STATE OF TEXAS MEDICAID MANAGED CARE STAR+PLUS … · 2020. 4. 30. · STAR+PLUS is a Texas...

Prepared for:

Texas Health and Human Services Commission

UMCC 529-12-0002 V2.26, STAR+PLUS Expansion 529-10-0020 V1.30, STAR+PLUS MRSA

529-13-0042 V1.15

Prepared by:

Evan L. Dial, F.S.A., M.A.A.A.

Khiem D. Ngo, F.S.A., M.A.A.A.

David G. Wilkes F.S.A., M.A.A.A.

Rudd and Wisdom, Inc.

June 29, 2018

STATE OF TEXAS

MEDICAID MANAGED CARE

STAR+PLUS PROGRAM RATE SETTING

STATE FISCAL YEAR 2019

TABLE OF CONTENTS

I. Introduction ........................................................................................................................1

II. Overview of Rate Setting Methodology ............................................................................4

III. Adjustment Factors ............................................................................................................8

IV. Administrative Fees, Taxes and Risk Margin ..................................................................15

V. Summary ..........................................................................................................................16

VI. Actuarial Certification .....................................................................................................18

VII. Attachments .....................................................................................................................19

1

I. Introduction

Rudd and Wisdom, Inc. has been retained by the Texas Health and Human Services

Commission (HHSC) to develop the state fiscal year 2019 (FY2019, September 1, 2018

through August 31, 2019) premium rates for health plans participating in the Texas

Medicaid STAR+PLUS program. This report presents the rating methodology and

assumptions used in developing the premium rates.

STAR+PLUS is a Texas Medicaid managed care program for people who have disabilities

or are age 65 and older. STAR+PLUS members get Medicaid health-care and long-term

services and supports through a medical plan that they choose. The STAR+PLUS program

expanded to include individuals with Intellectual and Developmental Disabilities (IDD) on

September 1, 2014 and to include individuals in a nursing facility on March 1, 2015. Effective September 1, 2017, members in the HHSC Medicaid for Breast and Cervical Cancer

(MBCCP) program began receiving their Medicaid services through managed care and are a

separate risk group in the STAR+PLUS program. There are thirteen STAR+PLUS service

delivery areas (SDAs). STAR+PLUS Medicaid members can select from at least two health

plans in each SDA. There are a total of five health plans serving the various SDAs

throughout the state.

Rudd and Wisdom has provided actuarial services to the Texas Medicaid program for over

30 years. We have participated in the state’s managed care rating process since its inception

in 1993. This year, as in previous years, we have worked closely with HHSC in developing

the FY2019 STAR+PLUS premium rates.

Rudd and Wisdom has relied on the following data sources as provided by HHSC, the

participating health plans and the agency’s External Quality Review Organization (EQRO):

Monthly enrollment by risk group for each health plan. This includes historical

enrollment since September 2014 and a projection of future enrollment through August

2019. These projections were prepared by HHS System Forecasting staff.

Detailed MCO encounter data for FY2017. The encounter data is a dataset that includes

the detail claim information for every claim incurred during FY2017 and paid through

November 30, 2017. The dataset includes but is not limited to (1) individual member

information – date of birth, risk group, health plan; (2) provider information – type of

provider, NPI, bill type, taxonomy code; (3) procedure information – diagnosis,

procedure code, claim modifier; and (4) payment information – paid amount, billed

amount. This information is used to identify the providers and services which will

receive or have received reimbursement changes in order to determine the cost impact of

such changes.

Claim lag reports by SDA and risk group for each health plan for the period September

2014 through February 2018. These reports were prepared by the health plans and

include monthly paid claims by month of service. These reports summarize the detail

encounter data.

Financial Statistical Reports (FSR) for each participating health plan for FY2016,

FY2017 and the first six months of FY2018. The FSR contains detailed information

regarding monthly enrollment, revenue, incurred claims and administrative expenses, as

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reported by the health plan. These reports are prepared by the health plans and are

audited by an external audit organization. A health plan that participates in multiple

programs and/or service areas submits a separate FSR for each individual area and

program combination.

Reports from the EQRO summarizing their analysis of the health plan’s encounter

claims data.

Reports from the health plans providing information on high volume claimants during

the experience period.

Current (FY2018) premium rates by risk group for each health plan.

Information from both HHSC and the health plans regarding recent changes in covered

services and provider reimbursement under the Medicaid program.

Information from the health plans regarding current and projected payment rates for

certain capitated services, such as mental health and vision.

- Subcapitated services make up approximately 0.25% of total medical plan

cost and are most commonly vision and behavioral health arrangements.

Information about these arrangements was provided by the health plans and

verified with the FSRs. These items were reviewed for reasonableness by

comparing the reported expense amounts from the various health plans to

those arrangements of other health plans.

Information from the health plans regarding service coordination expenses.

- Service Coordination expenses make up approximately 3.3% of total plan

cost and are separate from the included administrative allowance.

Information about service coordination expenses was provided by the health

plans and verified with the FSRs. These items were reviewed for

reasonableness by comparing the reported expense amounts from the various

health plans to those arrangements of other health plans.

FY2017 acuity risk adjustment analysis provided by the EQRO for each health plan.

Information from the health plans regarding current and projected reinsurance premium

rates.

Information provided by HHSC regarding FY2017 health plan claims cost by type of

service for certain services. This information was obtained from the encounter database.

Information provided by HHSC regarding proposed FY2019 Medicaid provider

reimbursement rates.

A listing of individuals enrolled in the MBCCP program during the period September

2012 through August 2017.

Monthly fee-for-service claims data for each MBCCP member.

After accumulating all of the information to be used in the rate setting process, a

comparison of the various sources of claims data was performed to check for consistency.

We compared (i) the claim lag reports provided by the MCOs, (ii) the claim amounts

reported in the FSRs and (iii) the claim amounts in the encounter data files. The three data

sources are compared to ensure consistent results such that the three are considered

interchangeable in aggregate. Although interchangeable in total, each data source has a

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unique role in the analysis. FSR data provides high level summary information of claims

data, subcapitated expenses, reinsurance expenses and administrative costs. In some cases,

this information is available at the risk group level while for others it is only provided at an

aggregated level. MCO summary reports provide HHSC-specified data points at a more

granular level such as subcapitated expenses by service, claim lag data by service, other

medical expenses and large claimant information. The detail encounter data provides claim

data at the most granular level including information for individual claims such as provider,

procedure code, diagnostic information, etc. The use of these multiple data sources allows

for a dynamic, flexible rating model that is not constrained to the data limitation of a single

source.

All data requested by the actuary was provided by HHSC and the participating MCOs.

Although the above data was reviewed for reasonableness, Rudd and Wisdom did not audit

the data.

In addition to the review for reasonableness performed by Rudd and Wisdom, HHSC

employs the Institute for Child Health Policy (ICHP) as an External Quality Review

Organization. ICHP reviews the detail encounter data and provides certification of the data

quality. Below is an excerpt from their data certification report:

Based on an administrative review, the EQRO considers the required data elements for all

MCO/SA combinations in STAR+PLUS to be accurate, and complete, meeting the following

components of Texas Government Code § 533.0131 for data certification purposes:

1. The encounter data for the most recent measurement year are complete, accurate,

and reliable.

2. No statistically significant variability in the encounter data is attributable to

incompleteness, inaccuracy, or other deficiency as compared to equivalent data for

similar populations and when evaluated against professionally accepted standards.

Based on the review of the data by the EQRO, HHSC and Rudd and Wisdom, we have

concluded that all data sources are consistent, complete and accurate. It is our opinion that

the data collected for the rate development is high quality and we have no concerns over the

availability or applicability to the FY2019 rate development. The accumulation of data

sources noted above has been assigned full credibility.

Given the history of managed care data available for the STAR+PLUS program, the rate

development is based exclusively on managed care data with the exception of the MBCCP

members which were new to managed care effective September 1, 2017. The development

of the MBCCP risk group premium rates is described further in Attachment 10.

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II. Overview of the Rate Setting Methodology

This report details the development of the medical (acute and long term care) and

prescription drug components of the STAR+PLUS premium rate. The two components are

developed separately but follow similar methodologies in their calculations.

The actuarial model used to derive the FY2019 STAR+PLUS premium rates relies

primarily on historical health plan experience. The historical claims experience for the

program was analyzed and estimates for the base period were developed. Due to the

significant differences between claim run-out patterns, different base periods were selected

for medical and prescription drug. The base period for the medical component was defined

as FY2017 (September 1, 2016 through August 31, 2017) while the base period for the

prescription drug component was defined as CY2017 (January 1, 2017 through December

31, 2017). The primary reason for varying the base periods between medical and

prescription is that prescription drug claims complete much faster and therefore require

minimal estimation of incurred but unpaid claims. Estimates of the base period include an

estimate of incurred but unpaid claims (IBNR). The IBNR estimate is based on claims paid

through February 2018 and represents the following percentage of claims by type of

service:

- Medical - 0.22%

- Prescription Drug - 0.0%

These estimates were then projected to FY2019 using assumed trend rates. Other plan

expenditures such as capitated amounts, service coordination, reinsurance costs and

administrative expenses were added to the claims component in order to project the total

FY2019 cost under the health plan. These projected total cost rates were determined

separately for each risk group for each health plan. The results of this analysis were then

combined for all health plans in a service area in order to develop a set of community rates

for each service area.

The managed care service areas used in the analysis were as follows:

• Bexar County Service Area (San Antonio)

• Dallas County Service Area (Dallas)

• El Paso County Service Area (El Paso)

• Harris County Service Area (Houston)

• Hidalgo County Service Area (Hidalgo)

• Jefferson County Service Area (Beaumont)

• Lubbock County Service Area (Lubbock)

• Nueces County Service Area (Corpus Christi)

• Tarrant County Service Area (Fort Worth)

• Travis County Service Area (Austin)

• Medicaid Rural Service Area - Central (MRSA Central)

• Medicaid Rural Service Area - Northeast (MRSA Northeast)

• Medicaid Rural Service Area - West (MRSA West)

The risk groups (or rating populations) used in the analysis are as follows:

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• Medicaid Only – Other Community Care (OCC)

• Medicaid Only – Home and Community Based Services (HCBS)

• Dual Eligible – OCC

• Dual Eligible – HCBS

• Medicaid Only – Nursing Facility (NF)

• Dual Eligible – NF

• Intellectual and Developmentally Disabled over age 21 (IDD)

• Medicaid Breast and Cervical Cancer Program (MBCCP)

The services used in the analysis include the following:

Acute Care Services

• Ambulance Services

• Audiology Services

• Behavioral Health Services

• Birthing Center Services

• Chiropractic Services

• Dialysis

• Durable Medical Equipment and Supplies

• Emergency Services

• Family Planning Services

• Home Health Services

• Hospital Services - outpatient

• Lab, X-ray and Radiology Services

• Optometry

• Podiatry

• Prenatal Care

• Primary Care Services

• Specialty Physician Services

• Therapies - physical, occupational and speech

• Transplantation of Organs and Tissues

• Vision

• Inpatient Facility Services

• Prescription Drugs

Long Term Care Services

• Adult Foster Care

• Adaptive Aids and Medical Equipment

• Assisted Living

• Emergency Response Services

• Home Delivered Meals

• Medical Supplies

• Minor Home Modifications

• Nursing Services (in home)

• Personal Attendant Services

• Therapies – physical, occupational and speech

• Transition Services

• Nursing Facilities

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Services specifically excluded from the analysis include:

• Dental and Orthodontia Services with the exception of a small number of dental services

provided to STAR+PLUS HCBS waiver members

• Early Childhood Intervention (ECI) case management/service coordination

• Texas School Health and Related Services (SHARS)

• Health and Human Services Commission’s Non-Emergency Medical Transportation

• Tuberculosis services provided by DSHS-approved providers (directly observed therapy

and contact investigation)

• Certain high cost carve-out prescription drugs

All expenses related to these services, along with any other non-capitated services and any

value-added services have been excluded from the FY2019 rating analysis.

We projected the FY2019 cost for each individual health plan by estimating their base

period average claims cost and then applying trend and other adjustment factors. These

adjustment factors are described in Section III. We added capitation expenses for services

capitated by the health plan (such as vision and behavioral health), service coordinator

expenses for care coordination services, a reasonable provision for administrative expenses

and a risk margin. Attachment 2 presents a description and an example of the experience

analysis for a sample health plan. This type of analysis was conducted for each health plan.

The analysis of base period claims experience for each health plan attempted to identify and

adjust for any distortions in the data. Significant variations in experience, including the

impact from unusually large individual claims, were investigated; however, no such

adjustments were deemed to be necessary.

HHSC utilizes a community rating methodology in setting the STAR+PLUS base premium

rates. The base rates vary by service area and risk group but are the same for each health

plan in a service area. The community rates are developed by a weighted average of the

projected FY2019 cost for each health plan in the service area. The weights used in this

formula are the projected FY2019 number of clients enrolled in each health plan by risk

group. Attachment 3 presents the summary community rating exhibit for each service area

along with a description of the analysis.

The base community rate in each service area was adjusted to reflect the health status, or

acuity, of the population enrolled in each health plan. The purpose of acuity risk adjustment

is to recognize the anticipated cost differential between multiple health plans in a service

area by analyzing the health status of their respective memberships. Additional information

regarding risk adjustment is included in Section III below under Risk Adjustment and in

Attachments 8 and 9.

The final FY2019 premium rates were defined as the community rates with acuity risk

adjustment for acute care services, pharmacy services and long term care services. This is

the same methodology that was used during the FY2018 STAR+PLUS rate development

with the exception that the risk adjustment factors applied to the long term care component

have been assigned full credibility. HHSC, the EQRO and the participating STAR+PLUS

health plans have been working closely together in developing a risk adjustment model to

be applied to the long term care component of the premium. The methodology applied in

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the FY2019 rate development is a continuation of the process which is ongoing and will

continue to be refined for future rate developments.

Please note that the Dual Eligible risk groups exclude long term care experience for the

Dual Eligible Demonstration populations and are based exclusively on STAR+PLUS

program experience. Dual Eligible Demonstration members have been excluded from the

analysis and their corresponding claims experience and acuity does not impact the

STAR+PLUS rate development.

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III. Adjustment Factors

This section contains a description of the adjustment factors used in the FY2019

STAR+PLUS rate setting process.

Trend Factors - Medical

The rating methodology uses assumed trend factors to adjust the base period claims cost to

the projection period. The trend factors used in this analysis are a combination of

utilization and inflation components. The projected trend rate assumptions were

developed by the actuary based on an analysis of recent experience under the various

health plans. A single trend assumption applies to all service areas but varies by risk

group, type of service and projection year (FY2018 and FY2019).

The trend analysis included a review of health plan claims experience data through

February 2018. Based on this information, estimates of monthly incurred claims were

made through December 2017. The claims cost and trend experience was reviewed

separately by service area and risk group. The service area trends were then combined into

a statewide average using a weighted average formula with estimated incurred claims as

the weights. All historical trends have been calculated as the average cost per member per

month during a specified time period (monthly, quarterly or annually) compared to the

same time period from the prior year. For example, the FY2017 trend has been calculated

as the change in average cost per member per month during the period September 1, 2016

through August 31, 2017 (FY2017) compared to the average cost per member per month

during the period September 1, 2015 through August 31, 2016 (FY2016). The experience

trends for all time periods were adjusted to remove the impact of provider reimbursement

changes and other revisions that have impacted the cost of the program.

The FY2018 trend assumptions were developed from two components: (i) the actual

estimated trend for the period September 2017 through December 2017 and (ii) the

projected trend for the period January 2018 through August 2018. The trends for the final

eight months of FY2018 were projected using experience data from FY2015, FY2016

FY2017 and the first four months of FY2018. The weighting of each time period was

based on the number of months within each time period for each risk group. For example,

risk groups such as OCC and HCBS which have been in STAR+PLUS the entire time

during the observed fiscal years were blended using the following: 3/10 weighting for

FY2015, FY2016 and FY2017 and 1/10 weighting to the first four months of FY2018.

The nursing facility risk group was new to the STAR+PLUS program on March 1, 2015

and, therefore, the observed trend for FY2016 included six months (March 2016 through

August 2016). As a result, the observed trends were blended using the following: 3/11

weighting for FY2016, 6/11 weighting for FY2017 and 2/11 weighting for the first four

months of FY2018.

The FY2019 trend assumptions were then developed from a simple average of the FY2015

trend, FY2016 trend, FY2017 trend and FY2018 trend.

Attachment 4 is a summary of the trend analysis. The chart below presents the assumed

annual trend rates for FY2018 and FY2019.

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FY2018 FY2019

Acute Care

Medicaid Only - OCC 2.2% 1.6%

Medicaid Only - HCBS 2.0% 1.2%

Medicaid Only - NF 2.0% 1.2%

IDD 0.8% 1.9%

Long Term Care

Medicaid Only - OCC 5.2% 5.0%

Medicaid Only - HCBS 2.4% 1.4%

Dual Eligible - OCC 3.8% 3.1%

Dual Eligible - HCBS 3.7% 3.3%

Medicaid Only - NF 0.8% 1.4%

Dual Eligible - NF 1.1% 1.6%

Trend Factors - Pharmacy

The rating methodology uses assumed pharmacy trend factors to adjust the base period

(CY2017) claims cost to the rating period (FY2019). The trend rate assumptions were

developed by the actuary based on an analysis of recent pharmacy claims experience under

the STAR+PLUS program and the actuary’s professional judgment regarding anticipated

future cost changes. The trend rate assumptions vary by risk group but are the same for all

service areas.

The trend analysis included a review of STAR+PLUS utilization and cost experience data

paid through March 2018. Utilization (days supply per member) and cost per service (plan

payments per days supply) statistics were developed by risk group and drug type (brand,

generic and specialty) through February 2018. From this experience, the average annual

utilization and cost per service were determined for each of the five 12-month periods

ending February 2018.

Only those drugs covered under the capitated arrangement are included in the trend

analysis. Anti-viral agents used for the treatment of the Hepatitis C virus and the drug

Orkambi are currently not included in the analysis as those drugs are currently carved out

of the managed care contract. In addition, experience for the drugs Tamiflu and Makena

were removed from our trend analysis. Tamiflu was removed due to the significant

variation in the intensity of flu season from year to year. Makena was removed due to its

one-time distortion of pharmacy trends for pregnant women. Please note that while

excluded from the pharmacy trend analysis, the historical claims for Tamiflu and Makena

were included in the base period experience used in developing the pharmacy component

of the rates.

The STAR+PLUS pharmacy trend assumptions for the remainder of FY2018 and all of

FY2019 were developed by risk group using the following formula. The utilization and

cost per service trend assumptions were set equal to one-sixth of the experience trend rate

for the 12-month period ending February 2016 plus two-sixths of the experience trend rate

for the 12-month period ending February 2017 plus three-sixths of the experience trend

rate for the 12-month period ending February 2018. The final cost trend assumptions were

then determined by applying the assumed utilization and cost per service trends by

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individual drug type to actual experience for the 12-month period ending February 2018

and combining the results into a single trend assumption for each risk group.

Exhibit C in Attachment 4 includes a summary of the pharmacy trend analysis for

STAR+PLUS. The chart below presents the assumed annual pharmacy trend rates

applicable for the period 1/1/2018 through 8/31/2019.

OCC HCBS IDD NF

All SDAs 6.7 % 6.9 % 3.4 % -0.4 %

Please note that the MCOs were provided a detailed trend analysis file which included the

historical utilization and cost experience as well as all of the formulas and assumptions

used in developing the trend assumptions.

Provider Reimbursement Adjustments – Acute Care

Medicaid provider reimbursement changes were recognized for the following services:

hospital inpatient reimbursement revisions, potentially preventable readmission

reimbursement reductions, potentially preventable complications reimbursement

reductions, therapy reimbursement revisions, therapy policy revisions, radiology

reimbursement reductions, anesthesiology reimbursement revisions and ambulance

reimbursement revisions.

The rating adjustments for these provider reimbursement changes were calculated by

applying actual health plan encounter data to the old and new reimbursement bases and the

resulting impact determined. Attachment 5 presents a summary of the derivation of these

adjustment factors.

Tort and Coordination of Benefit Recoveries

Effective September 1, 2017 HHSC instituted a change in policy that shifts claim

recoveries associated with tort and coordination of benefit recoveries beyond 120 days

from the MCOs to HHSC. Exhibit G of Attachment 5 presents a summary of the

necessary rating adjustment factors.

Removal of Invalid Clinician Administered Drugs (CADs)

By HHSC rule, all outpatient medical claims for clinician-administered drugs must contain

a Healthcare Common Procedure Coding System (HCPCS) code, an NDC number, the

NDC unit of measure, and the NDC quantity. The MCO must edit claims using the Texas

HHSC NDC to HCPCS Crosswalk file. If such a claim is missing the NDC information, or

the NDC is not valid for the corresponding HCPCS code, then the drug is not considered a

covered Medicaid benefit and the MCO must deny or reject the entire claim or claim line

item. As a result, the base period data was reviewed and clinician administered drugs

which were submitted under an invalid NDC were excluded from the rating analysis.

Exhibit H of Attachment 5 presents a summary of the derivation of this adjustment factor.

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Elimination of the NorthSTAR Program

Effective January 1, 2017 the NorthSTAR program was discontinued. Historically the

NorthSTAR program provided all behavioral health services for Medicaid clients residing

in the Dallas service area. Due to the elimination of the NorthSTAR program, behavioral

health services are now carved into the STAR+PLUS program for the Dallas service area

as with all other service areas. As a result, it is necessary to adjust the Dallas service area

base period data to include these behavioral health services for the period September 1,

2016 through December 31, 2016. Exhibit I of Attachment 5 presents a summary of this

adjustment factor.

IMD Cost Removal

By regulation, cost for managed care members ages 21 through 64 who have an IMD stay

in excess of 15 days during a month may not be used in the rate development. Claims data

for all such members has been identified and removed from the rate analysis. A summary

of the derivation of these adjustment factors is presented in Attachment 5 - Exhibit J.

FQHC Wrap Payment Removal

Effective September 1, 2017, MCOs are no longer required to reimburse FQHCs the full

encounter rate. The MCOs are expected to reimburse FQHCs at a rate that is comparable

to the reimbursement of all other non-FQHC providers providing similar services.

Subsequently, the FQHC will be reimbursed up to their full encounter rate outside of the

capitation rate. The rating adjustment was calculated by repricing all FQHC claims at the

fee-for-service equivalent paid for non-FQHC providers for the same services. The

difference between the full encounter rate and this estimated fee-for-service equivalent

was assumed to be the wrap payment that is no longer covered under the capitation rate.

Exhibit K of Attachment 5 presents a summary of the derivation of these adjustment

factors.

Preferred Drug List Changes

HHSC has recently implemented numerous changes to the Preferred Drug List (PDL).

These changes include some of the program’s highest expenditure drugs and will have a

significant impact on managed care pharmacy cost. Some of the PDL changes were

implemented during the experience period used to develop the rates and some were

implemented after the experience period. We developed adjustment factors to reflect the

anticipated cost impact of the PDL changes. Exhibit M of Attachment 5 includes

additional information regarding the application of the PDL changes adjustment factors.

Drug Carve In

HHSC currently excludes several low-utilization, high-cost drugs from the capitated

arrangement. These drugs are covered services under the plan but their cost is reimbursed

to the MCOs using a non-risk arrangement. We have now accumulated sufficient

experience to project utilization and cost for some of these “carve-out” drugs. Anti-viral

medications for the treatment of Hepatitis C (Epclusa, Harvoni, Viekira Pak, etc.) and

Orkambi (a treatment for Cystic Fibrosis) will be added to capitated services effective

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September 1, 2018. Exhibit N of attachment 5 includes additional information regarding

the derivation of the rate adjustments for these services.

Removal of STAR+PLUS Members Under Age 21

Effective November 1, 2016 STAR+PLUS members under age 21 were removed from the

STAR+PLUS program and enrolled in the STAR Kids program. Attachment 6 presents a

summary of the adjustment factors applicable to the base period data as a result of this

eligibility change.

Carve in Relocation Services

Effective September 1, 2017 relocation services were carved into the STAR+PLUS

program. Previously, relocation services which assist Medicaid-eligible nursing facility

residents to relocate from nursing facilities to community-based settings, were carved out

and reimbursed through the Fee-for-Service program. This adjustment impacts the nursing

facility populations only. Attachment 7 provides additional information about this

adjustment.

Community First Choice Initiative (CFC)

Effective June 1, 2015, Texas implemented a CFC initiative within the STAR+PLUS

program that expanded access to certain habilitation and attendant care services. As a

result of CFC, Texas receives an enhanced federal medical assistance percentage (FMAP)

on CFC eligible clients and services. The impact of CFC on program cost is included in

the FY2017 base period and no further adjustments are necessary. Attachment 14 details

the development of the CFC portion of the premium eligible for an enhanced FMAP.

Risk Adjustment

Several risk adjustment techniques are employed in the rate setting methodology.

Premium rates are established separately by area of the state and risk group in order to

recognize the inherent geographical and demographical variation in the cost of delivering

care. In addition, the rating methodology includes a health status adjustment.

The acute care and pharmacy portions of the base community rate in each service area was

adjusted to reflect the health status, or acuity, of the population enrolled in each health

plan. The purpose of acuity risk adjustment is to recognize the anticipated cost differential

between multiple health plans in a service area by analyzing the health status of their

respective memberships. The risk analysis was performed by the University of Florida’s

Institute for Child Health Policy (ICHP). The methodology used to incorporate the acuity

risk adjustment is the Chronic Illness and Disability Payment System (CDPS). Additional

information regarding this acuity risk adjustment is included in Attachment 8.

Although the results of the risk adjustment analysis were reviewed for reasonableness,

Rudd and Wisdom did not audit the risk adjustment data or the results of ICHP’s analysis.

The long term care portion of the base community rate in each service area was also

adjusted to reflect the health status, or acuity of the population enrolled in each health

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plan. Prior to FY2018 no acuity model was readily available on which to measure the

relative differences among the health plans. HHSC, the EQRO and the health plans

formed a workgroup tasked with developing a long term care acuity model. The

workgroup analyzed available long term care data and publicly available models and

developed a preliminary model which was first applied in FY2018 and has been updated

for FY2019. The long term care acuity factors have been given 100% credibility for

FY2019. Additional information regarding this acuity risk adjustment is included in

Attachment 9.

Network Access Improvement Program (NAIP)

Effective March 1, 2015, several health plans implemented programs aimed at improving

network access for Medicaid members. The NAIP is designed to further the state's goal of

increasing the availability and effectiveness of primary care for Medicaid beneficiaries by

incentivizing various institutions to provide higher quality, well-coordinated, and

continuous care.

Attachment 11 presents the development of the NAIP add-on amounts to be included in

the capitation rates effective September 1, 2018 along with additional information

concerning the NAIP program.

Quality Incentive Payment Program for Nursing Facilities (QIPP)

Effective September 1, 2017 HHSC implemented the QIPP program which is designed to

incentivize nursing facilities to improve quality and innovation in the provision of nursing

facility services, using the CMS five-star rating system as its measure of success. The

QIPP provides enhanced payment for nursing facilities which demonstrate improvement

on specific quality goals.

Attachment 12 presents the development of the QIPP add-on amounts to be included in the

capitation rates effective September 1, 2018 along with additional information concerning

the QIPP program.

Uniform Hospital Reimbursement Program (UHRIP)

Effective December 1, 2017, HHSC implemented a pilot of the Uniform Hospital Rate

Increase Program (UHRIP) in the Bexar and El Paso service delivery areas. The program

expanded statewide effective March 1, 2018. UHRIP is a Medicaid managed care hospital

directed payment program authorized under federal regulations at 42 CFR 438.6(c). CMS

approved HHSC's statewide implementation of the program on August 18, 2017. The

UHRIP program increases the reimbursement to contracted hospitals by a level percentage

that varies by hospital class. HHSC has identified the following classes of hospitals within

each SDA and the rate increase for each:

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SDA Children's

Non-

Urban

Public

Rural

Private

Rural

Public

State-

owned

Urban

Public Other

Bexar 2% 38% 14% 17% 0% 38% 38%

Dallas 2% 57% 0% 0% 62% 62% 62%

El Paso 2% 0% 0% 0% 0% 43% 43%

Harris 0% 42% 14% 17% 0% 46% 46%

Hidalgo 0% 0% 0% 14% 0% 0% 36%

Jefferson 0% 0% 6% 6% 0% 0% 50%

Lubbock 3% 0% 4% 9% 0% 72% 40%

Nueces 0% 46% 7% 19% 0% 51% 51%

Tarrant 2% 0% 24% 24% 0% 66% 66%

Travis 1% 0% 7% 0% 0% 56% 56%

MRSA Central 0% 0% 16% 18% 0% 0% 50%

MRSA Northeast 0% 0% 15% 19% 0% 0% 52%

MRSA West 0% 62% 4% 25% 0% 68% 68%

All MCOs are required to increase their reimbursement rates to contracted hospitals by the

established percentage rate increase. Attachment 13 presents the development of the

UHRIP add-on amounts to be included in the capitation rates effective September 1, 2018

along with additional information concerning the UHRIP program.

15

IV. Administrative Fees, Taxes and Risk Margin

The rating methodology includes an explicit provision for administrative expenses. The

amount allocated for administrative expenses is $20.00 pmpm plus 5.75% of gross

premium for medical services and $1.80 pmpm for pharmacy services. This amount is

intended to provide for all administrative-related services performed by the health plan.

The administrative allowance for medical services is split between a fixed and variable

component in order to allocate a larger percentage of the administrative dollars to the

higher cost risk groups.

The administrative fee amounts were determined based on a review of the administrative

expenses of the STAR+PLUS health plans as reported in their audited Financial

Statistical Reports (FSRs). The table below summarizes the reported administrative

expenses for the past four fiscal years for the STAR+PLUS program.

Avg. Admin.

Expense

FY15 83.02

FY16 99.19

FY17 84.54

FY18 92.61

4 Year Average 89.84

Based on the administrative formula included in the rate development, the average

administrative expense provision included in the capitation rates is approximately $89

which is in line with the historical average cost. The fixed and variable components of

the administrative cost assumption are not intended to account for different

administrative cost categories. The combined administrative assumption is intended to be

a reasonable amount to cover all administrative costs. This formula is reviewed annually

to ensure consistency with the reported administrative costs.

The premium rates also include an amount for premium tax (1.75% of premium),

maintenance tax ($0.06 pmpm) and a risk margin (1.75% of premium). The premium tax

and maintenance tax are based on Texas Department of Insurance requirements.

The capitation rates included in this document do not include provision for the

Affordable Care Act (ACA) Health Insurance Providers Fee. HHSC will develop and

implement a procedure for reimbursing the health plans for (i) the ACA Health Insurance

Providers Fee, (ii) any applicable federal income tax impact resulting from payment of

the ACA Health Insurance Providers Fee and (iii) any applicable state premium tax

impact resulting from payment of the ACA Health Insurance Providers Fee. Such

reimbursement will be provided separately based on a CMS-approved methodology, if

necessary or applicable. HHSC has included the Health Insurance Providers Fee in the

managed care capitation rates for each of 2014, 2015 and 2016 through amendments to

the initially certified rates for these time periods.

16

V. Summary

The chart below presents the results of the FY2019 STAR+PLUS rating analysis and

includes all components of the premium – acute care, long term care, prescription drugs

NAIP, UHRIP and QIPP. Texas is eligible for an enhanced FMAP rate for CFC services.

Attachment 14 details the development of the CFC component of the total premium rate.

Health Plan

Medicaid

Only

Medicaid

Only

Dual Eligible

Dual Eligible

OCC HCBS OCC HCBS

Monthly Premium Rates

Amerigroup - Bexar

$1,503.54 $5,276.51

$395.96 $2,119.64

Molina - Bexar

1,361.32 4,446.66

402.58 1,989.36

Superior - Bexar

1,667.51 4,920.34

459.44 2,087.13

Molina - Dallas

1,661.36 4,594.26

421.98 1,846.32

Superior - Dallas

1,573.70 4,870.98

379.94 1,895.56

Amerigroup - El Paso

1,541.76 4,887.62

522.75 1,972.31

Molina - El Paso

1,852.66 4,995.27

612.09 2,158.55

Amerigroup - Harris

1,702.01 5,528.35

353.65 2,159.07

Molina - Harris

1,570.49 5,426.99

370.98 2,153.05

United - Harris

1,967.41 5,363.06

412.25 2,174.87

Health Spring - Hidalgo

1,886.02 5,022.97

1,023.79 2,488.25

Molina - Hidalgo

1,873.10 5,149.26

899.83 2,449.64

Superior - Hidalgo

2,101.44 5,133.19

1,163.21 2,483.50

Amerigroup - Jefferson

1,363.78 4,843.44

308.92 1,784.71

Molina - Jefferson

1,409.99 4,281.86

303.06 1,631.22

United - Jefferson

1,625.77 4,404.48

201.12 1,519.28

Amerigroup - Lubbock

1,486.46 4,144.66

157.90 1,476.81

Superior - Lubbock

1,399.01 4,910.47

199.23 1,598.72

Superior - Nueces

1,643.57 4,489.26

571.25 2,150.10

United - Nueces

1,880.61 4,741.87

460.15 2,111.09

Amerigroup - Tarrant

1,635.03 5,109.40

324.03 1,800.70

Health Spring - Tarrant

1,431.28 4,856.34

279.47 1,823.41

Amerigroup - Travis

1,512.19 5,664.03

361.14 1,929.37

United - Travis

1,574.15 5,609.76

180.40 1,856.01

Superior - MRSA Central

1,448.71 4,773.84

230.43 1,807.45

United - MRSA Central

1,381.52 5,186.52

238.93 1,937.94

Health Spring - MRSA Northeast

1,276.18 4,569.59

228.90 1,735.55

United - MRSA Northeast

1,400.20 4,872.38

254.01 1,594.02

Amerigroup - MRSA West

1,373.62 5,271.50

281.77 1,662.72

Superior - MRSA West

1,475.35 4,631.01

287.82 1,579.01

17

Health Plan

Medicaid

Only

Dual Eligible

IDD

NF NF Over 21 MBCCP

Monthly Premium Rates

Amerigroup - Bexar

$7,510.74 $4,723.93 $829.34 $2,876.06

Molina - Bexar

7,439.99 4,723.93 809.69 2,876.06

Superior - Bexar

7,903.61 4,723.93 1,128.83 2,876.06

Molina - Dallas

8,224.45 4,685.16 830.65 2,934.05

Superior - Dallas

8,686.54 4,685.16 878.80 2,934.05

Amerigroup - El Paso

9,304.98 4,310.90 1,525.58 2,088.20

Molina - El Paso

9,011.30 4,310.90 1,695.68 2,088.20

Amerigroup - Harris

7,816.53 4,507.15 969.80 3,064.96

Molina - Harris

7,865.68 4,507.15 943.38 3,064.96

United - Harris

8,071.21 4,507.15 1,072.36 3,064.96

Health Spring - Hidalgo

8,118.26 5,197.93 841.04 2,750.70

Molina - Hidalgo

8,578.74 5,197.93 988.77 2,750.70

Superior - Hidalgo

8,784.66 5,197.93 1,174.99 2,750.70

Amerigroup - Jefferson

7,447.49 4,395.83 931.64 2,827.18

Molina - Jefferson

7,069.27 4,395.83 838.76 2,827.18

United - Jefferson

7,431.31 4,395.83 986.39 2,827.18

Amerigroup - Lubbock

7,891.51 4,566.08 944.42 2,416.63

Superior - Lubbock

7,829.56 4,566.08 861.77 2,416.63

Superior - Nueces

7,081.03 4,689.51 1,171.34 2,561.24

United - Nueces

6,926.93 4,689.51 1,282.23 2,561.24

Amerigroup - Tarrant

7,731.33 4,500.53 953.82 2,730.96

Health Spring - Tarrant

7,134.21 4,500.53 777.28 2,730.96

Amerigroup - Travis

7,700.09 4,811.96 813.38 3,147.96

United - Travis

7,913.53 4,811.96 1,095.91 3,147.96

Superior - MRSA Central

6,878.87 4,511.89 1,058.09 3,871.54

United - MRSA Central

6,973.79 4,511.89 937.73 3,871.54

Health Spring - MRSA Northeast

7,634.18 4,548.67 858.22 3,043.38

United - MRSA Northeast

7,545.72 4,548.67 940.79 3,043.38

Amerigroup - MRSA West

7,613.93 4,646.40 1,004.90 2,673.63

Superior - MRSA West

7,798.25 4,646.40 960.62 2,673.63

Attachment 1 presents additional information regarding the breakdown of the components

of the FY2019 rates.

Attachment 16 presents the required rating index summarizing the applicable sections

from the 2018-2019 Medicaid Managed Care Rate Development Guide.

18

VI. Actuarial Certification of FY2019 STAR+PLUS Health Plan Premium Rates

We, Evan L. Dial, Khiem D. Ngo and David G. Wilkes are principals with the firm of Rudd

and Wisdom, Inc., Consulting Actuaries (Rudd and Wisdom). We are Fellows of the

Society of Actuaries and members of the American Academy of Actuaries. We meet the

Academy’s qualification standards for rendering this opinion.

Rudd and Wisdom has been retained by the Texas Health and Human Services Commission

(HHSC) to assist in the development of the STAR+PLUS premium rates for the period

September 1, 2018 through August 31, 2019 and to provide the actuarial certification

required under Centers for Medicare and Medicaid Services (CMS) requirements 42 CFR

438.4.

I certify that the FY2019 premium rates developed by HHSC and Rudd and Wisdom satisfy

the following:

(a) The premium rates have been developed in accordance with generally accepted

actuarial principles and practices;

(b) The premium rates are appropriate for the populations and services covered under the

managed care contract; and

(c) The premium rates are actuarially sound as defined in the regulations.

We have relied on historical experience data and program information provided to us by

HHSC. We have reviewed the data for reasonableness but have not audited the data.

Please note that actual health plan contractor experience will differ from these projections.

Rudd and Wisdom has developed these rates on behalf of the State to demonstrate

compliance with the CMS requirements under 42 CFR 438.3(c), 438.3(e), 438.4, 438.5,

438.6 and 438.7. Any health plan contracting with the State should analyze its own

projected premium needs before deciding whether to contract with the State.

_________________________ _____________________________

Evan L. Dial, F.S.A., M.A.A.A. David G. Wilkes, F.S.A., M.A.A.A.

_____________________________

Khiem D. Ngo, F.S.A., M.A.A.A.

19

VII. Attachments

20

Attachment 1

Summary of FY2019 STAR+PLUS Rating Analysis

Exhibit A. This exhibit presents summary information regarding the FY2019 rates. Included on

the exhibit are current premium rates split between medical (acute care and long term care),

prescription drug, NAIP, QIPP and UHRIP rates; FY2019 premium rates split between medical

(acute care and long term care), prescription drug, NAIP, QIPP and UHRIP rates; and a

comparison of FY2018 and FY2019 premium rates.

Exhibit B. This exhibit presents a comparison of the projected expenditures under the current

premium rates and the FY2019 premium rates. The projection is split by medical, pharmacy,

NAIP/QIPP and UHRIP.

Attachment 1 - Exhibit A

FY2019 STAR+PLUS Rating Summary

Medicaid Only Dual Eligible Nursing Facility

OCC HCBS OCC HCBS Medicaid Only Dual Eligible IDD MBCCP

FY2018 Acute Care Premium Rates pmpm

Amerigroup - Bexar 585.25 1,400.68 0.00 0.00 1,396.99 0.00 379.59 1,702.64

Molina - Bexar 483.65 1,180.80 0.00 0.00 1,396.99 0.00 309.76 1,702.64

Superior - Bexar 598.92 1,296.23 0.00 0.00 1,396.99 0.00 443.33 1,702.64

Molina - Dallas 719.46 1,824.38 0.00 0.00 1,885.66 0.00 363.75 1,925.11

Superior - Dallas 697.49 1,874.31 0.00 0.00 1,885.66 0.00 366.62 1,925.11

Amerigroup - El Paso 615.74 1,593.93 0.00 0.00 1,828.51 0.00 515.88 1,180.50

Molina - El Paso 675.37 1,484.16 0.00 0.00 1,828.51 0.00 560.59 1,180.50

Amerigroup - Harris 709.55 1,953.72 0.00 0.00 1,572.09 0.00 392.12 1,966.73

Molina - Harris 664.99 1,884.07 0.00 0.00 1,572.09 0.00 390.70 1,966.73

United - Harris 814.80 1,867.99 0.00 0.00 1,572.09 0.00 445.03 1,966.73

Health Spring - Hidalgo 519.54 1,244.42 0.00 0.00 1,707.95 0.00 415.06 1,892.97

Molina - Hidalgo 558.00 1,341.87 0.00 0.00 1,707.95 0.00 515.55 1,892.97

Superior - Hidalgo 576.69 1,382.39 0.00 0.00 1,707.95 0.00 549.26 1,892.97

Amerigroup - Jefferson 590.33 1,923.50 0.00 0.00 1,505.40 0.00 373.20 2,279.43

Molina - Jefferson 604.88 1,634.37 0.00 0.00 1,505.40 0.00 350.48 2,279.43

United - Jefferson 712.92 1,870.60 0.00 0.00 1,505.40 0.00 409.86 2,279.43

Amerigroup - Lubbock 594.30 1,458.95 0.00 0.00 1,184.35 0.00 364.97 1,366.98

Superior - Lubbock 564.31 1,677.27 0.00 0.00 1,184.35 0.00 398.45 1,366.98

Superior - Nueces 565.52 1,303.00 0.00 0.00 1,410.44 0.00 562.32 1,807.40

United - Nueces 599.72 1,389.98 0.00 0.00 1,410.44 0.00 557.57 1,807.40

Amerigroup - Tarrant 749.15 1,651.04 0.00 0.00 1,494.91 0.00 396.91 1,700.29

Health Spring - Tarrant 605.64 1,528.16 0.00 0.00 1,494.91 0.00 323.11 1,700.29

Amerigroup - Travis 557.30 1,701.65 0.00 0.00 961.69 0.00 298.20 1,670.63

United - Travis 608.91 1,687.92 0.00 0.00 961.69 0.00 426.02 1,670.63

Superior - MRSA Central 601.78 1,297.53 0.00 0.00 1,186.56 0.00 425.57 2,207.75

United - MRSA Central 575.72 1,466.92 0.00 0.00 1,186.56 0.00 427.22 2,207.75

Health Spring - MRSA Northeast 552.05 1,339.63 0.00 0.00 1,361.68 0.00 352.67 1,942.20

United - MRSA Northeast 627.67 1,577.01 0.00 0.00 1,361.68 0.00 393.97 1,942.20

Amerigroup - MRSA West 563.15 1,293.86 0.00 0.00 1,321.68 0.00 385.42 1,589.19

Superior - MRSA West 614.90 1,229.42 0.00 0.00 1,321.68 0.00 384.70 1,589.19

21





FY2018 Long Term Care Premium Rates pmpm

Amerigroup - Bexar 243.44 1,871.28 366.65 1,947.98 4,855.57 4,214.00 0.00 0.00

Molina - Bexar 232.96 1,633.03 386.02 1,906.91 4,855.57 4,214.00 0.00 0.00

Superior - Bexar 294.50 1,884.21 435.85 1,950.87 4,855.57 4,214.00 0.00 0.00

Molina - Dallas 269.53 1,607.80 381.23 1,778.57 4,696.51 4,170.56 0.00 0.00

Superior - Dallas 222.94 1,534.73 355.15 1,775.45 4,696.51 4,170.56 0.00 0.00

Amerigroup - El Paso 263.09 1,479.81 483.59 1,905.39 5,119.26 4,469.37 0.00 0.00

Molina - El Paso 342.21 1,581.04 548.46 1,997.25 5,119.26 4,469.37 0.00 0.00

Amerigroup - Harris 233.93 1,923.76 348.89 1,949.57 4,753.99 4,159.30 0.00 0.00

Molina - Harris 245.93 1,876.78 348.68 1,977.76 4,753.99 4,159.30 0.00 0.00

United - Harris 299.97 1,894.12 376.56 1,991.36 4,753.99 4,159.30 0.00 0.00

Health Spring - Hidalgo 786.87 2,114.72 1,000.58 2,294.25 4,779.49 4,571.24 0.00 0.00

Molina - Hidalgo 693.10 2,079.56 901.47 2,252.87 4,779.49 4,571.24 0.00 0.00

Superior - Hidalgo 793.73 2,118.60 1,136.24 2,289.94 4,779.49 4,571.24 0.00 0.00

Amerigroup - Jefferson 165.51 1,486.30 274.13 1,674.87 4,512.69 3,926.98 0.00 0.00

Molina - Jefferson 191.41 1,356.95 259.78 1,603.59 4,512.69 3,926.98 0.00 0.00

United - Jefferson 163.28 1,373.06 161.63 1,524.22 4,512.69 3,926.98 0.00 0.00

Amerigroup - Lubbock 97.92 1,131.15 144.53 1,401.05 4,531.65 3,938.70 0.00 0.00

Superior - Lubbock 111.66 1,316.23 170.72 1,471.93 4,531.65 3,938.70 0.00 0.00

Superior - Nueces 364.08 1,798.82 551.48 1,980.53 4,435.12 4,227.08 0.00 0.00

United - Nueces 358.81 1,813.26 441.66 1,946.75 4,435.12 4,227.08 0.00 0.00

Amerigroup - Tarrant 151.44 1,537.66 280.90 1,662.47 4,451.14 4,005.83 0.00 0.00

Health Spring - Tarrant 192.77 1,595.55 234.03 1,712.31 4,451.14 4,005.83 0.00 0.00

Amerigroup - Travis 260.55 1,934.81 319.81 1,784.48 4,752.45 4,135.95 0.00 0.00

United - Travis 168.42 1,897.78 185.00 1,750.06 4,752.45 4,135.95 0.00 0.00

Superior - MRSA Central 156.09 1,967.75 233.25 1,743.94 4,330.23 3,998.45 0.00 0.00

United - MRSA Central 130.63 2,055.80 229.78 1,815.73 4,330.23 3,998.45 0.00 0.00

Health Spring - MRSA Northeast 154.47 1,567.52 214.76 1,589.54 4,532.80 4,033.89 0.00 0.00

United - MRSA Northeast 147.65 1,610.45 212.02 1,501.10 4,532.80 4,033.89 0.00 0.00

Amerigroup - MRSA West 115.92 1,719.02 251.68 1,561.57 4,402.07 3,893.23 0.00 0.00

Superior - MRSA West 143.43 1,568.15 253.28 1,511.84 4,402.07 3,893.23 0.00 0.00

22





FY2018 Prescription Drug Premium Rates pmpm

Amerigroup - Bexar 469.29 1,076.05 0.00 0.00 661.57 0.00 460.27 450.21

Molina - Bexar 387.82 907.14 0.00 0.00 661.57 0.00 375.59 450.21

Superior - Bexar 480.26 995.81 0.00 0.00 661.57 0.00 537.56 450.21

Molina - Dallas 395.80 746.03 0.00 0.00 548.64 0.00 313.77 339.02

Superior - Dallas 383.71 766.45 0.00 0.00 548.64 0.00 316.24 339.02

Amerigroup - El Paso 461.12 1,039.87 0.00 0.00 398.81 0.00 828.63 657.41

Molina - El Paso 505.78 968.25 0.00 0.00 398.81 0.00 900.45 657.41

Amerigroup - Harris 512.43 1,056.84 0.00 0.00 684.02 0.00 483.21 423.48

Molina - Harris 480.24 1,019.16 0.00 0.00 684.02 0.00 481.47 423.48

United - Harris 588.43 1,010.47 0.00 0.00 684.02 0.00 548.41 423.48

Health Spring - Hidalgo 518.83 927.81 0.00 0.00 616.58 0.00 370.84 399.55

Molina - Hidalgo 557.24 1,000.47 0.00 0.00 616.58 0.00 460.61 399.55

Superior - Hidalgo 575.90 1,030.67 0.00 0.00 616.58 0.00 490.73 399.55

Amerigroup - Jefferson 430.35 962.44 0.00 0.00 715.83 0.00 433.51 613.42

Molina - Jefferson 440.95 817.77 0.00 0.00 715.83 0.00 407.12 613.42

United - Jefferson 519.71 935.97 0.00 0.00 715.83 0.00 476.09 613.42

Amerigroup - Lubbock 455.94 916.07 0.00 0.00 783.56 0.00 371.64 404.13

Superior - Lubbock 432.93 1,053.16 0.00 0.00 783.56 0.00 405.73 404.13

Superior - Nueces 473.22 873.72 0.00 0.00 637.31 0.00 458.36 397.39

United - Nueces 501.83 932.05 0.00 0.00 637.31 0.00 454.50 397.39

Amerigroup - Tarrant 513.46 1,147.26 0.00 0.00 713.65 0.00 490.16 629.77

Health Spring - Tarrant 415.11 1,061.87 0.00 0.00 713.65 0.00 399.02 629.77

Amerigroup - Travis 465.17 1,106.05 0.00 0.00 977.57 0.00 412.33 579.30

United - Travis 508.25 1,097.12 0.00 0.00 977.57 0.00 589.08 579.30

Superior - MRSA Central 424.41 799.61 0.00 0.00 567.13 0.00 438.97 614.97

United - MRSA Central 406.03 904.00 0.00 0.00 567.13 0.00 440.67 614.97

Health Spring - MRSA Northeast 388.25 862.93 0.00 0.00 708.68 0.00 438.96 439.49

United - MRSA Northeast 441.43 1,015.84 0.00 0.00 708.68 0.00 490.36 439.49

Amerigroup - MRSA West 408.54 915.20 0.00 0.00 691.08 0.00 448.38 327.52

Superior - MRSA West 446.08 869.62 0.00 0.00 691.08 0.00 447.54 327.52

23





FY2018 NAIP pmpm

Amerigroup - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Molina - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Bexar 7.97 7.97 0.00 0.00 0.00 0.00 7.97 0.00

Molina - Dallas 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Dallas 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Amerigroup - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Amerigroup - Harris 28.96 28.96 0.00 0.00 0.00 0.00 28.96 0.00

Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

United - Harris 31.14 31.14 0.00 0.00 0.00 0.00 31.14 0.00


Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Hidalgo 3.38 3.38 0.00 0.00 0.00 0.00 3.38 0.00





Superior - Lubbock 16.31 16.31 0.00 0.00 0.00 0.00 16.31 0.00

Superior - Nueces 36.95 36.95 0.00 0.00 0.00 0.00 36.95 0.00

United - Nueces 118.20 118.20 0.00 0.00 0.00 0.00 118.20 0.00

Amerigroup - Tarrant 4.63 4.63 0.00 0.00 0.00 0.00 4.63 0.00

Health Spring - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Amerigroup - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

United - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00




United - MRSA Northeast 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00



24





3/1/2018-8/31/2018 QIPP pmpm


Molina - Bexar 0.00 0.00 0.00 0.00 637.60 637.60 0.00 0.00

Superior - Bexar 0.00 0.00 0.00 0.00 637.60 637.60 0.00 0.00

Molina - Dallas 0.00 0.00 0.00 0.00 640.31 640.31 0.00 0.00

Superior - Dallas 0.00 0.00 0.00 0.00 640.31 640.31 0.00 0.00


Molina - El Paso 0.00 0.00 0.00 0.00 60.98 60.98 0.00 0.00


Molina - Harris 0.00 0.00 0.00 0.00 530.50 530.50 0.00 0.00

United - Harris 0.00 0.00 0.00 0.00 530.50 530.50 0.00 0.00


Molina - Hidalgo 0.00 0.00 0.00 0.00 560.58 560.58 0.00 0.00







Superior - Nueces 0.00 0.00 0.00 0.00 584.28 584.28 0.00 0.00

United - Nueces 0.00 0.00 0.00 0.00 584.28 584.28 0.00 0.00




United - Travis 0.00 0.00 0.00 0.00 784.65 784.65 0.00 0.00







25





3/1/2018-8/31/2018 UHRIP pmpm


Molina - Bexar 68.16 126.85 0.00 0.00 123.89 0.00 50.35 216.70

Superior - Bexar 80.84 154.07 0.00 0.00 208.41 0.00 33.02 216.70

Molina - Dallas 181.45 328.82 0.00 0.00 434.28 0.00 40.67 486.24

Superior - Dallas 192.74 380.23 0.00 0.00 654.45 0.00 52.59 486.24


Molina - El Paso 87.00 155.88 0.00 0.00 230.71 0.00 31.38 114.95


Molina - Harris 127.88 294.48 0.00 0.00 246.19 0.00 53.44 346.10

United - Harris 137.54 216.97 0.00 0.00 243.43 0.00 48.91 346.10


Molina - Hidalgo 86.42 205.03 0.00 0.00 325.13 0.00 47.64 258.63







Superior - Nueces 118.89 252.78 0.00 0.00 326.21 0.00 94.72 397.61

United - Nueces 144.55 280.98 0.00 0.00 482.61 0.00 120.61 397.61




United - Travis 7.18 8.89 0.00 0.00 12.08 0.00 6.33 17.14







26





FY2018 Total Premium Rates pmpm

Amerigroup - Bexar 1,361.16 4,467.55 366.65 1,947.98 7,733.11 4,851.60 868.04 2,369.55

