1,351.64 $52.47Hospital OutpatientEmergency Room $206,500 677 1,146.8 $305.02 $29.15Surgery 3,724 35 59.3 106.41 0.53Radiology 55,619 370 626.8 150.32 7.85Pathology 24,015 561 950.3 42.81 3.39Pharmacy 112,964 768 1,301.0 147.09 15.95Cardiovascular 5,966 85 144.0 70.19 0.84PT/OT/ST 11,593 125 211.7 92.75 1.64Psychiatric 133 5 8.5 26.61 0.02Substance Abuse 0 0 0.0 0.00 0.00Other 94,274 2,075 3,515.0 45.43 13.31

$514,789 4,701 7,963.3 $109.51 $72.67Professional and Other State Plan ServicesAmbulatory Surgery Center $1,022 12 20.3 $85.16 $0.14Office Visits 21,401 1,437 2,434.2 14.89 3.02Preventive Medicine 2,413 50 84.7 48.27 0.34Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 716 175 296.4 4.09 0.10Psychiatric and Substance Abuse 517 17 28.8 30.42 0.07Radiology and Pathology 3,445 252 426.9 13.67 0.49Home Health and Private Duty Nursing 87,957 1,618 2,740.8 54.36 12.42Ambulance 8,227 1,132 1,917.6 7.27 1.16Non-Emergency Transportation 321,024 6,280 10,638.1 51.12 45.32Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 565 12 20.3 47.12 0.08Adult Medical Day Care 59,212 3,673 6,221.9 16.12 8.36Personal Care 290,183 54,855 92,922.2 5.29 40.96Durable Medical Equipment 244,403 273,596 463,460.7 0.89 34.50Other 45,972 26,864 45,506.5 1.71 6.49

$1,087,058 369,973 626,719.5 $2.94 $153.45Prescription DrugsGeneric Scripts $9,445 2,995 5,073.4 $3.15 $1.33Single-Source Brand 41 2 3.4 20.32 0.01Multi-Source Brand 9 1 1.7 9.19 0.00Specialty 0 0 0.0 0.00 0.00Other 44 16 27.1 2.77 0.01

$9,539 3,014 5,105.6 $3.16 $1.35Mental Health CenterCase Management $196,977 550 931.7 $358.14 $27.81Long Term Support Service 220,172 8,912 15,096.6 24.71 31.08Partial Hospital 11,796 120 203.3 98.30 1.67Psychotherapy 10,464 261 442.1 40.09 1.48Evidence Based Practice 902 34 57.6 26.54 0.13Medication Management 1,720 60 101.6 28.66 0.24Emergency Service 24/7 1,220 52 88.1 23.46 0.17APRTP 3,294 6 10.2 549.00 0.46Supported Employment Services 4,326 163 276.1 26.54 0.61Harbor Homes 14,923 128 216.8 116.59 2.11Other 9,424 533 902.9 17.68 1.33

$475,219 10,819 18,327.0 $43.92 $67.08All Services $2,458,305 275 390,127 465.8 660,859.5 $6.30 $347.02




Eligibility Category: Developmentally Disabled - Dual Eligibles


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$188,273 102 667 122.0 798.0 $1,845.82 $18.77Hospital OutpatientEmergency Room $100,259 575 687.9 $174.36 $10.00Surgery 3,207 36 43.1 89.09 0.32Radiology 28,804 292 349.3 98.64 2.87Pathology 20,908 510 610.1 41.00 2.08Pharmacy 103,228 345 412.7 299.21 10.29Cardiovascular 5,417 62 74.2 87.36 0.54PT/OT/ST 13,071 206 246.4 63.45 1.30Psychiatric 648 20 23.9 32.41 0.06Substance Abuse 0 0 0.0 0.00 0.00Other 86,059 1,953 2,336.5 44.07 8.58

$361,601 3,999 4,784.2 $90.42 $36.05Professional and Other State Plan ServicesAmbulatory Surgery Center $915 21 25.1 $43.59 $0.09Office Visits 27,805 1,418 1,696.4 19.61 2.77Preventive Medicine 8,536 350 418.7 24.39 0.85Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,155 224 268.0 5.16 0.12Psychiatric and Substance Abuse 6,786 172 205.8 39.45 0.68Radiology and Pathology 2,594 223 266.8 11.63 0.26Home Health and Private Duty Nursing 481,162 44,913 53,731.6 10.71 47.97Ambulance 1,677 51 61.0 32.88 0.17Non-Emergency Transportation 78,502 1,814 2,170.2 43.28 7.83Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 2,918 21 25.1 138.94 0.29Adult Medical Day Care 97,927 2,219 2,654.7 44.13 9.76Personal Care 18,399 3,478 4,160.9 5.29 1.83Durable Medical Equipment 286,617 525,434 628,602.1 0.55 28.57Other 41,911 14,912 17,839.9 2.81 4.18


$10,475 2,487 2,975.3 $4.21 $1.04Mental Health CenterCase Management $55,278 156 186.6 $354.35 $5.51Long Term Support Service 222,883 9,191 10,995.6 24.25 22.22Partial Hospital 28,638 313 374.5 91.49 2.86Psychotherapy 14,867 607 726.2 24.49 1.48Evidence Based Practice 6,257 324 387.6 19.31 0.62Medication Management 3,023 87 104.1 34.75 0.30Emergency Service 24/7 962 41 49.1 23.46 0.10APRTP 9,882 18 21.5 549.00 0.99Supported Employment Services 4,883 184 220.1 26.54 0.49Harbor Homes 326 10 12.0 32.65 0.03Other 44,368 1,902 2,275.5 23.33 4.42

$391,367 12,833 15,352.7 $30.50 $39.02All Services $2,008,620 102 615,236 122.0 736,036.5 $3.26 $200.25




Eligibility Category: Developmentally Disabled and In-Home Supports Children


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$228,427 43 231 146.6 787.5 $5,312.26 $64.90Hospital OutpatientEmergency Room $39,433 105 358.0 $375.55 $11.20Surgery 9,173 4 13.6 2,293.21 2.61Radiology 28,319 121 412.5 234.04 8.05Pathology 15,332 189 644.4 81.12 4.36Pharmacy 61,400 216 736.4 284.26 17.44Cardiovascular 3,221 12 40.9 268.40 0.92PT/OT/ST 47,578 878 2,993.3 54.19 13.52Psychiatric 314 1 3.4 313.72 0.09Substance Abuse 0 0 0.0 0.00 0.00Other 40,853 131 446.6 311.85 11.61

$245,622 1,657 5,649.2 $148.23 $69.78Professional and Other State Plan ServicesAmbulatory Surgery Center $3,568 7 23.9 $509.77 $1.01Office Visits 58,549 1,048 3,572.9 55.87 16.63Preventive Medicine 8,462 448 1,527.4 18.89 2.40Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 188,762 6,932 23,633.1 27.23 53.63Psychiatric and Substance Abuse 14,158 261 889.8 54.25 4.02Radiology and Pathology 7,036 482 1,643.3 14.60 2.00Home Health and Private Duty Nursing 1,539,151 158,938 541,863.2 9.68 437.28Ambulance 9,981 402 1,370.5 24.83 2.84Non-Emergency Transportation 15,313 22 75.0 696.05 4.35Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 11,238 109 371.6 103.10 3.19Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,109,232 532,131 1,814,180.5 2.08 315.14Other 81,968 2,505 8,540.2 32.72 23.29

$3,047,420 703,285 2,397,691.4 $4.33 $865.79Prescription DrugsGeneric Scripts $166,538 5,578 19,016.9 $29.86 $47.31Single-Source Brand 191,035 887 3,024.0 215.37 54.27Multi-Source Brand 199,709 618 2,106.9 323.15 56.74Specialty 135,002 55 187.5 2,454.59 38.35Other 0 14 47.7 0.00 0.00

$692,284 7,152 24,383.1 $96.80 $196.68Mental Health CenterCase Management $135,377 378 1,288.7 $358.14 $38.46Long Term Support Service 201,463 8,581 29,255.0 23.48 57.24Partial Hospital 699 7 23.9 99.90 0.20Psychotherapy 41,179 894 3,047.9 46.06 11.70Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 80 3 10.2 26.64 0.02Emergency Service 24/7 94 4 13.6 23.46 0.03APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 12,161 151 514.8 80.53 3.45

$391,052 10,018 34,154.1 $39.03 $111.10All Services $4,604,805 43 722,343 146.6 2,462,665.4 $6.37 $1,308.25




Eligibility Category: Acquired Brain Disorder - Dual Eligibles

Member Months: 762

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $15,176 12 81 189.1 1,276.2 $1,264.67 $19.93Surgical 0 0 0 0.0 0.0 0.00 0.00Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 1,260 1 6 15.8 94.5 1,260.00 1.65Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$16,436 13 87 204.8 1,370.8 $1,264.31 $21.58Hospital OutpatientEmergency Room $13,123 59 929.6 $222.42 $17.23Surgery 451 10 157.6 45.13 0.59Radiology 2,150 30 472.7 71.66 2.82Pathology 2,968 51 803.6 58.19 3.90Pharmacy 6,698 31 488.4 216.07 8.79Cardiovascular 113 2 31.5 56.60 0.15PT/OT/ST 1,874 37 583.0 50.65 2.46Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 10,434 197 3,104.0 52.96 13.70

$37,811 417 6,570.3 $90.67 $49.65Professional and Other State Plan ServicesAmbulatory Surgery Center $50 1 15.8 $49.56 $0.07Office Visits 2,390 154 2,426.5 15.52 3.14Preventive Medicine 363 9 141.8 40.32 0.48Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 51 8 126.0 6.37 0.07Psychiatric and Substance Abuse 72 1 15.8 72.00 0.09Radiology and Pathology 375 21 330.9 17.87 0.49Home Health and Private Duty Nursing 2,434 27 425.4 90.16 3.20Ambulance 620 40 630.2 15.50 0.81Non-Emergency Transportation 14,662 312 4,915.9 46.99 19.25Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 0 0 0.0 0.00 0.00Adult Medical Day Care 11,227 228 3,592.4 49.24 14.74Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 71,152 79,821 1,257,673.2 0.89 93.42Other 3,157 1,217 19,175.3 2.59 4.14

$106,553 81,839 1,289,469.1 $1.30 $139.91Prescription DrugsGeneric Scripts $1,954 414 6,523.1 $4.72 $2.57Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$1,954 414 6,523.1 $4.72 $2.57Mental Health CenterCase Management $6,088 17 267.9 $358.14 $7.99Long Term Support Service 21,092 675 10,635.4 31.25 27.69Partial Hospital 300 3 47.3 99.90 0.39Psychotherapy 556 17 267.9 32.68 0.73Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 533 20 315.1 26.64 0.70Emergency Service 24/7 235 10 157.6 23.46 0.31APRTP 0 0 0.0 0.00 0.00Supported Employment Services 1,035 39 614.5 26.54 1.36Harbor Homes 0 0 0.0 0.00 0.00Other 10,374 375 5,908.6 27.66 13.62

$40,212 1,156 18,214.1 $34.79 $52.80All Services $202,966 13 83,913 204.8 1,322,147.4 $2.42 $266.50




Eligibility Category: Severe/Persistent Mental Illness - Dual Eligibles


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$137,614 54 344 169.2 1,077.9 $2,548.40 $35.93Hospital OutpatientEmergency Room $81,141 444 1,391.2 $182.75 $21.19Surgery 854 18 56.4 47.43 0.22Radiology 27,041 196 614.1 137.97 7.06Pathology 14,486 291 911.8 49.78 3.78Pharmacy 50,314 332 1,040.3 151.55 13.14Cardiovascular 2,396 27 84.6 88.73 0.63PT/OT/ST 5,440 88 275.7 61.82 1.42Psychiatric 1,167 6 18.8 194.53 0.30Substance Abuse 0 0 0.0 0.00 0.00Other 46,334 975 3,055.0 47.52 12.10

$229,173 2,377 7,448.0 $96.41 $59.84Professional and Other State Plan ServicesAmbulatory Surgery Center $1,551 26 81.5 $59.65 $0.40Office Visits 11,926 635 1,989.7 18.78 3.11Preventive Medicine 3,192 61 191.1 52.33 0.83Maternity 6 1 3.1 6.10 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 791 122 382.3 6.49 0.21Psychiatric and Substance Abuse 5,275 56 175.5 94.19 1.38Radiology and Pathology 3,026 259 811.5 11.68 0.79Home Health and Private Duty Nursing 1,517 51 159.8 29.75 0.40Ambulance 2,002 66 206.8 30.33 0.52Non-Emergency Transportation 9,592 90 282.0 106.58 2.50Opioid Treatment Program 12,519 1,225 3,838.4 10.22 3.27Federally Qualified and Rural Health Clinics 4,815 41 128.5 117.44 1.26Adult Medical Day Care 5,162 179 560.9 28.84 1.35Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 17,409 7,811 24,474.6 2.23 4.55Other 19,919 5,475 17,155.1 3.64 5.20

$98,702 16,098 50,440.7 $6.13 $25.77Prescription DrugsGeneric Scripts $3,118 722 2,262.3 $4.32 $0.81Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$3,118 722 2,262.3 $4.32 $0.81Mental Health CenterCase Management $1,084,418 3,160 9,901.4 $343.17 $283.16Long Term Support Service 2,381,654 77,286 242,164.2 30.82 621.88Partial Hospital 170,406 1,790 5,608.7 95.20 44.50Psychotherapy 80,527 3,105 9,729.1 25.93 21.03Evidence Based Practice 31,766 1,580 4,950.7 20.11 8.29Medication Management 39,480 1,287 4,032.6 30.68 10.31Emergency Service 24/7 32,727 1,395 4,371.0 23.46 8.55APRTP 21,411 39 122.2 549.00 5.59Supported Employment Services 169,096 6,387 20,012.7 26.48 44.15Harbor Homes 50,491 898 2,813.7 56.23 13.18Other 36,276 1,873 5,868.8 19.37 9.47

$4,098,252 98,800 309,575.1 $41.48 $1,070.11All Services $4,566,859 54 118,341 169.2 370,803.9 $38.59 $1,192.46




Eligibility Category: Severe Mental Illness - Dual Eligibles

Member Months: 506

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $18,298 10 237 237.3 5,625.0 $1,829.80 $36.19Surgical 1,260 1 2 23.7 47.5 1,260.00 2.49Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 2,520 2 11 47.5 261.1 1,260.00 4.98Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$22,078 13 250 308.5 5,933.5 $1,698.31 $43.67Hospital OutpatientEmergency Room $21,265 113 2,682.0 $188.18 $42.06Surgery 52 1 23.7 52.46 0.10Radiology 5,355 74 1,756.3 72.37 10.59Pathology 2,140 52 1,234.2 41.15 4.23Pharmacy 5,881 40 949.4 147.03 11.63Cardiovascular 306 6 142.4 51.06 0.61PT/OT/ST 2,822 44 1,044.3 64.13 5.58Psychiatric 163 4 94.9 40.70 0.32Substance Abuse 0 0 0.0 0.00 0.00Other 6,306 155 3,678.8 40.68 12.47

$44,290 489 11,606.0 $90.57 $87.60Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 2,817 142 3,370.2 19.84 5.57Preventive Medicine 137 8 189.9 17.10 0.27Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 0 0 0.0 0.00 0.00Psychiatric and Substance Abuse 2,713 24 569.6 113.05 5.37Radiology and Pathology 692 33 783.2 20.96 1.37Home Health and Private Duty Nursing 0 0 0.0 0.00 0.00Ambulance 83 4 94.9 20.77 0.16Non-Emergency Transportation 572 2 47.5 285.89 1.13Opioid Treatment Program 2,678 263 6,242.1 10.18 5.30Federally Qualified and Rural Health Clinics 518 3 71.2 172.67 1.02Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 3,135 1,098 26,060.0 2.85 6.20Other 3,043 2,445 58,029.8 1.24 6.02

$16,388 4,022 95,458.5 $4.07 $32.41Prescription DrugsGeneric Scripts $202 31 735.8 $6.53 $0.40Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$202 31 735.8 $6.53 $0.40Mental Health CenterCase Management $101,369 299 7,096.5 $339.03 $200.49Long Term Support Service 39,840 1,665 39,517.2 23.93 78.80Partial Hospital 2,214 23 545.9 96.25 4.38Psychotherapy 13,061 515 12,223.0 25.36 25.83Evidence Based Practice 1,764 107 2,539.5 16.49 3.49Medication Management 2,548 82 1,946.2 31.07 5.04Emergency Service 24/7 305 13 308.5 23.46 0.60APRTP 8,621 16 379.7 538.81 17.05Supported Employment Services 10,298 388 9,208.8 26.54 20.37Harbor Homes 65 2 47.5 32.63 0.13Other 7,041 229 5,435.1 30.75 13.93

$187,125 3,339 79,248.1 $56.04 $370.10All Services $270,083 13 8,131 308.5 192,981.8 $33.22 $534.18




Eligibility Category: Low Utilizer - Dual Eligibles

Member Months: 355

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$5,068 4 8 135.1 270.2 $1,267.00 $14.26Hospital OutpatientEmergency Room $4,447 20 675.4 $222.34 $12.51Surgery 0 0 0.0 0.00 0.00Radiology 1,465 17 574.1 86.18 4.12Pathology 478 19 641.6 25.15 1.34Pharmacy 4,376 21 709.1 208.36 12.31Cardiovascular 131 4 135.1 32.83 0.37PT/OT/ST 308 6 202.6 51.40 0.87Psychiatric 78 1 33.8 77.68 0.22Substance Abuse 0 0 0.0 0.00 0.00Other 2,518 73 2,465.1 34.49 7.09

$13,801 161 5,436.8 $85.72 $38.84Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 1,975 71 2,397.6 27.82 5.56Preventive Medicine 234 10 337.7 23.40 0.66Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 20 2 67.5 9.89 0.06Psychiatric and Substance Abuse 470 24 810.5 19.59 1.32Radiology and Pathology 305 22 742.9 13.87 0.86Home Health and Private Duty Nursing 0 0 0.0 0.00 0.00Ambulance 0 0 0.0 0.00 0.00Non-Emergency Transportation 720 0 0.0 0.00 2.03Opioid Treatment Program 123 12 405.2 10.22 0.35Federally Qualified and Rural Health Clinics 0 0 0.0 0.00 0.00Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,296 601 20,295.1 2.16 3.65Other 1,952 2,320 78,343.8 0.84 5.49


$63 24 810.5 $2.61 $0.18Mental Health CenterCase Management $65,982 188 6,348.5 $350.97 $185.68Long Term Support Service 8,409 343 11,582.7 24.52 23.66Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 3,643 241 8,138.3 15.11 10.25Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 1,733 64 2,161.2 27.08 4.88Emergency Service 24/7 352 15 506.5 23.46 0.99APRTP 0 0 0.0 0.00 0.00Supported Employment Services 2,627 99 3,343.1 26.54 7.39Harbor Homes 0 0 0.0 0.00 0.00Other 2,176 92 3,106.7 23.66 6.12

$84,922 1,042 35,187.2 $81.50 $238.98All Services $110,948 4 4,297 135.1 145,104.8 $25.82 $312.21




Eligibility Category: Serious Emotionally Disturbed Child


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $25,968 4 56 20.9 292.8 $6,492.04 $11.31Surgical 37,742 3 38 15.7 198.7 12,580.75 16.44Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 380,384 24 290 125.5 1,516.1 15,849.34 165.71Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$444,094 31 384 162.1 2,007.5 $14,325.63 $193.47Hospital OutpatientEmergency Room $41,441 125 653.5 $331.53 $18.05Surgery 151 1 5.2 151.36 0.07Radiology 14,419 53 277.1 272.05 6.28Pathology 13,252 146 763.3 90.76 5.77Pharmacy 17,330 178 930.5 97.36 7.55Cardiovascular 662 4 20.9 165.48 0.29PT/OT/ST 11,570 358 1,871.5 32.32 5.04Psychiatric 1,022 6 31.4 170.28 0.45Substance Abuse 0 0 0.0 0.00 0.00Other 21,826 116 606.4 188.16 9.51

$121,673 987 5,159.8 $123.28 $53.01Professional and Other State Plan ServicesAmbulatory Surgery Center $1,064 4 20.9 $265.90 $0.46Office Visits 30,516 552 2,885.7 55.28 13.29Preventive Medicine 6,694 304 1,589.2 22.02 2.92Maternity 769 4 18.8 213.30 0.33Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 16,451 557 2,911.9 29.53 7.17Psychiatric and Substance Abuse 5,325 96 501.9 55.47 2.32Radiology and Pathology 5,657 347 1,814.0 16.30 2.46Home Health and Private Duty Nursing 31,923 3,433 17,946.9 9.30 13.91Ambulance 5,968 435 2,274.1 13.72 2.60Non-Emergency Transportation 3,862 29 151.6 133.19 1.68Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 13,527 113 590.7 119.71 5.89Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 48,707 25,476 133,182.4 1.91 21.22Other 37,541 1,839 9,613.9 20.41 16.35

$208,003 33,189 173,502.1 $6.27 $90.62Prescription DrugsGeneric Scripts $67,805 2,888 15,097.8 $23.48 $29.54Single-Source Brand 90,552 411 2,148.6 220.32 39.45Multi-Source Brand 199,312 487 2,545.9 409.26 86.83Specialty 211,656 43 224.8 4,922.23 92.21Other 0 0 0.0 0.00 0.00

$569,324 3,829 20,017.1 $148.69 $248.02Mental Health CenterCase Management $496,382 1,386 7,245.7 $358.14 $216.25Long Term Support Service 400,640 17,278 90,325.3 23.19 174.54Partial Hospital 11,013 113 590.7 97.46 4.80Psychotherapy 242,086 5,313 27,775.1 45.56 105.46Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 590 19 99.3 31.06 0.26Emergency Service 24/7 235 10 52.3 23.46 0.10APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 52,174 572 2,990.3 91.21 22.73

$1,203,120 24,691 129,078.7 $48.73 $524.14All Services $2,546,215 31 63,080 162.1 329,765.1 $40.37 $1,109.25



SFY 2016 MCO Encounter Base Experience Data

Eligibility Category: Low Income Children - Age 2-11 Months


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $843,689 362 1,346 78.0 289.8 $2,330.63 $15.14Surgical 1,296,987 39 363 8.4 78.2 33,256.07 23.27Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$2,140,675 401 1,709 86.3 368.0 $5,338.34 $38.41Hospital OutpatientEmergency Room $773,095 3,823 823.2 $202.22 $13.87Surgery 146,088 204 43.9 716.12 2.62Radiology 156,368 861 185.4 181.61 2.81Pathology 54,520 5,734 1,234.7 9.51 0.98Pharmacy 63,991 5,607 1,207.4 11.41 1.15Cardiovascular 51,542 222 47.8 232.17 0.92PT/OT/ST 59,153 1,952 420.3 30.30 1.06Psychiatric 449 1 0.2 448.50 0.01Substance Abuse 0 0 0.0 0.00 0.00Other 531,207 9,903 2,132.4 53.64 9.53

$1,836,412 28,307 6,095.4 $64.87 $32.95Professional and Other State Plan ServicesAmbulatory Surgery Center $12,360 33 7.1 $374.55 $0.22Office Visits 908,810 16,906 3,640.4 53.76 16.31Preventive Medicine 1,119,290 58,995 12,703.6 18.97 20.09Maternity 0 0 0.0 0.00 0.00Certified Midwife 4,706 117 25.2 40.22 0.08PT/OT/ST 26,033 944 203.3 27.58 0.47Psychiatric and Substance Abuse 705 7 1.5 100.71 0.01Radiology and Pathology 59,729 4,679 1,007.5 12.77 1.07Home Health and Private Duty Nursing 205,689 7,156 1,540.9 28.74 3.69Ambulance 59,298 3,506 755.0 16.91 1.06Non-Emergency Transportation 86,941 28,563 6,150.6 3.04 1.56Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 1,065,376 12,187 2,624.3 87.42 19.12Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,280,755 563,952 121,437.5 2.27 22.98Other 866,722 35,562 7,657.7 24.37 15.55

$5,696,415 732,607 157,754.5 $7.78 $102.22Prescription DrugsGeneric Scripts $231,956 13,479 2,902.5 $17.21 $4.16Single-Source Brand 165,713 1,079 232.3 153.58 2.97Multi-Source Brand 14,103 150 32.3 94.02 0.25Specialty 379,296 143 30.8 2,652.42 6.81Other 0 0 0.0 0.00 0.00

$791,067 14,851 3,197.9 $53.27 $14.20Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 0 0 0.0 0.00 0.00Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 0 0 0.0 0.00 0.00Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$0 0 0.0 $0.00 $0.00All Services $10,464,569 401 777,474 86.3 167,415.8 $13.46 $187.78




Eligibility Category: Low Income Children - Age 1-18 Years


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $3,111,488 605 2,267 8.0 29.8 $5,142.96 $3.41Surgical 2,983,834 215 1,132 2.8 14.9 13,878.30 3.27Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 15,547 7 27 0.1 0.4 2,220.95 0.02Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 2,542,096 308 2,526 4.0 33.2 8,253.56 2.78Alcohol and Drug Abuse 29,458 6 25 0.1 0.3 4,909.61 0.03Other 141 2 2 0.0 0.0 70.58 0.00

$8,682,564 1,143 5,979 15.0 78.6 $7,596.29 $9.51Hospital OutpatientEmergency Room $8,534,093 28,859 379.2 $295.72 $9.35Surgery 3,290,435 3,362 44.2 978.71 3.60Radiology 3,093,775 13,900 182.7 222.57 3.39Pathology 1,026,529 99,923 1,313.1 10.27 1.12Pharmacy 1,748,344 133,157 1,749.8 13.13 1.91Cardiovascular 380,773 1,377 18.1 276.52 0.42PT/OT/ST 1,026,560 30,757 404.2 33.38 1.12Psychiatric 141,410 753 9.9 187.80 0.15Substance Abuse 98 1 0.0 98.34 0.00Other 4,583,726 168,504 2,214.3 27.20 5.02

$23,825,743 480,593 6,315.4 $49.58 $26.09Professional and Other State Plan ServicesAmbulatory Surgery Center $385,476 1,141 15.0 $337.84 $0.42Office Visits 8,775,289 156,400 2,055.2 56.11 9.61Preventive Medicine 3,528,524 149,237 1,961.1 23.64 3.86Maternity 66,199 286 3.8 231.84 0.07Certified Midwife 995 7 0.1 150.61 0.00PT/OT/ST 1,998,179 62,295 818.6 32.08 2.19Psychiatric and Substance Abuse 3,589,963 54,357 714.3 66.04 3.93Radiology and Pathology 1,165,767 78,882 1,036.6 14.78 1.28Home Health and Private Duty Nursing 817,638 63,884 839.5 12.80 0.90Ambulance 452,242 25,130 330.2 18.00 0.50Non-Emergency Transportation 1,173,559 533,266 7,007.6 2.20 1.29Opioid Treatment Program 8,922 873 11.5 10.22 0.01Federally Qualified and Rural Health Clinics 5,626,450 47,926 629.8 117.40 6.16Adult Medical Day Care 88 8 0.1 10.94 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 2,994,578 1,040,076 13,667.5 2.88 3.28Other 6,656,076 488,022 6,413.0 13.64 7.29

$37,239,947 2,701,789 35,503.8 $13.78 $40.78Prescription DrugsGeneric Scripts $10,214,834 265,002 3,482.4 $38.55 $11.19Single-Source Brand 9,372,546 50,095 658.3 187.10 10.26Multi-Source Brand 2,496,576 8,696 114.3 287.09 2.73Specialty 7,770,331 1,935 25.4 4,015.67 8.51Other 61 7 0.1 8.70 0.00

$29,854,348 325,735 4,280.4 $91.65 $32.69Mental Health CenterCase Management $1,360,932 3,800 49.9 $358.14 $1.49Long Term Support Service 756,807 18,606 244.5 40.68 0.83Partial Hospital 3,136 32 0.4 97.99 0.00Psychotherapy 699,930 12,727 167.2 55.00 0.77Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 586 22 0.3 26.64 0.00Emergency Service 24/7 1,126 48 0.6 23.46 0.00APRTP 7,686 14 0.2 549.00 0.01Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 600,548 4,755 62.5 126.30 0.66

$3,430,752 40,004 525.7 $85.76 $3.76All Services $103,033,353 1,143 3,554,100 15.0 46,703.9 $28.99 $112.83




Eligibility Category: Low Income Adults


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $1,356,519 431 1,572 33.0 120.3 $3,147.38 $8.65Surgical 1,567,292 218 975 16.7 74.6 7,189.41 10.00Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 350,465 152 542 11.6 41.5 2,305.69 2.24Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 292,227 77 440 5.9 33.7 3,795.15 1.86Alcohol and Drug Abuse 52,670 23 120 1.8 9.2 2,290.00 0.34Other 0 0 0 0.0 0.0 0.00 0.00

$3,619,173 901 3,649 69.0 279.3 $4,016.84 $23.09Hospital OutpatientEmergency Room $5,713,268 11,472 878.2 $498.02 $36.45Surgery 1,683,481 1,914 146.5 879.56 10.74Radiology 2,157,456 13,175 1,008.6 163.75 13.76Pathology 1,007,351 82,228 6,294.8 12.25 6.43Pharmacy 936,278 172,467 13,202.9 5.43 5.97Cardiovascular 154,468 973 74.5 158.75 0.99PT/OT/ST 521,056 17,361 1,329.0 30.01 3.32Psychiatric 4,234 81 6.2 52.28 0.03Substance Abuse 3,524 22 1.7 160.19 0.02Other 2,496,542 94,678 7,247.9 26.37 15.93

$14,677,659 394,371 30,190.4 $37.22 $93.64Professional and Other State Plan ServicesAmbulatory Surgery Center $151,548 493 37.7 $307.40 $0.97Office Visits 3,065,295 53,039 4,060.3 57.79 19.55Preventive Medicine 1,075,971 28,943 2,215.7 37.18 6.86Maternity 1,247,653 5,115 391.6 243.91 7.96Certified Midwife 32,412 210 16.1 154.04 0.21PT/OT/ST 275,443 11,650 891.8 23.64 1.76Psychiatric and Substance Abuse 1,499,259 17,695 1,354.6 84.73 9.56Radiology and Pathology 1,848,304 75,804 5,803.1 24.38 11.79Home Health and Private Duty Nursing 163,392 4,058 310.7 40.26 1.04Ambulance 300,049 14,071 1,077.2 21.32 1.91Non-Emergency Transportation 2,326,253 213,082 16,312.2 10.92 14.84Opioid Treatment Program 1,791,129 175,257 13,416.5 10.22 11.43Federally Qualified and Rural Health Clinics 2,836,124 22,666 1,735.2 125.13 18.09Adult Medical Day Care 28,308 1,217 93.2 23.26 0.18Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 748,651 42,810 3,277.3 17.49 4.78Other 3,405,124 303,738 23,252.2 11.21 21.72

$20,794,916 969,849 74,245.2 $21.44 $132.66Prescription DrugsGeneric Scripts $4,580,994 197,052 15,085.0 $23.25 $29.22Single-Source Brand 5,736,954 29,244 2,238.7 196.18 36.60Multi-Source Brand 697,862 2,754 210.8 253.40 4.45Specialty 3,073,322 1,025 78.5 2,998.36 19.61Other 257 4 0.3 64.18 0.00

$14,089,388 230,079 17,613.3 $61.24 $89.88Mental Health CenterCase Management $101,712 284 21.7 $358.14 $0.65Long Term Support Service 93,432 1,591 121.8 58.73 0.60Partial Hospital 938 10 0.8 93.77 0.01Psychotherapy 281,513 5,599 428.6 50.28 1.80Evidence Based Practice 472 23 1.8 20.51 0.00Medication Management 320 12 0.9 26.64 0.00Emergency Service 24/7 282 12 0.9 23.46 0.00APRTP 28,548 52 4.0 549.00 0.18Supported Employment Services 3,397 115 8.8 29.54 0.02Harbor Homes 5 1 0.1 5.00 0.00Other 176,104 1,860 142.4 94.68 1.12

$686,722 9,559 731.8 $71.84 $4.38All Services $53,867,859 901 1,607,507 69.0 123,060.1 $33.51 $343.65






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$1,017,407 60 600 39.8 398.4 $16,956.78 $56.30Hospital OutpatientEmergency Room $260,457 651 432.3 $400.09 $14.41Surgery 91,704 90 59.8 1,018.93 5.07Radiology 70,967 369 245.0 192.32 3.93Pathology 35,092 3,056 2,029.2 11.48 1.94Pharmacy 9,377 3,997 2,654.0 2.35 0.52Cardiovascular 15,477 66 43.8 234.50 0.86PT/OT/ST 31,800 1,004 666.6 31.67 1.76Psychiatric 891 14 9.3 63.64 0.05Substance Abuse 0 0 0.0 0.00 0.00Other 160,853 7,490 4,973.3 21.48 8.90

$676,616 16,737 11,113.2 $40.43 $37.44Professional and Other State Plan ServicesAmbulatory Surgery Center $4,284 16 10.6 $267.73 $0.24Office Visits 204,793 3,620 2,403.6 56.57 11.33Preventive Medicine 65,918 2,708 1,798.1 24.34 3.65Maternity 5,302 25 16.4 215.18 0.29Certified Midwife 661 6 4.0 110.18 0.04PT/OT/ST 59,882 2,060 1,367.8 29.07 3.31Psychiatric and Substance Abuse 292,751 5,263 3,494.6 55.62 16.20Radiology and Pathology 54,265 2,839 1,885.1 19.11 3.00Home Health and Private Duty Nursing 129,606 7,506 4,983.9 17.27 7.17Ambulance 19,389 830 551.1 23.36 1.07Non-Emergency Transportation 37,886 12,432 8,254.7 3.05 2.10Opioid Treatment Program 9,924 971 644.7 10.22 0.55Federally Qualified and Rural Health Clinics 123,607 1,093 725.7 113.09 6.84Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 178,866 101,803 67,596.3 1.76 9.90Other 212,377 18,814 12,492.3 11.29 11.75