Molina - Bexar 1,172.59 3,847.82 386.02 1,906.91 7,675.62 4,851.60 735.70 2,369.55

Superior - Bexar 1,462.49 4,338.29 435.85 1,950.87 7,760.14 4,851.60 1,021.88 2,369.55

Molina - Dallas 1,566.24 4,507.03 381.23 1,778.57 8,205.40 4,810.87 718.19 2,750.37

Superior - Dallas 1,496.88 4,555.72 355.15 1,775.45 8,425.57 4,810.87 735.45 2,750.37

Amerigroup - El Paso 1,391.29 4,247.04 483.59 1,905.39 7,712.33 4,530.35 1,377.61 1,952.86

Molina - El Paso 1,610.36 4,189.33 548.46 1,997.25 7,638.27 4,530.35 1,492.42 1,952.86

Amerigroup - Harris 1,620.99 5,343.04 348.89 1,949.57 7,930.13 4,689.80 949.76 2,736.31

Molina - Harris 1,519.04 5,074.49 348.68 1,977.76 7,786.79 4,689.80 925.61 2,736.31

United - Harris 1,871.88 5,020.69 376.56 1,991.36 7,784.03 4,689.80 1,073.49 2,736.31

Health Spring - Hidalgo 1,890.22 4,435.08 1,000.58 2,294.25 7,846.53 5,131.82 808.17 2,551.15

Molina - Hidalgo 1,894.76 4,626.93 901.47 2,252.87 7,989.73 5,131.82 1,023.80 2,551.15

Superior - Hidalgo 2,030.04 4,707.90 1,136.24 2,289.94 8,083.53 5,131.82 1,106.18 2,551.15

Amerigroup - Jefferson 1,283.75 4,666.84 274.13 1,674.87 7,605.93 4,491.57 833.07 3,316.89

Molina - Jefferson 1,360.78 4,055.39 259.78 1,603.59 7,673.48 4,491.57 779.73 3,316.89

United - Jefferson 1,574.16 4,593.83 161.63 1,524.22 7,696.15 4,491.57 976.50 3,316.89

Amerigroup - Lubbock 1,335.02 3,927.88 144.53 1,401.05 7,559.89 4,651.09 820.62 2,122.60

Superior - Lubbock 1,265.52 4,445.64 170.72 1,471.93 7,541.73 4,651.09 875.37 2,122.60

Superior - Nueces 1,558.66 4,265.27 551.48 1,980.53 7,393.36 4,811.36 1,152.35 2,602.40

United - Nueces 1,723.11 4,534.47 441.66 1,946.75 7,549.76 4,811.36 1,250.88 2,602.40

Amerigroup - Tarrant 1,639.87 4,792.63 280.90 1,662.47 7,843.81 4,622.75 954.42 2,801.20

Health Spring - Tarrant 1,343.92 4,527.52 234.03 1,712.31 7,538.69 4,622.75 763.36 2,801.20

Amerigroup - Travis 1,288.92 4,754.70 319.81 1,784.48 7,505.29 4,920.60 712.02 2,267.07

United - Travis 1,292.76 4,691.71 185.00 1,750.06 7,488.44 4,920.60 1,021.43 2,267.07

Superior - MRSA Central 1,362.44 4,430.98 233.25 1,743.94 7,113.19 4,583.52 958.81 3,489.24

United - MRSA Central 1,294.85 4,777.73 229.78 1,815.73 6,958.58 4,583.52 983.04 3,489.24

Health Spring - MRSA Northeast 1,187.43 3,990.79 214.76 1,589.54 7,516.14 4,598.89 828.89 2,687.66

United - MRSA Northeast 1,311.92 4,403.23 212.02 1,501.10 7,390.84 4,598.89 917.89 2,687.66

Amerigroup - MRSA West 1,256.62 4,273.33 251.68 1,561.57 7,605.53 4,735.39 935.26 2,327.81

Superior - MRSA West 1,390.15 3,957.59 253.28 1,511.84 7,696.49 4,735.39 923.66 2,327.81

27





FY2019 Acute Care Premium Rates pmpm (Community Rates with Risk Adjustment)

Amerigroup - Bexar 626.60 1,659.50 0.00 0.00 1,413.61 0.00 386.58 1,929.05

Molina - Bexar 544.70 1,397.22 0.00 0.00 1,327.02 0.00 371.16 1,929.05

Superior - Bexar 643.28 1,462.64 0.00 0.00 1,524.46 0.00 503.81 1,929.05

Molina - Dallas 719.58 1,694.59 0.00 0.00 2,024.74 0.00 405.69 1,948.28

Superior - Dallas 691.22 1,849.77 0.00 0.00 2,208.12 0.00 435.57 1,948.28

Amerigroup - El Paso 659.50 1,696.53 0.00 0.00 2,949.65 0.00 611.53 1,150.26

Molina - El Paso 732.32 1,672.59 0.00 0.00 2,596.47 0.00 635.80 1,150.26

Amerigroup - Harris 728.87 1,908.16 0.00 0.00 1,563.09 0.00 389.93 2,007.40

Molina - Harris 671.50 1,895.28 0.00 0.00 1,511.68 0.00 392.03 2,007.40

United - Harris 825.67 1,885.24 0.00 0.00 1,758.78 0.00 439.42 2,007.40

Health Spring - Hidalgo 508.07 1,392.98 0.00 0.00 1,973.04 0.00 419.83 1,836.78

Molina - Hidalgo 529.68 1,477.59 0.00 0.00 2,172.56 0.00 483.47 1,836.78

Superior - Hidalgo 568.47 1,455.30 0.00 0.00 2,388.98 0.00 579.51 1,836.78

Amerigroup - Jefferson 618.01 1,911.39 0.00 0.00 1,454.37 0.00 417.66 2,063.96

Molina - Jefferson 626.55 1,713.37 0.00 0.00 1,291.24 0.00 395.85 2,063.96

United - Jefferson 738.49 1,805.93 0.00 0.00 1,538.32 0.00 440.90 2,063.96

Amerigroup - Lubbock 658.85 1,530.60 0.00 0.00 1,571.54 0.00 408.70 1,451.88

Superior - Lubbock 617.43 1,779.06 0.00 0.00 1,575.78 0.00 387.55 1,451.88

Superior - Nueces 577.74 1,302.53 0.00 0.00 1,211.92 0.00 527.13 1,624.85

United - Nueces 640.11 1,413.92 0.00 0.00 1,147.27 0.00 514.82 1,624.85

Amerigroup - Tarrant 694.78 1,670.53 0.00 0.00 1,560.10 0.00 397.48 1,638.07

Health Spring - Tarrant 590.51 1,581.37 0.00 0.00 1,360.87 0.00 328.95 1,638.07

Amerigroup - Travis 595.05 1,648.64 0.00 0.00 1,058.05 0.00 320.23 1,678.04

United - Travis 651.60 1,724.66 0.00 0.00 1,192.63 0.00 433.40 1,678.04

Superior - MRSA Central 630.05 1,458.07 0.00 0.00 1,150.68 0.00 467.59 2,205.78

United - MRSA Central 606.35 1,604.71 0.00 0.00 1,258.51 0.00 420.84 2,205.78

Health Spring - MRSA Northeast 563.54 1,477.75 0.00 0.00 1,445.86 0.00 391.85 2,099.95

United - MRSA Northeast 630.03 1,721.07 0.00 0.00 1,475.12 0.00 423.95 2,099.95

Amerigroup - MRSA West 586.88 1,726.89 0.00 0.00 1,405.73 0.00 432.05 1,753.49

Superior - MRSA West 613.71 1,507.15 0.00 0.00 1,457.15 0.00 417.71 1,753.49

28





FY2019 Long Term Care Premium Rates pmpm (Community Rates with Risk Adjustment)

Amerigroup - Bexar 234.85 2,011.99 395.96 2,119.64 4,571.17 4,093.08 0.00 0.00

Molina - Bexar 230.96 1,644.88 402.58 1,989.36 4,571.17 4,093.08 0.00 0.00

Superior - Bexar 321.11 2,018.56 459.44 2,087.13 4,571.17 4,093.08 0.00 0.00

Molina - Dallas 301.97 1,616.62 421.98 1,846.32 4,499.94 4,037.53 0.00 0.00

Superior - Dallas 238.02 1,596.35 379.94 1,895.56 4,499.94 4,037.53 0.00 0.00

Amerigroup - El Paso 278.81 1,724.56 522.75 1,972.31 5,018.23 4,201.58 0.00 0.00

Molina - El Paso 402.97 1,784.61 612.09 2,158.55 5,018.23 4,201.58 0.00 0.00

Amerigroup - Harris 234.94 2,089.30 353.65 2,159.07 4,748.34 3,954.73 0.00 0.00

Molina - Harris 261.95 1,995.38 370.98 2,153.05 4,748.34 3,954.73 0.00 0.00

United - Harris 316.06 2,064.16 412.25 2,174.87 4,748.34 3,954.73 0.00 0.00

Health Spring - Hidalgo 776.01 2,396.50 1,023.79 2,488.25 4,740.91 4,497.00 0.00 0.00

Molina - Hidalgo 697.02 2,328.82 899.83 2,449.64 4,740.91 4,497.00 0.00 0.00

Superior - Hidalgo 843.42 2,382.17 1,163.21 2,483.50 4,740.91 4,497.00 0.00 0.00

Amerigroup - Jefferson 174.79 1,684.24 308.92 1,784.71 4,308.81 3,767.63 0.00 0.00

Molina - Jefferson 210.27 1,419.99 303.06 1,631.22 4,308.81 3,767.63 0.00 0.00

United - Jefferson 169.40 1,396.27 201.12 1,519.28 4,308.81 3,767.63 0.00 0.00

Amerigroup - Lubbock 92.67 1,290.92 157.90 1,476.81 4,276.55 3,808.15 0.00 0.00

Superior - Lubbock 127.22 1,499.94 199.23 1,598.72 4,276.55 3,808.15 0.00 0.00

Superior - Nueces 383.77 1,938.42 571.25 2,150.10 4,344.98 4,105.12 0.00 0.00

United - Nueces 391.91 1,925.63 460.15 2,111.09 4,344.98 4,105.12 0.00 0.00

Amerigroup - Tarrant 166.00 1,781.52 324.03 1,800.70 4,171.29 3,826.12 0.00 0.00

Health Spring - Tarrant 210.72 1,792.08 279.47 1,823.41 4,171.29 3,826.12 0.00 0.00

Amerigroup - Travis 255.14 2,202.70 361.14 1,929.37 4,587.16 4,050.55 0.00 0.00

United - Travis 153.35 2,075.00 180.40 1,856.01 4,587.16 4,050.55 0.00 0.00

Superior - MRSA Central 167.13 1,913.02 230.43 1,807.45 4,249.20 3,890.22 0.00 0.00

United - MRSA Central 133.48 2,106.35 238.93 1,937.94 4,249.20 3,890.22 0.00 0.00

Health Spring - MRSA Northeast 169.34 1,809.71 228.90 1,735.55 4,451.44 3,961.94 0.00 0.00

United - MRSA Northeast 172.05 1,753.09 254.01 1,594.02 4,451.44 3,961.94 0.00 0.00

Amerigroup - MRSA West 123.27 1,970.33 281.77 1,662.72 4,395.44 3,844.63 0.00 0.00

Superior - MRSA West 171.81 1,754.71 287.82 1,579.01 4,395.44 3,844.63 0.00 0.00

29





FY2019 Prescription Drug Premium Rates pmpm (Community Rates with Risk Adjustment)

Amerigroup - Bexar 543.24 1,337.59 0.00 0.00 712.53 0.00 416.75 567.48

Molina - Bexar 472.24 1,126.18 0.00 0.00 668.89 0.00 400.13 567.48

Superior - Bexar 557.70 1,178.92 0.00 0.00 768.41 0.00 543.12 567.48

Molina - Dallas 453.24 879.51 0.00 0.00 524.20 0.00 350.26 454.99

Superior - Dallas 435.37 960.04 0.00 0.00 571.68 0.00 376.06 454.99

Amerigroup - El Paso 513.24 1,234.40 0.00 0.00 563.23 0.00 855.41 755.57

Molina - El Paso 569.91 1,216.98 0.00 0.00 495.79 0.00 889.37 755.57

Amerigroup - Harris 567.43 1,153.90 0.00 0.00 645.91 0.00 496.52 691.79

Molina - Harris 522.77 1,146.11 0.00 0.00 624.67 0.00 499.20 691.79

United - Harris 642.79 1,140.04 0.00 0.00 726.78 0.00 559.54 691.79

Health Spring - Hidalgo 537.84 1,055.02 0.00 0.00 443.80 0.00 392.94 653.46

Molina - Hidalgo 560.71 1,119.10 0.00 0.00 488.68 0.00 452.51 653.46

Superior - Hidalgo 601.79 1,102.22 0.00 0.00 537.35 0.00 542.40 653.46

Amerigroup - Jefferson 477.72 1,014.22 0.00 0.00 712.90 0.00 456.72 460.33




Superior - Lubbock 475.91 1,139.07 0.00 0.00 756.89 0.00 411.24 564.80

Superior - Nueces 516.49 921.04 0.00 0.00 573.32 0.00 536.99 563.32

United - Nueces 572.24 999.80 0.00 0.00 542.74 0.00 524.45 563.32

Amerigroup - Tarrant 557.82 1,194.25 0.00 0.00 792.96 0.00 489.52 616.86

Health Spring - Tarrant 474.10 1,130.51 0.00 0.00 691.70 0.00 405.13 616.86

Amerigroup - Travis 547.28 1,458.99 0.00 0.00 950.87 0.00 443.81 1,100.74

United - Travis 599.30 1,526.27 0.00 0.00 1,071.82 0.00 600.64 1,100.74

Superior - MRSA Central 491.70 1,043.12 0.00 0.00 543.29 0.00 489.53 1,092.56

United - MRSA Central 473.20 1,148.03 0.00 0.00 594.20 0.00 440.58 1,092.56

Health Spring - MRSA Northeast 438.74 1,002.72 0.00 0.00 767.77 0.00 432.57 572.40

United - MRSA Northeast 490.50 1,167.83 0.00 0.00 783.30 0.00 468.01 572.40

Amerigroup - MRSA West 482.95 1,144.91 0.00 0.00 671.50 0.00 473.91 463.37


30





FY2019 NAIP Rates pmpm


Molina - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Bexar 7.91 7.91 0.00 0.00 0.00 0.00 7.91 0.00

Molina - Dallas 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Dallas 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00

United - Harris 29.47 29.47 0.00 0.00 0.00 0.00 29.47 0.00


Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00







Superior - Nueces 37.82 37.82 0.00 0.00 0.00 0.00 37.82 0.00

United - Nueces 119.68 119.68 0.00 0.00 0.00 0.00 119.68 0.00




United - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00







31





FY2019 QIPP Rates pmpm


Molina - Bexar 0.00 0.00 0.00 0.00 630.85 630.85 0.00 0.00

Superior - Bexar 0.00 0.00 0.00 0.00 630.85 630.85 0.00 0.00

Molina - Dallas 0.00 0.00 0.00 0.00 647.63 647.63 0.00 0.00

Superior - Dallas 0.00 0.00 0.00 0.00 647.63 647.63 0.00 0.00


Molina - El Paso 0.00 0.00 0.00 0.00 109.32 109.32 0.00 0.00


Molina - Harris 0.00 0.00 0.00 0.00 552.42 552.42 0.00 0.00

United - Harris 0.00 0.00 0.00 0.00 552.42 552.42 0.00 0.00


Molina - Hidalgo 0.00 0.00 0.00 0.00 700.93 700.93 0.00 0.00







Superior - Nueces 0.00 0.00 0.00 0.00 584.39 584.39 0.00 0.00

United - Nueces 0.00 0.00 0.00 0.00 584.39 584.39 0.00 0.00




United - Travis 0.00 0.00 0.00 0.00 761.41 761.41 0.00 0.00







32





FY2019 UHRIP Rates pmpm


Molina - Bexar 113.42 278.38 0.00 0.00 242.06 0.00 38.40 379.53

Superior - Bexar 137.51 252.31 0.00 0.00 408.72 0.00 73.99 379.53

Molina - Dallas 186.57 403.54 0.00 0.00 527.94 0.00 74.70 530.78

Superior - Dallas 209.09 464.82 0.00 0.00 759.17 0.00 67.17 530.78


Molina - El Paso 147.46 321.09 0.00 0.00 791.49 0.00 170.51 182.37


Molina - Harris 114.27 390.22 0.00 0.00 428.57 0.00 52.15 365.77

United - Harris 153.42 244.15 0.00 0.00 284.89 0.00 43.93 365.77


Molina - Hidalgo 85.69 223.75 0.00 0.00 475.66 0.00 52.79 260.46







Superior - Nueces 127.75 289.45 0.00 0.00 366.42 0.00 69.40 373.07

United - Nueces 156.67 282.84 0.00 0.00 307.55 0.00 123.28 373.07




United - Travis 169.90 283.83 0.00 0.00 300.51 0.00 61.87 369.18







33





FY2019 Total Premium Rates pmpm

Amerigroup - Bexar 1,503.54 5,276.51 395.96 2,119.64 7,510.74 4,723.93 829.34 2,876.06

Molina - Bexar 1,361.32 4,446.66 402.58 1,989.36 7,439.99 4,723.93 809.69 2,876.06

Superior - Bexar 1,667.51 4,920.34 459.44 2,087.13 7,903.61 4,723.93 1,128.83 2,876.06

Molina - Dallas 1,661.36 4,594.26 421.98 1,846.32 8,224.45 4,685.16 830.65 2,934.05

Superior - Dallas 1,573.70 4,870.98 379.94 1,895.56 8,686.54 4,685.16 878.80 2,934.05

Amerigroup - El Paso 1,541.76 4,887.62 522.75 1,972.31 9,304.98 4,310.90 1,525.58 2,088.20

Molina - El Paso 1,852.66 4,995.27 612.09 2,158.55 9,011.30 4,310.90 1,695.68 2,088.20

Amerigroup - Harris 1,702.01 5,528.35 353.65 2,159.07 7,816.53 4,507.15 969.80 3,064.96

Molina - Harris 1,570.49 5,426.99 370.98 2,153.05 7,865.68 4,507.15 943.38 3,064.96

United - Harris 1,967.41 5,363.06 412.25 2,174.87 8,071.21 4,507.15 1,072.36 3,064.96

Health Spring - Hidalgo 1,886.02 5,022.97 1,023.79 2,488.25 8,118.26 5,197.93 841.04 2,750.70

Molina - Hidalgo 1,873.10 5,149.26 899.83 2,449.64 8,578.74 5,197.93 988.77 2,750.70

Superior - Hidalgo 2,101.44 5,133.19 1,163.21 2,483.50 8,784.66 5,197.93 1,174.99 2,750.70

Amerigroup - Jefferson 1,363.78 4,843.44 308.92 1,784.71 7,447.49 4,395.83 931.64 2,827.18

Molina - Jefferson 1,409.99 4,281.86 303.06 1,631.22 7,069.27 4,395.83 838.76 2,827.18

United - Jefferson 1,625.77 4,404.48 201.12 1,519.28 7,431.31 4,395.83 986.39 2,827.18

Amerigroup - Lubbock 1,486.46 4,144.66 157.90 1,476.81 7,891.51 4,566.08 944.42 2,416.63

Superior - Lubbock 1,399.01 4,910.47 199.23 1,598.72 7,829.56 4,566.08 861.77 2,416.63

Superior - Nueces 1,643.57 4,489.26 571.25 2,150.10 7,081.03 4,689.51 1,171.34 2,561.24

United - Nueces 1,880.61 4,741.87 460.15 2,111.09 6,926.93 4,689.51 1,282.23 2,561.24

Amerigroup - Tarrant 1,635.03 5,109.40 324.03 1,800.70 7,731.33 4,500.53 953.82 2,730.96

Health Spring - Tarrant 1,431.28 4,856.34 279.47 1,823.41 7,134.21 4,500.53 777.28 2,730.96

Amerigroup - Travis 1,512.19 5,664.03 361.14 1,929.37 7,700.09 4,811.96 813.38 3,147.96

United - Travis 1,574.15 5,609.76 180.40 1,856.01 7,913.53 4,811.96 1,095.91 3,147.96

Superior - MRSA Central 1,448.71 4,773.84 230.43 1,807.45 6,878.87 4,511.89 1,058.09 3,871.54

United - MRSA Central 1,381.52 5,186.52 238.93 1,937.94 6,973.79 4,511.89 937.73 3,871.54

Health Spring - MRSA Northeast 1,276.18 4,569.59 228.90 1,735.55 7,634.18 4,548.67 858.22 3,043.38

United - MRSA Northeast 1,400.20 4,872.38 254.01 1,594.02 7,545.72 4,548.67 940.79 3,043.38

Amerigroup - MRSA West 1,373.62 5,271.50 281.77 1,662.72 7,613.93 4,646.40 1,004.90 2,673.63

Superior - MRSA West 1,475.35 4,631.01 287.82 1,579.01 7,798.25 4,646.40 960.62 2,673.63

34





FY2019 Acute Care Premium Rate Change

Amerigroup - Bexar 7.1% 18.5% 0.0% 0.0% 1.2% 0.0% 1.8% 13.3%

Molina - Bexar 12.6% 18.3% 0.0% 0.0% -5.0% 0.0% 19.8% 13.3%

Superior - Bexar 7.4% 12.8% 0.0% 0.0% 9.1% 0.0% 13.6% 13.3%

Molina - Dallas 0.0% -7.1% 0.0% 0.0% 7.4% 0.0% 11.5% 1.2%

Superior - Dallas -0.9% -1.3% 0.0% 0.0% 17.1% 0.0% 18.8% 1.2%

Amerigroup - El Paso 7.1% 6.4% 0.0% 0.0% 61.3% 0.0% 18.5% -2.6%

Molina - El Paso 8.4% 12.7% 0.0% 0.0% 42.0% 0.0% 13.4% -2.6%

Amerigroup - Harris 2.7% -2.3% 0.0% 0.0% -0.6% 0.0% -0.6% 2.1%

Molina - Harris 1.0% 0.6% 0.0% 0.0% -3.8% 0.0% 0.3% 2.1%

United - Harris 1.3% 0.9% 0.0% 0.0% 11.9% 0.0% -1.3% 2.1%

Health Spring - Hidalgo -2.2% 11.9% 0.0% 0.0% 15.5% 0.0% 1.1% -3.0%

Molina - Hidalgo -5.1% 10.1% 0.0% 0.0% 27.2% 0.0% -6.2% -3.0%

Superior - Hidalgo -1.4% 5.3% 0.0% 0.0% 39.9% 0.0% 5.5% -3.0%

Amerigroup - Jefferson 4.7% -0.6% 0.0% 0.0% -3.4% 0.0% 11.9% -9.5%

Molina - Jefferson 3.6% 4.8% 0.0% 0.0% -14.2% 0.0% 12.9% -9.5%

United - Jefferson 3.6% -3.5% 0.0% 0.0% 2.2% 0.0% 7.6% -9.5%

Amerigroup - Lubbock 10.9% 4.9% 0.0% 0.0% 32.7% 0.0% 12.0% 6.2%

Superior - Lubbock 9.4% 6.1% 0.0% 0.0% 33.1% 0.0% -2.7% 6.2%

Superior - Nueces 2.2% 0.0% 0.0% 0.0% -14.1% 0.0% -6.3% -10.1%

United - Nueces 6.7% 1.7% 0.0% 0.0% -18.7% 0.0% -7.7% -10.1%

Amerigroup - Tarrant -7.3% 1.2% 0.0% 0.0% 4.4% 0.0% 0.1% -3.7%

Health Spring - Tarrant -2.5% 3.5% 0.0% 0.0% -9.0% 0.0% 1.8% -3.7%

Amerigroup - Travis 6.8% -3.1% 0.0% 0.0% 10.0% 0.0% 7.4% 0.4%

United - Travis 7.0% 2.2% 0.0% 0.0% 24.0% 0.0% 1.7% 0.4%

Superior - MRSA Central 4.7% 12.4% 0.0% 0.0% -3.0% 0.0% 9.9% -0.1%

United - MRSA Central 5.3% 9.4% 0.0% 0.0% 6.1% 0.0% -1.5% -0.1%

Health Spring - MRSA Northeast 2.1% 10.3% 0.0% 0.0% 6.2% 0.0% 11.1% 8.1%

United - MRSA Northeast 0.4% 9.1% 0.0% 0.0% 8.3% 0.0% 7.6% 8.1%

Amerigroup - MRSA West 4.2% 33.5% 0.0% 0.0% 6.4% 0.0% 12.1% 10.3%

Superior - MRSA West -0.2% 22.6% 0.0% 0.0% 10.2% 0.0% 8.6% 10.3%

35





FY2019 Long Term Care Premium Rate Change

Amerigroup - Bexar -3.5% 7.5% 8.0% 8.8% -5.9% -2.9% 0.0% 0.0%

Molina - Bexar -0.9% 0.7% 4.3% 4.3% -5.9% -2.9% 0.0% 0.0%

Superior - Bexar 9.0% 7.1% 5.4% 7.0% -5.9% -2.9% 0.0% 0.0%

Molina - Dallas 12.0% 0.5% 10.7% 3.8% -4.2% -3.2% 0.0% 0.0%

Superior - Dallas 6.8% 4.0% 7.0% 6.8% -4.2% -3.2% 0.0% 0.0%

Amerigroup - El Paso 6.0% 16.5% 8.1% 3.5% -2.0% -6.0% 0.0% 0.0%

Molina - El Paso 17.8% 12.9% 11.6% 8.1% -2.0% -6.0% 0.0% 0.0%

Amerigroup - Harris 0.4% 8.6% 1.4% 10.7% -0.1% -4.9% 0.0% 0.0%

Molina - Harris 6.5% 6.3% 6.4% 8.9% -0.1% -4.9% 0.0% 0.0%

United - Harris 5.4% 9.0% 9.5% 9.2% -0.1% -4.9% 0.0% 0.0%

Health Spring - Hidalgo -1.4% 13.3% 2.3% 8.5% -0.8% -1.6% 0.0% 0.0%

Molina - Hidalgo 0.6% 12.0% -0.2% 8.7% -0.8% -1.6% 0.0% 0.0%

Superior - Hidalgo 6.3% 12.4% 2.4% 8.5% -0.8% -1.6% 0.0% 0.0%

Amerigroup - Jefferson 5.6% 13.3% 12.7% 6.6% -4.5% -4.1% 0.0% 0.0%

Molina - Jefferson 9.9% 4.6% 16.7% 1.7% -4.5% -4.1% 0.0% 0.0%

United - Jefferson 3.7% 1.7% 24.4% -0.3% -4.5% -4.1% 0.0% 0.0%

Amerigroup - Lubbock -5.4% 14.1% 9.3% 5.4% -5.6% -3.3% 0.0% 0.0%

Superior - Lubbock 13.9% 14.0% 16.7% 8.6% -5.6% -3.3% 0.0% 0.0%

Superior - Nueces 5.4% 7.8% 3.6% 8.6% -2.0% -2.9% 0.0% 0.0%

United - Nueces 9.2% 6.2% 4.2% 8.4% -2.0% -2.9% 0.0% 0.0%

Amerigroup - Tarrant 9.6% 15.9% 15.4% 8.3% -6.3% -4.5% 0.0% 0.0%

Health Spring - Tarrant 9.3% 12.3% 19.4% 6.5% -6.3% -4.5% 0.0% 0.0%

Amerigroup - Travis -2.1% 13.8% 12.9% 8.1% -3.5% -2.1% 0.0% 0.0%

United - Travis -8.9% 9.3% -2.5% 6.1% -3.5% -2.1% 0.0% 0.0%

Superior - MRSA Central 7.1% -2.8% -1.2% 3.6% -1.9% -2.7% 0.0% 0.0%

United - MRSA Central 2.2% 2.5% 4.0% 6.7% -1.9% -2.7% 0.0% 0.0%

Health Spring - MRSA Northeast 9.6% 15.5% 6.6% 9.2% -1.8% -1.8% 0.0% 0.0%

United - MRSA Northeast 16.5% 8.9% 19.8% 6.2% -1.8% -1.8% 0.0% 0.0%

Amerigroup - MRSA West 6.3% 14.6% 12.0% 6.5% -0.2% -1.2% 0.0% 0.0%

Superior - MRSA West 19.8% 11.9% 13.6% 4.4% -0.2% -1.2% 0.0% 0.0%

36





FY2019 Prescription Drug Premium Rate Change

Amerigroup - Bexar 15.8% 24.3% 0.0% 0.0% 7.7% 0.0% -9.5% 26.0%

Molina - Bexar 21.8% 24.1% 0.0% 0.0% 1.1% 0.0% 6.5% 26.0%

Superior - Bexar 16.1% 18.4% 0.0% 0.0% 16.1% 0.0% 1.0% 26.0%

Molina - Dallas 14.5% 17.9% 0.0% 0.0% -4.5% 0.0% 11.6% 34.2%

Superior - Dallas 13.5% 25.3% 0.0% 0.0% 4.2% 0.0% 18.9% 34.2%

Amerigroup - El Paso 11.3% 18.7% 0.0% 0.0% 41.2% 0.0% 3.2% 14.9%

Molina - El Paso 12.7% 25.7% 0.0% 0.0% 24.3% 0.0% -1.2% 14.9%

Amerigroup - Harris 10.7% 9.2% 0.0% 0.0% -5.6% 0.0% 2.8% 63.4%

Molina - Harris 8.9% 12.5% 0.0% 0.0% -8.7% 0.0% 3.7% 63.4%

United - Harris 9.2% 12.8% 0.0% 0.0% 6.3% 0.0% 2.0% 63.4%

Health Spring - Hidalgo 3.7% 13.7% 0.0% 0.0% -28.0% 0.0% 6.0% 63.5%

Molina - Hidalgo 0.6% 11.9% 0.0% 0.0% -20.7% 0.0% -1.8% 63.5%

Superior - Hidalgo 4.5% 6.9% 0.0% 0.0% -12.8% 0.0% 10.5% 63.5%

Amerigroup - Jefferson 11.0% 5.4% 0.0% 0.0% -0.4% 0.0% 5.4% -25.0%

Molina - Jefferson 9.8% 11.2% 0.0% 0.0% -11.6% 0.0% 6.3% -25.0%

United - Jefferson 9.8% 2.4% 0.0% 0.0% 5.3% 0.0% 1.3% -25.0%

Amerigroup - Lubbock 11.4% 7.0% 0.0% 0.0% -3.7% 0.0% 16.7% 39.8%

Superior - Lubbock 9.9% 8.2% 0.0% 0.0% -3.4% 0.0% 1.4% 39.8%

Superior - Nueces 9.1% 5.4% 0.0% 0.0% -10.0% 0.0% 17.2% 41.8%

United - Nueces 14.0% 7.3% 0.0% 0.0% -14.8% 0.0% 15.4% 41.8%

Amerigroup - Tarrant 8.6% 4.1% 0.0% 0.0% 11.1% 0.0% -0.1% -2.0%

Health Spring - Tarrant 14.2% 6.5% 0.0% 0.0% -3.1% 0.0% 1.5% -2.0%

Amerigroup - Travis 17.7% 31.9% 0.0% 0.0% -2.7% 0.0% 7.6% 90.0%

United - Travis 17.9% 39.1% 0.0% 0.0% 9.6% 0.0% 2.0% 90.0%

Superior - MRSA Central 15.9% 30.5% 0.0% 0.0% -4.2% 0.0% 11.5% 77.7%

United - MRSA Central 16.5% 27.0% 0.0% 0.0% 4.8% 0.0% 0.0% 77.7%

Health Spring - MRSA Northeast 13.0% 16.2% 0.0% 0.0% 8.3% 0.0% -1.5% 30.2%

United - MRSA Northeast 11.1% 15.0% 0.0% 0.0% 10.5% 0.0% -4.6% 30.2%

Amerigroup - MRSA West 18.2% 25.1% 0.0% 0.0% -2.8% 0.0% 5.7% 41.5%

Superior - MRSA West 13.2% 14.9% 0.0% 0.0% 0.7% 0.0% 2.4% 41.5%

37





FY2019 NAIP Premium Rate Change

Amerigroup - Bexar 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Molina - Bexar 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Bexar -0.8% -0.8% 0.0% 0.0% 0.0% 0.0% -0.8% 0.0%

Molina - Dallas 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Dallas 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


Molina - El Paso 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Harris 9.8% 9.8% 0.0% 0.0% 0.0% 0.0% 9.8% 0.0%

Molina - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Harris -5.4% -5.4% 0.0% 0.0% 0.0% 0.0% -5.4% 0.0%

Health Spring - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Molina - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Hidalgo 0.6% 0.6% 0.0% 0.0% 0.0% 0.0% 0.6% 0.0%

Amerigroup - Jefferson 9.7% 9.7% 0.0% 0.0% 0.0% 0.0% 9.7% 0.0%

Molina - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Jefferson -5.5% -5.5% 0.0% 0.0% 0.0% 0.0% -5.5% 0.0%


Superior - Lubbock -2.3% -2.3% 0.0% 0.0% 0.0% 0.0% -2.3% 0.0%

Superior - Nueces 2.4% 2.4% 0.0% 0.0% 0.0% 0.0% 2.4% 0.0%

United - Nueces 1.3% 1.3% 0.0% 0.0% 0.0% 0.0% 1.3% 0.0%

Amerigroup - Tarrant 7.1% 7.1% 0.0% 0.0% 0.0% 0.0% 7.1% 0.0%

Health Spring - Tarrant 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - MRSA Central -0.2% -0.2% 0.0% 0.0% 0.0% 0.0% -0.2% 0.0%




Amerigroup - MRSA West 3.8% 3.8% 0.0% 0.0% 0.0% 0.0% 3.8% 0.0%

Superior - MRSA West -1.8% -1.8% 0.0% 0.0% 0.0% 0.0% -1.8% 0.0%

38





FY2019 QIPP Premium Rate Change

Amerigroup - Bexar 0.0% 0.0% 0.0% 0.0% -1.1% -1.1% 0.0% 0.0%

Molina - Bexar 0.0% 0.0% 0.0% 0.0% -1.1% -1.1% 0.0% 0.0%

Superior - Bexar 0.0% 0.0% 0.0% 0.0% -1.1% -1.1% 0.0% 0.0%

Molina - Dallas 0.0% 0.0% 0.0% 0.0% 1.1% 1.1% 0.0% 0.0%

Superior - Dallas 0.0% 0.0% 0.0% 0.0% 1.1% 1.1% 0.0% 0.0%


Molina - El Paso 0.0% 0.0% 0.0% 0.0% 79.3% 79.3% 0.0% 0.0%

Amerigroup - Harris 0.0% 0.0% 0.0% 0.0% 4.1% 4.1% 0.0% 0.0%

Molina - Harris 0.0% 0.0% 0.0% 0.0% 4.1% 4.1% 0.0% 0.0%

United - Harris 0.0% 0.0% 0.0% 0.0% 4.1% 4.1% 0.0% 0.0%

Health Spring - Hidalgo 0.0% 0.0% 0.0% 0.0% 25.0% 25.0% 0.0% 0.0%

Molina - Hidalgo 0.0% 0.0% 0.0% 0.0% 25.0% 25.0% 0.0% 0.0%


Amerigroup - Jefferson 0.0% 0.0% 0.0% 0.0% 11.3% 11.3% 0.0% 0.0%

Molina - Jefferson 0.0% 0.0% 0.0% 0.0% 11.3% 11.3% 0.0% 0.0%

United - Jefferson 0.0% 0.0% 0.0% 0.0% 11.3% 11.3% 0.0% 0.0%


Superior - Lubbock 0.0% 0.0% 0.0% 0.0% 6.4% 6.4% 0.0% 0.0%

Superior - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Tarrant 0.0% 0.0% 0.0% 0.0% 9.3% 9.3% 0.0% 0.0%

Health Spring - Tarrant 0.0% 0.0% 0.0% 0.0% 9.3% 9.3% 0.0% 0.0%

Amerigroup - Travis 0.0% 0.0% 0.0% 0.0% -3.0% -3.0% 0.0% 0.0%

United - Travis 0.0% 0.0% 0.0% 0.0% -3.0% -3.0% 0.0% 0.0%

Superior - MRSA Central 0.0% 0.0% 0.0% 0.0% 6.3% 6.3% 0.0% 0.0%




Amerigroup - MRSA West 0.0% 0.0% 0.0% 0.0% -4.8% -4.8% 0.0% 0.0%

Superior - MRSA West 0.0% 0.0% 0.0% 0.0% -4.8% -4.8% 0.0% 0.0%

39





FY2019 UHRIP Premium Rate Change

Amerigroup - Bexar 56.5% 123.7% 0.0% 0.0% 0.7% 0.0% -7.7% 75.1%

Molina - Bexar 66.4% 119.5% 0.0% 0.0% 95.4% 0.0% -23.7% 75.1%

Superior - Bexar 70.1% 63.8% 0.0% 0.0% 96.1% 0.0% 124.1% 75.1%

Molina - Dallas 2.8% 22.7% 0.0% 0.0% 21.6% 0.0% 83.7% 9.2%

Superior - Dallas 8.5% 22.2% 0.0% 0.0% 16.0% 0.0% 27.7% 9.2%


Molina - El Paso 69.5% 106.0% 0.0% 0.0% 243.1% 0.0% 443.4% 58.7%

Amerigroup - Harris 2.1% -9.1% 0.0% 0.0% -21.2% 0.0% 13.4% 5.7%

Molina - Harris -10.6% 32.5% 0.0% 0.0% 74.1% 0.0% -2.4% 5.7%

United - Harris 11.5% 12.5% 0.0% 0.0% 17.0% 0.0% -10.2% 5.7%

Health Spring - Hidalgo -1.4% 20.5% 0.0% 0.0% 42.7% 0.0% 26.9% 0.7%

Molina - Hidalgo -0.8% 9.1% 0.0% 0.0% 46.3% 0.0% 10.8% 0.7%

Superior - Hidalgo 5.0% 10.0% 0.0% 0.0% -0.6% 0.0% -20.9% 0.7%

Amerigroup - Jefferson -5.1% -21.2% 0.0% 0.0% 11.6% 0.0% 141.5% -28.6%

Molina - Jefferson -28.1% -2.8% 0.0% 0.0% -44.5% 0.0% -54.6% -28.6%

United - Jefferson -19.9% -43.8% 0.0% 0.0% -49.2% 0.0% -41.8% -28.6%

Amerigroup - Lubbock 24.0% -19.9% 0.0% 0.0% 52.5% 0.0% 27.9% 13.8%

Superior - Lubbock 15.8% 24.5% 0.0% 0.0% 40.2% 0.0% -14.3% 13.8%

Superior - Nueces 7.5% 14.5% 0.0% 0.0% 12.3% 0.0% -26.7% -6.2%

United - Nueces 8.4% 0.7% 0.0% 0.0% -36.3% 0.0% 2.2% -6.2%

Amerigroup - Tarrant -4.4% 1.3% 0.0% 0.0% -6.1% 0.0% -1.4% 1.0%

Health Spring - Tarrant 19.6% 3.1% 0.0% 0.0% -10.0% 0.0% 4.8% 1.0%

Amerigroup - Travis 1844.4% 2801.6% 0.0% 0.0% 1084.2% 0.0% 3211.4% 2053.9%

United - Travis 2266.3% 3092.7% 0.0% 0.0% 2387.7% 0.0% 877.4% 2053.9%

Superior - MRSA Central -11.5% -1.8% 0.0% 0.0% -29.3% 0.0% 7.4% -14.0%

United - MRSA Central -7.7% -6.7% 0.0% 0.0% -13.6% 0.0% -33.7% -14.0%

Health Spring - MRSA Northeast 12.8% 26.6% 0.0% 0.0% 9.9% 0.0% -9.3% 21.3%


Amerigroup - MRSA West 7.5% 26.4% 0.0% 0.0% -2.6% 0.0% -5.2% 11.1%

Superior - MRSA West -0.4% 29.5% 0.0% 0.0% 1.9% 0.0% -8.8% 11.1%

40





FY2019 Total Premium Rate Change

Amerigroup - Bexar 10.5% 18.1% 8.0% 8.8% -2.9% -2.6% -4.5% 21.4%

Molina - Bexar 16.1% 15.6% 4.3% 4.3% -3.1% -2.6% 10.1% 21.4%

Superior - Bexar 14.0% 13.4% 5.4% 7.0% 1.8% -2.6% 10.5% 21.4%

Molina - Dallas 6.1% 1.9% 10.7% 3.8% 0.2% -2.6% 15.7% 6.7%

Superior - Dallas 5.1% 6.9% 7.0% 6.8% 3.1% -2.6% 19.5% 6.7%

Amerigroup - El Paso 10.8% 15.1% 8.1% 3.5% 20.7% -4.8% 10.7% 6.9%

Molina - El Paso 15.0% 19.2% 11.6% 8.1% 18.0% -4.8% 13.6% 6.9%

Amerigroup - Harris 5.0% 3.5% 1.4% 10.7% -1.4% -3.9% 2.1% 12.0%

Molina - Harris 3.4% 6.9% 6.4% 8.9% 1.0% -3.9% 1.9% 12.0%

United - Harris 5.1% 6.8% 9.5% 9.2% 3.7% -3.9% -0.1% 12.0%

Health Spring - Hidalgo -0.2% 13.3% 2.3% 8.5% 3.5% 1.3% 4.1% 7.8%

Molina - Hidalgo -1.1% 11.3% -0.2% 8.7% 7.4% 1.3% -3.4% 7.8%


Amerigroup - Jefferson 6.2% 3.8% 12.7% 6.6% -2.1% -2.1% 11.8% -14.8%

Molina - Jefferson 3.6% 5.6% 16.7% 1.7% -7.9% -2.1% 7.6% -14.8%

United - Jefferson 3.3% -4.1% 24.4% -0.3% -3.4% -2.1% 1.0% -14.8%

Amerigroup - Lubbock 11.3% 5.5% 9.3% 5.4% 4.4% -1.8% 15.1% 13.9%

Superior - Lubbock 10.5% 10.5% 16.7% 8.6% 3.8% -1.8% -1.6% 13.9%

Superior - Nueces 5.4% 5.3% 3.6% 8.6% -4.2% -2.5% 1.6% -1.6%

United - Nueces 9.1% 4.6% 4.2% 8.4% -8.2% -2.5% 2.5% -1.6%

Amerigroup - Tarrant -0.3% 6.6% 15.4% 8.3% -1.4% -2.6% -0.1% -2.5%

Health Spring - Tarrant 6.5% 7.3% 19.4% 6.5% -5.4% -2.6% 1.8% -2.5%

Amerigroup - Travis 17.3% 19.1% 12.9% 8.1% 2.6% -2.2% 14.2% 38.9%

United - Travis 21.8% 19.6% -2.5% 6.1% 5.7% -2.2% 7.3% 38.9%

Superior - MRSA Central 6.3% 7.7% -1.2% 3.6% -3.3% -1.6% 10.4% 11.0%

United - MRSA Central 6.7% 8.6% 4.0% 6.7% 0.2% -1.6% -4.6% 11.0%

Health Spring - MRSA Northeast 7.5% 14.5% 6.6% 9.2% 1.6% -1.1% 3.5% 13.2%

United - MRSA Northeast 6.7% 10.7% 19.8% 6.2% 2.1% -1.1% 2.5% 13.2%

Amerigroup - MRSA West 9.3% 23.4% 12.0% 6.5% 0.1% -1.9% 7.4% 14.9%

Superior - MRSA West 6.1% 17.0% 13.6% 4.4% 1.3% -1.9% 4.0% 14.9%

41

Attachment 1 - Exhibit B


Projected PMPM Projected FY2019 Premium

FY2018 Rates FY2019 Rates FY2018 Rates FY2019 Rates % Rate Change

Non-Nursing Facility

Medical (1) 854.88 898.11 4,819,503,915 5,063,176,313 5.1%

Pharmacy 243.26 271.54 1,371,423,661 1,530,824,006 11.6%

NAIP 5.74 5.79 32,355,459 32,647,329 0.9%

UHRIP 63.07 72.16 355,539,506 406,808,704 14.4%

Total 1,166.95 1,247.59 6,578,822,542 7,033,456,352 6.9%

Nursing Facility

Medical (1) 4,324.85 4,214.63 2,562,384,570 2,497,076,743 -2.5%

Pharmacy 78.57 80.24 46,551,758 47,537,865 2.1%

QIPP 625.81 647.56 370,778,643 383,663,144 3.5%

UHRIP 40.15 45.38 23,786,502 26,884,892 13.0%

Total 5,069.38 4,987.80 3,003,501,474 2,955,162,644 -1.6%

Total - Excluding MBCCP

Medical (1) 1,184.88 1,213.51 7,381,888,486 7,560,253,056 2.4%

Pharmacy 227.60 253.34 1,417,975,420 1,578,361,871 11.3%

NAIP & QIPP 64.71 66.82 403,134,102 416,310,473 3.3%

UHRIP 60.89 69.61 379,326,008 433,693,596 14.3%

Total 1,538.07 1,603.29 9,582,324,016 9,988,618,996 4.2%

MBCCP

Medical 1,810.77 1,834.05 94,172,546 95,383,452 1.3%

Pharmacy 463.23 647.83 24,091,002 33,691,832 39.9%

NAIP & QIPP 0.00 0.00 0 0 0.0%

UHRIP 333.81 380.34 17,360,354 19,780,434 13.9%

Total 2,607.80 2,862.22 135,623,902 148,855,718 9.8%

Total - Including MBCCP

Medical (1) 1,190.06 1,218.64 7,476,061,032 7,655,636,508 2.4%

Pharmacy 229.55 256.61 1,442,066,422 1,612,053,703 11.8%

NAIP & QIPP 64.17 66.27 403,134,102 416,310,473 3.3%

UHRIP 63.15 72.19 396,686,362 453,474,030 14.3%

Total 1,546.93 1,613.71 9,717,947,918 10,137,474,715 4.3%

Notes:

(1) Includes LTSS.

42

43

Attachment 2

Individual Health Plan Experience Analysis

The following exhibits present a summary of the experience analysis performed for each health

plan. The exhibits in this section use hypothetical experience data from a sample health plan.

The actual analysis is based on experience data provided by each health plan. This data was

checked for reasonableness by comparing to other data sources provided by HHSC, the EQRO

and the health plan. Below is a brief description of each of the exhibits contained in this

attachment.

Exhibit A. This exhibit shows a sample of the monthly enrollment by risk group for the period

September 2014 through February 2018. All of this information was provided by HHSC.

Exhibit B. This exhibit shows a sample of a claim lag report for one risk group. This report

includes claim amounts by payment month and month of service. We analyzed claims

experience for the period September 2014 through February 2018. This information was

provided by the MCO and reconciled with the audited FSRs and certified encounter data.

Exhibit C. This exhibit shows the calculation of estimated monthly incurred claims for one risk

group. The report includes the following information: (i) monthly enrollment, (ii) claim amounts

incurred in that month and paid through February 28, 2018, (iii) estimated proportion of that

month’s incurred claims paid through February 28, 2018 (completion factor), (iv) estimated

incurred claims, (v) estimated incurred claims pmpm and (vi) the ratio of this month’s incurred

claims pmpm to the same statistic from one year ago (trend factor). The assumed completion

factors and estimated incurred claims were derived based on the actual historical claims payment

pattern of the health plan.

Exhibit D. This exhibit is a summary of the sample health plan’s projected FY2019 cost based

on the health plan’s actual experience. The top of the exhibit shows summary base period

(FY2017) enrollment, premium and claims experience. Next are projected FY2019 enrollment

and premium based on current rates. Trend assumptions for FY2018 and FY2019 are used to

project the average base period claims cost to FY2019. Adjustment factors are used to recognize

the cost impact of benefit and provider reimbursement changes. Combining these factors results

in projected FY2019 incurred claims.

In addition to incurred claims, provision is also made for services that are capitated by the health

plan, such as vision and behavioral health services. Other expenses such as those related to the

coordination of care are included. The cost of reinsurance is also considered. In developing the

cost of reinsurance, an assumption is made regarding how much the health plan is expected to

receive in reinsurance recoveries (reimbursements from the reinsurance company for large

claims). We have assumed that the net cost of reinsurance (reinsurance premium less

reinsurance recoveries) is the minimum of (a) the actual reinsurance premium rate and (b) $0.50

pmpm.

A provision for administrative expenses is included in the amount of $20.00 pmpm and 5.75% of

gross premium. Additional provisions are also included for premium tax (1.75% of premium),

maintenance tax ($0.06 pmpm) and risk margin (1.75% of premium).

44

At the bottom of Exhibit D is a summary of the projected FY2019 cost based on the above

assumptions. Cost projections are presented separately for acute care and long term care

services.


Sample HMO

Enrollment and Premium Experience

Number of Members

Total

Month OCC HCBS OCC HCBS Members

Sep-14 2,508 161 5,000 783 8,452

Oct-14 2,485 165 4,990 790 8,430

Nov-14 2,468 173 4,953 796 8,390

Dec-14 2,448 176 4,918 796 8,338

Jan-15 2,423 176 4,917 781 8,297

Feb-15 2,385 181 4,929 773 8,268

Mar-15 2,416 184 5,070 765 8,435

Apr-15 2,411 189 4,690 765 8,055

May-15 2,398 195 4,398 713 7,704

Jun-15 2,398 202 4,083 685 7,368

Jul-15 2,381 206 3,724 648 6,959

Aug-15 2,368 209 3,309 572 6,458

Sep-15 2,351 211 3,372 615 6,549

Oct-15 2,346 209 3,424 617 6,596

Nov-15 2,354 211 3,484 626 6,675

Dec-15 2,334 209 3,489 628 6,660

Jan-16 2,327 213 3,434 617 6,591

Feb-16 2,326 214 3,475 617 6,632

Mar-16 2,306 221 3,516 622 6,665

Apr-16 2,296 220 3,532 639 6,687

May-16 2,294 216 3,576 638 6,724

Jun-16 2,288 218 3,597 644 6,747

Jul-16 2,256 231 3,617 646 6,750

Aug-16 2,245 230 3,613 653 6,741

Sep-16 2,213 237 3,606 653 6,709

Oct-16 2,189 238 3,588 666 6,681

Nov-16 2,128 238 3,611 665 6,642

Dec-16 2,117 241 3,576 662 6,596

Jan-17 2,116 239 3,339 625 6,319

Feb-17 2,147 240 3,384 630 6,401

Mar-17 2,140 241 3,385 633 6,399

Apr-17 2,191 249 3,414 627 6,481

May-17 2,185 250 3,446 635 6,516

Jun-17 2,194 253 3,465 648 6,560

Jul-17 2,183 258 3,469 654 6,564

Aug-17 2,177 259 3,407 645 6,488

Sep-17 2,183 257 3,401 647 6,489

Oct-17 2,185 254 3,397 634 6,470

Nov-17 2,179 251 3,415 635 6,480

Dec-17 2,245 268 3,426 626 6,565

Jan-18 2,314 270 3,385 626 6,595

Feb-18 2,353 275 3,405 616 6,649

FY2015 29,089 2,217 54,981 8,867 95,154

FY2016 27,723 2,603 42,129 7,562 80,017

FY2017 25,980 2,943 41,690 7,743 78,356

Medicaid Only Dual Eligible

45


Sample HMO

Claims Lag Report

Month

Incurred Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17

Sep-15 (6,948) (640) (2,433) 0 0 3,895 0 0 0 0 (31) (126) 0 0 0 0

Oct-15 280 147 (1,483) 0 (5,721) 0 0 (347) 0 (476) 0 (259) (445) (237) (71) 0

Nov-15 (15) 700 (1,578) (144) (1,398) (75) 1,922 0 625 (156) (576) (9) (234) (127) (114) 0

Dec-15 780 (516) (4,707) (5,474) (635) 4,095 0 0 0 (300) 0 (50) (8) (307) (254) 0

Jan-16 1,057 (8,968) (731) (4,053) (2,346) 4,510 (976) (1,965) 0 (29) 0 0 (11,760) (11) 11,760 0

Feb-16 1,495 2,703 (3,725) (31) 29 (2,107) 0 0 0 0 (68) (62) (40) (94) 0 0

Mar-16 1,289 1,009 (1,406) (347) 111 0 11,670 (10) (1,177) 0 0 (54) (56) 196 0 (306)

Apr-16 11,328 1,079 (1,425) 889 (87) (409) 16,692 (1,967) (687) 186 0 0 (24) 175 (50) 0

May-16 24,121 3,996 3,841 431 (756) 0 7,770 86 0 0 0 (47) 0 (147) (29) 0

Jun-16 214,125 89,705 (10,428) 3,012 (136) (605) 17,986 (405) 0 0 2,026 (120) 15,437 191 (924) (9)

Jul-16 85,767 19,905 3,341 8,393 366 7,653 222,027 532 0 325 (363) (269) (5) (989) (22) 1,575

Aug-16 515,992 45,279 31,104 7,204 8,179 4,042 14,949 154 (1,902) (48) (2,036) 133 (152) 1,077 (413) 42

Sep-16 420,956 527,285 118,771 13,072 9,146 4,202 9,024 (138) 1,519 (31) (4,398) (29) (1,373) 1,725 8 0

Oct-16 366,805 580,643 50,421 47,245 21,548 13,069 3,699 (519) (3,259) 113 (46) 302 1,997 0 370

Nov-16 290,745 398,673 95,554 16,195 20,246 4,568 2,171 2,687 131 (569) 24 1,453 0 0

Dec-16 266,223 541,585 162,229 26,164 8,786 754 210 203 564 524 703 0 865

Jan-17 286,175 566,875 127,294 34,133 10,425 21,331 3,061 (2,071) 8,846 (5,979) (89) 2,829

Feb-17 262,333 575,508 62,470 24,846 1,595 59 4,335 (805) (4,461) 21 42

Mar-17 447,209 653,329 99,671 25,546 26,147 4,438 279 (3,374) 229 33

Apr-17 311,194 540,258 102,519 91,683 11,888 (2,611) 2,762 (1,308) (502)

May-17 376,204 826,943 130,552 42,405 20,623 (26,821) 24,375 533

Jun-17 499,731 663,507 78,233 9,442 4,727 4,228 10,899

Jul-17 392,051 667,940 109,727 59,767 5,643 585

Aug-17 520,387 615,708 68,358 31,946 12,034

Sep-17 322,424 621,498 70,785 33,929

Oct-17 482,157 757,503 358,642

Nov-17 339,678 714,735

Dec-17 383,606

Jan-18

Feb-18

1,257,031 1,036,761 986,307 732,442 973,403 1,055,667 1,509,606 1,072,934 1,049,750 1,471,517 1,302,054 1,324,479 1,086,932 1,204,107 1,242,848 1,519,230

46

Attachment 2 - Exhibit C

Sample HMO

Estimated Claims Experience

Acute Care - Medicaid Only OCC

Inc & Pd Compl Est Inc Est Inc

Month Members Claims Factor Claims pmpm Trend

Sep-14 2,508 952,351 1.000 952,351 379.73

Oct-14 2,485 885,150 1.000 885,150 356.20

Nov-14 2,468 811,982 1.000 811,982 329.00

Dec-14 2,448 1,106,853 1.000 1,106,853 452.15

Jan-15 2,423 1,243,665 1.000 1,243,665 513.27

Feb-15 2,385 958,105 1.000 958,105 401.72

Mar-15 2,416 1,133,905 1.000 1,133,905 469.33

Apr-15 2,411 1,204,904 1.000 1,204,904 499.75

May-15 2,398 1,261,776 1.000 1,261,776 526.18

Jun-15 2,398 1,247,116 1.000 1,247,116 520.07

Jul-15 2,381 1,042,119 1.000 1,042,119 437.68

Aug-15 2,368 957,152 1.000 957,152 404.20

Sep-15 2,351 884,487 1.000 884,487 376.22 0.991

Oct-15 2,346 992,525 1.000 992,525 423.07 1.188

Nov-15 2,354 1,136,483 1.000 1,136,483 482.79 1.467

Dec-15 2,334 1,346,358 1.000 1,346,358 576.85 1.276

Jan-16 2,327 1,181,548 1.000 1,181,548 507.76 0.989

Feb-16 2,326 956,772 1.000 956,772 411.34 1.024

Mar-16 2,306 1,025,694 1.000 1,025,694 444.79 0.948

Apr-16 2,296 1,113,048 1.000 1,113,048 484.78 0.970

May-16 2,294 1,065,403 1.000 1,065,403 464.43 0.883

Jun-16 2,288 1,469,382 1.000 1,469,382 642.21 1.235

Jul-16 2,256 1,296,115 1.000 1,296,115 574.52 1.313

Aug-16 2,245 1,040,121 1.000 1,040,121 463.31 1.146

Sep-16 2,213 1,099,609 1.000 1,099,609 496.89 1.321

Oct-16 2,189 1,068,903 1.000 1,068,903 488.31 1.154

Nov-16 2,128 831,980 1.000 831,980 390.97 0.810

Dec-16 2,117 1,010,358 1.000 1,010,358 477.26 0.827

Jan-17 2,116 1,054,092 1.000 1,054,092 498.15 0.981

Feb-17 2,147 926,231 1.000 926,231 431.41 1.049

Mar-17 2,140 1,254,930 1.000 1,254,930 586.42 1.318

Apr-17 2,191 1,057,321 0.998 1,059,440 483.54 0.997

May-17 2,185 1,397,811 0.998 1,400,612 641.01 1.380

Jun-17 2,194 1,270,092 0.999 1,271,363 579.47 0.902

Jul-17 2,183 1,234,810 0.998 1,237,285 566.78 0.987

Aug-17 2,177 1,249,639 0.998 1,252,143 575.17 1.241

Sep-17 2,183 1,265,768 0.995 1,272,129 582.61 1.173

Oct-17 2,185 1,623,689 0.995 1,631,848 746.76 1.529

Nov-17 2,179 1,199,479 0.981 1,222,710 561.23 1.435

Dec-17 2,245 1,128,058 0.953 1,183,692 527.28 1.105

FY2015 29,089 12,805,078 12,805,078 440.20

FY2016 27,723 13,507,936 13,507,936 487.25 1.107

FY2017 25,980 13,455,776 13,466,946 518.36 1.064

47

Attachment 2 - Exhibit D

Sample HMO

Experienced Based Renewal Rating

Amount pmpm Amount pmpm

FY2017 Experience Period

Member Months 25,980 2,943

Estimated FY2017 Incurred Claims

Acute Care 13,466,946 518.36 4,021,241 1,366.37

Long Term Care 3,804,853 146.45 3,132,805 1,064.49

Total 17,271,799 664.81 7,154,046 2,430.87

Projected FY2019 Member Months 26,119 3,043

Projected FY2019 Premium

At Current Rates 18,716,936 716.61 8,563,724 2,813.83

Annual Cost Trend Assumptions

Acute Care

FY2018 2.2 % 2.0 %

FY2019 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 %

FY2019 5.0 % 1.4 %

Provider Reimbursement Adjustment

Acute Care - Non Inpatient 0.9800 0.9905

Acute Care - Inpatient 1.0087 1.0065

Long Term Care 1.0000 1.0000

Other Reimbursement Adjustment 1.0033 1.0000

Projected Incurred Claims

Acute Care 13,942,652 533.82 4,279,407 1,406.11

LTC 4,239,225 162.31 3,363,921 1,105.30

Total 18,181,877 696.12 7,643,328 2,511.41

Capitation Expenses

Vision 9,142 0.35 4,504 1.48

Behavioral Health 0 0.00 0 0.00

PCP 0 0.00 0 0.00

Other - Settlements 31,081 1.19 13,269 4.36

Total 40,223 1.54 17,774 5.84

Medicaid Only - OCC Medicaid Only - HCBS

48


Sample HMO

Experienced Based Renewal Rating

Amount pmpm Amount pmpm

Medicaid Only - OCC Medicaid Only - HCBS

Other Expenses

Service Coordination 1,103,516 42.25 128,585 42.25

Other 0 0.00 105,090 34.53

Total 1,103,516 42.25 233,675 76.78

Reinsurance Expenses

Gross Premium 79,662 3.05 9,282 3.05

Projected Reinsurance Recoveries 66,603 2.55 7,761 2.55

Net Reinsurance Cost 13,059 0.50 1,522 0.50

Administrative Expenses

Fixed Amount 522,374 20.00 60,869 20.00

Percentage of Premium 1,258,513 5.75% 504,185 5.75%

Total 1,780,887 68.18 565,054 21.63

Risk Margin 383,026 1.75% 153,448 1.75%

Premium Tax 383,026 1.75% 153,448 1.75%

Maintenance Tax 1,567 0.06 183 0.06

Projected Total Cost

Acute Care 15,865,251 607.43 4,774,528 1,568.79

LTC 6,021,930 230.56 3,993,902 1,312.30

Total 21,887,181 837.99 8,768,431 2,881.09

49

50

Attachment 3

Community Experience Analysis – Medical

The following exhibits present a summary of the acute care and long term care experience

analysis performed for each managed care service area. HHSC utilizes an adjusted community

rating methodology in setting the STAR+PLUS premium rates. The base community rates by

risk group vary by service area but are the same for each health plan in a service area. The

community rates are developed by a weighted average of the projected FY2019 cost for each

health plan in the service area. The weights used in this formula are the projected number of

FY2019 clients enrolled in each health plan.

Below is a brief description of the exhibits contained in this attachment. The exhibits present the

derivation of the FY2019 STAR+PLUS community rates for the following service areas:

Exhibit A.1 – Bexar Service Area

Exhibit B.1 – Dallas Service Area

Exhibit C.1 – El Paso Service Area

Exhibit D.1 – Harris Service Area

Exhibit E.1 – Hidalgo Service Area

Exhibit F.1 – Jefferson Service Area

Exhibit G.1 – Lubbock Service Area

Exhibit H.1 – Nueces Service Area

Exhibit I.1 – Tarrant Service Area

Exhibit J.1 – Travis Service Area

Exhibit K.1 – MRSA Central Service Area

Exhibit L.1 – MRSA Northeast Service Area

Exhibit M.1 – MRSA West Service Area

These exhibits show projected FY2019 experience for each of the service areas. These amounts

were derived by summing amounts from each individual health plan in the service area. The

experience analysis for individual health plans is described in Attachment 2. The top portion of

the exhibit shows summary base period (FY2017) experience and projected FY2019 enrollment,

and incurred claims experience.

In addition to incurred claims, provision is also made for services that are capitated by the health

plans, such as vision and behavioral health services. Other expenses such as those related to the

coordination of care are also included.

The cost of reinsurance is also considered. In developing the cost of reinsurance we make an

assumption regarding how much the health plan is expected to receive in reinsurance recoveries

(reimbursements from the reinsurance company for large claims). We have assumed that the net

cost of reinsurance (reinsurance premium less reinsurance recoveries) is the minimum of (a) the

actual reinsurance premium rate and (b) $0.50 pmpm.

A provision for administrative expenses is included in the amount of $20.00 pmpm and 5.75% of

51

gross premium. Additional provisions are also included for premium tax (1.75% of premium),

maintenance tax ($0.06 pmpm) and risk margin (1.75% of premium).

The bottom of the exhibit shows a summary of the projected FY2019 cost based on these

assumptions. Cost projections are presented separately for acute care and long term care services.

Long term care services are carved out of managed care for the IDD risk group. As a result,

these services are not included in the rate development for this risk group and the premium is for

acute care services only.

Community Experience Analysis – Pharmacy

The following exhibits present a summary of the pharmacy experience analysis performed for

each STAR+PLUS service area for pharmacy services. As with medical, HHSC utilizes a

community rating methodology in setting the pharmacy capitation rates. The base community

rates by risk group vary by service area but are the same for each health plan in a service area.

Below is a brief description of the exhibits contained in this attachment. The exhibits present the

derivation of the FY2019 STAR+PLUS pharmacy community capitation rates for the following

service areas:

Exhibit A.2 – Bexar Service Area

Exhibit B.2 – Dallas Service Area

Exhibit C.2 – El Paso Service Area

Exhibit D.2 – Harris Service Area

Exhibit E.2 – Hidalgo Service Area

Exhibit F.2 – Jefferson Service Area

Exhibit G.2 – Lubbock Service Area

Exhibit H.2 – Nueces Service Area

Exhibit I.2 – Tarrant Service Area

Exhibit J.2 – Travis Service Area

Exhibit K.2 – MRSA Central Service Area

Exhibit L.2 – MRSA Northeast Service Area

Exhibit M.2 – MRSA West Service Area

These exhibits present projected FY2019 experience for each service area and risk group. These

amounts were derived by summing amounts from each individual health plan in the service area.

The experience analysis for individual health plans is described in Attachment 2. The exhibits

show (a) summary base period (CY2017) enrollment and estimated incurred claims, (b)

projected rating period enrollment, (c) assumed trend and claims adjustment factor assumptions,

(d) projected rating period incurred claims, (e) non-benefit costs for administrative expenses,

taxes and risk margin and (f) total projected rating period costs.

A provision for administrative expenses is included in the amount of $1.80 pmpm. Additional

provisions are also included for premium tax (1.75% of premium) and risk margin (1.75% of

premium).

Information on the medical and pharmacy rate development for the MBCCP population can be

52

found in Attachment 10.

Attachment 3 - Exhibit A.1


Bexar SDA Total - Medical

Amount pmpm Amount pmpm Amount pmpm Amount pmpm


Member Months 233,078 21,781 197,636 33,271

Estimated Incurred Claims - Acute Care

Professional 35,960,490 154.29 6,796,349 312.03 0 0.00 0 0.00

Emergency Room 11,171,380 47.93 1,798,941 82.59 0 0.00 0 0.00

Outpatient Facility 14,270,840 61.23 3,357,409 154.14 0 0.00 0 0.00

Inpatient Facility 45,381,177 194.70 9,333,631 428.52 0 0.00 0 0.00

Other Acute Care 17,563,742 75.36 6,732,538 309.10 0 0.00 0 0.00

Acute Care Total 124,347,628 533.50 28,018,868 1,286.39 0 0.00 0 0.00

Estimated Incurred Claims - Long Term Care

Attendant Care 44,174,756 189.53 33,789,380 1,551.32 57,504,600 290.96 50,130,125 1,506.72

Nursing Facility 145,148 0.62 369,113 16.95 554,506 2.81 836,528 25.14

Other Long Term Care 2,441,679 10.48 2,124,960 97.56 3,452,892 17.47 5,275,910 158.57

Long Term Care Total 46,761,583 200.63 36,283,453 1,665.83 61,511,997 311.24 56,242,564 1,690.44

Total - All Claims 171,109,211 734.13 64,302,321 2,952.22 61,511,997 311.24 56,242,564 1,690.44

Projected FY2019 Member Months 227,267 23,482 195,001 34,626


Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %


Acute Care - Non Inpatient 0.9800 0.9905 1.0000 1.0000

Acute Care - Inpatient 1.0087 1.0065 1.0000 1.0000

Long Term Care 1.0000 1.0000 1.0000 1.0000

Other Adjustment - Removal of < Age 21 1.0033 1.0000 1.0000 1.0000

Medicaid Only - OCC Medicaid Only - HCBS Dual Eligible - OCC Dual Eligible - HCBS

53






Projected FY2019 Incurred Claims

Acute Care 124,863,890 549.41 31,085,938 1,323.80 0 0.00 0 0.00

LTC 50,531,349 222.34 40,617,294 1,729.69 64,951,057 333.08 62,702,048 1,810.83

Total 175,395,239 771.76 71,703,233 3,053.49 64,951,057 333.08 62,702,048 1,810.83

Capitation Expenses & Refunds 1,526,776 6.72 184,481 7.86 74,430 0.38 34,274 0.99

Service Coordination & Other Expenses 8,728,679 38.41 1,083,589 46.14 7,483,646 38.38 1,642,041 47.42

Net Reinsurance Cost 21,105 0.09 2,339 0.10 26,683 0.14 4,998 0.14


Fixed Amount 4,545,348 20.00 469,648 20.00 3,900,016 20.00 692,522 20.00

Percentage of Premium 12,053,190 5.75% 4,653,521 5.75% 4,843,783 5.75% 4,123,397 5.75%

Total 16,598,538 73.04 5,123,169 218.17 8,743,799 44.84 4,815,919 139.08

Risk Margin 3,668,362 1.75% 1,416,289 1.75% 1,474,195 1.75% 1,254,947 1.75%

Premium Tax 3,668,362 1.75% 1,416,289 1.75% 1,474,195 1.75% 1,254,947 1.75%

Maintenance Tax 13,636 0.06 1,409 0.06 11,700 0.06 2,078 0.06


Acute Care 142,873,071 628.66 34,685,376 1,477.08 111,419 0.57 43,275 1.25

LTC 66,747,626 293.70 46,245,421 1,969.37 84,128,286 431.43 71,667,977 2,069.77

Total 209,620,698 922.35 80,930,797 3,446.45 84,239,705 432.00 71,711,252 2,071.02

54





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility

Other Long Term Care

Long Term Care Total

Total - All Claims

Projected FY2019 Member Months


Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019


Acute Care - Non Inpatient

Acute Care - Inpatient

Long Term Care

Other Adjustment - Removal of < Age 21

Total


6,410 37,988 20,950 551,114

1,852,423 288.99 0 0.00 1,564,246 74.67 46,173,508 83.78

293,387 45.77 0 0.00 447,152 21.34 13,710,861 24.88

598,912 93.43 0 0.00 867,595 41.41 19,094,755 34.65

4,697,006 732.76 0 0.00 2,178,199 103.97 61,590,013 111.76

687,663 107.28 0 0.00 2,609,862 124.58 27,593,804 50.07

8,129,391 1,268.24 0 0.00 7,667,054 365.97 168,162,941 305.13

57,298 8.94 167,019 4.40 0 0.00 185,823,178 337.18

25,569,142 3,988.95 134,285,062 3,534.93 0 0.00 161,759,498 293.51

3,023 0.47 356,054 9.37 0 0.00 13,654,518 24.78

25,629,463 3,998.36 134,808,134 3,548.70 0 0.00 361,237,194 655.47

33,758,854 5,266.59 134,808,134 3,548.70 7,667,054 365.97 529,400,135 960.60

6,497 38,651 21,085 546,610

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9894 1.0000 0.9870

1.0118 1.0000 1.0060

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

Dual Eligible - NF IDDMedicaid Only - NF

55





Acute Care

LTC

Total

Capitation Expenses & Refunds

Service Coordination & Other Expenses

Net Reinsurance Cost


Fixed Amount

Percentage of Premium

Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



8,514,872 1,310.53 0 0.00 7,869,945 373.25 172,334,646 315.28

26,552,831 4,086.77 140,887,671 3,645.14 0 0.00 386,242,251 706.61

35,067,703 5,397.30 140,887,671 3,645.14 7,869,945 373.25 558,576,896 1,021.89

28,080 4.32 104,221 2.70 19,361 0.92 1,971,622 3.61

301,322 46.38 1,792,913 46.39 813,340 38.57 21,845,530 39.97

984 0.15 6,957 0.18 1,502 0.07 64,569 0.12

129,945 20.00 773,016 20.00 421,704 20.00 10,932,199 20.00

2,251,112 5.75% 9,096,538 5.75% 578,302 5.75% 37,599,843 5.75%

2,381,058 366.47 9,869,554 255.35 1,000,006 47.43 48,532,042 88.79

685,121 1.75% 2,768,512 1.75% 176,005 1.75% 11,443,431 1.75%

685,121 1.75% 2,768,512 1.75% 176,005 1.75% 11,443,431 1.75%

390 0.06 2,319 0.06 1,265 0.06 32,797 0.06

9,449,679 1,454.41 122,510 3.17 9,161,187 434.48 196,446,517 359.39

29,700,100 4,571.17 158,078,148 4,089.91 896,243 42.51 457,463,801 836.91

39,149,779 6,025.57 158,200,658 4,093.08 10,057,430 476.99 653,910,318 1,196.30

56



Bexar SDA Total - Pharmacy


CY2017 Experience Period

Member Months 227,726 22,472 6,558 21,061

Experience Period Cost

Estimated Incurred Claims 99,407,443 436.52 21,835,305 971.68 4,576,619 697.83 10,562,473 501.51

Pay and Chase Recoveries -584,776 -2.57 -62,328 -2.77 -18,017 -2.75 -54,837 -2.60

Total Cost 98,822,667 433.95 21,772,977 968.91 4,558,602 695.08 10,507,636 498.91


Annual Trend Assumption 6.7 % 6.9 % -0.4 % 3.4 %

Adjustment Factors

PDL Adjustment 0.9801 0.9853 0.9712 0.9280

Carve-In Adjustment 1.1061 1.0751 1.0523 1.0100

Projected Incurred Claims 119,120,667 524.14 26,936,380 1,147.09 4,584,709 705.64 10,424,860 494.42

Administrative Expenses 409,081 1.80 42,268 1.80 11,695 1.80 37,953 1.80

Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %

Projected Total Cost 123,865,024 545.02 27,957,149 1,190.56 4,763,114 733.09 10,842,294 514.21

*Excludes Dual Eligible risk groups which do

not receive prescription drug coverage

through the STAR+PLUS program.

Medicaid Only - OCC Medicaid Only - HCBS Medicaid Only - NF IDD

57



Bexar SDA Total - Pharmacy


Member Months


Estimated Incurred Claims

Pay and Chase Recoveries

Total Cost


Annual Trend Assumption

Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

277,817

136,381,840 490.91

-719,958 -2.59

135,661,882 488.31

278,332

161,066,617 578.68

500,998 1.80

167,427,580 601.54

Total*

58

Attachment 3 - Exhibit B.1


Dallas SDA Total - Medical



Member Months 325,882 24,695 254,070 45,998


Professional 39,515,366 121.26 7,529,321 304.89 0 0.00 0 0.00

Emergency Room 21,221,122 65.12 2,369,927 95.97 0 0.00 0 0.00



Other Acute Care 17,492,543 53.68 6,723,755 272.27 0 0.00 0 0.00

Acute Care Total 188,625,336 578.81 35,921,174 1,454.59 0 0.00 0 0.00


Attendant Care 57,380,984 176.08 27,146,053 1,099.25 66,901,784 263.32 55,204,481 1,200.15

Nursing Facility 503,482 1.54 1,349,847 54.66 1,181,803 4.65 3,084,409 67.06



Total - All Claims 247,931,193 760.80 68,458,075 2,772.14 72,864,253 286.79 68,869,519 1,497.23



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



59







Acute Care 198,446,180 622.28 44,952,556 1,569.17 0 0.00 0 0.00

LTC 64,323,685 201.70 39,191,247 1,368.06 77,036,147 306.91 78,878,784 1,603.86

Total 262,769,865 823.99 84,143,803 2,937.23 77,036,147 306.91 78,878,784 1,603.86

Capitation Expenses & Refunds 1,131,964 3.55 134,810 4.71 -190,861 -0.76 -13,693 -0.28




Fixed Amount 6,378,001 20.00 572,946 20.00 5,020,043 20.00 983,610 20.00


Total 24,337,476 76.32 6,101,565 212.99 10,866,678 43.29 6,245,805 127.00

Risk Margin 5,465,927 1.75% 1,682,623 1.75% 1,779,411 1.75% 1,601,537 1.75%

Premium Tax 5,465,927 1.75% 1,682,623 1.75% 1,779,411 1.75% 1,601,537 1.75%

Maintenance Tax 19,134 0.06 1,719 0.06 15,060 0.06 2,951 0.06


Acute Care 225,346,370 706.64 50,032,274 1,746.49 -123,101 -0.49 4,665 0.09

LTC 86,992,332 272.79 46,117,608 1,609.84 101,803,724 405.59 91,511,759 1,860.73

Total 312,338,702 979.43 96,149,883 3,356.33 101,680,623 405.10 91,516,424 1,860.83

60





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


9,742 56,239 26,009 742,635

2,894,159 297.08 0 0.00 1,552,110 59.68 51,490,956 69.34

822,555 84.43 0 0.00 579,977 22.30 24,993,581 33.66

1,733,140 177.90 0 0.00 738,526 28.40 39,015,356 52.54

10,024,376 1,028.99 0 0.00 2,599,386 99.94 105,774,547 142.43

1,530,788 157.13 0 0.00 2,454,349 94.37 28,201,436 37.97

17,005,018 1,745.54 0 0.00 7,924,347 304.68 249,475,875 335.93

179,196 18.39 134,934 2.40 0 0.00 206,947,432 278.67

38,132,495 3,914.24 195,504,330 3,476.31 0 0.00 239,756,366 322.85

18,023 1.85 992,765 17.65 0 0.00 21,834,475 29.40

38,329,714 3,934.48 196,632,029 3,496.36 0 0.00 468,538,274 630.91

55,334,732 5,680.02 196,632,029 3,496.36 7,924,347 304.68 718,014,149 966.85

9,253 55,645 26,460 739,089

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

1.0425 1.0000 1.0252

1.0114 1.0000 1.0062

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


61





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



17,579,250 1,899.80 0 0.00 8,542,059 322.83 269,520,045 364.67

37,211,538 4,021.48 199,842,502 3,591.38 0 0.00 496,483,902 671.75

54,790,789 5,921.28 199,842,502 3,591.38 8,542,059 322.83 766,003,947 1,036.42

48,044 5.19 194,834 3.50 -22,919 -0.87 1,282,179 1.73

449,604 48.59 2,714,946 48.79 1,076,532 40.68 33,187,008 44.90

2,727 0.29 18,194 0.33 6,592 0.25 227,016 0.31

185,064 20.00 1,112,900 20.00 529,206 20.00 14,781,771 20.00

3,515,058 5.75% 12,918,442 5.75% 642,039 5.75% 51,672,463 5.75%

3,700,122 399.88 14,031,342 252.16 1,171,246 44.26 66,454,234 89.91

1,069,800 1.75% 3,931,700 1.75% 195,403 1.75% 15,726,402 1.75%

1,069,800 1.75% 3,931,700 1.75% 195,403 1.75% 15,726,402 1.75%

555 0.06 3,339 0.06 1,588 0.06 44,345 0.06

19,492,646 2,106.59 234,742 4.22 9,979,643 377.16 304,967,238 412.63

41,638,796 4,499.94 224,433,815 4,033.31 1,186,261 44.83 593,684,295 803.27

61,131,442 6,606.52 224,668,556 4,037.53 11,165,904 421.99 898,651,533 1,215.89

62



Dallas SDA Total - Pharmacy



Member Months 321,097 26,362 9,886 26,163



Pay and Chase Recoveries -1,295,117 -4.03 -115,036 -4.36 -40,142 -4.06 -99,211 -3.79

Total Cost 113,352,490 353.02 19,381,433 735.20 5,183,868 524.36 9,045,973 345.75



Adjustment Factors

PDL Adjustment 0.9860 0.9876 0.9827 0.9568


Projected Incurred Claims 136,396,389 427.71 25,006,777 872.92 4,853,343 524.50 9,255,171 349.78


Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %

Projected Total Cost 141,938,248 445.09 25,967,194 906.44 5,046,631 545.39 9,640,207 364.33





63



Dallas SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

383,508

148,513,270 387.25

-1,549,506 -4.04

146,963,765 383.21

383,261

175,511,680 457.94

689,870 1.80

182,592,280 476.42

Total*

64

Attachment 3 - Exhibit C.1


El Paso SDA Total - Medical



Member Months 74,384 8,231 137,882 13,819


Professional 12,971,806 174.39 2,983,941 362.52 0 0.00 0 0.00

Emergency Room 3,323,575 44.68 797,580 96.90 0 0.00 0 0.00



Other Acute Care 8,006,503 107.64 2,541,885 308.82 0 0.00 0 0.00

Acute Care Total 44,940,896 604.17 12,124,165 1,472.99 0 0.00 0 0.00


Attendant Care 14,669,587 197.21 9,407,754 1,142.97 48,518,479 351.88 18,234,000 1,319.49




Total - All Claims 61,991,405 833.40 24,059,858 2,923.08 58,656,061 425.41 23,120,832 1,673.12



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



65







Acute Care 44,699,125 607.77 12,878,196 1,515.27 0 0.00 0 0.00

LTC 18,640,609 253.45 12,796,666 1,505.68 62,848,095 455.26 24,450,601 1,792.28

Total 63,339,734 861.22 25,674,862 3,020.95 62,848,095 455.26 24,450,601 1,792.28

Capitation Expenses & Refunds 103,946 1.41 23,687 2.79 69,740 0.51 22,682 1.66

Service Coordination & Other Expenses 2,675,353 36.38 658,245 77.45 5,155,381 37.34 900,662 66.02



Fixed Amount 1,470,934 20.00 169,978 20.00 2,760,964 20.00 272,844 20.00


Total 5,754,772 78.25 1,850,920 217.78 7,251,892 52.53 1,898,146 139.14

Risk Margin 1,303,777 1.75% 511,591 1.75% 1,366,804 1.75% 494,657 1.75%

Premium Tax 1,303,777 1.75% 511,591 1.75% 1,366,804 1.75% 494,657 1.75%

Maintenance Tax 4,413 0.06 510 0.06 8,283 0.06 819 0.06


Acute Care 50,534,432 687.11 14,313,777 1,684.19 116,624 0.84 29,296 2.15

LTC 23,967,107 325.88 14,919,983 1,755.51 77,986,471 564.92 28,236,833 2,069.82

Total 74,501,539 1,012.98 29,233,760 3,439.70 78,103,096 565.77 28,266,129 2,071.97

66





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


714 6,293 6,309 247,632

300,021 420.20 0 0.00 686,888 108.87 16,942,656 68.42

62,086 86.96 0 0.00 123,634 19.60 4,306,876 17.39

131,534 184.22 0 0.00 915,673 145.14 11,200,634 45.23

1,205,644 1,688.58 0 0.00 792,587 125.63 18,284,573 73.84

49,483 69.30 0 0.00 623,384 98.81 11,221,254 45.31

1,748,768 2,449.25 0 0.00 3,142,165 498.04 61,955,993 250.19

15,559 21.79 72,885 11.58 0 0.00 90,918,264 367.15

3,114,093 4,361.47 22,798,035 3,622.76 0 0.00 26,760,820 108.07

11,002 15.41 59,063 9.39 0 0.00 19,154,650 77.35

3,140,654 4,398.67 22,929,984 3,643.73 0 0.00 136,833,734 552.57

4,889,421 6,847.93 22,929,984 3,643.73 3,142,165 498.04 198,789,727 802.76

722 5,721 6,394 246,572

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9801 1.0000 0.9835

1.0085 1.0000 1.0021

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


67





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



1,804,053 2,498.97 0 0.00 3,223,540 504.18 62,604,914 253.90

3,245,702 4,495.94 21,410,992 3,742.75 0 0.00 143,392,665 581.54

5,049,755 6,994.91 21,410,992 3,742.75 3,223,540 504.18 205,997,579 835.45

5,631 7.80 25,722 4.50 7,403 1.16 258,811 1.05

32,637 45.21 259,437 45.35 225,988 35.35 9,907,704 40.18

197 0.27 1,603 0.28 1,050 0.16 60,974 0.25

14,438 20.00 114,413 20.00 127,872 20.00 4,931,443 20.00

323,312 5.75% 1,382,060 5.75% 227,227 5.75% 14,013,609 5.75%

337,750 467.85 1,496,473 261.59 355,099 55.54 18,945,052 76.83

98,399 1.75% 420,627 1.75% 69,156 1.75% 4,265,011 1.75%

98,399 1.75% 420,627 1.75% 69,156 1.75% 4,265,011 1.75%

43 0.06 343 0.06 384 0.06 14,794 0.06

2,000,060 2,770.48 30,110 5.26 3,702,754 579.14 70,727,053 286.84

3,622,752 5,018.23 24,005,714 4,196.32 249,022 38.95 172,987,883 701.57

5,622,812 7,788.70 24,035,824 4,201.58 3,951,776 618.08 243,714,936 988.41

68



El Paso SDA Total - Pharmacy



Member Months 73,438 8,360 730 6,320


Estimated Incurred Claims 33,552,656 456.89 8,616,818 1,030.71 385,785 528.77 5,325,580 842.66


Total Cost 33,158,692 451.52 8,557,822 1,023.65 380,710 521.82 5,300,218 838.64

Projected FY2019 Member Months 73,547 8,499 722 6,394


Adjustment Factors

PDL Adjustment 0.9760 0.9830 0.9814 0.9389


Projected Incurred Claims 37,818,366 514.21 10,034,948 1,180.73 367,243 508.70 5,322,815 832.52


Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %

Projected Total Cost 39,327,202 534.72 10,414,762 1,225.42 381,909 529.02 5,527,796 864.58





69



El Paso SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

88,847

47,880,839 538.91

-483,397 -5.44

47,397,442 533.47

89,161

53,543,371 600.52

160,490 1.80

55,651,670 624.17

Total*

70

Attachment 3 - Exhibit D.1


Harris SDA Total - Medical



Member Months 499,725 33,350 504,003 58,097


Professional 82,133,833 164.36 15,060,793 451.60 0 0.00 0 0.00

Emergency Room 35,001,496 70.04 4,177,896 125.27 0 0.00 0 0.00



Other Acute Care 26,739,261 53.51 4,103,765 123.05 0 0.00 0 0.00

Acute Care Total 329,540,263 659.44 55,270,915 1,657.30 0 0.00 0 0.00


Attendant Care 83,043,370 166.18 38,773,264 1,162.62 123,777,137 245.59 83,259,521 1,433.11

Nursing Facility 340,883 0.68 2,283,727 68.48 848,382 1.68 3,411,269 58.72



Total - All Claims 424,429,907 849.33 113,223,978 3,395.02 136,194,591 270.23 102,159,040 1,758.42



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



71







Acute Care 337,974,369 676.22 57,623,024 1,700.00 0 0.00 0 0.00

LTC 105,732,824 211.55 61,159,908 1,804.34 146,156,012 289.19 110,532,442 1,883.66

Total 443,707,193 887.77 118,782,932 3,504.34 146,156,012 289.19 110,532,442 1,883.66

Capitation Expenses & Refunds 4,095,940 8.20 319,970 9.44 1,269,742 2.51 201,705 3.44




Fixed Amount 9,996,042 20.00 677,920 20.00 10,107,970 20.00 1,173,593 20.00


Total 40,158,559 80.35 8,386,668 247.42 21,252,666 42.05 8,484,912 144.60

Risk Margin 9,179,896 1.75% 2,346,141 1.75% 3,391,864 1.75% 2,225,184 1.75%

Premium Tax 9,179,896 1.75% 2,346,141 1.75% 3,391,864 1.75% 2,225,184 1.75%

Maintenance Tax 29,988 0.06 2,034 0.06 30,324 0.06 3,521 0.06


Acute Care 385,390,755 771.09 64,216,191 1,894.51 1,441,721 2.85 228,061 3.89

LTC 139,174,758 278.46 69,848,997 2,060.69 192,379,086 380.65 126,925,305 2,163.02

Total 524,565,513 1,049.55 134,065,188 3,955.19 193,820,807 383.50 127,153,366 2,166.91

72





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


10,321 69,036 44,797 1,219,329

3,728,858 361.29 0 0.00 4,500,119 100.46 105,423,604 86.46

639,765 61.99 0 0.00 916,968 20.47 40,736,125 33.41

2,144,990 207.83 0 0.00 2,814,932 62.84 71,117,417 58.33

7,562,863 732.76 0 0.00 3,693,893 82.46 162,693,394 133.43

646,892 62.68 0 0.00 1,924,666 42.96 33,414,584 27.40

14,723,368 1,426.54 0 0.00 13,850,578 309.19 413,385,124 339.03

119,331 11.56 460,107 6.66 0 0.00 329,432,730 270.18

42,725,917 4,139.71 235,188,484 3,406.75 0 0.00 284,798,663 233.57

70,686 6.85 880,019 12.75 0 0.00 56,409,490 46.26

42,915,934 4,158.12 236,528,610 3,426.16 0 0.00 670,640,883 550.01

57,639,302 5,584.66 236,528,610 3,426.16 13,850,578 309.19 1,084,026,007 889.03

10,955 67,361 45,652 1,221,744

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9977 1.0000 0.9808

1.0078 1.0000 1.0049

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


73





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



16,220,247 1,480.61 0 0.00 14,289,432 313.01 426,107,072 348.77

46,559,932 4,250.06 237,062,488 3,519.27 0 0.00 707,203,606 578.85

62,780,178 5,730.67 237,062,488 3,519.27 14,289,432 313.01 1,133,310,678 927.62

115,560 10.55 324,186 4.81 389,412 8.53 6,716,515 5.50

483,993 44.18 3,007,942 44.65 1,654,073 36.23 46,967,964 38.44

1,017 0.09 7,933 0.12 2,874 0.06 93,964 0.08

219,102 20.00 1,347,224 20.00 913,036 20.00 24,434,888 20.00

4,029,784 5.75% 15,317,735 5.75% 1,093,074 5.75% 76,767,874 5.75%

4,248,887 387.84 16,664,959 247.40 2,006,111 43.94 101,202,761 82.83

1,226,456 1.75% 4,661,919 1.75% 332,675 1.75% 23,364,136 1.75%

1,226,456 1.75% 4,661,919 1.75% 332,675 1.75% 23,364,136 1.75%

657 0.06 4,042 0.06 2,739 0.06 73,305 0.06

18,064,575 1,648.96 365,971 5.43 17,187,320 376.49 486,894,594 398.52

52,018,630 4,748.34 266,029,417 3,949.30 1,822,670 39.93 848,198,863 694.25

70,083,205 6,397.30 266,395,388 3,954.73 19,009,990 416.41 1,335,093,457 1,092.78

74



Harris SDA Total - Pharmacy



Member Months 492,723 33,393 10,409 45,192




Total Cost 239,568,019 486.21 32,148,179 962.71 6,846,373 657.73 22,637,280 500.91



Adjustment Factors

PDL Adjustment 0.9880 0.9899 0.9867 0.9593




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






75



Harris SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

581,718

302,321,411 519.70

-1,121,559 -1.93

301,199,851 517.78

590,305

356,504,957 603.93

1,062,549 1.80

370,536,276 627.70

Total*

76

Attachment 3 - Exhibit E.1


Hidalgo SDA Total - Medical



Member Months 182,990 27,003 411,376 116,869


Professional 27,690,678 151.32 7,727,726 286.18 0 0.00 0 0.00

Emergency Room 5,430,361 29.68 1,288,091 47.70 0 0.00 0 0.00



Other Acute Care 14,334,073 78.33 9,576,357 354.64 0 0.00 0 0.00

Acute Care Total 83,382,665 455.67 33,914,029 1,255.94 0 0.00 0 0.00


Attendant Care 91,656,014 500.88 49,163,654 1,820.67 291,116,576 707.67 210,071,316 1,797.49

Nursing Facility 79,379 0.43 451,277 16.71 622,874 1.51 1,697,830 14.53



Total - All Claims 191,909,313 1,048.74 88,428,662 3,274.77 345,006,144 838.66 237,526,931 2,032.42



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



77







Acute Care 82,791,352 476.88 37,791,572 1,292.12 0 0.00 0 0.00

LTC 116,066,301 668.54 61,310,068 2,096.23 358,043,794 897.52 260,806,011 2,177.17

Total 198,857,654 1,145.42 99,101,640 3,388.35 358,043,794 897.52 260,806,011 2,177.17

Capitation Expenses & Refunds 1,457,193 8.39 258,813 8.85 1,243,648 3.12 471,714 3.94




Fixed Amount 3,472,235 20.00 584,955 20.00 7,978,518 20.00 2,395,824 20.00


Total 16,830,122 96.94 7,007,276 239.58 32,276,324 80.91 19,462,824 162.47

Risk Margin 4,065,444 1.75% 1,954,619 1.75% 7,394,984 1.75% 5,194,304 1.75%

Premium Tax 4,065,444 1.75% 1,954,619 1.75% 7,394,984 1.75% 5,194,304 1.75%

Maintenance Tax 10,417 0.06 1,755 0.06 23,936 0.06 7,187 0.06


Acute Care 94,458,140 544.08 42,178,884 1,442.12 1,434,343 3.60 536,184 4.48

LTC 137,852,951 794.03 69,513,643 2,376.72 421,136,189 1,055.68 296,281,197 2,473.31

Total 232,311,091 1,338.11 111,692,527 3,818.84 422,570,532 1,059.27 296,817,381 2,477.79

78





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


2,498 27,198 11,884 779,818

898,323 359.62 0 0.00 943,391 79.38 37,260,117 47.78

107,635 43.09 0 0.00 162,138 13.64 6,988,225 8.96

444,589 177.98 0 0.00 374,862 31.54 17,163,536 22.01

2,963,463 1,186.33 0 0.00 1,032,777 86.90 38,901,564 49.89

445,545 178.36 0 0.00 2,179,261 183.38 26,535,237 34.03

4,859,554 1,945.38 0 0.00 4,692,430 394.85 126,848,678 162.66

63,536 25.43 322,933 11.87 0 0.00 642,394,029 823.77

10,279,359 4,115.04 103,980,970 3,823.11 0 0.00 117,111,689 150.18

21,076 8.44 1,811,869 66.62 0 0.00 102,548,382 131.50

10,363,971 4,148.91 106,115,772 3,901.60 0 0.00 862,054,099 1,105.46

15,223,525 6,094.29 106,115,772 3,901.60 4,692,430 394.85 988,902,778 1,268.12

2,455 27,525 11,781 763,337

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9987 1.0000 0.9921

1.0061 1.0000 1.0023

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


79





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



4,952,542 2,017.72 0 0.00 4,751,186 403.30 130,286,652 170.68

10,408,772 4,240.65 110,309,093 4,007.63 0 0.00 916,944,040 1,201.23

15,361,314 6,258.37 110,309,093 4,007.63 4,751,186 403.30 1,047,230,691 1,371.91

15,384 6.27 132,640 4.82 46,499 3.95 3,625,890 4.75

118,148 48.13 1,330,272 48.33 474,885 40.31 32,137,451 42.10

422 0.17 5,234 0.19 1,419 0.12 105,450 0.14

49,090 20.00 550,495 20.00 235,618 20.00 15,266,737 20.00

984,914 5.75% 7,117,289 5.75% 349,138 5.75% 69,596,354 5.75%

1,034,004 421.26 7,667,784 278.58 584,757 49.64 84,863,091 111.17

299,756 1.75% 2,166,131 1.75% 106,259 1.75% 21,181,499 1.75%

299,756 1.75% 2,166,131 1.75% 106,259 1.75% 21,181,499 1.75%

147 0.06 1,651 0.06 707 0.06 45,800 0.06

5,492,256 2,237.61 151,927 5.52 5,548,682 470.99 149,800,416 196.24

11,636,676 4,740.91 123,627,010 4,491.48 523,290 44.42 1,060,570,956 1,389.39

17,128,932 6,978.51 123,778,937 4,497.00 6,071,971 515.41 1,210,371,371 1,585.63

80



Hidalgo SDA Total - Pharmacy



Member Months 174,339 27,855 2,543 11,844




Total Cost 85,546,681 490.69 26,188,295 940.16 1,234,735 485.64 5,338,560 450.76



Adjustment Factors

PDL Adjustment 0.9847 0.9904 0.9813 0.9730




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






81



Hidalgo SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

216,580

119,036,831 549.62

-728,559 -3.36

118,308,272 546.26

217,095

133,606,922 615.43

390,771 1.80

138,857,713 639.62

Total*

82

Attachment 3 - Exhibit F.1


Jefferson SDA Total - Medical



Member Months 98,146 6,640 86,808 15,333


Professional 15,159,163 154.46 2,439,227 367.35 0 0.00 0 0.00

Emergency Room 5,728,885 58.37 776,035 116.87 0 0.00 0 0.00



Other Acute Care 3,697,695 37.68 970,648 146.18 0 0.00 0 0.00

Acute Care Total 55,670,786 567.22 10,389,467 1,564.68 0 0.00 0 0.00


Attendant Care 9,686,795 98.70 6,175,272 930.01 14,892,090 171.55 16,458,842 1,073.43


Other Long Term Care 1,229,360 12.53 1,805,688 271.94 668,085 7.70 3,515,810 229.30


Total - All Claims 66,700,896 679.61 18,409,754 2,772.55 16,118,057 185.67 20,360,304 1,327.87



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



83







Acute Care 56,530,075 582.21 10,996,314 1,602.01 0 0.00 0 0.00

LTC 12,142,727 125.06 8,608,757 1,254.18 17,339,979 198.71 22,246,053 1,422.45

Total 68,672,802 707.27 19,605,071 2,856.19 17,339,979 198.71 22,246,053 1,422.45


Service Coordination & Other Expenses 3,618,494 37.27 549,062 79.99 3,277,965 37.56 1,056,923 67.58



Fixed Amount 1,941,923 20.00 137,281 20.00 1,745,298 20.00 312,786 20.00


Total 6,672,542 68.72 1,424,978 207.60 3,163,994 36.26 1,809,836 115.72

Risk Margin 1,439,754 1.75% 391,908 1.75% 431,777 1.75% 455,624 1.75%

Premium Tax 1,439,754 1.75% 391,908 1.75% 431,777 1.75% 455,624 1.75%

Maintenance Tax 5,826 0.06 412 0.06 5,236 0.06 938 0.06


Acute Care 64,524,391 664.54 12,236,846 1,782.74 24,509 0.28 11,750 0.75

LTC 17,747,242 182.78 10,157,885 1,479.87 24,648,461 282.46 26,023,912 1,664.01

Total 82,271,633 847.32 22,394,731 3,262.61 24,672,970 282.74 26,035,661 1,664.76

84





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


2,686 22,259 5,126 236,998

701,956 261.34 0 0.00 472,160 92.11 18,772,507 79.21

152,880 56.92 0 0.00 66,076 12.89 6,723,876 28.37

546,025 203.29 0 0.00 292,857 57.13 12,489,563 52.70

1,742,486 648.73 0 0.00 661,278 129.00 28,041,682 118.32

218,180 81.23 0 0.00 139,313 27.18 5,025,836 21.21

3,361,527 1,251.50 0 0.00 1,631,684 318.32 71,053,464 299.81

12,765 4.75 51,629 2.32 0 0.00 47,277,393 199.48

10,046,940 3,740.48 72,400,209 3,252.63 0 0.00 83,543,963 352.51

58,021 21.60 177,235 7.96 0 0.00 7,454,200 31.45

10,117,726 3,766.84 72,629,073 3,262.91 0 0.00 138,275,556 583.45

13,479,252 5,018.34 72,629,073 3,262.91 1,631,684 318.32 209,329,020 883.25

2,812 23,227 5,016 237,920

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9961 1.0000 0.9910

1.0029 1.0000 1.0001

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


85





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



3,628,838 1,290.54 0 0.00 1,625,483 324.05 72,780,710 305.90

10,826,079 3,850.13 77,847,831 3,351.58 0 0.00 149,011,425 626.31

14,454,917 5,140.67 77,847,831 3,351.58 1,625,483 324.05 221,792,136 932.21

20,019 7.12 46,403 2.00 30,645 6.11 544,503 2.29

126,790 45.09 1,052,337 45.31 187,587 37.40 9,869,158 41.48

467 0.17 4,113 0.18 519 0.10 44,424 0.19

56,237 20.00 464,544 20.00 100,324 20.00 4,758,393 20.00

928,782 5.75% 5,031,907 5.75% 123,228 5.75% 15,017,979 5.75%

985,019 350.31 5,496,451 236.64 223,552 44.57 19,776,372 83.12

282,673 1.75% 1,531,450 1.75% 37,504 1.75% 4,570,689 1.75%

282,673 1.75% 1,531,450 1.75% 37,504 1.75% 4,570,689 1.75%

169 0.06 1,394 0.06 301 0.06 14,275 0.06

4,036,899 1,435.66 55,665 2.40 1,936,388 386.03 82,826,448 348.13

12,115,829 4,308.81 87,455,764 3,765.23 206,708 41.21 178,355,799 749.65

16,152,727 5,744.47 87,511,429 3,767.63 2,143,096 427.24 261,182,247 1,097.78

86



Jefferson SDA Total - Pharmacy



Member Months 96,696 6,776 2,683 5,097




Total Cost 40,685,198 420.75 5,303,382 782.69 1,852,064 690.33 2,231,865 437.88



Adjustment Factors

PDL Adjustment 0.9833 0.9858 0.9877 0.9699




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






87



Jefferson SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

111,251

50,340,058 452.49

-267,549 -2.40

50,072,509 450.08

111,788

58,367,230 522.12

201,219 1.80

60,692,693 542.93

Total*

88

Attachment 3 - Exhibit G.1


Lubbock SDA Total - Medical



Member Months 57,797 3,325 63,264 6,955


Professional 7,119,191 123.18 757,605 227.85 0 0.00 0 0.00

Emergency Room 2,559,559 44.29 219,539 66.03 0 0.00 0 0.00



Other Acute Care 3,559,239 61.58 1,031,986 310.37 0 0.00 0 0.00

Acute Care Total 31,256,455 540.80 4,827,911 1,452.00 0 0.00 0 0.00


Attendant Care 2,758,110 47.72 3,213,998 966.62 4,907,380 77.57 6,469,954 930.26


Other Long Term Care 550,377 9.52 605,517 182.11 1,018,793 16.10 1,828,715 262.94


Total - All Claims 34,625,401 599.09 8,726,517 2,624.52 6,232,351 98.51 8,572,147 1,232.52



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



89







Acute Care 31,739,538 552.16 4,754,251 1,491.85 0 0.00 0 0.00

LTC 3,699,983 64.37 3,879,819 1,217.46 6,623,719 105.43 9,360,669 1,320.30

Total 35,439,521 616.53 8,634,071 2,709.32 6,623,719 105.43 9,360,669 1,320.30

Capitation Expenses & Refunds 272,508 4.74 13,389 4.20 -47,446 -0.76 -4,720 -0.67


Net Reinsurance Cost 2,299 0.04 127 0.04 2,513 0.04 284 0.04


Fixed Amount 1,149,652 20.00 63,736 20.00 1,256,552 20.00 141,796 20.00

Percentage of Premium 2,470,064 5.75% 560,936 5.75% 639,328 5.75% 622,331 5.75%

Total 3,619,716 62.97 624,672 196.02 1,895,881 30.18 764,127 107.78

Risk Margin 751,759 1.75% 170,720 1.75% 194,578 1.75% 189,405 1.75%

Premium Tax 751,759 1.75% 170,720 1.75% 194,578 1.75% 189,405 1.75%

Maintenance Tax 3,449 0.06 191 0.06 3,770 0.06 425 0.06


Acute Care 36,415,491 633.50 5,292,528 1,660.76 -49,513 -0.79 -4,889 -0.69

LTC 6,542,151 113.81 4,462,881 1,400.42 11,168,265 177.76 10,828,030 1,527.26

Total 42,957,643 747.32 9,755,409 3,061.18 11,118,752 176.97 10,823,141 1,526.57

90





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


2,396 18,956 7,116 159,809

573,296 239.27 0 0.00 596,778 83.86 9,046,870 56.61

141,611 59.10 0 0.00 127,939 17.98 3,048,647 19.08

548,233 228.81 0 0.00 455,890 64.07 8,299,695 51.94

1,861,699 777.00 0 0.00 441,048 61.98 15,844,422 99.15

175,406 73.21 0 0.00 525,641 73.87 5,292,272 33.12

3,300,246 1,377.40 0 0.00 2,147,294 301.76 41,531,906 259.88

13,155 5.49 10,156 0.54 0 0.00 17,372,753 108.71

8,945,874 3,733.67 62,578,536 3,301.25 0 0.00 72,243,616 452.06

1,381 0.58 33,791 1.78 0 0.00 4,038,574 25.27

8,960,410 3,739.74 62,622,483 3,303.57 0 0.00 93,654,943 586.04

12,260,655 5,117.13 62,622,483 3,303.57 2,147,294 301.76 135,186,849 845.93

2,478 19,412 6,980 159,456

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9933 1.0000 0.9721

1.0074 1.0000 1.0043

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


91





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



3,525,506 1,422.73 0 0.00 2,112,034 302.60 42,131,329 264.22

9,471,929 3,822.43 65,870,108 3,393.35 0 0.00 98,906,227 620.27

12,997,435 5,245.16 65,870,108 3,393.35 2,112,034 302.60 141,037,556 884.49

26 0.01 -13,038 -0.67 -2,385 -0.34 218,333 1.37

108,829 43.92 837,088 43.12 256,961 36.82 6,035,736 37.85

99 0.04 776 0.04 279 0.04 6,378 0.04

49,560 20.00 388,231 20.00 139,594 20.00 3,189,121 20.00

833,582 5.75% 4,250,522 5.75% 158,840 5.75% 9,535,603 5.75%

883,142 356.39 4,638,753 238.97 298,433 42.76 12,724,724 79.80

253,699 1.75% 1,293,637 1.75% 48,342 1.75% 2,902,140 1.75%

253,699 1.75% 1,293,637 1.75% 48,342 1.75% 2,902,140 1.75%

149 0.06 1,165 0.06 419 0.06 9,567 0.06

3,899,850 1,573.80 -13,512 -0.70 2,479,274 355.21 48,019,230 301.14

10,597,227 4,276.55 73,935,638 3,808.85 283,153 40.57 117,817,345 738.87

14,497,077 5,850.35 73,922,126 3,808.15 2,762,427 395.78 165,836,575 1,040.01

92



Lubbock SDA Total - Pharmacy



Member Months 57,301 3,247 2,391 7,084




Total Cost 22,877,437 399.25 3,008,755 926.61 1,807,008 755.68 2,891,138 408.14



Adjustment Factors

PDL Adjustment 0.9803 0.9891 0.9694 0.9350




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






93



Lubbock SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

70,023

30,713,523 438.62

-129,184 -1.84

30,584,339 436.77

70,127

34,866,800 497.19

126,229 1.80

36,262,206 517.09

Total*

94

Attachment 3 - Exhibit H.1


Nueces SDA Total - Medical



Member Months 86,973 9,862 99,674 28,608


Professional 12,252,011 140.87 2,751,743 279.02 0 0.00 0 0.00

Emergency Room 4,816,564 55.38 815,440 82.69 0 0.00 0 0.00



Other Acute Care 3,989,078 45.87 2,062,611 209.15 0 0.00 0 0.00

Acute Care Total 44,836,234 515.52 11,529,710 1,169.10 0 0.00 0 0.00


Attendant Care 20,866,607 239.92 14,678,334 1,488.37 34,448,603 345.61 44,771,677 1,565.01