$1,399,510 159,986 106,229.1 $8.75 $77.44Prescription DrugsGeneric Scripts $706,241 15,367 10,203.6 $45.96 $39.08Single-Source Brand 334,183 1,679 1,114.8 199.04 18.49Multi-Source Brand 290,041 724 480.7 400.61 16.05Specialty 537,295 157 104.2 3,422.26 29.73Other 6 3 2.0 2.07 0.00

$1,867,767 17,930 11,905.4 $104.17 $103.35Mental Health CenterCase Management $58,735 164 108.9 $358.14 $3.25Long Term Support Service 28,462 493 327.3 57.73 1.57Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 27,622 447 296.8 61.79 1.53Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 3,294 6 4.0 549.00 0.18Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 36,906 278 184.6 132.76 2.04

$155,020 1,388 921.6 $111.69 $8.58All Services $5,116,320 60 196,641 39.8 130,567.7 $26.02 $283.10




Eligibility Category: Breast and Cervical Cancer Program


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$69,264 16 58 120.0 435.2 $4,328.99 $43.31Hospital OutpatientEmergency Room $60,295 83 622.7 $726.45 $37.70Surgery 101,864 113 847.8 901.45 63.69Radiology 228,180 1,122 8,418.1 203.37 142.67Pathology 20,348 1,727 12,957.3 11.78 12.72Pharmacy 692,408 48,110 360,959.8 14.39 432.92Cardiovascular 2,847 36 270.1 79.08 1.78PT/OT/ST 16,167 602 4,516.7 26.85 10.11Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 94,735 5,570 41,790.6 17.01 59.23

$1,216,844 57,363 430,383.2 $21.21 $760.81Professional and Other State Plan ServicesAmbulatory Surgery Center $3,707 11 82.5 $337.03 $2.32Office Visits 72,173 1,229 9,220.9 58.72 45.12Preventive Medicine 6,004 139 1,042.9 43.19 3.75Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 7,757 332 2,490.9 23.36 4.85Psychiatric and Substance Abuse 12,967 183 1,373.0 70.86 8.11Radiology and Pathology 58,503 1,660 12,454.7 35.24 36.58Home Health and Private Duty Nursing 20,076 543 4,074.0 36.97 12.55Ambulance 1,859 55 412.7 33.79 1.16Non-Emergency Transportation 7,206 1,301 9,761.1 5.54 4.51Opioid Treatment Program 3,730 365 2,738.5 10.22 2.33Federally Qualified and Rural Health Clinics 22,510 156 1,170.4 144.29 14.07Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 11,381 1,453 10,901.6 7.83 7.12Other 221,558 14,010 105,114.2 15.81 138.53

$449,431 21,437 160,837.6 $20.97 $281.00Prescription DrugsGeneric Scripts $77,618 3,512 26,349.8 $22.10 $48.53Single-Source Brand 68,844 285 2,138.3 241.56 43.04Multi-Source Brand 9,427 46 345.1 204.93 5.89Specialty 239,554 49 367.6 4,888.86 149.78Other 0 0 0.0 0.00 0.00

$395,443 3,892 29,200.9 $101.60 $247.24Mental Health CenterCase Management $3,940 11 82.5 $358.14 $2.46Long Term Support Service 252 3 22.5 83.91 0.16Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 1,830 24 180.1 76.26 1.14Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 2,196 4 30.0 549.00 1.37Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 1,615 19 142.6 84.99 1.01

$9,832 61 457.7 $161.19 $6.15All Services $2,140,814 16 82,811 120.0 621,314.5 $25.85 $1,338.51






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$782,897 28 262 61.1 572.0 $27,960.60 $142.45Hospital OutpatientEmergency Room $46,166 106 231.4 $435.53 $8.40Surgery 42,131 34 74.2 1,239.14 7.67Radiology 52,935 225 491.3 235.27 9.63Pathology 19,996 1,591 3,473.7 12.57 3.64Pharmacy 16,111 3,231 7,054.4 4.99 2.93Cardiovascular 14,277 66 144.1 216.32 2.60PT/OT/ST 70,223 1,961 4,281.6 35.81 12.78Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 120,539 1,293 2,823.1 93.22 21.93

$382,378 8,507 18,573.8 $44.95 $69.57Professional and Other State Plan ServicesAmbulatory Surgery Center $22,601 10 21.8 $2,260.12 $4.11Office Visits 77,589 1,236 2,698.6 62.77 14.12Preventive Medicine 9,067 407 888.6 22.28 1.65Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 116,583 4,290 9,366.6 27.18 21.21Psychiatric and Substance Abuse 32,765 1,017 2,220.5 32.22 5.96Radiology and Pathology 22,380 712 1,554.5 31.43 4.07Home Health and Private Duty Nursing 811,154 91,852 200,545.5 8.83 147.59Ambulance 6,014 561 1,224.9 10.72 1.09Non-Emergency Transportation 20,663 4,076 8,899.4 5.07 3.76Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 12,442 100 218.3 124.42 2.26Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 371,448 221,998 484,700.5 1.67 67.58Other 239,494 9,484 20,706.9 25.25 43.58

$1,742,200 335,743 733,046.2 $5.19 $316.99Prescription DrugsGeneric Scripts $265,175 6,376 13,921.1 $41.59 $48.25Single-Source Brand 403,757 981 2,141.9 411.58 73.46Multi-Source Brand 110,431 296 646.3 373.08 20.09Specialty 992,072 221 482.5 4,489.01 180.50Other 8,000 0 0.0 0.00 1.46

$1,779,435 7,874 17,191.7 $225.99 $323.76Mental Health CenterCase Management $21,847 61 133.2 $358.14 $3.97Long Term Support Service 15,190 515 1,124.4 29.50 2.76Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 16,568 344 751.1 48.16 3.01Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 282 12 26.2 23.46 0.05APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 6,583 66 144.1 99.74 1.20

$60,469 998 2,179.0 $60.59 $11.00All Services $4,747,378 28 353,384 61.1 771,562.8 $13.43 $863.77




Eligibility Category: Elderly and Disabled Adults


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $4,702,613 1,249 6,308 180.4 911.0 $3,765.10 $56.60Surgical 4,252,146 429 3,816 62.0 551.1 9,911.76 51.17Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 16,069 7 29 1.0 4.2 2,295.61 0.19Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 720,454 154 1,157 22.2 167.1 4,678.27 8.67Alcohol and Drug Abuse 189,032 66 360 9.5 52.0 2,864.12 2.27Other 1,339 29 45 4.2 6.5 46.17 0.02

$9,881,653 1,934 11,715 279.3 1,691.9 $5,109.44 $118.92Hospital OutpatientEmergency Room $4,957,358 8,363 1,207.8 $592.77 $59.66Surgery 1,614,761 2,272 328.1 710.72 19.43Radiology 2,379,492 10,741 1,551.2 221.53 28.64Pathology 756,751 64,534 9,319.8 11.73 9.11Pharmacy 1,981,392 276,124 39,877.2 7.18 23.85Cardiovascular 272,513 1,430 206.5 190.57 3.28PT/OT/ST 612,224 20,647 2,981.8 29.65 7.37Psychiatric 65,116 170 24.6 383.03 0.78Substance Abuse 225 2 0.3 112.29 0.00Other 3,072,581 73,430 10,604.6 41.84 36.98

$15,712,412 457,713 66,101.8 $34.33 $189.10Professional and Other State Plan ServicesAmbulatory Surgery Center $254,135 844 121.9 $301.11 $3.06Office Visits 2,650,079 44,307 6,398.7 59.81 31.89Preventive Medicine 230,013 10,007 1,445.2 22.99 2.77Maternity 30,085 168 24.2 179.52 0.36Certified Midwife 149 3 0.4 49.76 0.00PT/OT/ST 237,833 9,958 1,438.1 23.88 2.86Psychiatric and Substance Abuse 743,634 9,735 1,405.9 76.39 8.95Radiology and Pathology 1,174,905 50,911 7,352.4 23.08 14.14Home Health and Private Duty Nursing 1,460,090 68,966 9,959.9 21.17 17.57Ambulance 588,833 24,587 3,550.8 23.95 7.09Non-Emergency Transportation 2,171,073 146,705 21,186.8 14.80 26.13Opioid Treatment Program 773,602 75,695 10,931.7 10.22 9.31Federally Qualified and Rural Health Clinics 1,625,501 11,904 1,719.1 136.55 19.56Adult Medical Day Care 512,375 21,348 3,083.0 24.00 6.17Personal Care 596,409 110,507 15,959.2 5.40 7.18Durable Medical Equipment 1,855,636 348,822 50,376.0 5.32 22.33Other 4,928,471 306,208 44,221.8 16.10 59.31

$19,832,824 1,240,675 179,175.2 $15.99 $238.68Prescription DrugsGeneric Scripts $6,699,170 267,052 38,567.0 $25.09 $80.62Single-Source Brand 11,750,535 43,625 6,300.2 269.35 141.42Multi-Source Brand 2,000,005 5,723 826.5 349.47 24.07Specialty 8,467,176 3,182 459.5 2,660.96 101.90Other 37 3 0.4 12.20 0.00

$28,916,923 319,585 46,153.7 $90.48 $348.01Mental Health CenterCase Management $324,475 906 130.8 $358.14 $3.90Long Term Support Service 282,089 6,939 1,002.1 40.65 3.39Partial Hospital 28,569 301 43.5 94.91 0.34Psychotherapy 285,803 6,252 902.9 45.71 3.44Evidence Based Practice 5,561 320 46.2 17.38 0.07Medication Management 8,950 274 39.6 32.66 0.11Emergency Service 24/7 680 29 4.2 23.46 0.01APRTP 48,861 89 12.9 549.00 0.59Supported Employment Services 26,912 852 123.0 31.59 0.32Harbor Homes 11 2 0.3 5.53 0.00Other 226,826 2,637 380.8 86.02 2.73

$1,238,735 18,601 2,686.3 $66.60 $14.91All Services $75,582,546 1,934 2,048,289 279.3 295,808.9 $36.90 $909.62






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $805,796 520 2,689 104.3 539.1 $1,549.61 $13.46Surgical 362,923 200 1,207 40.1 242.0 1,814.61 6.06Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 10,347 7 11 1.4 2.2 1,478.14 0.17Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 70,129 31 245 6.2 49.1 2,262.21 1.17Alcohol and Drug Abuse 25,871 15 76 3.0 15.2 1,724.75 0.43Other 92 5 5 1.0 1.0 18.32 0.00

$1,275,158 778 4,233 156.0 848.7 $1,639.02 $21.31Hospital OutpatientEmergency Room $1,275,299 4,177 837.5 $305.31 $21.31Surgery 446,597 1,599 320.6 279.30 7.46Radiology 504,006 4,832 968.8 104.31 8.42Pathology 110,704 16,129 3,233.8 6.86 1.85Pharmacy 848,703 194,478 38,991.5 4.36 14.18Cardiovascular 57,735 836 167.6 69.06 0.96PT/OT/ST 118,828 8,996 1,803.6 13.21 1.99Psychiatric 5,030 120 24.1 41.92 0.08Substance Abuse 0 0 0.0 0.00 0.00Other 1,073,119 64,701 12,972.1 16.59 17.93

$4,440,021 295,868 59,319.5 $15.01 $74.18Professional and Other State Plan ServicesAmbulatory Surgery Center $66,980 415 83.2 $161.40 $1.12Office Visits 700,702 24,466 4,905.3 28.64 11.71Preventive Medicine 65,995 3,333 668.2 19.80 1.10Maternity 31,034 222 44.4 140.08 0.52Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 49,076 5,705 1,143.8 8.60 0.82Psychiatric and Substance Abuse 219,433 3,476 696.9 63.13 3.67Radiology and Pathology 200,288 14,781 2,963.5 13.55 3.35Home Health and Private Duty Nursing 120,618 5,502 1,103.1 21.92 2.02Ambulance 123,081 7,755 1,554.8 15.87 2.06Non-Emergency Transportation 1,318,944 96,288 19,305.1 13.70 22.04Opioid Treatment Program 524,524 51,323 10,289.9 10.22 8.76Federally Qualified and Rural Health Clinics 216,629 3,394 680.5 63.83 3.62Adult Medical Day Care 18,750 716 143.6 26.19 0.31Personal Care 350,528 65,217 13,075.6 5.37 5.86Durable Medical Equipment 385,857 131,080 26,280.7 2.94 6.45Other 1,141,380 208,308 41,764.3 5.48 19.07

$5,533,821 621,981 124,702.9 $8.90 $92.46Prescription DrugsGeneric Scripts $53,724 2,785 558.4 $19.29 $0.90Single-Source Brand 3,147 91 18.2 34.58 0.05Multi-Source Brand 523 15 3.0 34.84 0.01Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$57,394 2,891 579.6 $19.85 $0.96Mental Health CenterCase Management $218,115 609 122.1 $358.15 $3.64Long Term Support Service 173,101 4,183 838.7 41.38 2.89Partial Hospital 8,134 89 17.8 91.39 0.14Psychotherapy 105,724 3,342 670.0 31.63 1.77Evidence Based Practice 4,273 155 31.1 27.57 0.07Medication Management 5,249 194 38.9 27.06 0.09Emergency Service 24/7 422 18 3.6 23.46 0.01APRTP 27,999 51 10.2 549.00 0.47Supported Employment Services 15,844 557 111.7 28.45 0.26Harbor Homes 3,702 42 8.4 88.15 0.06Other 99,101 2,232 447.5 44.40 1.66

$661,664 11,472 2,300.1 $57.68 $11.05All Services $11,968,058 778 936,445 156.0 187,750.8 $12.78 $199.96




Eligibility Category: Newborn Kick Payment


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $4,019,501 997 6,520 377.5 2,468.8 $4,031.60 $1,521.96Surgical 122,246 15 136 5.7 51.5 8,149.72 46.29Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 983,708 1,744 3,788 660.4 1,434.3 564.05 372.48Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$5,125,454 2,756 10,444 1,043.5 3,954.6 $1,859.74 $1,940.72Hospital OutpatientEmergency Room $79,851 332 125.7 $240.52 $30.24Surgery 10,311 19 7.2 542.67 3.90Radiology 17,391 129 48.8 134.81 6.59Pathology 11,724 1,363 516.1 8.60 4.44Pharmacy 671 784 296.9 0.86 0.25Cardiovascular 523 29 11.0 18.02 0.20PT/OT/ST 2,430 46 17.4 52.82 0.92Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 116,354 2,031 769.0 57.29 44.06

$239,254 4,733 1,792.1 $50.55 $90.59Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 113,294 2,145 812.2 52.82 42.90Preventive Medicine 290,102 6,919 2,619.8 41.93 109.85Maternity 0 0 0.0 0.00 0.00Certified Midwife 543 13 4.9 41.80 0.21PT/OT/ST 370 14 5.3 26.45 0.14Psychiatric and Substance Abuse 0 0 0.0 0.00 0.00Radiology and Pathology 13,043 1,039 393.4 12.55 4.94Home Health and Private Duty Nursing 74,233 1,416 536.2 52.42 28.11Ambulance 51,787 2,397 907.6 21.60 19.61Non-Emergency Transportation 4,251 126 47.7 33.74 1.61Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 228,530 1,507 570.6 151.65 86.53Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 19,142 10,180 3,854.6 1.88 7.25Other 677,826 11,306 4,281.0 59.95 256.65

$1,473,122 37,062 14,033.3 $39.75 $557.79Prescription DrugsGeneric Scripts $8,117 607 229.8 $13.37 $3.07Single-Source Brand 1,692 23 8.7 73.55 0.64Multi-Source Brand 675 19 7.2 35.54 0.26Specialty 1,410 1 0.4 1,409.66 0.53Other 0 0 0.0 0.00 0.00

$11,894 650 246.1 $18.30 $4.50Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 0 0 0.0 0.00 0.00Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 0 0 0.0 0.00 0.00Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$0 0 0.0 $0.00 $0.00All Services $6,849,724 2,756 52,889 1,043.5 20,026.1 $129.51 $2,593.61




Eligibility Category: Neonatal Abstinence Syndrome Kick Payment

Member Months: 169

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $1,323,912 202 2,364 1,195.3 13,988.2 $6,554.02 $7,833.80Surgical 14,765 3 25 17.8 147.9 4,921.62 87.37Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 1,058 2 7 11.8 41.4 529.08 6.26Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$1,339,735 207 2,396 1,224.9 14,177.5 $6,472.15 $7,927.43Hospital OutpatientEmergency Room $5,164 17 100.6 $303.79 $30.56Surgery 0 0 0.0 0.00 0.00Radiology 667 5 29.6 133.49 3.95Pathology 440 57 337.3 7.72 2.60Pharmacy 982 26 153.8 37.76 5.81Cardiovascular 1,546 12 71.0 128.86 9.15PT/OT/ST 0 0 0.0 0.00 0.00Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 7,393 147 869.8 50.29 43.75

$16,193 264 1,562.1 $61.34 $95.82Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 6,098 116 686.4 52.57 36.08Preventive Medicine 21,396 460 2,721.9 46.51 126.60Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,887 84 497.0 22.46 11.16Psychiatric and Substance Abuse 0 0 0.0 0.00 0.00Radiology and Pathology 1,110 95 562.1 11.69 6.57Home Health and Private Duty Nursing 16,025 181 1,071.0 88.54 94.82Ambulance 2,276 112 662.7 20.32 13.47Non-Emergency Transportation 1,425 41 242.6 34.74 8.43Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 12,473 80 473.4 155.92 73.81Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 5,377 2,629 15,556.2 2.05 31.82Other 132,922 2,621 15,508.9 50.71 786.52

$200,989 6,419 37,982.2 $31.31 $1,189.28Prescription DrugsGeneric Scripts $579 51 301.8 $11.36 $3.43Single-Source Brand 44 2 11.8 21.76 0.26Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$623 53 313.6 $11.75 $3.69Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 0 0 0.0 0.00 0.00Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 0 0 0.0 0.00 0.00Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$0 0 0.0 $0.00 $0.00All Services $1,557,540 207 9,132 1,224.9 54,035.5 $170.56 $9,216.21




Eligibility Category: Maternity Kick Payment


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $211,886 104 266 30.7 78.5 $2,037.36 $62.54Surgical 35,322 10 23 3.0 6.8 3,532.16 10.43Maternity Delivery 5,904,853 2,610 7,007 770.4 2,068.2 2,262.40 1,742.87Maternity Non-Delivery 41,263 18 42 5.3 12.4 2,292.37 12.18Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$6,193,323 2,742 7,338 809.3 2,165.9 $2,258.69 $1,828.02Hospital OutpatientEmergency Room $21,870 30 8.9 $728.99 $6.46Surgery 4,333 6 1.8 722.15 1.28Radiology 7,819 63 18.6 124.11 2.31Pathology 7,079 573 169.1 12.35 2.09Pharmacy 8,535 2,549 752.4 3.35 2.52Cardiovascular 88 1 0.3 87.55 0.03PT/OT/ST 83 1 0.3 82.79 0.02Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 84,090 1,397 412.3 60.19 24.82

$133,896 4,620 1,363.6 $28.98 $39.52Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 4,354 88 26.0 49.47 1.29Preventive Medicine 3,508 174 51.4 20.16 1.04Maternity 1,927,235 4,222 1,246.2 456.45 568.84Certified Midwife 21,340 49 14.5 435.67 6.30PT/OT/ST 63 22 6.5 2.88 0.02Psychiatric and Substance Abuse 0 0 0.0 0.00 0.00Radiology and Pathology 7,524 396 116.9 19.00 2.22Home Health and Private Duty Nursing 4,271 65 19.2 65.70 1.26Ambulance 10,791 1,447 427.1 7.46 3.19Non-Emergency Transportation 0 0 0.0 0.00 0.00Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 6,460 48 14.1 135.18 1.91Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 110 2 0.6 55.23 0.03Other 38,342 2,297 678.0 16.69 11.32

$2,023,998 8,810 2,600.3 $229.74 $597.40Prescription DrugsGeneric Scripts $0 0 0.0 $0.00 $0.00Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00


$0 0 0.0 $0.00 $0.00All Services $8,351,216 2,742 20,768 809.3 6,129.9 $402.12 $2,464.94




Eligibility Category: Nursing Facility Residents - Medicaid Only - Age 0-64


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $229,059 47 284 437.8 2,645.6 $4,873.60 $177.82Surgical 480,672 23 529 214.3 4,927.9 20,898.79 373.14Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 13,659 3 34 27.9 316.7 4,553.11 10.60Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 19,221 128 141 1,192.4 1,313.5 150.17 14.92

$742,612 201 988 1,872.4 9,203.7 $3,694.59 $576.48Hospital OutpatientEmergency Room $80,264 100 931.5 $802.64 $62.31Surgery 26,615 77 717.3 345.65 20.66Radiology 38,815 175 1,630.2 221.80 30.13Pathology 23,642 2,530 23,568.1 9.34 18.35Pharmacy 127,175 5,656 52,688.2 22.49 98.72Cardiovascular 2,812 20 186.3 140.62 2.18PT/OT/ST 2,752 74 689.3 37.19 2.14Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 155,596 2,750 25,617.5 56.58 120.79

$457,673 11,382 106,028.6 $40.21 $355.29Professional and Other State Plan ServicesAmbulatory Surgery Center $5,931 5 46.6 $1,186.18 $4.60Office Visits 28,510 394 3,670.3 72.36 22.13Preventive Medicine 1,344 24 223.6 56.01 1.04Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,384 132 1,229.6 25.64 2.63Psychiatric and Substance Abuse 13,536 338 3,148.6 40.05 10.51Radiology and Pathology 20,963 1,509 14,057.0 13.89 16.27Home Health and Private Duty Nursing 71,432 1,211 11,281.0 58.99 55.45Ambulance 81,662 4,999 46,568.0 16.34 63.39Non-Emergency Transportation 68,011 2,203 20,522.0 30.87 52.80Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 22,249 152 1,415.9 146.38 17.27Adult Medical Day Care 295 6 55.9 49.24 0.23Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 104,080 6,650 61,947.8 15.65 80.80Other 172,125 9,105 84,817.3 18.90 133.62

$593,524 26,728 248,983.6 $22.21 $460.75Prescription DrugsGeneric Scripts $371,931 14,132 131,646.1 $26.32 $288.73Single-Source Brand 398,911 1,191 11,094.7 334.94 309.67Multi-Source Brand 58,023 161 1,499.8 360.39 45.04Specialty 323,617 73 680.0 4,433.10 251.22Other 8 2 18.6 3.93 0.01


$10,606 120 1,117.9 $88.38 $8.23All Services $2,956,904 201 54,777 1,872.4 510,272.9 $53.98 $2,295.41




Eligibility Category: Nursing Facility Residents - Medicaid Only - Age 65+

Member Months: 871

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $114,247 31 149 427.3 2,053.9 $3,685.39 $131.24Surgical 90,253 5 152 68.9 2,095.3 18,050.59 103.67Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 4,098 21 21 289.5 289.5 195.16 4.71

$208,598 57 322 785.7 4,438.6 $3,659.62 $239.62Hospital OutpatientEmergency Room $44,451 52 716.8 $854.82 $51.06Surgery 8,922 17 234.3 524.81 10.25Radiology 33,748 101 1,392.2 334.14 38.77Pathology 15,855 1,461 20,139.3 10.85 18.21Pharmacy 5,956 2,495 34,392.5 2.39 6.84Cardiovascular 2,539 8 110.3 317.40 2.92PT/OT/ST 485 8 110.3 60.62 0.56Psychiatric 4,250 22 303.3 193.18 4.88Substance Abuse 0 0 0.0 0.00 0.00Other 116,052 884 12,185.6 131.28 133.31

$232,258 5,048 69,584.5 $46.01 $266.80Professional and Other State Plan ServicesAmbulatory Surgery Center $1,155 3 41.4 $384.99 $1.33Office Visits 8,298 142 1,957.4 58.44 9.53Preventive Medicine 134 8 110.3 16.78 0.15Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 577 25 344.6 23.08 0.66Psychiatric and Substance Abuse 3,700 85 1,171.7 43.52 4.25Radiology and Pathology 10,683 625 8,615.4 17.09 12.27Home Health and Private Duty Nursing 126,599 877 12,089.1 144.35 145.43Ambulance 23,806 893 12,309.6 26.66 27.35Non-Emergency Transportation 29,019 1,265 17,437.5 22.94 33.33Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 14,131 90 1,240.6 157.01 16.23Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 10,275 1,601 22,069.1 6.42 11.80Other 61,390 2,819 38,858.7 21.78 70.52


$385,581 9,226 127,176.5 $41.79 $442.92Mental Health CenterCase Management $3,223 9 124.1 $358.14 $3.70Long Term Support Service 420 5 68.9 83.91 0.48Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 320 6 82.7 53.29 0.37Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 80 3 41.4 26.64 0.09Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 396 6 82.7 65.98 0.45

$4,438 29 399.8 $153.05 $5.10All Services $1,120,641 57 23,058 785.7 317,844.7 $48.60 $1,287.30






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $66,527 45 288 249.1 1,594.1 $1,478.38 $30.69Surgical 66,317 11 226 60.9 1,250.9 6,028.78 30.59Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 14,107 74 165 409.6 913.3 190.64 6.51

$146,951 130 679 719.5 3,758.2 $1,130.39 $67.78Hospital OutpatientEmergency Room $29,025 78 431.7 $372.11 $13.39Surgery 25,894 96 531.4 269.73 11.94Radiology 17,159 137 758.3 125.25 7.91Pathology 3,344 669 3,702.9 5.00 1.54Pharmacy 24,449 9,613 53,207.1 2.54 11.28Cardiovascular 1,523 17 94.1 89.57 0.70PT/OT/ST 1,568 60 332.1 26.14 0.72Psychiatric 25 1 5.5 25.30 0.01Substance Abuse 0 0 0.0 0.00 0.00Other 53,407 3,106 17,191.4 17.19 24.63

$156,393 13,777 76,254.5 $11.35 $72.14Professional and Other State Plan ServicesAmbulatory Surgery Center $379 2 11.1 $189.41 $0.17Office Visits 13,267 499 2,761.9 26.59 6.12Preventive Medicine 142 6 33.2 23.70 0.07Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 330 40 221.4 8.25 0.15Psychiatric and Substance Abuse 8,688 433 2,396.6 20.06 4.01Radiology and Pathology 4,725 545 3,016.5 8.67 2.18Home Health and Private Duty Nursing 4,628 78 431.7 59.33 2.13Ambulance 31,220 1,442 7,981.3 21.65 14.40Non-Emergency Transportation 95,907 3,515 19,455.2 27.29 44.24Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 7,036 97 536.9 72.54 3.25Adult Medical Day Care 49 1 5.5 49.25 0.02Personal Care 1,689 312 1,726.9 5.41 0.78Durable Medical Equipment 20,443 2,396 13,261.7 8.53 9.43Other 63,541 7,350 40,681.6 8.65 29.31


$8,228 1,727 9,558.8 $4.76 $3.80Mental Health CenterCase Management $5,373 15 83.0 $358.21 $2.48Long Term Support Service 1,510 36 199.3 41.93 0.70Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 3,118 41 226.9 76.05 1.44Evidence Based Practice 80 3 16.6 26.54 0.04Medication Management 1,801 34 188.2 52.97 0.83Emergency Service 24/7 117 5 27.7 23.46 0.05APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 891 25 138.4 35.63 0.41

$12,889 159 880.1 $81.06 $5.95All Services $576,505 130 33,058 719.5 182,973.2 $17.44 $265.91






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $365,185 271 1,419 136.5 714.9 $1,347.55 $15.33Surgical 86,309 56 378 28.2 190.4 1,541.24 3.62Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 13,818 9 183 4.5 92.2 1,535.33 0.58Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 24,421 253 421 127.5 212.1 96.53 1.03

$489,734 589 2,401 296.7 1,209.6 $831.47 $20.56Hospital OutpatientEmergency Room $187,253 411 207.1 $455.60 $7.86Surgery 40,526 199 100.3 203.65 1.70Radiology 122,589 799 402.5 153.43 5.15Pathology 9,427 1,533 772.3 6.15 0.40Pharmacy 28,619 8,492 4,278.3 3.37 1.20Cardiovascular 22,077 143 72.0 154.38 0.93PT/OT/ST 4,690 98 49.4 47.86 0.20Psychiatric 543 15 7.6 36.20 0.02Substance Abuse 0 0 0.0 0.00 0.00Other 126,084 5,729 2,886.3 22.01 5.29

$541,808 17,419 8,775.8 $31.10 $22.75Professional and Other State Plan ServicesAmbulatory Surgery Center $3,617 22 11.1 $164.40 $0.15Office Visits 37,274 1,483 747.1 25.13 1.56Preventive Medicine 3,428 208 104.8 16.48 0.14Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 449 70 35.3 6.41 0.02Psychiatric and Substance Abuse 30,323 1,499 755.2 20.23 1.27Radiology and Pathology 27,741 2,301 1,159.3 12.06 1.16Home Health and Private Duty Nursing 23,120 279 140.6 82.87 0.97Ambulance 68,492 3,153 1,588.5 21.72 2.88Non-Emergency Transportation 367,372 22,751 11,462.1 16.15 15.42Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 16,804 460 231.8 36.53 0.71Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 78,044 9,129 4,599.2 8.55 3.28Other 399,543 27,240 13,723.6 14.67 16.77

$1,056,206 68,595 34,558.5 $15.40 $44.34Prescription DrugsGeneric Scripts $66,309 15,878 7,999.4 $4.18 $2.78Single-Source Brand 2,711 240 120.9 11.29 0.11Multi-Source Brand 877 60 30.2 14.62 0.04Specialty 0 0 0.0 0.00 0.00Other 72 9 4.5 8.05 0.00

$69,969 16,187 8,155.1 $4.32 $2.94Mental Health CenterCase Management $716 2 1.0 $358.14 $0.03Long Term Support Service 3,377 41 20.7 82.36 0.14Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 1,327 38 19.1 34.93 0.06Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 1,151 43 21.7 26.77 0.05

$6,571 124 62.5 $53.00 $0.28All Services $2,164,288 589 104,726 296.7 52,761.4 $20.67 $90.86




Eligibility Category: Community Residents - Medicaid Only - Age 0-64


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $564,658 131 779 472.7 2,811.2 $4,310.36 $169.81Surgical 370,579 30 638 108.3 2,302.4 12,352.65 111.44Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 17,418 3 36 10.8 129.9 5,805.89 5.24Alcohol and Drug Abuse 4,158 2 4 7.2 14.4 2,079.16 1.25Other 61 1 1 3.6 3.6 61.19 0.02

$956,874 167 1,458 602.7 5,261.5 $5,729.79 $287.76Hospital OutpatientEmergency Room $285,208 423 1,526.5 $674.25 $85.77Surgery 87,715 145 523.3 604.93 26.38Radiology 124,565 570 2,057.0 218.53 37.46Pathology 41,030 4,296 15,503.1 9.55 12.34Pharmacy 115,119 16,003 57,750.5 7.19 34.62Cardiovascular 11,080 78 281.5 142.04 3.33PT/OT/ST 50,258 1,831 6,607.6 27.45 15.11Psychiatric 65 1 3.6 65.00 0.02Substance Abuse 0 0 0.0 0.00 0.00Other 168,853 2,925 10,555.5 57.73 50.78

$883,892 26,272 94,808.6 $33.64 $265.81Professional and Other State Plan ServicesAmbulatory Surgery Center $7,522 22 79.4 $341.89 $2.26Office Visits 148,162 2,517 9,083.2 58.86 44.56Preventive Medicine 8,174 339 1,223.4 24.11 2.46Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 10,362 426 1,537.3 24.32 3.12Psychiatric and Substance Abuse 15,752 225 812.0 70.01 4.74Radiology and Pathology 47,203 2,585 9,328.6 18.26 14.20Home Health and Private Duty Nursing 429,807 17,094 61,687.7 25.14 129.25Ambulance 96,371 2,795 10,086.4 34.48 28.98Non-Emergency Transportation 214,303 6,786 24,488.9 31.58 64.45Opioid Treatment Program 3,914 383 1,382.1 10.22 1.18Federally Qualified and Rural Health Clinics 89,167 665 2,399.8 134.09 26.81Adult Medical Day Care 22,950 946 3,413.9 24.26 6.90Personal Care 862,224 159,773 576,577.9 5.40 259.29Durable Medical Equipment 530,985 221,668 799,940.4 2.40 159.68Other 569,771 27,139 97,937.4 20.99 171.35

$3,056,667 443,363 1,599,978.2 $6.89 $919.22Prescription DrugsGeneric Scripts $618,210 25,825 93,195.5 $23.94 $185.91Single-Source Brand 1,063,378 3,517 12,691.9 302.35 319.79Multi-Source Brand 128,108 352 1,270.3 363.94 38.53Specialty 1,277,560 307 1,107.9 4,161.43 384.20Other 0 0 0.0 0.00 0.00

$3,087,256 30,001 108,265.6 $102.91 $928.42Mental Health CenterCase Management $185,875 519 1,872.9 $358.14 $55.90Long Term Support Service 162,716 6,603 23,828.5 24.64 48.93Partial Hospital 6,593 66 238.2 99.90 1.98Psychotherapy 42,479 712 2,569.4 59.66 12.77Evidence Based Practice 3,026 114 411.4 26.54 0.91Medication Management 3,327 106 382.5 31.39 1.00Emergency Service 24/7 2,815 120 433.0 23.46 0.85APRTP 8,235 15 54.1 549.00 2.48Supported Employment Services 8,599 324 1,169.2 26.54 2.59Harbor Homes 43,800 365 1,317.2 120.00 13.17Other 24,226 336 1,212.5 72.10 7.29

$491,692 9,280 33,489.0 $52.98 $147.87All Services $8,476,382 167 510,374 602.7 1,841,803.0 $16.61 $2,549.08




Eligibility Category: Community Residents - Medicaid Only - Age 65+


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$316,284 75 530 553.0 3,907.8 $4,217.12 $194.34Hospital OutpatientEmergency Room $121,669 115 847.9 $1,058.00 $74.76Surgery 16,066 24 177.0 669.43 9.87Radiology 45,561 211 1,555.8 215.93 27.99Pathology 16,590 1,870 13,788.1 8.87 10.19Pharmacy 9,215 6,613 48,759.6 1.39 5.66Cardiovascular 3,972 29 213.8 136.97 2.44PT/OT/ST 10,826 356 2,624.9 30.41 6.65Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 60,644 1,077 7,941.0 56.31 37.26

$284,544 10,295 75,908.0 $27.64 $174.84Professional and Other State Plan ServicesAmbulatory Surgery Center $4,106 13 95.9 $315.81 $2.52Office Visits 58,026 990 7,299.6 58.61 35.65Preventive Medicine 4,764 145 1,069.1 32.86 2.93Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 2,144 86 634.1 24.93 1.32Psychiatric and Substance Abuse 531 8 59.0 66.42 0.33Radiology and Pathology 19,184 905 6,672.8 21.20 11.79Home Health and Private Duty Nursing 125,569 2,050 15,115.2 61.25 77.15Ambulance 21,515 813 5,994.5 26.46 13.22Non-Emergency Transportation 41,929 2,812 20,733.7 14.91 25.76Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 29,703 201 1,482.0 147.77 18.25Adult Medical Day Care 159,660 6,804 50,167.9 23.47 98.10Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 103,889 70,950 523,135.0 1.46 63.83Other 152,642 6,480 47,778.9 23.56 93.79

$723,662 92,257 680,237.7 $7.84 $444.65Prescription DrugsGeneric Scripts $176,506 10,492 77,360.6 $16.82 $108.45Single-Source Brand 330,772 1,510 11,133.7 219.05 203.24Multi-Source Brand 85,752 217 1,600.0 395.17 52.69Specialty 12,899 7 51.6 1,842.74 7.93Other 0 0 0.0 0.00 0.00

$605,929 12,226 90,145.9 $49.56 $372.31Mental Health CenterCase Management $34,381 96 707.8 $358.14 $21.13Long Term Support Service 15,909 668 4,925.4 23.82 9.78Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 790 12 88.5 65.81 0.49Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 213 8 59.0 26.64 0.13Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 6,974 477 3,517.1 14.62 4.29

$58,268 1,261 9,297.7 $46.21 $35.80All Services $1,988,686 75 116,569 553.0 859,497.2 $17.06 $1,221.93






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$446,264 243 1,701 475.5 3,328.3 $1,836.48 $72.77Hospital OutpatientEmergency Room $208,545 596 1,166.2 $349.91 $34.00Surgery 85,592 470 919.6 182.11 13.96Radiology 50,698 693 1,356.0 73.16 8.27Pathology 9,955 2,434 4,762.6 4.09 1.62Pharmacy 131,447 38,364 75,066.5 3.43 21.43Cardiovascular 6,872 123 240.7 55.87 1.12PT/OT/ST 20,198 1,581 3,093.5 12.78 3.29Psychiatric 120 3 5.9 40.07 0.02Substance Abuse 0 0 0.0 0.00 0.00Other 213,176 9,991 19,549.3 21.34 34.76

$726,603 54,255 106,160.2 $13.39 $118.48Professional and Other State Plan ServicesAmbulatory Surgery Center $2,818 31 60.7 $90.92 $0.46Office Visits 92,010 4,111 8,044.0 22.38 15.00Preventive Medicine 3,137 180 352.2 17.43 0.51Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 10,189 1,039 2,033.0 9.81 1.66Psychiatric and Substance Abuse 7,729 144 281.8 53.67 1.26Radiology and Pathology 25,835 2,469 4,831.1 10.46 4.21Home Health and Private Duty Nursing 249,539 7,396 14,471.7 33.74 40.69Ambulance 53,621 2,920 5,713.5 18.36 8.74Non-Emergency Transportation 475,258 15,168 29,679.1 31.33 77.49Opioid Treatment Program 11,109 1,087 2,126.9 10.22 1.81Federally Qualified and Rural Health Clinics 14,067 348 680.9 40.42 2.29Adult Medical Day Care 24,769 969 1,896.0 25.56 4.04Personal Care 2,385,976 442,281 865,406.9 5.39 389.05Durable Medical Equipment 325,238 191,683 375,064.2 1.70 53.03Other 293,362 48,437 94,776.2 6.06 47.83

$3,974,657 718,263 1,405,418.1 $5.53 $648.10Prescription DrugsGeneric Scripts $8,197 1,912 3,741.2 $4.29 $1.34Single-Source Brand 898 35 68.5 25.66 0.15Multi-Source Brand 53 3 5.9 17.68 0.01Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$9,148 1,950 3,815.5 $4.69 $1.49Mental Health CenterCase Management $424,083 1,184 2,316.7 $358.18 $69.15Long Term Support Service 474,062 17,753 34,737.1 26.70 77.30Partial Hospital 26,236 265 518.5 99.00 4.28Psychotherapy 44,560 1,174 2,297.2 37.96 7.27Evidence Based Practice 4,585 286 559.6 16.03 0.75Medication Management 6,652 223 436.3 29.83 1.08Emergency Service 24/7 2,698 110 215.2 24.53 0.44APRTP 20,313 37 72.4 549.00 3.31Supported Employment Services 19,746 744 1,455.8 26.54 3.22Harbor Homes 18,000 150 293.5 120.00 2.94Other 26,683 730 1,428.4 36.55 4.35

$1,067,619 22,656 44,330.8 $47.12 $174.08All Services $6,224,291 243 798,825 475.5 1,563,053.0 $7.79 $1,014.92






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$559,264 427 2,381 432.4 2,410.9 $1,309.75 $47.19Hospital OutpatientEmergency Room $313,699 753 762.4 $416.60 $26.47Surgery 54,897 319 323.0 172.09 4.63Radiology 125,437 908 919.4 138.15 10.58Pathology 10,040 2,450 2,480.7 4.10 0.85Pharmacy 84,996 28,552 28,910.2 2.98 7.17Cardiovascular 13,818 198 200.5 69.79 1.17PT/OT/ST 19,414 1,772 1,794.2 10.96 1.64Psychiatric 1,143 13 13.2 87.90 0.10Substance Abuse 0 0 0.0 0.00 0.00Other 145,623 8,224 8,327.2 17.71 12.29

$769,067 43,189 43,730.9 $17.81 $64.89Professional and Other State Plan ServicesAmbulatory Surgery Center $12,154 97 98.2 $125.30 $1.03Office Visits 124,541 5,639 5,709.8 22.09 10.51Preventive Medicine 3,012 180 182.3 16.73 0.25Maternity 20 1 1.0 20.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 4,772 674 682.5 7.08 0.40Psychiatric and Substance Abuse 3,046 130 131.6 23.43 0.26Radiology and Pathology 33,898 3,394 3,436.6 9.99 2.86Home Health and Private Duty Nursing 55,377 1,283 1,299.1 43.16 4.67Ambulance 96,645 4,353 4,407.6 22.20 8.15Non-Emergency Transportation 562,456 21,153 21,418.4 26.59 47.46Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 10,914 319 323.0 34.21 0.92Adult Medical Day Care 114,714 4,886 4,947.3 23.48 9.68Personal Care 507,398 94,015 95,194.6 5.40 42.81Durable Medical Equipment 320,945 415,666 420,881.3 0.77 27.08Other 304,291 48,888 49,501.4 6.22 25.68


$18,750 5,270 5,336.1 $3.56 $1.58Mental Health CenterCase Management $303,175 845 855.6 $358.79 $25.58Long Term Support Service 365,316 14,075 14,251.6 25.95 30.82Partial Hospital 19,136 193 195.4 99.15 1.61Psychotherapy 16,833 467 472.9 36.04 1.42Evidence Based Practice 3,153 132 133.7 23.88 0.27Medication Management 6,786 248 251.1 27.36 0.57Emergency Service 24/7 4,809 179 181.2 26.87 0.41APRTP 0 0 0.0 0.00 0.00Supported Employment Services 929 35 35.4 26.54 0.08Harbor Homes 28,941 241 244.0 120.09 2.44Other 20,313 1,029 1,041.9 19.74 1.71

$769,391 17,444 17,662.9 $44.11 $64.92All Services $4,270,654 427 668,962 432.4 677,355.3 $6.38 $360.35




Eligibility Category: Developmentally Disabled - Medicaid Only


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$696,970 124 954 96.9 745.6 $5,620.72 $45.39Hospital OutpatientEmergency Room $285,654 568 443.9 $502.91 $18.61Surgery 81,892 124 96.9 660.42 5.33Radiology 132,424 535 418.1 247.52 8.62Pathology 56,592 5,602 4,378.4 10.10 3.69Pharmacy 108,095 17,290 13,513.5 6.25 7.04Cardiovascular 37,581 109 85.2 344.78 2.45PT/OT/ST 44,935 1,423 1,112.2 31.58 2.93Psychiatric 1,680 14 10.9 120.00 0.11Substance Abuse 0 0 0.0 0.00 0.00Other 136,750 4,276 3,342.0 31.98 8.91

$885,601 29,941 23,401.3 $29.58 $57.68Professional and Other State Plan ServicesAmbulatory Surgery Center $4,890 15 11.7 $326.01 $0.32Office Visits 196,059 3,425 2,676.9 57.24 12.77Preventive Medicine 39,664 1,720 1,344.3 23.06 2.58Maternity 20 1 0.8 20.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 43,314 1,846 1,442.8 23.46 2.82Psychiatric and Substance Abuse 91,445 1,480 1,156.7 61.79 5.96Radiology and Pathology 51,300 2,894 2,261.9 17.73 3.34Home Health and Private Duty Nursing 2,554,499 239,392 187,104.1 10.67 166.38Ambulance 56,406 2,518 1,968.0 22.40 3.67Non-Emergency Transportation 47,646 10,775 8,421.5 4.42 3.10Opioid Treatment Program 3,608 353 275.9 10.22 0.23Federally Qualified and Rural Health Clinics 98,477 899 702.6 109.54 6.41Adult Medical Day Care 28,126 985 769.9 28.55 1.83Personal Care 136,287 25,251 19,735.7 5.40 8.88Durable Medical Equipment 907,872 745,493 582,662.7 1.22 59.13Other 257,333 17,541 13,709.7 14.67 16.76

$4,516,947 1,054,588 824,245.3 $4.28 $294.20Prescription DrugsGeneric Scripts $1,423,664 42,074 32,884.2 $33.84 $92.73Single-Source Brand 1,269,199 3,257 2,545.6 389.68 82.67Multi-Source Brand 1,070,062 2,272 1,775.8 470.98 69.69Specialty 743,387 178 139.1 4,176.33 48.42Other 457 19 14.9 24.04 0.03

$4,506,768 47,800 37,359.5 $94.28 $293.53Mental Health CenterCase Management $55,870 156 121.9 $358.14 $3.64Long Term Support Service 102,056 3,759 2,938.0 27.15 6.65Partial Hospital 8,430 85 66.4 99.18 0.55Psychotherapy 96,865 1,985 1,551.4 48.80 6.31Evidence Based Practice 4,910 185 144.6 26.54 0.32Medication Management 3,351 88 68.8 38.08 0.22Emergency Service 24/7 305 13 10.2 23.46 0.02APRTP 2,745 5 3.9 549.00 0.18Supported Employment Services 3,211 103 80.5 31.18 0.21Harbor Homes 0 0 0.0 0.00 0.00Other 75,914 1,032 806.6 73.56 4.94

$353,658 7,411 5,792.3 $47.72 $23.03All Services $10,959,944 124 1,140,694 96.9 891,544.0 $9.61 $713.84






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $159,937 124 602 76.6 371.9 $1,289.82 $8.23Surgical 68,095 34 378 21.0 233.5 2,002.80 3.51Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 9,376 5 29 3.1 17.9 1,875.16 0.48Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 10,642 6 64 3.7 39.5 1,773.65 0.55

$248,050 169 1,073 104.4 662.9 $1,467.75 $12.77Hospital OutpatientEmergency Room $220,209 770 475.7 $285.99 $11.34Surgery 72,766 347 214.4 209.70 3.75Radiology 97,877 790 488.0 123.90 5.04Pathology 13,750 2,449 1,512.9 5.61 0.71Pharmacy 58,332 18,288 11,297.6 3.19 3.00Cardiovascular 16,531 155 95.8 106.65 0.85PT/OT/ST 23,122 1,745 1,078.0 13.25 1.19Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 144,027 9,287 5,737.1 15.51 7.41

$646,616 33,831 20,899.5 $19.11 $33.29Professional and Other State Plan ServicesAmbulatory Surgery Center $2,655 16 9.9 $165.93 $0.14Office Visits 137,190 5,254 3,245.7 26.11 7.06Preventive Medicine 21,401 975 602.3 21.95 1.10Maternity 859 7 4.1 130.01 0.04Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 6,181 716 442.3 8.63 0.32Psychiatric and Substance Abuse 25,927 670 413.9 38.70 1.33Radiology and Pathology 24,699 2,051 1,267.0 12.04 1.27Home Health and Private Duty Nursing 1,050,143 97,182 60,035.3 10.81 54.06Ambulance 21,949 1,505 929.7 14.58 1.13Non-Emergency Transportation 136,151 14,677 9,066.9 9.28 7.01Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 18,480 335 206.9 55.16 0.95Adult Medical Day Care 79,193 1,640 1,013.1 48.29 4.08Personal Care 53,564 9,928 6,133.1 5.40 2.76Durable Medical Equipment 537,078 658,990 407,098.3 0.82 27.65Other 228,803 27,466 16,967.4 8.33 11.78


$20,063 5,585 3,450.2 $3.59 $1.03Mental Health CenterCase Management $121,129 339 209.4 $357.31 $6.24Long Term Support Service 295,380 10,354 6,396.3 28.53 15.21Partial Hospital 41,451 424 261.9 97.76 2.13Psychotherapy 64,682 1,920 1,186.1 33.69 3.33Evidence Based Practice 9,367 597 368.8 15.69 0.48Medication Management 10,964 354 218.7 30.97 0.56Emergency Service 24/7 2,651 110 68.0 24.10 0.14APRTP 8,235 15 9.3 549.00 0.42Supported Employment Services 10,298 385 237.8 26.75 0.53Harbor Homes 0 0 0.0 0.00 0.00Other 94,039 2,857 1,764.9 32.92 4.84

$658,196 17,355 10,721.2 $37.93 $33.88All Services $3,917,198 169 879,256 104.4 543,169.8 $4.46 $201.66






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$699,577 76 577 74.6 566.4 $9,204.96 $57.23Hospital OutpatientEmergency Room $151,830 441 432.9 $344.29 $12.42Surgery 109,866 108 106.0 1,017.28 8.99Radiology 96,640 342 335.7 282.57 7.91Pathology 41,774 3,400 3,337.7 12.29 3.42Pharmacy 20,134 4,540 4,456.8 4.43 1.65Cardiovascular 18,601 64 62.8 290.63 1.52PT/OT/ST 73,179 1,938 1,902.5 37.76 5.99Psychiatric 88 1 1.0 87.82 0.01Substance Abuse 0 0 0.0 0.00 0.00Other 164,920 4,491 4,408.7 36.72 13.49

$677,032 15,325 15,044.1 $44.18 $55.39Professional and Other State Plan ServicesAmbulatory Surgery Center $13,722 18 17.7 $762.36 $1.12Office Visits 194,632 3,068 3,011.8 63.44 15.92Preventive Medicine 32,907 1,309 1,285.0 25.14 2.69Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 208,140 7,162 7,030.7 29.06 17.03Psychiatric and Substance Abuse 105,084 3,272 3,212.0 32.12 8.60Radiology and Pathology 33,571 1,364 1,339.0 24.61 2.75Home Health and Private Duty Nursing 2,177,628 233,254 228,978.3 9.34 178.14Ambulance 32,343 2,251 2,209.7 14.37 2.65Non-Emergency Transportation 49,115 9,246 9,076.5 5.31 4.02Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 47,067 413 405.4 113.96 3.85Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,282,803 770,104 755,987.5 1.67 104.94Other 278,604 30,506 29,946.8 9.13 22.79

$4,455,616 1,061,967 1,042,500.5 $4.20 $364.50Prescription DrugsGeneric Scripts $963,848 21,547 21,152.0 $44.73 $78.85Single-Source Brand 600,653 2,157 2,117.5 278.47 49.14Multi-Source Brand 488,640 1,129 1,108.3 432.81 39.97Specialty 261,285 97 95.2 2,693.66 21.37Other 11 1 1.0 10.70 0.00

$2,314,437 24,931 24,474.0 $92.83 $189.33Mental Health CenterCase Management $534,345 1,492 1,464.7 $358.14 $43.71Long Term Support Service 762,575 31,250 30,677.2 24.40 62.38Partial Hospital 1,662 17 16.7 97.75 0.14Psychotherapy 228,426 4,376 4,295.8 52.20 18.69Evidence Based Practice 4,008 151 148.2 26.54 0.33Medication Management 2,708 88 86.4 30.77 0.22Emergency Service 24/7 6,053 257 252.3 23.55 0.50APRTP 0 0 0.0 0.00 0.00Supported Employment Services 1,274 48 47.1 26.54 0.10Harbor Homes 0 0 0.0 0.00 0.00Other 71,518 838 822.6 85.34 5.85

$1,612,568 38,517 37,811.0 $41.87 $131.92All Services $9,759,231 76 1,141,317 74.6 1,120,395.9 $8.55 $798.36




Eligibility Category: Acquired Brain Disorder - Medicaid Only

Member Months: 611

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$128,783 25 214 491.0 4,203.2 $5,151.31 $210.79Hospital OutpatientEmergency Room $31,859 44 864.2 $724.07 $52.15Surgery 10,062 15 294.6 670.77 16.47Radiology 10,702 71 1,394.5 150.74 17.52Pathology 6,841 639 12,550.7 10.71 11.20Pharmacy 728 596 11,706.1 1.22 1.19Cardiovascular 19 1 19.6 19.11 0.03PT/OT/ST 13,075 439 8,622.5 29.78 21.40Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 55,920 306 6,010.2 182.75 91.53

$129,207 2,111 41,462.5 $61.21 $211.48Professional and Other State Plan ServicesAmbulatory Surgery Center $2,188 10 196.4 $218.81 $3.58Office Visits 21,936 399 7,836.8 54.98 35.90Preventive Medicine 2,660 96 1,885.6 27.71 4.35Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 5,096 212 4,163.9 24.04 8.34Psychiatric and Substance Abuse 2,188 48 942.8 45.58 3.58Radiology and Pathology 5,834 336 6,599.4 17.36 9.55Home Health and Private Duty Nursing 22,928 592 11,627.6 38.73 37.53Ambulance 7,253 580 11,391.9 12.50 11.87Non-Emergency Transportation 13,590 686 13,473.8 19.81 22.24Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 8,011 57 1,119.5 140.55 13.11Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 62,425 56,893 1,117,445.6 1.10 102.18Other 34,222 1,283 25,199.6 26.67 56.01

$188,329 61,192 1,201,883.0 $3.08 $308.25Prescription DrugsGeneric Scripts $97,868 4,335 85,144.5 $22.58 $160.19Single-Source Brand 115,917 393 7,719.0 294.96 189.73Multi-Source Brand 35,247 69 1,355.2 510.83 57.69Specialty 95,574 75 1,473.1 1,274.32 156.43Other 0 0 0.0 0.00 0.00

$344,607 4,872 95,691.8 $70.73 $564.04Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 587 7 137.5 83.91 0.96Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 5,303 68 1,335.6 77.99 8.68Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 4,619 54 1,060.6 85.54 7.56

$10,510 129 2,533.7 $81.47 $17.20All Services $801,436 25 68,518 491.0 1,345,774.3 $11.70 $1,311.76






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $32,701 24 96 210.0 840.0 $1,362.54 $23.84Surgical 16,265 3 10 26.2 87.5 5,421.51 11.86Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 1,288 1 2 8.7 17.5 1,288.00 0.94Alcohol and Drug Abuse 1,288 1 3 8.7 26.2 1,288.00 0.94Other 0 0 0 0.0 0.0 0.00 0.00

$51,541 29 111 253.7 971.2 $1,777.29 $37.58Hospital OutpatientEmergency Room $18,283 59 516.2 $309.88 $13.33Surgery 8,031 50 437.5 160.63 5.86Radiology 7,843 82 717.5 95.65 5.72Pathology 1,242 246 2,152.5 5.05 0.91Pharmacy 6,297 3,070 26,862.1 2.05 4.59Cardiovascular 495 13 113.7 38.07 0.36PT/OT/ST 5,745 528 4,619.9 10.88 4.19Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 16,851 1,159 10,141.1 14.54 12.29

$64,788 5,207 45,560.6 $12.44 $47.24Professional and Other State Plan ServicesAmbulatory Surgery Center $737 3 26.2 $245.71 $0.54Office Visits 13,218 565 4,943.7 23.39 9.64Preventive Medicine 1,134 43 376.2 26.38 0.83Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 2,494 391 3,421.2 6.38 1.82Psychiatric and Substance Abuse 858 28 245.0 30.65 0.63Radiology and Pathology 4,394 345 3,018.7 12.74 3.20Home Health and Private Duty Nursing 90,775 15,316 134,013.2 5.93 66.19Ambulance 6,272 525 4,593.7 11.95 4.57Non-Emergency Transportation 30,782 1,755 15,356.0 17.54 22.45Opioid Treatment Program 2,821 276 2,415.0 10.22 2.06Federally Qualified and Rural Health Clinics 1,523 48 420.0 31.73 1.11Adult Medical Day Care 2,265 46 402.5 49.24 1.65Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 87,187 116,788 1,021,881.3 0.75 63.57Other 34,640 6,192 54,179.3 5.59 25.26

$279,102 142,321 1,245,292.0 $1.96 $203.51Prescription DrugsGeneric Scripts $3,104 726 6,352.4 $4.28 $2.26Single-Source Brand 50 19 166.2 2.65 0.04Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$3,155 745 6,518.7 $4.23 $2.30Mental Health CenterCase Management $10,028 28 245.0 $358.14 $7.31Long Term Support Service 11,036 411 3,596.2 26.85 8.05Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 2,542 138 1,207.5 18.42 1.85Evidence Based Practice 49 2 17.5 24.27 0.04Medication Management 719 27 236.2 26.64 0.52Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 9,830 325 2,843.7 30.25 7.17

$34,204 931 8,146.1 $36.74 $24.94All Services $432,790 29 149,315 253.7 1,306,488.7 $2.90 $315.57




Eligibility Category: Severe/Persistent Mental Illness - Medicaid Only


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $467,315 133 663 120.6 601.3 $3,513.65 $35.32Surgical 275,024 38 334 34.5 302.9 7,237.47 20.78Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 4,093 2 5 1.8 4.5 2,046.46 0.31Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 530,224 127 905 115.2 820.7 4,174.99 40.07Alcohol and Drug Abuse 19,824 9 39 8.2 35.4 2,202.71 1.50Other 0 0 0 0.0 0.0 0.00 0.00

$1,296,480 309 1,946 280.2 1,764.8 $4,195.73 $97.98Hospital OutpatientEmergency Room $1,059,895 1,942 1,761.2 $545.77 $80.10Surgery 222,543 277 251.2 803.40 16.82Radiology 280,999 1,474 1,336.7 190.64 21.24Pathology 120,394 10,335 9,372.6 11.65 9.10Pharmacy 127,899 20,767 18,833.3 6.16 9.67Cardiovascular 34,680 170 154.2 204.00 2.62PT/OT/ST 72,673 2,725 2,471.3 26.67 5.49Psychiatric 33,987 116 105.2 292.99 2.57Substance Abuse 0 0 0.0 0.00 0.00Other 270,699 9,384 8,510.2 28.85 20.46

$2,223,767 47,190 42,795.8 $47.12 $168.06Professional and Other State Plan ServicesAmbulatory Surgery Center $23,639 68 61.7 $347.63 $1.79Office Visits 395,483 6,606 5,990.9 59.87 29.89Preventive Medicine 43,359 2,070 1,877.2 20.95 3.28Maternity 10,425 63 57.5 164.32 0.79Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 37,901 1,568 1,422.0 24.17 2.86Psychiatric and Substance Abuse 115,248 1,486 1,347.6 77.56 8.71Radiology and Pathology 185,409 8,930 8,098.5 20.76 14.01Home Health and Private Duty Nursing 124,257 4,782 4,336.7 25.98 9.39Ambulance 136,852 4,450 4,035.6 30.75 10.34Non-Emergency Transportation 430,166 25,718 23,323.2 16.73 32.51Opioid Treatment Program 84,908 8,308 7,534.4 10.22 6.42Federally Qualified and Rural Health Clinics 264,516 2,011 1,823.7 131.53 19.99Adult Medical Day Care 7,977 302 273.9 26.41 0.60Personal Care 1,737 322 292.0 5.40 0.13Durable Medical Equipment 215,076 36,912 33,474.9 5.83 16.25Other 600,976 29,965 27,174.8 20.06 45.42

$2,677,929 133,561 121,124.7 $20.05 $202.38Prescription DrugsGeneric Scripts $1,892,133 70,148 63,616.1 $26.97 $143.00Single-Source Brand 2,614,972 7,813 7,085.5 334.69 197.62Multi-Source Brand 619,215 1,430 1,296.8 433.02 46.80Specialty 1,727,104 661 599.5 2,612.87 130.52Other 19 2 1.8 9.61 0.00

$6,853,443 80,054 72,599.7 $85.61 $517.94Mental Health CenterCase Management $3,608,977 10,077 9,138.7 $358.14 $272.74Long Term Support Service 3,477,461 119,914 108,748.1 29.00 262.80Partial Hospital 147,529 1,547 1,402.9 95.36 11.15Psychotherapy 848,998 15,012 13,614.1 56.55 64.16Evidence Based Practice 64,039 3,589 3,254.8 17.84 4.84Medication Management 62,798 2,141 1,941.6 29.33 4.75Emergency Service 24/7 56,586 2,412 2,187.4 23.46 4.28APRTP 90,036 164 148.7 549.00 6.80Supported Employment Services 301,521 10,949 9,929.5 27.54 22.79Harbor Homes 0 0 0.0 0.00 0.00Other 420,609 5,958 5,403.2 70.60 31.79

$9,078,554 171,763 155,769.1 $52.86 $686.10All Services $22,130,174 309 434,514 280.2 394,054.1 $50.93 $1,672.46






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$529,807 198 1,324 193.1 1,291.5 $2,675.79 $43.07Hospital OutpatientEmergency Room $346,884 1,350 1,316.8 $256.95 $28.20Surgery 81,052 339 330.7 239.09 6.59Radiology 87,526 881 859.3 99.35 7.11Pathology 16,577 2,544 2,481.5 6.52 1.35Pharmacy 31,752 34,128 33,289.0 0.93 2.58Cardiovascular 11,573 160 156.1 72.33 0.94PT/OT/ST 26,965 2,194 2,140.1 12.29 2.19Psychiatric 6,643 135 131.7 49.21 0.54Substance Abuse 0 0 0.0 0.00 0.00Other 137,759 11,367 11,087.6 12.12 11.20

$746,732 53,098 51,792.6 $14.06 $60.70Professional and Other State Plan ServicesAmbulatory Surgery Center $9,392 62 60.5 $151.49 $0.76Office Visits 133,306 5,159 5,032.2 25.84 10.84Preventive Medicine 12,573 561 547.2 22.41 1.02Maternity 1,491 21 20.9 69.61 0.12Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 8,436 915 892.5 9.22 0.69Psychiatric and Substance Abuse 45,273 658 641.8 68.80 3.68Radiology and Pathology 37,224 2,732 2,664.8 13.63 3.03Home Health and Private Duty Nursing 10,794 141 137.5 76.55 0.88Ambulance 33,183 1,888 1,841.6 17.58 2.70Non-Emergency Transportation 401,222 25,326 24,703.4 15.84 32.61Opioid Treatment Program 93,003 9,100 8,876.3 10.22 7.56Federally Qualified and Rural Health Clinics 43,601 748 729.6 58.29 3.54Adult Medical Day Care 49,716 1,075 1,048.6 46.25 4.04Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 42,095 21,988 21,447.4 1.91 3.42Other 224,851 29,785 29,052.8 7.55 18.28


$11,661 1,849 1,803.5 $6.31 $0.95Mental Health CenterCase Management $3,614,112 10,153 9,903.4 $355.96 $293.77Long Term Support Service 4,762,651 170,223 166,038.2 27.98 387.13Partial Hospital 236,566 2,464 2,403.4 96.01 19.23Psychotherapy 421,502 13,581 13,247.1 31.04 34.26Evidence Based Practice 90,119 4,836 4,717.1 18.63 7.33Medication Management 114,924 3,917 3,820.7 29.34 9.34Emergency Service 24/7 52,911 2,167 2,113.7 24.42 4.30APRTP 217,969 397 387.2 549.04 17.72Supported Employment Services 600,146 21,311 20,787.1 28.16 48.78Harbor Homes 63,645 535 521.8 118.96 5.17Other 205,187 6,034 5,885.7 34.01 16.68

$10,379,732 235,618 229,825.5 $44.05 $843.71All Services $12,814,092 198 392,048 193.1 382,410.3 $32.68 $1,041.59




Eligibility Category: Severe Mental Illness - Medicaid Only


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$1,422,424 281 1,926 285.5 1,956.6 $5,062.01 $120.42Hospital OutpatientEmergency Room $1,005,165 1,947 1,978.0 $516.26 $85.10Surgery 167,455 247 250.9 677.96 14.18Radiology 277,812 1,406 1,428.4 197.59 23.52Pathology 110,195 8,743 8,882.1 12.60 9.33Pharmacy 131,586 25,771 26,180.9 5.11 11.14Cardiovascular 16,028 112 113.8 143.11 1.36PT/OT/ST 57,751 2,130 2,163.9 27.11 4.89Psychiatric 5,832 58 58.9 100.55 0.49Substance Abuse 976 6 6.1 162.60 0.08Other 256,013 11,108 11,284.7 23.05 21.67

$2,028,812 51,528 52,347.6 $39.37 $171.76Professional and Other State Plan ServicesAmbulatory Surgery Center $31,690 90 91.4 $352.11 $2.68Office Visits 383,648 6,358 6,459.1 60.34 32.48Preventive Medicine 61,899 1,720 1,747.4 35.99 5.24Maternity 24,385 145 147.3 168.20 2.06Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 35,579 1,479 1,502.5 24.06 3.01Psychiatric and Substance Abuse 228,782 1,870 1,899.7 122.34 19.37Radiology and Pathology 205,492 8,547 8,683.0 24.04 17.40Home Health and Private Duty Nursing 51,129 1,465 1,488.3 34.90 4.33Ambulance 99,533 3,302 3,354.5 30.14 8.43Non-Emergency Transportation 475,970 29,849 30,323.8 15.95 40.30Opioid Treatment Program 209,551 20,504 20,830.1 10.22 17.74Federally Qualified and Rural Health Clinics 284,569 2,088 2,121.2 136.29 24.09Adult Medical Day Care 1,494 63 64.0 23.71 0.13Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 131,597 16,591 16,854.9 7.93 11.14Other 643,837 44,804 45,516.7 14.37 54.51

$2,869,153 138,875 141,084.0 $20.66 $242.90Prescription DrugsGeneric Scripts $1,009,595 40,684 41,331.1 $24.82 $85.47Single-Source Brand 1,357,414 5,282 5,366.0 256.99 114.92Multi-Source Brand 245,033 586 595.3 418.15 20.74Specialty 578,971 207 210.3 2,796.96 49.02Other 0 0 0.0 0.00 0.00

$3,191,013 46,759 47,502.8 $68.24 $270.15Mental Health CenterCase Management $2,124,486 5,932 6,026.4 $358.14 $179.86Long Term Support Service 537,829 20,292 20,614.8 26.50 45.53Partial Hospital 3,582 38 38.6 94.26 0.30Psychotherapy 747,498 11,425 11,606.7 65.43 63.28Evidence Based Practice 27,476 1,504 1,527.9 18.27 2.33Medication Management 12,413 425 431.8 29.21 1.05Emergency Service 24/7 9,572 408 414.5 23.46 0.81APRTP 67,527 123 125.0 549.00 5.72Supported Employment Services 126,145 4,587 4,660.0 27.50 10.68Harbor Homes 0 0 0.0 0.00 0.00Other 291,778 3,367 3,420.6 86.66 24.70

$3,948,305 48,101 48,866.1 $82.08 $334.26All Services $13,459,708 281 287,189 285.5 291,757.2 $46.87 $1,139.48






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$188,578 55 302 173.4 952.1 $3,428.69 $49.54Hospital OutpatientEmergency Room $165,393 573 1,806.5 $288.64 $43.45Surgery 21,484 68 214.4 315.94 5.64Radiology 31,304 340 1,071.9 92.07 8.22Pathology 10,109 1,242 3,915.6 8.14 2.66Pharmacy 8,390 6,183 19,492.6 1.36 2.20Cardiovascular 2,792 24 75.7 116.34 0.73PT/OT/ST 11,662 832 2,623.0 14.02 3.06Psychiatric 245 8 25.2 30.66 0.06Substance Abuse 0 0 0.0 0.00 0.00Other 43,014 2,533 7,985.6 16.98 11.30

$294,393 11,803 37,210.4 $24.94 $77.34Professional and Other State Plan ServicesAmbulatory Surgery Center $7,372 27 85.1 $273.05 $1.94Office Visits 57,216 1,873 5,904.9 30.55 15.03Preventive Medicine 6,963 224 706.2 31.09 1.83Maternity 933 7 21.5 136.94 0.25Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,920 198 624.2 9.70 0.50Psychiatric and Substance Abuse 33,813 279 879.6 121.19 8.88Radiology and Pathology 17,876 1,215 3,830.4 14.71 4.70Home Health and Private Duty Nursing 1,983 64 201.8 30.99 0.52Ambulance 15,186 653 2,058.7 23.26 3.99Non-Emergency Transportation 228,285 11,168 35,208.5 20.44 59.97Opioid Treatment Program 51,949 5,083 16,024.8 10.22 13.65Federally Qualified and Rural Health Clinics 11,492 257 810.2 44.72 3.02Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 18,395 7,411 23,364.1 2.48 4.83Other 78,417 7,558 23,827.5 10.38 20.60