Total - All Claims 68,807,390 791.14 27,658,814 2,804.58 38,185,750 383.11 49,660,090 1,735.88



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



95







Acute Care 44,628,911 529.04 12,309,429 1,201.45 0 0.00 0 0.00

LTC 25,810,684 305.97 17,398,697 1,698.18 41,260,250 409.99 55,628,802 1,859.51

Total 70,439,596 835.01 29,708,125 2,899.62 41,260,250 409.99 55,628,802 1,859.51





Fixed Amount 1,687,151 20.00 204,910 20.00 2,012,734 20.00 598,316 20.00


Total 6,520,333 77.29 2,136,324 208.51 5,008,335 49.77 4,264,013 142.53

Risk Margin 1,470,969 1.75% 587,822 1.75% 911,705 1.75% 1,115,647 1.75%

Premium Tax 1,470,969 1.75% 587,822 1.75% 911,705 1.75% 1,115,647 1.75%

Maintenance Tax 5,061 0.06 615 0.06 6,038 0.06 1,795 0.06


Acute Care 51,341,274 608.62 13,779,549 1,344.94 137,314 1.36 40,141 1.34

LTC 32,714,070 387.80 19,810,252 1,933.55 51,960,086 516.31 63,711,108 2,129.68

Total 84,055,344 996.42 33,589,801 3,278.49 52,097,400 517.68 63,751,249 2,131.02

96





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


2,321 23,697 5,858 256,993

440,922 189.97 0 0.00 472,921 80.73 15,917,597 61.94

116,811 50.33 0 0.00 131,998 22.53 5,880,812 22.88

114,490 49.33 0 0.00 114,697 19.58 6,578,835 25.60

1,420,616 612.07 0 0.00 872,326 148.91 25,621,791 99.70

277,970 119.76 0 0.00 785,129 134.03 7,114,787 27.68

2,370,808 1,021.46 0 0.00 2,377,071 405.78 61,113,823 237.80

37,852 16.31 109,087 4.60 0 0.00 114,912,160 447.14

8,743,323 3,767.05 84,161,212 3,551.56 0 0.00 93,751,036 364.80

32,260 13.90 123,190 5.20 0 0.00 12,489,828 48.60

8,813,435 3,797.26 84,393,489 3,561.36 0 0.00 221,153,024 860.54

11,184,243 4,818.72 84,393,489 3,561.36 2,377,071 405.78 282,266,847 1,098.34

2,381 23,349 5,829 256,715

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

1.0001 1.0000 0.9758

1.0047 1.0000 1.0026

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


97





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



2,522,057 1,059.45 0 0.00 2,377,013 407.77 61,837,410 240.88

9,239,356 3,881.22 85,415,126 3,658.14 0 0.00 234,752,916 914.45

11,761,413 4,940.68 85,415,126 3,658.14 2,377,013 407.77 296,590,326 1,155.33

15,629 6.57 26,118 1.12 37,394 6.41 1,237,030 4.82

109,708 46.09 1,075,502 46.06 224,196 38.46 10,589,087 41.25

47 0.02 452 0.02 115 0.02 5,268 0.02

47,611 20.00 466,987 20.00 116,586 20.00 5,134,294 20.00

756,184 5.75% 5,511,483 5.75% 174,601 5.75% 19,868,161 5.75%

803,794 337.65 5,978,470 256.04 291,186 49.95 25,002,455 97.39

230,143 1.75% 1,677,408 1.75% 53,139 1.75% 6,046,832 1.75%

230,143 1.75% 1,677,408 1.75% 53,139 1.75% 6,046,832 1.75%

143 0.06 1,401 0.06 350 0.06 15,403 0.06

2,807,684 1,179.44 29,279 1.25 2,789,485 478.53 70,924,726 276.28

10,343,336 4,344.98 95,822,606 4,103.87 247,048 42.38 274,608,506 1,069.70

13,151,020 5,524.41 95,851,885 4,105.12 3,036,533 520.91 345,533,232 1,345.98

98



Nueces SDA Total - Pharmacy



Member Months 85,160 9,984 2,233 5,874




Total Cost 37,464,642 439.93 8,214,112 822.72 1,237,872 554.30 2,891,770 492.28



Adjustment Factors

PDL Adjustment 0.9859 0.9896 0.9746 0.9487




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






99



Nueces SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

103,252

50,103,514 485.26

-295,118 -2.86

49,808,396 482.40

102,813

57,776,050 561.95

185,063 1.80

60,063,329 584.20

Total*

100

Attachment 3 - Exhibit I.1


Tarrant SDA Total - Medical



Member Months 194,780 12,845 158,315 24,317


Professional 25,280,304 129.79 3,365,165 261.98 0 0.00 0 0.00

Emergency Room 14,710,646 75.52 1,866,792 145.33 0 0.00 0 0.00



Other Acute Care 10,071,075 51.70 1,278,222 99.51 0 0.00 0 0.00

Acute Care Total 111,070,332 570.23 18,616,009 1,449.28 0 0.00 0 0.00


Attendant Care 20,483,979 105.16 13,606,639 1,059.29 31,061,073 196.20 27,325,648 1,123.73


Other Long Term Care 775,638 3.98 5,032,191 391.76 1,941,239 12.26 7,046,318 289.77


Total - All Claims 132,566,741 680.60 37,876,188 2,948.71 33,839,074 213.75 35,584,100 1,463.34



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



101







Acute Care 114,387,875 589.07 20,044,241 1,490.87 0 0.00 0 0.00

LTC 23,811,820 122.63 20,932,163 1,556.91 36,450,828 228.75 40,556,149 1,567.56

Total 138,199,695 711.70 40,976,405 3,047.78 36,450,828 228.75 40,556,149 1,567.56

Capitation Expenses & Refunds 198,327 1.02 12,736 0.95 -23,568 -0.15 5,978 0.23




Fixed Amount 3,883,660 20.00 268,893 20.00 3,187,021 20.00 517,442 20.00


Total 13,327,601 68.63 2,926,794 217.69 6,049,662 37.96 3,203,637 123.83

Risk Margin 2,874,243 1.75% 808,926 1.75% 871,238 1.75% 817,538 1.75%

Premium Tax 2,874,243 1.75% 808,926 1.75% 871,238 1.75% 817,538 1.75%

Maintenance Tax 11,651 0.06 807 0.06 9,561 0.06 1,552 0.06


Acute Care 129,824,975 668.57 22,247,214 1,654.72 -20,777 -0.13 7,478 0.29

LTC 34,417,476 177.24 23,977,152 1,783.40 49,805,832 312.55 46,708,953 1,805.38

Total 164,242,451 845.81 46,224,366 3,438.12 49,785,055 312.42 46,716,431 1,805.67

102





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


8,057 54,566 22,957 475,837

2,495,703 309.76 0 0.00 1,288,025 56.11 32,429,197 68.15

540,089 67.03 0 0.00 557,104 24.27 17,674,631 37.14

1,717,003 213.11 0 0.00 2,107,674 91.81 36,342,951 76.38

5,155,163 639.84 0 0.00 1,410,231 61.43 47,161,258 99.11

756,705 93.92 0 0.00 1,213,875 52.88 13,319,876 27.99

10,664,663 1,323.65 0 0.00 6,576,908 286.49 146,927,913 308.78

54,159 6.72 82,186 1.51 0 0.00 92,613,686 194.63

29,321,900 3,639.31 178,644,964 3,273.92 0 0.00 210,873,899 443.16

11,481 1.42 2,365,665 43.35 0 0.00 17,172,532 36.09

29,387,540 3,647.45 181,092,815 3,318.78 0 0.00 320,660,117 673.89

40,052,203 4,971.11 181,092,815 3,318.78 6,576,908 286.49 467,588,029 982.66

8,214 52,583 24,320 477,968

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9878 1.0000 0.9745

1.0063 1.0000 1.0033

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


103





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



11,155,426 1,358.16 0 0.00 6,997,073 287.71 152,584,614 319.24

30,621,295 3,728.11 179,255,398 3,408.98 0 0.00 331,627,654 693.83

41,776,721 5,086.27 179,255,398 3,408.98 6,997,073 287.71 484,212,268 1,013.06

8,650 1.05 -6,692 -0.13 25,352 1.04 220,782 0.46

350,193 42.64 2,275,206 43.27 849,528 34.93 17,779,746 37.20

236 0.03 1,338 0.03 708 0.03 14,061 0.03

164,273 20.00 1,051,667 20.00 486,399 20.00 9,559,355 20.00

2,680,201 5.75% 11,568,434 5.75% 529,730 5.75% 32,429,043 5.75%

2,844,474 346.31 12,620,101 240.00 1,016,128 41.78 41,988,398 87.85

815,713 1.75% 3,520,828 1.75% 161,222 1.75% 9,869,709 1.75%

815,713 1.75% 3,520,828 1.75% 161,222 1.75% 9,869,709 1.75%

493 0.06 3,155 0.06 1,459 0.06 28,678 0.06

12,350,752 1,503.69 -5,899 -0.11 8,276,573 340.32 172,680,318 361.28

34,261,440 4,171.29 201,196,061 3,826.23 936,119 38.49 391,303,033 818.68

46,612,193 5,674.98 201,190,162 3,826.12 9,212,693 378.81 563,983,351 1,179.96

104



Tarrant SDA Total - Pharmacy



Member Months 192,749 13,097 8,141 23,476




Total Cost 84,800,160 439.95 13,061,207 997.29 5,737,427 704.77 10,528,773 448.50



Adjustment Factors

PDL Adjustment 0.9787 0.9761 0.9844 0.9276




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






105



Tarrant SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

237,462

114,234,363 481.06

-106,796 -0.45

114,127,567 480.61

240,161

132,506,527 551.74

432,290 1.80

137,760,433 573.62

Total*

106

Attachment 3 - Exhibit J.1


Travis SDA Total - Medical



Member Months 111,764 7,817 111,650 19,413


Professional 18,058,909 161.58 3,998,303 511.49 0 0.00 0 0.00

Emergency Room 6,890,512 61.65 639,291 81.78 0 0.00 0 0.00



Other Acute Care 7,476,902 66.90 510,780 65.34 0 0.00 0 0.00

Acute Care Total 63,172,989 565.24 11,726,415 1,500.12 0 0.00 0 0.00


Attendant Care 11,658,147 104.31 9,662,786 1,236.12 18,877,149 169.07 25,595,517 1,318.47


Other Long Term Care 2,586,901 23.15 4,286,244 548.32 978,901 8.77 3,585,807 184.71


Total - All Claims 77,477,107 693.22 25,861,710 3,308.39 20,234,914 181.24 29,663,656 1,528.03



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



107







Acute Care 61,192,286 547.17 11,337,118 1,517.72 0 0.00 0 0.00

LTC 15,848,064 141.71 14,025,359 1,877.60 21,705,575 193.95 31,713,643 1,636.86

Total 77,040,351 688.89 25,362,477 3,395.32 21,705,575 193.95 31,713,643 1,636.86





Fixed Amount 2,236,665 20.00 149,397 20.00 2,238,219 20.00 387,494 20.00


Total 7,545,817 67.47 1,792,353 239.95 3,996,920 35.72 2,493,624 128.71

Risk Margin 1,615,829 1.75% 500,030 1.75% 535,257 1.75% 640,996 1.75%

Premium Tax 1,615,829 1.75% 500,030 1.75% 535,257 1.75% 640,996 1.75%

Maintenance Tax 6,710 0.06 448 0.06 6,715 0.06 1,162 0.06


Acute Care 69,979,169 625.75 12,602,993 1,687.18 -135,085 -1.21 -23,359 -1.21

LTC 22,353,908 199.89 15,970,160 2,137.95 30,721,186 274.51 36,651,701 1,891.73

Total 92,333,077 825.63 28,573,153 3,825.14 30,586,101 273.31 36,628,342 1,890.52

108





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


4,184 35,677 14,280 304,785

1,062,820 254.02 0 0.00 1,699,714 119.03 24,819,746 81.43

173,042 41.36 0 0.00 264,858 18.55 7,967,703 26.14

702,806 167.97 0 0.00 558,070 39.08 12,561,702 41.21

1,962,812 469.12 0 0.00 1,419,145 99.38 29,405,837 96.48

211,086 50.45 0 0.00 424,797 29.75 8,623,565 28.29

4,112,566 982.93 0 0.00 4,366,583 305.78 83,378,553 273.57

69,632 16.64 131,631 3.69 0 0.00 65,994,862 216.53

16,594,643 3,966.21 125,031,726 3,504.55 0 0.00 142,732,900 468.31

134,690 32.19 356,361 9.99 0 0.00 11,928,904 39.14

16,798,966 4,015.05 125,519,718 3,518.23 0 0.00 220,656,666 723.97

20,911,532 4,997.98 125,519,718 3,518.23 4,366,583 305.78 304,035,219 997.54

3,999 36,028 14,386 305,002

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9973 1.0000 0.9600

1.0044 1.0000 1.0019

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


109





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



4,064,738 1,016.33 0 0.00 4,345,796 302.10 80,939,938 265.38

16,412,981 4,103.83 130,199,530 3,613.84 0 0.00 229,905,153 753.78

20,477,719 5,120.16 130,199,530 3,613.84 4,345,796 302.10 310,845,091 1,019.16

18,497 4.63 -40,024 -1.11 91,516 6.36 486,383 1.59

171,735 42.94 1,551,862 43.07 521,247 36.23 11,694,247 38.34

75 0.02 636 0.02 160 0.01 5,730 0.02

79,989 20.00 720,561 20.00 287,710 20.00 6,100,036 20.00

1,314,628 5.75% 8,391,181 5.75% 332,473 5.75% 20,855,221 5.75%

1,394,616 348.70 9,111,742 252.91 620,183 43.11 26,955,256 88.38

400,104 1.75% 2,553,838 1.75% 101,187 1.75% 6,347,241 1.75%

400,104 1.75% 2,553,838 1.75% 101,187 1.75% 6,347,241 1.75%

240 0.06 2,162 0.06 863 0.06 18,300 0.06

4,517,064 1,129.43 -43,402 -1.20 5,207,764 362.01 92,105,144 301.98

18,346,027 4,587.16 145,976,987 4,051.76 574,377 39.93 270,594,345 887.19

22,863,091 5,716.59 145,933,584 4,050.55 5,782,141 401.94 362,699,490 1,189.17

110



Travis SDA Total - Pharmacy



Member Months 110,529 7,665 4,320 14,413


Estimated Incurred Claims 50,516,597 457.04 9,259,079 1,207.90 4,183,866 968.39 7,650,644 530.81


Total Cost 50,335,965 455.41 9,247,059 1,206.33 4,176,905 966.78 7,622,311 528.84



Adjustment Factors

PDL Adjustment 0.9853 0.9917 0.9608 0.9336




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %

Projected Total Cost 64,362,072 575.52 11,153,269 1,493.11 4,059,488 1,015.02 8,013,416 557.05





111



Travis SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

136,928

71,610,186 522.98

-227,945 -1.66

71,382,241 521.31

137,688

84,274,817 612.07

247,838 1.80

87,588,245 636.14

Total*

112

Attachment 3 - Exhibit K.1


MRSA Central SDA Total - Medical



Member Months 134,568 6,494 129,939 16,018


Professional 18,196,529 135.22 1,849,782 284.84 0 0.00 0 0.00

Emergency Room 6,736,056 50.06 542,595 83.55 0 0.00 0 0.00



Other Acute Care 5,711,325 42.44 1,567,260 241.34 0 0.00 0 0.00

Acute Care Total 72,028,286 535.26 8,574,090 1,320.31 0 0.00 0 0.00


Attendant Care 10,574,621 78.58 9,379,796 1,444.38 17,594,925 135.41 21,557,920 1,345.86




Total - All Claims 83,985,246 624.11 19,373,098 2,983.23 18,908,140 145.52 24,428,569 1,525.07



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



113







Acute Care 73,197,153 538.86 9,432,098 1,340.99 0 0.00 0 0.00

LTC 13,350,803 98.29 12,144,857 1,726.67 20,438,516 155.73 27,056,865 1,633.69

Total 86,547,956 637.15 21,576,954 3,067.66 20,438,516 155.73 27,056,865 1,633.69

Capitation Expenses & Refunds 1,056,370 7.78 53,119 7.55 -91,515 -0.70 -11,631 -0.70




Fixed Amount 2,716,726 20.00 140,674 20.00 2,624,908 20.00 331,237 20.00


Total 8,773,571 64.59 1,539,342 218.85 4,400,024 33.53 2,122,139 128.13

Risk Margin 1,843,388 1.75% 425,682 1.75% 540,253 1.75% 545,057 1.75%

Premium Tax 1,843,388 1.75% 425,682 1.75% 540,253 1.75% 545,057 1.75%

Maintenance Tax 8,150 0.06 422 0.06 7,875 0.06 994 0.06


Acute Care 84,365,221 621.08 10,520,225 1,495.69 -98,317 -0.75 -12,495 -0.75

LTC 20,971,220 154.39 13,804,446 1,962.62 30,969,898 235.97 31,158,622 1,881.35

Total 105,336,441 775.47 24,324,671 3,458.31 30,871,581 235.22 31,146,127 1,880.60

114





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


5,644 51,324 10,283 354,270

1,289,220 228.42 0 0.00 797,562 77.56 22,133,093 62.48

262,891 46.58 0 0.00 248,066 24.12 7,789,608 21.99

604,089 107.03 0 0.00 456,586 44.40 14,325,637 40.44

3,289,416 582.82 0 0.00 1,237,641 120.36 37,260,925 105.18

508,619 90.12 0 0.00 878,201 85.40 8,665,404 24.46

5,954,234 1,054.97 0 0.00 3,618,056 351.85 90,174,667 254.54

25,091 4.45 110,121 2.15 0 0.00 59,242,475 167.22

20,717,148 3,670.65 172,663,537 3,364.19 0 0.00 194,477,863 548.95

209,827 37.18 359,867 7.01 0 0.00 6,457,932 18.23

20,952,066 3,712.27 173,133,526 3,373.34 0 0.00 260,178,269 734.41

26,906,299 4,767.24 173,133,526 3,373.34 3,618,056 351.85 350,352,936 988.94

5,727 52,756 10,303 359,463

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9897 1.0000 0.9706

1.0026 1.0000 1.0036

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


115





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



6,187,985 1,080.56 0 0.00 3,627,212 352.04 92,444,448 257.17

21,728,851 3,794.36 182,801,382 3,465.02 0 0.00 277,521,273 772.04

27,916,836 4,874.92 182,801,382 3,465.02 3,627,212 352.04 369,965,721 1,029.22

20,361 3.56 -38,206 -0.72 16,299 1.58 1,004,798 2.80

264,428 46.18 2,426,907 46.00 400,554 38.88 14,576,630 40.55

125 0.02 953 0.02 298 0.03 7,545 0.02

114,532 20.00 1,055,125 20.00 206,069 20.00 7,189,270 20.00

1,794,166 5.75% 11,800,922 5.75% 269,350 5.75% 24,885,970 5.75%

1,908,699 333.30 12,856,047 243.69 475,419 46.14 32,075,240 89.23

546,051 1.75% 3,591,585 1.75% 81,976 1.75% 7,573,991 1.75%

546,051 1.75% 3,591,585 1.75% 81,976 1.75% 7,573,991 1.75%

344 0.06 3,165 0.06 618 0.06 21,568 0.06

6,869,350 1,199.55 -41,049 -0.78 4,242,970 411.80 105,845,904 294.46

24,333,545 4,249.20 205,274,467 3,891.00 441,382 42.84 326,953,579 909.56

31,202,895 5,448.74 205,233,418 3,890.22 4,684,352 454.64 432,799,483 1,204.02

116



MRSA Central SDA Total - Pharmacy



Member Months 134,075 6,705 5,645 10,346




Total Cost 50,352,373 375.55 6,017,465 897.47 3,171,243 561.76 4,686,890 453.01



Adjustment Factors

PDL Adjustment 0.9850 0.9871 0.9762 0.9552




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






117



MRSA Central SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

156,771

64,628,486 412.25

-400,515 -2.55

64,227,971 409.69

158,900

78,373,873 493.23

286,020 1.80

81,512,842 512.98

Total*

118

Attachment 3 - Exhibit L.1


MRSA Northeast SDA Total - Medical



Member Months 205,601 16,156 185,407 53,013


Professional 27,947,567 135.93 5,637,084 348.92 0 0.00 0 0.00

Emergency Room 8,850,380 43.05 1,179,606 73.01 0 0.00 0 0.00



Other Acute Care 7,854,471 38.20 2,825,388 174.88 0 0.00 0 0.00

Acute Care Total 105,452,054 512.90 22,612,864 1,399.66 0 0.00 0 0.00


Attendant Care 17,441,184 84.83 18,355,171 1,136.12 25,014,785 134.92 57,120,663 1,077.48

Nursing Facility 235,805 1.15 1,091,454 67.56 780,156 4.21 5,658,469 106.74



Total - All Claims 126,298,276 614.29 46,936,850 2,905.23 27,724,979 149.54 70,810,674 1,335.72



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



119







Acute Care 107,454,606 520.36 23,588,068 1,423.20 0 0.00 0 0.00

LTC 23,180,874 112.25 25,909,909 1,563.29 29,773,611 160.03 75,694,540 1,430.85

Total 130,635,480 632.61 49,497,977 2,986.49 29,773,611 160.03 75,694,540 1,430.85

Capitation Expenses & Refunds 1,110,097 5.38 80,504 4.86 -935 -0.01 43,032 0.81


Net Reinsurance Cost 0 0.00 0 0.00 0 0.00 0 0.00


Fixed Amount 4,130,046 20.00 331,480 20.00 3,721,006 20.00 1,058,033 20.00


Total 13,251,855 64.17 3,542,246 213.72 6,304,790 33.89 6,105,952 115.42

Risk Margin 2,776,203 1.75% 977,190 1.75% 786,369 1.75% 1,536,323 1.75%

Premium Tax 2,776,203 1.75% 977,190 1.75% 786,369 1.75% 1,536,323 1.75%

Maintenance Tax 12,390 0.06 994 0.06 11,163 0.06 3,174 0.06


Acute Care 123,385,208 597.50 26,255,659 1,584.15 -1,030 -0.01 47,418 0.90

LTC 35,254,940 170.72 29,583,753 1,784.95 44,936,395 241.53 87,742,486 1,658.60

Total 158,640,148 768.22 55,839,412 3,369.10 44,935,365 241.52 87,789,904 1,659.49

120





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


7,453 67,575 13,169 548,374

1,761,191 236.31 0 0.00 1,207,433 91.69 36,553,275 66.66

349,495 46.89 0 0.00 226,958 17.23 10,606,440 19.34

1,595,658 214.10 0 0.00 437,482 33.22 27,327,214 49.83

5,396,920 724.13 0 0.00 1,122,756 85.26 54,996,023 100.29

452,063 60.66 0 0.00 1,019,022 77.38 12,150,944 22.16

9,555,327 1,282.08 0 0.00 4,013,651 304.78 141,633,896 258.28

145,601 19.54 173,854 2.57 0 0.00 118,251,258 215.64

28,778,454 3,861.32 226,373,207 3,349.95 0 0.00 262,917,544 479.45

82,599 11.08 5,612,887 83.06 0 0.00 23,703,660 43.23

29,006,653 3,891.94 232,159,948 3,435.59 0 0.00 404,872,462 738.31

38,561,980 5,174.02 232,159,948 3,435.59 4,013,651 304.78 546,506,358 996.59

7,822 71,001 13,294 554,145

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9921 1.0000 0.9745

1.0022 1.0000 1.0019

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


121





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



10,292,532 1,315.85 0 0.00 4,063,487 305.65 145,398,693 262.38

31,115,893 3,978.00 250,557,859 3,528.95 0 0.00 436,232,685 787.22

41,408,425 5,293.85 250,557,859 3,528.95 4,063,487 305.65 581,631,378 1,049.60

43,552 5.57 -417 -0.01 70,258 5.28 1,346,090 2.43

364,566 46.61 3,298,242 46.45 519,969 39.11 23,168,568 41.81

0 0.00 0 0.00 0 0.00 0 0.00

156,440 20.00 1,420,012 20.00 265,889 20.00 11,082,906 20.00

2,659,475 5.75% 16,174,763 5.75% 311,761 5.75% 39,110,277 5.75%

2,815,915 360.00 17,594,775 247.81 577,650 43.45 50,193,182 90.58

809,405 1.75% 4,922,754 1.75% 94,884 1.75% 11,903,128 1.75%

809,405 1.75% 4,922,754 1.75% 94,884 1.75% 11,903,128 1.75%

469 0.06 4,260 0.06 798 0.06 33,249 0.06

11,432,601 1,461.60 -460 -0.01 4,848,961 364.74 165,968,357 299.50

34,819,136 4,451.44 281,300,687 3,961.95 572,968 43.10 514,210,365 927.93

46,251,737 5,913.04 281,300,227 3,961.94 5,421,929 407.83 680,178,722 1,227.44

122



MRSA Northeast SDA Total - Pharmacy



Member Months 204,338 16,293 7,370 13,167




Total Cost 76,376,961 373.78 14,539,157 892.37 5,395,792 732.09 5,509,037 418.41



Adjustment Factors

PDL Adjustment 0.9939 0.9945 0.9949 0.9780




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






123



MRSA Northeast SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

241,168

101,917,330 422.60

-96,384 -0.40

101,820,947 422.20

244,193

121,084,917 495.86

439,547 1.80

125,932,087 515.71

Total*

124

Attachment 3 - Exhibit M.1


MRSA West SDA Total - Medical



Member Months 141,958 7,196 196,107 30,292


Professional 19,643,690 138.38 1,902,837 264.43 0 0.00 0 0.00

Emergency Room 6,435,987 45.34 594,884 82.67 0 0.00 0 0.00



Other Acute Care 8,917,645 62.82 2,084,701 289.70 0 0.00 0 0.00

Acute Care Total 74,070,626 521.78 10,081,517 1,400.99 0 0.00 0 0.00


Attendant Care 12,033,863 84.77 9,805,151 1,362.58 34,280,463 174.80 34,282,504 1,131.73


Other Long Term Care 582,620 4.10 1,062,194 147.61 2,195,810 11.20 4,474,025 147.70


Total - All Claims 86,840,772 611.74 21,216,265 2,948.34 37,201,667 189.70 40,010,678 1,320.83



Acute Care

FY2018 2.2 % 2.0 % 2.2 % 2.0 %

FY2019 1.6 % 1.2 % 1.6 % 1.2 %

Long Term Care

FY2018 5.2 % 2.4 % 3.8 % 3.7 %

FY2019 5.0 % 1.4 % 3.1 % 3.3 %




Long Term Care 1.0000 1.0000 1.0000 1.0000



125







Acute Care 73,944,320 526.21 11,834,404 1,420.94 0 0.00 0 0.00

LTC 13,998,201 99.62 13,381,277 1,606.67 39,123,992 203.01 43,598,961 1,414.90

Total 87,942,521 625.82 25,215,680 3,027.61 39,123,992 203.01 43,598,961 1,414.90



Net Reinsurance Cost 5,621 0.04 333 0.04 7,709 0.04 1,233 0.04


Fixed Amount 2,810,456 20.00 166,571 20.00 3,854,321 20.00 616,281 20.00


Total 8,934,315 63.58 1,799,455 216.06 7,009,006 36.37 3,500,912 113.61

Risk Margin 1,863,783 1.75% 496,965 1.75% 960,122 1.75% 877,931 1.75%

Premium Tax 1,863,783 1.75% 496,965 1.75% 960,122 1.75% 877,931 1.75%

Maintenance Tax 8,431 0.06 500 0.06 11,563 0.06 1,849 0.06


Acute Care 84,858,647 603.88 13,173,901 1,581.77 -145,707 -0.76 -18,895 -0.61

LTC 21,643,251 154.02 15,224,075 1,827.93 55,009,804 285.44 50,186,381 1,628.68

Total 106,501,898 757.90 28,397,975 3,409.71 54,864,097 284.69 50,167,486 1,628.07

126





Member Months


Professional

Emergency Room

Outpatient Facility

Inpatient Facility

Other Acute Care

Acute Care Total


Attendant Care

Nursing Facility



Total - All Claims



Acute Care

FY2018

FY2019

Long Term Care

FY2018

FY2019




Long Term Care


Total


5,426 55,518 13,182 449,679

1,164,271 214.57 0 0.00 1,232,950 93.53 23,943,748 53.25

297,319 54.80 0 0.00 252,312 19.14 7,580,502 16.86

722,962 133.24 0 0.00 758,696 57.56 15,167,122 33.73

3,922,101 722.83 0 0.00 1,121,636 85.09 35,930,672 79.90

730,968 134.72 0 0.00 1,045,223 79.29 12,778,538 28.42

6,837,622 1,260.16 0 0.00 4,410,817 334.61 95,400,582 212.15

21,393 3.94 73,415 1.32 0 0.00 90,496,788 201.25

20,839,113 3,840.60 185,020,613 3,332.62 0 0.00 208,260,336 463.13

698 0.13 69,064 1.24 0 0.00 8,384,411 18.65

20,861,204 3,844.67 185,163,091 3,335.19 0 0.00 307,141,535 683.02

27,698,826 5,104.83 185,163,091 3,335.19 4,410,817 334.61 402,542,117 895.18

5,719 55,766 13,202 447,069

2.0 % 2.0 % 0.8 %

1.2 % 1.2 % 1.9 %

0.8 % 1.1 % 0.0 %

1.4 % 1.6 % 0.0 %

0.9940 1.0000 0.9457

1.0029 1.0000 1.0010

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000


127





Acute Care

LTC

Total





Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Acute Care

LTC

Total

Total



7,416,527 1,296.73 0 0.00 4,295,451 325.36 97,490,702 218.07

22,475,465 3,929.69 191,044,209 3,425.83 0 0.00 323,622,104 723.88

29,891,992 5,226.42 191,044,209 3,425.83 4,295,451 325.36 421,112,806 941.94

55 0.01 -45,351 -0.81 -8,029 -0.61 519,613 1.16

252,168 44.09 2,447,545 43.89 497,001 37.65 16,995,551 38.02

229 0.04 2,231 0.04 528 0.04 17,883 0.04

114,388 20.00 1,115,317 20.00 264,046 20.00 8,941,380 20.00

1,917,248 5.75% 12,327,955 5.75% 319,959 5.75% 28,361,221 5.75%

2,031,636 355.22 13,443,273 241.07 584,005 44.24 37,302,601 83.44

583,510 1.75% 3,751,986 1.75% 97,379 1.75% 8,631,676 1.75%

583,510 1.75% 3,751,986 1.75% 97,379 1.75% 8,631,676 1.75%

343 0.06 3,346 0.06 792 0.06 26,824 0.06

8,204,162 1,434.44 -47,516 -0.85 5,016,846 380.00 111,041,438 248.38

25,139,281 4,395.44 214,446,741 3,845.48 547,659 41.48 382,197,192 854.90

33,343,444 5,829.88 214,399,225 3,844.63 5,564,506 421.48 493,238,630 1,103.27

128



MRSA West SDA Total - Pharmacy



Member Months 140,573 7,539 5,456 13,210




Total Cost 57,245,386 407.23 6,641,241 880.87 3,641,557 667.41 5,947,092 450.19



Adjustment Factors

PDL Adjustment 0.9776 0.9840 0.9690 0.9335




Risk Margin 1.75 % 1.75 % 1.75 % 1.75 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 %






129



MRSA West SDA Total - Pharmacy


Member Months




Total Cost



Adjustment Factors

PDL Adjustment

Carve-In Adjustment



Risk Margin

Premium Tax





Amount pmpm

166,778

73,803,851 442.53

-328,573 -1.97

73,475,277 440.56

167,773

85,185,634 507.74

301,991 1.80

88,588,213 528.02

Total*

130

131

Attachment 4

Trend Analysis - Medical

The FY2019 rating methodology uses assumed trend factors to adjust the base period claims cost

to the projection period. The trend factors used in this analysis are a combination of utilization

and inflation components. Separate trend factors were developed by type of service – acute care

and long term care services. The projected trend rate assumptions were developed by the actuary

based on an analysis of recent experience under the various health plans. A single trend

assumption applied to all service areas but varies by type of service, risk group and year.

The trend analysis included a review of health plan claims experience data through February

2018. Based on this information, estimates of monthly incurred claims were made through

December 2017. The claims cost and trend experience was reviewed separately by service area,

type of service and risk group. The service area trends were then combined into a statewide

average using a weighted average formula with estimated incurred claims as the weights.

Exhibit A provides a summary of the FY2015, FY2016, FY2017 and FY2018 trends by service

area, type of service and risk group. The FY2018 trend represents the trend during the period

September 2017 through December 2017. All trends have been calculated as the average cost

per member per month during the specified time period compared to the average cost during the

same time period from the prior year. For example, the FY2017 trend is calculated as the

average cost per member per month during FY2017 divided by the average cost per member per

month during FY2016.

All trends have been adjusted to remove the impact of the various provider reimbursement

changes that have impacted the program. These adjustments are made for all items that have

materially impacted historical costs and have distorted the trend from one time period to the next.

For example, the carve in of mental health rehabilitation services and targeted case management

on September 1, 2014 distorts the FY2015 trend given that the carve in of these services

increases the average cost. As a result, the FY2015 observed trends were adjusted to remove the

impact of the increased cost associated with these services to ensure the average cost during

FY2014 and FY2015 are based on comparable services and reimbursement levels and the

underlying trend is calculated.

On Exhibit A, the service area trends have been combined into a statewide weighted average by

weighting the service area specific trends by each area’s proportion of the total incurred claims.

The FY2018 trend assumptions were developed from two components: (i) the actual estimated

trend for the period September 2017 through December 2017 and (ii) the projected trend for the

period January 2018 through August 2018. The trends for the final eight months of FY2018

were projected using statewide experience from FY2015, FY2016, FY2017 and 9/2017-12/2017.

The weighting of each time period was based on the number of months within each time period.

The OCC and HCBS risk groups have been in STAR+PLUS the entire time during the observed

fiscal years and the historical trends were blended using the following: 3/10 weighting for

FY2015, FY2016 and FY2017 and 1/10 weighting to the first four months of FY2018. The IDD

risk group entered STAR+PLUS on September 1, 2014 and therefore do not have trend

information available for FY2015. The historical trends for this risk group were weighted using

the following: 3/7 weighting for FY2016 and FY2017 and 1/7 for FY2018. The nursing facility

132

risk group was new to the STAR+PLUS program on March 1, 2015 and therefore the observed

trend for FY2016 only included six months (March 2016 through August 2016). As a result, the

observed trends were blended using the following: 3/11 weighting for FY2016, 6/11 weighting

for FY2017 and 2/11 weighting for the first four months of FY2018.

The FY2019 trend assumptions were then developed from a simple average of the FY2015,

FY2016, FY2017 and FY2018 trends. Exhibit B provides a summary of the statewide average

trends by type of service and risk group for FY2015, FY2016, FY2017 and the first four months

of FY2018. In addition, the exhibit includes the trend assumptions developed based on the

described methodology for FY2018 and FY2019.

An exception was made for the Medicaid Only Nursing Facility risk group’s acute care trend

assumptions. The observed trends for this relatively small risk group have shown large

fluctuation during the initial observation periods. The methodology described above would

result in negative trend assumptions which are primarily driven by a large reduction in the

observed trend during the first four months of FY2018. As a result, we believe a more

reasonable assumption is to continue assuming that the acute care trends for this risk group will

be similar to the acute care trends for the HCBS risk group, which most closely resembles the

demographics of this population. Such fluctuation doesn’t appear to impact the long term care

trends for this group and no such adjustments were made for the long term care assumptions.

Although the acute care medical trends were reviewed by component, a single acute care trend

assumption was selected and applied in aggregate. The MCO is paid a single capitation rate that

does not vary by medical component. Splitting the analysis into separate components does not

add any additional accuracy to the analysis but could increase the probability of distortions in the

projection due to reporting differences among fiscal years, small sample sizes in a given category

of service, or variations in the trend projections that could emerge for a category. There is

significant interaction amongst all categories of service as MCOs may shift cost away from

inpatient toward outpatient and looking at an individual category in isolation could lead to

overgeneralizations.

Use of the aggregate trend captures all interactions between categories of service, including the

ongoing shifts that occur, and is reflective of the expected level of trend in future periods.

Because historical trends are adjusted to account for provider reimbursement changes, the

primary driver of the trend assumptions is utilization changes. As a result, we have not separated

the trend assumption into separate utilization and inflation components. Rather our trend

combines the full impact of inflation, utilization, changes in mixes of services and all other cost

drivers into a single assumption.

Although trends were reviewed at the SDA level, it was determined that a statewide average

trend is appropriate as the long term variation in average trends among the service areas is

relatively small. SDA trends will continue to be monitored in future rate developments.

Trend Analysis - Pharmacy


(CY2017) claims cost to the rating period (FY2019). The trend rate assumptions were developed

by the actuary based on an analysis of recent pharmacy claims experience under the

STAR+PLUS program and the actuary’s professional judgment regarding anticipated future cost

133

changes. The trend rate assumptions vary by risk group but are the same for all service areas.

The trend analysis included a review of STAR+PLUS utilization and cost experience data paid

through March 2018. Utilization (days supply per member) and cost per service (plan payments

per days supply) statistics were developed by risk group and drug type (brand, generic and

specialty) through February 2018. From this experience, the average annual utilization and cost

per service were determined for each of the five 12-month periods ending February 2018.

Only those drugs covered under the capitated arrangement are included in the trend analysis.

Anti-viral agents used for the treatment of Hepatitis C virus and the drug Orkambi are not

included in the analysis as those drugs are currently carved out of the managed care contract. In

addition, experience for the drugs Tamiflu and Makena were removed from our trend analysis.

Tamiflu was removed due to the significant variation in the intensity of flu season from year to

year. Makena was removed due to its one-time distortion of pharmacy trends for pregnant

women.

An additional adjustment to the trend analysis was made to the recent experience for the drug

Nasonex. Nasonex was removed from the preferred drug list (PDL) on July 27, 2017. The PDL

change resulted in Nasonex utilization shifting to Fluticasone (a generic drug in the same drug

class as Nasonex). Our rating methodology includes an adjustment factor to recognize the

impact of the PDL changes (discussed in Attachment 5). Since the PDL change for Nasonex

overlaps the experience period used in our trend analysis, we adjusted the trend analysis in order

to avoid “double-counting” the cost impact of the Nasonex change. For purposes of our trend

analysis, we revised the utilization and cost experience for the period between the PDL change

(7/27/2017) and the end of the trend experience period (2/28/2018) for Nasonex and Fluticasone

to reflect the experience prior to the PDL change. Please note that we did not change total

pharmacy utilization. We only changed the mix of services between the two drugs.

Please note that while excluded from (or adjusted in) the pharmacy trend analysis, the historical

claims for Tamiflu, Makena and Nasonex were included in the base period experience used in

developing the pharmacy component of the rate.

The STAR+PLUS pharmacy trend assumptions for the remainder of FY2018 and all of FY2019

were developed by risk group using the following formula. For the OCC and HCBS risk groups,

the utilization and cost per service trend assumptions were set equal to one-sixth of the

experience trend rate for the 12-month period ending February 2016 plus two-sixths of the

experience trend rate for the 12-month period ending February 2017 plus three-sixths of the

experience trend rate for the 12-month period ending February 2018. For the IDD and NF risk

groups, since they only entered STAR+PLUS in September 2014 and March 2015, respectively,

the utilization and cost per service trend assumptions were set equal to one-third of the

experience trend rate for the 12-month period ending February 2017 plus two-thirds of the

experience trend rate for the 12-month period ending February 2018. The final cost trend

assumptions were then determined by applying the assumed utilization and cost per service

trends by individual drug type to actual experience for the 12-month period ending February

2018 and combining the results into a single trend assumption for each risk group.

Exhibit C includes a summary of the STAR+PLUS pharmacy trend analysis and the derivation

of the trend assumptions used in the rating analysis.

134

Information on the medical and pharmacy trend assumptions for the MBCCP population can be

found in Attachment 10.


FY2019 STAR+PLUS Rating

Analysis of Trend Factors - Medical

Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis

Medicaid Only OCC

FY2015

-Professoinal 1.006 1.013 0.868 0.991 0.898 0.929 0.917 1.012 1.093 0.903

-Outpatient - ER 0.937 0.912 0.910 1.089 1.053 0.993 0.910 1.070 1.030 1.025

-Outpatient - Non ER 0.869 0.957 0.798 1.046 0.844 1.124 0.958 1.082 0.920 1.139

-Inpatient 0.954 0.950 0.940 0.960 0.946 0.980 1.131 0.875 1.002 1.043

-Other Acute Care 1.020 1.072 1.260 1.026 0.996 1.021 1.107 0.880 1.132 1.118

-Total Acute Care 0.967 0.970 0.978 0.998 0.927 0.988 1.038 0.955 1.042 1.001

-Long Term Care 0.998 1.099 1.062 1.046 1.035 1.121 0.961 1.053 1.079 1.024

FY2016

-Professoinal 1.055 1.036 1.089 1.116 1.059 1.108 1.012 1.043 1.073 0.923

-Outpatient - ER 0.947 1.035 1.052 1.090 1.212 1.100 1.095 1.116 0.955 1.021


-Inpatient 1.031 1.046 0.883 1.054 1.027 0.941 0.800 0.995 1.014 0.995

-Other Acute Care 1.047 0.992 1.258 1.162 0.967 0.989 1.167 0.960 1.646 1.410

-Total Acute Care 1.025 1.028 1.019 1.058 1.042 0.987 0.932 1.014 1.042 1.005

-Long Term Care 0.954 1.046 1.032 1.022 0.987 1.060 0.886 1.020 0.863 1.067

FY2017

-Professoinal 1.057 1.011 1.105 0.971 0.947 0.972 1.048 0.964 0.953 1.037

-Outpatient - ER 1.008 0.977 1.117 1.092 1.177 1.152 1.238 1.051 0.863 0.974


-Inpatient 1.094 1.064 1.133 1.021 0.945 1.117 1.117 1.126 0.900 1.135

-Other Acute Care 1.093 1.059 0.933 1.027 1.000 1.051 0.918 1.026 1.009 1.078

-Total Acute Care 1.070 1.015 1.073 1.014 0.972 1.054 1.100 1.045 0.927 1.068

-Long Term Care 1.113 1.108 1.094 1.102 1.061 1.071 0.973 1.140 1.070 0.993

FY2018

-Professoinal 0.988 1.029 1.023 0.977 1.019 1.014 1.065 1.035 1.053 0.908

-Outpatient - ER 0.954 0.797 0.915 0.939 1.142 1.162 1.286 1.002 0.924 0.998


-Inpatient 1.167 1.070 1.154 1.021 0.888 1.097 1.207 1.040 1.136 0.931

-Other Acute Care 1.094 1.009 1.054 1.119 0.937 0.948 1.054 1.112 1.098 0.961

-Total Acute Care 1.081 0.985 1.075 1.006 1.005 1.056 1.138 1.056 1.083 0.947

-Long Term Care 1.001 1.087 1.111 1.085 1.015 1.029 0.993 1.055 1.086 0.974

135



Analysis of HMO Trend Factors - Medical

MRSA MRSA MRSA Weighted

Central Northeast West Average

Medicaid Only OCC

FY2015

-Professoinal 0.980

-Outpatient - ER 1.010

-Outpatient - Non ER 0.977

-Inpatient 0.967

-Other Acute Care 1.066

-Total Acute Care 0.987

-Long Term Care 1.047

FY2016

-Professoinal 1.071 1.091 1.081 1.071

-Outpatient - ER 1.116 1.017 1.203 1.054

-Outpatient - Non ER 1.004 0.894 0.974 0.968

-Inpatient 1.000 1.080 1.040 1.026

-Other Acute Care 0.994 1.045 1.203 1.140

-Total Acute Care 1.026 1.035 1.069 1.035

-Long Term Care 1.117 1.001 1.021 1.005

FY2017

-Professoinal 1.022 1.041 1.023 1.003

-Outpatient - ER 1.018 0.997 1.061 1.031


-Inpatient 1.048 0.947 0.993 1.034

-Other Acute Care 0.965 1.044 1.028 1.029

-Total Acute Care 1.043 1.012 1.021 1.021

-Long Term Care 1.157 1.212 1.139 1.097

FY2018

-Professoinal 0.984 1.000 1.003 1.001

-Outpatient - ER 1.119 1.228 1.092 0.993


-Inpatient 1.090 0.980 1.037 1.058

-Other Acute Care 1.093 1.071 0.976 1.053

-Total Acute Care 1.076 1.048 1.022 1.033

-Long Term Care 1.063 1.119 1.087 1.056

136





Medicaid Only HCBS

FY2015

-Professoinal 0.998 0.981 0.933 1.015 0.947 0.979 0.792 0.999 1.104 1.033

-Outpatient - ER 0.797 0.856 1.229 1.053 1.122 0.934 0.774 1.004 1.009 1.123


-Inpatient 0.913 0.640 0.827 0.817 1.048 0.787 1.050 1.128 0.881 0.820

-Other Acute Care 1.098 0.985 1.088 1.083 1.099 0.965 1.129 0.885 1.002 0.983

-Total Acute Care 0.975 0.802 0.949 0.928 1.025 0.906 0.983 1.022 0.987 0.943

-Long Term Care 1.047 0.991 0.990 1.029 0.999 0.937 0.972 1.062 1.039 0.973

FY2016

-Professoinal 1.154 1.171 1.188 1.124 1.140 1.128 1.207 1.107 1.190 1.150

-Outpatient - ER 1.048 1.026 1.145 1.234 1.221 1.132 1.332 1.226 1.118 1.152


-Inpatient 0.971 1.208 1.010 1.023 1.106 1.208 1.434 0.958 0.993 1.093

-Other Acute Care 0.969 1.024 1.645 1.116 0.990 0.830 1.410 1.058 2.067 1.443

-Total Acute Care 0.983 1.094 1.083 1.065 1.071 1.090 1.280 1.042 1.073 1.090

-Long Term Care 0.903 0.911 0.943 0.975 0.957 0.874 0.989 0.965 0.988 0.947

FY2017

-Professoinal 1.167 0.921 1.151 0.857 1.003 0.917 1.083 0.842 0.885 0.970

-Outpatient - ER 1.068 0.869 1.000 0.999 1.126 1.148 0.929 1.038 0.769 0.946


-Inpatient 1.048 0.952 1.027 0.998 0.981 1.020 0.836 1.047 1.021 1.001

-Other Acute Care 1.123 0.907 1.076 1.035 1.100 0.939 1.069 0.950 1.042 0.787

-Total Acute Care 1.100 0.923 1.049 0.953 1.032 0.977 1.023 0.959 0.991 0.963

-Long Term Care 1.046 0.978 1.117 1.083 1.105 1.041 1.120 1.050 1.117 1.113

FY2018

-Professoinal 1.088 0.857 1.130 0.952 1.065 1.110 1.012 1.076 0.851 0.770

-Outpatient - ER 0.879 0.833 1.059 0.791 1.185 1.021 1.072 0.765 0.856 1.239


-Inpatient 1.227 0.695 1.097 1.094 1.226 1.113 0.816 0.994 0.979 1.081

-Other Acute Care 1.072 0.908 1.015 1.075 1.186 0.961 0.849 1.019 1.194 1.016

-Total Acute Care 1.143 0.796 1.017 1.040 1.140 1.057 0.916 0.983 1.024 0.937

-Long Term Care 1.019 0.989 1.071 1.056 1.071 1.020 0.945 0.997 1.134 1.099

137






Medicaid Only HCBS

FY2015

-Professoinal 1.003

-Outpatient - ER 0.998

-Outpatient - Non ER 0.915

-Inpatient 0.863

-Other Acute Care 1.049

-Total Acute Care 0.944


FY2016

-Professoinal 1.070 1.152 1.191 1.145

-Outpatient - ER 1.398 1.262 1.778 1.182


-Inpatient 1.076 1.073 1.057 1.074

-Other Acute Care 1.002 1.394 1.042 1.135

-Total Acute Care 1.075 1.156 1.099 1.077

-Long Term Care 0.879 0.936 0.981 0.946

FY2017

-Professoinal 1.010 0.945 1.267 0.968

-Outpatient - ER 1.096 0.993 1.217 0.991


-Inpatient 1.114 1.102 1.241 1.021

-Other Acute Care 0.952 1.027 1.292 1.049

-Total Acute Care 1.073 1.055 1.216 1.009

-Long Term Care 0.967 1.097 1.088 1.071

FY2018

-Professoinal 1.072 1.104 1.248 1.008

-Outpatient - ER 0.933 1.337 0.915 0.953


-Inpatient 1.064 1.042 0.935 1.053

-Other Acute Care 0.760 1.167 0.810 1.053

-Total Acute Care 0.983 1.178 0.949 1.036

-Long Term Care 0.957 1.050 1.045 1.045

138





Medicaid Only Nursing Facility

FY2015

-Professoinal

-Outpatient - ER

-Outpatient - Non ER

-Inpatient

-Other Acute Care

-Total Acute Care

-Long Term Care

FY2016

-Professoinal 1.101 1.229 1.336 1.018 1.060 1.082 0.870 1.187 0.967 1.050

-Outpatient - ER 0.889 1.519 2.009 1.026 0.830 1.263 1.136 1.126 0.732 0.831


-Inpatient 0.850 1.361 1.853 0.781 0.575 0.895 0.977 1.647 0.908 0.912

-Other Acute Care 0.859 1.050 0.907 0.742 0.767 0.665 1.218 0.965 2.664 0.546

-Total Acute Care 0.908 1.363 1.416 0.840 0.677 0.942 1.046 1.369 0.982 0.907

-Long Term Care 0.988 1.055 1.042 1.049 1.040 1.005 1.050 1.024 0.999 1.045

FY2017

-Professoinal 1.063 0.984 1.161 1.066 1.300 0.962 1.106 0.795 1.161 1.188

-Outpatient - ER 1.093 1.012 2.168 0.925 1.353 1.124 1.476 1.162 0.837 1.288


-Inpatient 0.989 0.987 1.433 1.016 1.121 0.793 1.332 0.739 0.871 1.044

-Other Acute Care 1.108 1.158 0.964 0.792 1.216 1.494 1.052 0.835 1.034 1.341

-Total Acute Care 1.008 0.987 1.288 1.013 1.156 0.906 1.260 0.778 0.944 1.148

-Long Term Care 0.991 1.003 0.985 1.038 1.014 1.007 0.977 1.016 0.960 1.011

FY2018

-Professoinal 0.799 0.791 0.682 1.032 0.599 0.812 0.844 0.797 0.891 1.001

-Outpatient - ER 0.897 0.550 0.713 1.024 0.896 1.347 0.834 0.907 0.999 1.308


-Inpatient 0.822 0.690 0.342 1.039 0.475 0.757 0.617 1.190 0.821 1.259

-Other Acute Care 1.360 0.992 0.434 0.809 1.518 0.855 1.287 0.656 0.771 1.087

-Total Acute Care 0.856 0.730 0.517 1.012 0.678 0.846 0.688 1.006 0.854 1.124

-Long Term Care 0.993 0.934 0.940 1.001 0.977 0.925 1.041 0.928 1.000 0.986

139






Medicaid Only Nursing Facility

FY2015

-Professoinal

-Outpatient - ER


-Inpatient

-Other Acute Care

-Total Acute Care

-Long Term Care

FY2016

-Professoinal 1.066 0.868 1.129 1.059

-Outpatient - ER 1.145 0.907 1.269 1.112


-Inpatient 0.858 0.713 1.185 1.004

-Other Acute Care 0.867 0.592 1.499 1.199

-Total Acute Care 0.922 0.756 1.177 1.015

-Long Term Care 1.035 1.078 1.040 1.036

FY2017

-Professoinal 0.915 0.915 0.952 1.046

-Outpatient - ER 0.883 0.898 0.944 1.021


-Inpatient 0.965 1.003 1.046 1.004

-Other Acute Care 0.888 1.008 1.137 1.072

-Total Acute Care 0.968 1.012 1.006 1.014

-Long Term Care 1.019 1.020 1.048 1.010

FY2018

-Professoinal 0.946 0.834 0.793 0.881

-Outpatient - ER 1.057 1.069 0.782 0.947


-Inpatient 0.740 0.823 0.897 0.855

-Other Acute Care 0.979 1.122 1.391 1.111

-Total Acute Care 0.837 0.883 0.910 0.875

-Long Term Care 1.064 1.059 0.992 0.995

140





IDD

FY2015

-Professoinal

-Outpatient - ER


-Inpatient

-Other Acute Care

-Total Acute Care

-Long Term Care

FY2016

-Professoinal 1.104 1.041 1.102 0.924 0.953 0.996 1.209 0.994 0.890 1.137

-Outpatient - ER 1.042 1.031 0.975 0.940 1.166 1.396 1.103 0.880 1.131 0.979


-Inpatient 0.985 0.987 1.057 0.811 0.776 0.461 0.994 0.867 0.694 0.901

-Other Acute Care 1.188 1.027 0.725 0.984 1.152 0.699 1.287 0.951 1.344 0.982

-Total Acute Care 1.096 1.021 1.024 0.895 0.992 0.773 1.115 0.921 0.978 1.014

FY2017

-Professoinal 1.093 1.171 1.088 1.037 1.073 0.843 1.100 0.764 1.097 0.872

-Outpatient - ER 1.033 1.159 0.984 1.004 1.212 0.808 1.150 1.137 0.889 0.838


-Inpatient 1.260 1.567 1.459 0.951 0.969 1.919 0.996 0.823 0.994 1.483

-Other Acute Care 1.127 0.915 1.271 0.952 1.032 0.839 0.863 1.106 0.933 1.126

-Total Acute Care 1.135 1.149 1.151 0.993 1.019 1.133 1.014 0.922 0.972 1.077

FY2018

-Professoinal 0.938 1.172 0.943 1.029 0.992 1.152 1.040 1.085 1.119 0.998

-Outpatient - ER 1.178 0.578 1.673 1.042 1.063 1.882 1.114 0.960 0.924 1.531


-Inpatient 0.744 0.759 0.709 0.943 0.802 4.241 1.382 0.520 0.753 1.364

-Other Acute Care 0.782 0.933 1.521 0.838 0.918 1.397 1.242 0.518 1.097 1.668

-Total Acute Care 0.823 0.870 0.995 0.973 0.919 1.491 1.219 0.662 0.969 1.187

141






IDD

FY2015

-Professoinal

-Outpatient - ER


-Inpatient

-Other Acute Care

-Total Acute Care

-Long Term Care

FY2016

-Professoinal 1.288 1.001 1.063 1.029

-Outpatient - ER 1.168 1.009 1.143 1.043


-Inpatient 1.669 0.768 0.766 0.901

-Other Acute Care 1.061 0.991 0.985 1.079

-Total Acute Care 1.287 0.918 0.933 0.989

FY2017

-Professoinal 0.894 1.112 1.085 1.036

-Outpatient - ER 1.232 1.019 1.093 1.034


-Inpatient 1.138 1.223 1.092 1.202

-Other Acute Care 1.085 1.161 0.961 1.028

-Total Acute Care 1.084 1.124 1.085 1.060

FY2018

-Professoinal 0.962 0.858 1.116 1.030

-Outpatient - ER 1.134 1.552 0.932 1.129


-Inpatient 0.799 1.101 0.863 1.014

-Other Acute Care 1.045 1.172 0.889 1.004

-Total Acute Care 0.950 1.135 0.991 0.986

142





Dual Eligible OCC

FY2015

-Long Term Care 1.002 1.054 1.048 1.011 0.993 1.021 0.954 1.014 1.032 0.928

FY2016

-Long Term Care 1.006 1.022 1.033 1.036 0.995 0.996 0.924 1.034 1.152 0.994

FY2017

-Long Term Care 1.086 1.076 1.080 1.072 1.034 1.091 1.067 1.071 1.058 1.087

FY2018

-Long Term Care 1.064 1.077 1.089 1.112 1.003 1.124 1.044 0.974 1.130 1.090

Dual Eligible HCBS

FY2015

-Long Term Care 1.038 1.016 0.986 1.039 1.025 0.999 0.989 1.041 1.017 1.010

FY2016

-Long Term Care 0.980 0.987 0.948 0.991 0.998 0.962 1.029 1.033 1.032 0.957

FY2017

-Long Term Care 1.052 1.030 1.038 1.091 1.074 1.028 1.086 1.082 1.055 1.086

FY2018

-Long Term Care 1.042 1.040 1.068 1.040 1.053 1.008 1.041 0.989 1.086 1.064

Dual Eligible Nursing Facility

FY2016 1.047 1.035 1.006 1.012 1.014 1.029 0.995 1.041 0.998 1.010

-Long Term Care

FY2017 1.036 1.018 1.045 1.019 1.021 1.007 1.006 1.011 1.010 1.017

-Long Term Care

FY2018 1.007 1.008 0.949 0.985 1.006 0.935 1.034 0.919 1.031 0.992

-Long Term Care

143






Dual Eligible OCC

FY2015


FY2016

-Long Term Care 1.080 1.043 0.943 1.015

FY2017

-Long Term Care 1.081 1.175 1.102 1.063

FY2018

-Long Term Care 0.996 1.074 1.060 1.052

Dual Eligible HCBS

FY2015


FY2016

-Long Term Care 1.032 1.097 1.026 1.006

FY2017

-Long Term Care 1.050 1.067 1.046 1.065

FY2018

-Long Term Care 0.976 1.030 1.081 1.044

Dual Eligible Nursing Facility

FY2016 1.032 1.028 1.038 1.023

-Long Term Care

FY2017 1.012 1.017 1.021 1.018

-Long Term Care

FY2018 1.002 1.021 1.001 1.000

-Long Term Care

144



Trend Assumptions - Medical

FY2015 FY2016 (2) FY2017 9/17-12/17 (3) 1/18-8/18 (4) FY2018 (5) FY2019 (6)

Statewide Average Trend (1)

Acute Care

Medicaid Only OCC -1.3 % 3.5 % 2.1 % 3.3 % 1.6 % 2.2 % 1.6 %

Medicaid Only HCBS -5.6 % 7.7 % 0.9 % 3.6 % 1.2 % 2.0 % 1.2 %

Medicaid Only NF (7) 1.5 % 1.4 % -12.5 % -1.1 % 2.0 % 1.2 %

IDD -1.1 % 6.0 % -1.4 % 1.9 % 0.8 % 1.9 %

Long Term Care

Medicaid Only OCC 4.7 % 0.5 % 9.7 % 5.6 % 5.0 % 5.2 % 5.0 %

Medicaid Only HCBS 1.5 % -5.4 % 7.1 % 4.5 % 1.4 % 2.4 % 1.4 %

Medicaid Only NF 3.6 % 1.0 % -0.5 % 1.4 % 0.8 % 1.4 %

Dual Eligible OCC 0.7 % 1.5 % 6.3 % 5.2 % 3.1 % 3.8 % 3.1 %

Dual Eligible HCBS 2.4 % 0.6 % 6.5 % 4.4 % 3.3 % 3.7 % 3.3 %

Dual Eligible NF 2.3 % 1.8 % 0.0 % 1.6 % 1.1 % 1.6 %

Footnotes

(1) All trends are net of reimbursement changes.