$531,800 36,017 113,547.3 $14.77 $139.71Prescription DrugsGeneric Scripts $5,345 232 731.4 $23.04 $1.40Single-Source Brand 101 4 12.6 25.24 0.03Multi-Source Brand 37 1 3.2 37.14 0.01Specialty 0 0 0.0 0.00 0.00Other 38 1 3.2 37.99 0.01

$5,521 238 750.3 $23.20 $1.45Mental Health CenterCase Management $778,349 2,172 6,847.5 $358.36 $204.49Long Term Support Service 255,407 9,754 30,750.6 26.18 67.10Partial Hospital 8,108 83 261.7 97.69 2.13Psychotherapy 153,737 3,917 12,348.8 39.25 40.39Evidence Based Practice 12,530 600 1,891.6 20.88 3.29Medication Management 13,115 471 1,484.9 27.85 3.45Emergency Service 24/7 3,097 128 403.5 24.19 0.81APRTP 28,548 52 163.9 549.00 7.50Supported Employment Services 62,768 2,163 6,819.1 29.02 16.49Harbor Homes 0 0 0.0 0.00 0.00Other 60,239 1,155 3,641.3 52.15 15.83

$1,375,897 20,495 64,612.9 $67.13 $361.47All Services $2,396,189 55 68,855 173.4 217,073.0 $34.80 $629.52




Eligibility Category: Low Utilizer - Medicaid Only


BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$93,386 23 126 225.3 1,234.5 $4,060.27 $76.24Hospital OutpatientEmergency Room $60,439 114 1,116.9 $530.17 $49.35Surgery 11,649 21 205.7 554.72 9.51Radiology 19,901 124 1,214.9 160.49 16.25Pathology 10,033 785 7,690.9 12.78 8.19Pharmacy 3,134 1,020 9,993.3 3.07 2.56Cardiovascular 2,071 16 156.8 129.41 1.69PT/OT/ST 13,005 392 3,840.6 33.18 10.62Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 22,025 294 2,880.4 74.91 17.98

$142,257 2,766 27,099.4 $51.43 $116.14Professional and Other State Plan ServicesAmbulatory Surgery Center $2,679 8 78.4 $334.92 $2.19Office Visits 35,052 586 5,741.2 59.82 28.62Preventive Medicine 4,711 232 2,273.0 20.31 3.85Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,814 151 1,479.4 25.26 3.11Psychiatric and Substance Abuse 6,081 85 832.8 71.54 4.96Radiology and Pathology 11,340 617 6,045.0 18.38 9.26Home Health and Private Duty Nursing 1,996 51 499.7 39.13 1.63Ambulance 9,111 203 1,988.9 44.88 7.44Non-Emergency Transportation 32,538 2,955 28,951.1 11.01 26.57Opioid Treatment Program 12,213 1,195 11,707.8 10.22 9.97Federally Qualified and Rural Health Clinics 19,356 135 1,322.6 143.38 15.80Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 27,734 2,875 28,167.3 9.65 22.64Other 50,208 2,139 20,956.5 23.47 40.99

$216,834 11,232 110,043.6 $19.30 $177.03Prescription DrugsGeneric Scripts $160,343 5,621 55,070.8 $28.53 $130.91Single-Source Brand 190,102 631 6,182.1 301.27 155.21Multi-Source Brand 59,486 133 1,303.0 447.26 48.57Specialty 38,685 31 303.7 1,247.89 31.58Other 0 0 0.0 0.00 0.00

$448,616 6,416 62,859.7 $69.92 $366.27Mental Health CenterCase Management $252,131 704 6,897.3 $358.14 $205.85Long Term Support Service 25,136 986 9,660.2 25.49 20.52Partial Hospital 5,195 52 509.5 99.90 4.24Psychotherapy 42,662 747 7,318.6 57.11 34.83Evidence Based Practice 165 18 176.4 9.19 0.14Medication Management 5,887 221 2,165.2 26.64 4.81Emergency Service 24/7 680 29 284.1 23.46 0.56APRTP 17,568 32 313.5 549.00 14.34Supported Employment Services 3,663 102 999.3 35.91 2.99Harbor Homes 0 0 0.0 0.00 0.00Other 28,398 392 3,840.6 72.44 23.19

$381,486 3,283 32,164.6 $116.20 $311.46All Services $1,282,578 23 23,823 225.3 233,401.8 $53.84 $1,047.15






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$16,134 13 78 113.4 680.2 $1,241.09 $11.73Hospital OutpatientEmergency Room $28,194 100 872.1 $281.94 $20.49Surgery 8,987 38 331.4 236.50 6.53Radiology 10,236 111 968.0 92.21 7.44Pathology 2,468 241 2,101.7 10.24 1.79Pharmacy 918 1,944 16,953.0 0.47 0.67Cardiovascular 535 15 130.8 35.66 0.39PT/OT/ST 4,704 323 2,816.8 14.56 3.42Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 15,446 1,105 9,636.4 13.98 11.22

$71,487 3,877 33,810.1 $18.44 $51.95Professional and Other State Plan ServicesAmbulatory Surgery Center $1,354 6 52.3 $225.63 $0.98Office Visits 13,887 520 4,534.8 26.71 10.09Preventive Medicine 1,686 41 357.5 41.11 1.22Maternity 3 1 8.7 3.35 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 413 70 610.4 5.90 0.30Psychiatric and Substance Abuse 795 27 235.5 29.44 0.58Radiology and Pathology 4,146 317 2,764.5 13.08 3.01Home Health and Private Duty Nursing 134 2 17.4 67.03 0.10Ambulance 1,463 140 1,220.9 10.45 1.06Non-Emergency Transportation 22,455 1,953 17,031.5 11.50 16.32Opioid Treatment Program 1,584 155 1,351.7 10.22 1.15Federally Qualified and Rural Health Clinics 5,616 59 514.5 95.19 4.08Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 7,102 848 7,395.1 8.38 5.16Other 27,041 4,387 38,257.7 6.16 19.65


$398 63 549.4 $6.32 $0.29Mental Health CenterCase Management $280,879 784 6,837.0 $358.26 $204.12Long Term Support Service 25,277 979 8,537.6 25.82 18.37Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 24,263 656 5,720.8 36.99 17.63Evidence Based Practice 743 28 244.2 26.54 0.54Medication Management 6,203 219 1,909.8 28.32 4.51Emergency Service 24/7 70 3 26.2 23.46 0.05APRTP 5,490 10 87.2 549.00 3.99Supported Employment Services 10,450 394 3,436.0 26.52 7.59Harbor Homes 0 0 0.0 0.00 0.00Other 16,234 425 3,706.3 38.20 11.80

$369,610 3,498 30,505.0 $105.66 $268.60All Services $545,308 13 16,042 113.4 139,897.3 $33.99 $396.29






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $422,010 65 284 12.0 52.4 $6,492.47 $6.48Surgical 432,268 26 127 4.8 23.4 16,625.71 6.64Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 10,513 5 9 0.9 1.7 2,102.66 0.16Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 4,143,773 433 4,004 79.8 738.1 9,569.92 63.65Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$5,008,566 529 4,424 97.5 815.5 $9,467.99 $76.94Hospital OutpatientEmergency Room $1,366,676 3,643 671.5 $375.15 $20.99Surgery 264,944 283 52.2 936.20 4.07Radiology 278,871 1,438 265.1 193.93 4.28Pathology 139,940 12,576 2,318.2 11.13 2.15Pharmacy 249,758 65,327 12,042.2 3.82 3.84Cardiovascular 47,724 143 26.4 333.74 0.73PT/OT/ST 147,963 4,991 920.0 29.65 2.27Psychiatric 120,691 456 84.1 264.67 1.85Substance Abuse 0 0 0.0 0.00 0.00Other 580,863 13,191 2,431.6 44.03 8.92

$3,197,431 102,048 18,811.2 $31.33 $49.12Professional and Other State Plan ServicesAmbulatory Surgery Center $34,249 94 17.3 $364.35 $0.53Office Visits 927,849 15,814 2,915.1 58.67 14.25Preventive Medicine 252,600 9,697 1,787.5 26.05 3.88Maternity 9,298 44 8.1 210.92 0.14Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 232,055 8,035 1,481.1 28.88 3.56Psychiatric and Substance Abuse 226,626 3,567 657.5 63.53 3.48Radiology and Pathology 153,442 10,026 1,848.2 15.30 2.36Home Health and Private Duty Nursing 64,718 10,257 1,890.7 6.31 0.99Ambulance 155,673 7,914 1,458.8 19.67 2.39Non-Emergency Transportation 206,764 46,471 8,566.3 4.45 3.18Opioid Treatment Program 5,090 498 91.8 10.22 0.08Federally Qualified and Rural Health Clinics 557,029 4,305 793.6 129.39 8.56Adult Medical Day Care 44 4 0.7 10.94 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 301,833 120,099 22,138.6 2.51 4.64Other 964,327 51,754 9,540.2 18.63 14.81

$4,091,595 288,579 53,195.7 $14.18 $62.85Prescription DrugsGeneric Scripts $3,485,540 73,970 13,635.4 $47.12 $53.54Single-Source Brand 1,992,498 9,394 1,731.7 212.10 30.61Multi-Source Brand 1,188,516 3,224 594.3 368.65 18.26Specialty 1,091,085 246 45.3 4,435.30 16.76Other 15 2 0.4 7.59 0.00

$7,757,654 86,836 16,007.0 $89.34 $119.17Mental Health CenterCase Management $13,855,004 38,686 7,131.2 $358.14 $212.83Long Term Support Service 7,020,573 278,818 51,396.3 25.18 107.85Partial Hospital 78,168 807 148.8 96.86 1.20Psychotherapy 7,850,511 141,214 26,030.9 55.59 120.59Evidence Based Practice 80 3 0.6 26.54 0.00Medication Management 6,607 248 45.7 26.64 0.10Emergency Service 24/7 13,091 558 102.9 23.46 0.20APRTP 14,274 26 4.8 549.00 0.22Supported Employment Services 3,158 117 21.6 26.99 0.05Harbor Homes 0 0 0.0 0.00 0.00Other 1,211,495 12,874 2,373.1 94.10 18.61

$30,052,961 473,351 87,255.9 $63.49 $461.65All Services $50,108,207 529 955,238 97.5 176,085.3 $52.46 $769.73






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $1,325,938 271 1,285 61.1 289.6 $4,892.76 $24.90Surgical 398,481 40 609 9.0 137.2 9,962.03 7.48Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 2,912 1 3 0.2 0.7 2,911.75 0.05Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$1,727,331 312 1,897 70.3 427.5 $5,536.32 $32.44Hospital OutpatientEmergency Room $826,503 3,627 817.3 $227.88 $15.52Surgery 203,644 230 51.8 885.41 3.82Radiology 174,909 852 192.0 205.29 3.28Pathology 60,041 5,392 1,215.1 11.14 1.13Pharmacy 34,423 5,596 1,261.0 6.15 0.65Cardiovascular 31,490 176 39.7 178.92 0.59PT/OT/ST 59,319 1,905 429.3 31.14 1.11Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 507,097 9,762 2,199.8 51.95 9.52

$1,897,424 27,540 6,206.0 $68.90 $35.63Professional and Other State Plan ServicesAmbulatory Surgery Center $12,382 31 7.0 $399.43 $0.23Office Visits 909,973 16,745 3,773.4 54.34 17.09Preventive Medicine 1,069,567 55,858 12,587.3 19.15 20.09Maternity 0 0 0.0 0.00 0.00Certified Midwife 3,625 97 21.9 37.37 0.07PT/OT/ST 27,060 942 212.3 28.73 0.51Psychiatric and Substance Abuse 671 7 1.6 95.79 0.01Radiology and Pathology 76,113 5,367 1,209.4 14.18 1.43Home Health and Private Duty Nursing 145,092 5,188 1,169.1 27.97 2.72Ambulance 73,624 4,433 999.0 16.61 1.38Non-Emergency Transportation 69,413 23,678 5,335.7 2.93 1.30Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 963,032 11,099 2,501.1 86.77 18.08Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,520,044 569,031 128,228.0 2.67 28.54Other 1,093,573 41,718 9,400.9 26.21 20.54

$5,964,169 734,194 165,446.6 $8.12 $112.00Prescription DrugsGeneric Scripts $232,888 12,938 2,915.5 $18.00 $4.37Single-Source Brand 173,827 987 222.4 176.12 3.26Multi-Source Brand 10,476 125 28.2 83.81 0.20Specialty 597,492 146 32.9 4,092.41 11.22Other 27 2 0.5 13.34 0.00

$1,014,710 14,198 3,199.4 $71.47 $19.05Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 0 0 0.0 0.00 0.00Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 0 0 0.0 0.00 0.00Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$0 0 0.0 $0.00 $0.00All Services $10,603,633 312 777,829 70.3 175,279.5 $13.63 $199.12






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $2,986,493 563 1,968 7.5 26.2 $5,304.61 $3.31Surgical 3,956,140 196 1,181 2.6 15.7 20,184.39 4.38Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 23,859 11 36 0.1 0.5 2,168.99 0.03Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 2,290,739 336 2,464 4.5 32.8 6,817.67 2.54Alcohol and Drug Abuse 17,053 6 54 0.1 0.7 2,842.17 0.02Other 184 3 28 0.0 0.4 61.17 0.00

$9,274,467 1,115 5,731 14.8 76.2 $8,317.91 $10.28Hospital OutpatientEmergency Room $8,711,649 27,052 359.8 $322.03 $9.66Surgery 3,324,525 3,381 45.0 983.30 3.68Radiology 2,697,282 12,972 172.5 207.93 2.99Pathology 1,137,805 102,855 1,368.1 11.06 1.26Pharmacy 1,702,725 163,322 2,172.3 10.43 1.89Cardiovascular 368,314 1,221 16.2 301.65 0.41PT/OT/ST 1,131,981 34,392 457.4 32.91 1.25Psychiatric 258,991 733 9.7 353.33 0.29Substance Abuse 2,583 23 0.3 112.29 0.00Other 4,596,810 150,182 1,997.5 30.61 5.10

$23,932,666 496,133 6,599.0 $48.24 $26.53Professional and Other State Plan ServicesAmbulatory Surgery Center $400,792 1,057 14.1 $379.18 $0.44Office Visits 8,613,516 153,620 2,043.3 56.07 9.55Preventive Medicine 3,545,825 146,131 1,943.7 24.26 3.93Maternity 74,961 340 4.5 220.35 0.08Certified Midwife 927 5 0.1 201.15 0.00PT/OT/ST 2,265,010 69,817 928.6 32.44 2.51Psychiatric and Substance Abuse 3,419,770 51,484 684.8 66.42 3.79Radiology and Pathology 1,289,700 82,151 1,092.7 15.70 1.43Home Health and Private Duty Nursing 1,381,305 103,317 1,374.2 13.37 1.53Ambulance 512,912 28,613 380.6 17.93 0.57Non-Emergency Transportation 1,043,306 428,998 5,706.0 2.43 1.16Opioid Treatment Program 5,427 531 7.1 10.22 0.01Federally Qualified and Rural Health Clinics 5,828,297 48,550 645.8 120.05 6.46Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 3,033,957 1,240,567 16,500.5 2.45 3.36Other 7,676,161 507,859 6,754.9 15.11 8.51

$39,091,866 2,863,040 38,080.6 $13.65 $43.33Prescription DrugsGeneric Scripts $10,816,447 265,266 3,528.2 $40.78 $11.99Single-Source Brand 9,147,276 46,337 616.3 197.41 10.14Multi-Source Brand 1,256,529 3,784 50.3 332.06 1.39Specialty 8,917,972 2,064 27.5 4,320.72 9.88Other 26 4 0.1 6.49 0.00

$30,138,251 317,455 4,222.4 $94.94 $33.41Mental Health CenterCase Management $1,293,446 3,616 48.1 $357.70 $1.43Long Term Support Service 702,649 22,141 294.5 31.74 0.78Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 642,526 11,885 158.1 54.06 0.71Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 586 22 0.3 26.64 0.00Emergency Service 24/7 633 27 0.4 23.46 0.00APRTP 8,784 16 0.2 549.00 0.01Supported Employment Services 2,336 88 1.2 26.54 0.00Harbor Homes 4 1 0.0 4.15 0.00Other 537,498 4,223 56.2 127.28 0.60

$3,188,461 42,019 558.9 $75.88 $3.53All Services $105,625,710 1,115 3,724,378 14.8 49,537.1 $28.36 $117.08






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $1,421,996 439 1,767 39.8 160.3 $3,239.17 $10.75Surgical 1,304,005 172 774 15.6 70.2 7,581.43 9.86Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 253,087 120 402 10.9 36.5 2,109.06 1.91Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 313,638 71 459 6.4 41.6 4,417.44 2.37Alcohol and Drug Abuse 278,753 94 989 8.5 89.7 2,965.46 2.11Other 193 4 4 0.4 0.4 48.34 0.00

$3,571,673 900 4,395 81.6 398.7 $3,968.53 $27.00Hospital OutpatientEmergency Room $4,778,934 8,931 810.1 $535.10 $36.12Surgery 1,416,821 1,594 144.6 888.85 10.71Radiology 1,804,995 11,188 1,014.8 161.33 13.64Pathology 901,222 71,159 6,454.6 12.66 6.81Pharmacy 615,216 179,905 16,318.5 3.42 4.65Cardiovascular 123,373 747 67.8 165.16 0.93PT/OT/ST 379,705 13,045 1,183.3 29.11 2.87Psychiatric 42,918 232 21.0 184.99 0.32Substance Abuse 42,044 374 33.9 112.42 0.32Other 2,079,183 75,580 6,855.6 27.51 15.72

$12,184,410 362,755 32,904.2 $33.59 $92.10Professional and Other State Plan ServicesAmbulatory Surgery Center $139,018 435 39.5 $319.58 $1.05Office Visits 2,622,954 45,105 4,091.3 58.15 19.83Preventive Medicine 873,864 21,860 1,982.8 39.98 6.61Maternity 1,259,196 4,940 448.1 254.90 9.52Certified Midwife 37,226 153 13.8 244.07 0.28PT/OT/ST 224,367 9,578 868.8 23.43 1.70Psychiatric and Substance Abuse 1,931,009 24,328 2,206.7 79.37 14.60Radiology and Pathology 1,629,533 63,799 5,787.0 25.54 12.32Home Health and Private Duty Nursing 128,100 3,520 319.3 36.39 0.97Ambulance 257,072 12,357 1,120.9 20.80 1.94Non-Emergency Transportation 2,912,535 202,959 18,409.7 14.35 22.02Opioid Treatment Program 1,668,198 163,223 14,805.4 10.22 12.61Federally Qualified and Rural Health Clinics 2,508,088 19,371 1,757.1 129.48 18.96Adult Medical Day Care 14,864 627 56.9 23.71 0.11Personal Care 28,474 5,277 478.7 5.40 0.22Durable Medical Equipment 608,027 37,431 3,395.2 16.24 4.60Other 3,001,928 267,440 24,258.5 11.22 22.69

$19,844,453 882,403 80,039.5 $22.49 $150.00Prescription DrugsGeneric Scripts $3,748,927 169,161 15,344.0 $22.16 $28.34Single-Source Brand 5,420,199 26,369 2,391.8 205.55 40.97Multi-Source Brand 290,731 1,080 98.0 269.20 2.20Specialty 3,317,524 949 86.1 3,495.81 25.08Other 328 8 0.7 40.98 0.00

$12,777,708 197,567 17,920.6 $64.68 $96.58Mental Health CenterCase Management $103,907 293 26.6 $354.63 $0.79Long Term Support Service 87,208 1,304 118.3 66.88 0.66Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 201,849 3,490 316.6 57.84 1.53Evidence Based Practice 190 15 1.4 12.66 0.00Medication Management 1,279 48 4.4 26.64 0.01Emergency Service 24/7 798 34 3.1 23.46 0.01APRTP 39,528 72 6.5 549.00 0.30Supported Employment Services 3,822 144 13.1 26.54 0.03Harbor Homes 23 5 0.5 4.57 0.00Other 184,566 1,906 172.9 96.83 1.40

$623,168 7,311 663.2 $85.24 $4.71All Services $49,001,412 900 1,454,431 81.6 131,926.1 $33.69 $370.39






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $110,575 31 81 18.0 46.9 $3,566.95 $5.34Surgical 912,108 9 446 5.2 258.5 101,345.36 44.05Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 2,548 1 2 0.6 1.2 2,547.57 0.12Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 449,489 42 578 24.3 335.0 10,702.11 21.71Alcohol and Drug Abuse 1,380 2 4 1.2 2.3 690.00 0.07Other 0 0 0 0.0 0.0 0.00 0.00

$1,476,100 85 1,111 49.3 643.9 $17,365.88 $71.29Hospital OutpatientEmergency Room $295,624 750 434.7 $394.17 $14.28Surgery 97,230 98 56.8 992.14 4.70Radiology 86,300 409 237.0 211.00 4.17Pathology 49,062 3,903 2,262.0 12.57 2.37Pharmacy 20,156 6,982 4,046.4 2.89 0.97Cardiovascular 9,323 60 34.8 155.39 0.45PT/OT/ST 42,397 1,204 697.8 35.21 2.05Psychiatric 10,018 16 9.3 626.10 0.48Substance Abuse 0 0 0.0 0.00 0.00Other 183,532 3,997 2,316.4 45.92 8.86

$793,642 17,419 10,095.1 $45.56 $38.33Professional and Other State Plan ServicesAmbulatory Surgery Center $15,326 45 26.1 $340.57 $0.74Office Visits 241,250 4,128 2,392.4 58.44 11.65Preventive Medicine 81,139 3,247 1,881.8 24.99 3.92Maternity 4,596 19 11.0 241.35 0.22Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 83,468 3,004 1,741.0 27.79 4.03Psychiatric and Substance Abuse 305,692 4,927 2,855.4 62.04 14.76Radiology and Pathology 54,333 2,489 1,442.5 21.83 2.62Home Health and Private Duty Nursing 488,035 18,482 10,711.2 26.41 23.57Ambulance 32,185 2,077 1,203.7 15.50 1.55Non-Emergency Transportation 53,938 11,750 6,809.7 4.59 2.60Opioid Treatment Program 7,716 755 437.6 10.22 0.37Federally Qualified and Rural Health Clinics 165,443 1,443 836.3 114.65 7.99Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 271,968 109,312 63,351.3 2.49 13.13Other 299,556 16,185 9,379.9 18.51 14.47


$2,031,475 21,423 12,415.6 $94.83 $98.11Mental Health CenterCase Management $81,298 227 131.6 $358.14 $3.93Long Term Support Service 27,899 661 383.1 42.21 1.35Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 39,513 576 333.8 68.60 1.91Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 70 3 1.7 23.46 0.00APRTP 1,098 2 1.2 549.00 0.05Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 40,564 315 182.6 128.78 1.96

$190,442 1,784 1,033.9 $106.75 $9.20All Services $6,596,306 85 219,600 49.3 127,268.3 $30.04 $318.57






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$82,848 22 88 169.3 677.2 $3,765.80 $53.13Hospital OutpatientEmergency Room $43,846 62 477.1 $707.19 $28.12Surgery 61,051 88 677.2 693.76 39.15Radiology 230,438 1,072 8,249.9 214.96 147.78Pathology 22,389 2,034 15,653.2 11.01 14.36Pharmacy 340,902 31,907 245,549.5 10.68 218.63Cardiovascular 7,139 43 330.9 166.01 4.58PT/OT/ST 14,383 483 3,717.1 29.78 9.22Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 108,504 4,567 35,146.7 23.76 69.59

$828,650 40,256 309,801.7 $20.58 $531.43Professional and Other State Plan ServicesAmbulatory Surgery Center $7,433 17 130.8 $437.23 $4.77Office Visits 78,996 1,315 10,120.0 60.07 50.66Preventive Medicine 4,624 131 1,008.1 35.30 2.97Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 4,040 176 1,354.5 22.96 2.59Psychiatric and Substance Abuse 17,234 209 1,608.4 82.46 11.05Radiology and Pathology 47,688 1,435 11,043.5 33.23 30.58Home Health and Private Duty Nursing 39,017 338 2,601.2 115.43 25.02Ambulance 2,898 209 1,608.4 13.87 1.86Non-Emergency Transportation 5,803 973 7,488.0 5.96 3.72Opioid Treatment Program 3,720 364 2,801.3 10.22 2.39Federally Qualified and Rural Health Clinics 21,679 153 1,177.5 141.69 13.90Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 20,257 11,750 90,425.5 1.72 12.99Other 320,632 18,876 145,265.7 16.99 205.63



$1,575 10 77.0 $157.52 $1.01All Services $2,397,801 22 80,283 169.3 617,841.0 $29.87 $1,537.75






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $167,706 21 131 34.4 214.8 $7,986.00 $22.92Surgical 1,475,881 12 163 19.7 267.3 122,990.09 201.69Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 6,260 3 23 4.9 37.7 2,086.61 0.86Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$1,649,847 36 317 59.0 519.8 $45,829.08 $225.46Hospital OutpatientEmergency Room $55,177 144 236.1 $383.18 $7.54Surgery 76,285 57 93.5 1,338.33 10.42Radiology 72,734 257 421.5 283.01 9.94Pathology 45,398 2,384 3,909.5 19.04 6.20Pharmacy 184,590 4,246 6,962.9 43.47 25.23Cardiovascular 18,233 70 114.8 260.47 2.49PT/OT/ST 109,107 2,950 4,837.7 36.99 14.91Psychiatric 2,758 9 14.8 306.45 0.38Substance Abuse 0 0 0.0 0.00 0.00Other 166,043 1,328 2,177.8 125.03 22.69

$730,325 11,445 18,768.5 $63.81 $99.80Professional and Other State Plan ServicesAmbulatory Surgery Center $2,138 3 4.9 $712.54 $0.29Office Visits 114,412 1,554 2,548.4 73.62 15.64Preventive Medicine 11,975 540 885.5 22.18 1.64Maternity 274 6 9.8 45.70 0.04Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 170,135 6,719 11,018.4 25.32 23.25Psychiatric and Substance Abuse 34,967 1,205 1,976.1 29.02 4.78Radiology and Pathology 32,019 1,033 1,694.0 31.00 4.38Home Health and Private Duty Nursing 1,590,658 169,251 277,552.1 9.40 217.37Ambulance 11,423 752 1,233.2 15.19 1.56Non-Emergency Transportation 34,586 5,303 8,696.3 6.52 4.73Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 8,266 64 105.0 129.15 1.13Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 737,464 379,032 621,568.7 1.95 100.78Other 510,567 12,016 19,704.9 42.49 69.77

$3,258,883 577,478 946,997.3 $5.64 $445.35Prescription DrugsGeneric Scripts $325,150 8,307 13,622.5 $39.14 $44.43Single-Source Brand 482,419 1,401 2,297.5 344.34 65.93Multi-Source Brand 79,671 273 447.7 291.84 10.89Specialty 1,667,128 256 419.8 6,512.22 227.82Other 475 3 4.9 158.40 0.06


$46,359 681 1,116.8 $68.08 $6.34All Services $8,240,257 36 600,161 59.0 984,194.8 $13.73 $1,126.09






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $4,675,745 1,199 6,391 177.3 944.9 $3,899.70 $57.61Surgical 3,874,921 431 3,308 63.7 489.1 8,990.54 47.74Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 19,436 7 51 1.0 7.5 2,776.52 0.24Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 589,931 144 887 21.3 131.1 4,096.75 7.27Alcohol and Drug Abuse 289,336 93 869 13.7 128.5 3,111.14 3.56Other 285 7 7 1.0 1.0 40.77 0.00

$9,449,654 1,881 11,513 278.1 1,702.1 $5,023.74 $116.42Hospital OutpatientEmergency Room $4,726,465 7,400 1,094.0 $638.71 $58.23Surgery 1,765,947 2,464 364.3 716.70 21.76Radiology 2,331,808 10,724 1,585.5 217.44 28.73Pathology 717,459 61,974 9,162.5 11.58 8.84Pharmacy 1,990,998 266,163 39,350.7 7.48 24.53Cardiovascular 242,042 1,348 199.3 179.56 2.98PT/OT/ST 559,522 19,763 2,921.8 28.31 6.89Psychiatric 138,713 283 41.8 490.15 1.71Substance Abuse 12,913 115 17.0 112.29 0.16Other 3,010,696 74,169 10,965.5 40.59 37.09

$15,496,563 444,403 65,702.4 $34.87 $190.92Professional and Other State Plan ServicesAmbulatory Surgery Center $235,664 726 107.3 $324.61 $2.90Office Visits 2,570,430 42,375 6,264.9 60.66 31.67Preventive Medicine 212,230 9,798 1,448.6 21.66 2.61Maternity 32,080 183 27.0 175.69 0.40Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 227,434 9,516 1,406.9 23.90 2.80Psychiatric and Substance Abuse 975,270 14,753 2,181.1 66.11 12.02Radiology and Pathology 1,263,676 47,602 7,037.7 26.55 15.57Home Health and Private Duty Nursing 1,673,710 65,832 9,732.9 25.42 20.62Ambulance 518,561 25,288 3,738.7 20.51 6.39Non-Emergency Transportation 2,718,382 161,007 23,804.0 16.88 33.49Opioid Treatment Program 864,594 84,596 12,507.0 10.22 10.65Federally Qualified and Rural Health Clinics 1,731,987 12,578 1,859.6 137.70 21.34Adult Medical Day Care 492,015 20,477 3,027.4 24.03 6.06Personal Care 558,683 103,728 15,335.6 5.39 6.88Durable Medical Equipment 1,616,681 308,970 45,679.4 5.23 19.92Other 4,589,347 294,107 43,482.0 15.60 56.54

$20,280,747 1,201,536 177,640.1 $16.88 $249.87Prescription DrugsGeneric Scripts $5,926,281 267,272 39,514.6 $22.17 $73.01Single-Source Brand 11,883,025 43,991 6,503.8 270.12 146.40Multi-Source Brand 1,022,832 2,532 374.3 403.96 12.60Specialty 8,771,127 2,849 421.2 3,078.67 108.06Other 232 6 0.9 38.62 0.00

$27,603,497 316,650 46,814.9 $87.17 $340.08Mental Health CenterCase Management $349,646 977 144.4 $357.88 $4.31Long Term Support Service 328,688 10,056 1,486.7 32.69 4.05Partial Hospital 15,562 157 23.2 99.12 0.19Psychotherapy 248,395 5,122 757.3 48.50 3.06Evidence Based Practice 4,206 250 37.0 16.82 0.05Medication Management 11,455 388 57.4 29.52 0.14Emergency Service 24/7 5,748 245 36.2 23.46 0.07APRTP 40,626 74 10.9 549.00 0.50Supported Employment Services 12,421 468 69.2 26.54 0.15Harbor Homes 13 3 0.4 4.19 0.00Other 222,112 2,534 374.6 87.65 2.74

$1,238,871 20,274 2,997.4 $61.11 $15.26All Services $74,069,332 1,881 1,994,376 278.1 294,857.0 $37.14 $912.56






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $970,424 678 2,885 119.6 509.0 $1,431.30 $14.27Surgical 422,726 232 1,294 40.9 228.3 1,822.09 6.22Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 14,252 9 31 1.6 5.5 1,583.50 0.21Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 46,081 29 194 5.1 34.2 1,589.00 0.68Alcohol and Drug Abuse 87,372 37 394 6.5 69.5 2,361.41 1.28Other 482 21 24 3.7 4.2 22.94 0.01

$1,541,336 1,006 4,822 177.5 850.7 $1,532.14 $22.66Hospital OutpatientEmergency Room $1,462,299 4,393 775.1 $332.87 $21.50Surgery 537,428 2,129 375.6 252.43 7.90Radiology 763,325 6,231 1,099.3 122.50 11.22Pathology 143,732 19,284 3,402.3 7.45 2.11Pharmacy 1,173,885 326,251 57,560.2 3.60 17.26Cardiovascular 117,922 1,231 217.2 95.79 1.73PT/OT/ST 135,411 10,281 1,813.9 13.17 1.99Psychiatric 9,001 144 25.4 62.51 0.13Substance Abuse 8,534 76 13.4 112.29 0.13Other 1,298,978 71,484 12,611.9 18.17 19.10

$5,650,514 441,504 77,894.2 $12.80 $83.08Professional and Other State Plan ServicesAmbulatory Surgery Center $62,055 412 72.7 $150.62 $0.91Office Visits 771,918 27,418 4,837.3 28.15 11.35Preventive Medicine 67,600 2,963 522.8 22.81 0.99Maternity 24,535 242 42.7 101.38 0.36Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 56,101 5,581 984.7 10.05 0.82Psychiatric and Substance Abuse 391,550 5,797 1,022.8 67.54 5.76Radiology and Pathology 264,117 14,791 2,609.6 17.86 3.88Home Health and Private Duty Nursing 110,860 12,824 2,262.5 8.64 1.63Ambulance 154,753 9,082 1,602.3 17.04 2.28Non-Emergency Transportation 1,694,972 112,893 19,917.6 15.01 24.92Opioid Treatment Program 589,472 57,677 10,175.9 10.22 8.67Federally Qualified and Rural Health Clinics 235,358 3,581 631.8 65.72 3.46Adult Medical Day Care 85,592 3,170 559.3 27.00 1.26Personal Care 310,396 57,525 10,149.1 5.40 4.56Durable Medical Equipment 388,456 150,590 26,568.5 2.58 5.71Other 1,251,837 190,603 33,627.9 6.57 18.41

$6,459,571 655,149 115,587.4 $9.86 $94.97Prescription DrugsGeneric Scripts $37,719 3,951 697.1 $9.55 $0.55Single-Source Brand 5,118 118 20.8 43.37 0.08Multi-Source Brand 581 21 3.7 27.67 0.01Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$43,418 4,090 721.6 $10.62 $0.64Mental Health CenterCase Management $312,230 880 155.3 $354.81 $4.59Long Term Support Service 223,580 7,556 1,333.1 29.59 3.29Partial Hospital 8,284 84 14.8 98.62 0.12Psychotherapy 101,670 3,243 572.2 31.35 1.49Evidence Based Practice 3,249 119 21.0 27.30 0.05Medication Management 6,816 239 42.2 28.52 0.10Emergency Service 24/7 2,416 103 18.2 23.46 0.04APRTP 23,607 44 7.8 536.52 0.35Supported Employment Services 43,924 1,661 293.0 26.44 0.65Harbor Homes 11,656 139 24.5 83.86 0.17Other 111,478 2,919 515.0 38.19 1.64

$848,912 16,987 2,997.0 $49.97 $12.48All Services $14,543,750 1,006 1,122,552 177.5 198,050.8 $12.96 $213.83






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $3,727,461 958 5,742 408.9 2,450.7 $3,890.88 $1,590.89Surgical 1,187,062 11 175 4.7 74.7 107,914.76 506.64Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 843,182 1,464 3,150 624.8 1,344.4 575.94 359.87Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$5,757,706 2,433 9,067 1,038.4 3,869.8 $2,366.50 $2,457.41Hospital OutpatientEmergency Room $75,616 305 130.2 $247.92 $32.27Surgery 6,604 15 6.4 440.25 2.82Radiology 16,419 122 52.1 134.58 7.01Pathology 7,273 1,019 434.9 7.14 3.10Pharmacy 387 603 257.4 0.64 0.17Cardiovascular 793 20 8.5 39.65 0.34PT/OT/ST 3,324 76 32.4 43.74 1.42Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 83,441 1,292 551.4 64.58 35.61

$193,858 3,452 1,473.3 $56.16 $82.74Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 116,121 2,024 863.8 57.37 49.56Preventive Medicine 273,722 6,450 2,752.9 42.44 116.83Maternity 0 0 0.0 0.00 0.00Certified Midwife 341 8 3.4 42.63 0.15PT/OT/ST 238 10 4.3 23.81 0.10Psychiatric and Substance Abuse 146 2 0.9 72.91 0.06Radiology and Pathology 20,377 1,239 528.8 16.45 8.70Home Health and Private Duty Nursing 57,901 986 420.8 58.72 24.71Ambulance 35,295 1,760 751.2 20.05 15.06Non-Emergency Transportation 3,511 107 45.7 32.82 1.50Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 193,234 1,283 547.6 150.61 82.47Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 31,927 14,559 6,213.8 2.19 13.63Other 840,380 11,208 4,783.6 74.98 358.68

$1,573,193 39,636 16,916.8 $39.69 $671.44Prescription DrugsGeneric Scripts $9,173 575 245.4 $15.95 $3.92Single-Source Brand 9,793 17 7.3 576.06 4.18Multi-Source Brand 716 25 10.7 28.64 0.31Specialty 18 2 0.9 8.84 0.01Other 0 0 0.0 0.00 0.00


$0 0 0.0 $0.00 $0.00All Services $7,544,457 2,433 52,774 1,038.4 22,524.1 $142.96 $3,220.00





Member Months: 154

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $1,113,163 181 2,018 1,175.3 13,103.9 $6,150.07 $7,228.33Surgical 74,764 3 196 19.5 1,272.7 24,921.19 485.48Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 350 1 1 6.5 6.5 350.00 2.27Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$1,188,276 185 2,215 1,201.3 14,383.1 $6,423.12 $7,716.08Hospital OutpatientEmergency Room $3,606 12 77.9 $300.49 $23.42Surgery 0 0 0.0 0.00 0.00Radiology 544 4 26.0 135.97 3.53Pathology 216 28 181.8 7.72 1.40Pharmacy 38 11 71.4 3.43 0.24Cardiovascular 713 7 45.5 101.79 4.63PT/OT/ST 0 0 0.0 0.00 0.00Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 6,354 66 428.6 96.27 41.26

$11,470 128 831.2 $89.61 $74.48Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 5,504 113 733.8 48.70 35.74Preventive Medicine 23,008 442 2,870.1 52.05 149.40Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,402 59 383.1 23.76 9.10Psychiatric and Substance Abuse 320 1 6.5 319.80 2.08Radiology and Pathology 1,857 155 1,006.5 11.98 12.06Home Health and Private Duty Nursing 15,338 193 1,253.2 79.47 99.60Ambulance 8,560 314 2,039.0 27.26 55.58Non-Emergency Transportation 902 15 97.4 60.11 5.86Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 12,326 80 519.5 154.07 80.04Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 7,683 3,937 25,564.9 1.95 49.89Other 149,658 2,842 18,454.5 52.66 971.80

$226,556 8,151 52,928.6 $27.79 $1,471.14Prescription DrugsGeneric Scripts $878 65 422.1 $13.51 $5.70Single-Source Brand 131 2 13.0 65.41 0.85Multi-Source Brand 9 1 6.5 8.67 0.06Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00


$0 0 0.0 $0.00 $0.00All Services $1,427,321 185 10,562 1,201.3 68,584.4 $135.14 $9,268.32






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $88,260 44 96 14.5 31.7 $2,005.91 $29.14Surgical 1,744 1 2 0.3 0.7 1,743.60 0.58Maternity Delivery 5,598,386 2,470 6,635 815.5 2,190.5 2,266.55 1,848.26Maternity Non-Delivery 52,567 31 55 10.2 18.2 1,695.72 17.35Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$5,740,957 2,546 6,788 840.5 2,241.0 $2,254.89 $1,895.33Hospital OutpatientEmergency Room $30,924 41 13.5 $754.24 $10.21Surgery 4,916 8 2.6 614.48 1.62Radiology 10,516 80 26.4 131.46 3.47Pathology 8,312 636 210.0 13.07 2.74Pharmacy 11,479 1,771 584.7 6.48 3.79Cardiovascular 0 0 0.0 0.00 0.00PT/OT/ST 101 2 0.7 50.64 0.03Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 62,171 1,273 420.3 48.84 20.53

$128,419 3,811 1,258.2 $33.70 $42.40Professional and Other State Plan ServicesAmbulatory Surgery Center $0 0 0.0 $0.00 $0.00Office Visits 18,482 94 31.0 196.62 6.10Preventive Medicine 1,845 34 11.2 54.25 0.61Maternity 1,711,136 3,515 1,160.6 486.76 564.92Certified Midwife 23,896 35 11.5 685.37 7.89PT/OT/ST 91 4 1.3 22.78 0.03Psychiatric and Substance Abuse 0 0 0.0 0.00 0.00Radiology and Pathology 6,707 316 104.3 21.22 2.21Home Health and Private Duty Nursing 124 3 1.0 41.20 0.04Ambulance 13,929 1,187 391.9 11.73 4.60Non-Emergency Transportation 0 0 0.0 0.00 0.00Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 3,650 31 10.2 117.75 1.21Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 0 0 0.0 0.00 0.00Other 38,539 3,319 1,095.7 11.61 12.72

$1,818,399 8,538 2,818.8 $212.97 $600.33Prescription DrugsGeneric Scripts $0 0 0.0 $0.00 $0.00Single-Source Brand 0 0 0.0 0.00 0.00Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00


$0 0 0.0 $0.00 $0.00All Services $7,687,775 2,546 19,137 840.5 6,318.0 $401.72 $2,538.06






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $246,755 52 393 467.5 3,533.1 $4,745.30 $184.86Surgical 253,860 17 226 152.8 2,031.8 14,932.96 190.19Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 3,326 1 7 9.0 62.9 3,326.00 2.49Alcohol and Drug Abuse 1,301 1 5 9.0 45.0 1,300.80 0.97Other 6,105 84 91 755.2 818.1 72.68 4.57

$511,347 155 722 1,393.5 6,490.9 $3,299.01 $383.09Hospital OutpatientEmergency Room $72,212 76 683.2 $950.16 $54.10Surgery 31,329 51 458.5 614.29 23.47Radiology 36,418 148 1,330.5 246.07 27.28Pathology 21,637 2,365 21,261.6 9.15 16.21Pharmacy 142,970 8,330 74,887.6 17.16 107.11Cardiovascular 3,807 17 152.8 223.96 2.85PT/OT/ST 961 20 179.8 48.07 0.72Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 195,692 1,943 17,467.8 100.72 146.61

$505,026 12,950 116,421.9 $39.00 $378.35Professional and Other State Plan ServicesAmbulatory Surgery Center $9,463 8 71.9 $1,182.85 $7.09Office Visits 33,689 365 3,281.4 92.30 25.24Preventive Medicine 770 35 314.7 22.00 0.58Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,118 104 935.0 29.98 2.34Psychiatric and Substance Abuse 21,853 517 4,647.9 42.27 16.37Radiology and Pathology 16,233 1,126 10,122.9 14.42 12.16Home Health and Private Duty Nursing 49,291 669 6,014.4 73.68 36.93Ambulance 107,381 11,716 105,328.1 9.17 80.45Non-Emergency Transportation 76,347 2,176 19,562.5 35.09 57.20Opioid Treatment Program 266 26 233.7 10.22 0.20Federally Qualified and Rural Health Clinics 30,910 201 1,807.0 153.78 23.16Adult Medical Day Care 547 15 134.9 36.47 0.41Personal Care 1,246 231 2,076.7 5.40 0.93Durable Medical Equipment 164,948 8,214 73,844.7 20.08 123.58Other 209,231 7,296 65,591.8 28.68 156.75

$725,292 32,699 293,967.4 $22.18 $543.37Prescription DrugsGeneric Scripts $420,696 13,737 123,497.1 $30.63 $315.18Single-Source Brand 401,315 1,148 10,320.6 349.58 300.66Multi-Source Brand 15,732 47 422.5 334.72 11.79Specialty 489,622 124 1,114.8 3,948.56 366.81Other 0 0 0.0 0.00 0.00

$1,327,365 15,056 135,355.0 $88.16 $994.43Mental Health CenterCase Management $3,223 9 80.9 $358.14 $2.41Long Term Support Service 2,562 86 773.1 29.79 1.92Partial Hospital 500 5 45.0 99.90 0.37Psychotherapy 6,431 131 1,177.7 49.09 4.82Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 600 5 45.0 120.00 0.45Other 2,311 26 233.7 88.90 1.73

$15,627 262 2,355.4 $59.64 $11.71All Services $3,084,657 155 61,689 1,393.5 554,590.6 $50.00 $2,310.95





Member Months: 928

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $106,211 31 173 400.7 2,236.1 $3,426.16 $114.40Surgical 33,699 4 31 51.7 400.7 8,424.63 36.30Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 1,764 9 9 116.3 116.3 196.04 1.90

$141,674 44 213 568.7 2,753.1 $3,219.86 $152.60Hospital OutpatientEmergency Room $36,809 36 465.3 $1,022.47 $39.65Surgery 11,906 11 142.2 1,082.39 12.82Radiology 7,738 30 387.8 257.95 8.33Pathology 13,059 1,689 21,830.6 7.73 14.07Pharmacy 7,773 3,254 42,058.6 2.39 8.37Cardiovascular 2,426 9 116.3 269.54 2.61PT/OT/ST 775 16 206.8 48.44 0.83Psychiatric 886 5 64.6 177.12 0.95Substance Abuse 0 0 0.0 0.00 0.00Other 203,421 1,208 15,613.6 168.39 219.10

$284,793 6,258 80,885.8 $45.51 $306.75Professional and Other State Plan ServicesAmbulatory Surgery Center $368 1 12.9 $367.71 $0.40Office Visits 9,927 154 1,990.5 64.46 10.69Preventive Medicine 369 22 284.4 16.75 0.40Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 499 16 206.8 31.16 0.54Psychiatric and Substance Abuse 2,879 83 1,072.8 34.69 3.10Radiology and Pathology 9,564 654 8,453.1 14.62 10.30Home Health and Private Duty Nursing 86,485 612 7,910.2 141.32 93.15Ambulance 23,262 887 11,464.6 26.23 25.06Non-Emergency Transportation 55,507 1,996 25,798.7 27.81 59.79Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 10,920 69 891.8 158.25 11.76Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 13,134 1,844 23,834.0 7.12 14.15Other 79,971 2,493 32,222.5 32.08 86.14



$2,345 13 168.0 $180.39 $2.53All Services $1,095,450 44 24,585 568.7 317,765.7 $44.56 $1,179.91






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $127,947 95 554 322.7 1,882.1 $1,346.82 $36.22Surgical 16,940 13 108 44.2 366.9 1,303.09 4.80Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 1,288 1 5 3.4 17.0 1,288.00 0.36Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 7,786 85 184 288.8 625.1 91.60 2.20

$153,962 194 851 659.1 2,891.1 $793.62 $43.59Hospital OutpatientEmergency Room $64,267 165 560.5 $389.50 $18.19Surgery 19,121 115 390.7 166.27 5.41Radiology 29,142 212 720.2 137.46 8.25Pathology 3,577 711 2,415.5 5.03 1.01Pharmacy 40,063 15,910 54,050.4 2.52 11.34Cardiovascular 3,405 24 81.5 141.88 0.96PT/OT/ST 1,075 99 336.3 10.86 0.30Psychiatric 3,743 10 34.0 374.32 1.06Substance Abuse 0 0 0.0 0.00 0.00Other 108,223 4,111 13,966.1 26.33 30.64

$272,617 21,357 72,555.3 $12.76 $77.18Professional and Other State Plan ServicesAmbulatory Surgery Center $1,423 6 20.4 $237.10 $0.40Office Visits 21,532 809 2,748.4 26.62 6.10Preventive Medicine 438 25 84.9 17.52 0.12Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 191 26 88.3 7.34 0.05Psychiatric and Substance Abuse 11,491 413 1,403.1 27.82 3.25Radiology and Pathology 7,630 696 2,364.5 10.96 2.16Home Health and Private Duty Nursing 2,917 88 299.0 33.15 0.83Ambulance 61,955 2,127 7,226.0 29.13 17.54Non-Emergency Transportation 138,484 4,946 16,802.8 28.00 39.21Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 6,206 91 309.2 68.20 1.76Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 2,309 428 1,454.0 5.40 0.65Durable Medical Equipment 65,786 8,724 29,637.7 7.54 18.62Other 112,612 10,719 36,415.2 10.51 31.88


$11,175 2,730 9,274.5 $4.09 $3.16Mental Health CenterCase Management $9,320 26 88.3 $358.48 $2.64Long Term Support Service 26,652 1,088 3,696.2 24.50 7.55Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 3,657 73 248.0 50.10 1.04Evidence Based Practice 1,004 38 129.1 26.41 0.28Medication Management 781 16 54.4 48.83 0.22Emergency Service 24/7 328 14 47.6 23.46 0.09APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 1,225 33 112.1 37.12 0.35

$42,967 1,288 4,375.7 $33.36 $12.16All Services $913,696 194 55,324 659.1 187,949.9 $16.52 $258.67






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $628,925 485 2,187 152.3 686.6 $1,296.75 $16.45Surgical 66,893 50 269 15.7 84.5 1,337.86 1.75Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 15,002 6 157 1.9 49.3 2,500.34 0.39Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 47,988 376 410 118.1 128.7 127.63 1.26

$758,809 917 3,023 287.9 949.1 $827.49 $19.85Hospital OutpatientEmergency Room $320,899 694 217.9 $462.39 $8.40Surgery 61,400 278 87.3 220.86 1.61Radiology 297,846 1,128 354.2 264.05 7.79Pathology 11,598 1,943 610.0 5.97 0.30Pharmacy 61,360 28,054 8,808.0 2.19 1.61Cardiovascular 50,122 210 65.9 238.68 1.31PT/OT/ST 6,332 225 70.6 28.14 0.17Psychiatric 1,275 30 9.4 42.49 0.03Substance Abuse 0 0 0.0 0.00 0.00Other 242,787 11,270 3,538.4 21.54 6.35

$1,053,618 43,832 13,761.7 $24.04 $27.57Professional and Other State Plan ServicesAmbulatory Surgery Center $5,205 49 15.4 $106.23 $0.14Office Visits 60,000 2,365 742.5 25.37 1.57Preventive Medicine 4,977 360 113.0 13.82 0.13Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,224 66 20.7 18.54 0.03Psychiatric and Substance Abuse 40,281 1,469 461.2 27.42 1.05Radiology and Pathology 46,518 3,131 983.0 14.86 1.22Home Health and Private Duty Nursing 32,048 465 146.0 68.92 0.84Ambulance 120,223 5,770 1,811.6 20.84 3.15Non-Emergency Transportation 566,273 35,297 11,082.0 16.04 14.82Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 27,091 614 192.8 44.12 0.71Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 118,665 14,652 4,600.2 8.10 3.10Other 639,292 41,873 13,146.6 15.27 16.73


$101,529 25,317 7,948.6 $4.01 $2.66Mental Health CenterCase Management $1,433 4 1.3 $358.14 $0.04Long Term Support Service 4,117 79 24.8 52.11 0.11Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 1,275 92 28.9 13.85 0.03Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 263 11 3.5 23.95 0.01Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 359 1 0.3 358.74 0.01Other 2,565 82 25.7 31.28 0.07

$10,011 269 84.5 $37.22 $0.26All Services $3,585,764 917 178,552 287.9 56,058.9 $20.08 $93.82






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $639,814 154 1,261 504.2 4,128.8 $4,154.64 $174.57Surgical 213,353 29 266 95.0 870.9 7,357.01 58.21Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 17,853 5 19 16.4 62.2 3,570.69 4.87Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 1,264 4 4 13.1 13.1 316.06 0.34

$872,285 192 1,550 628.6 5,075.0 $4,543.15 $238.00Hospital OutpatientEmergency Room $356,723 470 1,538.9 $758.99 $97.33Surgery 92,069 163 533.7 564.84 25.12Radiology 131,932 846 2,770.0 155.95 36.00Pathology 45,811 4,571 14,966.4 10.02 12.50Pharmacy 264,253 23,232 76,066.6 11.37 72.10Cardiovascular 14,301 90 294.7 158.90 3.90PT/OT/ST 87,632 2,901 9,498.5 30.21 23.91Psychiatric 22,978 42 137.5 547.10 6.27Substance Abuse 0 0 0.0 0.00 0.00Other 219,626 3,856 12,625.4 56.96 59.93

$1,235,326 36,171 118,431.7 $34.15 $337.06Professional and Other State Plan ServicesAmbulatory Surgery Center $11,508 44 144.1 $261.54 $3.14Office Visits 170,755 2,741 8,974.6 62.30 46.59Preventive Medicine 8,437 363 1,188.5 23.24 2.30Maternity 233 2 6.5 116.60 0.06Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 13,480 572 1,872.9 23.57 3.68Psychiatric and Substance Abuse 24,079 300 982.3 80.26 6.57Radiology and Pathology 58,833 2,826 9,252.9 20.82 16.05Home Health and Private Duty Nursing 850,560 41,562 136,083.0 20.46 232.08Ambulance 91,772 3,992 13,070.7 22.99 25.04Non-Emergency Transportation 316,009 9,631 31,534.0 32.81 86.22Opioid Treatment Program 9,801 959 3,140.0 10.22 2.67Federally Qualified and Rural Health Clinics 87,607 679 2,223.2 129.02 23.90Adult Medical Day Care 50,028 2,735 8,955.0 18.29 13.65Personal Care 1,011,463 187,484 613,863.1 5.39 275.98Durable Medical Equipment 598,156 235,937 772,508.7 2.54 163.21Other 591,500 34,943 114,410.9 16.93 161.39

$3,894,222 524,770 1,718,210.3 $7.42 $1,062.54Prescription DrugsGeneric Scripts $696,165 29,270 95,836.3 $23.78 $189.95Single-Source Brand 1,520,155 3,849 12,602.5 394.95 414.78Multi-Source Brand 56,368 154 504.2 366.02 15.38Specialty 1,496,365 320 1,047.7 4,676.14 408.29Other 0 0 0.0 0.00 0.00

$3,769,052 33,593 109,990.7 $112.20 $1,028.39Mental Health CenterCase Management $213,451 596 1,951.4 $358.14 $58.24Long Term Support Service 210,428 8,500 27,830.8 24.76 57.42Partial Hospital 1,798 18 58.9 99.90 0.49Psychotherapy 51,507 967 3,166.2 53.26 14.05Evidence Based Practice 1,131 57 186.6 19.84 0.31Medication Management 3,949 122 399.5 32.37 1.08Emergency Service 24/7 2,651 113 370.0 23.46 0.72APRTP 0 0 0.0 0.00 0.00Supported Employment Services 10,298 388 1,270.4 26.54 2.81Harbor Homes 12,120 101 330.7 120.00 3.31Other 29,150 399 1,306.4 73.06 7.95

$536,483 11,261 36,870.9 $47.64 $146.38All Services $10,307,369 192 607,345 628.6 1,988,578.7 $16.97 $2,812.38






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$554,188 127 988 786.8 6,120.7 $4,363.68 $286.10Hospital OutpatientEmergency Room $142,921 161 997.4 $887.71 $73.78Surgery 22,817 35 216.8 651.92 11.78Radiology 65,528 217 1,344.3 301.97 33.83Pathology 18,923 1,969 12,198.0 9.61 9.77Pharmacy 12,456 6,506 40,304.7 1.91 6.43Cardiovascular 4,408 30 185.9 146.93 2.28PT/OT/ST 12,394 505 3,128.5 24.54 6.40Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 84,313 1,657 10,265.1 50.88 43.53

$363,761 11,080 68,640.7 $32.83 $187.79Professional and Other State Plan ServicesAmbulatory Surgery Center $8,796 21 130.1 $418.88 $4.54Office Visits 63,727 1,075 6,659.6 59.28 32.90Preventive Medicine 4,527 150 929.3 30.18 2.34Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,012 34 210.6 29.76 0.52Psychiatric and Substance Abuse 544 9 55.8 60.44 0.28Radiology and Pathology 25,087 1,252 7,756.1 20.04 12.95Home Health and Private Duty Nursing 256,728 2,814 17,432.7 91.23 132.54Ambulance 34,521 1,156 7,161.4 29.86 17.82Non-Emergency Transportation 58,303 3,009 18,640.8 19.38 30.10Opioid Treatment Program 930 91 563.7 10.22 0.48Federally Qualified and Rural Health Clinics 53,314 393 2,434.6 135.66 27.52Adult Medical Day Care 177,766 9,822 60,847.3 18.10 91.77Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 142,185 104,893 649,812.7 1.36 73.40Other 223,373 7,135 44,201.4 31.31 115.32


$812,310 13,849 85,794.6 $58.65 $419.36Mental Health CenterCase Management $41,186 115 712.4 $358.14 $21.26Long Term Support Service 42,479 1,754 10,866.0 24.22 21.93Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 4,167 55 340.7 75.76 2.15Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 559 21 130.1 26.64 0.29Emergency Service 24/7 258 11 68.1 23.46 0.13APRTP 2,745 5 31.0 549.00 1.42Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 8,077 498 3,085.1 16.22 4.17

$99,471 2,459 15,233.5 $40.45 $51.35All Services $2,880,543 127 160,230 786.8 992,625.7 $17.98 $1,487.08






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $374,895 264 1,371 347.3 1,803.8 $1,420.06 $41.10Surgical 107,130 48 562 63.2 739.4 2,231.88 11.75Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 5,797 5 44 6.6 57.9 1,159.46 0.64Alcohol and Drug Abuse 3,746 2 20 2.6 26.3 1,873.05 0.41Other 1,844 5 9 6.6 11.8 368.81 0.20

$493,412 324 2,006 426.3 2,639.2 $1,522.88 $54.10Hospital OutpatientEmergency Room $336,886 1,031 1,356.5 $326.76 $36.94Surgery 117,568 569 748.6 206.62 12.89Radiology 102,344 1,067 1,403.8 95.92 11.22Pathology 16,516 3,239 4,261.5 5.10 1.81Pharmacy 212,755 71,360 93,886.3 2.98 23.33Cardiovascular 21,348 206 271.0 103.63 2.34PT/OT/ST 32,315 2,834 3,728.6 11.40 3.54Psychiatric 1,102 12 15.8 91.83 0.12Substance Abuse 0 0 0.0 0.00 0.00Other 260,056 16,303 21,449.4 15.95 28.51

$1,100,889 96,621 127,121.5 $11.39 $120.70Professional and Other State Plan ServicesAmbulatory Surgery Center $9,762 61 80.3 $160.03 $1.07Office Visits 142,695 6,146 8,086.1 23.22 15.65Preventive Medicine 6,130 218 286.8 28.12 0.67Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 7,653 809 1,064.4 9.46 0.84Psychiatric and Substance Abuse 8,857 221 290.8 40.08 0.97Radiology and Pathology 33,203 3,015 3,966.7 11.01 3.64Home Health and Private Duty Nursing 376,771 11,638 15,311.8 32.37 41.31Ambulance 130,987 5,637 7,416.4 23.24 14.36Non-Emergency Transportation 714,700 21,752 28,618.5 32.86 78.36Opioid Treatment Program 21,339 2,088 2,747.1 10.22 2.34Federally Qualified and Rural Health Clinics 20,944 524 689.4 39.97 2.30Adult Medical Day Care 19,121 1,537 2,022.2 12.44 2.10Personal Care 3,908,279 724,507 953,213.0 5.39 428.50Durable Medical Equipment 502,355 336,715 443,006.2 1.49 55.08Other 299,074 41,750 54,929.3 7.16 32.79

$6,201,870 1,156,618 1,521,729.0 $5.36 $679.97Prescription DrugsGeneric Scripts $12,727 3,199 4,208.8 $3.98 $1.40Single-Source Brand 261 69 90.8 3.79 0.03Multi-Source Brand 457 10 13.2 45.75 0.05Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$13,446 3,278 4,312.8 $4.10 $1.47Mental Health CenterCase Management $621,754 1,800 2,368.2 $345.42 $68.17Long Term Support Service 844,159 32,518 42,783.0 25.96 92.55Partial Hospital 25,148 260 342.1 96.72 2.76Psychotherapy 46,942 1,697 2,232.7 27.66 5.15Evidence Based Practice 10,615 450 592.1 23.59 1.16Medication Management 9,007 310 407.9 29.05 0.99Emergency Service 24/7 7,531 322 423.6 23.39 0.83APRTP 18,119 33 43.4 549.07 1.99Supported Employment Services 38,751 1,463 1,924.8 26.49 4.25Harbor Homes 54,677 462 607.8 118.35 5.99Other 31,001 989 1,301.2 31.35 3.40

$1,707,704 40,304 53,026.8 $42.37 $187.23All Services $9,517,322 324 1,298,827 426.3 1,708,829.3 $7.33 $1,043.47






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $781,547 578 2,859 377.9 1,869.1 $1,352.16 $42.58Surgical 146,460 100 715 65.4 467.4 1,464.60 7.98Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 16,940 13 163 8.5 106.6 1,303.09 0.92Alcohol and Drug Abuse 2,604 2 16 1.3 10.5 1,302.00 0.14Other 858 7 7 4.6 4.6 122.51 0.05

$948,409 700 3,760 457.6 2,458.1 $1,354.87 $51.67Hospital OutpatientEmergency Room $624,202 1,407 919.8 $443.64 $34.01Surgery 104,901 580 379.2 180.86 5.71Radiology 172,880 1,737 1,135.6 99.53 9.42Pathology 20,024 4,298 2,809.8 4.66 1.09Pharmacy 122,214 51,677 33,783.9 2.36 6.66Cardiovascular 38,444 374 244.5 102.79 2.09PT/OT/ST 28,304 2,339 1,529.1 12.10 1.54Psychiatric 6,274 29 19.0 216.35 0.34Substance Abuse 0 0 0.0 0.00 0.00Other 299,956 19,427 12,700.4 15.44 16.34

$1,417,200 81,868 53,521.4 $17.31 $77.21Professional and Other State Plan ServicesAmbulatory Surgery Center $10,422 119 77.8 $87.58 $0.57Office Visits 197,767 8,791 5,747.1 22.50 10.77Preventive Medicine 5,101 349 228.2 14.62 0.28Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 2,429 426 278.5 5.70 0.13Psychiatric and Substance Abuse 7,579 288 188.3 26.31 0.41Radiology and Pathology 47,449 4,926 3,220.4 9.63 2.58Home Health and Private Duty Nursing 68,586 1,587 1,037.5 43.22 3.74Ambulance 205,898 7,427 4,855.4 27.72 11.22Non-Emergency Transportation 1,112,764 36,207 23,670.4 30.73 60.62Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 21,084 636 415.8 33.15 1.15Adult Medical Day Care 74,320 5,692 3,721.2 13.06 4.05Personal Care 883,996 163,834 107,106.8 5.40 48.16Durable Medical Equipment 489,865 657,454 429,812.0 0.75 26.69Other 473,399 74,529 48,723.5 6.35 25.79


$37,595 9,883 6,461.0 $3.80 $2.05Mental Health CenterCase Management $544,975 1,550 1,013.3 $351.60 $29.69Long Term Support Service 698,143 28,099 18,369.8 24.85 38.03Partial Hospital 36,445 371 242.5 98.24 1.99Psychotherapy 25,860 736 481.2 35.14 1.41Evidence Based Practice 6,607 334 218.4 19.78 0.36Medication Management 4,647 162 105.9 28.69 0.25Emergency Service 24/7 6,923 295 192.9 23.47 0.38APRTP 0 0 0.0 0.00 0.00Supported Employment Services 1,009 38 24.8 26.54 0.05Harbor Homes 41,827 346 226.2 120.89 2.28Other 32,144 1,712 1,119.2 18.78 1.75

$1,398,580 33,643 21,994.2 $41.57 $76.19All Services $7,402,442 700 1,091,419 457.6 713,517.5 $6.78 $403.28






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$784,342 119 1,029 91.9 794.5 $6,591.11 $50.47Hospital OutpatientEmergency Room $365,519 552 426.2 $662.17 $23.52Surgery 78,229 161 124.3 485.89 5.03Radiology 121,264 424 327.4 286.00 7.80Pathology 58,027 5,251 4,054.4 11.05 3.73Pharmacy 27,525 7,281 5,621.8 3.78 1.77Cardiovascular 46,555 115 88.8 404.82 3.00PT/OT/ST 37,364 1,162 897.2 32.15 2.40Psychiatric 615 7 5.4 87.82 0.04Substance Abuse 0 0 0.0 0.00 0.00Other 102,519 2,904 2,242.2 35.30 6.60

$837,616 17,857 13,787.6 $46.91 $53.89Professional and Other State Plan ServicesAmbulatory Surgery Center $6,592 18 13.9 $366.22 $0.42Office Visits 209,534 3,432 2,649.9 61.05 13.48Preventive Medicine 41,902 1,818 1,403.7 23.05 2.70Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 73,923 3,618 2,793.5 20.43 4.76Psychiatric and Substance Abuse 89,944 1,503 1,160.5 59.84 5.79Radiology and Pathology 48,171 2,800 2,161.9 17.20 3.10Home Health and Private Duty Nursing 2,486,220 217,175 167,683.7 11.45 159.97Ambulance 60,757 3,141 2,425.2 19.34 3.91Non-Emergency Transportation 62,400 9,602 7,413.8 6.50 4.02Opioid Treatment Program 3,628 355 274.1 10.22 0.23Federally Qualified and Rural Health Clinics 102,329 741 572.1 138.10 6.58Adult Medical Day Care 16,232 759 586.0 21.39 1.04Personal Care 126,192 23,387 18,057.4 5.40 8.12Durable Medical Equipment 952,303 752,646 581,128.1 1.27 61.27Other 346,629 18,136 14,003.0 19.11 22.30

$4,626,755 1,039,131 802,327.0 $4.45 $297.70Prescription DrugsGeneric Scripts $1,403,518 43,247 33,391.6 $32.45 $90.31Single-Source Brand 1,313,959 2,848 2,199.0 461.36 84.54Multi-Source Brand 770,841 1,699 1,311.8 453.70 49.60Specialty 913,013 215 166.0 4,246.57 58.75Other 0 0 0.0 0.00 0.00

$4,401,330 48,009 37,068.4 $91.68 $283.19Mental Health CenterCase Management $61,958 173 133.6 $358.14 $3.99Long Term Support Service 102,436 2,995 2,312.5 34.20 6.59Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 95,196 2,090 1,613.7 45.55 6.13Evidence Based Practice 4,116 159 122.8 25.89 0.26Medication Management 3,714 89 68.7 41.72 0.24Emergency Service 24/7 352 15 11.6 23.46 0.02APRTP 13,176 24 18.5 549.00 0.85Supported Employment Services 7,192 271 209.2 26.54 0.46Harbor Homes 0 0 0.0 0.00 0.00Other 68,863 984 759.8 69.98 4.43

$357,002 6,800 5,250.4 $52.50 $22.97All Services $11,007,045 119 1,112,826 91.9 859,227.9 $9.89 $708.22






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $363,084 217 1,354 87.6 546.3 $1,673.20 $12.21Surgical 71,708 47 345 19.0 139.2 1,525.70 2.41Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 12,853 10 52 4.0 21.0 1,285.32 0.43Alcohol and Drug Abuse 4,390 1 27 0.4 10.9 4,390.20 0.15Other 2,093 1 30 0.4 12.1 2,093.00 0.07

$454,128 276 1,808 111.4 729.5 $1,645.39 $15.27Hospital OutpatientEmergency Room $339,351 1,154 465.6 $294.06 $11.41Surgery 140,051 625 252.2 224.08 4.71Radiology 184,762 1,085 437.8 170.29 6.21Pathology 26,711 4,381 1,767.7 6.10 0.90Pharmacy 84,894 33,251 13,416.6 2.55 2.85Cardiovascular 49,255 288 116.2 171.03 1.66PT/OT/ST 46,005 3,587 1,447.3 12.83 1.55Psychiatric 263 7 2.8 37.53 0.01Substance Abuse 0 0 0.0 0.00 0.00Other 238,124 17,484 7,054.7 13.62 8.01