(2) Nursing facility population was carved into managed care on 3/1/2015. FY2016 trend for nursing facility is for the period 3/16-8/16.

(3) Average trend during the period 9/1/2017-12/31/2017.

(4) Assumed trend during the period 1/1/2018-8/31/2018. Equals weighted average of the Statewide FY2015, FY2016, FY2017 and 9/17-12/17 trends.

Weighted based on number of months.

(5) Combined 9/17-12/17 and 1/18-8/18 into single trend assumption based on number of months.

(6) Average trend during FY2015-FY2018.

(7) Due to relatively small size and large fluctuation in initial acute care costs, Medicaid Only nursing facility trends set equal to average

Medicaid Only HCBS trend for acute care services only.

Trend Assumptions

145



STAR+PLUS Pharmacy Trends

Case-Mix

OCC HCBS IDD NF Total Adjusted

Annual Trend in Number of Scripts per Member per Month

Brand Drugs

3/2013-2/2014 -7.7 % -6.7 % -7.2 % -7.6 %

3/2014-2/2015 -11.9 % -10.2 % -11.2 % -4.6 %

3/2015-2/2016 -9.5 % -5.6 % -6.0 % -3.9 %

3/2016-2/2017 -5.5 % -5.6 % -9.6 % -11.3 % -5.1 % -6.1 %

3/2017-2/2018 -4.8 % -4.8 % -7.9 % -7.7 % -4.3 % -5.2 %

Use -5.8 % -5.2 % -8.5 % -8.9 % -5.9 % -6.0 %

Generic Drugs

3/2013-2/2014 10.0 % 9.3 % 10.4 % 9.9 %

3/2014-2/2015 1.4 % 2.6 % 2.3 % 10.1 %

3/2015-2/2016 0.8 % 3.6 % 6.0 % 8.3 %

3/2016-2/2017 4.1 % 2.3 % 3.2 % -1.6 % 4.5 % 3.4 %

3/2017-2/2018 6.0 % 3.6 % 6.4 % -2.4 % 6.2 % 5.2 %

Use 4.5 % 3.2 % 5.4 % -2.1 % 4.2 % 4.0 %

Specialty Drugs

3/2013-2/2014 4.4 % -3.3 % 4.2 % 3.5 %

3/2014-2/2015 -5.3 % -4.7 % -6.6 % -1.8 %

3/2015-2/2016 -4.3 % -5.9 % -3.7 % 0.5 %

3/2016-2/2017 -0.3 % -1.6 % 3.8 % -6.4 % -0.3 % -0.6 %

3/2017-2/2018 4.6 % 6.8 % 10.5 % -5.7 % 4.9 % 4.6 %

Use 1.5 % 1.9 % 8.3 % -6.0 % 1.6 % 1.5 %

All Drugs

3/2013-2/2014 5.6 % 5.2 % 6.0 % 5.5 %

3/2014-2/2015 -1.5 % -0.3 % -0.7 % 6.8 %

3/2015-2/2016 -1.2 % 1.7 % 3.5 % 5.9 %

3/2016-2/2017 2.3 % 0.8 % 1.1 % -3.1 % 2.8 % 1.7 %

3/2017-2/2018 4.2 % 2.2 % 4.3 % -3.1 % 4.5 % 3.5 %

Use 3.0 % 1.9 % 3.7 % -3.0 % 2.7 % 2.6 %

Annual Trend in Days Supply per Member per Month

Brand Drugs

3/2013-2/2014 -8.5 % -7.4 % -8.0 % -8.4 %

3/2014-2/2015 -12.2 % -10.5 % -11.4 % -4.9 %

3/2015-2/2016 -9.7 % -6.2 % -7.2 % -5.3 %

3/2016-2/2017 -5.6 % -5.6 % -9.8 % -10.6 % -5.3 % -6.1 %

3/2017-2/2018 -4.6 % -4.5 % -8.1 % -7.4 % -4.1 % -5.0 %

Use -5.8 % -5.2 % -8.6 % -8.5 % -5.9 % -6.0 %

146




Case-Mix


Generic Drugs

3/2013-2/2014 12.1 % 10.3 % 12.5 % 11.8 %

3/2014-2/2015 2.7 % 3.0 % 3.8 % 2.8 %

3/2015-2/2016 2.6 % 4.8 % 7.2 % 2.9 %

3/2016-2/2017 4.9 % 2.9 % 3.9 % -1.6 % 5.3 % 4.6 %

3/2017-2/2018 7.2 % 4.5 % 6.7 % -1.3 % 7.4 % 6.8 %

Use 5.7 % 4.0 % 5.8 % -1.4 % 5.3 % 5.5 %

Specialty Drugs

3/2013-2/2014 4.8 % -3.0 % 4.5 % 3.8 %

3/2014-2/2015 -5.2 % -4.9 % -6.6 % -5.2 %

3/2015-2/2016 -3.6 % -5.8 % -4.3 % -3.9 %

3/2016-2/2017 1.4 % -0.5 % 5.3 % -4.8 % 1.4 % 1.2 %

3/2017-2/2018 5.3 % 7.1 % 14.2 % -3.4 % 5.7 % 5.5 %

Use 2.5 % 2.4 % 11.2 % -3.9 % 2.7 % 2.5 %

All Drugs

3/2013-2/2014 6.6 % 5.5 % 7.0 % 6.4 %

3/2014-2/2015 -0.7 % -0.2 % 0.2 % -0.7 %

3/2015-2/2016 0.1 % 2.4 % 4.2 % 0.4 %

3/2016-2/2017 3.0 % 1.3 % 1.6 % -2.8 % 3.4 % 2.7 %

3/2017-2/2018 5.3 % 3.0 % 4.6 % -2.1 % 5.5 % 4.9 %

Use 4.0 % 2.5 % 4.0 % -2.2 % 3.6 % 3.8 %

Annual Trend in Incurred Claims per Days Supply

Brand Drugs

3/2013-2/2014 12.4 % 13.7 % 12.6 % 12.6 %

3/2014-2/2015 13.4 % 15.6 % 15.1 % 13.7 %

3/2015-2/2016 14.7 % 16.0 % 16.8 % 14.9 %

3/2016-2/2017 7.5 % 7.4 % 5.1 % 6.4 % 7.4 % 7.5 %

3/2017-2/2018 9.4 % 8.5 % 6.4 % 7.3 % 9.1 % 9.2 %

Use 9.7 % 9.4 % 6.0 % 7.0 % 9.2 % 9.7 %

Generic Drugs

3/2013-2/2014 -2.3 % -5.0 % -2.5 % -2.7 %

3/2014-2/2015 -0.1 % 5.3 % 2.3 % 0.8 %

3/2015-2/2016 10.8 % 12.0 % 12.3 % 11.0 %

3/2016-2/2017 2.3 % 3.9 % -0.6 % 2.2 % 0.0 % 2.6 %

3/2017-2/2018 -9.2 % -10.7 % -5.7 % -3.7 % 0.0 % -9.5 %

Use -2.0 % -2.0 % -4.0 % -1.7 % -6.3 % -2.0 %

Specialty Drugs

3/2013-2/2014 4.9 % 14.9 % 5.7 % 6.6 %

3/2014-2/2015 9.4 % 13.5 % 9.7 % 10.1 %

3/2015-2/2016 15.9 % 11.5 % 14.9 % 15.0 %

3/2016-2/2017 12.4 % 9.9 % 29.6 % 8.5 % 12.6 % 12.0 %

3/2017-2/2018 7.5 % 15.3 % 8.9 % 12.9 % 8.8 % 8.9 %

Use 10.5 % 12.9 % 15.8 % 11.4 % 11.1 % 10.9 %

147




Case-Mix


All Drugs

3/2013-2/2014 -0.9 % 1.0 % -0.8 % -0.6 %

3/2014-2/2015 1.8 % 5.4 % 2.5 % 2.4 %

3/2015-2/2016 7.2 % 6.6 % 6.1 % 7.1 %

3/2016-2/2017 2.9 % 2.8 % -0.9 % 0.5 % 2.5 % 2.9 %

3/2017-2/2018 0.7 % 3.6 % -2.5 % 2.3 % 1.0 % 1.2 %

Use 2.6 % 4.2 % -0.6 % 1.8 % 2.6 % 2.9 %

Annual Trend in Incurred Claims per Member per Month

Brand Drugs

3/2013-2/2014 2.8 % 5.2 % 3.6 % 3.2 %

3/2014-2/2015 -0.5 % 3.4 % 1.9 % 0.1 %

3/2015-2/2016 3.6 % 8.9 % 8.4 % 4.4 %

3/2016-2/2017 1.5 % 1.4 % -5.2 % -4.8 % 1.8 % 1.5 %

3/2017-2/2018 4.3 % 3.6 % -2.2 % -0.6 % 4.6 % 4.2 %

Use 3.2 % 3.8 % -3.2 % -2.0 % 2.8 % 3.4 %

Generic Drugs

3/2013-2/2014 9.6 % 4.8 % 9.7 % 8.8 %

3/2014-2/2015 2.7 % 8.4 % 6.2 % 3.6 %

3/2015-2/2016 13.7 % 17.4 % 20.4 % 14.3 %

3/2016-2/2017 7.4 % 6.9 % 3.3 % 0.6 % 8.0 % 7.3 %

3/2017-2/2018 -2.6 % -6.6 % 0.6 % -5.0 % -1.8 % -3.3 %

Use 3.4 % 1.9 % 1.5 % -3.1 % 2.9 % 3.3 %

Specialty Drugs

3/2013-2/2014 10.0 % 11.5 % 10.5 % 10.2 %

3/2014-2/2015 3.7 % 7.9 % 2.4 % 4.2 %

3/2015-2/2016 11.7 % 5.0 % 9.9 % 10.8 %

3/2016-2/2017 14.0 % 9.4 % 36.5 % 3.2 % 14.2 % 13.4 %

3/2017-2/2018 13.2 % 23.5 % 24.3 % 9.1 % 15.1 % 14.5 %

Use 13.2 % 15.7 % 28.4 % 7.1 % 14.1 % 13.6 %

All Drugs

3/2013-2/2014 5.6 % 6.6 % 6.2 % 5.7 %

3/2014-2/2015 1.1 % 5.2 % 2.6 % 1.7 %

3/2015-2/2016 7.3 % 9.3 % 10.5 % 7.6 %

3/2016-2/2017 6.0 % 4.2 % 0.7 % -2.2 % 6.0 % 5.7 %

3/2017-2/2018 6.0 % 6.7 % 1.9 % 0.2 % 6.5 % 6.1 %

Use 6.7 % 6.9 % 3.4 % -0.4 % 6.3 % 6.7 %

Generic Dispensing Rate (Days Supply)

3/2013-2/2014 75.8 % 76.0 % 75.8 % 75.8 %

3/2014-2/2015 78.5 % 78.4 % 80.7 % 78.5 % 75.2 %

3/2015-2/2016 80.5 % 80.2 % 82.6 % 86.0 % 80.8 % 80.8 %

3/2016-2/2017 82.0 % 81.5 % 84.4 % 87.1 % 82.3 % 82.3 %

3/2017-2/2018 83.5 % 82.7 % 86.2 % 87.7 % 83.8 % 83.8 %

Use 85.6 % 84.5 % 88.4 % 88.8 % 85.8 % 85.8 %

148

149

Attachment 5

Provider Reimbursement and Benefit Revisions Effective During FY2017, FY2018 and FY2019

This attachment presents information regarding rating adjustments for the various acute care

provider reimbursement and benefit revisions that became effective (or will become effective)

after the base period used in rate setting and before the end of FY2019.

All adjustments have been calculated through an analysis of health plan encounter data repriced

using the old and new reimbursement terms and the impact determined as the relative change in

cost. For each adjustment, the applicable FY2017 encounter data was repriced using the FFS

reimbursement in place during FY2017, the FFS reimbursement that will be in place during

FY2019 and the applicable percentage change determined. Although the MCOs are not required

to change their reimbursement levels based on changes implemented by HHSC, the Medicaid fee

schedule serves as a primary negotiating tool for both MCOs and providers in Texas. Many

MCO/provider reimbursement contracts are directly tied to the Medicaid FFS fee schedule

through established percentages (e.g. 100%, 102%, 95% etc.) As a result, MCO reimbursement

has historically changed in conjunction with Medicaid FFS fee schedule changes, both increases

and decreases. Furthermore, it is common for provider reimbursement contracts that are directly

tied to the Medicaid fee schedule (i.e. set at a % of Medicaid) to automatically adjust when the

Medicaid fee schedule changes with no further need for recontracting. The correlation between

managed care reimbursement and FFS fee schedules has been consistently observed throughout

the history of the Texas managed care programs and is reiterated through discussions with the

MCOs.

Several hospitals have had their inpatient Standard Dollar Amount (SDA) revised as a result of

annual reevaluations. Exhibit A presents a summary of the derivation of the rating adjustment

factors.

Beginning May 1, 2013 HHSC implemented revisions to hospital reimbursement to account for

Potentially Preventable Readmissions (PPR). The reimbursement reductions amount to 1-2%

depending on a hospital’s performance during the evaluation time period and can change from

one fiscal year to the next. A new PPR reduction list will become effective September 1, 2018.

As a result, the adjustment factors shown in Exhibit B represent the restoration of those

reductions that were in place during FY2017 net of those reductions that will be in place during

FY2019.

Effective March 1, 2014 HHSC implemented revisions to hospital reimbursement to account for

Potentially Preventable Complications (PPC). The reimbursement reductions amount to 2-2.5%

depending on a hospital’s performance during the evaluation time period and can change from

one fiscal year to the next. A new PPC reduction list will become effective September 1, 2018.

As of the completion of this report, the final FY2019 PPC list was not yet available. When

completed, HHSC and its actuaries will evaluate if there is a material difference between the

updated PPC list and the list in place during the FY2017 base period. If determined to be

material a mid-year rate adjustment may be necessary.

Effective December 15, 2016 HHSC made revisions to the reimbursement for certain speech,

physical and occupational therapy services. Further revisions for these services were effective

150

September 1, 2017. Exhibit C presents a summary of the derivation of the rating adjustment

factors as a result of the aggregated changes.

Effective September 1, 2018 HHSC will make revisions to the therapy policies which will

impact the reimbursement for therapy services provided by an assistant. Therapy assistant

services will be reimbursed at a rate that is 70% of the therapy fee schedule. Exhibit D presents

a summary of the derivation of the rating adjustment factors.

Effective February 1, 2017 HHSC revised the fee schedule for diagnostic radiology services,

which includes hospital outpatient diagnostic radiology services. Fee schedule changes varied

for professional, urban hospitals and rural hospitals. Exhibit E presents a summary of the

derivation of the rating adjustment factors.

Effective November 1, 2017 HHSC made revisions to the reimbursement for anesthesiology

services. Exhibit F presents a summary of the derivation of the rating adjustment factors.

Effective September 1, 2017 HHSC instituted a change in policy that shifts claim recoveries

associated with tort and coordination of benefit recoveries beyond 120 days from the MCOs to

HHSC. Exhibit G presents a summary of the necessary rating adjustment factors. The

adjustment factors have been calculated in aggregate across all non-dual risk groups. Tort and

coordination of benefit recovery information was not available at the risk group level.

Invalid clinician administered drugs (CAD) have been removed from the base period. HHSC has

provided guidance to the MCOs which specifies the reporting requirements for a CAD to be

considered a valid claim. Those claims not meeting these requirements are assumed to be invalid

and have been removed from the rating analysis. Exhibit H presents a summary of the derivation

of the rating adjustment factors.

On January 1, 2017, the NorthSTAR program, a managed care program for the delivery of

mental health services in the Dallas SDA, was discontinued. As a result, behavioral health

services previously carved out of the STAR+PLUS program for the Dallas SDA became

capitated services like all other STAR+PLUS SDAs. As a result of data issues, the most recent

complete, credible data for the NorthSTAR program that the Department of State Health

Services (DSHS) could provide the actuaries was FY2013. Exhibit I presents a summary of the

derivation of the rating adjustment factor in the Dallas SDA. The adjustment was calculated by

comparing FY2013 NorthSTAR claims to all other STAR+PLUS claims in the Dallas SDA and

assuming a comparable distribution moving forward. This adjustment is calculated as one third

of the full adjustment factor given that it only impacts the first four months of the base period.

Effective January 1, 2017 these behavioral health services are included in the Dallas SDA

managed care data.

Base period data has been analyzed and costs for members age 21 to 64 with an IMD stay in

excess of 15 days in a month have been removed from the analysis. The rating adjustment

factors were estimated by the following steps:

1. Identifying a list of all members age 21-64 who had an IMD stay in excess of 15 days in

a month.

2. For these members and their applicable eligibility month, collect all IMD claims for these

individuals.

151

3. Remove these claims from the base period via the adjustment factors presented in Exhibit

J.

Additional IMD utilization statistics:

Age

# of

Unique

Mbrs.

Count

Range

Avg.

per

Utilizer

Min

Max

Median

Admits

Avg.

LOS

Months

7,945

15,743

1-12

2.0

1.0

12.0

1.0

14,726

NA

Days

7,945

136,247

1-259

17.1

1.0

259.0

11.0

14,726

9.3

Overall, the impact of IMD utilization for members ages 21-64 is very small in the STAR+PLUS

program. Total expenditures were $71.5 million during the base period which is approximately

1% of total medical claims. The average cost per day at the IMD facilities was compared to the

average cost per day for similar services at non IMD facilities and it was noted that, while IMD’s

were slightly less costly on average, the resulting difference was immaterial in the overall

STAR+PLUS program. For many reasons it is difficult to compare non-IMD reimbursement to

IMD reimbursement including the following:

Non-IMD state plan service unit costs are not uniform across all facilities/providers.

Each hospital that participates in the Texas Medicaid program has a unique standard

dollar amount which forms the basis for its reimbursement.

MCOs have unique contracts with each facility/provider.

Reimbursement can vary based on the acuity and needs of the member being served.

In order to estimate the impact of repricing IMD utilization at the non-IMD provider “cost” it is

necessary to make a variety of assumptions. In order to calculate this estimated adjustment, we

have “repriced” the IMD claims to the average cost at non-children’s hospitals for the primary

behavioral health services provided at IMDs. Children’s hospitals were excluded because (a)

they don’t provide a large volume of these services and (b) their average reimbursement is

significantly greater than other facilities. Estimates of the repricing of these IMD claims results

in varying levels of adjustments to the base period which fall in the range of -0.02% to +0.06%.

Given the immaterial size of such an adjustment and the uncertainty regarding the

reimbursement levels at non-IMD facilities for these services, no further adjustment was deemed

necessary to the IMD data other than removing those expenditures for members ages 21-64 who

had an IMD stay in excess of 15 days in a month.

Effective September 1, 2017 FQHC wrap payments were carved out of managed care. HHSC

has developed policy language to ensure that FQHCs are reimbursed their full encounter rate;

however, the MCOs are only be responsible for reimbursing the FQHC an amount no less than

the rate paid to non-FQHC providers providing similar services. This adjustment was calculated

by repricing all FQHC claims to the corresponding fee-for-service equivalent using the Medicaid

fee schedule by procedure code. The difference between the full encounter rate and the fee-for-

service equivalent is assumed to be the wrap payment which will be carved out and paid outside

the monthly capitation rate based on an HHSC-approved methodology. Exhibit K presents a

summary of the derivation of the rating adjustment factors.

152

Effective September 1, 2018 HHSC will make revision to the reimbursement for ambulance

services. Exhibit L presents a summary of the derivation of the rating adjustment factors.

HHSC has recently implemented numerous changes to the Preferred Drug List (PDL). These

changes include some of the program’s highest expenditure drugs (Abilify, Nasonex, Suprax and

Tamiflu) and will have a significant impact on managed care pharmacy cost. Some of the PDL

changes were implemented during the experience period used to develop the rates and some were


anticipated cost impact of the PDL changes. Exhibit M presents a summary of the derivation of

the rating adjustment factors.

HHSC currently excludes certain low-utilization, high-cost drugs from the capitated

arrangement. These drugs are covered under the plan but their cost is reimbursed to the MCOs

using a non-risk arrangement. We have now accumulated sufficient experience to project

utilization and cost for some of these “carve-out” drugs. Anti-viral medications for the treatment

of Hepatitis C (Epclusa, Harvoni, Viekira Pak, etc.) and Orkambi (a treatment for Cystic

Fibrosis) will be added to capitated services effective September 1, 2018. Exhibit N presents a

summary of the derivation of the rating adjustment factors.

For ease of reporting purposes, the numerous provider reimbursement adjustments described

above have been consolidated in the community rating exhibits included in Attachment 3. The

key below includes a description of where each adjustment has been included in Attachments 3.

Heading Attachment 5 Exhibits

Acute Care – Non Inpatient

C, D, E, F, H, I, J, K and L

Acute Care – Inpatient A, B and G

Please note that the incurred claims reported on Attachment 5 are developed from the FY2017

detail encounter data which only includes claims paid through November 2017. As a result, the

incurred claims reported on Attachment 3 vary slightly from Attachment 5 amounts for several

reasons including: (i) Attachment 3 incurred claims include claims paid through February 2018,

(ii) Attachment 3 incurred claims include a small amount of IBNR and (iii) certain subcapitated

expenses provided by affiliated providers are included in Attachment 3 incurred claims but not

available in the detailed encounter data files. As noted on pages 1-3 of this report, multiple data

sources were used in the rate development process with each being checked for consistency. The

detail encounter data is necessary for the adjustment factors detailed in this attachment as it is the

only data source that provides information at the claim level allowing for the repricing of claims

under varying reimbursement levels.

All adjustments were calculated independently by both HHSC and the Rudd and Wisdom

actuaries to ensure consistent results.

The FFS data readily available for the MBCCP population does not provide procedure code or

provider identification level of detail. Due to these data limitations, the impact of the medical

rate adjustments listed above could not be calculated for the expansion MBCCP population. As a

result, the rate adjustments for this population are assumed to be equal to the average rate

adjustments for the Medicaid Only OCC and HCBS risk groups as calculated for the existing

153

STAR+PLUS population. We believe this is a reasonable estimate of the impact of the various

reimbursement changes as these populations most closely match MBCCP members.


FY2019 STAR+PLUS Rating - Medical

Provider Reimbursement Adjustments - Inpatient Acute Care

Hospital Reimbursement Changes - Standard Dollar Amount


OCC HCBS OCC HCBS Medicaid Only Dual Eligible IDD Grand Total

Impact of Reimbursement Change (1)

Bexar 801,415 135,352 0 0 82,190 0 31,470 1,050,427

Dallas 1,194,238 190,000 0 0 164,724 0 35,403 1,584,365

El Paso -10,614 1,962 0 0 307 0 -2,956 -11,301

Harris 1,020,524 216,633 0 0 102,223 0 23,780 1,363,159

Hidalgo 176,764 68,904 0 0 21,402 0 5,486 272,556

Jefferson 111,539 26,571 0 0 10,571 0 1,763 150,444

Lubbock 31,479 4,041 0 0 7,564 0 2,261 45,345

Nueces 68,298 19,590 0 0 5,475 0 1,099 94,462

Tarrant 192,829 43,241 0 0 37,173 0 12,462 285,705

Travis 23,298 4,331 0 0 4,239 0 1,510 33,377

MRSA Central 91,668 13,132 0 0 7,260 0 5,010 117,070

MRSA Northeast 157,088 28,323 0 0 15,398 0 4,070 204,879

MRSA West 120,011 13,699 0 0 17,948 0 3,692 155,349

Total 3,978,538 765,777 0 0 476,475 0 125,049 5,345,839

FY2017 Total Acute Care Incurred Claims (2)

Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

154




Hospital Reimbursement Changes - Standard Dollar Amount



Rate Adjustment Factor (3)

Bexar 0.72% 0.50% 0.00% 0.00% 0.97% 0.00% 0.46% 0.68%

Dallas 0.64% 0.56% 0.00% 0.00% 0.98% 0.00% 0.46% 0.65%

El Paso -0.02% 0.02% 0.00% 0.00% 0.02% 0.00% -0.09% -0.02%

Harris 0.34% 0.40% 0.00% 0.00% 0.64% 0.00% 0.18% 0.35%

Hidalgo 0.23% 0.21% 0.00% 0.00% 0.45% 0.00% 0.12% 0.23%

Jefferson 0.21% 0.27% 0.00% 0.00% 0.29% 0.00% 0.13% 0.22%

Lubbock 0.11% 0.08% 0.00% 0.00% 0.22% 0.00% 0.11% 0.11%

Nueces 0.17% 0.17% 0.00% 0.00% 0.22% 0.00% 0.07% 0.17%

Tarrant 0.17% 0.23% 0.00% 0.00% 0.34% 0.00% 0.19% 0.19%

Travis 0.04% 0.03% 0.00% 0.00% 0.09% 0.00% 0.03% 0.04%

MRSA Central 0.14% 0.16% 0.00% 0.00% 0.12% 0.00% 0.15% 0.14%

MRSA Northeast 0.16% 0.13% 0.00% 0.00% 0.15% 0.00% 0.11% 0.15%

MRSA West 0.17% 0.14% 0.00% 0.00% 0.25% 0.00% 0.09% 0.17%

Total 0.32% 0.30% 0.00% 0.00% 0.50% 0.00% 0.20% 0.32%

Footnotes

(1) Equals the cost impact from reimbursement changes for hospital services at facilities whose standard dollar amount changed.

(2) Equals FY2017 health plan fee-for-service claims for all acute care services (from Encounter database).

(3) Equals Cost Impact divided by FY2017 Total Acute Care Incurred Claims.

155




Potentially Preventable Readmission (PPR) Reductions




Bexar 132,282 33,073 0 0 15,154 0 7,585 188,095

Dallas -134,355 -1,447 0 0 -2,616 0 -1,535 -139,952

El Paso 84,370 28,926 0 0 13,385 0 7,448 134,129

Harris 34,979 -18,855 0 0 -17,024 0 7,707 6,807

Hidalgo 46,195 23,853 0 0 4,222 0 1,649 75,918

Jefferson -32,987 -21,549 0 0 -4,398 0 -3,271 -62,206

Lubbock 99,412 16,978 0 0 16,296 0 5,406 138,092

Nueces 21,312 4,643 0 0 1,396 0 72 27,423

Tarrant 205,500 34,296 0 0 29,086 0 7,877 276,759

Travis 66,722 10,741 0 0 8,479 0 -513 85,430

MRSA Central -16,726 -2,341 0 0 -2,780 0 1,015 -20,832

MRSA Northeast -84,212 -16,894 0 0 -10,798 0 -3,685 -115,588

MRSA West 38,343 3,846 0 0 1,848 0 -113 43,924

Total 460,835 95,269 0 0 52,251 0 29,644 637,999


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

156




Potentially Preventable Readmission (PPR) Reductions




Bexar 0.12% 0.12% 0.00% 0.00% 0.18% 0.00% 0.11% 0.12%

Dallas -0.07% 0.00% 0.00% 0.00% -0.02% 0.00% -0.02% -0.06%

El Paso 0.19% 0.25% 0.00% 0.00% 0.77% 0.00% 0.24% 0.22%

Harris 0.01% -0.04% 0.00% 0.00% -0.11% 0.00% 0.06% 0.00%

Hidalgo 0.06% 0.07% 0.00% 0.00% 0.09% 0.00% 0.04% 0.06%

Jefferson -0.06% -0.22% 0.00% 0.00% -0.12% 0.00% -0.24% -0.09%

Lubbock 0.34% 0.35% 0.00% 0.00% 0.47% 0.00% 0.27% 0.35%

Nueces 0.05% 0.04% 0.00% 0.00% 0.06% 0.00% 0.00% 0.05%

Tarrant 0.19% 0.18% 0.00% 0.00% 0.27% 0.00% 0.12% 0.19%

Travis 0.12% 0.09% 0.00% 0.00% 0.18% 0.00% -0.01% 0.11%

MRSA Central -0.03% -0.03% 0.00% 0.00% -0.04% 0.00% 0.03% -0.02%

MRSA Northeast -0.08% -0.08% 0.00% 0.00% -0.11% 0.00% -0.10% -0.09%

MRSA West 0.06% 0.04% 0.00% 0.00% 0.03% 0.00% 0.00% 0.05%

Total 0.04% 0.04% 0.00% 0.00% 0.05% 0.00% 0.05% 0.04%

Footnotes

(1) Equals the net cost/savings resulting from PPR reductions that will become effective 9/1/2018 versus those effective during FY2017.



157



Provider Reimbursement Adjustments - Non-Inpatient Acute Care

Therapy Reimbursement Reduction




Bexar -129,799 -59,084 0 0 -11,078 0 -6,811 -206,772

Dallas -69,582 -36,527 0 0 -13,529 0 -4,300 -123,939

El Paso -32,257 -18,235 0 0 -1,413 0 -312 -52,216

Harris -222,403 -61,365 0 0 3,689 0 -2,119 -282,198

Hidalgo -20,083 -20,326 0 0 -160 0 2,108 -38,462

Jefferson -2,611 -7,381 0 0 -804 0 843 -9,952

Lubbock -11,586 -2,915 0 0 -989 0 -5,057 -20,548

Nueces 14,055 1,236 0 0 -723 0 1,812 16,379

Tarrant -40,066 -21,555 0 0 1,093 0 -533 -61,060

Travis -11,681 -9,615 0 0 4,093 0 689 -16,514

MRSA Central -10,251 -2,151 0 0 -2,611 0 -1,068 -16,082

MRSA Northeast -108,779 -61,902 0 0 3,826 0 -6,013 -172,867

MRSA West -18,459 -5,962 0 0 -447 0 -1,371 -26,240

Total -663,502 -305,782 0 0 -19,053 0 -22,133 -1,010,470


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

158




Therapy Reimbursement Reduction




Bexar -0.12% -0.22% 0.00% 0.00% -0.13% 0.00% -0.10% -0.13%

Dallas -0.04% -0.11% 0.00% 0.00% -0.08% 0.00% -0.06% -0.05%

El Paso -0.07% -0.16% 0.00% 0.00% -0.08% 0.00% -0.01% -0.09%

Harris -0.07% -0.11% 0.00% 0.00% 0.02% 0.00% -0.02% -0.07%

Hidalgo -0.03% -0.06% 0.00% 0.00% 0.00% 0.00% 0.05% -0.03%

Jefferson 0.00% -0.08% 0.00% 0.00% -0.02% 0.00% 0.06% -0.01%

Lubbock -0.04% -0.06% 0.00% 0.00% -0.03% 0.00% -0.25% -0.05%

Nueces 0.03% 0.01% 0.00% 0.00% -0.03% 0.00% 0.11% 0.03%

Tarrant -0.04% -0.11% 0.00% 0.00% 0.01% 0.00% -0.01% -0.04%

Travis -0.02% -0.08% 0.00% 0.00% 0.09% 0.00% 0.02% -0.02%

MRSA Central -0.02% -0.03% 0.00% 0.00% -0.04% 0.00% -0.03% -0.02%

MRSA Northeast -0.11% -0.28% 0.00% 0.00% 0.04% 0.00% -0.16% -0.13%

MRSA West -0.03% -0.06% 0.00% 0.00% -0.01% 0.00% -0.03% -0.03%

Total -0.05% -0.12% 0.00% 0.00% -0.02% 0.00% -0.04% -0.06%

Footnotes

(1) Equals the cost impact from reimbursement changes for therapy services effective 9/1/2017.



159




Therapy Policy Changes




Bexar -41,226 -17,762 0 0 -393 0 -1,251 -60,632

Dallas -5,753 -176 0 0 0 0 0 -5,930

El Paso -13,716 -2,198 0 0 0 0 -401 -16,315

Harris -13,139 -653 0 0 0 0 0 -13,793

Hidalgo -85,213 -34,170 0 0 0 0 -4,163 -123,546

Jefferson -522 -263 0 0 0 0 0 -785

Lubbock -2,671 -124 0 0 0 0 0 -2,794

Nueces -1,574 -336 0 0 0 0 0 -1,910

Tarrant -3,511 -66 0 0 0 0 0 -3,576

Travis -30,894 -3,616 0 0 0 0 -924 -35,434

MRSA Central -3,629 -783 0 0 0 0 0 -4,411

MRSA Northeast -33,821 -18,231 0 0 -514 0 -665 -53,231

MRSA West -3,053 -692 0 0 0 0 -650 -4,395

Total -238,722 -79,071 0 0 -907 0 -8,053 -326,752


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

160




Therapy Policy Changes




Bexar -0.04% -0.07% 0.00% 0.00% 0.00% 0.00% -0.02% -0.04%

Dallas 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

El Paso -0.03% -0.02% 0.00% 0.00% 0.00% 0.00% -0.01% -0.03%

Harris 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Hidalgo -0.11% -0.11% 0.00% 0.00% 0.00% 0.00% -0.09% -0.10%

Jefferson 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Lubbock -0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -0.01%

Nueces 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Tarrant 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Travis -0.05% -0.03% 0.00% 0.00% 0.00% 0.00% -0.02% -0.05%

MRSA Central -0.01% -0.01% 0.00% 0.00% 0.00% 0.00% 0.00% -0.01%

MRSA Northeast -0.03% -0.08% 0.00% 0.00% -0.01% 0.00% -0.02% -0.04%

MRSA West 0.00% -0.01% 0.00% 0.00% 0.00% 0.00% -0.02% 0.00%

Total -0.02% -0.03% 0.00% 0.00% 0.00% 0.00% -0.01% -0.02%

Footnotes

(1) Equals the cost reduction resulting from the therapy policy changes for assistant reimbursement effective 9/1/2018.



161

Attachment 5 - Exhibit E



Radiology Reimbursement Changes




Bexar -310,884 -52,999 0 0 -9,531 0 -13,220 -386,633

Dallas -594,059 -72,338 0 0 -20,215 0 -17,928 -704,540

El Paso -100,119 -12,561 0 0 -888 0 -1,768 -115,335

Harris -870,180 -97,164 0 0 -13,620 0 -18,310 -999,275

Hidalgo -177,331 -38,339 0 0 -3,300 0 -5,063 -224,034

Jefferson -153,135 -19,330 0 0 -4,551 0 -3,068 -180,085

Lubbock -56,434 -6,316 0 0 -5,028 0 -2,646 -70,423

Nueces -122,238 -20,375 0 0 -15 0 -4,261 -146,888

Tarrant -331,976 -41,216 0 0 -11,127 0 -7,443 -391,762

Travis -132,667 -18,964 0 0 -4,117 0 -7,662 -163,411

MRSA Central -183,953 -21,436 0 0 -9,116 0 -8,718 -223,223

MRSA Northeast -351,538 -61,976 0 0 -13,048 0 -10,059 -436,621

MRSA West -200,758 -15,342 0 0 -8,526 0 -7,834 -232,459

Total -3,585,271 -478,356 0 0 -103,083 0 -107,980 -4,274,690


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

162




Radiology Reimbursement Changes




Bexar -0.28% -0.20% 0.00% 0.00% -0.11% 0.00% -0.19% -0.25%

Dallas -0.32% -0.21% 0.00% 0.00% -0.12% 0.00% -0.23% -0.29%

El Paso -0.22% -0.11% 0.00% 0.00% -0.05% 0.00% -0.06% -0.19%

Harris -0.29% -0.18% 0.00% 0.00% -0.09% 0.00% -0.14% -0.26%

Hidalgo -0.23% -0.12% 0.00% 0.00% -0.07% 0.00% -0.11% -0.19%

Jefferson -0.28% -0.20% 0.00% 0.00% -0.13% 0.00% -0.23% -0.26%

Lubbock -0.19% -0.13% 0.00% 0.00% -0.14% 0.00% -0.13% -0.18%

Nueces -0.30% -0.18% 0.00% 0.00% 0.00% 0.00% -0.27% -0.26%

Tarrant -0.30% -0.22% 0.00% 0.00% -0.10% 0.00% -0.11% -0.27%

Travis -0.23% -0.15% 0.00% 0.00% -0.09% 0.00% -0.18% -0.21%

MRSA Central -0.28% -0.26% 0.00% 0.00% -0.15% 0.00% -0.27% -0.27%

MRSA Northeast -0.35% -0.28% 0.00% 0.00% -0.13% 0.00% -0.27% -0.32%

MRSA West -0.29% -0.15% 0.00% 0.00% -0.12% 0.00% -0.20% -0.26%

Total -0.29% -0.19% 0.00% 0.00% -0.11% 0.00% -0.17% -0.26%

Footnotes

(1) Equals the cost resulting from the rural hospital reimbursement changes for outpatient radiology 2/1/2017.



163

Attachment 5 - Exhibit F



Anesthesiology Reimbursement Changes




Bexar 116,642 24,700 0 0 5,017 0 10,083 156,442

Dallas 77,176 10,717 0 0 8,623 0 3,322 99,839

El Paso 20,566 4,967 0 0 1,376 0 -1,129 25,780

Harris -38,873 -5,762 0 0 -1,341 0 1,725 -44,252

Hidalgo 41,954 6,768 0 0 -450 0 1,939 50,211

Jefferson -20,561 -2,158 0 0 -697 0 -1,987 -25,403

Lubbock -16,935 -2,928 0 0 -2,229 0 -1,972 -24,064

Nueces 42,822 9,838 0 0 2,161 0 1,020 55,841

Tarrant 13,267 749 0 0 1,820 0 908 16,744

Travis -18,050 -3,173 0 0 -1,148 0 -2,425 -24,796

MRSA Central -17,398 1,153 0 0 753 0 -1,473 -16,964

MRSA Northeast -31,474 -4,537 0 0 -1,202 0 950 -36,263

MRSA West 17,284 -20 0 0 1,648 0 -628 18,284

Total 186,420 40,316 0 0 14,331 0 10,331 251,399


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

164




Anesthesiology Reimbursement Changes




Bexar 0.10% 0.09% 0.00% 0.00% 0.06% 0.00% 0.15% 0.10%

Dallas 0.04% 0.03% 0.00% 0.00% 0.05% 0.00% 0.04% 0.04%

El Paso 0.05% 0.04% 0.00% 0.00% 0.08% 0.00% -0.04% 0.04%

Harris -0.01% -0.01% 0.00% 0.00% -0.01% 0.00% 0.01% -0.01%

Hidalgo 0.05% 0.02% 0.00% 0.00% -0.01% 0.00% 0.04% 0.04%

Jefferson -0.04% -0.02% 0.00% 0.00% -0.02% 0.00% -0.15% -0.04%

Lubbock -0.06% -0.06% 0.00% 0.00% -0.06% 0.00% -0.10% -0.06%

Nueces 0.11% 0.09% 0.00% 0.00% 0.09% 0.00% 0.06% 0.10%

Tarrant 0.01% 0.00% 0.00% 0.00% 0.02% 0.00% 0.01% 0.01%

Travis -0.03% -0.03% 0.00% 0.00% -0.02% 0.00% -0.06% -0.03%

MRSA Central -0.03% 0.01% 0.00% 0.00% 0.01% 0.00% -0.05% -0.02%

MRSA Northeast -0.03% -0.02% 0.00% 0.00% -0.01% 0.00% 0.03% -0.03%

MRSA West 0.02% 0.00% 0.00% 0.00% 0.02% 0.00% -0.02% 0.02%

Total 0.01% 0.02% 0.00% 0.00% 0.01% 0.00% 0.02% 0.02%

Footnotes

(1) Equals the cost impact from reimbursement changes for anesthesiology services effective 11/1/2017.



165

Attachment 5 - Exhibit G



Tort and COB Adjustment

Estimated FY2017 Acute Rate Adj

Impact (1) Care Inc Claims (2) Factor (3)


Bexar 42,074 154,278,645 0.03%

Dallas 446,146 245,207,961 0.18%

El Paso 39,481 61,096,092 0.06%

Harris 956,917 385,345,876 0.25%

Hidalgo 78,716 120,221,830 0.07%

Jefferson 81,963 69,103,992 0.12%

Lubbock 18,950 39,815,689 0.05%

Nueces 105,960 55,840,174 0.19%

Tarrant 34,109 146,865,497 0.02%

Travis 135,207 78,462,560 0.17%

MRSA Central 149,616 83,573,679 0.18%

MRSA Northeast 245,840 135,927,864 0.18%

MRSA West 6,248 90,461,270 0.01%

Total 2,341,227 1,666,201,129 0.14%

Footnotes

(1) Equals the cost impact from policy changes for tort and COB claims beyond 120 days effective 9/1/2017 .



166

Attachment 5 - Exhibit H



Remove Invalid CAD Encounters



Impact of Claim Removal (1)

Bexar -102,150 -2,878 0 0 -2,956 0 -16 -107,999

Dallas -40,202 -3,087 0 0 -246 0 -2 -43,538

El Paso -15,226 -6,839 0 0 -40 0 -2,144 -24,249

Harris -299,249 -39,013 0 0 -7,641 0 -3,866 -349,768

Hidalgo -156,638 -28,891 0 0 -426 0 -928 -186,883

Jefferson -33,905 -2,107 0 0 -71 0 -272 -36,354

Lubbock -19,556 -621 0 0 -15 0 -316 -20,509

Nueces -43,291 -1,874 0 0 -82 0 -510 -45,758

Tarrant -259,472 -14,076 0 0 -51,216 0 -1,611 -326,375

Travis -94,180 -2,241 0 0 -147 0 -818 -97,387

MRSA Central -53,289 -1,018 0 0 -1,191 0 -119 -55,617

MRSA Northeast -409,083 -59,619 0 0 -17,270 0 -7,861 -493,833

MRSA West -48,170 -550 0 0 -5,319 0 -21,039 -75,078

Total -1,574,411 -162,814 0 0 -86,621 0 -39,502 -1,863,347


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

167

Attachment 5 - Exhibit H



Remove Invalid CAD Encounters




Bexar -0.09% -0.01% 0.00% 0.00% -0.03% 0.00% 0.00% -0.07%

Dallas -0.02% -0.01% 0.00% 0.00% 0.00% 0.00% 0.00% -0.02%

El Paso -0.03% -0.06% 0.00% 0.00% 0.00% 0.00% -0.07% -0.04%

Harris -0.10% -0.07% 0.00% 0.00% -0.05% 0.00% -0.03% -0.09%

Hidalgo -0.20% -0.09% 0.00% 0.00% -0.01% 0.00% -0.02% -0.16%

Jefferson -0.06% -0.02% 0.00% 0.00% 0.00% 0.00% -0.02% -0.05%

Lubbock -0.07% -0.01% 0.00% 0.00% 0.00% 0.00% -0.02% -0.05%

Nueces -0.11% -0.02% 0.00% 0.00% 0.00% 0.00% -0.03% -0.08%

Tarrant -0.23% -0.07% 0.00% 0.00% -0.47% 0.00% -0.02% -0.22%

Travis -0.17% -0.02% 0.00% 0.00% 0.00% 0.00% -0.02% -0.12%

MRSA Central -0.08% -0.01% 0.00% 0.00% -0.02% 0.00% 0.00% -0.07%

MRSA Northeast -0.41% -0.27% 0.00% 0.00% -0.17% 0.00% -0.21% -0.36%

MRSA West -0.07% -0.01% 0.00% 0.00% -0.07% 0.00% -0.54% -0.08%

Total -0.13% -0.06% 0.00% 0.00% -0.09% 0.00% -0.06% -0.11%

Footnotes

(1) Equals the cost impact from removing invalid CADs.



168

Attachment 5 - Exhibit I



Elimination of NorthSTAR Program

Medicaid Only

FY2013 Claims Paid - Dallas SDA

NorthSTAR BH (1) 29,222,219

STAR+PLUS Non-BH (2) 178,909,457

Adjustment Factor 0.0544

Footnotes:

(1) Equals the total North STAR cost for behavioral health service in FY2013.

(2) Equals FY2013 health plan fee-for-service claims for all services excluding behavioral health.

(3) Equals North STAR BH divdied by STAR+PLUS Non-BH multiplieid by 1/3.

169

Attachment 5 - Exhibit J



Removal of Cost for Members with IMD in excess of 15 Days in a Month



Impact of Cost Removal (1)

Bexar -708,884 -47,054 0 0 -68,585 0 -40,533 -865,055

Dallas -4,118,220 -372,410 0 0 -161,071 0 -171,234 -4,822,935

El Paso -1,200,099 -28,170 0 0 -33,262 0 -40,918 -1,302,450

Harris -4,354,322 -330,296 0 0 -9,425 0 -118,744 -4,812,787

Hidalgo -184,366 -22,615 0 0 -20 0 -12,258 -219,259

Jefferson -243,836 0 0 0 -7,547 0 0 -251,382

Lubbock -160,075 -5,795 0 0 -12,226 0 0 -178,096

Nueces -203,433 0 0 0 0 0 0 -203,433

Tarrant -893,560 -60,395 0 0 -73,043 0 -145,813 -1,172,811

Travis -1,316,704 -22,937 0 0 0 0 -41,009 -1,380,650

MRSA Central -702,601 -53,556 0 0 -24,406 0 -38,056 -818,618

MRSA Northeast -582,678 -32,698 0 0 -44,500 0 -22,343 -682,219

MRSA West -571,458 -64,193 0 0 -25,352 0 -21,262 -682,266

Total -15,240,236 -1,040,119 0 0 -459,437 0 -652,170 -17,391,963


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

170

Attachment 5 - Exhibit J



Removal of Cost for Members with IMD in excess of 15 Days in a Month




Bexar -0.63% -0.17% 0.00% 0.00% -0.81% 0.00% -0.59% -0.56%

Dallas -2.20% -1.10% 0.00% 0.00% -0.96% 0.00% -2.22% -1.97%

El Paso -2.69% -0.24% 0.00% 0.00% -1.92% 0.00% -1.31% -2.13%

Harris -1.44% -0.62% 0.00% 0.00% -0.06% 0.00% -0.92% -1.25%

Hidalgo -0.23% -0.07% 0.00% 0.00% 0.00% 0.00% -0.27% -0.18%

Jefferson -0.45% 0.00% 0.00% 0.00% -0.21% 0.00% 0.00% -0.36%

Lubbock -0.54% -0.12% 0.00% 0.00% -0.35% 0.00% 0.00% -0.45%

Nueces -0.50% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -0.36%

Tarrant -0.81% -0.32% 0.00% 0.00% -0.67% 0.00% -2.24% -0.80%

Travis -2.32% -0.18% 0.00% 0.00% 0.00% 0.00% -0.94% -1.76%

MRSA Central -1.07% -0.64% 0.00% 0.00% -0.39% 0.00% -1.18% -0.98%

MRSA Northeast -0.58% -0.15% 0.00% 0.00% -0.45% 0.00% -0.59% -0.50%

MRSA West -0.82% -0.64% 0.00% 0.00% -0.35% 0.00% -0.54% -0.75%

Total -1.22% -0.41% 0.00% 0.00% -0.48% 0.00% -1.05% -1.04%

Footnotes

(1) Equals the cost impact resulting from the removal of claims for members with an IMD stay in excess of 15 days in a month.