$1,109,415 61,862 24,961.0 $17.93 $37.30Professional and Other State Plan ServicesAmbulatory Surgery Center $8,997 45 18.2 $199.93 $0.30Office Visits 214,953 8,439 3,405.1 25.47 7.23Preventive Medicine 34,382 1,441 581.4 23.86 1.16Maternity 47 2 0.8 23.50 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 7,820 1,052 424.5 7.43 0.26Psychiatric and Substance Abuse 60,961 1,401 565.3 43.51 2.05Radiology and Pathology 65,458 3,122 1,259.7 20.97 2.20Home Health and Private Duty Nursing 1,513,870 129,828 52,384.9 11.66 50.90Ambulance 44,384 3,319 1,339.2 13.37 1.49Non-Emergency Transportation 258,781 21,924 8,846.2 11.80 8.70Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 33,381 602 242.9 55.45 1.12Adult Medical Day Care 124,156 2,866 1,156.4 43.32 4.17Personal Care 70,367 13,045 5,263.6 5.39 2.37Durable Medical Equipment 794,177 1,079,710 435,657.5 0.74 26.70Other 320,066 44,983 18,150.4 7.12 10.76

$3,551,800 1,311,779 529,296.1 $2.71 $119.43Prescription DrugsGeneric Scripts $35,837 10,066 4,061.6 $3.56 $1.21Single-Source Brand 3,361 117 47.2 28.73 0.11Multi-Source Brand 267 26 10.5 10.27 0.01Specialty 0 0 0.0 0.00 0.00Other 71 13 5.2 5.43 0.00

$39,536 10,222 4,124.5 $3.87 $1.33Mental Health CenterCase Management $167,313 482 194.5 $347.12 $5.63Long Term Support Service 519,281 20,117 8,117.1 25.81 17.46Partial Hospital 56,566 585 236.0 96.69 1.90Psychotherapy 79,188 2,620 1,057.2 30.22 2.66Evidence Based Practice 14,600 752 303.4 19.41 0.49Medication Management 14,873 489 197.3 30.42 0.50Emergency Service 24/7 1,431 64 25.8 22.36 0.05APRTP 31,296 73 29.5 428.71 1.05Supported Employment Services 12,926 493 198.9 26.22 0.43Harbor Homes 229 8 3.2 28.64 0.01Other 114,810 3,612 1,457.4 31.79 3.86

$1,012,514 29,295 11,820.4 $34.56 $34.05All Services $6,167,394 276 1,414,966 111.4 570,931.6 $4.36 $207.38






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$1,300,333 111 925 88.7 739.3 $11,714.71 $86.61Hospital OutpatientEmergency Room $226,588 529 422.8 $428.33 $15.09Surgery 141,431 207 165.4 683.24 9.42Radiology 146,304 519 414.8 281.90 9.74Pathology 54,186 3,784 3,024.4 14.32 3.61Pharmacy 105,028 11,718 9,365.8 8.96 7.00Cardiovascular 23,244 121 96.7 192.10 1.55PT/OT/ST 124,446 3,547 2,835.0 35.08 8.29Psychiatric 672 6 4.8 111.95 0.04Substance Abuse 0 0 0.0 0.00 0.00Other 256,685 5,228 4,178.6 49.10 17.10

$1,078,585 25,659 20,508.4 $42.04 $71.84Professional and Other State Plan ServicesAmbulatory Surgery Center $25,839 32 25.6 $807.47 $1.72Office Visits 283,981 4,010 3,205.1 70.82 18.91Preventive Medicine 40,649 2,000 1,598.5 20.32 2.71Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 364,387 13,267 10,603.9 27.47 24.27Psychiatric and Substance Abuse 88,802 1,860 1,486.6 47.74 5.91Radiology and Pathology 41,472 1,877 1,500.2 22.10 2.76Home Health and Private Duty Nursing 3,490,164 314,812 251,618.7 11.09 232.46Ambulance 39,502 2,729 2,181.2 14.48 2.63Non-Emergency Transportation 77,193 10,066 8,045.4 7.67 5.14Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 52,631 449 358.9 117.22 3.51Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 1,813,250 1,072,810 857,461.2 1.69 120.77Other 493,496 42,450 33,928.9 11.63 32.87

$6,811,366 1,466,362 1,172,014.1 $4.65 $453.67Prescription DrugsGeneric Scripts $1,064,020 26,845 21,456.3 $39.64 $70.87Single-Source Brand 855,816 2,703 2,160.4 316.62 57.00Multi-Source Brand 497,117 1,041 832.0 477.54 33.11Specialty 304,698 124 99.1 2,457.24 20.29Other 0 0 0.0 0.00 0.00

$2,721,650 30,713 24,547.9 $88.62 $181.28Mental Health CenterCase Management $603,824 1,692 1,352.4 $356.87 $40.22Long Term Support Service 815,088 35,132 28,079.8 23.20 54.29Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 214,886 4,552 3,638.3 47.21 14.31Evidence Based Practice 3,026 114 91.1 26.54 0.20Medication Management 534 19 15.2 28.11 0.04Emergency Service 24/7 587 25 20.0 23.46 0.04APRTP 0 0 0.0 0.00 0.00Supported Employment Services 2,760 104 83.1 26.54 0.18Harbor Homes 0 0 0.0 0.00 0.00Other 67,020 796 636.2 84.20 4.46

$1,707,725 42,434 33,916.1 $40.24 $113.74All Services $13,619,659 111 1,566,093 88.7 1,251,725.8 $8.70 $907.14





Member Months: 631

BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$70,401 16 162 304.3 3,080.8 $4,400.04 $111.57Hospital OutpatientEmergency Room $31,803 51 969.9 $623.60 $50.40Surgery 17,280 36 684.6 480.01 27.39Radiology 7,243 46 874.8 157.45 11.48Pathology 7,421 668 12,703.4 11.11 11.76Pharmacy 2,377 996 18,940.9 2.39 3.77Cardiovascular 2,547 13 247.2 195.93 4.04PT/OT/ST 11,147 477 9,071.1 23.37 17.67Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 20,299 1,071 20,367.2 18.95 32.17

$100,118 3,358 63,859.1 $29.81 $158.66Professional and Other State Plan ServicesAmbulatory Surgery Center $1,133 4 76.1 $283.36 $1.80Office Visits 23,650 408 7,758.9 57.96 37.48Preventive Medicine 2,369 90 1,711.5 26.32 3.75Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,895 166 3,156.8 23.47 6.17Psychiatric and Substance Abuse 2,270 34 646.6 66.76 3.60Radiology and Pathology 5,997 293 5,572.0 20.47 9.50Home Health and Private Duty Nursing 18,284 667 12,684.3 27.41 28.98Ambulance 7,372 511 9,717.7 14.43 11.68Non-Emergency Transportation 1,345 280 5,324.8 4.80 2.13Opioid Treatment Program 0 0 0.0 0.00 0.00Federally Qualified and Rural Health Clinics 9,455 68 1,293.2 139.04 14.98Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 64,444 53,433 1,016,136.0 1.21 102.13Other 33,845 2,612 49,672.4 12.96 53.64

$174,058 58,566 1,113,750.3 $2.97 $275.84Prescription DrugsGeneric Scripts $97,349 4,453 84,682.8 $21.86 $154.27Single-Source Brand 129,489 393 7,473.7 329.49 205.21Multi-Source Brand 16,160 35 665.6 461.73 25.61Specialty 116,501 91 1,730.5 1,280.23 184.62Other 0 0 0.0 0.00 0.00

$359,499 4,972 94,552.6 $72.30 $569.72Mental Health CenterCase Management $0 0 0.0 $0.00 $0.00Long Term Support Service 1,091 13 247.2 83.91 1.73Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 4,303 66 1,255.1 65.20 6.82Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 0 0 0.0 0.00 0.00Emergency Service 24/7 0 0 0.0 0.00 0.00APRTP 0 0 0.0 0.00 0.00Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 3,876 44 836.7 88.10 6.14

$9,270 123 2,339.1 $75.37 $14.69All Services $713,345 16 67,181 304.3 1,277,581.8 $10.62 $1,130.47






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $35,196 27 181 152.1 1,019.5 $1,303.56 $16.52Surgical 18,601 4 106 22.5 597.0 4,650.32 8.73Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$53,797 31 287 174.6 1,616.5 $1,735.40 $25.25Hospital OutpatientEmergency Room $42,029 120 675.9 $350.24 $19.73Surgery 16,625 74 416.8 224.66 7.80Radiology 15,613 126 709.7 123.91 7.33Pathology 1,732 354 1,993.8 4.89 0.81Pharmacy 6,520 5,872 33,073.1 1.11 3.06Cardiovascular 1,694 25 140.8 67.77 0.80PT/OT/ST 7,861 774 4,359.4 10.16 3.69Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 0 0 0.0 0.00 0.00Other 22,279 1,701 9,580.6 13.10 10.46

$114,352 9,046 50,950.1 $12.64 $53.67Professional and Other State Plan ServicesAmbulatory Surgery Center $595 4 22.5 $148.80 $0.28Office Visits 21,203 943 5,311.3 22.48 9.95Preventive Medicine 2,271 99 557.6 22.94 1.07Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 2,317 382 2,151.6 6.07 1.09Psychiatric and Substance Abuse 3,907 68 383.0 57.45 1.83Radiology and Pathology 4,686 351 1,977.0 13.35 2.20Home Health and Private Duty Nursing 51,774 8,350 47,030.0 6.20 24.30Ambulance 4,783 380 2,140.3 12.59 2.25Non-Emergency Transportation 66,264 2,787 15,697.3 23.78 31.10Opioid Treatment Program 3,802 372 2,095.2 10.22 1.78Federally Qualified and Rural Health Clinics 2,308 67 377.4 34.44 1.08Adult Medical Day Care 1,773 36 202.8 49.26 0.83Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 157,064 179,464 1,010,801.8 0.88 73.72Other 37,290 6,808 38,345.0 5.48 17.50

$360,036 200,111 1,127,092.7 $1.80 $168.99Prescription DrugsGeneric Scripts $6,400 1,467 8,262.6 $4.36 $3.00Single-Source Brand 100 33 185.9 3.05 0.05Multi-Source Brand 0 0 0.0 0.00 0.00Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$6,501 1,500 8,448.5 $4.33 $3.05Mental Health CenterCase Management $9,672 34 191.5 $284.47 $4.54Long Term Support Service 23,543 954 5,373.2 24.68 11.05Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 5,986 186 1,047.6 32.19 2.81Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 925 35 197.1 26.44 0.43Emergency Service 24/7 305 13 73.2 23.46 0.14APRTP 3,294 6 33.8 549.00 1.55Supported Employment Services 0 0 0.0 0.00 0.00Harbor Homes 0 0 0.0 0.00 0.00Other 19,596 670 3,773.7 29.25 9.20

$63,322 1,898 10,690.2 $33.36 $29.72All Services $598,009 31 212,842 174.6 1,198,798.0 $2.81 $280.68






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$1,483,268 319 2,548 281.7 2,250.1 $4,649.74 $109.15Hospital OutpatientEmergency Room $1,067,300 1,909 1,685.8 $559.09 $78.54Surgery 231,963 286 252.6 811.06 17.07Radiology 246,156 1,920 1,695.5 128.21 18.11Pathology 118,528 10,179 8,988.7 11.64 8.72Pharmacy 78,208 22,553 19,915.8 3.47 5.76Cardiovascular 47,449 186 164.3 255.10 3.49PT/OT/ST 77,172 2,775 2,450.5 27.81 5.68Psychiatric 50,846 126 111.3 403.54 3.74Substance Abuse 2,185 19 16.8 115.00 0.16Other 286,036 10,736 9,480.6 26.64 21.05

$2,205,843 50,689 44,761.7 $43.52 $162.33Professional and Other State Plan ServicesAmbulatory Surgery Center $30,213 95 83.9 $318.03 $2.22Office Visits 441,673 7,016 6,195.6 62.95 32.50Preventive Medicine 45,443 1,497 1,321.9 30.36 3.34Maternity 13,280 78 69.1 169.66 0.98Certified Midwife 290 1 0.9 290.00 0.02PT/OT/ST 31,748 1,282 1,132.1 24.76 2.34Psychiatric and Substance Abuse 157,715 2,032 1,794.4 77.62 11.61Radiology and Pathology 207,891 8,653 7,641.2 24.03 15.30Home Health and Private Duty Nursing 172,538 5,605 4,949.6 30.78 12.70Ambulance 133,026 4,398 3,883.7 30.25 9.79Non-Emergency Transportation 570,807 29,758 26,278.3 19.18 42.00Opioid Treatment Program 103,304 10,108 8,926.0 10.22 7.60Federally Qualified and Rural Health Clinics 274,105 2,045 1,805.9 134.04 20.17Adult Medical Day Care 10,438 408 360.3 25.58 0.77Personal Care 13,608 2,522 2,227.1 5.40 1.00Durable Medical Equipment 213,412 43,118 38,076.0 4.95 15.70Other 652,681 33,012 29,151.7 19.77 48.03

$3,072,173 151,628 133,897.7 $20.26 $226.08Prescription DrugsGeneric Scripts $1,892,666 73,474 64,882.3 $25.76 $139.28Single-Source Brand 3,156,362 8,626 7,617.3 365.91 232.27Multi-Source Brand 315,132 649 573.1 485.57 23.19Specialty 2,037,024 675 596.1 3,017.81 149.90Other 63 2 1.8 31.56 0.00

$7,401,246 83,426 73,670.6 $88.72 $544.65Mental Health CenterCase Management $3,819,563 10,666 9,418.8 $358.11 $281.08Long Term Support Service 3,577,010 131,317 115,961.5 27.24 263.23Partial Hospital 146,897 1,537 1,357.3 95.57 10.81Psychotherapy 892,015 17,098 15,098.6 52.17 65.64Evidence Based Practice 51,215 3,247 2,867.3 15.77 3.77Medication Management 49,643 1,643 1,450.9 30.21 3.65Emergency Service 24/7 56,890 2,425 2,141.4 23.46 4.19APRTP 127,917 233 205.8 549.00 9.41Supported Employment Services 280,422 10,566 9,330.5 26.54 20.64Harbor Homes 240 1 0.9 239.77 0.02Other 427,303 6,098 5,384.9 70.07 31.44

$9,429,116 184,831 163,217.8 $51.01 $693.88All Services $23,591,646 319 473,122 281.7 417,797.8 $49.86 $1,736.08






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$359,585 203 1,185 161.7 944.0 $1,771.35 $23.87Hospital OutpatientEmergency Room $424,200 1,509 1,202.1 $281.11 $28.16Surgery 115,108 427 340.2 269.57 7.64Radiology 136,674 1,199 955.2 113.99 9.07Pathology 26,865 3,688 2,938.0 7.28 1.78Pharmacy 90,963 29,965 23,871.1 3.04 6.04Cardiovascular 22,376 185 147.4 120.95 1.49PT/OT/ST 35,460 3,156 2,514.2 11.24 2.35Psychiatric 10,916 136 108.3 80.26 0.72Substance Abuse 0 0 0.0 0.00 0.00Other 194,901 12,898 10,275.0 15.11 12.94

$1,057,463 53,163 42,351.3 $19.89 $70.20Professional and Other State Plan ServicesAmbulatory Surgery Center $7,504 46 36.6 $163.12 $0.50Office Visits 158,936 5,905 4,704.1 26.92 10.55Preventive Medicine 18,890 679 540.9 27.82 1.25Maternity 2,932 26 21.1 110.83 0.19Certified Midwife 31 1 0.8 31.00 0.00PT/OT/ST 7,190 930 740.9 7.73 0.48Psychiatric and Substance Abuse 88,987 1,242 989.4 71.65 5.91Radiology and Pathology 47,269 3,106 2,474.3 15.22 3.14Home Health and Private Duty Nursing 19,573 657 523.4 29.79 1.30Ambulance 32,909 1,617 1,288.2 20.35 2.18Non-Emergency Transportation 515,043 31,578 25,156.0 16.31 34.19Opioid Treatment Program 107,982 10,565 8,416.4 10.22 7.17Federally Qualified and Rural Health Clinics 37,977 735 585.5 51.67 2.52Adult Medical Day Care 67,316 1,518 1,209.3 44.35 4.47Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 47,506 22,014 17,537.1 2.16 3.15Other 252,107 39,675 31,606.4 6.35 16.74


$16,439 2,628 2,093.5 $6.26 $1.09Mental Health CenterCase Management $4,362,876 12,750 10,157.1 $342.19 $289.63Long Term Support Service 6,485,677 233,724 186,192.0 27.75 430.56Partial Hospital 379,191 4,001 3,187.3 94.77 25.17Psychotherapy 451,755 16,786 13,372.3 26.91 29.99Evidence Based Practice 74,019 4,491 3,577.7 16.48 4.91Medication Management 120,875 4,002 3,188.1 30.20 8.02Emergency Service 24/7 48,613 2,078 1,655.4 23.39 3.23APRTP 230,038 420 334.6 547.71 15.27Supported Employment Services 730,044 27,799 22,145.6 26.26 48.46Harbor Homes 93,246 779 620.6 119.70 6.19Other 212,935 7,271 5,792.3 29.29 14.14

$13,189,269 314,101 250,222.9 $41.99 $875.58All Services $16,034,908 203 491,371 161.7 391,442.2 $32.63 $1,064.49






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$1,267,250 247 1,749 309.5 2,191.2 $5,130.57 $132.31Hospital OutpatientEmergency Room $846,443 1,640 2,054.7 $516.12 $88.37Surgery 208,344 226 283.1 921.87 21.75Radiology 222,895 1,082 1,355.6 206.00 23.27Pathology 98,138 7,415 9,289.9 13.24 10.25Pharmacy 186,806 28,649 35,892.9 6.52 19.50Cardiovascular 18,203 122 152.8 149.21 1.90PT/OT/ST 59,130 1,862 2,332.8 31.76 6.17Psychiatric 28,579 72 90.2 396.93 2.98Substance Abuse 9,994 89 111.5 112.29 1.04Other 268,028 7,237 9,066.9 37.04 27.98

$1,946,558 48,394 60,630.4 $40.22 $203.23Professional and Other State Plan ServicesAmbulatory Surgery Center $23,505 67 83.9 $350.82 $2.45Office Visits 337,493 5,416 6,785.4 62.31 35.24Preventive Medicine 40,647 1,173 1,469.6 34.65 4.24Maternity 25,225 155 194.1 162.83 2.63Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 48,695 2,105 2,637.2 23.13 5.08Psychiatric and Substance Abuse 232,507 2,521 3,158.4 92.23 24.27Radiology and Pathology 185,597 6,926 8,677.2 26.80 19.38Home Health and Private Duty Nursing 69,145 1,240 1,553.5 55.76 7.22Ambulance 90,364 2,991 3,747.3 30.21 9.43Non-Emergency Transportation 554,510 29,855 37,403.8 18.57 57.89Opioid Treatment Program 182,362 17,843 22,354.6 10.22 19.04Federally Qualified and Rural Health Clinics 239,323 1,685 2,111.1 142.03 24.99Adult Medical Day Care 2,653 113 141.6 23.48 0.28Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 85,227 14,736 18,462.0 5.78 8.90Other 571,232 39,055 48,930.0 14.63 59.64

$2,688,485 125,881 157,709.8 $21.36 $280.69Prescription DrugsGeneric Scripts $768,778 34,173 42,813.6 $22.50 $80.26Single-Source Brand 1,267,197 4,690 5,875.9 270.19 132.30Multi-Source Brand 110,478 268 335.8 412.23 11.53Specialty 536,827 208 260.6 2,580.90 56.05Other 105 5 6.3 20.94 0.01

$2,683,385 39,344 49,292.1 $68.20 $280.16Mental Health CenterCase Management $1,851,942 5,171 6,478.5 $358.14 $193.35Long Term Support Service 569,207 22,477 28,160.3 25.32 59.43Partial Hospital 2,199 26 32.6 84.58 0.23Psychotherapy 668,330 11,209 14,043.2 59.62 69.78Evidence Based Practice 30,414 1,582 1,982.0 19.22 3.18Medication Management 13,532 467 585.1 28.98 1.41Emergency Service 24/7 10,322 440 551.3 23.46 1.08APRTP 97,198 179 224.3 543.00 10.15Supported Employment Services 120,067 4,524 5,667.9 26.54 12.54Harbor Homes 16 1 1.3 15.88 0.00Other 277,408 3,189 3,995.3 86.99 28.96

$3,640,635 49,265 61,721.6 $73.90 $380.10All Services $12,226,313 247 264,633 309.5 331,545.1 $46.20 $1,276.48






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$99,497 55 250 209.0 950.2 $1,809.04 $31.51Hospital OutpatientEmergency Room $136,826 416 1,581.1 $328.91 $43.34Surgery 28,517 103 391.5 276.86 9.03Radiology 32,033 324 1,231.4 98.87 10.15Pathology 11,551 1,348 5,123.4 8.57 3.66Pharmacy 19,519 5,881 22,352.2 3.32 6.18Cardiovascular 4,479 33 125.4 135.72 1.42PT/OT/ST 9,463 569 2,162.6 16.63 3.00Psychiatric 78 3 11.4 25.99 0.02Substance Abuse 0 0 0.0 0.00 0.00Other 51,111 2,484 9,441.1 20.58 16.19

$293,577 11,161 42,420.1 $26.30 $92.98Professional and Other State Plan ServicesAmbulatory Surgery Center $3,947 16 60.8 $246.69 $1.25Office Visits 48,494 1,555 5,910.2 31.19 15.36Preventive Medicine 5,356 119 452.3 45.01 1.70Maternity 2,092 22 83.8 94.93 0.66Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 2,708 280 1,064.2 9.67 0.86Psychiatric and Substance Abuse 53,257 593 2,253.8 89.81 16.87Radiology and Pathology 15,341 955 3,629.7 16.06 4.86Home Health and Private Duty Nursing 7,799 533 2,025.8 14.63 2.47Ambulance 15,701 730 2,774.5 21.51 4.97Non-Emergency Transportation 203,311 10,699 40,664.2 19.00 64.39Opioid Treatment Program 62,814 6,146 23,359.4 10.22 19.90Federally Qualified and Rural Health Clinics 14,872 250 950.2 59.49 4.71Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 10,062 3,121 11,862.1 3.22 3.19Other 81,571 10,022 38,091.1 8.14 25.84

$527,326 35,041 133,182.1 $15.05 $167.02Prescription DrugsGeneric Scripts $2,045 284 1,079.4 $7.20 $0.65Single-Source Brand 84 3 11.4 28.06 0.03Multi-Source Brand 34 1 3.8 34.16 0.01Specialty 0 0 0.0 0.00 0.00Other 0 0 0.0 0.00 0.00

$2,163 288 1,094.6 $7.51 $0.69Mental Health CenterCase Management $667,862 1,870 7,107.4 $357.15 $211.53Long Term Support Service 257,758 9,238 35,111.3 27.90 81.64Partial Hospital 15,467 156 592.9 99.15 4.90Psychotherapy 116,839 3,559 13,526.9 32.83 37.01Evidence Based Practice 13,417 757 2,877.2 17.72 4.25Medication Management 4,377 154 585.3 28.42 1.39Emergency Service 24/7 2,205 94 357.3 23.46 0.70APRTP 19,764 36 136.8 549.00 6.26Supported Employment Services 53,479 2,041 7,757.3 26.20 16.94Harbor Homes 65 2 7.6 32.26 0.02Other 103,945 2,008 7,631.9 51.77 32.92

$1,255,178 19,915 75,691.9 $63.03 $397.55All Services $2,177,741 55 66,655 209.0 253,339.0 $32.67 $689.75






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge



$94,024 20 127 207.6 1,318.0 $4,701.22 $81.32Hospital OutpatientEmergency Room $40,340 85 882.2 $474.59 $34.89Surgery 13,192 26 269.8 507.38 11.41Radiology 17,631 105 1,089.7 167.91 15.25Pathology 10,597 818 8,489.4 12.95 9.16Pharmacy 39,688 5,397 56,011.6 7.35 34.32Cardiovascular 2,726 12 124.5 227.16 2.36PT/OT/ST 4,701 190 1,971.9 24.74 4.07Psychiatric 0 0 0.0 0.00 0.00Substance Abuse 449 4 41.5 112.29 0.39Other 16,367 550 5,708.1 29.76 14.16

$145,691 7,187 74,588.7 $20.27 $126.00Professional and Other State Plan ServicesAmbulatory Surgery Center $8,049 34 352.9 $236.75 $6.96Office Visits 36,366 599 6,216.6 60.71 31.45Preventive Medicine 4,670 313 3,248.4 14.92 4.04Maternity 42 2 20.8 21.02 0.04Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 3,656 152 1,577.5 24.05 3.16Psychiatric and Substance Abuse 4,100 71 736.9 57.74 3.55Radiology and Pathology 17,049 586 6,081.7 29.09 14.74Home Health and Private Duty Nursing 3,150 88 913.3 35.79 2.72Ambulance 6,949 251 2,604.9 27.69 6.01Non-Emergency Transportation 40,270 3,165 32,847.3 12.72 34.83Opioid Treatment Program 16,127 1,578 16,376.9 10.22 13.95Federally Qualified and Rural Health Clinics 15,342 112 1,162.4 136.98 13.27Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 15,452 2,994 31,072.6 5.16 13.36Other 66,549 3,082 31,985.9 21.59 57.56


$421,940 5,761 59,789.3 $73.24 $364.92Mental Health CenterCase Management $234,224 654 6,787.4 $358.14 $202.57Long Term Support Service 6,167 250 2,594.6 24.67 5.33Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 25,168 381 3,954.1 66.06 21.77Evidence Based Practice 0 0 0.0 0.00 0.00Medication Management 6,101 229 2,376.6 26.64 5.28Emergency Service 24/7 70 3 31.1 23.46 0.06APRTP 3,843 7 72.6 549.00 3.32Supported Employment Services 2,256 85 882.2 26.54 1.95Harbor Homes 0 0 0.0 0.00 0.00Other 23,986 353 3,663.5 67.95 20.74

$301,814 1,962 20,362.2 $153.83 $261.03All Services $1,201,241 20 28,064 207.6 291,256.2 $42.80 $1,038.90






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $12,863 9 24 70.7 188.6 $1,429.19 $8.42Surgical 3,948 3 8 23.6 62.9 1,316.00 2.59Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 0 0 0 0.0 0.0 0.00 0.00Alcohol and Drug Abuse 1,288 1 6 7.9 47.1 1,288.00 0.84Other 0 0 0 0.0 0.0 0.00 0.00

$18,099 13 38 102.2 298.6 $1,392.21 $11.85Hospital OutpatientEmergency Room $26,511 109 856.5 $243.22 $17.36Surgery 18,523 56 440.1 330.77 12.13Radiology 12,074 124 974.4 97.37 7.91Pathology 1,540 264 2,074.6 5.83 1.01Pharmacy 3,126 3,751 29,476.1 0.83 2.05Cardiovascular 1,798 17 133.6 105.77 1.18PT/OT/ST 2,197 263 2,066.7 8.35 1.44Psychiatric 2,228 15 117.9 148.50 1.46Substance Abuse 225 2 15.7 112.29 0.15Other 21,214 1,173 9,217.7 18.09 13.89

$89,434 5,774 45,373.2 $15.49 $58.57Professional and Other State Plan ServicesAmbulatory Surgery Center $2,869 18 141.4 $159.40 $1.88Office Visits 15,698 561 4,408.4 27.98 10.28Preventive Medicine 2,539 35 275.0 72.53 1.66Maternity 0 0 0.0 0.00 0.00Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 1,432 221 1,736.7 6.48 0.94Psychiatric and Substance Abuse 3,001 75 589.4 40.02 1.97Radiology and Pathology 5,838 305 2,396.7 19.14 3.82Home Health and Private Duty Nursing 0 0 0.0 0.00 0.00Ambulance 1,812 51 400.8 35.52 1.19Non-Emergency Transportation 13,674 1,757 13,806.8 7.78 8.95Opioid Treatment Program 4,323 423 3,324.0 10.22 2.83Federally Qualified and Rural Health Clinics 3,801 52 408.6 73.09 2.49Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 2,611 841 6,608.7 3.10 1.71Other 39,574 7,268 57,113.3 5.44 25.92


$531 76 597.2 $6.98 $0.35Mental Health CenterCase Management $356,104 1,004 7,889.6 $354.69 $233.19Long Term Support Service 26,623 1,142 8,974.1 23.31 17.43Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 24,299 729 5,728.6 33.33 15.91Evidence Based Practice 2,388 90 707.2 26.54 1.56Medication Management 9,663 357 2,805.4 27.07 6.33Emergency Service 24/7 1,056 45 353.6 23.46 0.69APRTP 0 0 0.0 0.00 0.00Supported Employment Services 16,933 643 5,052.8 26.33 11.09Harbor Homes 0 0 0.0 0.00 0.00Other 15,478 528 4,149.1 29.31 10.14

$452,543 4,538 35,660.5 $99.72 $296.35All Services $657,778 13 22,033 102.2 173,139.6 $29.85 $430.75






BenefitsTotal Paid

DollarsTotal Paid


Admits Per 1,000


Average Paid Charge


CostHospital InpatientMedical $267,289 72 248 12.9 44.4 $3,712.35 $3.99Surgical 166,232 17 76 3.0 13.6 9,778.38 2.48Maternity Delivery 0 0 0 0.0 0.0 0.00 0.00Maternity Non-Delivery 0 0 0 0.0 0.0 0.00 0.00Well Newborn 0 0 0 0.0 0.0 0.00 0.00Psychiatric 3,157,789 368 3,488 65.9 624.8 8,580.95 47.14Alcohol and Drug Abuse 0 0 0 0.0 0.0 0.00 0.00Other 0 0 0 0.0 0.0 0.00 0.00

$3,591,311 457 3,812 81.9 682.9 $7,858.45 $53.61Hospital OutpatientEmergency Room $1,350,589 3,442 616.6 $392.38 $20.16Surgery 315,650 373 66.8 846.25 4.71Radiology 260,586 1,469 263.2 177.39 3.89Pathology 149,809 12,951 2,320.0 11.57 2.24Pharmacy 208,468 19,318 3,460.6 10.79 3.11Cardiovascular 32,985 123 22.0 268.17 0.49PT/OT/ST 137,064 4,314 772.8 31.77 2.05Psychiatric 107,096 507 90.8 211.23 1.60Substance Abuse 1,797 15 2.7 119.80 0.03Other 536,753 14,876 2,664.9 36.08 8.01

$3,100,798 57,388 10,280.3 $54.03 $46.29Professional and Other State Plan ServicesAmbulatory Surgery Center $29,989 104 18.6 $288.35 $0.45Office Visits 975,596 15,830 2,835.7 61.63 14.56Preventive Medicine 285,934 10,456 1,873.1 27.35 4.27Maternity 4,676 16 2.9 291.65 0.07Certified Midwife 0 0 0.0 0.00 0.00PT/OT/ST 275,664 10,093 1,808.0 27.31 4.12Psychiatric and Substance Abuse 205,154 3,225 577.7 63.61 3.06Radiology and Pathology 154,468 10,336 1,851.6 14.94 2.31Home Health and Private Duty Nursing 162,586 15,754 2,822.1 10.32 2.43Ambulance 148,517 9,295 1,665.1 15.98 2.22Non-Emergency Transportation 210,082 38,512 6,898.9 5.45 3.14Opioid Treatment Program 1,002 98 17.6 10.22 0.01Federally Qualified and Rural Health Clinics 584,771 4,511 808.1 129.63 8.73Adult Medical Day Care 0 0 0.0 0.00 0.00Personal Care 0 0 0.0 0.00 0.00Durable Medical Equipment 333,803 139,569 25,002.0 2.39 4.98Other 931,734 52,811 9,460.4 17.64 13.91

$4,303,974 310,610 55,641.9 $13.86 $64.25Prescription DrugsGeneric Scripts $3,384,737 78,304 14,027.2 $43.23 $50.53Single-Source Brand 2,145,943 9,398 1,683.5 228.34 32.03Multi-Source Brand 738,475 1,916 343.2 385.43 11.02Specialty 1,472,517 266 47.7 5,535.78 21.98Other 8 2 0.4 4.01 0.00

$7,741,680 89,886 16,102.0 $86.13 $115.57Mental Health CenterCase Management $14,662,000 40,954 7,336.4 $358.01 $218.88Long Term Support Service 7,621,881 329,420 59,011.5 23.14 113.78Partial Hospital 0 0 0.0 0.00 0.00Psychotherapy 7,589,820 138,652 24,837.8 54.74 113.30Evidence Based Practice 186 7 1.3 26.54 0.00Medication Management 5,674 213 38.2 26.64 0.08Emergency Service 24/7 14,991 639 114.5 23.46 0.22APRTP 6,039 11 2.0 549.00 0.09Supported Employment Services 3,875 146 26.2 26.54 0.06Harbor Homes 0 0 0.0 0.00 0.00Other 1,201,220 12,986 2,326.3 92.50 17.93

$31,105,686 523,028 93,694.0 $59.47 $464.35All Services $49,843,450 457 984,724 81.9 176,401.1 $50.62 $744.07


Appendix B1New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Projected Medical Costs by Rate CellData Adjustments for SFY 2016 FFS Base Experience Data


Benefits


CostIBNR

AdjustmentReimbursement

AdjustmentUtilization

Trend FactorsUnit Cost

Trend Factors

MCO Reimbursement

Adjustment

Managed Care Savings

Adjustment

Pharmacy Rebate

Adjustment PDN AdjustmentNEMT

Adjustment BCH SettlementStop Loss

Adjustment

Projected Per Capita Monthly

Paid CostHospital InpatientMedical $7.13 1.0000 0.9991 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 $5.97Surgical 1.19 1.0000 1.0913 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 1.09Maternity Delivery 0.00 1.0000 1.0000 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Maternity Non-Delivery 0.00 1.0000 1.0000 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Well Newborn 0.00 1.0000 1.0000 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Psychiatric 34.46 1.0000 1.1261 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 32.54Alcohol and Drug Abuse 0.00 1.0000 1.0000 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 0.00 1.0000 1.0000 1.0000 1.0064 1.0200 0.8168 1.0000 1.0000 1.0000 1.0000 1.0000 0.00

$42.79 $39.60Hospital OutpatientEmergency Room $14.41 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 $19.10Surgery 0.31 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 0.41Radiology 2.42 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 3.20Pathology 1.58 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 2.09Pharmacy 5.23 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 6.94Cardiovascular 0.12 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 0.16PT/OT/ST 4.93 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 6.53Psychiatric 0.00 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 0.00Substance Abuse 0.00 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 0.00Other 7.76 1.0000 1.0000 1.0612 1.0364 1.0200 0.8168 1.0000 1.0000 1.0000 1.4465 1.0000 10.29

$36.76 $48.72Professional and Other State Plan ServicesAmbulatory Surgery Center $0.80 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 $0.77Office Visits 10.28 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 9.85Preventive Medicine 4.08 1.0000 1.0354 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 4.05Maternity 0.10 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.09Certified Midwife 0.00 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.00PT/OT/ST 4.65 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 4.46Psychiatric and Substance Abuse 9.64 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 9.23Radiology and Pathology 3.20 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 3.07Home Health and Private Duty Nursing 52.79 1.0000 1.1719 1.0303 1.0000 1.0100 0.9204 1.0000 1.0123 1.0000 1.0000 1.0000 59.98Ambulance 0.70 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.67Non-Emergency Transportation 0.63 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 3.7077 1.0000 1.0000 2.24Opioid Treatment Program 0.49 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.47Federally Qualified and Rural Health Clinics 2.70 1.0000 1.0681 1.0303 1.0000 1.0000 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 2.74Adult Medical Day Care 0.00 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Personal Care 0.00 1.0000 1.0000 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Durable Medical Equipment 29.05 1.0000 1.0097 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 28.09Other 8.34 1.0000 0.9997 1.0303 1.0000 1.0100 0.9204 1.0000 1.0000 1.0000 1.0000 1.0000 7.98

$127.47 $133.70Prescription DrugsGeneric Scripts $21.48 1.0000 1.0000 1.0409 0.8492 1.0000 0.8955 0.9675 1.0000 1.0000 1.0000 1.0000 $16.45Single-Source Brand 14.33 1.0000 1.0000 0.7695 0.9022 1.0000 0.8955 0.9675 1.0000 1.0000 1.0000 1.0000 8.62Multi-Source Brand 35.04 1.0000 1.0000 0.7695 0.9022 1.0000 0.8955 0.9675 1.0000 1.0000 1.0000 1.0000 21.08Specialty 3.62 1.0000 1.0000 0.7956 1.0628 1.0000 0.8955 0.9675 1.0000 1.0000 1.0000 1.0000 2.65Other 0.00 1.0000 1.0000 1.0409 0.8492 1.0000 0.8955 0.9675 1.0000 1.0000 1.0000 1.0000 0.00

$74.48 $48.80Mental Health CenterCase Management $2.69 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 $2.77Long Term Support Service 1.31 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.35Partial Hospital 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Psychotherapy 1.94 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 2.00Evidence Based Practice 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Medication Management 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Emergency Service 24/7 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00APRTP 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Supported Employment Services 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Harbor Homes 0.00 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 2.22 1.0000 1.0000 1.0303 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 2.29

$8.16 $8.41All Services $289.65 $279.23





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$4.75 $4.89All Services $1,269.87 $1,149.67





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$6.39 $6.59All Services $181.19 $180.17





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$6.85 $7.05All Services $212.78 $205.38





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.18 $0.18All Services $75.40 $70.82





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$146.91 $151.37All Services $1,096.41 $1,045.99





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$67.08 $69.12All Services $347.02 $322.18





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$39.02 $40.20All Services $200.25 $202.43





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$111.10 $114.47All Services $1,308.25 $1,419.04





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$52.80 $54.40All Services $266.50 $256.02





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$1,070.11 $1,102.53All Services $1,192.46 $1,236.68





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$370.10 $381.32All Services $534.18 $576.32





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$238.98 $246.22All Services $312.21 $324.21





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$524.14 $540.02All Services $1,109.25 $1,145.40



SFY 2019 Projected Medical Costs by Rate CellData Adjustments for SFY 2016 MCO Encounter Base Experience Data


Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.00 $0.00All Services $187.78 $188.41





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$3.76 $4.05All Services $112.83 $116.24





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$4.38 $4.74All Services $343.65 $372.63





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$8.58 $9.28All Services $283.10 $272.09





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$6.15 $6.65All Services $1,338.51 $1,509.92





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$11.00 $11.90All Services $863.77 $694.06





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$14.91 $16.13All Services $909.62 $958.51





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$11.05 $11.96All Services $199.96 $208.12





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment


Paid CostHospital InpatientMedical $1,521.96 1.0000 0.9998 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 $1,516.11Surgical 46.29 1.0000 0.9328 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 43.02Maternity Delivery 0.00 1.0000 0.9991 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Maternity Non-Delivery 0.00 1.0000 0.9991 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Well Newborn 372.48 1.0000 1.0397 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 385.86Psychiatric 0.00 1.0000 0.9991 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Alcohol and Drug Abuse 0.00 1.0000 0.9991 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 0.00 1.0000 0.9991 1.0000 1.0064 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00

$1,940.72 $1,944.99Hospital OutpatientEmergency Room $30.24 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 $32.92Surgery 3.90 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 4.25Radiology 6.59 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 7.17Pathology 4.44 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 4.83Pharmacy 0.25 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.28Cardiovascular 0.20 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.22PT/OT/ST 0.92 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 1.00Psychiatric 0.00 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Substance Abuse 0.00 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 44.06 1.0000 1.0000 1.0612 1.0364 1.0000 0.9900 1.0000 1.0000 1.0000 1.0000 1.0000 47.97




$0.00 $0.00All Services $2,593.61 $2,625.77





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment





$1,189.28 $1,224.91Prescription DrugsGeneric Scripts $3.43 1.0000 1.0000 1.0000 1.0000 1.0000 0.9950 0.9675 1.0000 1.0000 1.0000 1.0000 $3.30Single-Source Brand 0.26 1.0000 1.0000 1.0000 1.0000 1.0000 0.9950 0.9675 1.0000 1.0000 1.0000 1.0000 0.25Multi-Source Brand 0.00 1.0000 1.0000 1.0000 1.0000 1.0000 0.9950 0.9675 1.0000 1.0000 1.0000 1.0000 0.00Specialty 0.00 1.0000 1.0000 1.0000 1.0000 1.0000 0.9950 0.9675 1.0000 1.0000 1.0000 1.0000 0.00Other 0.00 1.0000 1.0000 1.0000 1.0000 1.0000 0.9950 0.9675 1.0000 1.0000 1.0000 1.0000 0.00


$0.00 $0.00All Services $9,216.21 $9,233.53





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment


Paid CostHospital InpatientMedical $62.54 1.0000 0.9384 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 $58.77Surgical 10.43 1.0000 1.0221 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 10.67Maternity Delivery 1,742.87 1.0000 1.0673 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 1,862.74Maternity Non-Delivery 12.18 1.0000 0.9781 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 11.93Well Newborn 0.00 1.0000 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Psychiatric 0.00 1.0000 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Alcohol and Drug Abuse 0.00 1.0000 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 0.00 1.0000 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00





$0.00 $0.00All Services $2,464.94 $2,603.05





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$8.23 $8.91All Services $2,295.41 $2,329.64





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$5.10 $5.52All Services $1,287.30 $1,272.51





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$5.95 $6.43All Services $265.91 $270.22





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.28 $0.30All Services $90.86 $92.10





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$147.87 $155.63All Services $2,549.08 $2,625.47





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$35.80 $38.73All Services $1,221.93 $1,237.32





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$174.08 $188.33All Services $1,014.92 $1,054.50





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$64.92 $70.23All Services $360.35 $369.85





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$23.03 $24.92All Services $713.84 $740.81





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$33.88 $36.66All Services $201.66 $215.28





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$131.92 $142.71All Services $798.36 $835.52





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$17.20 $18.61All Services $1,311.76 $1,428.14





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$24.94 $26.98All Services $315.57 $324.49





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$686.10 $742.23All Services $1,672.46 $1,747.48





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$843.71 $912.74All Services $1,041.59 $1,109.02





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$334.26 $361.61All Services $1,139.48 $1,182.91





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$361.47 $391.05All Services $629.52 $653.52





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$311.46 $336.94All Services $1,047.15 $1,064.82





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$268.60 $290.58All Services $396.29 $418.49





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$461.65 $499.43All Services $769.73 $778.70





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.00 $0.00All Services $199.12 $200.11





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$3.53 $3.78All Services $117.08 $120.18





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$4.71 $5.06All Services $370.39 $398.53





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$9.20 $9.87All Services $318.57 $316.88





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$1.01 $1.08All Services $1,537.75 $1,747.03





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$6.34 $6.56All Services $1,126.09 $998.45





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$15.26 $16.37All Services $912.56 $973.98





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$12.48 $13.39All Services $213.83 $219.24





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.00 $0.00All Services $3,220.00 $2,816.29





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.00 $0.00All Services $9,268.32 $8,654.97





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment


Paid CostHospital InpatientMedical $29.14 1.0053 0.9580 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 $28.10Surgical 0.58 1.0053 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.58Maternity Delivery 1,848.26 1.0053 1.0459 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 1,945.92Maternity Non-Delivery 17.35 1.0053 1.1162 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 19.50Well Newborn 0.00 1.0053 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Psychiatric 0.00 1.0053 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Alcohol and Drug Abuse 0.00 1.0053 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Other 0.00 1.0053 1.0000 1.0000 1.0064 1.0000 0.9950 1.0000 1.0000 1.0000 1.0000 1.0000 0.00





$0.00 $0.00All Services $2,538.06 $2,656.72





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment






$994.43 $1,017.62Mental Health CenterCase Management $2.41 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 $2.59Long Term Support Service 1.92 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 2.06Partial Hospital 0.37 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.40Psychotherapy 4.82 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 5.16Evidence Based Practice 0.00 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Medication Management 0.00 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Emergency Service 24/7 0.00 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00APRTP 0.00 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Supported Employment Services 0.00 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.00Harbor Homes 0.45 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.48Other 1.73 1.0500 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.85

$11.71 $12.54All Services $2,310.95 $2,302.18





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$2.53 $2.71All Services $1,179.91 $1,160.98





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$12.16 $13.05All Services $258.67 $260.58





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$0.26 $0.28All Services $93.82 $93.98





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment






$1,028.39 $1,001.84Mental Health CenterCase Management $58.24 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 $61.06Long Term Support Service 57.42 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 60.20Partial Hospital 0.49 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 0.51Psychotherapy 14.05 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 14.73Evidence Based Practice 0.31 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 0.32Medication Management 1.08 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 1.13Emergency Service 24/7 0.72 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 0.76APRTP 0.00 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 0.00Supported Employment Services 2.81 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 2.95Harbor Homes 3.31 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 3.47Other 7.95 1.0501 1.0000 1.0201 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 1.0000 0.9788 8.34

$146.38 $153.47All Services $2,812.38 $2,799.94





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$51.35 $55.01All Services $1,487.08 $1,495.63





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$187.23 $200.82All Services $1,043.47 $1,068.81





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$76.19 $81.72All Services $403.28 $406.29





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$22.97 $24.55All Services $708.22 $739.38





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$34.05 $36.52All Services $207.38 $214.65





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$113.74 $121.96All Services $907.14 $942.11





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$14.69 $15.75All Services $1,130.47 $1,179.97





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$29.72 $31.88All Services $280.68 $284.50





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$693.88 $743.62All Services $1,736.08 $1,780.22





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$875.58 $939.12All Services $1,064.49 $1,121.93





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$380.10 $407.39All Services $1,276.48 $1,309.14





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$397.55 $426.45All Services $689.75 $706.54





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$261.03 $279.73All Services $1,038.90 $1,048.89





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$296.35 $317.85All Services $430.75 $452.32





Benefits


CostIBNR




Trend Factors

MCO Reimbursement

Adjustment


Adjustment

Pharmacy Rebate



Adjustment







$464.35 $498.14All Services $744.07 $764.02


Appendix C1New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Projected Medical Costs by Rate CellBlended Projected SFY 2019 Medical Costs from SFY 2016 Experience

Eligibility CategoryFFS Member

Months

FFS Projected Per Capita Monthly Paid

CostEncounter Member

Months

Encounter Projected Per Capita Monthly

Paid Cost

Blended Projected Per Capita Monthly

Paid Cost Opioid Adjustment

Final Blended Projected Per Capita Monthly Paid Cost

Low Income Children - Age 2-11 Months 0 $0.00 55,728 $188.41 $188.41 0.999 $188.24Low Income Children - Age 1-18 Years 0 0.00 913,183 116.24 116.24 1.001 116.34Low Income Adults 0 0.00 156,753 372.63 372.63 1.093 407.19Foster Care / Adoption 2,528 279.23 18,073 272.09 272.96 1.006 274.49Breast and Cervical Cancer Program 0 0.00 1,599 1,509.92 1,509.92 0.998 1,506.97Severely Disabled Children 2,863 1,149.67 5,496 694.06 850.12 1.000 850.50Elderly and Disabled Adults 0 0.00 83,092 958.51 958.51 1.037 994.00Dual Eligibles 13,808 180.17 59,852 208.12 202.88 1.049 212.79Newborn Kick Payment 0 0.00 2,641 2,625.77 2,625.77 1.000 2,625.77Neonatal Abstinence Syndrome Kick Payment 0 0.00 169 9,233.53 9,233.53 1.000 9,233.53Maternity Kick Payment 0 0.00 3,388 2,603.05 2,603.05 1.000 2,603.05

Nursing Facility Residents - Medicaid Only - Age 0-64 0 $0.00 1,288 $2,329.64 $2,329.64 1.031 $2,401.53Nursing Facility Residents - Medicaid Only - Age 65+ 0 0.00 871 1,272.51 1,272.51 0.986 1,254.76Nursing Facility Residents - Dual Eligibles - Age 0-64 1,554 205.38 2,168 270.22 243.15 1.004 244.24Nursing Facility Residents - Dual Eligibles - Age 65+ 19,392 70.82 23,819 92.10 82.55 1.001 82.63Community Residents - Medicaid Only - Age 0-64 0 0.00 3,325 2,625.47 2,625.47 1.006 2,640.41Community Residents - Medicaid Only - Age 65+ 0 0.00 1,627 1,237.32 1,237.32 1.001 1,237.94Community Residents - Dual Eligibles - Age 0-64 3,166 1,045.99 6,133 1,054.50 1,051.61 1.003 1,054.94Community Residents - Dual Eligibles - Age 65+ 7,084 322.18 11,851 369.85 352.02 0.998 351.46Developmentally Disabled - Medicaid Only 0 0.00 15,354 740.81 740.81 1.001 741.36Developmentally Disabled - Dual Eligibles 10,031 202.43 19,425 215.28 210.91 1.000 210.92Developmentally Disabled and In-Home Supports Children 3,520 1,419.04 12,224 835.52 965.98 1.000 966.30Acquired Brain Disorder - Medicaid Only 0 0.00 611 1,428.14 1,428.14 1.021 1,457.53Acquired Brain Disorder - Dual Eligibles 762 256.02 1,371 324.49 300.04 1.011 303.43

Severe/Persistent Mental Illness - Medicaid Only 0 $0.00 13,232 $1,747.48 $1,747.48 1.014 $1,772.22Severe/Persistent Mental Illness - Dual Eligibles 3,830 1,236.68 12,302 1,109.02 1,139.33 1.012 1,152.68Severe Mental Illness - Medicaid Only 0 0.00 11,812 1,182.91 1,182.91 1.067 1,262.54Severe Mental Illness - Dual Eligibles 506 576.32 3,806 653.52 644.47 1.086 699.97Low Utilizer - Medicaid Only 0 0.00 1,225 1,064.82 1,064.82 1.109 1,181.36Low Utilizer - Dual Eligibles 355 324.21 1,376 418.49 399.14 1.018 406.46Serious Emotionally Disturbed Child 2,295 1,145 65,098 779 791 0.999 790.35Total * 71,694 $401.21 1,502,696 $304.11 $308.53 1.023 $315.66* Member Months totals exclude kicks.



SFY 2019 Projected Medical Costs by Rate CellBlended Projected SFY 2019 Medical Costs from SFY 2017 Experience


Months



Months


Paid Cost




Low Income Children - Age 2-11 Months 0 $0.00 53,252 $200.11 $200.11 1.000 $200.19Low Income Children - Age 1-18 Years 0 0.00 902,203 120.18 120.18 1.001 120.34Low Income Adults 0 0.00 132,295 398.53 398.53 1.063 423.73Foster Care / Adoption 0 0.00 20,706 316.88 316.88 1.002 317.66Breast and Cervical Cancer Program 0 0.00 1,559 1,747.03 1,747.03 0.999 1,744.77Severely Disabled Children 0 0.00 7,318 998.45 998.45 1.000 998.47Elderly and Disabled Adults 0 0.00 81,166 973.98 973.98 1.023 996.36Dual Eligibles 0 0.00 68,016 219.24 219.24 1.032 226.17Newborn Kick Payment 0 0.00 2,343 2,816.29 2,816.29 1.000 2,816.29Neonatal Abstinence Syndrome Kick Payment 0 0.00 154 8,654.97 8,654.97 1.000 8,654.97Maternity Kick Payment 0 0.00 3,029 2,656.72 2,656.72 1.000 2,656.72

Nursing Facility Residents - Medicaid Only - Age 0-64 0 $0.00 1,335 $2,302.18 $2,302.18 1.003 $2,308.14Nursing Facility Residents - Medicaid Only - Age 65+ 0 0.00 928 1,160.98 1,160.98 1.000 1,160.98Nursing Facility Residents - Dual Eligibles - Age 0-64 0 0.00 3,532 260.58 260.58 1.002 261.08Nursing Facility Residents - Dual Eligibles - Age 65+ 0 0.00 38,221 93.98 93.98 1.000 94.00Community Residents - Medicaid Only - Age 0-64 0 0.00 3,665 2,799.94 2,799.94 0.999 2,798.51Community Residents - Medicaid Only - Age 65+ 0 0.00 1,937 1,495.63 1,495.63 1.000 1,495.74Community Residents - Dual Eligibles - Age 0-64 0 0.00 9,121 1,068.81 1,068.81 1.002 1,070.66Community Residents - Dual Eligibles - Age 65+ 0 0.00 18,356 406.29 406.29 1.000 406.29Developmentally Disabled - Medicaid Only 0 0.00 15,542 739.38 739.38 1.001 740.02Developmentally Disabled - Dual Eligibles 0 0.00 29,740 214.65 214.65 1.001 214.80Developmentally Disabled and In-Home Supports Children 0 0.00 15,014 942.11 942.11 1.000 942.09Acquired Brain Disorder - Medicaid Only 0 0.00 631 1,179.97 1,179.97 1.007 1,188.15Acquired Brain Disorder - Dual Eligibles 0 0.00 2,131 284.50 284.50 1.010 287.25

Severe/Persistent Mental Illness - Medicaid Only 0 $0.00 13,589 $1,780.22 $1,780.22 1.008 $1,794.19Severe/Persistent Mental Illness - Dual Eligibles 0 0.00 15,063 1,121.93 1,121.93 1.010 1,133.28Severe Mental Illness - Medicaid Only 0 0.00 9,578 1,309.14 1,309.14 1.037 1,357.62Severe Mental Illness - Dual Eligibles 0 0.00 3,157 706.54 706.54 1.036 731.99Low Utilizer - Medicaid Only 0 0.00 1,156 1,048.89 1,048.89 1.072 1,124.19Low Utilizer - Dual Eligibles 0 0.00 1,527 452.32 452.32 1.021 461.71Serious Emotionally Disturbed Child 0 0 66,988 764 764 1.000 764.11Total * 1,517,726 $316.06 $316.06 1.014 $320.57* Member Months totals exclude kicks.



SFY 2019 Projected Medical Costs by Rate CellBlended Projected SFY 2019 Medical Costs – Combined SFY 2016 and SFY 2017


Months



Months


Paid Cost




Low Income Children - Age 2-11 Months 0 $0.00 108,979 $194.13 $194.13 1.000 $194.08Low Income Children - Age 1-18 Years 0 0.00 1,815,386 118.20 118.20 1.001 118.33Low Income Adults 0 0.00 289,048 384.48 384.48 1.079 414.76Foster Care / Adoption 2,528 279.23 38,778 296.00 294.98 1.004 296.13Breast and Cervical Cancer Program 0 0.00 3,159 1,626.97 1,626.97 0.998 1,624.36Severely Disabled Children 2,863 1,149.67 12,814 867.89 919.35 1.000 919.57Elderly and Disabled Adults 0 0.00 164,259 966.15 966.15 1.030 995.17Dual Eligibles 13,808 180.17 127,868 214.04 210.74 1.040 219.22Newborn Kick Payment 0 0.00 4,984 2,715.33 2,715.33 1.000 2,715.33Neonatal Abstinence Syndrome Kick Payment 0 0.00 323 8,957.69 8,957.69 1.000 8,957.69Maternity Kick Payment 0 0.00 6,417 2,628.38 2,628.38 1.000 2,628.38

Nursing Facility Residents - Medicaid Only - Age 0-64 0 $0.00 2,623 $2,315.66 $2,315.66 1.017 $2,354.01Nursing Facility Residents - Medicaid Only - Age 65+ 0 0.00 1,799 1,214.95 1,214.95 0.993 1,206.36Nursing Facility Residents - Dual Eligibles - Age 0-64 1,554 205.38 5,700 264.25 251.64 1.003 252.44Nursing Facility Residents - Dual Eligibles - Age 65+ 19,392 70.82 62,040 93.26 87.91 1.001 87.97Community Residents - Medicaid Only - Age 0-64 0 0.00 6,990 2,716.95 2,716.95 1.002 2,723.30Community Residents - Medicaid Only - Age 65+ 0 0.00 3,565 1,377.69 1,377.69 1.000 1,378.03Community Residents - Dual Eligibles - Age 0-64 3,166 1,045.99 15,254 1,063.06 1,060.12 1.002 1,062.72Community Residents - Dual Eligibles - Age 65+ 7,084 322.18 30,207 391.99 378.73 0.999 378.45Developmentally Disabled - Medicaid Only 0 0.00 30,895 740.09 740.09 1.001 740.68Developmentally Disabled - Dual Eligibles 10,031 202.43 49,165 214.90 212.79 1.000 212.87Developmentally Disabled and In-Home Supports Children 3,520 1,419.04 27,238 894.28 954.33 1.000 954.48Acquired Brain Disorder - Medicaid Only 0 0.00 1,242 1,302.05 1,302.05 1.014 1,320.66Acquired Brain Disorder - Dual Eligibles 762 256.02 3,502 300.16 292.28 1.010 295.34

Severe/Persistent Mental Illness - Medicaid Only 0 $0.00 26,821 $1,764.06 $1,764.06 1.011 $1,783.35Severe/Persistent Mental Illness - Dual Eligibles 3,830 1,236.68 27,366 1,116.13 1,130.93 1.011 1,143.31Severe Mental Illness - Medicaid Only 0 0.00 21,390 1,239.43 1,239.43 1.053 1,305.12Severe Mental Illness - Dual Eligibles 506 576.32 6,964 677.56 670.71 1.064 713.50Low Utilizer - Medicaid Only 0 0.00 2,381 1,057.08 1,057.08 1.091 1,153.60Low Utilizer - Dual Eligibles 355 324.21 2,903 436.29 424.06 1.020 432.35Serious Emotionally Disturbed Child 2,295 1,145 132,086 771 778 1.000 777.27Total * 71,694 $401.21 3,020,422 $310.11 $312.23 1.019 $318.07* Member Months totals exclude kicks.


Appendix DNew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Final Rate Cell Capitation RatesMedicaid Care Management Benefit Add-Ons



Paid Cost

PMPM Add-On for Expanded Mental Health

Services

PMPM Add-On for Smoking Cessation

IMD SUD Rate Add-On

CMHC Fee Schedule Increase DRF Beds

Gender Dysphoria

Adjustment

Applied Behavior Analysis

(ABA)

White Mountain

Community Center

Behavioral Health

Treatment Center

Final Base Capitation

Rate

Low Income Children - Age 2-11 Months $194.08 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.18 $0.00 $194.26Low Income Children - Age 1-18 Years 118.33 0.00 0.00 0.28 0.19 0.00 0.12 2.53 0.07 0.00 121.52Low Income Adults 414.76 0.00 0.00 0.00 0.11 0.00 0.15 0.00 0.19 0.00 415.21Foster Care / Adoption 296.13 0.00 0.00 18.36 0.39 0.00 0.00 1.76 0.24 0.00 316.88Breast and Cervical Cancer Program 1,624.36 0.00 0.00 0.00 0.06 0.00 0.00 0.00 0.10 0.00 1,624.52Severely Disabled Children 919.57 0.00 0.00 2.21 0.39 0.00 0.68 22.21 0.00 0.00 945.07Elderly and Disabled Adults 995.17 0.00 0.00 0.00 0.73 0.00 1.11 0.23 0.10 0.00 997.33Dual Eligibles 219.22 0.00 0.00 0.00 0.73 0.00 0.37 0.00 0.05 0.00 220.37Newborn Kick Payment 2,715.33 0.00 0.00 0.00 0.00 0.00 0.00 0.00 1.76 0.00 2,717.10Neonatal Abstinence Syndrome Kick Payment 8,957.69 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 8,957.69Maternity Kick Payment 2,628.38 0.00 6.75 0.00 0.00 0.00 0.00 0.00 0.28 0.00 2,635.41

Nursing Facility Residents - Medicaid Only - Age 0-64 $2,354.01 $0.00 $0.00 $0.00 $0.52 $0.00 $0.00 $0.00 0.00 $0.00 $2,354.52Nursing Facility Residents - Medicaid Only - Age 65+ 1,206.36 0.00 0.00 0.00 0.14 0.00 0.00 0.00 0.00 0.00 1,206.51Nursing Facility Residents - Dual Eligibles - Age 0-64 252.44 0.00 0.00 0.00 0.80 0.00 0.00 0.00 0.00 0.00 253.24Nursing Facility Residents - Dual Eligibles - Age 65+ 87.97 0.00 0.00 0.00 0.01 0.00 0.00 0.00 0.00 0.00 87.98Community Residents - Medicaid Only - Age 0-64 2,723.30 39.78 0.00 0.00 7.83 0.00 1.36 0.00 0.02 0.35 2,772.65Community Residents - Medicaid Only - Age 65+ 1,378.03 15.49 0.00 0.00 3.16 0.00 0.00 0.00 0.00 0.14 1,396.82Community Residents - Dual Eligibles - Age 0-64 1,062.72 54.31 0.00 0.00 12.04 0.00 0.55 0.00 0.12 0.48 1,130.22Community Residents - Dual Eligibles - Age 65+ 378.45 21.61 0.00 0.00 4.85 0.00 0.00 0.00 0.00 0.19 405.10Developmentally Disabled - Medicaid Only 740.68 8.15 0.00 0.00 0.92 0.00 0.00 0.00 0.03 0.07 749.85Developmentally Disabled - Dual Eligibles 212.87 11.81 0.00 0.00 2.12 0.00 0.00 0.00 0.06 0.10 226.96Developmentally Disabled and In-Home Supports Children 954.48 44.15 0.00 4.94 9.37 0.00 0.00 65.46 0.04 0.39 1,078.83Acquired Brain Disorder - Medicaid Only 1,320.66 4.98 0.00 0.00 0.02 0.00 0.00 0.00 0.00 0.04 1,325.71Acquired Brain Disorder - Dual Eligibles 295.34 9.85 0.00 0.00 1.30 0.00 0.00 0.00 0.00 0.09 306.58

Severe/Persistent Mental Illness - Medicaid Only $1,783.35 $228.37 $0.00 $0.00 $45.45 $0.00 $0.00 $0.00 $0.11 $2.01 $2,059.29Severe/Persistent Mental Illness - Dual Eligibles 1,143.31 334.61 0.00 0.00 73.71 0.00 0.00 0.00 0.13 2.95 1,554.72Severe Mental Illness - Medicaid Only 1,305.12 163.37 0.00 0.00 28.13 0.00 0.00 0.00 0.16 1.44 1,498.22Severe Mental Illness - Dual Eligibles 713.50 176.06 0.00 0.00 33.48 0.00 0.00 0.00 0.22 1.55 924.81Low Utilizer - Medicaid Only 1,153.60 118.81 0.00 0.00 23.52 0.00 0.00 0.00 0.13 1.05 1,297.10Low Utilizer - Dual Eligibles 432.35 150.08 0.00 0.00 31.98 0.00 0.00 0.00 0.14 1.32 615.88Serious Emotionally Disturbed Child 777.27 0.00 0.00 0.94 35.90 0.00 0.00 0.72 0.09 1.61 816.52


Appendix ENew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Final Rate Cell Capitation RatesFinal Base Capitation Rate Development


Projected Per Capita

Monthly Paid Cost

TPL & Other Transactional Adjustment

Adjusted Per Capita

Monthly Paid Cost

Admin Load

Admin Expense

Margin Load

Margin Expense

CMHC Directed Payment

Premium Tax

AdjustmentPremium

Tax Amount

Final Capitation

Rate

Low Income Children - Age 2-11 Months $194.26 1.0000 $194.26 9.8% $21.42 1.5% $3.28 $0.00 2.0% $4.47 $223.43Low Income Children - Age 1-18 Years 121.52 1.0000 121.52 9.8% 13.40 1.5% 2.05 0.00 2.0% 2.80 139.77Low Income Adults 415.21 1.0000 415.21 9.8% 45.78 1.5% 7.02 0.00 2.0% 9.55 477.56Foster Care / Adoption 316.88 0.9989 316.54 9.8% 34.90 1.5% 5.35 0.00 2.0% 7.28 364.07Breast and Cervical Cancer Program 1,624.52 1.0000 1,624.52 7.5% 134.36 1.5% 26.78 0.00 2.0% 36.44 1,822.10Severely Disabled Children 945.07 0.9958 941.08 7.5% 77.83 1.5% 15.52 0.00 2.0% 21.11 1,055.54Elderly and Disabled Adults 997.33 1.0000 997.33 7.5% 82.49 1.5% 16.44 0.00 2.0% 22.37 1,118.63Dual Eligibles 220.37 0.9985 220.03 6.0% 14.32 1.5% 3.57 0.00 2.0% 4.86 242.77Newborn Kick Payment 2,717.10 1.0000 2,717.10 3.8% 107.90 1.5% 43.02 0.00 2.0% 58.53 2,926.55Neonatal Abstinence Syndrome Kick Payment 8,957.69 1.0000 8,957.69 3.8% 355.72 1.5% 141.83 0.00 2.0% 192.96 9,648.20Maternity Kick Payment 2,635.41 1.0000 2,635.41 3.8% 104.66 1.5% 41.73 0.00 2.0% 56.77 2,838.56

Nursing Facility Residents - Medicaid Only - Age 0-64 $2,354.52 1.0000 $2,354.52 7.5% $194.73 1.5% $38.82 $0.00 2.0% $52.82 $2,640.90Nursing Facility Residents - Medicaid Only - Age 65+ 1,206.51 1.0000 1,206.51 7.5% 99.79 1.5% 19.89 0.00 2.0% 27.07 1,353.25Nursing Facility Residents - Dual Eligibles - Age 0-64 253.24 0.9968 252.42 6.0% 16.43 1.5% 4.09 0.00 2.0% 5.57 278.52Nursing Facility Residents - Dual Eligibles - Age 65+ 87.98 0.9965 87.67 6.0% 5.71 1.5% 1.42 0.00 2.0% 1.93 96.73Community Residents - Medicaid Only - Age 0-64 2,772.65 1.0000 2,772.65 7.5% 229.32 1.5% 45.72 8.40 2.0% 62.37 3,118.44Community Residents - Medicaid Only - Age 65+ 1,396.82 1.0000 1,396.82 7.5% 115.53 1.5% 23.03 3.27 2.0% 31.40 1,570.04Community Residents - Dual Eligibles - Age 0-64 1,130.22 0.9969 1,126.68 6.0% 73.33 1.5% 18.27 11.46 2.0% 25.10 1,254.84Community Residents - Dual Eligibles - Age 65+ 405.10 0.9970 403.89 6.0% 26.29 1.5% 6.55 4.56 2.0% 9.01 450.30Developmentally Disabled - Medicaid Only 749.85 1.0000 749.85 7.5% 62.02 1.5% 12.36 1.72 2.0% 16.86 842.80Developmentally Disabled - Dual Eligibles 226.96 0.9970 226.29 6.0% 14.73 1.5% 3.67 2.49 2.0% 5.04 252.23Developmentally Disabled and In-Home Supports Children 1,078.83 0.9969 1,075.44 7.5% 88.95 1.5% 17.73 9.32 2.0% 24.32 1,215.75Acquired Brain Disorder - Medicaid Only 1,325.71 1.0000 1,325.71 7.5% 109.65 1.5% 21.86 1.05 2.0% 29.76 1,488.03Acquired Brain Disorder - Dual Eligibles 306.58 0.9971 305.69 6.0% 19.90 1.5% 4.96 2.08 2.0% 6.79 339.41

Severe/Persistent Mental Illness - Medicaid Only $2,059.29 1.0000 $2,059.29 7.5% $170.32 1.5% $33.95 $48.20 2.0% $47.18 $2,358.94Severe/Persistent Mental Illness - Dual Eligibles 1,554.72 0.9975 1,550.86 6.0% 100.94 1.5% 25.15 70.63 2.0% 35.67 1,783.25Severe Mental Illness - Medicaid Only 1,498.22 1.0000 1,498.22 7.5% 123.91 1.5% 24.70 34.48 2.0% 34.31 1,715.63Severe Mental Illness - Dual Eligibles 924.81 0.9989 923.82 6.0% 60.13 1.5% 14.98 37.16 2.0% 21.14 1,057.24Low Utilizer - Medicaid Only 1,297.10 1.0000 1,297.10 7.5% 107.28 1.5% 21.39 25.08 2.0% 29.61 1,480.45Low Utilizer - Dual Eligibles 615.88 0.9985 614.93 6.0% 40.02 1.5% 9.97 31.68 2.0% 14.22 710.82Serious Emotionally Disturbed Child 816.52 0.9995 816.14 7.5% 67.50 1.5% 13.46 38.51 2.0% 19.09 954.70



APPENDIX F State of New Hampshire


Comparison of SFY 2019 Capitation Rates to SFY 2018 Capitation Rates


Appendix FNew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Final Rate Cell Capitation RatesComparison of Composite Rates to SFY 2018 Capitation Rates


SFY 2019 Projected Member Months

SFY 2018 Rates

SFY 2019 Rates

Proposed Rate Change

Low Income Children - Age 2-11 Months 54,722 $230.25 $223.43 -3.0%Low Income Children - Age 1-18 Years 881,864 130.78 139.77 6.9%Low Income Adults 118,718 398.96 477.56 19.7%Foster Care / Adoption 22,099 320.15 364.07 13.7%Breast and Cervical Cancer Program 1,617 1,612.84 1,822.10 13.0%Severely Disabled Children 7,361 1,162.00 1,055.54 -9.2%Elderly and Disabled Adults 77,912 1,050.22 1,118.63 6.5%Dual Eligibles 66,546 227.70 242.77 6.6%Newborn Kick Payment 2,340 3,215.44 2,926.55 -9.0%Neonatal Abstinence Syndrome Kick Payment 154 3,215.44 9,648.20 200.1%Maternity Kick Payment 3,337 3,168.61 2,838.56 -10.4%

Nursing Facility Residents - Medicaid Only - Age 0-64 1,003 $2,118.93 $2,640.90 24.6%Nursing Facility Residents - Medicaid Only - Age 65+ 1,110 1,295.89 1,353.25 4.4%Nursing Facility Residents - Dual Eligibles - Age 0-64 3,660 247.69 278.52 12.4%Nursing Facility Residents - Dual Eligibles - Age 65+ 42,171 85.64 96.73 12.9%Community Residents - Medicaid Only - Age 0-64 4,775 3,068.03 3,118.44 1.6%Community Residents - Medicaid Only - Age 65+ 2,274 1,430.97 1,570.04 9.7%Community Residents - Dual Eligibles - Age 0-64 11,132 1,209.45 1,254.84 3.8%Community Residents - Dual Eligibles - Age 65+ 22,913 399.92 450.30 12.6%Developmentally Disabled - Medicaid Only 15,513 878.44 842.80 -4.1%Developmentally Disabled - Dual Eligibles 30,351 248.76 252.23 1.4%Developmentally Disabled and In-Home Supports Children 13,695 1,227.94 1,215.75 -1.0%Acquired Brain Disorder - Medicaid Only 659 1,356.89 1,488.03 9.7%Acquired Brain Disorder - Dual Eligibles 2,276 311.11 339.41 9.1%

Severe/Persistent Mental Illness - Medicaid Only 14,618 $2,232.40 $2,358.94 5.7%Severe/Persistent Mental Illness - Dual Eligibles 13,955 1,699.66 1,783.25 4.9%Severe Mental Illness - Medicaid Only 7,890 1,504.34 1,715.63 14.0%Severe Mental Illness - Dual Eligibles 2,524 992.34 1,057.24 6.5%Low Utilizer - Medicaid Only 899 1,402.41 1,480.45 5.6%Low Utilizer - Dual Eligibles 1,068 566.73 710.82 25.4%Serious Emotionally Disturbed Child 60,356 919.20 954.70 3.9%

Base Population Rate Cells 1,230,840 $251.13 $269.78 7.43%NF Residents and Waiver Population Rate Cells 151,531 582.11 601.38 3.31%Behavioral Health Population Rate Cells 101,310 1,264.16 1,335.36 5.63%Total 1,483,681 $354.10 $376.41 6.30%* Member Months totals exclude kicks.