171

Attachment 5 - Exhibit K



Remove FQHC Wrap Payments




Bexar -1,062,814 -100,581 0 0 -3,077 0 -38,101 -1,204,573

Dallas -632,474 -68,230 0 0 -1,586 0 -24,121 -726,411

El Paso -203,477 -14,555 0 0 -432 0 -5,100 -223,563

Harris -2,358,437 -134,107 0 0 -5,726 0 -107,433 -2,605,704

Hidalgo -655,324 -81,465 0 0 -2,119 0 -17,994 -756,902

Jefferson -719,076 -64,288 0 0 -361 0 -7,581 -791,306

Lubbock -360,899 -26,801 0 0 -1,197 0 -46,418 -435,316

Nueces -526,642 -84,675 0 0 -1,142 0 -35,357 -647,817

Tarrant -118,017 -9,700 0 0 -709 0 -12,588 -141,014

Travis -2,627,320 -225,629 0 0 -11,517 0 -123,653 -2,988,118

MRSA Central -1,314,310 -81,874 0 0 -27,062 0 -46,432 -1,469,678

MRSA Northeast -1,282,841 -143,398 0 0 -4,498 0 -51,251 -1,481,987

MRSA West -1,499,787 -104,126 0 0 -4,458 0 -162,152 -1,770,522

Total -13,361,417 -1,139,428 0 0 -63,883 0 -678,180 -15,242,910


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

172

Attachment 5 - Exhibit K



Remove FQHC Wrap Payments




Bexar -0.95% -0.37% 0.00% 0.00% -0.04% 0.00% -0.55% -0.78%

Dallas -0.34% -0.20% 0.00% 0.00% -0.01% 0.00% -0.31% -0.30%

El Paso -0.46% -0.12% 0.00% 0.00% -0.02% 0.00% -0.16% -0.37%

Harris -0.78% -0.25% 0.00% 0.00% -0.04% 0.00% -0.83% -0.68%

Hidalgo -0.84% -0.25% 0.00% 0.00% -0.04% 0.00% -0.39% -0.63%

Jefferson -1.32% -0.66% 0.00% 0.00% -0.01% 0.00% -0.56% -1.15%

Lubbock -1.22% -0.56% 0.00% 0.00% -0.03% 0.00% -2.30% -1.09%

Nueces -1.30% -0.74% 0.00% 0.00% -0.05% 0.00% -2.23% -1.16%

Tarrant -0.11% -0.05% 0.00% 0.00% -0.01% 0.00% -0.19% -0.10%

Travis -4.62% -1.79% 0.00% 0.00% -0.25% 0.00% -2.84% -3.81%

MRSA Central -2.00% -0.98% 0.00% 0.00% -0.44% 0.00% -1.44% -1.76%

MRSA Northeast -1.28% -0.65% 0.00% 0.00% -0.05% 0.00% -1.35% -1.09%

MRSA West -2.16% -1.04% 0.00% 0.00% -0.06% 0.00% -4.14% -1.96%

Total -1.07% -0.44% 0.00% 0.00% -0.07% 0.00% -1.10% -0.91%

Footnotes

(1) Equals the cost impact from removing FQHC wrap payments from the capitation rate effective 9/1/2017.



173

Attachment 5 - Exhibit L



Ambulance Reimbursement Changes




Bexar -807 -277 0 0 -184 0 -47 -1,315

Dallas -4,058 -7,226 0 0 -1,758 0 -43 -13,086

El Paso -3,308 -29 0 0 -5 0 -9 -3,351

Harris -2,781 -584 0 0 -307 0 -97 -3,770

Hidalgo -5,414 -1,227 0 0 -135 0 -177 -6,953

Jefferson -2,665 -254 0 0 -124 0 -28 -3,071

Lubbock -2,058 -38 0 0 -2,119 0 -7 -4,223

Nueces -496 -275 0 0 -60 0 -886 -1,717

Tarrant -339 -51 0 0 -80 0 -20 -489

Travis -2,277 -56 0 0 -54 0 -24 -2,412

MRSA Central -1,967 -83 0 0 -118 0 -21 -2,189

MRSA Northeast -10,086 -157 0 0 -1,171 0 -16 -11,429

MRSA West -22,283 -3,456 0 0 -553 0 -24 -26,316

Total -58,538 -13,715 0 0 -6,670 0 -1,399 -80,322


Bexar 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

Lubbock 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

Total 1,251,819,516 256,301,204 0 0 96,152,422 0 61,927,987 1,666,201,129

174

Attachment 5 - Exhibit L



Ambulance Reimbursement Changes




Bexar 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Dallas 0.00% -0.02% 0.00% 0.00% -0.01% 0.00% 0.00% -0.01%

El Paso -0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -0.01%

Harris 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Hidalgo -0.01% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -0.01%

Jefferson 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Lubbock -0.01% 0.00% 0.00% 0.00% -0.06% 0.00% 0.00% -0.01%

Nueces 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% -0.06% 0.00%

Tarrant 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

Travis 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

MRSA Central 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

MRSA Northeast -0.01% 0.00% 0.00% 0.00% -0.01% 0.00% 0.00% -0.01%

MRSA West -0.03% -0.03% 0.00% 0.00% -0.01% 0.00% 0.00% -0.03%

Total 0.00% -0.01% 0.00% 0.00% -0.01% 0.00% 0.00% 0.00%

Footnotes

(1) Equals the cost impact from reimbursement changes for ambulance services effective 9/1/2018.



175

Attachment 5 - Exhibit M

FY2019 STAR+PLUS Rating - Pharmacy

Rx Adjustments

PDL Changes



Impact of PDL (1)

Bexar -1,946,996 -319,914 0 0 -142,172 0 -765,354 -3,174,436

Dallas -1,567,880 -243,376 0 0 -109,439 0 -402,825 -2,323,521

El Paso -800,167 -145,488 0 0 -8,468 0 -326,703 -1,280,825

Harris -2,839,956 -320,055 0 0 -95,870 0 -914,236 -4,170,117

Hidalgo -1,300,185 -251,442 0 0 -28,476 0 -144,565 -1,724,668

Jefferson -669,278 -76,164 0 0 -24,213 0 -68,734 -838,390

Lubbock -447,973 -32,608 0 0 -57,134 0 -188,856 -726,570

Nueces -522,027 -84,854 0 0 -35,381 0 -149,602 -791,863

Tarrant -1,808,112 -309,926 0 0 -91,732 0 -758,518 -2,968,288

Travis -734,282 -77,237 0 0 -168,843 0 -507,571 -1,487,934

MRSA Central -744,167 -77,281 0 0 -82,680 0 -209,940 -1,114,067

MRSA Northeast -459,440 -80,372 0 0 -28,549 0 -120,365 -688,727

MRSA West -1,272,990 -106,133 0 0 -118,987 0 -395,810 -1,893,919

Total -15,113,453 -2,124,850 0 0 -991,944 0 -4,953,078 -23,183,326

CY2017 Total Incurred Claims (2)

Bexar 97,735,497 21,692,423 0 0 4,931,038 0 10,630,083 134,989,040

Dallas 112,111,579 19,699,373 0 0 6,339,035 0 9,317,707 147,467,694

El Paso 33,286,216 8,575,568 0 0 455,939 0 5,344,172 47,661,895

Harris 236,441,335 31,615,631 0 0 7,207,966 0 22,457,738 297,722,670

Hidalgo 84,952,635 26,211,209 0 0 1,526,224 0 5,357,684 118,047,752

Jefferson 40,022,354 5,376,850 0 0 1,969,758 0 2,280,985 49,649,947

Lubbock 22,731,646 2,995,603 0 0 1,864,420 0 2,906,212 30,497,880

Nueces 36,926,982 8,188,378 0 0 1,395,006 0 2,917,284 49,427,650

Tarrant 84,990,004 12,991,272 0 0 5,891,985 0 10,483,569 114,356,830

Travis 50,075,265 9,320,388 0 0 4,308,679 0 7,642,322 71,346,654

MRSA Central 49,530,185 5,977,912 0 0 3,474,968 0 4,686,284 63,669,348

MRSA Northeast 75,548,522 14,593,292 0 0 5,637,824 0 5,466,888 101,246,526

MRSA West 56,751,494 6,624,510 0 0 3,840,640 0 5,951,833 73,168,477

Total 981,103,714 173,862,408 0 0 48,843,481 0 95,442,761 1,299,252,364

176

Attachment 5 - Exhibit M


Rx Adjustments

PDL Changes




Bexar -1.99% -1.47% 0.00% 0.00% -2.88% 0.00% -7.20% -2.35%

Dallas -1.40% -1.24% 0.00% 0.00% -1.73% 0.00% -4.32% -1.58%

El Paso -2.40% -1.70% 0.00% 0.00% -1.86% 0.00% -6.11% -2.69%

Harris -1.20% -1.01% 0.00% 0.00% -1.33% 0.00% -4.07% -1.40%

Hidalgo -1.53% -0.96% 0.00% 0.00% -1.87% 0.00% -2.70% -1.46%

Jefferson -1.67% -1.42% 0.00% 0.00% -1.23% 0.00% -3.01% -1.69%

Lubbock -1.97% -1.09% 0.00% 0.00% -3.06% 0.00% -6.50% -2.38%

Nueces -1.41% -1.04% 0.00% 0.00% -2.54% 0.00% -5.13% -1.60%

Tarrant -2.13% -2.39% 0.00% 0.00% -1.56% 0.00% -7.24% -2.60%

Travis -1.47% -0.83% 0.00% 0.00% -3.92% 0.00% -6.64% -2.09%

MRSA Central -1.50% -1.29% 0.00% 0.00% -2.38% 0.00% -4.48% -1.75%

MRSA Northeast -0.61% -0.55% 0.00% 0.00% -0.51% 0.00% -2.20% -0.68%

MRSA West -2.24% -1.60% 0.00% 0.00% -3.10% 0.00% -6.65% -2.59%

Total -1.54% -1.22% 0.00% 0.00% -2.03% 0.00% -5.19% -1.78%

Footnotes

(1) Equals the cost impact from preferred drug list (PDL) changes.

(2) Equals calendar year 2017 managed care pharmacy incurred claims.

(3) Equals Cost Impact of PDL changes divided by CY2017 Pharmacy Incurred Claims.

177

Attachment 5 - Exhibit N


Rx Adjustments

Carve-In Drugs



Impact of Drug Carve-In (1)

Bexar 10,368,809 1,628,859 0 0 258,120 0 106,278 12,362,065

Dallas 11,534,590 1,491,030 0 0 156,752 0 0 13,182,373

El Paso 1,575,697 427,954 0 0 0 0 0 2,003,652

Harris 18,671,427 1,146,758 0 0 123,766 0 80,396 20,022,347

Hidalgo 2,472,449 291,060 0 0 33,956 0 0 2,797,465

Jefferson 2,862,334 303,640 0 0 0 0 0 3,165,974

Lubbock 1,739,245 0 0 0 0 0 0 1,739,245

Nueces 3,057,643 54,050 0 0 0 0 97,327 3,209,020

Tarrant 6,457,616 618,855 0 0 398,281 0 203,248 7,678,001

Travis 5,370,699 710,767 0 0 256,803 0 200,920 6,539,189

MRSA Central 6,461,860 245,636 0 0 0 0 0 6,707,496

MRSA Northeast 6,060,631 641,871 0 0 184,474 0 0 6,886,976

MRSA West 4,374,274 283,322 0 0 101,624 0 0 4,759,220

Total 81,007,274 7,843,802 0 0 1,513,776 0 688,169 91,053,021

CY2017 Total Incurred Claims (2)

Bexar 97,735,497 21,692,423 0 0 4,931,038 0 10,630,083 134,989,040

Dallas 112,111,579 19,699,373 0 0 6,339,035 0 9,317,707 147,467,694

El Paso 33,286,216 8,575,568 0 0 455,939 0 5,344,172 47,661,895

Harris 236,441,335 31,615,631 0 0 7,207,966 0 22,457,738 297,722,670

Hidalgo 84,952,635 26,211,209 0 0 1,526,224 0 5,357,684 118,047,752

Jefferson 40,022,354 5,376,850 0 0 1,969,758 0 2,280,985 49,649,947

Lubbock 22,731,646 2,995,603 0 0 1,864,420 0 2,906,212 30,497,880

Nueces 36,926,982 8,188,378 0 0 1,395,006 0 2,917,284 49,427,650

Tarrant 84,990,004 12,991,272 0 0 5,891,985 0 10,483,569 114,356,830

Travis 50,075,265 9,320,388 0 0 4,308,679 0 7,642,322 71,346,654

MRSA Central 49,530,185 5,977,912 0 0 3,474,968 0 4,686,284 63,669,348

MRSA Northeast 75,548,522 14,593,292 0 0 5,637,824 0 5,466,888 101,246,526

MRSA West 56,751,494 6,624,510 0 0 3,840,640 0 5,951,833 73,168,477

Total 981,103,714 173,862,408 0 0 48,843,481 0 95,442,761 1,299,252,364

178

Attachment 5 - Exhibit N


Rx Adjustments

Carve-In Drugs




Bexar 10.61% 7.51% 0.00% 0.00% 5.23% 0.00% 1.00% 9.16%

Dallas 10.29% 7.57% 0.00% 0.00% 2.47% 0.00% 0.00% 8.94%

El Paso 4.73% 4.99% 0.00% 0.00% 0.00% 0.00% 0.00% 4.20%

Harris 7.90% 3.63% 0.00% 0.00% 1.72% 0.00% 0.36% 6.73%

Hidalgo 2.91% 1.11% 0.00% 0.00% 2.22% 0.00% 0.00% 2.37%

Jefferson 7.15% 5.65% 0.00% 0.00% 0.00% 0.00% 0.00% 6.38%

Lubbock 7.65% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 5.70%

Nueces 8.28% 0.66% 0.00% 0.00% 0.00% 0.00% 3.34% 6.49%

Tarrant 7.60% 4.76% 0.00% 0.00% 6.76% 0.00% 1.94% 6.71%

Travis 10.73% 7.63% 0.00% 0.00% 5.96% 0.00% 2.63% 9.17%

MRSA Central 13.05% 4.11% 0.00% 0.00% 0.00% 0.00% 0.00% 10.53%

MRSA Northeast 8.02% 4.40% 0.00% 0.00% 3.27% 0.00% 0.00% 6.80%

MRSA West 7.71% 4.28% 0.00% 0.00% 2.65% 0.00% 0.00% 6.50%

Total 8.26% 4.51% 0.00% 0.00% 3.10% 0.00% 0.72% 7.01%

Footnotes

(1) Equals the cost impact from drug carve-in changes.

(2) Equals calendar year 2017 managed care pharmacy incurred claims.

(3) Equals Cost Impact of Drug Carve-in changes divided by CY2017 Pharmacy Incurred Claims.

179

180

Attachment 6

Removal of STAR+PLUS Members Under Age 21

Effective November 1, 2016 all STAR+PLUS members under age 21 were removed from the

STAR+PLUS program and moved to the STAR Kids managed care program. This change only

impacted the Medicaid Only OCC risk group. As a result, the impact of this eligibility change

on the first two months of the medical base period must be adjusted for. The impact of this

eligibility change was studied by comparing the average base period cost of STAR+PLUS

members over and under age 21. The attached exhibit provides the development of the

adjustment factors applied to the medical rating. No adjustment is needed to the pharmacy rating

analysis since the base period is calendar year 2017, after the eligibility criteria had changed.

The calculation of the medical adjustment factor includes both acute care and long term care

claims and has been applied equally to both components of the rate development.

The adjustment factor is a function of both the average cost differential between the age groups

and the relative proportion of the population within each. Service areas such as Harris and

Hidalgo, where the under 21 population made up a large percentage of the total, have larger

adjustment factors than the other service areas.

Attachment 6


Other Adjustments

Removal of Members Under Age 21

Adjustment

Under Age 21 Age 21 & Over Total Factor (2)

FY2017 Member Months

Bexar 3,885 229,217 233,102

Dallas 2,301 323,631 325,932

El Paso 639 73,745 74,384

Harris 10,212 489,575 499,787

Hidalgo 7,466 175,528 182,994

Jefferson 1,160 97,008 98,168

Lubbock 629 57,169 57,798

Nueces 1,042 85,930 86,972

Tarrant 2,866 191,940 194,806

Travis 1,142 110,649 111,791

MRSA Central 1,131 133,439 134,570

MRSA Northeast 966 204,672 205,638

MRSA West 875 141,107 141,982

Total 34,314 2,313,610 2,347,924

FY2017 Total Incurred Claims (1)

Bexar 2,101,169 154,920,348 157,021,517

Dallas 912,532 244,032,912 244,945,444

El Paso 466,347 60,807,103 61,273,450

Harris 4,687,913 385,060,801 389,748,714

Hidalgo 3,936,999 182,336,428 186,273,426

Jefferson 289,743 63,991,087 64,280,830

Lubbock 363,304 32,148,269 32,511,572

Nueces 446,813 62,747,542 63,194,355

Tarrant 1,165,169 130,436,144 131,601,313

Travis 537,913 68,251,963 68,789,876

MRSA Central 531,629 75,698,533 76,230,161

MRSA Northeast 288,057 117,613,165 117,901,222

MRSA West 297,540 81,412,170 81,709,709

Total 16,025,128 1,659,456,463 1,675,481,591

FY2016 Per Member Per Month

Bexar 540.84 675.87 673.62 1.0033

Dallas 396.58 754.05 751.52 1.0034

El Paso 729.81 824.56 823.74 1.0010

Harris 459.06 786.52 779.83 1.0086

Hidalgo 527.32 1,038.79 1,017.92 1.0205

Jefferson 249.78 659.65 654.80 1.0074

Lubbock 577.59 562.34 562.51 0.9997

Nueces 428.80 730.22 726.61 1.0050

Tarrant 406.55 679.57 675.55 1.0059

Travis 471.03 616.83 615.35 1.0024

MRSA Central 470.05 567.29 566.47 1.0014

MRSA Northeast 298.20 574.64 573.34 1.0023

MRSA West 340.05 576.95 575.49 1.0025

Total 467.01 717.26 713.60 1.0051

Footnotes

(1) Equals FY2017 health plan fee-for-service claims for all services (from Encounter database).

(2) Equals the ratio of the average cost for members age 21 & over to the total average cost.

Medicaid Only OCC

181

182

Attachment 7

Carve In Relocation Services

The Health and Human Services Commission (HHSC), on behalf of the Department of Aging

and Disability Services (DADS), previously had six contractors to develop and implement

relocation services to assist Medicaid eligible nursing facility residents to relocate from nursing

facilities to community-based settings. Relocation contractors must provide relocation assistance

to Medicaid eligible nursing home residents seeking to relocate to a community-based setting of

their choice. Effective September 1, 2017 these services were carved into the STAR+PLUS

program.

The estimated impact was derived from estimating the average relocation cost per member per

month spread across the Nursing Facility risk groups. Cost breakdown was not available by

service area, therefore the average statewide amount had been calculated and applied uniformly.

This adjustment has been included in the rate development as an addition to the service

coordination amounts included in Attachment 3.

The current relocation services total cost is approximately $5,000,000. Dividing this by the

projected nursing facility enrollment of 656,000 member months results in a per member per

month add-on of $7.62 which only applies to the Nursing Facility risk groups.

183

Attachment 8

Acuity Risk Adjustment – Acute Care

The rate setting methodology incorporates a risk adjustment technique that is designed to adjust

the base community rate in each service area to reflect the health status, or acuity, of the

population enrolled in each health plan. The purpose of acuity risk adjustment is to recognize

the anticipated cost differential between multiple health plans in a service area by analyzing the

health status of their respective memberships.

This analysis is performed by the University of Florida’s Institute for Child Health Policy

(ICHP) through their role as the EQRO. ICHP uses the Chronic Illness and Disability Payment

System (CDPS) model to perform the acuity analysis. Exhibit A provides a brief description of

the CDPS analysis as provided by ICHP in their summary report. Exhibits B-E present a

summary of the risk adjustment analysis results by risk group. All information was provided by

ICHP and reviewed by the actuary for reasonableness.

The column titled Case Mix on the chart is the risk adjustment factor. It is the ratio of the

predicted average cost of the individual health plan’s membership divided by the predicted

average cost of the entire service area’s membership. The risk adjustment factor is applied to the

acute care portion of the community rate for each health plan and risk group.

If necessary, an additional adjustment was made to the risk adjustment factors to ensure that, in

total, they produce the same premium as the community rates (budget neutral). Exhibit F

summarizes the raw, unadjusted risk adjustment factors (case-mix), the budget neutral

adjustment applied equally to each risk group within each service area along with the resulting

adjusted risk adjustment factors which are used to calculate the risk adjusted community rates.

Attachment 8 – Exhibit A

184

Technical Specifications

TEXAS Actuarial Analysis (CDPS+Rx)

Programs: STAR, CHIP, CHIP Perinatal, STAR+PLUS, STAR Kids

Reporting Period: State Fiscal Year 2017

The Institute for Child Health Policy

University of Florida

The External Quality Review Organization

for Texas Medicaid Managed Care and CHIP

Issue Date: March 20, 2018

Actuarial Analysis Technical Specifications Attachment 8 – Exhibit A

185

The University of Florida Institute for Child Health Policy (ICHP), the Texas external quality review

organization (EQRO), conducted health-based risk analyses for STAR, CHIP, STAR+PLUS, STAR Kids, and

CHIP Perinatal at the request of the Texas Health and Human Services (HHS). ICHP performed these

analyses using the Chronic Illness and Disability Payment System (CDPS) Version 6.2.2, which classifies

diagnostic and pharmaceutical information in order to facilitate a comparison of managed care

organizations’ actual and expected expenditures.

In its basic form, the CDPS package groups the International Classification of Diseases diagnostic codes

found in health-care encounter data into a series of diagnosis categories. Users of the CDPS package

have the option of including pharmacy data as well as medical encounter data in their analyses by

following an alternative model, called CDPS+Rx. In addition to grouping diagnostic codes into diagnosis

categories as in the basic CDPS model, CDPS+Rx also groups the National Drug Codes (NDCs) found in

pharmacy data into a series of pharmacy categories. More information about CDPS is available at

http://cdps.ucsd.edu.

Data Source

Program Data Source

STAR Member level enrollment data (SFY2014-SFY2017) MCO medical and pharmacy encounters (SFY2014-SFY2017) CHIP

Member level enrollment data (SFY2014-SFY2017) MCO medical and pharmacy encounters (SFY2014-SFY2017) STAR+PLUS

Member level enrollment data (SFY2014-SFY2017) MCO medical and pharmacy encounters (SFY2014-SFY2017) STAR Kids STAR Kids Eligibility data for SFY2014-SFY2016 (provided by HHS)

STAR Kids enrollment data from November 2016 to August 2017 FFS and MCO medical and pharmacy claims/encounters (SFY2014-SFY2017,

FFS data was only included for SFY2014-SFY2016) CHIP Perinatal Member level enrollment data (SFY2017) MCO medical and pharmacy encounters (SFY2017)

Time Period Covered: The EQRO incorporates all dates of service from SFY2017 in its analyses, including

medical and pharmacy encounters received by the EQRO through January 2018, except for STAR Kids

data, which was received by the EQRO through February 2018.

http://cdps.ucsd.edu/


186

New BABY Categories: CDPS uses individual diagnostic codes to classify patients based on their disease

states into broader diagnostic groups for prediction of health expenditures. In addition to adult

diagnostic codes, neonatal codes were also included in the system. CDPS classifies neonatal codes into

one of five groups:

BABY 1: Extremely low birth weight

BABY 2: Very low birth weight

BABY 3: Serious perinatal problem

BABY 4: Other perinatal problem

BABY 5: Normal, single birth

From a clinical perspective it was noted that the diagnostic codes included in BABY 3 and BABY 4 had

significant clinical variability, including variability in resource utilization during hospitalization.

Given this concern, the EQRO and faculty neonatologists at the University of Florida College of Medicine

have attempted to reorganize the diagnostic codes into more homogeneous groups from both a clinical

severity and cost perspective in order to reduce the previous variability within the groups. The following

new BABY categories were created:

BABY 1: Extreme prematurity/Extremely low birth weight (<28 weeks)

BABY 2: Very premature/Very low birth weight (28-31 weeks)

BABY 3: Mild prematurity (32-36 weeks)

BABY 4: Critical problem of the neonate

BABY 5: Moderate problem of the neonate

BABY 6: Mild problem of the neonate

BABY 7: Single, term infants without problems

BABY 8: Twin infants

The hierarchy of the new BABY categories is: 1 > 2 > 4 > 3 > 5 > 8 > 7. And BABY 6 (Mild problem of the

neonate) is additive to other BABY categories.

The EQRO mapped newly added neonatal diagnostic codes from the 2018 edition of ICD-10-CM to BABY

categories and modified the mapping of some existing codes. The new mapping was shared with HHS

early this year.


187

Enrollment Criteria: The EQRO analysis excludes all enrollees ages ≥ 1 that were not enrolled in the

program continuously for at least four months in a state fiscal year; a one-month gap in enrollment

within the four-month period was permitted, and the gap is only allowed in between the active period

but not at the beginning or the end. However, all infants less than one year old are included as long as

they were enrolled in the program at least 1 month within the state fiscal year. Transferees (clients that

changed MCOs during the year) are included in the models and are assigned to the health plan with

which they were most recently enrolled in the state fiscal year.

The EQRO previously required enrollees of age ≥ 1 to be continuously enrolled for at least six months

within a state fiscal year (allowing for a one-month gap within the six months). Starting in SFY2017, the

continuous enrollment requirement changes to four months (still allowing for a one-month gap in

between). Changing the enrollment criteria length allows more enrollees to be included in the analysis

while still excluding those who were not enrolled long enough to have sufficient information to

determine their health status. By changing the requirement from six to four months, enrollees meeting

the continuous enrollment criteria increased from 78% to 88% in STAR population. This revised

continuous enrollment period is similar to what is used in other analyses. For example, 3MTM requires

members to enroll at least 3 months during a year in order to be assigned a clinical risk group (CRG).

Risk Groups: The EQRO conducts CDPS analyses for the following state-defined risk groups.

Program Risk Group

STAR Less than 1 Year of Age * Age 1 to 5 * Age 6 to 14 * Age 15 to 18 * Age 19 to 20 * TANF Adults (risk group code 003) Pregnant Women (risk group code 005, 020) CHIP Less than 1 Year of Age * Age 1 to 5 * Age 6 to 14 * Age 15 to 20 * STAR+PLUS Medicaid Only Community (risk group code 100) Medicaid Only SPW (risk group code 111) Intellectual Developmental Disabilities (risk group code 122)

Medicaid Only Nursing Facility (risk group code 120)


188

STAR Kids

Less than 1 Year of Age * Age 15 to 20 * MDCP Waiver (risk group code 604) YES Waiver (risk group code 605) IDD Waiver (risk group code 606) CHIP Perinatal Perinatal Mother <= 198% FPL (risk group code 309)

*Note: age is calculated on the last day of the analysis year

The EQRO uses monthly risk-group information found in PPS enrollment files to identify enrollees’ risk

groups. In general, each enrollee is assigned to the risk group to which he or she was assigned for the

majority of time during the analysis year. The only exception is for pregnant women. This cohort is

assigned to pregnant women risk groups if they were assigned in the eligibility data for any month of the

analysis year. For age-related risk groups, the EQRO uses the age of the enrollee at the end of the

analysis year.

Enrollees of age < 21 previously enrolled in STAR+PLUS have been transferred to STAR Kids, so HHS

excluded all enrollees of age < 21 from STAR+PLUS in this analysis.

CDPS+Rx Weights: The EQRO uses the concurrent risk adjustment option within CDPS whereby both

expenditures and diagnostic categorization for each enrollee are based upon the year in which the

expenditures and diagnoses were recorded. This is in contrast to the retrospective option whereby

current year expenditures are modeled as a function of the diagnoses recorded in the preceding year.

The expenditures per month for each eligible member (expenditure PMPM) are calculated from the

encounter data. Texas-specific weights are developed using linear regression models with CDPS

diagnostic and pharmacy categories as the independent variables and cost as the dependent variable,

using the most recent three years of historical data. The Consumer Price Index (medical care

component) is used to adjust expenditures when fitting these models.

Ancillary services in the following list are excluded when assigning the CDPS category but included when

calculating cost.

CPT code range 70000 to 79999, Radiology procedures

CPT code range 80000 to 89999, Pathology and laboratory procedures

The EQRO calculates Texas-specific weights for STAR, CHIP, STAR+PLUS and STAR Kids. CHIP Perinatal

population is not big enough to build weights on, so the EQRO applied STAR weights to CHIP Perinatal


189

population. To get a full picture of the health status, the EQRO includes NorthSTAR encounter data in

the calculation of STAR, STAR+PLUS and STAR Kids weights.

CDPS includes both empirical and clinical input with many diagnostic subcategories ordered by expected

clinical severity such that the diagnoses in the higher severity subcategories were expected to exhibit

higher costs and hence positive weights. When reverse or negative weights occur, we combine

subcategories together to ensure that the weights make intuitive sense.

Presentation of Results: The EQRO presents the results from its CDPS analysis in accompanying Excel

spreadsheets organized by MCO and SDA for each risk group.

For each MCO, MCO/SDA combination and each risk group, the EQRO calculated two ratios:

Case Mix Ratio =Plan Predicted Expenditures Per Member Per Month

Group Predicted Expenditures Per Member Per Month

Spending Ratio =Plan Actual Expenditures Per Member Per Month

Plan Predicted Expenditures Per Member Per Month

The case-mix ratio, measures the MCO’s expected expenditures given the diagnostic mix of its enrollees

relative to the expected expenditures across all MCOs for that group. The spend ratio, measures the

MCO’s actual expenditures for enrollees in a given risk group relative to the expenditures that are

expected given the health status of the MCO’s enrollees in the risk group.


Reporting Period: Sep 1, 2016 to Aug 31, 2017

SA/Health Plan

Number of

Enrollees

Percent

Affected

Actual PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM

Payment Case Mix Spend Ratio

CDPS

STAR+PLUS--Medicaid-Only OCC 204,526 100.00 1,212.99 1,212.99 1.00 1.00

Bexar 20,227 100.00 1,197.08 1,184.40 1.00 1.01

Amerigroup 4,123 20.38 1,145.60 1,180.50 1.00 0.97

Molina 2,313 11.44 1,108.49 1,026.21 0.87 1.08

Superior 13,791 68.18 1,227.04 1,211.93 1.02 1.01

Dallas 28,529 100.00 1,146.42 1,200.97 1.00 0.95

Molina 15,596 54.67 1,209.68 1,222.85 1.02 0.99

Superior 12,933 45.33 1,070.36 1,174.65 0.98 0.91

El Paso 6,496 100.00 1,299.90 1,266.39 1.00 1.03

Amerigroup 4,061 62.52 1,195.94 1,216.29 0.96 0.98

Molina 2,435 37.48 1,474.60 1,350.58 1.07 1.09

Harris 43,215 100.00 1,360.88 1,297.23 1.00 1.05

Amerigroup 17,423 40.32 1,292.86 1,228.35 0.95 1.05

Molina 4,709 10.90 1,260.42 1,131.67 0.87 1.11

United Health Care (United) 21,083 48.79 1,439.85 1,391.49 1.07 1.03

Hidalgo 15,389 100.00 1,589.16 1,189.59 1.00 1.34

HealthSpring 4,148 26.95 1,549.90 1,111.04 0.93 1.40

Molina 3,265 21.22 1,504.78 1,158.30 0.97 1.30

Superior 7,976 51.83 1,643.90 1,243.14 1.05 1.32

Jefferson 8,565 100.00 1,115.48 1,187.13 1.00 0.94

Amerigroup 3,108 36.29 1,049.09 1,107.94 0.93 0.95

Molina 2,450 28.60 1,133.48 1,123.26 0.95 1.01


Lubbock 5,071 100.00 1,025.75 1,214.03 1.00 0.84

Amerigroup 2,007 39.58 1,100.31 1,262.31 1.04 0.87

Superior 3,064 60.42 977.75 1,182.94 0.97 0.83

MRSA Central 11,887 100.00 1,033.75 1,132.18 1.00 0.91

Superior 7,412 62.35 1,037.78 1,148.13 1.01 0.90


MRSA Northeast 18,165 100.00 1,007.99 1,128.45 1.00 0.89

Health Spring 9,020 49.66 978.37 1,065.33 0.94 0.92


MRSA West 12,490 100.00 1,034.82 1,164.87 1.00 0.89

Amerigroup 4,549 36.42 1,051.59 1,131.82 0.97 0.93

Superior 7,941 63.58 1,025.33 1,183.56 1.02 0.87

Nueces 7,542 100.00 1,250.57 1,257.79 1.00 0.99

Superior 3,864 51.23 1,200.57 1,194.97 0.95 1.00


Tarrant 17,098 100.00 1,161.98 1,305.48 1.00 0.89

Amerigroup 12,998 76.02 1,166.45 1,353.83 1.04 0.86

Health Spring 4,100 23.98 1,147.67 1,150.65 0.88 1.00

Travis 9,852 100.00 1,199.28 1,079.59 1.00 1.11

Amerigroup 4,645 47.15 1,195.14 1,028.17 0.95 1.16United Health Care (United) 5,207 52.85 1,203.01 1,125.89 1.04 1.07

TEXAS STAR+PLUS CDPS SDA/Health Plan Risk

STAR+PLUS

Notes: 1. CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees

who had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 4 continuous months

(age≥1) (permitting one month lapse in enrollment within the 4 months period).

190



SA/Health Plan

Number of

Enrollees

Percent

Affected

Actual PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

STAR+PLUS--Medicaid-Only HCBS 16,244 100.00 3,983.18 3,983.18 1.00 1.00

Bexar 1,920 100.00 3,957.12 3,815.69 1.00 1.04

Amerigroup 228 11.88 3,799.46 4,287.25 1.12 0.89

Molina 263 13.70 3,382.23 3,609.64 0.95 0.94

Superior 1,429 74.43 4,087.60 3,778.67 0.99 1.08

Dallas 2,158 100.00 3,483.38 3,809.15 1.00 0.91

Molina 1,456 67.47 3,360.35 3,699.13 0.97 0.91

Superior 702 32.53 3,739.12 4,037.84 1.06 0.93

El Paso 714 100.00 3,971.84 3,954.61 1.00 1.00

Amerigroup 382 53.50 3,875.29 3,980.61 1.01 0.97

Molina 332 46.50 4,083.92 3,924.42 0.99 1.04

Harris 2,921 100.00 4,386.62 4,317.81 1.00 1.02

Amerigroup 875 29.96 4,297.61 4,350.45 1.01 0.99

Molina 502 17.19 4,507.57 4,321.09 1.00 1.04


Hidalgo 2,348 100.00 4,236.20 3,580.37 1.00 1.18

HealthSpring 610 25.98 4,205.78 3,455.23 0.97 1.22

Molina 451 19.21 4,136.71 3,665.10 1.02 1.13

Superior 1,287 54.81 4,284.99 3,609.80 1.01 1.19

Jefferson 589 100.00 3,670.00 4,064.48 1.00 0.90

Amerigroup 136 23.09 3,804.50 4,361.79 1.07 0.87

Molina 315 53.48 3,614.03 3,909.91 0.96 0.92

United Health Care (United) 138 23.43 3,663.59 4,121.13 1.01 0.89

Lubbock 289 100.00 3,486.20 4,111.28 1.00 0.85

Amerigroup 136 47.06 3,260.95 3,787.18 0.92 0.86

Superior 153 52.94 3,688.22 4,401.96 1.07 0.84

MRSA Central 581 100.00 3,759.62 3,993.63 1.00 0.94

Superior 424 72.98 3,613.65 3,889.65 0.97 0.93


MRSA Northeast 1,422 100.00 3,803.68 3,945.50 1.00 0.96

Health Spring 784 55.13 3,485.35 3,674.94 0.93 0.95


MRSA West 637 100.00 3,844.11 4,102.89 1.00 0.94

Amerigroup 227 35.64 3,995.38 4,469.80 1.09 0.89

Superior 410 64.36 3,760.89 3,901.02 0.95 0.96

Nueces 865 100.00 3,614.91 3,838.48 1.00 0.94

Superior 528 61.04 3,606.79 3,715.51 0.97 0.97


Tarrant 1,114 100.00 4,005.53 4,507.28 1.00 0.89

Amerigroup 873 78.37 3,970.89 4,559.68 1.01 0.87

Health Spring 241 21.63 4,131.80 4,316.32 0.96 0.96

Travis 686 100.00 4,646.28 4,152.54 1.00 1.12

Amerigroup 305 44.46 4,309.68 4,049.69 0.98 1.06United Health Care (United) 381 55.54 4,920.83 4,236.43 1.02 1.16


STAR+PLUS




191



SA/Health Plan

Number of

Enrollees

Percent

Affected

Actual PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

STAR+PLUS--Medicaid-Only NF 6,241 100.00 5,818.95 5,818.95 1.00 1.00

Bexar 592 100.00 5,925.06 6,055.12 1.00 0.98

Amerigroup 142 23.99 5,450.15 5,916.41 0.98 0.92

Molina 148 25.00 6,213.13 5,554.01 0.92 1.12

Superior 302 51.01 6,002.97 6,380.36 1.05 0.94

Dallas 924 100.00 6,123.13 6,051.46 1.00 1.01

Molina 524 56.71 6,155.29 5,818.84 0.96 1.06

Superior 400 43.29 6,082.42 6,345.86 1.05 0.96

El Paso 63 100.00 6,666.27 6,793.12 1.00 0.98

Amerigroup 33 52.38 5,823.23 7,218.66 1.06 0.81

Molina 30 47.62 7,535.57 6,354.32 0.94 1.19

Harris 973 100.00 6,196.40 6,876.35 1.00 0.90

Amerigroup 373 38.34 5,963.63 6,559.46 0.95 0.91

Molina 172 17.68 6,123.88 6,343.73 0.92 0.97


Hidalgo 228 100.00 6,185.46 6,146.69 1.00 1.01

HealthSpring 53 23.25 5,876.09 5,457.05 0.89 1.08

Molina 70 30.70 6,123.52 6,008.89 0.98 1.02

Superior 105 46.05 6,392.23 6,607.45 1.07 0.97

Jefferson 244 100.00 5,506.93 5,447.52 1.00 1.01

Amerigroup 81 33.20 5,375.64 5,540.84 1.02 0.97

Molina 78 31.97 5,707.86 4,919.35 0.90 1.16


Lubbock 219 100.00 5,938.18 6,572.02 1.00 0.90

Amerigroup 113 51.60 5,964.36 6,563.37 1.00 0.91

Superior 106 48.40 5,910.66 6,581.11 1.00 0.90

MRSA Central 520 100.00 5,263.35 4,890.66 1.00 1.08

Superior 290 55.77 5,196.34 4,698.07 0.96 1.11


MRSA Northeast 670 100.00 5,654.24 5,261.07 1.00 1.07

Health Spring 320 47.76 5,695.85 5,205.93 0.99 1.09


MRSA West 490 100.00 5,682.91 5,279.72 1.00 1.08

Amerigroup 202 41.22 5,682.16 5,168.69 0.98 1.10

Superior 288 58.78 5,683.44 5,357.73 1.01 1.06

Nueces 211 100.00 5,149.49 5,252.33 1.00 0.98

Superior 119 56.40 5,334.67 5,374.36 1.02 0.99


Tarrant 735 100.00 5,567.45 5,719.95 1.00 0.97

Amerigroup 552 75.10 5,621.42 5,910.35 1.03 0.95

Health Spring 183 24.90 5,407.48 5,155.59 0.90 1.05

Travis 372 100.00 5,827.87 5,130.63 1.00 1.14

Amerigroup 185 49.73 5,947.21 4,819.71 0.94 1.23United Health Care (United) 187 50.27 5,711.91 5,432.74 1.06 1.05


STAR+PLUS




192



SA/Health Plan

Number of

Enrollees

Percent

Affected

Actual PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

STAR+PLUS--IDD 17,435 100.00 803.44 803.44 1.00 1.00

Bexar 1,811 100.00 879.38 845.35 1.00 1.04

Amerigroup 279 15.41 738.61 685.98 0.81 1.08

Molina 126 6.96 606.78 658.62 0.78 0.92

Superior 1,406 77.64 932.07 893.99 1.06 1.04

Dallas 2,231 100.00 637.70 672.60 1.00 0.95

Molina 1,002 44.91 629.28 646.33 0.96 0.97

Superior 1,229 55.09 644.53 693.94 1.03 0.93

El Paso 542 100.00 1,363.41 1,070.81 1.00 1.27

Amerigroup 398 73.43 1,404.25 1,059.68 0.99 1.33

Molina 144 26.57 1,249.96 1,101.74 1.03 1.13

Harris 3,880 100.00 815.44 819.38 1.00 1.00

Amerigroup 1,464 37.73 829.70 767.77 0.94 1.08

Molina 379 9.77 812.13 771.91 0.94 1.05

United Health Care (United) 2,037 52.50 805.84 865.22 1.06 0.93

Hidalgo 1,015 100.00 866.90 944.95 1.00 0.92

HealthSpring 285 28.08 677.41 769.76 0.81 0.88

Molina 203 20.00 802.89 886.44 0.94 0.91

Superior 527 51.92 994.38 1,062.53 1.12 0.94

Jefferson 438 100.00 732.97 832.37 1.00 0.88

Amerigroup 98 22.37 1,025.01 813.66 0.98 1.26

Molina 83 18.95 644.98 771.17 0.93 0.84

United Health Care (United) 257 58.68 650.64 858.93 1.03 0.76

Lubbock 612 100.00 701.25 846.25 1.00 0.83

Amerigroup 233 38.07 847.40 874.27 1.03 0.97

Superior 379 61.93 611.42 829.03 0.98 0.74

MRSA Central 893 100.00 768.49 734.02 1.00 1.05

Superior 658 73.68 826.07 753.39 1.03 1.10


MRSA Northeast 1,119 100.00 744.81 738.80 1.00 1.01

Health Spring 564 50.40 664.96 710.14 0.96 0.94


MRSA West 1,144 100.00 780.38 810.31 1.00 0.96

Amerigroup 308 26.92 904.81 830.60 1.03 1.09

Superior 836 73.08 735.75 803.03 0.99 0.92

Nueces 504 100.00 790.98 873.56 1.00 0.91

Superior 254 50.40 893.87 883.77 1.01 1.01


Tarrant 2,004 100.00 749.20 762.73 1.00 0.98

Amerigroup 1,448 72.26 758.74 801.19 1.05 0.95

Health Spring 556 27.74 724.48 663.06 0.87 1.09

Travis 1,242 100.00 921.74 801.04 1.00 1.15

Amerigroup 331 26.65 910.69 636.13 0.79 1.43United Health Care (United) 911 73.35 925.75 860.92 1.07 1.08


STAR+PLUS




193



Adjusted Acuity Scores

Medicaid Medicaid Medicaid

Only OCC Only HCBS Only NF IDD

Unadjusted Acuity Scores (1)

Amerigroup - Bexar 0.99670 1.12359 0.97709 0.81148

Molina - Bexar 0.86643 0.94600 0.91724 0.77911

Superior - Bexar 1.02324 0.99030 1.05371 1.05754

Molina - Dallas 1.01822 0.97112 0.96156 0.96095

Superior - Dallas 0.97809 1.06004 1.04865 1.03173

Amerigroup - El Paso 0.96044 1.00657 1.06264 0.98960

Molina - El Paso 1.06648 0.99237 0.93541 1.02889

Amerigroup - Harris 0.94690 1.00756 0.95392 0.93702

Molina - Harris 0.87237 1.00076 0.92254 0.94207

United - Harris 1.07266 0.99545 1.07334 1.05595

HealthSpring - Hidalgo 0.93397 0.96505 0.88780 0.81461

Molina - Hidalgo 0.97370 1.02366 0.97758 0.93809

Superior - Hidalgo 1.04502 1.00822 1.07496 1.12444

Amerigroup - Jefferson 0.93329 1.07315 1.01713 0.97753

Molina - Jefferson 0.94620 0.96197 0.90304 0.92648

United - Jefferson 1.11524 1.01394 1.07585 1.03192

Amerigroup - Lubbock 1.03977 0.92117 0.99868 1.03311

Superior - Lubbock 0.97440 1.07070 1.00138 0.97965

Superior - Nueces 0.95006 0.96797 1.02323 1.01169

United - Nueces 1.05262 1.05074 0.96865 0.98808

Amerigroup - Tarrant 1.03704 1.01162 1.03329 1.05042

HealthSpring - Tarrant 0.88140 0.95763 0.90133 0.86932

Amerigroup - Travis 0.95238 0.97523 0.93940 0.79413

United - Travis 1.04289 1.02020 1.05888 1.07475

Superior - MRSA Central 1.01408 0.97396 0.96062 1.02638

United - MRSA Central 0.97592 1.07192 1.05065 0.92375

HealthSpring - MRSA Northeast 0.94407 0.93143 0.98952 0.96122

United - MRSA Northeast 1.05546 1.08479 1.00954 1.03995

Amerigroup - MRSA West 0.97163 1.08943 0.97897 1.02504

Superior - MRSA West 1.01605 0.95080 1.01478 0.99102

194






Budget Neutrality Adjustment (2)


Molina - Bexar 1.00003 0.99993 0.99474 0.99875

Superior - Bexar 1.00003 0.99993 0.99474 0.99875

Molina - Dallas 1.00009 0.99914 0.99957 1.00044

Superior - Dallas 1.00009 0.99914 0.99957 1.00044


Molina - El Paso 0.99936 1.00075 1.00191 0.99978


Molina - Harris 0.99825 0.99965 0.99372 0.99933

United - Harris 0.99825 0.99965 0.99372 0.99933


Molina - Hidalgo 0.99983 1.00091 0.99320 0.99994







Superior - Nueces 0.99917 1.00052 1.00421 1.00024

United - Nueces 0.99917 1.00052 1.00421 1.00024




United - Travis 0.99849 1.00197 0.99724 1.00327







195






Budget Neutral Acuity Scores (3)


Molina - Bexar 0.86646 0.94593 0.91241 0.77814

Superior - Bexar 1.02327 0.99022 1.04817 1.05622

Molina - Dallas 1.01832 0.97029 0.96115 0.96138

Superior - Dallas 0.97818 1.05913 1.04820 1.03219


Molina - El Paso 1.06580 0.99311 0.93719 1.02866


Molina - Harris 0.87085 1.00041 0.91675 0.94144

United - Harris 1.07079 0.99510 1.06660 1.05524


Molina - Hidalgo 0.97353 1.02459 0.97093 0.93803







Superior - Nueces 0.94927 0.96847 1.02754 1.01194

United - Nueces 1.05175 1.05129 0.97273 0.98832




United - Travis 1.04132 1.02221 1.05596 1.07826







Footnotes:

(1) Raw acuity scores as developed by ICHP. Equals the case mix factors from Exhibits B-E.

(2) Budget neutral adjustment applied uniformly within each service area to ensure acuity

adjustment is budget neutral in total.

(3) Adjusted acuity scores applied to FY2019 Acute Care Community Rates.

196

197

Attachment 9

Acuity Risk Adjustment – Long Term Care

Over the past three years HHSC formed a workgroup with the MCOs, the EQRO and Rudd and

Wisdom to study the impact of acuity on long term care costs. This study involved a review of

long term care acuity models utilized by other states, the availability and quality of long term

care related diagnostic information and the relative differences in cost among the MCOs within

each service area. It was determined that the acuity difference resulting from long term care

service needs is best evaluated through a combination of medical diagnostic information and

functional assessment data. Functional assessment data includes a review of the activities of

daily living (ADLs) – bathing, dressing, eating, etc. Information on ADLs is collected by HHSC

and the MCOs through the ongoing assessment process utilized to determine eligibility for

waiver services. Although this data provides thorough, meaningful information on an individual

member’s functional status it was determined that (a) it is not readily available for a large

percentage of STAR+PLUS members and (b) it is not currently available in a consistent format

that could be readily utilized for acuity evaluation. Although HHSC and the MCOs are

continuing to pursue the collection of this information it was determined that it would not be a

sufficient source for the FY2019 acuity analysis.

As an interim step, HHSC developed a long term care acuity model that measures the relative

acuity among the health plans within a service area by analyzing the relative percentage of

unique members who utilize Personal Attendant Services (PAS). PAS accounts for 83% of all

long term care services for the OCC and HCBS risk groups and is the greatest indicator of

relative cost for a given population.

Using the FY2017 encounter data, HHSC identified the following statistics for each MCO within

each service area:

1. Total number of unique members during FY2017.

2. Total number of unique PAS utilizers during FY2017.

3. Percentage of unique members utilizing PAS during FY2017.

Data was collected separately for the following risk groups:

1. Medicaid Only OCC

2. Medicaid Only HCBS

3. Dual Eligible OCC

4. Dual Eligible HCBS

The relative acuity of each MCO within each service area was then defined as:

MCO % of unique members utilizing PAS

SDA % of unique members utilizing PAS

An MCO that enrolls a higher percentage of members who utilize PAS than the overall SDA

average has an acuity score greater than 1.0.

Exhibit A provides a brief description of the HHSC analysis as provided by HHSC in their

summary report. Exhibits B-E present a summary of the long term care risk adjustment analysis

198

results by risk group. All information was provided by HHSC and reviewed by the actuary for

reasonableness.

Given that this is the second year that risk adjustment has been applied to the long term care

component of the premium we have increased the credibility factor from 75% to 100% of the

calculated risk scores.

If necessary, an additional adjustment was made to the risk adjustment factors to ensure that, in

total, they produce the same premium as the community rates (budget neutral). Exhibit F

summarizes the raw, unadjusted risk adjustment factors, the budget neutral adjustment applied

equally to each risk group within each service area along with the resulting adjusted long term

care risk adjustment factors which are used to calculate the risk adjusted community rates.

This long term care acuity model does not impact the nursing facility risk groups since attendant

care is not a significant cost for these populations. The impact of relative acuity differences on

the nursing facility populations is continuing to be studied but no adjustments will be made for

the FY2019 premium rates.

Attachment 9 – Exhibit A

199

Technical Specifications for LTSS Risk Adjustment, STAR+PLUS, State

Fiscal Year 2017

Background

The functional conditions of elders and individuals with disabilities receiving Long-Term

Support and Services (LTSS) from MCOs are highly diverse. To improve the accuracy and

provide more equitable payments to MCOs that provide the services in STAR+PLUS program,

HHSC calculated risk scores for "Attendant Care Services" using STAR+PLUS Enrollment and

Encounter data.

Data Source

Enrollment data was used to collect members eligible to receive PAS in STAR+PLUS program.

Encounter data was used to collect information on the number of actual members who utilized

the services. Only paid claims, with financial arrangement codes from 06 to 10 were included in

this analysis.

Analysis

Percent utilization and risk scores were calculated using the following formulas:

Percent utilization =MCO Number of PAS Utilizers

MCO Number of Eligible Enrollees

Risk Score = Percent of MCO PAS Utilizers

Percent of SDA PAS Utilizers

The analyses were stratified by Home and Community Based Services (HCBS) and Other

Community Care (OCC) programs for dual and non-dual status.

The risk scores were used to adjust the SFY2019 STAR+PLUS LTSS capitation rates. The

acuity factors were developed and applied at 100% of the MCOs factors to adjust the rates.