APPENDIX G State of New Hampshire


SFY 2019 Capitation Rate Development Estimated Fiscal Impact


Appendix GNew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

SFY 2019 Final Base Rate Cell Capitation RatesEstimated Fiscal Impact of Medicaid Care Management Program



Average Total Capitation

Rate

Federal Capitation

Rate Liability

Federal Capitation Total Cost Liability

State Capitation

Rate Liability

State Capitation Total Cost Liability

Low Income Children - Age 2-11 Months 54,722 $223.43 $111.72 $6,113,309 $111.72 $6,113,309Low Income Children - Age 1-18 Years 881,864 139.77 69.89 61,629,097 69.89 61,629,097Low Income Adults 118,718 477.56 238.78 28,347,406 238.78 28,347,406Foster Care / Adoption 22,099 364.07 182.04 4,022,792 182.04 4,022,792Breast and Cervical Cancer Program 1,617 1,822.10 911.05 1,473,063 911.05 1,473,063Severely Disabled Children 7,361 1,055.54 527.77 3,885,169 527.77 3,885,169Elderly and Disabled Adults 77,912 1,118.63 559.32 43,577,319 559.32 43,577,319Dual Eligibles 66,546 242.77 121.39 8,077,699 121.39 8,077,699Newborn Kick Payment 2,340 2,926.55 1,463.28 3,424,081 1,463.28 3,424,081Neonatal Abstinence Syndrome Kick Payment 154 9,648.20 4,824.10 741,964 4,824.10 741,964Maternity Kick Payment 3,337 2,838.56 1,419.28 4,735,616 1,419.28 4,735,616

Nursing Facility Residents - Medicaid Only - Age 0-64 1,003 $2,640.90 $1,320.45 $1,323,858 $1,320.45 $1,323,858Nursing Facility Residents - Medicaid Only - Age 65+ 1,110 1,353.25 676.63 751,129 676.63 751,129Nursing Facility Residents - Dual Eligibles - Age 0-64 3,660 278.52 139.26 509,752 139.26 509,752Nursing Facility Residents - Dual Eligibles - Age 65+ 42,171 96.73 48.37 2,039,579 48.37 2,039,579Community Residents - Medicaid Only - Age 0-64 4,775 3,118.44 1,559.22 7,445,103 1,559.22 7,445,103Community Residents - Medicaid Only - Age 65+ 2,274 1,570.04 785.02 1,784,921 785.02 1,784,921Community Residents - Dual Eligibles - Age 0-64 11,132 1,254.84 627.42 6,984,720 627.42 6,984,720Community Residents - Dual Eligibles - Age 65+ 22,913 450.30 225.15 5,158,959 225.15 5,158,959Developmentally Disabled - Medicaid Only 15,513 842.80 421.40 6,536,978 421.40 6,536,978Developmentally Disabled - Dual Eligibles 30,351 252.23 126.12 3,827,666 126.12 3,827,666Developmentally Disabled and In-Home Supports Children 13,695 1,215.75 607.88 8,324,910 607.88 8,324,910Acquired Brain Disorder - Medicaid Only 659 1,488.03 744.02 490,108 744.02 490,108Acquired Brain Disorder - Dual Eligibles 2,276 339.41 169.71 386,166 169.71 386,166

Severe/Persistent Mental Illness - Medicaid Only 14,618 $2,358.94 $1,179.47 $17,241,625 $1,179.47 $17,241,625Severe/Persistent Mental Illness - Dual Eligibles 13,955 1,783.25 891.63 12,442,802 891.63 12,442,802Severe Mental Illness - Medicaid Only 7,890 1,715.63 857.82 6,767,894 857.82 6,767,894Severe Mental Illness - Dual Eligibles 2,524 1,057.24 528.62 1,334,286 528.62 1,334,286Low Utilizer - Medicaid Only 899 1,480.45 740.23 665,753 740.23 665,753Low Utilizer - Dual Eligibles 1,068 710.82 355.41 379,437 355.41 379,437Serious Emotionally Disturbed Child 60,356 954.70 477.35 28,810,870 477.35 28,810,870

Base Population Rate Cells 1,230,840 $269.78 $134.89 $166,027,515 $134.89 $166,027,515NF Residents and Waiver Population Rate Cells 151,531 601.38 300.69 45,563,849 300.69 45,563,849Behavioral Health Population Rate Cells 101,310 1,335.36 667.68 67,642,667 667.68 67,642,667Total 1,483,681 $376.41 $188.20 $279,234,031 $188.20 $279,234,031* Member Months totals exclude kicks.



APPENDICES H ‒ K State of New Hampshire


SFY 2019 Capitation Rate Development Other Supporting Exhibits


Appendix H1New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

CMHC ServicesCommunity Mental Health Agreement Add-on Development

CMHA Services

SFY 2019 Budgeted for

Medicaid ServicesPortion Allocated to

MCM PopulationPortion Allocated to

Step 1 ServicesSFY 2019 MCM

Population Funding

Mobile Crisis Teams $1,467,300 93.1% 74.4% $1,015,922Community Crisis Apartments 657,000 93.1% 74.4% 454,890Assertive Community Treatment Teams 10,605,100 93.1% 74.4% 7,342,705Supported Employment 5,250,000 93.1% 74.4% 3,634,968Total CMHA Funding $17,979,400 $12,448,485


Appendix H2New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

CMHC ServicesCommunity Mental Health Agreement Add-on Development

Rate Cells

Total Base Experience Data CMHC

Expenditures

Total Base Experience Data CMHC

Expenditures Distribution

SFY 2019 Allocated

CMHA Funding


PMPM Add-On

Community Residents - Medicaid Only - Age 0-64 $536,483 1.5% $189,940 4,775 $39.78Community Residents - Medicaid Only - Age 65+ 99,471 0.3% 35,217 2,274 15.49 Community Residents - Dual Eligibles - Age 0-64 1,707,704 4.9% 604,606 11,132 54.31 Community Residents - Dual Eligibles - Age 65+ 1,398,580 4.0% 495,162 22,913 21.61 Developmentally Disabled - Medicaid Only 357,002 1.0% 126,395 15,513 8.15 Developmentally Disabled - Dual Eligibles 1,012,514 2.9% 358,477 30,351 11.81 Developmentally Disabled and In-Home Supports Children 1,707,725 4.9% 604,614 13,695 44.15 Acquired Brain Disorder - Medicaid Only 9,270 0.0% 3,282 659 4.98 Acquired Brain Disorder - Dual Eligibles 63,322 0.2% 22,419 2,276 9.85 Severe/Persistent Mental Illness - Medicaid Only 9,429,116 26.8% 3,338,342 14,618 228.37 Severe/Persistent Mental Illness - Dual Eligibles 13,189,269 37.5% 4,669,610 13,955 334.61 Severe Mental Illness - Medicaid Only 3,640,635 10.4% 1,288,953 7,890 163.37 Severe Mental Illness - Dual Eligibles 1,255,178 3.6% 444,391 2,524 176.06 Low Utilizer - Medicaid Only 301,814 0.9% 106,856 899 118.81 Low Utilizer - Dual Eligibles 452,543 1.3% 160,221 1,068 150.08 Total $35,160,626 100.0% $12,448,485 144,541 $86.12


Appendix I1New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

Opioid Addiction Treatment Trend Adjustment Development - SFY 2016 Base Data

SFY 2016 Projected SFY 2019 SFY 2016 Projected SFY 2019

Rate Cell

Opioid Addiction

Population

Non-Opioid Addiction

PopulationTotal

Population

Opioid Addiction

Enrollment Trend

Opioid Addiction

Population


PopulationTotal

Population

Opioid Treatment

Cost

Other Cost For Opioid Addiction


Population Total

Projected Enrollment Mix PMPM

Rate Adjustment

Low Income Children - Age 2-11 Months 7 55,721 55,728 -10.1% 5 54,718 54,722 $0.80 $5,804.19 $185.52 $186.17 $186.00 0.9991 Low Income Children - Age 1-18 Years 210 912,972 913,183 2.8% 229 881,636 881,864 305.79 2,467.04 110.78 111.40 111.50 1.0009 Low Income Adults 13,304 143,449 156,753 0.4% 13,480 105,238 118,718 479.26 383.19 289.49 338.12 369.47 1.0927 Foster Care / Adoption 100 17,973 18,073 17.3% 161 21,938 22,099 252.36 634.94 278.52 281.88 283.45 1.0056 Breast and Cervical Cancer Program 32 1,567 1,599 12.0% 45 1,572 1,617 244.29 552.38 1,385.45 1,373.67 1,370.98 0.9980 Severely Disabled Children 7 5,489 5,496 -5.5% 6 7,356 7,361 21.78 23.13 862.75 861.71 862.10 1.0005 Elderly and Disabled Adults 6,041 77,060 83,101 9.4% 7,908 70,004 77,912 513.44 1,037.19 862.27 912.30 946.08 1.0370 Dual Eligibles 3,080 56,790 59,870 11.0% 4,214 62,332 66,546 442.24 266.60 171.12 198.79 208.50 1.0489

Nursing Facility Residents - Medicaid Only - Age 0-64 11 1,277 1,288 29.0% 24 979 1,003 $114.77 $6,810.29 $2,257.67 $2,297.53 $2,368.43 1.0309 Nursing Facility Residents - Medicaid Only - Age 65+ 2 869 871 -100.0% - 1,110 1,110 8.25 9,067.40 1,268.32 1,286.26 1,268.32 0.9861 Nursing Facility Residents - Dual Eligibles - Age 0-64 5 2,163 2,168 52.5% 18 3,643 3,660 35.15 675.94 262.81 263.85 265.03 1.0045 Nursing Facility Residents - Dual Eligibles - Age 65+ 16 23,803 23,819 43.9% 48 42,123 42,171 9.47 261.81 85.80 85.93 86.02 1.0010 Community Residents - Medicaid Only - Age 0-64 114 3,211 3,325 19.2% 193 4,582 4,775 426.63 3,662.86 2,496.54 2,551.14 2,565.66 1.0057 Community Residents - Medicaid Only - Age 65+ 5 1,622 1,627 18.3% 8 2,265 2,274 76.22 2,093.14 1,216.68 1,219.61 1,220.22 1.0005 Community Residents - Dual Eligibles - Age 0-64 175 5,963 6,138 28.2% 369 10,763 11,132 201.73 1,100.29 1,005.97 1,014.42 1,017.64 1.0032 Community Residents - Dual Eligibles - Age 65+ 48 11,803 11,851 12.3% 68 22,845 22,913 70.25 857.05 355.32 357.64 357.08 0.9984 Developmentally Disabled - Medicaid Only 93 15,264 15,356 5.6% 109 15,403 15,513 71.74 1,021.34 709.21 711.52 712.05 1.0007 Developmentally Disabled - Dual Eligibles 19 19,408 19,427 24.9% 37 30,314 30,351 49.26 132.30 198.33 198.32 198.33 1.0001 Developmentally Disabled and In-Home Supports Children 33 12,191 12,224 -9.1% 25 13,670 13,695 40.93 480.92 794.29 793.56 793.82 1.0003 Acquired Brain Disorder - Medicaid Only 15 596 611 21.2% 26 633 659 416.48 2,309.31 1,280.28 1,314.82 1,341.88 1.0206 Acquired Brain Disorder - Dual Eligibles 21 1,350 1,371 25.5% 42 2,234 2,276 513.84 115.08 309.38 314.27 317.82 1.0113

Severe/Persistent Mental Illness - Medicaid Only 903 12,368 13,270 16.2% 1,416 13,202 14,618 $523.95 $1,509.56 $1,642.50 $1,669.09 $1,692.73 1.0142 Severe/Persistent Mental Illness - Dual Eligibles 732 11,621 12,353 14.4% 1,096 12,860 13,955 443.20 1,016.14 1,008.91 1,035.60 1,047.73 1.0117 Severe Mental Illness - Medicaid Only 1,848 9,978 11,827 -2.3% 1,722 6,168 7,890 492.15 1,252.65 1,026.60 1,138.85 1,215.52 1.0673 Severe Mental Illness - Dual Eligibles 441 3,378 3,819 6.0% 526 1,998 2,524 529.96 612.55 560.29 627.53 681.56 1.0861 Low Utilizer - Medicaid Only 80 1,144 1,225 13.3% 117 783 899 560.57 1,857.34 949.19 1,045.51 1,159.94 1.1094 Low Utilizer - Dual Eligibles 68 1,313 1,382 6.9% 83 984 1,068 112.33 440.61 385.81 394.09 401.32 1.0184 Serious Emotionally Disturbed Child 65 65,033 65,098 -23.2% 30 60,326 60,356 231.68 2,202.79 766.70 768.37 767.55 0.9989 *Exhibit excludes kick


Appendix I2New Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

Opioid Addiction Treatment Trend Adjustment Development - SFY 2017 Base Data

SFY 2017 Projected SFY 2019 SFY 2017 Projected SFY 2019

Rate Cell

Opioid Addiction

Population


PopulationTotal

Population

Opioid Addiction

Enrollment Trend

Opioid Addiction

Population


PopulationTotal

Population

Opioid Treatment

Cost

Other Cost For Opioid Addiction


Population Total

Projected Enrollment Mix PMPM

Rate Adjustment

Low Income Children - Age 2-11 Months 4 53,248 53,252 8.7% 5 54,718 54,722 $0.44 $6,997.20 $197.66 $198.17 $198.25 1.0004 Low Income Children - Age 1-18 Years 193 902,010 902,203 8.7% 229 881,636 881,864 493.79 2,542.02 115.20 115.83 115.98 1.0013 Low Income Adults 12,946 119,349 132,295 2.0% 13,480 105,238 118,718 600.29 398.75 294.75 363.67 386.68 1.0633 Foster Care / Adoption 136 20,570 20,706 8.7% 161 21,938 22,099 316.87 526.75 313.63 317.11 317.89 1.0025 Breast and Cervical Cancer Program 38 1,521 1,559 8.7% 45 1,572 1,617 305.75 253.70 1,601.01 1,575.63 1,573.59 0.9987 Severely Disabled Children 5 7,313 7,318 8.7% 6 7,356 7,361 112.22 1,097.21 1,123.73 1,123.79 1,123.81 1.0000 Elderly and Disabled Adults 7,009 74,185 81,193 6.2% 7,908 70,004 77,912 619.00 908.99 854.76 912.87 933.85 1.0230 Dual Eligibles 3,788 64,250 68,038 5.5% 4,214 62,332 66,546 492.80 234.60 178.92 209.46 216.08 1.0316

Nursing Facility Residents - Medicaid Only - Age 0-64 20 1,315 1,335 8.7% 24 979 1,003 $246.16 $2,629.55 $2,299.30 $2,307.93 $2,313.91 1.0026 Nursing Facility Residents - Medicaid Only - Age 65+ - 928 928 8.7% - 1,110 1,110 - - 1,172.69 1,172.69 1,172.69 1.0000 Nursing Facility Residents - Dual Eligibles - Age 0-64 15 3,520 3,535 8.7% 18 3,643 3,660 74.60 867.22 249.01 251.95 252.43 1.0019 Nursing Facility Residents - Dual Eligibles - Age 65+ 40 38,181 38,221 8.7% 48 42,123 42,171 39.47 256.71 85.53 85.75 85.77 1.0003 Community Residents - Medicaid Only - Age 0-64 163 3,506 3,669 8.7% 193 4,582 4,775 493.60 3,470.98 2,751.48 2,805.45 2,804.01 0.9995 Community Residents - Medicaid Only - Age 65+ 7 1,930 1,937 8.7% 8 2,265 2,274 164.91 1,409.60 1,484.59 1,484.92 1,485.03 1.0001 Community Residents - Dual Eligibles - Age 0-64 312 8,821 9,133 8.7% 369 10,763 11,132 349.00 926.55 1,025.71 1,034.26 1,036.05 1.0017 Community Residents - Dual Eligibles - Age 65+ 58 18,298 18,356 8.7% 68 22,845 22,913 128.37 645.82 395.14 396.33 396.33 1.0000 Developmentally Disabled - Medicaid Only 92 15,452 15,544 8.7% 109 15,403 15,513 113.94 1,010.89 699.64 702.17 702.77 1.0009 Developmentally Disabled - Dual Eligibles 31 29,720 29,751 8.7% 37 30,314 30,351 304.96 300.24 199.87 200.30 200.43 1.0007 Developmentally Disabled and In-Home Supports Children 21 14,993 15,014 8.7% 25 13,670 13,695 23.85 812.61 901.52 901.42 901.41 1.0000 Acquired Brain Disorder - Medicaid Only 22 609 631 8.7% 26 633 659 463.08 1,647.61 1,101.14 1,136.34 1,144.22 1.0069 Acquired Brain Disorder - Dual Eligibles 35 2,098 2,133 8.7% 42 2,234 2,276 535.11 256.31 267.04 275.68 278.34 1.0097

Severe/Persistent Mental Illness - Medicaid Only 1,200 12,426 13,625 8.6% 1,416 13,202 14,618 $642.30 $1,454.59 $1,675.65 $1,712.75 $1,726.19 1.0078 Severe/Persistent Mental Illness - Dual Eligibles 863 14,262 15,125 12.7% 1,096 12,860 13,955 485.84 899.47 1,013.64 1,034.84 1,045.31 1.0101 Severe Mental Illness - Medicaid Only 1,793 7,811 9,603 -2.0% 1,722 6,168 7,890 627.03 1,170.76 1,142.09 1,264.48 1,311.31 1.0370 Severe Mental Illness - Dual Eligibles 481 2,683 3,164 4.5% 526 1,998 2,524 525.97 511.38 606.94 672.37 696.59 1.0360 Low Utilizer - Medicaid Only 99 1,057 1,156 8.7% 117 783 899 534.04 1,751.36 905.39 1,023.28 1,096.74 1.0718 Low Utilizer - Dual Eligibles 71 1,461 1,532 8.7% 83 984 1,068 177.87 417.05 404.45 413.23 421.81 1.0207 Serious Emotionally Disturbed Child 25 66,963 66,988 8.7% 30 60,326 60,356 122.84 1,223.80 730.58 730.81 730.90 1.0001 *Exhibit excludes kick


Appendix JNew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate DevelopmentNational Drug Codes for Carved-Out Prescription Drugs

* A Hepatitis C supplemental drug is carved out if there's an accompanying treatment drug in the same month.

Hepatitis C Hepatitis C HyperammonemiaHemophilia (Treatment) (Supplemental)* (Carbaglu & Ravicti)

00026037220 00003001101 00004008694 5227603126000026037230 00003021301 00004035009 5227603120500026037250 00003021501 00004035239 7598700500600026037920 00006307401 00004035730 7632501000400026037930 00006307402 00004036030 7632501002500026037950 00074006328 0000403653000026378220 00074308228 0007431971600026378225 00074309328 0007432245600026378330 59676022528 0007432395600026378335 61958150101 0007432715600026378550 61958180101 0007432825600026378555 61958220101 0008503140200026378660 0008511940300026378665 0008512790100026378770 0008512910100026378775 0008512970100026379220 0008512970200026379330 0008513040100026379550 0008513160100026379660 0008513160200026379770 0008513180100026382125 0008513230100026382225 0008513230200026382425 0008513270400026382650 0008513510500026382850 0008513680100053623302 0008513700100053761505 0008513700200053761510 0008513850700053761520 0008543530100053762005 0008543540100053762010 0008543550100053762020 0008543560100053763302 0009372275800053763402 0009372276300053765601 0009372277200053765602 0009372277700053765604 0009372328100053765605 0018720060100053766801 0018720060500053766802 0018720070200053766804 0018720070600053813001 0040620461600053813002 0040622604200053813004 0040622605600053813005 0040622607000053813102 0040622608400053813202 0078120430400053813302 0078120431600053813402 0078120434200053813502 0078120436700169701001 0078151772800169701301 1624100695600169702001 1624100697600169704001 1624100705600169705001 1624100707600169706001 1624103377600169706101 2349001410500169706201 3877902560800169720101 3877902560900169720201 42291071818



Hepatitis CHemophilia (Supplemental)*

00169720501 4229107185600169720801 4229107187000169781001 4229107188400169781501 4945262210100169782001 4945262210200169782501 4945262210300169783001 4945262210400169785001 4988400453200944058101 4988400717600944130110 4988403387600944130210 4988403407600944130310 4988408565600944130410 4988408569200944283110 4988408569300944283210 4988408569400944283310 5116701000100944283401 5116701000300944283410 5155208130400944283501 5155208130500944283510 5192716710000944284110 5473809501600944284210 5473809515600944284310 5473809525600944284410 5473809531800944284510 5473809534200944292102 5473809535600944292202 5473809537000944292302 5473809538400944292402 5486845210000944293001 5486845210100944293101 5486845210200944293201 5486845210300944293301 5486848870000944293501 5486848880000944293502 5486850350000944293503 5486850360000944293504 5486850360100944293801 5993015230100944293802 5993015230200944293803 5993015230300944294001 5993015230400944294002 6299120770100944294003 6299120770200944294004 6299120770300944294010 6337002193500944294110 6337002194500944294210 6337002195000944294310 6337002195500944294410 6411600310100944294510 6411600310600944294610 6411600312400944294810 6411600390100944296010 6411600390600944296110 6411600392400944296210 6586202076800944296310 6586202901800944296410 6586202904200944296510 6586202905600944302602 6586202907000944302802 6586202908400944303002 6643501011800944303202 66435010142



Hepatitis CHemophilia (Supplemental)*

00944303402 6643501015600944304510 6643501017000944304610 6643501018400944304710 6643501021600944305102 6643501035600944305202 6643501045600944305302 6643501055600944305402 6643501059900944394002 6643501065600944394202 6643501069900944394402 6643501075600944394602 6643501079900944425202 6643501085600944425402 6643501089900944425602 6643502011500944425802 6643502019500944462201 6643502019600944462301 6643502019900944462401 6643502020900944462501 6643502029500944500101 6808401501100944500105 6808401506500944500110 6808401791100944755102 6808401796500944755302 6838200460313533066520 6838200461013533066530 6838200462813533066550 6838202600450242092001 6838202600750242092101 6838202600950242092201 6838202601050242092301 6838202601252769046001 683820260285327002700553270027105532700271065327002720553270027206583940001015839400010558394000106583940002015839400020558394000206583940003015839400030558394000306583940005025839400050458394000602583940006045839400070258394000704583940008025839400080358394001102583940011045839400120158394001202583940013015839400130258394001401



Hemophilia58394001402583940015015839400150258394001603583940022035839400230358394002403583940025035839406330358394063403583940635035839406360358394063703638330386026383303870263833051802638330615026383306160263833061702638330891516383389150164193022203641930222046419302220564193022302641930224026419302250264193024402641930423026419304240264193042502641930445026420877520164208775301644060483086440604840864406048508644060486086440604870864406048808644060489086440608010164406080201644060803016440608040164406080501644060806016440608070164406091101644060922016440609330164406094401644060966016440609770167467018101674670181026746701820167467018202685163200026851632000368516320004



Hemophilia6851632000568516320101685163202026851632030268516320401685163205026851632060268516360002685163600046851636000568516360006685163601026851636020268516360302685163604026851636050268516360602685164600016851646000268516460101685164602016851646030268516460402685164605016851646060168516460702685164608026851646090268516461002689820139016898201400168982014101689820142016898201430168982014401689820145016898201460168982018201689820182026991104740269911047502699110476026991104770269911047802699110864026991108650269911086602699110867027050402820570504028305705040284057050402850670504028606705040287057050402880570504028905761250250207612505003076125066730761250667507612506725076125067351


Appendix KNew Hampshire Department of Health and Human ServicesMedicaid Care Management Capitation Rate Development

Summary of Estimated MCM Enrollment by Fiscal YearAverage Annual Member Count

Eligibility Category SFY 2016 SFY 2017

SFY 2018 Projected for

SFY 2018 Rates

SFY 2018 Updated

Projections SFY 2019 SFY 2020

MCM ProgramLow Income Children - Age 2-11 Months 4,644 4,438 4,414 4,485 4,560 4,624 Low Income Children - Age 1-18 Years 76,099 75,184 74,943 74,083 73,489 73,103 Low Income Adults 13,063 11,025 11,104 10,226 9,893 9,665 Foster Care / Adoption 1,506 1,725 1,685 1,806 1,842 1,866 Breast and Cervical Cancer Program 133 130 133 134 135 135 Severely Disabled Children 458 610 622 606 613 617 Elderly and Disabled Adults 6,925 6,766 6,878 6,599 6,493 6,427 Dual Eligibles 4,989 5,670 5,576 5,587 5,546 5,517 Newborn Kick Payment (includes NAS) 240 212 194 215 208 203 Maternity Kick Payment 282 252 254 284 278 272

Nursing Facility Residents - Medicaid Only - Age 0-64 107 111 112 93 84 77 Nursing Facility Residents - Medicaid Only - Age 65+ 73 77 88 85 93 99 Nursing Facility Residents - Dual Eligibles - Age 0-64 181 295 296 302 305 308 Nursing Facility Residents - Dual Eligibles - Age 65+ 1,985 3,185 3,208 3,327 3,514 3,654 Community Residents - Medicaid Only - Age 0-64 277 306 323 354 398 434 Community Residents - Medicaid Only - Age 65+ 136 161 152 181 189 195 Community Residents - Dual Eligibles - Age 0-64 512 761 716 856 928 986 Community Residents - Dual Eligibles - Age 65+ 988 1,530 1,515 1,723 1,909 2,060 Developmentally Disabled - Medicaid Only 1,280 1,295 1,287 1,297 1,293 1,291 Developmentally Disabled - Dual Eligibles 1,619 2,479 2,493 2,506 2,529 2,545 Developmentally Disabled and In-Home Supports Children 1,019 1,251 1,130 1,185 1,141 1,112 Acquired Brain Disorder - Medicaid Only 51 53 52 54 55 56 Acquired Brain Disorder - Dual Eligibles 114 178 195 181 190 196

Severe/Persistent Mental Illness - Medicaid Only 1,106 1,135 1,153 1,182 1,218 1,243 Severe/Persistent Mental Illness - Dual Eligibles 1,029 1,260 1,233 1,211 1,163 1,129 Severe Mental Illness - Medicaid Only 986 800 795 697 657 631 Severe Mental Illness - Dual Eligibles 318 264 240 227 210 199 Low Utilizer - Medicaid Only 102 96 89 85 75 68 Low Utilizer - Dual Eligibles 115 128 118 103 89 81 Serious Emotionally Disturbed Child 5,425 5,582 5,804 5,256 5,030 4,861

Base Population Rate Cells 107,817 105,547 105,355 103,525 102,570 101,954 NF Residents and Waiver Population Rate Cells 8,340 11,682 11,567 12,144 12,628 13,013 Behavioral Health Population Rate Cells 9,081 9,266 9,431 8,761 8,442 8,213 Total 125,238 126,495 126,354 124,431 123,640 123,180 * Member totals exclude kicks



APPENDIX L State of New Hampshire


SFY 2019 Actuarial Certification

June 11, 2018 Milliman

June 11, 2018

New Hampshire Department of Health and Human Services

Capitated Contracts Ratesetting Actuarial Certification

SFY 2019 Medicaid Care Management Program Capitation Rates I, John D. Meerschaert, am associated with the firm of Milliman, Inc., am a member of the American Academy of Actuaries, and meet its Qualification Standards for Statements of Actuarial Opinion. I was retained by the New Hampshire Department of Health and Human Services (DHHS) to perform an actuarial certification of the Medicaid care management program capitation rates for SFY 2019 for filing with the Centers for Medicare and Medicaid Services (CMS). I reviewed the calculated capitation rates and am familiar with the relevant requirements of 42 CFR 438; the CMS “Attachment A, PAHP, PIHP and MCO Contracts Financial Review Documentation for At-risk Capitated Contracts Ratesetting;” the 2018-2019 Medicaid Managed Care Rate Development Guide and Actuarial Standard of Practice (ASOP) 49. I examined the actuarial assumptions and actuarial methods used in setting the capitation rates for SFY 2019. To the best of my information, knowledge and belief, the capitation rates offered by DHHS are in compliance with the relevant requirements of 42 § CFR 438.3(c), 438.3(e), 438.4 (excluding paragraph (b)(9)), 438.5, 438.6, and 438.7. The attached actuarial report describes the capitation rate setting methodology. In my opinion, the capitation rates are actuarially sound, as defined in Actuarial Standard of Practice (ASOP) 49, were developed in accordance with generally accepted actuarial principles and practices, and are appropriate for the populations to be covered and the services to be furnished under the contract. In making my opinion, I relied upon the accuracy of the underlying claims and eligibility data records prepared by DHHS, as well as encounter data, financial data summaries, and other information prepared by the participating MCOs. A copy of the reliance letter received from DHHS is attached and constitutes part of this opinion. I did not audit the data and calculations, but did review them for reasonableness and consistency and did not find material defects. In other respects, my examination included such review of the underlying assumptions and methods used and such tests of the calculations as I considered necessary. The capitation rates developed may not be appropriate for any specific MCO. Any MCO will need to review the rates in relation to the benefits provided. Each MCO should compare the rates with its own experience, expenses, capital and surplus, and profit requirements prior to agreeing to contract with DHHS. The MCO may require rates above, equal to, or below the actuarially sound capitation rates. Actuarial methods, considerations, and analyses used in forming my opinion conform to the appropriate Standards of Practice as promulgated from time-to-time by the Actuarial Standards Board, whose standards form the basis of this Statement of Opinion. It should be emphasized that capitation rates are a projection of future costs based on a set of assumptions. Actual costs will be dependent on each contracted MCO’s situation and experience. This Opinion assumes the reader is familiar with the New Hampshire Medicaid program, Medicaid eligibility rules, and actuarial rating techniques. The Opinion is intended for the State of New Hampshire and the Centers for Medicare and Medicaid Services and should not be relied on by other parties. The reader should be advised by actuaries or other professionals competent in the area of actuarial rate projections of the type in this Opinion, so as to properly interpret the projection results.

John D. Meerschaert

Member, American Academy of Actuaries June 11, 2018



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