Long Term Care Acuity Analysis

Medicaid Only OCC

Unique Unique Percent Risk

Members Utilizers Utilization Score

Amerigroup - Bexar 4,911 768 15.6% 0.8033

Molina - Bexar 2,770 426 15.4% 0.7900

Superior - Bexar 15,742 3,366 21.4% 1.0983

Bexar SDA Total 23,423 4,560 19.5% 1.0000

Molina - Dallas 18,269 3,835 21.0% 1.1073

Superior - Dallas 15,411 2,550 16.5% 0.8728

Dallas SDA Total 33,680 6,385 19.0% 1.0000

Amerigroup - El Paso 4,676 826 17.7% 0.8551

Molina - El Paso 2,871 733 25.5% 1.2359

El Paso SDA Total 7,547 1,559 20.7% 1.0000

Amerigroup - Harris 20,432 3,091 15.1% 0.8474

Molina - Harris 5,798 978 16.9% 0.9449

United - Harris 24,548 4,996 20.4% 1.1400

Harris SDA Total 50,778 9,065 17.9% 1.0000

HealthSpring - Hidalgo 4,838 2,311 47.8% 0.9775

Molina - Hidalgo 3,841 1,648 42.9% 0.8780

Superior - Hidalgo 9,261 4,808 51.9% 1.0624

Hidalgo SDA Total 17,940 8,767 48.9% 1.0000

Amerigroup - Jefferson 3,660 440 12.0% 0.9550

Molina - Jefferson 2,918 422 14.5% 1.1488

United - Jefferson 3,622 422 11.7% 0.9255

Jefferson SDA Total 10,200 1,284 12.6% 1.0000

Amerigroup - Lubbock 2,344 135 5.8% 0.8166

Superior - Lubbock 3,554 281 7.9% 1.1210

Lubbock SDA Total 5,898 416 7.1% 1.0000

Superior - Nueces 4,533 1,175 25.9% 0.9898

United - Nueces 4,284 1,134 26.5% 1.0108

Nueces SDA Total 8,817 2,309 26.2% 1.0000

Amerigroup - Tarrant 15,437 1,505 9.7% 0.9363

HealthSpring - Tarrant 5,220 646 12.4% 1.1885

Tarrant SDA Total 20,657 2,151 10.4% 1.0000

Amerigroup - Travis 5,639 772 13.7% 1.2641

United - Travis 6,198 510 8.2% 0.7598

Travis SDA Total 11,837 1,282 10.8% 1.0000

Superior - MRSA Central 8,593 881 10.3% 1.0838

United - MRSA Central 5,361 439 8.2% 0.8657

MRSA Central SDA Total 13,954 1,320 9.5% 1.0000

HealthSpring - MRSA Northeast 10,410 1,181 11.3% 0.9920

United - MRSA Northeast 10,619 1,224 11.5% 1.0079

MRSA Northeast SDA Total 21,029 2,405 11.4% 1.0000

Amerigroup - MRSA West 5,415 487 9.0% 0.8007

Superior - MRSA West 9,310 1,167 12.5% 1.1159

MRSA West SDA Total 14,725 1,654 11.2% 1.0000

200




Medicaid Only HCBS



Amerigroup - Bexar 288 223 77.4% 1.0231

Molina - Bexar 327 207 63.3% 0.8364

Superior - Bexar 1,770 1,375 77.7% 1.0265

Bexar SDA Total 2,385 1,805 75.7% 1.0000

Molina - Dallas 1,909 1,363 71.4% 1.0043

Superior - Dallas 973 686 70.5% 0.9917

Dallas SDA Total 2,882 2,049 71.1% 1.0000

Amerigroup - El Paso 448 349 77.9% 0.9834

Molina - El Paso 423 341 80.6% 1.0176

El Paso SDA Total 871 690 79.2% 1.0000

Amerigroup - Harris 1,099 852 77.5% 1.0145

Molina - Harris 651 482 74.0% 0.9689

United - Harris 1,837 1,407 76.6% 1.0023

Harris SDA Total 3,587 2,741 76.4% 1.0000

HealthSpring - Hidalgo 767 734 95.7% 1.0089

Molina - Hidalgo 571 531 93.0% 0.9804



Amerigroup - Jefferson 163 140 85.9% 1.1452

Molina - Jefferson 406 294 72.4% 0.9655

United - Jefferson 191 136 71.2% 0.9494

Jefferson SDA Total 760 570 75.0% 1.0000

Amerigroup - Lubbock 171 102 59.6% 0.9194

Superior - Lubbock 202 140 69.3% 1.0682

Lubbock SDA Total 373 242 64.9% 1.0000

Superior - Nueces 646 572 88.5% 1.0026

United - Nueces 407 358 88.0% 0.9959

Nueces SDA Total 1,053 930 88.3% 1.0000

Amerigroup - Tarrant 1,177 802 68.1% 0.9988

HealthSpring - Tarrant 302 207 68.5% 1.0047


Amerigroup - Travis 381 326 85.6% 1.0329

United - Travis 464 374 80.6% 0.9730

Travis SDA Total 845 700 82.8% 1.0000

Superior - MRSA Central 547 389 71.1% 0.9725

United - MRSA Central 212 166 78.3% 1.0708

MRSA Central SDA Total 759 555 73.1% 1.0000

HealthSpring - MRSA Northeast 985 746 75.7% 1.0143

United - MRSA Northeast 811 595 73.4% 0.9826


Amerigroup - MRSA West 286 248 86.7% 1.0782

Superior - MRSA West 562 434 77.2% 0.9602

MRSA West SDA Total 848 682 80.4% 1.0000

201




Dual Eligible OCC



Amerigroup - Bexar 5,466 1,354 24.8% 0.9177

Molina - Bexar 4,578 1,153 25.2% 0.9330

Superior - Bexar 11,669 3,354 28.7% 1.0648

Bexar SDA Total 21,713 5,861 27.0% 1.0000

Molina - Dallas 16,893 4,439 26.3% 1.0418

Superior - Dallas 11,412 2,700 23.7% 0.9381

Dallas SDA Total 28,305 7,139 25.2% 1.0000

Amerigroup - El Paso 7,406 2,365 31.9% 0.9244

Molina - El Paso 6,793 2,540 37.4% 1.0824

El Paso SDA Total 14,199 4,905 34.5% 1.0000


Molina - Harris 6,788 1,595 23.5% 0.9693

United - Harris 24,679 6,444 26.1% 1.0771

Harris SDA Total 53,749 13,030 24.2% 1.0000


Molina - Hidalgo 10,341 5,508 53.3% 0.8502



Amerigroup - Jefferson 3,551 762 21.5% 1.0935

Molina - Jefferson 3,520 741 21.1% 1.0727

United - Jefferson 2,040 285 14.0% 0.7119


Amerigroup - Lubbock 3,594 375 10.4% 0.8955

Superior - Lubbock 2,894 381 13.2% 1.1298

Lubbock SDA Total 6,488 756 11.7% 1.0000

Superior - Nueces 5,342 2,097 39.3% 1.1005

United - Nueces 4,728 1,495 31.6% 0.8865

Nueces SDA Total 10,070 3,592 35.7% 1.0000


HealthSpring - Tarrant 4,481 687 15.3% 0.8925


Amerigroup - Travis 6,206 1,354 21.8% 1.3129

United - Travis 5,643 615 10.9% 0.6558

Travis SDA Total 11,849 1,969 16.6% 1.0000

Superior - MRSA Central 6,127 909 14.8% 0.9799

United - MRSA Central 7,651 1,177 15.4% 1.0161





Amerigroup - MRSA West 10,362 2,097 20.2% 0.9898



202




Dual Eligible HCBS



Amerigroup - Bexar 723 617 85.3% 1.0235

Molina - Bexar 854 684 80.1% 0.9606

Superior - Bexar 2,154 1,810 84.0% 1.0078

Bexar SDA Total 3,731 3,111 83.4% 1.0000

Molina - Dallas 3,611 2,782 77.0% 0.9918

Superior - Dallas 1,617 1,279 79.1% 1.0183

Dallas SDA Total 5,228 4,061 77.7% 1.0000

Amerigroup - El Paso 785 640 81.5% 0.9548

Molina - El Paso 789 704 89.2% 1.0450

El Paso SDA Total 1,574 1,344 85.4% 1.0000


Molina - Harris 1,009 851 84.3% 0.9936

United - Harris 3,526 3,004 85.2% 1.0037

Harris SDA Total 6,318 5,363 84.9% 1.0000


Molina - Hidalgo 2,485 2,385 96.0% 0.9886



Amerigroup - Jefferson 575 528 91.8% 1.0715

Molina - Jefferson 784 658 83.9% 0.9794

United - Jefferson 284 222 78.2% 0.9122


Amerigroup - Lubbock 447 336 75.2% 0.9675

Superior - Lubbock 306 249 81.4% 1.0474

Lubbock SDA Total 753 585 77.7% 1.0000

Superior - Nueces 1,500 1,408 93.9% 1.0090

United - Nueces 1,442 1,329 92.2% 0.9907

Nueces SDA Total 2,942 2,737 93.0% 1.0000


HealthSpring - Tarrant 650 468 72.0% 1.0097


Amerigroup - Travis 934 841 90.0% 1.0212

United - Travis 1,121 971 86.6% 0.9824

Travis SDA Total 2,055 1,812 88.2% 1.0000

Superior - MRSA Central 784 630 80.4% 0.9612

United - MRSA Central 997 859 86.2% 1.0305





Amerigroup - MRSA West 1,882 1,661 88.3% 1.0215



203





Medicaid Medicaid Dual Dual

Only OCC Only HCBS Eligible OCC Eligible HCBS

Unadjusted Acuity Scores (1)


Molina - Bexar 0.78996 0.83644 0.93304 0.96056

Superior - Bexar 1.09833 1.02646 1.06482 1.00776

Molina - Dallas 1.10729 1.00425 1.04185 0.99182

Superior - Dallas 0.87281 0.99166 0.93805 1.01827


Molina - El Paso 1.23594 1.01761 1.08241 1.04496


Molina - Harris 0.94486 0.96892 0.96927 0.99360

United - Harris 1.14002 1.00232 1.07709 1.00367


Molina - Hidalgo 0.87798 0.98037 0.85016 0.98862







Superior - Nueces 0.98980 1.00256 1.10049 1.00897

United - Nueces 1.01079 0.99594 0.88646 0.99067




United - Travis 0.75975 0.97300 0.65584 0.98235







204







Budget Neutrality Adjustment (2)


Molina - Bexar 0.99546 0.99856 0.99879 1.00002

Superior - Bexar 0.99546 0.99856 0.99879 1.00002

Molina - Dallas 0.99970 0.99996 0.99982 1.00039

Superior - Dallas 0.99970 0.99996 0.99982 1.00039


Molina - El Paso 1.00050 0.99898 0.99952 0.99696


Molina - Harris 0.99562 0.99937 0.99803 1.00001

United - Harris 0.99562 0.99937 0.99803 1.00001


Molina - Hidalgo 0.99983 0.99947 0.99920 1.00002







Superior - Nueces 0.99981 0.99996 1.00272 0.99998

United - Nueces 0.99981 0.99996 1.00272 0.99998




United - Travis 1.00979 0.99749 1.00642 0.99938







205







Budget Neutral Acuity Scores (3)


Molina - Bexar 0.78638 0.83524 0.93191 0.96057

Superior - Bexar 1.09334 1.02498 1.06353 1.00778

Molina - Dallas 1.10696 1.00421 1.04166 0.99221

Superior - Dallas 0.87255 0.99162 0.93789 1.01867


Molina - El Paso 1.23657 1.01658 1.08188 1.04179


Molina - Harris 0.94072 0.96831 0.96736 0.99361

United - Harris 1.13503 1.00169 1.07497 1.00368


Molina - Hidalgo 0.87783 0.97985 0.84948 0.98864







Superior - Nueces 0.98961 1.00252 1.10349 1.00895

United - Nueces 1.01059 0.99590 0.88887 0.99065




United - Travis 0.76719 0.97055 0.66005 0.98174







Footnotes:

(1) Acuity scores as developed by HHSC from Exhibits B-E.

(2) Budget neutral adjustment applied uniformly within each service area to ensure acuity

adjustment is budget neutral in total.

(3) Adjusted acuity scores applied to FY2019 Long Term Care Community Rates.

206

207

Attachment 10

Medicaid Breast and Cervical Cancer Program (MBCCP) Rate Development

Effective September 1, 2017 members in the Medicaid Breast and Cervical Cancer program

(MBCCP) began receiving their Medicaid services through managed care. Rudd and Wisdom

worked closely with HHSC to collect a list of Medicaid IDs for members enrolled in the MBCCP

program during the period September 1, 2012 through August 31, 2017. Using this ID list, HHSC

collected all claims data for these members during their applicable eligibility periods from internal

data warehouses. All data was checked for reasonableness by comparing the data collected by

multiple internal groups for different analyses. Data was collected independently by HHSC

Actuarial Analysis and HHSC System Forecasting. There was reasonable consistency between the

multiple data sources and the collected data was assumed to be reasonable and appropriate for the

FY2019 rate development calculations.

The actuarial model used to develop the MBCCP medical premium rates follows very closely to

the model described throughout this report for the existing STAR+PLUS population with the

exception that historical fee-for-service data was used in place of managed care data which is not

yet available. Below is a description of the trend, benefit and provider reimbursement

adjustments, managed care discount and administrative provisions included in the MBCCP rates.

The actuarial model used to develop the MBCCP prescription drug premium rates also follows

the general STAR+PLUS rating methodology with the exception that the base period used was

September 1, 2017 through February 28, 2018, in order to include managed are experience.

Below is a description of the trend, benefit and provider reimbursement adjustments, managed

care discount and administrative provisions included in the MBCCP rates.

Trend Factors - Medical

The trend assumptions are based on an analysis of historical MBCCP trends under the existing

FFS program. The medical trend assumption was developed as the average FFS trend during the

prior four fiscal years. The chart below summarizes the historical medical trend and the annual

trend assumptions

Historical Trend

FY2014 3.1%

FY2015 -3.3%

FY2016 -2.4%

FY2017 5.4%

Average 0.7%

Trend Assumption 0.7%

Trend Factors – Rx


(September 1, 2017 through February 28, 2018) claims cost to the rating period (FY2019). The

trend rate assumption was developed by the actuary based on an analysis of recent pharmacy

208

claims experience for MBCCP clients. This analysis included experience for MBCCP FFS

clients prior to September 1, 2017. The future trend rate assumption is the same for all service

areas.

The trend analysis included a review of utilization and cost experience data paid through March

31, 2018. Incurred monthly utilization (days supply per member) and cost per service (plan

payments per days supply) statistics were developed by program (FFS and managed care

separately), risk group and drug type (brand, generic and specialty) through August 2017. From

this experience, the average annual utilization and cost per service were determined for each of

the four 12-month periods ending August 2017.

Only those drugs currently covered under the capitated arrangement are included in the trend

analysis. Anti-viral agents used for the treatment of the Hepatitis C virus and the drug Orkambi

are not included in the analysis as those drugs are currently carved out of the managed care

contract. In addition, experience for the drugs Tamiflu and Makena were removed from our

trend analysis. Tamiflu was removed due to the significant variation in the intensity of flu

season from year to year. Makena was removed due to its one-time distortion of pharmacy

trends for pregnant women.

An additional adjustment to the trend analysis was made to the recent experience for the drug

Nasonex. Nasonex was removed from the preferred drug list (PDL) on July 27, 2017. The PDL

change resulted in Nasonex utilization shifting to Fluticasone (a generic drug in the same drug

class as Nasonex). Our rating methodology includes an adjustment factor to recognize the

impact of the PDL changes (discussed in Attachment 5). Since the PDL change for Nasonex

overlaps the experience period used in our trend analysis, we adjusted the trend analysis in order

to avoid “double-counting” the cost impact of the Nasonex change. For purposes of our trend

analysis, we revised the utilization and cost experience for the period between the PDL change

(7/27/2017) and the end of the trend experience period (8/31/2017) for Nasonex and Fluticasone

to reflect the experience prior to the PDL change. Please note that we did not change total

pharmacy utilization. We only changed the mix of services between the two drugs.

Please note that while excluded from (or adjusted in) the pharmacy trend analysis, the historical

claims for Tamiflu, Makena and Nasonex were included in the base period experience used in

developing the pharmacy component of the rate.

The MBCCP pharmacy trend assumptions for FY2018 and FY2019 were developed using the

following formula. For each risk group/drug type combination, the utilization and cost per

service trend assumptions were set equal to one-sixth of the experience trend rate for the 12-

month period ending August 2015 plus two-sixths of the experience trend rate for the 12-month

period ending August 2016 plus three-sixths of the experience trend rate for the 12-month period

ending August 2017. The final cost trend assumptions were then determined by applying the

assumed utilization and cost per service trends by individual drug type to actual experience for

the 12-month period ending August 2017 and combining the results into a single trend

assumption for each risk group. Exhibit C presents a summary of the pharmacy trend analysis

for MBCCP.

Please note that the MCOs were provided a detailed trend analysis file which included the

historical utilization and cost experience as well as all of the formulas and assumptions used in

developing the trend assumptions.

209


The types of adjustments for benefit and provider reimbursement changes are the same as those

detailed in Attachment 5. The adjustment factors used for the MBCCP rate development are the

SDA average of the factors for the Medicaid Only (OCC and HCBS) risk groups as previously

described. Due to lack of detail data on which to calculate the exact impact of the various

provider reimbursement changes, the STAR+PLUS average adjustment for the Medicaid Only

populations is assumed to be a reasonable proxy of the impact on the MBCCP population.

The following adjustments are not applicable to the MBCCP rate development:

CAD removal – invalid CADs are rejected in the FFS program and therefore not

included in the base period data.

North STAR adjustment – the FFS behavioral health claims for these members are

included in the base period data.

Preferred Drug List Changes

HHSC has recently implemented numerous changes to the Preferred Drug List (PDL). These

changes include some of the program’s highest expenditure drugs (Abilify, Nasonex, Suprax and

Tamiflu) and will have a significant impact on managed care pharmacy cost. Some of the PDL

changes were implemented during the experience period used to develop the rates and some were


anticipated cost impact of the PDL changes. Exhibit D presents a summary of the derivation of

the rating adjustment factors.

Drug Carve-In

HHSC currently excludes certain low-utilization, high-cost drugs from the capitated

arrangement. These drugs are covered under the plan but their cost is reimbursed to the MCOs

using a non-risk arrangement. We have now accumulated sufficient experience to project

utilization and cost for some these “carve-out” drugs. Anti-viral medications for the treatment of

Hepatitis C (Epclusa, Harvoni, Viekira Pak, etc.) and Orkambi (a treatment for Cystic Fibrosis)

will be added to capitated services effective September 1, 2018. Exhibit E presents a summary

of the derivation of the rating adjustment factors.

Seasonality

In developing the pharmacy component of the capitation rate, the base period is less that a full

year (September 1, 2017 through February 28, 2018). This was done in order to use managed

care experience exclusively in the rate setting. Since the base period and rating period do not

include the same months, it is necessary to evaluate the impact of seasonality on the average

cost. We performed such an analysis and included a seasonality adjustment factor in the rate

development. The adjustment was calculated as the average of the ratio of the September

through February average cost to the full fiscal year for the past four complete fiscal years.

FY2014 FY2015 FY2016 FY2017 Average

1.045 1.110 1.081 1.123 1.090

210

Managed Care Discount Factor - Medical

In developing the FY2019 projected claims, we have assumed that the base period per-capita

claims cost for FFS clients will be reduced by 8.3% under managed care. The 8.3% assumption

was developed by evaluating past managed care expansions as well as the unique characteristics

of the MBCCP program.

The MBCCP population is unique because there is no group currently under managed care that

matches the demographic make-up of this group. Various managed care programs in Texas

cover a range of Medicaid eligible members including children (STAR), disabled adults

(STAR+PLUS), Foster Care Children (STAR Health) and disabled children (STAR Kids);

however, no single population exactly matches the MBCCP group which includes characteristics

of many of these programs. Based on studies of a variety of recent populations that shifted

between fee-for-service and managed care, the cost differential between the programs has ranged

from 8% to 10%.

An additional analysis was performed to estimate the savings necessary such that the cost under

the STAR+PLUS model for the MBCCP population (including administrative expenses and risk

margin) would be the same as the projected FY2019 gross cost under the FFS model.

To determine the managed care efficiency factor necessary in order to satisfy our breakeven cost

criteria, we must solve the following equation for X.

$1,772.01 + $4.50 pmpm = $1,772.01 pmpm (1-X) + $20.00 pmpm

(1 - 5.75% - 1.75%)

$1,772.01 = statewide average FY2016 MBCCP cost

$4.50 = high level estimate of internal administrative costs associated with FFS

$20.00 = fixed administrative cost under STAR+PLUS

5.75% = variable administrative cost under STAR+PLUS

1.75% = risk margin under STAR+PLUS

Therefore, in order for the gross cost under STAR+PLUS to be the same as the projected gross

cost under the FFS model, the FFS claims cost would need to be discounted by 8.3%.

Given that the 8.3% breakeven estimate is within the range of the managed care savings

calculated for other Medicaid populations we believe it is reasonable and appropriate to assume a

savings of 8.3% for medical services under managed care for the MBCCP population.

This assumption will be reevaluated as actual managed care experience becomes available for

the MBCCP population in future rate developments.

Managed Care Discount Factor - Rx

The base period for this year’s MBCCP pharmacy component of the rate (September 1, 2017

through February 28, 2018) includes managed care experience only. Unlike medical

expenditures, managed care savings for pharmacy claims are almost immediate as the primary

driver for pharmacy savings are directly tied to reimbursement differences between FFS and

managed care. As a result, no adjustment is necessary to recognize any difference in pharmacy

211

reimbursement between the base period and the FY2019 rating period.

Administrative Fees, Service Coordination and Risk Margin

The rating methodology includes the same provision for health plan administrative services, risk

margin, and taxes as the existing STAR+PLUS program as described in Section IV. In addition

to administrative fees, the FY2018 MBCCP rates include a provision for service coordination in

the amount of $30.00. This was determined based on a review of the average service

coordination expenses per member per month for the OCC and HCBS risk groups. The MBCCP

population will receive a level of service coordination that is comparable to the OCC and HCBS

risk groups which we have concluded is a reasonable proxy for the service coordination cost for

for this new population. As actual service coordination experience is collected under managed

care for the MBCCP population, this assumption will be updated in future rate developments.

Summary

The attached exhibits present a summary of the MBCCP community rating exhibit for each

service area split between medical (Exhibit A) and pharmacy (Exhibit B). FY2019 premium

rates will vary between service delivery areas but will be the same for all health plans within a

given area.



MBCCP - Medical



Member Months 4,620 6,207 3,853 12,565


Professional 4,330,419 937.32 3,706,482 597.15 2,010,269 521.74 2,925,717 232.85

Inpatient 1,531,496 331.49 1,927,946 310.61 732,336 190.07 4,612,094 367.06

Outpatient 2,502,435 541.65 6,026,555 970.93 1,383,512 359.07 16,714,687 1,330.26

LTC 58,832 12.73 37,662 6.07 93,546 24.28 156,956 12.49

Other 103,134 22.32 11,369 1.83 8,393 2.18 15,806 1.26

Total 8,526,315 1,845.52 11,710,014 1,886.58 4,228,056 1,097.34 24,425,259 1,943.91



FY2018 0.7 % 0.7 % 0.7 % 0.7 %

FY2019 0.7 % 0.7 % 0.7 % 0.7 %

Adjustment Factors

Acute Care Non-Inpatient 0.9912 0.9766 0.9755 0.9833

Acute Care Inpatient 1.0079 1.0057 1.0018 1.0035

Long Term Care 1.0000 1.0000 1.0000 1.0000

Other Adjustments 0.9916 0.9968 0.9961 0.9930

Managed Care Savings 0.9170 0.9170 0.9170 0.9170

Projected FY2019 Incurred Claims 7,111,986 1,700.05 9,106,703 1,717.50 3,443,796 993.30 20,025,446 1,771.16


Service Coordination Expense 125,502 30.00 159,069 30.00 104,011 30.00 339,192 30.00


Fixed Amount 83,668 20.00 106,046 20.00 69,340 20.00 226,128 20.00

Percentage of Premium 464,023 5.75% 593,995 5.75% 229,309 5.75% 1,305,050 5.75%

Total 547,691 130.92 700,041 132.03 298,649 86.14 1,531,178 135.43

Risk Margin 141,224 1.75 % 180,781 1.75 % 69,790 1.75 % 397,189 1.75 %

Premium Tax 141,224 1.75 % 180,781 1.75 % 69,790 1.75 % 397,189 1.75 %

Maintenance Tax 251 0.06 318 0.06 208 0.06 678 0.06

Projected Total Cost 8,069,971 1,929.05 10,330,344 1,948.28 3,987,976 1,150.26 22,696,526 2,007.40

Bexar Dallas El Paso Harris

212



MBCCP - Medical


Member Months


Professional

Inpatient

Outpatient

LTC

Other

Total



FY2018

FY2019

Adjustment Factors

Acute Care Non-Inpatient

Acute Care Inpatient

Long Term Care

Other Adjustments

Managed Care Savings



Service Coordination Expense


Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



7,367 2,111 1,581 2,155

5,944,377 806.89 824,805 390.72 257,274 162.73 942,107 437.17

2,080,699 282.44 746,516 353.63 507,653 321.10 548,371 254.46

3,837,007 520.84 2,618,020 1,240.18 1,420,752 898.64 1,726,478 801.15

1,042,045 141.45 22,531 10.67 632 0.40 128,262 59.52

14,835 2.01 1,066 0.51 20 0.01 5,045 2.34

12,918,963 1,753.63 4,212,939 1,995.71 2,186,330 1,382.88 3,350,263 1,554.65

6,466 1,838 1,378 2,011

0.7 % 0.7 % 0.7 % 0.7 %

0.7 % 0.7 % 0.7 % 0.7 %

0.9950 0.9929 0.9922 0.9946

1.0028 1.0013 1.0044 1.0022

1.0000 1.0000 1.0000 1.0000

0.9934 0.9878 0.9887 0.9882

0.9170 0.9170 0.9170 0.9170

10,450,508 1,616.32 3,350,592 1,822.48 1,745,951 1,267.02 2,863,491 1,423.99

3,233 0.50 919 0.50 689 0.50 1,005 0.50

193,969 30.00 55,154 30.00 41,340 30.00 60,327 30.00

129,313 20.00 36,769 20.00 27,560 20.00 40,218 20.00

682,866 5.75% 218,186 5.75% 115,039 5.75% 187,875 5.75%

812,179 125.61 254,956 138.68 142,599 103.48 228,093 113.43

207,829 1.75 % 66,404 1.75 % 35,012 1.75 % 57,179 1.75 %

207,829 1.75 % 66,404 1.75 % 35,012 1.75 % 57,179 1.75 %

388 0.06 110 0.06 83 0.06 121 0.06

11,875,934 1,836.78 3,794,541 2,063.96 2,000,686 1,451.88 3,267,395 1,624.85

JeffersonHidalgo Lubbock Nueces

213



MBCCP - Medical


Member Months


Professional

Inpatient

Outpatient

LTC

Other

Total



FY2018

FY2019

Adjustment Factors



Long Term Care

Other Adjustments






Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



5,065 3,250 1,978 3,616

3,821,257 754.44 3,174,358 976.73 1,438,996 727.50 3,417,910 945.22

1,352,360 267.00 922,624 283.88 888,955 449.42 989,543 273.66

2,702,453 533.55 1,367,243 420.69 1,938,235 979.90 2,942,004 813.61

4,303 0.85 6,934 2.13 10,606 5.36 16,904 4.67

4,696 0.93 10,341 3.18 6,378 3.22 6,120 1.69

7,885,069 1,556.78 5,481,500 1,686.62 4,283,169 2,165.40 7,372,481 2,038.85

4,493 2,814 1,769 3,335

0.7 % 0.7 % 0.7 % 0.7 %

0.7 % 0.7 % 0.7 % 0.7 %

0.9893 0.9775 0.9865 0.9894

1.0037 1.0015 1.0011 1.0007

1.0000 1.0000 1.0000 1.0000

0.9990 0.9589 0.9812 0.9883

0.9170 0.9170 0.9170 0.9170

6,451,661 1,435.99 4,143,536 1,472.26 3,450,782 1,951.19 6,186,145 1,855.15

2,246 0.50 1,407 0.50 884 0.50 1,667 0.50

134,785 30.00 84,432 30.00 53,057 30.00 100,038 30.00

89,857 20.00 56,288 20.00 35,371 20.00 66,692 20.00

423,176 5.75% 271,554 5.75% 224,310 5.75% 402,642 5.75%

513,032 114.19 327,842 116.49 259,681 146.83 469,334 140.75

128,793 1.75 % 82,647 1.75 % 68,268 1.75 % 122,543 1.75 %

128,793 1.75 % 82,647 1.75 % 68,268 1.75 % 122,543 1.75 %

270 0.06 169 0.06 106 0.06 200 0.06

7,359,580 1,638.07 4,722,680 1,678.04 3,901,046 2,205.78 7,002,471 2,099.95

Tarrant Travis Central Northeast

214



MBCCP - Medical


Member Months


Professional

Inpatient

Outpatient

LTC

Other

Total



FY2018

FY2019

Adjustment Factors



Long Term Care

Other Adjustments






Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax


Amount pmpm

3,645

3,005,838 824.65

885,693 242.99

2,259,432 619.87

66,148 18.15

2,357 0.65

6,219,467 1,706.30

3,248

0.7 %

0.7 %

0.9889

1.0022

1.0000

0.9798

0.9170

5,004,377 1,540.74

1,624 0.50

97,441 30.00

64,961 20.00

327,487 5.75%

392,448 120.83

99,670 1.75 %

99,670 1.75 %

195 0.06

5,695,425 1,753.49

West

215



MBCCP - Pharmacy


9/2017-2/2018 Experience Period

Member Months 2,028 2,628 1,724 5,660

Estimated Incurred Claims 744,967 367.34 801,076 304.82 874,030 506.98 2,626,398 464.03


Annual Trend Assumption 24.8 % 24.8 % 24.8 % 24.8 %

Adjustment Factors

PDL Adjustment 0.9980 0.9977 0.9978 0.9979


Seasonality Adjustment 1.0900 1.0900 1.0900 1.0900

Projected FY2019 Incurred Claims 2,283,348 545.81 2,318,500 437.26 2,521,641 727.32 7,527,495 665.77


Risk Margin 41,544 1.75 % 42,218 1.75 % 45,842 1.75 % 136,878 1.75 %

Premium Tax 41,544 1.75 % 42,218 1.75 % 45,842 1.75 % 136,878 1.75 %


Bexar Dallas El Paso Harris

216



MBCCP - Pharmacy


Member Months




Adjustment Factors

PDL Adjustment

Carve-In Adjustment

Seasonality Adjustment



Risk Margin

Premium Tax



3,144 939 672 1,024

1,378,407 438.42 289,488 308.29 256,258 381.34 386,842 377.78

6,466 1,838 1,378 2,011

24.8 % 24.8 % 24.8 % 24.8 %

0.9975 0.9981 0.9908 0.9975

1.0000 1.0000 1.0000 1.0000

1.0900 1.0900 1.0900 1.0900

4,065,494 628.79 813,376 442.42 748,579 543.24 1,089,505 541.80

11,638 1.80 3,309 1.80 2,480 1.80 3,620 1.80

73,938 1.75 % 14,810 1.75 % 13,620 1.75 % 19,824 1.75 %

73,938 1.75 % 14,810 1.75 % 13,620 1.75 % 19,824 1.75 %

4,225,007 653.46 846,305 460.33 778,300 564.80 1,132,771 563.32

JeffersonHidalgo Lubbock Nueces

217



MBCCP - Pharmacy


Member Months




Adjustment Factors

PDL Adjustment

Carve-In Adjustment




Risk Margin

Premium Tax



2,256 1,413 898 1,661

938,619 416.05 715,691 506.50 569,852 634.58 637,950 384.08

4,493 2,814 1,769 3,335

24.8 % 24.8 % 24.8 % 24.8 %

0.9921 0.9953 0.9961 0.9970

1.0000 1.4630 1.1581 1.0000

1.0900 1.0900 1.0900 1.0900

2,666,370 593.47 2,984,434 1,060.42 1,861,433 1,052.52 1,835,898 550.56

8,087 1.80 5,066 1.80 3,183 1.80 6,002 1.80

48,501 1.75 % 54,214 1.75 % 33,814 1.75 % 33,402 1.75 %

48,501 1.75 % 54,214 1.75 % 33,814 1.75 % 33,402 1.75 %

2,771,458 616.86 3,097,927 1,100.74 1,932,245 1,092.56 1,908,705 572.40

Tarrant Travis Central Northeast

218



MBCCP - Pharmacy


Member Months




Adjustment Factors

PDL Adjustment

Carve-In Adjustment




Risk Margin

Premium Tax


Amount pmpm

1,589

501,316 315.49

3,248

24.8 %

0.9818

1.0000

1.0900

1,446,530 445.35

5,846 1.80

26,338 1.75 %

26,338 1.75 %

1,505,053 463.37

West

219


FY2019 STAR Rating Summary - Pharmacy

MBCCP Pharmacy Trends

Annual Trend in Number

of Scripts per Member

per Month

Annual Trend in Days

Supply per Member per

Month

Annual Trend in Incurred

Claims per Days Supply

Annual Trend in Incurred

Claims per Member per

Month

Generic Dispensing Rate

(Days Supply)

Brand Drugs

9/1/13-8/31/14 -12.8 % -12.0 % 9.7 % -3.4 %

9/1/14-8/31/15 -14.2 % -12.9 % 9.8 % -4.4 %

9/1/15-8/31/16 -8.6 % -8.1 % 14.4 % 5.2 %

9/1/16-8/31/17 -1.3 % -0.7 % 7.1 % 6.3 %

Use -5.9 % -5.2 % 10.0 % 4.3 %

Generic Drugs

9/1/13-8/31/14 2.2 % 4.3 % 0.3 % 4.6 %

9/1/14-8/31/15 -0.6 % 5.3 % 25.0 % 31.5 %

9/1/15-8/31/16 -0.4 % 2.2 % 2.0 % 4.2 %

9/1/16-8/31/17 0.0 % 2.3 % -20.9 % -19.1 %

Use -0.2 % 2.8 % -5.6 % -3.0 %

Specialty Drugs

9/1/13-8/31/14 -0.2 % 0.0 % 4.1 % 4.1 %

9/1/14-8/31/15 6.2 % 3.5 % 16.4 % 20.5 %

9/1/15-8/31/16 11.0 % 16.3 % 27.4 % 48.1 %

9/1/16-8/31/17 6.6 % 12.5 % 15.0 % 29.3 %

Use 8.0 % 12.2 % 19.4 % 34.0 %

All Drugs

9/1/13-8/31/14 -0.1 % 1.5 % 0.0 % 1.5 % 84.2 %

9/1/14-8/31/15 -2.2 % 2.6 % 10.9 % 13.8 % 86.4 %

9/1/15-8/31/16 -1.1 % 1.1 % 26.5 % 27.9 % 87.3 %

9/1/16-8/31/17 0.0 % 2.1 % 14.3 % 16.7 % 87.5 %

Use -0.6 % 2.1 % 22.2 % 24.8 % 88.6 %

220


FY2019 STAR Rating - Pharmacy

Rx Adjustments

Preferred Drug List Change - MBCCP

Cost Impact of PDL

Changes (1)

Base Period (9/2017

- 2/2018) Total

Incurred Claims (2)

Rate

Adjustment (3)

Bexar -1,472 737,781 -0.20 %

Dallas -1,781 779,492 -0.23 %

El Paso -1,911 856,975 -0.22 %

Harris -5,490 2,612,050 -0.21 %

Hidalgo -3,476 1,413,718 -0.25 %

Jefferson -552 289,057 -0.19 %

Lubbock -2,342 255,091 -0.92 %

Nueces -1,041 421,640 -0.25 %

Tarrant -7,541 951,303 -0.79 %

Travis -3,234 681,882 -0.47 %

MRSA Central -2,195 568,706 -0.39 %

MRSA Northeast -1,887 634,985 -0.30 %

MRSA West -8,828 485,040 -1.82 %

Total -41,750 10,687,720 -0.39 %

Footnotes:

(1) Equals the cost impact resulting from changes to the preferred drug list (PDL).

(2) Equals total incurred managed care pharmacy claims during the base period.

(3) Cost impact divided by Base Period Incurred Claims.

221


FY2019 STAR Rating - Pharmacy

Rx Adjustments

Drug Carve-In Adjustment Factors - MBCCP

Cost Impact of

Carve-in (1)

Base Period (9/2017

- 2/2018) Total

Incurred Claims (2) Rate Adjustment (3)

Bexar 26,162 737,781 3.55 %

Dallas 0 779,492 0.00 %

El Paso 0 856,975 0.00 %

Harris 0 2,612,050 0.00 %

Hidalgo 0 1,413,718 0.00 %

Jefferson 0 289,057 0.00 %

Lubbock 0 255,091 0.00 %

Nueces 0 421,640 0.00 %

Tarrant 0 951,303 0.00 %

Travis 315,691 681,882 46.30 %

MRSA Central 89,926 568,706 15.81 %

MRSA Northeast 0 634,985 0.00 %

MRSA West 0 485,040 0.00 %

Total 431,779 10,687,720 4.04 %

Footnotes:

(1) The cost adjustment impact from drug carve-in changes.

(2) Equals total incurred managed care pharmacy claims during the base period.

(3) Cost impact divided by Base Period Incurred Claims.

222

223

Attachment 11

Network Access Improvement Program (NAIP)

Effective March 1, 2015 several health plans implemented programs aimed at improving

network access for Medicaid members. The NAIP is designed to further the state's goal of

increasing the availability and effectiveness of primary care for Medicaid beneficiaries by

incentivizing various institutions to provide quality, well-coordinated, and continuous care. The

NAIP is intended to achieve the following objectives regarding health-related institutions (HRI):

Improve the availability of and Medicaid access to primary care physicians. This

program may also target specialist physicians willing to provide a medical home to

managed care members with special needs and conditions, and advanced practice

registered nurses (APRNs) and physician assistants (PAs) practicing under the

supervision of an HRI staff provider.

Enhance the coordination and continuity of services and quality of care of Medicaid

managed care members who receive primary care services through those physician

practices.

Increase access to primary care in these settings, underscoring the importance of primary

care residency programs and influencing future physician participation.

Promote provider education on Medicaid program requirements and the specialized needs

of Medicaid recipients.

Measure progress through increased primary care access and physician compliance with

selected quality objectives, to be determined later.

The NAIPs were developed independently by various managed care organizations and providers.

The NAIPs outline the services to be provided by the providers, measurements to evaluate their

effectiveness and the cost to be paid by the managed care organizations. Once agreed upon by

the MCOs and providers, the NAIP arrangements were reviewed by HHSC program staff for

quality and content. HHSC program staff then provided the actuary with the contracted financial

arrangements agreed to between each MCO and provider. The actuary used this information to

prepare the NAIP portion of the premium.

The NAIP amounts impact the following STAR+PLUS risk groups equally as the contracted

costs between the participating MCOs and providers are not delineated by risk group but are

applicable to the entire population:

• Medicaid Only – Other Community Care (OCC)

• Medicaid Only – Home and Community Based Services (HCBS)

• Intellectual and Developmentally Disabled over age 21 – IDD >21

The NAIP amounts are not applicable to the Dual Eligible, Nursing Facility or MBCCP risk

groups.

224

Exhibit A summarizes each of the NAIPs by health plan, service area and program. The

participating provider has been removed from the file in order to maintain the privacy of these

negotiated arrangements.

No additional NAIP arrangements have been permitted since FY2017 nor have the MCOs and

providers been permitted to negotiate financial terms that differ from those currently in place.

The following information is provided as requested in the 2018-2019 Managed Care Rate

Development Guide:

1. A description of the pass-through payment - CMS approved NAIP as an incentive

payment in September 2014. The program was implemented in March 2015.

Subsequently, CMS issued final Medicaid managed care rules. Following the publication

of those rules, CMS performed an informal review of NAIP and in September 2016

concluded NAIP was a pass-through payment, not an incentive. The program is a

voluntary program between MCOs and providers whereby agreements are entered into

between these two parties to improve access to care and services for Medicaid managed

care members. Examples include the recruitment of new primary care or specialty

physicians, expanded physician office hours, and other similar initiatives. Each project

had a specific associated cost which translated into a PMPM amount for the MCOs.

2. The amount of the pass-through payments both in total and on a per member per month

basis – The overall NAIP program cost is $427,344,142 of which $32,647,329 is

attributed to the STAR+PLUS program. The per member per month amounts are shown

in the attached exhibit and in Attachment 1 Exhibit A.

3. The providers receiving the pass-through payments –

Texas Tech University Health Sciences Center - El Paso

University of Texas Medical School - Houston (UT Physicians)

Texas Tech University Health Sciences Center – Lubbock

UT Southwestern Accountable Care Network

Texas A&M Health Science Center

Texas Tech University Health Sciences Center – Lubbock

Parkland Health & Hospital System

Childress County Hospital District

University Health System

Midland Memorial Hospital

University Medical Center – Lubbock

Harris Health System

Palo Pinto General Hospital

University Medical Center of El Paso

Christus Spohn Health System

225

4. The financing mechanism for the pass-through payments – The non-federal share is

provided by local governmental entities, including hospital districts.

5. The amount of pass-through payments incorporated into the capitation rates in the

previous period – The NAIP premiums in effect for FY2018 were estimated to be:

STAR $394,690,195

STAR+PLUS $32,612,529

Total $427,302,725

6. The amount of pass-through payments incorporated into capitation rates for the rating

period in effect on July 5, 2016 – The NAIP premiums in effect for FY2016 were:

STAR $479,056,321

STAR+PLUS $33,638,645

Total $512,694,966

7. The calculation of the base amount is included in Exhibit B. These amounts were

calculated by HHSC based on the following methodology:

Managed Care Encounter data and Fee for Service claim data was used to perform the

upper payment limit (UPL) test for inpatient Medicaid hospital services. The inpatient

test was performed by estimating the Medicare rates from the base rate adjusting for

Geographic Wage Index, Capital Wage Index and IME Operating and Capital factors.

The Medicaid claim and encounter data was mapped from APR DRG to MS DRG to

assign Medicare weights to each service. An estimated Medicare payment was

determined by multiplying the Medicare rate by the sum of the Medicare weights for each

provider. Medicaid payments were estimated in the same way using the Texas specific

APR DRG weights and Texas Medicaid specific rates. Medicaid payments were adjusted

to include quality incentive payments and NAIP payments.

The upper payment limit test for outpatient services used a payment to charge ratio.

General outpatient services (excluding services reimbursed on a fee schedule) were used

from both the Managed Care Encounter data and Fee for Service claim data. Medicare

charges and payments from the Medicare cost reports were used to calculate a Payment to

Charge Ratio for each hospital. The Medicare payment to charge ratio was then

multiplied by the Medicaid outpatient charges to estimate what Medicare would have

paid for the Medicaid services.

The total estimated Medicare payments for each category were compared to the Medicaid

payments for each category to perform the UPL tests.



Network Access Improvement Program (NAIP) Summary

MCO (1) Impacted Programs SDAs Impacted

Contracted

Cost (2)

Projected Member

Months (3) PMPM Impact

Amerigroup STAR Dallas 14,973,274 2,399,563 6.24

Amerigroup STAR Lubbock, MRSA West 1,583,949 465,867 3.40

Amerigroup STAR MRSA West, Tarrant 4,408,068 1,695,411 2.60

Amerigroup STAR, STAR+Plus Dallas, Tarrant 19,331,790 3,897,538 4.96

Amerigroup STAR, STAR+Plus Harris 36,833,631 1,391,524 26.47

Amerigroup STAR, STAR+Plus Harris, Jefferson 8,034,893 1,507,485 5.33

Amerigroup STAR, STAR+Plus Lubbock, MRSA West 12,979,275 549,736 23.61

Amerigroup STAR, STAR+Plus MRSA West 3,537,159 426,678 8.29

CFHP STAR Bexar 20,388,074 1,270,285 16.05

CHC STAR Harris 72,445,145 2,694,130 26.89

CHC STAR Jefferson 7,139,743 265,221 26.92

El Paso Health STAR El Paso 19,038,648 803,319 23.70

FirstCare STAR Lubbock, MRSA West 21,747,047 1,030,178 21.11

FirstCare STAR MRSA West 10,598,715 567,079 18.69

Molina STAR Dallas 1,506,486 293,091 5.14

PCHP STAR Dallas 32,242,360 2,015,147 16.00

Superior STAR Bexar 6,579,133 1,405,798 4.68

Superior STAR El Paso 11,864,611 633,793 18.72

Superior STAR Lubbock, MRSA West 4,149,458 1,317,288 3.15

Superior STAR, STAR+Plus Bexar 7,182,052 1,592,473 4.51

Superior STAR, STAR+Plus

Bexar, Hidalgo, MRSA Central,

MRSA West 5,932,215 5,544,126 1.07

Superior STAR, STAR+Plus

Bexar, Hidalgo, MRSA Central,

MRSA West, Nueces, Travis 16,018,450 6,874,871 2.33

Superior STAR, STAR+Plus Lubbock, MRSA West 23,275,410 1,460,189 15.94

Superior STAR, STAR+Plus MRSA Central 601,103 969,520 0.62

United STAR, STAR+Plus Harris 24,516,298 971,327 25.24

United STAR, STAR+Plus Harris, Jefferson 5,074,762 1,199,707 4.23

United STAR, STAR+Plus Jefferson 5,373,785 228,380 23.53

CHC STAR Harris, Jefferson 12,488,459 2,959,350 4.22

United STAR Nueces 1,409,935 49,092 28.72

Superior STAR, STAR+Plus Nueces 10,299,025 290,195 35.49

United STAR+Plus Nueces 5,791,188 48,389 119.68

Footnotes:

(1) MCOs may have NAIP arrangements with multiple providers.

(2) Based on contracted amounts between MCOs and providers.

(3) Based on HHSC's most recent caseload forecast. Includes all (i) all STAR Risk Groups except AAPCA, (ii) STAR+PLUS Medicaid Only OCC,

(iii) STAR+PLUS Medicaid Only HCBS and (iv) IDD <21 and >21.

226


Network Access Improvement Program (NAIP) Summary

Ownership Type

Outpatient

Medicare MCO

Est. Payment

Outpatient

Medicaid MCO

Payment Difference

Medicare MCO

Est. Inpatient

Payment

Medicaid MCO

Est. Inpatient

Payment

Medicaid MCO

Quality

Payments Difference

Medicaid MCO

NAIP Payments

Non-state Government 189,282,793 160,430,740 28,852,053 333,383,978 203,957,315 264,740 129,161,923 319,058,097

Private 1,131,407,968 1,095,069,433 36,338,535 2,417,513,697 1,593,905,069 9,176,246 814,432,381

State Owned 47,522,589 49,512,506 -1,989,917 7,034,821 2,800,083 4,234,738 41,641,372

State Owned - TEFRA 71,884,611 68,625,222 0 3,259,389 0

Grand Total 1,368,213,350 1,305,012,679 63,200,671 2,829,817,107 1,869,287,689 9,440,986 951,088,431 360,699,468

Ownership Type

Outpatient

Medicare FFS

Est. Payment

Outpatient

Medicaid FFS

Payments Difference

Medicare FFS

Est. Inpatient

Payment

Medicaid FFS

Est. Inpatient

Payment

Medicaid FFS

Quality

Payments Difference

Medicaid FFS

NAIP Payments

Non-state Government 68,616,084 46,858,505 21,757,579 563,925,947 316,711,672 115,323 247,098,951 0

Private 257,385,581 198,002,353 59,383,228 1,144,314,224 1,012,933,244 5,315,071 126,065,909 0

State Owned 45,496,335 26,529,925 18,966,410 5,522,865 3,540,708 1,982,157 0

State Owned - TEFRA 72,668,411 56,530,991 16,137,419 0

Grand Total 371,498,000 271,390,783 100,107,217 1,786,431,447 1,389,716,617 5,430,394 391,284,437 0

Total Base Payment

Outpatient 1,739,711,350 1,576,403,462 163,307,888 4,616,248,554 3,259,004,305 14,871,380 1,342,372,868 360,699,468

Year 1* Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 Year 8 Year 9 Year 10

Maximum Base Amount of

Pass-Through Payments 1,505,680,756 1,355,112,680 1,204,544,605 1,053,976,529 903,408,454 752,840,378 602,272,302 451,704,227 301,136,151 150,568,076

Reduction Amount 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076 150,568,076

*Total Base Payment Outpatient Difference plus Total Base Payment Inpatient Difference

MCO UPL Test Outpatient MCO UPL Test Inpatient

FFS UPL Test Outpatient FFS UPL Test Inpatient

Base Payment Reduction Schedule

227

228

Attachment 12

Quality Incentive Payment Program (QIPP)

Effective September 1, 2017 HHSC implemented the Quality Incentive Payment Program

(QIPP) which is designed to incentivize nursing facilities to improve quality and innovation in

the provision of nursing facility services, using the CMS five-star rating system as its measure of

success.

QIPP is open to two classes of facilities: non-state government owned nursing facilities and

private nursing facilities. Payments from managed care organizations to qualified nursing

facilities will be made based on improvement on specific quality indicators.

Attachment A is a detailed summary of the QIPP which HHSC provided to CMS during the

development phase.

Attachment B provides a summary of the QIPP add on amounts by service delivery area. The

QIPP program impacts members in both the STAR+PLUS and Dual Demonstration programs.

As a result, the eligible expenditures are spread across the two programs based on total

membership within the nursing facility risk groups. Contracted Cost ($420,857,928) is the total

dollar value of the program assigned to the providers within each of the SDAs who participate in

QIPP based on their percentage of Medicaid Fee-for-service (FFS) and Medicaid Manage Care

(MCO) days. The total program size was multiplied by each provider’s percent of FFS & MCO

days in the base period. There are three quality components in QIPP which determine if a

provider is paid in the program. Component 1 payments are received if the state receives

certification from the providers that they completed a Quality Assurance and Performance

Improvement (QAPI) meeting each month. Component 2 & 3 payments are received based on

incremental improvements to quality over the base period. If funds are not earned by providers

due to not meeting the QAPI reporting requirement or missing quality metrics, those funds move

into the lapse funds pool. Lapse funds are distributed quarterly to providers based on their

percent of total funding received in that quarter. The value of each component will vary based

on each facility in proportion to their total number of FFS & MCO days.

Introduction

This concept paper describes the Quality Incentive Payment Program (QIPP) proposed by Texas.

QIPP is designed to incentivize nursing facilities to improve quality and innovation in the

provision of nursing facility services, using the CMS five-star rating system as its measure of

success. HHSC proposes to implement QIPP no later than September 1, 2017.

Background

During the 83rd Session, the Texas Legislature outlined its goals for the managed care carve-in

of nursing facilities. In implementing the nursing facility carve-in, the Health and Human

Services Commission (HHSC) was directed to encourage transformative efforts in the delivery of

nursing facility services, including "efforts to promote a resident-centered care culture through

facility design and services provided" (S.B. 7, 83rd Texas Legislature, Regular Session).

In 2014, HHSC established the Minimum Payment Amount Program (MPAP). The MPAP,

which became effective March 1, 2015, established minimum payment amounts for qualified

nursing facilities participating in STAR+PLUS. The STAR+PLUS managed care organizations

pay the minimum payment amounts to qualified nursing facilities based on state direction. The

MPAP was always intended to be a short-term program that would ultimately transition to a

performance-based initiative.

The goal of transition was reinforced during the 84th Legislative Session. The General

Appropriations Act for the 2016-2017 Biennium contains HHSC Budget Rider 97, which directs

HHSC to transition the MPAP to QIPP.

Conceptual Framework

Eligibility


private nursing facilities. To ensure that QIPP funds are focused on the Medicaid population,

HHSC will limit private nursing facility eligibility to nursing facilities with Medicaid utilization

as a percentage of total utilization at least equal to the mean for all Medicaid nursing facilities in

Texas plus one standard deviation. Based on the most current data available from 2014 Texas

Medicaid nursing facility cost reports, this value is equal to 78 percent, meaning at least 78

percent of a facility's units of service must have been provided to Medicaid recipients for the

facility to be eligible to participate in QIPP.

Capitation Rate Structure

QIPP dollars will be limited by 1115 waiver budget neutrality room and the amount of IGT

available for the program. QIPP IGTs for a specific capitation rate period will be due to HHSC

approximately six months prior to the beginning of the rate period to allow HHSC's actuaries

certainty as to the amount funding to be incorporated into the capitation rates for QIPP. The

amount of the capitation related to QIPP will be determined by the amount of the non-federal

share available for the program six months prior to the start of the program year.

QIPP funds will be paid through three new components of the STAR+PLUS nursing facility

managed care per member per month capitation rates. Each component's value will be


229

determined as a percentage of the total amount of funding available for the QIPP program. The

managed care organizations' distribution of QIPP funds to the nursing facilities will be based on

each nursing facility's performance on a set of defined quality metrics.

QIPP Capitation Rate Components

Component One

o The total value of Component One will be equal to 110 percent of the non-federal share

of the QIPP program.

o Allocation of funds across qualifying non-state government-owned nursing facilities will

be based upon historical Medicaid days of nursing facility service.

o Monthly payment so non-state government-owned nursing facilities will be triggered by

the nursing facility's submission to the managed care organization of a monthly Quality

Assurance Performance Improvement Validation Report.

o Private NFs are not eligible for payments from Component One.

o The interim allocation of funds across qualifying non-state government-owned NFs will

be reconciled to the actual distribution of Medicaid NF days of service across these NFs

during the eligibility period as captured by HHSC's Medicaid contractors for fee-for-

service and managed care 180 days after the last day of the eligibility period. This

reconciliation will only be performed if the weighted average (weighted by Medicaid NF

days of service during the eligibility period) of the absolute values of percentage changes

between each NFs proportion of historical Medicaid days of NF service and actual

Medicaid days of NF service is greater than 20 percent.

Component Two

o The total value of Component Two will be equal to 35 percent of remaining QIPP funds

after accounting for the funding of Component One.

o Allocation of funds across qualifying non-state government-owned and private nursing

facilities will be based upon historical Medicaid days of nursing facility service.

o Quarterly payments to nursing facilities will be triggered by improvement on specific

quality indicators.

Component Three1

o The total value of Component Three will be equal to 65 percent of remaining QIPP funds

after accounting for the funding of Component One.

o Allocation of funds across qualifying non-state government-owned and private nursing

facilities will be based upon historical Medicaid days of nursing facility service.

o Quarterly payments to nursing facilities will be triggered by improvement on specific

quality indicators.

Lapsing Funds

o Funds that would lapse due to failure of one or more nursing facilities to meet metrics

will be distributed across all QIPP nursing facilities based on each facility's proportion of

1Payments made to facilities meeting the standards of Component Three will include both the 35% allocated for

Component Two and the remaining 65% allocated for Component Three.


230

total earned QIPP funds from Components One, Two, and Three combined.

Quality Design

Payments from managed care organizations to qualified nursing facilities will be made based on

improvement on specific quality indicators. QIPP includes four measures, equally weighted for

payment each quarter and currently utilized by CMS' star ratings for nursing facilities. Nursing

facilities must make incremental improvements towards pre-set goals to qualify for payments. A

nursing facility's baseline will remain the same throughout the measurement period, while the

amount of improvement required each quarter increases. Initial quarterly goals are based on 1.7

percent or 5.0 percent improvement from the baseline. Subsequent quarterly goals increase to 7

percent and 20 percent at the end of the year.

Quarter Total improvement from baseline

Component Two

Payment Standard

Component Three

Payment Standard

1 1.7% 5%

2 3.4% 10%

3 5.1% 15%

4 7% 20%

Quality targets will be quarterly in order to allow for quarterly payments. Each successful

nursing facility within a class will receive an equal payment amount per Medicaid day of service

with days of service based upon an historical measure. A nursing facility that performs better

than the benchmark may decline in performance and still earn 100 percent of the available funds

as long as the nursing facility remains above the benchmark.

Compliance with Approval Criteria

Utilization and Delivery of Services

The increased payments from managed care organizations to nursing facilities will be based on

the utilization and delivery of services to a Medicaid managed care member as determined using

historical data.

Expenditures and Classes


private nursing facilities. Within each of these classes, performance standards and incentive

payments are consistent.

Link to Goals and Objectives of State Quality Strategy

The goal of the QIPP program is to incentivize state nursing facilities to improve the quality of

care for their residents. Facilities will be able to achieve this goal by showing an improvement in

their baselines as they relate to each of the four quality measures:

High-risk residents with pressure ulcers;

Percent of residents who received an antipsychotic medication (long-stay);

Residents experiencing one or more falls with major injury; and


231

Residents who were physically restrained.

Providing payments through QIPP will create the incentive for facilities to focus on these four

measures, thereby improving quality across several areas of care to the residents. We expect that,

annually, the outcome of this program will be an overall improvement for each of the quality

measures among the participating facilities. This outcome is based on the expectation that

participating facilities will work to make performance improvements as required for quarterly

payments.

The 1115 quality strategy can be found in Attachment D of the 1115 waiver, and identifies as

goals of the strategy:

Transition from volume-based purchasing models to a pay-for-performance model;

Improve member satisfaction with care; and

Reduce payments for low quality care.

HHSC’s fundamental commitment is to contract for results. HHSC defines a successful result as

the generation of defined, measurable, and beneficial outcomes that satisfy the contract

requirements and support HHSC’s missions and objectives. The measures included in the QIPP

are consistent with HHSC's mission, which is to "maintain and improve the health and human

services system in Texas, and to administer its programs in accordance with the highest

standards of customer service and accountability for the effective use of funds".

Evaluation Plan

An evaluation of the CMS verified MDS data related to each of the four quality measures will be

completed to determine if participating nursing facilities are improving the care provided to their

residents. At the end of FY 2018 and subsequent FYs, we will evaluate the program’s

effectiveness by assessing if overall participating facilities are improving their performance and

thus meeting the goal of the Quality Incentive Payment Program.

Intergovernmental Transfer Fund Contributions and Provider Participation

Public and private nursing facilities may participate in QIPP. No nursing facility's participation

will be conditioned on the provision of an intergovernmental transfer of funds, nor on its entering

into or adhering to an intergovernmental transfer agreement. Private nursing facility participation

is limited to nursing facilities with Medicaid utilization at least equal to the mean Medicaid

nursing facility utilization rate for all Medicaid nursing facilities in Texas plus one standard

deviation.

Automatic Renewal

HHSC understands that the initiative is not eligible for automatic renewal and will seek approval

from CMS for any extension of the program beyond the initial approval period.

Conclusion

The State believes the only true measure of transformation is found in the actual, verified

improvement of care and quality of life. QIPP is intended to serve as a resource for nursing

facilities to leverage in order to achieve nursing facility transformation. The program is

structured to allow each participating nursing facility to design its own program to meet the

specific needs of its population.


232



Quality Incentive Payment Program (QIPP) Summary

MCOs (1) Impacted Programs SDA

Contracted Cost

(2)

Projected Member

Months (3)

PMPM

Impact

Amerigroup, Molina, Superior STAR+PLUS, Dual Demo Bexar 34,495,295$ 54,681 630.85$

Molina, Superior STAR+PLUS, Dual Demo Dallas 49,835,815 76,951 647.63

Amerigroup, Molina STAR+PLUS, Dual Demo El Paso 1,159,409 10,606 109.32

Amerigroup, Molina, United STAR+PLUS, Dual Demo Harris 52,951,659 95,854 552.42

HealthSpring, Molina, Hidalgo STAR+PLUS, Dual Demo Hidalgo 24,898,317 35,522 700.93

Amerigroup, Molina, United STAR+PLUS Jefferson 16,357,744 26,039 628.20

Amerigroup, Superior STAR+PLUS Lubbock 16,590,726 21,890 757.93

Superior, United STAR+PLUS Nueces 15,036,269 25,730 584.39

Amerigroup, HealthSpring STAR+PLUS, Dual Demo Tarrant 47,153,703 69,918 674.41

Amerigroup, United STAR+PLUS Travis 30,477,334 40,027 761.41

Superior, United STAR+PLUS MRSA Central 36,357,047 58,483 621.67

HealthSpring, United STAR+PLUS MRSA Northeast 46,247,569 78,823 586.73

Amerigroup, Superior STAR+PLUS MRSA West 49,297,038 61,485 801.77

Footnotes:

(1) All MCOs will participate with all QIPP providers in their SDAs.

(2) Based on the total funding available that is allocated by the number of historical Medicaid days for each facility.

(3) Based on HHSC most recent caseload forecast. Includes the following risk groups: (i) STAR+PLUS Medicaid Only Nursing Facility,

(ii) STAR+PLUS Dual Eligible Nursing Facility, and (iii) Dual Demo Nursing Facility.

233

234

Attachment 13

Uniform Hospital Rate Increase Program

Effective December 1, 2017, HHSC implemented a pilot of the Uniform Hospital Rate Increase

Program (UHRIP) in the Bexar and El Paso service delivery areas. CMS approved HHSC's

statewide implementation of the program on August 18, 2017 and the program was expanded

statewide March 1, 2018. UHRIP is a Medicaid managed care hospital directed payment

program authorized under federal regulation 42 CFR 438.6(c). UHRIP will increase the

reimbursement to contracted hospitals by a level percentage that varies by hospital class. HHSC

has identified the following classes of hospitals within each SDA and the rate increase for each:

SDA Children's

Non-

Urban

Public

Rural

Private

Rural

Public

State-

owned

Urban

Public Other

Bexar 2% 38% 14% 17% 0% 38% 38%

Dallas 2% 57% 0% 0% 62% 62% 62%

El Paso 2% 0% 0% 0% 0% 43% 43%

Harris 0% 42% 14% 17% 0% 46% 46%

Hidalgo 0% 0% 0% 14% 0% 0% 36%

Jefferson 0% 0% 6% 6% 0% 0% 50%

Lubbock 3% 0% 4% 9% 0% 72% 40%

Nueces 0% 46% 7% 19% 0% 51% 51%

Tarrant 2% 0% 24% 24% 0% 66% 66%

Travis 1% 0% 7% 0% 0% 56% 56%

MRSA Central 0% 0% 16% 18% 0% 0% 50%

MRSA Northeast 0% 0% 15% 19% 0% 0% 52%

MRSA West 0% 62% 4% 25% 0% 68% 68%

All MCOs within the SDA will be required to increase their reimbursement rates to contracted

hospitals by the established percentage rate increase. The Travis SDA will begin participating in

UHRIP on September 1, 2018.

UHRIP will only apply to the STAR and STAR+PLUS Medicaid managed care programs. The

UHRIP increase will apply to all services provided by a hospital with the following exceptions:

1. Services provided to members at a non-contracted facility.

2. Non-emergent services provided in an emergency room for non-rural facilities.

3. Services provided to a member at an out of area facility if the facility is located in a

SDA in which the MCO does not participate in the STAR or STAR+PLUS program.

The percentage increases by hospital were determined by HHSC according to the following

methodology:

Each SDA requests a specific percentage increase within the CMS-approved range for a hospital

class (the percentage increase for each hospital class in an SDA must not exceed the rate increase

range approved by CMS for each program period) and HHSC confirms that the requested

increase for the SDA class is no more than 95% of the Medicaid Shortfall threshold for that

class. HHSC then calculates the final percentage rate increases by multiplying the calculated

reduction factor by the requested SDA percentage rate increases that comply with the 95%

235

Medicaid Shortfall threshold. The reduction factor is calculated by dividing the budget neutrality

room allotment by the respective actuarial forecast for each SDA.

In the Texas Medicaid program, the actuary is not involved in the development of provider fee

schedules or reimbursement arrangements. The final UHRIP increases were determined by

HHSC and the MCOs are mandated to include such increases in their provider reimbursement

arrangements.

The estimated impact of the UHRIP increase was then estimated by collecting the encounter data

for all UHRIP-eligible facilities. Exclusions to the data were then applied based on the

contracting status of the MCO, facility/member location and emergency room status. The

UHRIP eligible claims were then increased by the applicable reimbursement change and the

impact on the base period for each individual MCO was determined.

Exhibit A presents a summary of the derivation of the rating adjustment factors which have been

calculated at the individual plan level due to variations in each MCO’s network configuration.

The adjustments have been calculated by applying the applicable percentage increase to each

MCO’s FY2017 encounter data. Unlike other adjustment factors which are applied at the

community level, the UHRIP adjustment factors have been calculated at the individual plan level

due to the fact that each MCO may have varying levels of utilization at each class of hospital and

could be disadvantaged if their actual utilization is higher or lower than the SDA average for a

given class.

Exhibit B presents a summary of the calculation of the UHRIP premium add-on rates by MCO

for all risk groups. The add-on is calculated as an MCO-specific amount due to the varying

impacts the mandated increases will have on expected reimbursement for each MCO. The add-

on is calculated as the projected FY2019 claims increased by the applicable UHRIP adjustment

factor plus provision for risk margin, taxes and administrative fees.

The UHRIP component of the rate includes separate administrative fees, taxes and risk margin

from the medical and pharmacy components of the rate. These amounts are defined as follows:

Administrative Fee – 2.5% of premium

Risk Margin – 5.0% of premium

Premium Tax – 1.75% of premium

Health Insurance Providers Fee Non-Exempt – 1.7% of premium

Health Insurance Providers Fee Exempt – 0.0% of premium

The 2.5% administrative fee was developed based on discussions between HHSC, the MCOs and

the contracted hospitals. While there is an expectation of increased administrative cost

associated with UHRIP as a result of contract negotiations, claims processing and other system

changes it is not expected that this increased burden will be significant. As a result, the standard

5.75% of premium applicable to the overall rate development was reduced to 2.5% for the

UHRIP component only.

The 5.0% risk margin is larger than the 1.75% risk margin applicable to the overall rate

development because the MCO will be at greater risk that utilization could shift between the

hospital classes, between the facilities and between the MCOs. The MCO will be required to

236

increase their reimbursement rates according to the defined increases and could experience

deviations from historical utilization patterns that are beyond their control.

The 1.75% premium tax remains unchanged from the overall rate development.

Unlike the rate development for the medical and pharmacy components of the rate, the UHRIP

premium will include a provision for the ACA Health Insurance Providers Fee (HIPF) where

applicable. The 1.7% was calculated as national average health insurance providers fee for the

period September 1, 2018 through August 31, 2019 as a percentage of net premiums grossed up

for federal income tax and state premium tax and takes into consideration the moratorium on

calendar year 2018 premiums. All taxes and fees are included in the UHRIP premium to ensure

all costs and taxes associated with the program can be supported by the total funds available.

HHSC will reconcile the provision for the UHRIP portion of the HIPF to each MCO’s actual

HIPF liability.



UHRIP Adjustment

Impact of UHRIP Rate Increase




Bexar SDA

Amerigroup 4,010,206 596,205 0 0 261,605 0 74,531 4,942,546

Molina 2,510,805 684,110 0 0 407,708 0 49,882 3,652,504

Superior 16,405,858 3,394,072 0 0 1,137,393 0 925,872 21,863,195

Bexar Total 22,926,869 4,674,386 0 0 1,806,706 0 1,050,285 30,458,245

Dallas SDA

Molina 27,382,684 5,056,381 0 0 2,126,982 0 712,453 35,278,500

Superior 25,206,840 3,099,798 0 0 2,903,789 0 789,374 31,999,801

Dallas Total 52,589,523 8,156,179 0 0 5,030,771 0 1,501,827 67,278,300

El Paso SDA

Amerigroup 3,730,750 891,180 0 0 233,342 0 240,540 5,095,813

Molina 3,562,529 1,011,107 0 0 222,119 0 245,882 5,041,636

El Paso Total 7,293,279 1,902,287 0 0 455,462 0 486,422 10,137,449

Harris SDA

Amerigroup 24,526,211 2,938,068 0 0 1,122,426 0 763,271 29,349,976

Molina 5,555,033 1,866,414 0 0 612,540 0 203,584 8,237,571

United 27,029,623 3,660,975 0 0 1,287,833 0 774,942 32,753,373

Harris Total 57,110,866 8,465,457 0 0 3,022,799 0 1,741,797 70,340,919

Hidalgo SDA

Health Spring 2,585,827 1,013,473 0 0 141,896 0 83,043 3,824,239

Molina 2,810,150 929,704 0 0 255,158 0 113,173 4,108,186

Superior 6,197,136 2,378,476 0 0 444,729 0 252,169 9,272,510

Hidalgo Total 11,593,113 4,321,653 0 0 841,784 0 448,385 17,204,935

Jefferson SDA

Amerigroup 2,757,058 295,715 0 0 259,240 0 30,266 3,342,279

Molina 2,233,414 651,703 0 0 168,756 0 8,837 3,062,710

United 3,231,181 318,954 0 0 190,756 0 86,657 3,827,547

Jefferson Total 8,221,652 1,266,372 0 0 618,752 0 125,760 10,232,536

237



UHRIP Adjustment




Lubbock SDA

Amerigroup 3,958,377 437,160 0 0 604,141 0 200,027 5,199,704

Superior 4,534,906 717,753 0 0 463,401 0 155,123 5,871,182

Lubbock Total 8,493,283 1,154,913 0 0 1,067,541 0 355,150 11,070,887

Nueces SDA

Superior 4,543,128 1,473,223 0 0 407,794 0 166,526 6,590,670

United 5,119,497 943,605 0 0 293,157 0 146,859 6,503,118

Nueces Total 9,662,625 2,416,827 0 0 700,951 0 313,384 13,093,788

Tarrant SDA

Amerigroup 27,344,705 4,138,276 0 0 2,852,399 0 896,245 35,231,624

Health Spring 5,980,232 766,694 0 0 409,182 0 244,686 7,400,794

Tarrant Total 33,324,937 4,904,970 0 0 3,261,580 0 1,140,931 42,632,418

Travis SDA

Amerigroup 5,626,792 1,135,451 0 0 612,624 0 167,353 7,542,221

United 7,550,733 1,194,973 0 0 700,020 0 585,600 10,031,326

Travis Total 13,177,525 2,330,424 0 0 1,312,645 0 752,953 17,573,547

MRSA Central SDA

Superior 10,717,615 1,407,333 0 0 876,766 0 593,863 13,595,577

United 6,753,799 510,641 0 0 582,786 0 151,756 7,998,983

Central Total 17,471,414 1,917,974 0 0 1,459,552 0 745,619 21,594,560

MRSA Northeast SDA

Health Spring 9,185,778 1,984,616 0 0 1,120,459 0 199,239 12,490,092

United 9,005,810 1,585,053 0 0 974,656 0 253,028 11,818,546

Northeast Total 18,191,587 3,569,668 0 0 2,095,115 0 452,267 24,308,637

MRSA West SDA

Amerigroup 6,761,265 853,809 0 0 680,055 0 203,281 8,498,409

Superior 11,909,834 1,434,992 0 0 1,291,812 0 498,300 15,134,938

West Total 18,671,098 2,288,801 0 0 1,971,867 0 701,581 23,633,347

238



UHRIP Adjustment





Bexar SDA

Amerigroup 22,466,281 3,502,407 0 0 1,619,538 0 843,012 28,431,238

Molina 13,268,671 3,880,132 0 0 2,369,694 0 346,986 19,865,482

Superior 76,146,337 19,603,185 0 0 4,515,984 0 5,716,419 105,981,925

Bexar Total 111,881,289 26,985,724 0 0 8,505,216 0 6,906,416 154,278,645

Dallas SDA

Molina 108,550,591 22,517,176 0 0 8,666,325 0 3,849,938 143,584,030

Superior 78,399,171 11,293,043 0 0 8,074,144 0 3,857,572 101,623,931

Dallas Total 186,949,761 33,810,220 0 0 16,740,469 0 7,707,511 245,207,961

El Paso SDA

Amerigroup 24,575,057 5,630,222 0 0 819,821 0 1,948,987 32,974,087

Molina 19,982,201 6,053,229 0 0 915,857 0 1,170,717 28,122,005

El Paso Total 44,557,258 11,683,451 0 0 1,735,679 0 3,119,704 61,096,092

Harris SDA

Amerigroup 121,518,241 16,324,627 0 0 6,008,926 0 5,358,150 149,209,944

Molina 40,967,734 13,262,208 0 0 2,948,607 0 1,732,776 58,911,325

United 140,349,085 24,103,628 0 0 6,994,760 0 5,777,134 177,224,607

Harris Total 302,835,060 53,690,462 0 0 15,952,293 0 12,868,059 385,345,876

Hidalgo SDA

Health Spring 19,732,548 8,560,906 0 0 1,047,674 0 958,347 30,299,475

Molina 18,880,517 6,446,282 0 0 1,468,632 0 888,483 27,683,914

Superior 39,857,853 17,394,992 0 0 2,261,540 0 2,724,056 62,238,441

Hidalgo Total 78,470,919 32,402,180 0 0 4,777,846 0 4,570,886 120,221,830

Jefferson SDA

Amerigroup 18,779,746 1,849,596 0 0 1,170,873 0 342,719 22,142,934

Molina 16,701,352 5,868,060 0 0 1,266,220 0 323,289 24,158,921

United 18,915,709 2,006,902 0 0 1,200,747 0 678,778 22,802,137

Jefferson Total 54,396,806 9,724,559 0 0 3,637,840 0 1,344,786 69,103,992

239



UHRIP Adjustment




Lubbock SDA

Amerigroup 13,646,786 2,016,872 0 0 2,064,829 0 1,038,174 18,766,661

Superior 15,859,241 2,799,293 0 0 1,411,013 0 979,481 21,049,029

Lubbock Total 29,506,027 4,816,165 0 0 3,475,843 0 2,017,655 39,815,689

Nueces SDA

Superior 18,847,351 6,621,834 0 0 1,435,774 0 988,966 27,893,925

United 21,545,226 4,762,969 0 0 1,039,204 0 598,851 27,946,250

Nueces Total 40,392,577 11,384,803 0 0 2,474,979 0 1,587,816 55,840,174

Tarrant SDA

Amerigroup 83,500,567 14,642,734 0 0 8,412,371 0 4,628,961 111,184,634

Health Spring 27,173,872 4,177,877 0 0 2,445,922 0 1,883,192 35,680,863

Tarrant Total 110,674,439 18,820,611 0 0 10,858,294 0 6,512,153 146,865,497

Travis SDA

Amerigroup 27,535,222 5,547,965 0 0 2,288,403 0 1,335,416 36,707,005

United 29,291,673 7,078,831 0 0 2,372,819 0 3,012,233 41,755,555

Travis Total 56,826,895 12,626,796 0 0 4,661,221 0 4,347,649 78,462,560

MRSA Central SDA

Superior 40,153,773 5,921,285 0 0 3,448,974 0 2,592,889 52,116,921

United 25,659,024 2,392,779 0 0 2,764,480 0 640,475 31,456,758

Central Total 65,812,797 8,314,063 0 0 6,213,455 0 3,233,364 83,573,679

MRSA Northeast SDA

Health Spring 49,764,452 12,439,689 0 0 5,317,636 0 1,960,426 69,482,203

United 50,327,798 9,637,788 0 0 4,647,113 0 1,832,962 66,445,661

Northeast Total 100,092,251 22,077,477 0 0 9,964,748 0 3,793,388 135,927,864

MRSA West SDA

Amerigroup 26,949,228 3,647,782 0 0 2,646,107 0 1,367,201 34,610,317

Superior 42,474,210 6,316,913 0 0 4,508,433 0 2,551,398 55,850,953

West Total 69,423,438 9,964,694 0 0 7,154,540 0 3,918,598 90,461,270

240



UHRIP Adjustment





Bexar SDA

Amerigroup 17.85% 17.02% 0.00% 0.00% 16.15% 0.00% 8.84% 17.38%

Molina 18.92% 17.63% 0.00% 0.00% 17.21% 0.00% 14.38% 18.39%

Superior 21.55% 17.31% 0.00% 0.00% 25.19% 0.00% 16.20% 20.63%

Bexar Total 20.49% 17.32% 0.00% 0.00% 21.24% 0.00% 15.21% 19.74%

Dallas SDA

Molina 25.23% 22.46% 0.00% 0.00% 24.54% 0.00% 18.51% 24.57%

Superior 32.15% 27.45% 0.00% 0.00% 35.96% 0.00% 20.46% 31.49%

Dallas Total 28.13% 24.12% 0.00% 0.00% 30.05% 0.00% 19.49% 27.44%

El Paso SDA

Amerigroup 15.18% 15.83% 0.00% 0.00% 28.46% 0.00% 12.34% 15.45%

Molina 17.83% 16.70% 0.00% 0.00% 24.25% 0.00% 21.00% 17.93%

El Paso Total 16.37% 16.28% 0.00% 0.00% 26.24% 0.00% 15.59% 16.59%

Harris SDA

Amerigroup 20.18% 18.00% 0.00% 0.00% 18.68% 0.00% 14.25% 19.67%

Molina 13.56% 14.07% 0.00% 0.00% 20.77% 0.00% 11.75% 13.98%

United 19.26% 15.19% 0.00% 0.00% 18.41% 0.00% 13.41% 18.48%

Harris Total 18.86% 15.77% 0.00% 0.00% 18.95% 0.00% 13.54% 18.25%

Hidalgo SDA

Health Spring 13.10% 11.84% 0.00% 0.00% 13.54% 0.00% 8.67% 12.62%

Molina 14.88% 14.42% 0.00% 0.00% 17.37% 0.00% 12.74% 14.84%

Superior 15.55% 13.67% 0.00% 0.00% 19.66% 0.00% 9.26% 14.90%

Hidalgo Total 14.77% 13.34% 0.00% 0.00% 17.62% 0.00% 9.81% 14.31%

Jefferson SDA

Amerigroup 14.68% 15.99% 0.00% 0.00% 22.14% 0.00% 8.83% 15.09%

Molina 13.37% 11.11% 0.00% 0.00% 13.33% 0.00% 2.73% 12.68%

United 17.08% 15.89% 0.00% 0.00% 15.89% 0.00% 12.77% 16.79%

Jefferson Total 15.11% 13.02% 0.00% 0.00% 17.01% 0.00% 9.35% 14.81%

241



UHRIP Adjustment




Lubbock SDA

Amerigroup 29.01% 21.68% 0.00% 0.00% 29.26% 0.00% 19.27% 27.71%

Superior 28.59% 25.64% 0.00% 0.00% 32.84% 0.00% 15.84% 27.89%

Lubbock Total 28.78% 23.98% 0.00% 0.00% 30.71% 0.00% 17.60% 27.81%

Nueces SDA

Superior 24.10% 22.25% 0.00% 0.00% 28.40% 0.00% 16.84% 23.63%

United 23.76% 19.81% 0.00% 0.00% 28.21% 0.00% 24.52% 23.27%

Nueces Total 23.92% 21.23% 0.00% 0.00% 28.32% 0.00% 19.74% 23.45%

Tarrant SDA

Amerigroup 32.75% 28.26% 0.00% 0.00% 33.91% 0.00% 19.36% 31.69%

Health Spring 22.01% 18.35% 0.00% 0.00% 16.73% 0.00% 12.99% 20.74%

Tarrant Total 30.11% 26.06% 0.00% 0.00% 30.04% 0.00% 17.52% 29.03%

Travis SDA

Amerigroup 20.43% 20.47% 0.00% 0.00% 26.77% 0.00% 12.53% 20.55%

United 25.78% 16.88% 0.00% 0.00% 29.50% 0.00% 19.44% 24.02%

Travis Total 23.19% 18.46% 0.00% 0.00% 28.16% 0.00% 17.32% 22.40%

MRSA Central SDA

Superior 26.69% 23.77% 0.00% 0.00% 25.42% 0.00% 22.90% 26.09%

United 26.32% 21.34% 0.00% 0.00% 21.08% 0.00% 23.69% 25.43%

Central Total 26.55% 23.07% 0.00% 0.00% 23.49% 0.00% 23.06% 25.84%

MRSA Northeast SDA

Health Spring 18.46% 15.95% 0.00% 0.00% 21.07% 0.00% 10.16% 17.98%

United 17.89% 16.45% 0.00% 0.00% 20.97% 0.00% 13.80% 17.79%

Northeast Total 18.17% 16.17% 0.00% 0.00% 21.03% 0.00% 11.92% 17.88%

242



UHRIP Adjustment




MRSA West SDA

Amerigroup 25.09% 23.41% 0.00% 0.00% 25.70% 0.00% 14.87% 24.55%

Superior 28.04% 22.72% 0.00% 0.00% 28.65% 0.00% 19.53% 27.10%

West Total 26.89% 22.97% 0.00% 0.00% 27.56% 0.00% 17.90% 26.13%

Footnotes

(1) Equals the cost impact from increased UHRIP reimbursement effective 9/1/2018.



243



UHRIP Adjustment

Calculation of UHRIP Premium Rate PMPM



FY2019 Projected Acute Care Incurred Claims (1)

Bexar SDA

Amerigroup 493.13 1,399.19 0.00 0.00 1,006.72 0.00 262.04 1,700.05

Molina 533.82 1,406.11 0.00 0.00 1,252.48 0.00 237.78 1,700.05

Superior 568.21 1,298.01 0.00 0.00 1,444.88 0.00 406.69 1,700.05

Dallas SDA

Molina 658.50 1,599.95 0.00 0.00 1,915.79 0.00 359.37 1,717.50

Superior 579.13 1,507.92 0.00 0.00 1,879.97 0.00 292.36 1,717.50

El Paso SDA

Amerigroup 529.18 1,305.80 0.00 0.00 2,079.34 0.00 423.16 993.30

Molina 736.47 1,712.18 0.00 0.00 2,906.50 0.00 723.03 993.30

Harris SDA

Amerigroup 613.26 1,707.72 0.00 0.00 1,462.40 0.00 322.16 1,771.16

Molina 750.41 2,469.72 0.00 0.00 1,837.44 0.00 395.23 1,771.16

United 709.36 1,431.28 0.00 0.00 1,378.04 0.00 291.71 1,771.16

Hidalgo SDA

Health Spring 435.71 1,342.32 0.00 0.00 1,707.24 0.00 290.35 1,616.32

Molina 512.79 1,381.77 0.00 0.00 2,438.52 0.00 368.98 1,616.32

Superior 483.08 1,238.38 0.00 0.00 1,886.49 0.00 477.73 1,616.32

Jefferson SDA

Amerigroup 533.41 1,271.21 0.00 0.00 1,380.42 0.00 523.75 1,822.48

Molina 591.81 1,918.46 0.00 0.00 1,390.09 0.00 327.58 1,822.48

United 621.85 1,211.94 0.00 0.00 1,131.57 0.00 248.25 1,822.48

Lubbock SDA

Amerigroup 624.63 1,312.55 0.00 0.00 1,614.95 0.00 362.44 1,267.02

Superior 506.19 1,654.80 0.00 0.00 1,253.89 0.00 264.48 1,267.02

Nueces SDA

Superior 472.05 1,158.44 0.00 0.00 1,148.94 0.00 366.98 1,423.99

United 587.17 1,271.41 0.00 0.00 970.85 0.00 447.70 1,423.99

244



UHRIP Adjustment




Tarrant SDA

Amerigroup 575.01 1,443.65 0.00 0.00 1,398.57 0.00 284.54 1,435.99

Health Spring 630.96 1,710.05 0.00 0.00 1,255.85 0.00 296.18 1,435.99

Travis SDA

Amerigroup 500.03 1,538.67 0.00 0.00 1,139.64 0.00 350.67 1,472.26

United 586.88 1,497.34 0.00 0.00 907.13 0.00 283.40 1,472.26

MRSA Central SDA

Superior 519.85 1,332.24 0.00 0.00 1,100.11 0.00 377.02 1,951.19

United 570.06 1,366.34 0.00 0.00 1,056.98 0.00 286.85 1,951.19

MRSA Northeast SDA

Health Spring 504.37 1,559.97 0.00 0.00 1,616.08 0.00 296.28 1,855.15

United 535.67 1,247.19 0.00 0.00 1,057.96 0.00 315.11 1,855.15

MRSA West SDA

Amerigroup 527.49 1,511.97 0.00 0.00 1,176.34 0.00 401.48 1,540.74

Superior 525.47 1,374.13 0.00 0.00 1,391.94 0.00 298.16 1,540.74

Rate Adjustment (2)

Bexar SDA

Amerigroup 0.1785 0.1702 0.0000 0.0000 0.1615 0.0000 0.0884 0.1988

Molina 0.1892 0.1763 0.0000 0.0000 0.1721 0.0000 0.1438 0.1988

Superior 0.2155 0.1731 0.0000 0.0000 0.2519 0.0000 0.1620 0.1988

Dallas SDA

Molina 0.2523 0.2246 0.0000 0.0000 0.2454 0.0000 0.1851 0.2752

Superior 0.3215 0.2745 0.0000 0.0000 0.3596 0.0000 0.2046 0.2752

El Paso SDA

Amerigroup 0.1518 0.1583 0.0000 0.0000 0.2846 0.0000 0.1234 0.1635

Molina 0.1783 0.1670 0.0000 0.0000 0.2425 0.0000 0.2100 0.1635

245



UHRIP Adjustment




Harris SDA

Amerigroup 0.2018 0.1800 0.0000 0.0000 0.1868 0.0000 0.1425 0.1839

Molina 0.1356 0.1407 0.0000 0.0000 0.2077 0.0000 0.1175 0.1839

United 0.1926 0.1519 0.0000 0.0000 0.1841 0.0000 0.1341 0.1839

Hidalgo SDA

Health Spring 0.1310 0.1184 0.0000 0.0000 0.1354 0.0000 0.0867 0.1435

Molina 0.1488 0.1442 0.0000 0.0000 0.1737 0.0000 0.1274 0.1435

Superior 0.1555 0.1367 0.0000 0.0000 0.1966 0.0000 0.0926 0.1435

Jefferson SDA

Amerigroup 0.1468 0.1599 0.0000 0.0000 0.2214 0.0000 0.0883 0.1480

Molina 0.1337 0.1111 0.0000 0.0000 0.1333 0.0000 0.0273 0.1480

United 0.1708 0.1589 0.0000 0.0000 0.1589 0.0000 0.1277 0.1480

Lubbock SDA

Amerigroup 0.2901 0.2168 0.0000 0.0000 0.2926 0.0000 0.1927 0.2811

Superior 0.2859 0.2564 0.0000 0.0000 0.3284 0.0000 0.1584 0.2811

Nueces SDA

Superior 0.2410 0.2225 0.0000 0.0000 0.2840 0.0000 0.1684 0.2333

United 0.2376 0.1981 0.0000 0.0000 0.2821 0.0000 0.2452 0.2333

Tarrant SDA

Amerigroup 0.3275 0.2826 0.0000 0.0000 0.3391 0.0000 0.1936 0.2952

Health Spring 0.2201 0.1835 0.0000 0.0000 0.1673 0.0000 0.1299 0.2952

Travis SDA

Amerigroup 0.2043 0.2047 0.0000 0.0000 0.2677 0.0000 0.1253 0.2233

United 0.2578 0.1688 0.0000 0.0000 0.2950 0.0000 0.1944 0.2233

MRSA Central SDA

Superior 0.2669 0.2377 0.0000 0.0000 0.2542 0.0000 0.2290 0.2616

United 0.2632 0.2134 0.0000 0.0000 0.2108 0.0000 0.2369 0.2616

246



UHRIP Adjustment




MRSA Northeast SDA

Health Spring 0.1846 0.1595 0.0000 0.0000 0.2107 0.0000 0.1016 0.1781

United 0.1789 0.1645 0.0000 0.0000 0.2097 0.0000 0.1380 0.1781

MRSA West SDA

Amerigroup 0.2509 0.2341 0.0000 0.0000 0.2570 0.0000 0.1487 0.2640

Superior 0.2804 0.2272 0.0000 0.0000 0.2865 0.0000 0.1953 0.2640

Non Benefit Component

Risk Margin 5.00 % 5.00 % 5.00 % 5.00 % 5.00 % 5.00 % 5.00 % 5.00 %

Admin. Fee 2.50 % 2.50 % 2.50 % 2.50 % 2.50 % 2.50 % 2.50 % 2.50 %

Premium Tax 1.75 % 1.75 % 1.75 % 1.75 % 1.75 % 1.75 % 1.75 % 1.75 %

Health Insurer Fee

Non-Exempt 1.70 % 1.70 % 1.70 % 1.70 % 1.70 % 1.70 % 1.70 % 1.70 %

Exempt 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

UHRIP Premium PMPM (3)

Bexar SDA

Amerigroup 98.85 267.43 0.00 0.00 182.58 0.00 26.01 379.53

Molina 113.42 278.38 0.00 0.00 242.06 0.00 38.40 379.53

Superior 137.51 252.31 0.00 0.00 408.72 0.00 73.99 379.53

Dallas SDA

Molina 186.57 403.54 0.00 0.00 527.94 0.00 74.70 530.78

Superior 209.09 464.82 0.00 0.00 759.17 0.00 67.17 530.78

El Paso SDA

Amerigroup 90.21 232.13 0.00 0.00 664.55 0.00 58.64 182.37

Molina 147.46 321.09 0.00 0.00 791.49 0.00 170.51 182.37

Harris SDA

Amerigroup 138.97 345.19 0.00 0.00 306.77 0.00 51.55 365.77

Molina 114.27 390.22 0.00 0.00 428.57 0.00 52.15 365.77

United 153.42 244.15 0.00 0.00 284.89 0.00 43.93 365.77

247



UHRIP Adjustment




Hidalgo SDA

Health Spring 64.10 178.47 0.00 0.00 259.58 0.00 28.27 260.46

Molina 85.69 223.75 0.00 0.00 475.66 0.00 52.79 260.46

Superior 84.36 190.10 0.00 0.00 416.49 0.00 49.68 260.46

Jefferson SDA

Amerigroup 87.93 228.26 0.00 0.00 343.21 0.00 51.93 302.89

Molina 88.85 239.35 0.00 0.00 208.08 0.00 10.04 302.89

United 119.27 216.26 0.00 0.00 201.92 0.00 35.60 302.89

Lubbock SDA

Amerigroup 203.49 319.55 0.00 0.00 530.64 0.00 78.43 399.95

Superior 162.51 476.46 0.00 0.00 462.41 0.00 47.04 399.95

Nueces SDA

Superior 127.75 289.45 0.00 0.00 366.42 0.00 69.40 373.07

United 156.67 282.84 0.00 0.00 307.55 0.00 123.28 373.07

Tarrant SDA

Amerigroup 211.47 458.14 0.00 0.00 532.57 0.00 61.86 476.03

Health Spring 155.95 352.38 0.00 0.00 235.94 0.00 43.20 476.03

Travis SDA

Amerigroup 114.72 353.70 0.00 0.00 342.60 0.00 49.34 369.18

United 169.90 283.83 0.00 0.00 300.51 0.00 61.87 369.18

MRSA Central SDA

Superior 155.81 355.61 0.00 0.00 314.03 0.00 96.95 573.20

United 168.49 327.43 0.00 0.00 250.21 0.00 76.31 573.20

248



UHRIP Adjustment




MRSA Northeast SDA

Health Spring 104.56 279.41 0.00 0.00 382.38 0.00 33.80 371.03

United 107.62 230.39 0.00 0.00 249.13 0.00 48.83 371.03

MRSA West SDA

Amerigroup 148.62 397.47 0.00 0.00 339.49 0.00 67.04 456.77

Superior 165.46 350.59 0.00 0.00 447.83 0.00 65.39 456.77

Footnotes

(1) Projected claims pmpm based on individual MCO rating described in Attachment 2.

(2) From Exhibit A.

(3) (1) x (2) divided by (1 - non-benefit component).

249

250

Attachment 14

Community First Choice Initiative (CFC)

Effective June 1, 2015 Texas began providing CFC services to individuals who:

have a physical or intellectual disability,

meet categorical coverage requirements for Medicaid or meet financial eligibility for

home and community based services, and

meet an institutional level of care.

The CFC services include:

Help with activities of daily living and health-related tasks through hands-on assistance,

supervision or cueing.

Services to help the individual learn how to care for themselves.

Backup systems or ways to ensure continuity of services and supports.

Training on how to select, manage and dismiss attendants.

As a result of CFC, Texas is eligible for an enhanced federal match rate on all CFC eligible

services. The calculation of the CFC portion of the rate is based on an estimation of the CFC

eligible services included in the STAR PLUS premium rate. This calculation involved the

following steps:

a. Collect a list of CFC eligible members which were enrolled in STAR+PLUS during

FY2017.

b. Using the detail encounter data, summarize all Personal Attendant Services (PAS)

utilized by the CFC eligible membership.

c. Determine the PAS utilization as a percentage of total long term care claims during

the FY2017 base period. This calculation is shown in Exhibit A.

d. Apply the CFC eligible PAS percentages calculated in Exhibit A to the long term care

portion of the premium to estimate the CFC portion of the premium. This calculation

is shown in Exhibit B.

The implementation of CFC did not impact the Nursing Facility, IDD or MBCCP risk groups.

The CFC portion of the total premium is $0.00 pmpm for these populations.



CFC Enhanced Match Rates

CFC Services as a Percentage of Total Long Term Care


OCC HCBS OCC HCBS Grand Total

CFC Eligible Services (1)

Amerigroup - Bexar 610,636 2,967,357 873,028 3,275,996 7,727,017

Molina - Bexar 236,692 2,423,941 443,790 6,214,765 9,319,187

Superior - Bexar 2,342,551 19,358,687 1,870,126 17,088,695 40,660,059

Molina - Dallas 2,033,336 15,108,222 2,380,379 20,494,369 40,016,305

Superior - Dallas 1,072,424 8,063,138 1,106,874 8,940,139 19,182,576

Amerigroup - El Paso 528,174 4,777,301 900,963 6,059,205 12,265,643

Molina - El Paso 587,236 4,936,107 877,835 7,427,131 13,828,309

Amerigroup - Harris 1,418,677 10,761,757 2,053,514 15,554,810 29,788,758

Molina - Harris 598,715 6,102,499 721,244 8,749,918 16,172,376

United - Harris 2,228,610 19,084,239 2,840,908 34,806,473 58,960,230

HealthSpring - Hidalgo 2,963,897 11,209,497 5,284,892 36,333,946 55,792,231

Molina - Hidalgo 965,631 7,393,905 2,101,566 24,642,220 35,103,323

Superior - Hidalgo 3,001,996 24,160,920 6,029,378 71,857,783 105,050,076

Amerigroup - Jefferson 174,159 1,555,709 307,308 2,647,984 4,685,159

Molina - Jefferson 403,239 3,000,993 541,974 3,994,240 7,940,445

United - Jefferson 139,781 1,311,651 49,602 709,594 2,210,628

Amerigroup - Lubbock 140,805 914,611 497,609 1,331,159 2,884,184

Superior - Lubbock 158,320 1,579,694 163,489 1,386,443 3,287,946

Superior - Nueces 745,413 7,755,333 1,299,114 12,022,497 21,822,357

United - Nueces 371,136 4,454,314 429,681 8,089,534 13,344,666

Amerigroup - Tarrant 1,977,940 9,485,734 3,261,645 7,614,563 22,339,883

HealthSpring - Tarrant 531,246 2,685,913 440,277 2,537,325 6,194,761

Amerigroup - Travis 519,945 4,686,014 992,271 6,606,662 12,804,892

United - Travis 532,837 4,007,641 696,195 5,503,478 10,740,151

Superior - MRSA Central 497,097 4,878,092 462,836 3,510,769 9,348,794

United - MRSA Central 332,714 1,957,003 817,694 3,915,454 7,022,865

Health Spring - MRSA Northeast 1,366,512 8,093,722 1,680,089 10,540,048 21,680,372

United - MRSA Northeast 687,512 6,337,844 791,564 9,382,004 17,198,923

Amerigroup - MRSA West 587,714 2,586,665 2,335,318 8,868,401 14,378,098

Superior - MRSA West 428,393 4,737,741 705,366 5,166,900 11,038,400

Total 28,183,338 206,376,243 42,956,527 355,272,504 632,788,611

251







FY2017 Total Long Term Care Claims Paid (2)

Amerigroup - Bexar 7,758,229 3,971,998 13,715,639 10,239,637 35,685,504

Molina - Bexar 3,779,077 3,207,947 11,542,415 11,512,598 30,042,037

Superior - Bexar 33,602,923 27,948,490 35,565,327 34,055,302 131,172,042

Molina - Dallas 34,766,943 20,263,057 44,483,956 45,403,943 144,917,899

Superior - Dallas 23,228,740 12,045,766 28,038,145 22,750,036 86,062,686

Amerigroup - El Paso 8,946,982 5,819,610 28,320,287 10,798,711 53,885,589

Molina - El Paso 7,769,210 5,965,849 29,901,776 11,955,596 55,592,431

Amerigroup - Harris 28,256,363 14,456,082 50,000,543 26,520,260 119,233,248

Molina - Harris 8,380,050 9,007,357 15,384,411 14,774,723 47,546,541

United - Harris 50,277,324 32,489,650 70,194,800 61,038,012 213,999,787

HealthSpring - Hidalgo 28,939,001 13,555,600 93,047,091 65,244,908 200,786,600

Molina - Hidalgo 18,440,341 9,346,626 66,690,953 44,824,199 139,302,118

Superior - Hidalgo 60,423,166 31,403,555 184,596,872 126,490,706 402,914,299

Amerigroup - Jefferson 3,358,625 2,427,792 6,795,377 8,421,545 21,003,339

Molina - Jefferson 3,387,171 3,456,038 7,002,942 8,718,540 22,564,691

United - Jefferson 3,138,228 1,898,579 1,963,470 3,072,605 10,072,881

Amerigroup - Lubbock 883,440 1,351,701 2,854,323 4,555,078 9,644,542

Superior - Lubbock 2,122,105 2,313,984 3,117,311 3,963,709 11,517,109

Superior - Nueces 11,944,377 9,967,892 23,472,376 26,347,063 71,731,707

United - Nueces 10,857,402 5,734,925 14,803,661 23,323,046 54,719,034

Amerigroup - Tarrant 14,277,500 14,412,265 25,747,250 26,872,644 81,309,659

HealthSpring - Tarrant 6,649,374 3,849,987 7,392,868 8,428,303 26,320,532

Amerigroup - Travis 8,192,668 5,538,848 14,736,344 14,669,990 43,137,849

United - Travis 3,770,314 7,399,146 5,601,290 15,195,162 31,965,912

Superior - MRSA Central 7,414,815 6,911,923 8,434,518 9,828,475 32,589,731

United - MRSA Central 3,002,550 3,341,797 10,692,280 14,578,296 31,614,923

Health Spring - MRSA Northeast 8,890,090 11,320,745 13,233,364 32,059,160 65,503,359

United - MRSA Northeast 8,918,882 12,141,451 14,758,329 39,462,382 75,281,044

Amerigroup - MRSA West 3,533,340 3,631,629 18,901,036 22,009,766 48,075,771

Superior - MRSA West 8,752,932 6,998,758 17,723,256 17,096,797 50,571,742

Total 423,662,159 292,179,045 868,712,212 764,211,191 2,348,764,606

252







CFC Eligible Services Percentage of Total Long Term Care

Amerigroup - Bexar 7.87% 74.71% 6.37% 31.99% 21.65%

Molina - Bexar 6.26% 75.56% 3.84% 53.98% 31.02%

Superior - Bexar 6.97% 69.27% 5.26% 50.18% 31.00%

Molina - Dallas 5.85% 74.56% 5.35% 45.14% 27.61%

Superior - Dallas 4.62% 66.94% 3.95% 39.30% 22.29%

Amerigroup - El Paso 5.90% 82.09% 3.18% 56.11% 22.76%

Molina - El Paso 7.56% 82.74% 2.94% 62.12% 24.87%

Amerigroup - Harris 5.02% 74.44% 4.11% 58.65% 24.98%

Molina - Harris 7.14% 67.75% 4.69% 59.22% 34.01%

United - Harris 4.43% 58.74% 4.05% 57.02% 27.55%

HealthSpring - Hidalgo 10.24% 82.69% 5.68% 55.69% 27.79%

Molina - Hidalgo 5.24% 79.11% 3.15% 54.98% 25.20%

Superior - Hidalgo 4.97% 76.94% 3.27% 56.81% 26.07%

Amerigroup - Jefferson 5.19% 64.08% 4.52% 31.44% 22.31%

Molina - Jefferson 11.90% 86.83% 7.74% 45.81% 35.19%

United - Jefferson 4.45% 69.09% 2.53% 23.09% 21.95%

Amerigroup - Lubbock 15.94% 67.66% 17.43% 29.22% 29.90%

Superior - Lubbock 7.46% 68.27% 5.24% 34.98% 28.55%

Superior - Nueces 6.24% 77.80% 5.53% 45.63% 30.42%

United - Nueces 3.42% 77.67% 2.90% 34.68% 24.39%

Amerigroup - Tarrant 13.85% 65.82% 12.67% 28.34% 27.48%

HealthSpring - Tarrant 7.99% 69.76% 5.96% 30.10% 23.54%

Amerigroup - Travis 6.35% 84.60% 6.73% 45.04% 29.68%

United - Travis 14.13% 54.16% 12.43% 36.22% 33.60%

Superior - MRSA Central 6.70% 70.58% 5.49% 35.72% 28.69%

United - MRSA Central 11.08% 58.56% 7.65% 26.86% 22.21%

Health Spring - MRSA Northeast 15.37% 71.49% 12.70% 32.88% 33.10%

United - MRSA Northeast 7.71% 52.20% 5.36% 23.77% 22.85%

Amerigroup - MRSA West 16.63% 71.23% 12.36% 40.29% 29.91%

Superior - MRSA West 4.89% 67.69% 3.98% 30.22% 21.83%

Total 6.65% 70.63% 4.94% 46.49% 26.94%

Footnotes

(1) Equals FY2017 health plan fee-for-service claims for CFC eligible members (from Encounter database).

(2) Equals FY2017 health plan fee-for-service claims for all long term care services (from Encounter database).

253





OCC HCBS OCC HCBS

STAR+PLUS Rates Effective 9/1/2018 (LTC Only)

Amerigroup - Bexar 234.85 2,011.99 395.96 2,119.64

Molina - Bexar 230.96 1,644.88 402.58 1,989.36

Superior - Bexar 321.11 2,018.56 459.44 2,087.13

Molina - Dallas 301.97 1,616.62 421.98 1,846.32

Superior - Dallas 238.02 1,596.35 379.94 1,895.56

Amerigroup - El Paso 278.81 1,724.56 522.75 1,972.31

Molina - El Paso 402.97 1,784.61 612.09 2,158.55

Amerigroup - Harris 234.94 2,089.30 353.65 2,159.07

Molina - Harris 261.95 1,995.38 370.98 2,153.05

United - Harris 316.06 2,064.16 412.25 2,174.87

HealthSpring - Hidalgo 776.01 2,396.50 1,023.79 2,488.25

Molina - Hidalgo 697.02 2,328.82 899.83 2,449.64

Superior - Hidalgo 843.42 2,382.17 1,163.21 2,483.50

Amerigroup - Jefferson 174.79 1,684.24 308.92 1,784.71

Molina - Jefferson 210.27 1,419.99 303.06 1,631.22

United - Jefferson 169.40 1,396.27 201.12 1,519.28

Amerigroup - Lubbock 92.67 1,290.92 157.90 1,476.81

Superior - Lubbock 127.22 1,499.94 199.23 1,598.72

Superior - Nueces 383.77 1,938.42 571.25 2,150.10

United - Nueces 391.91 1,925.63 460.15 2,111.09

Amerigroup - Tarrant 166.00 1,781.52 324.03 1,800.70

HealthSpring - Tarrant 210.72 1,792.08 279.47 1,823.41

Amerigroup - Travis 255.14 2,202.70 361.14 1,929.37

United - Travis 153.35 2,075.00 180.40 1,856.01

Superior - MRSA Central 167.13 1,913.02 230.43 1,807.45

United - MRSA Central 133.48 2,106.35 238.93 1,937.94

Health Spring - MRSA Northeast 169.34 1,809.71 228.90 1,735.55

United - MRSA Northeast 172.05 1,753.09 254.01 1,594.02

Amerigroup - MRSA West 123.27 1,970.33 281.77 1,662.72

Superior - MRSA West 171.81 1,754.71 287.82 1,579.01

254





OCC HCBS OCC HCBS

CFC Eligible Services as a Percentage of FY2017 Base Period (2)

Amerigroup - Bexar 7.9% 74.7% 6.4% 32.0%

Molina - Bexar 6.3% 75.6% 3.8% 54.0%

Superior - Bexar 7.0% 69.3% 5.3% 50.2%

Molina - Dallas 5.8% 74.6% 5.4% 45.1%

Superior - Dallas 4.6% 66.9% 3.9% 39.3%

Amerigroup - El Paso 5.9% 82.1% 3.2% 56.1%

Molina - El Paso 7.6% 82.7% 2.9% 62.1%

Amerigroup - Harris 5.0% 74.4% 4.1% 58.7%

Molina - Harris 7.1% 67.8% 4.7% 59.2%

United - Harris 4.4% 58.7% 4.0% 57.0%

HealthSpring - Hidalgo 10.2% 82.7% 5.7% 55.7%

Molina - Hidalgo 5.2% 79.1% 3.2% 55.0%

Superior - Hidalgo 5.0% 76.9% 3.3% 56.8%

Amerigroup - Jefferson 5.2% 64.1% 4.5% 31.4%

Molina - Jefferson 11.9% 86.8% 7.7% 45.8%

United - Jefferson 4.5% 69.1% 2.5% 23.1%

Amerigroup - Lubbock 15.9% 67.7% 17.4% 29.2%

Superior - Lubbock 7.5% 68.3% 5.2% 35.0%

Superior - Nueces 6.2% 77.8% 5.5% 45.6%

United - Nueces 3.4% 77.7% 2.9% 34.7%

Amerigroup - Tarrant 13.9% 65.8% 12.7% 28.3%

HealthSpring - Tarrant 8.0% 69.8% 6.0% 30.1%

Amerigroup - Travis 6.3% 84.6% 6.7% 45.0%

United - Travis 14.1% 54.2% 12.4% 36.2%

Superior - MRSA Central 6.7% 70.6% 5.5% 35.7%

United - MRSA Central 11.1% 58.6% 7.6% 26.9%

Health Spring - MRSA Northeast 15.4% 71.5% 12.7% 32.9%

United - MRSA Northeast 7.7% 52.2% 5.4% 23.8%

Amerigroup - MRSA West 16.6% 71.2% 12.4% 40.3%

Superior - MRSA West 4.9% 67.7% 4.0% 30.2%

(2) From Exhibit A.

255





OCC HCBS OCC HCBS

CFC Portion of LTC Premium (3)

Amerigroup - Bexar 18.48 1,503.10 25.20 678.14

Molina - Bexar 14.47 1,242.88 15.48 1,073.90

Superior - Bexar 22.39 1,398.17 24.16 1,047.31

Molina - Dallas 17.66 1,205.36 22.58 833.39

Superior - Dallas 10.99 1,068.56 15.00 744.90

Amerigroup - El Paso 16.46 1,415.69 16.63 1,106.67

Molina - El Paso 30.46 1,476.58 17.97 1,340.95

Amerigroup - Harris 11.80 1,555.37 14.52 1,266.35

Molina - Harris 18.72 1,351.87 17.39 1,275.08

United - Harris 14.01 1,212.48 16.68 1,240.20

HealthSpring - Hidalgo 79.48 1,981.73 58.15 1,385.67

Molina - Hidalgo 36.50 1,842.28 28.36 1,346.70

Superior - Hidalgo 41.90 1,832.77 37.99 1,410.85

Amerigroup - Jefferson 9.06 1,079.25 13.97 561.17

Molina - Jefferson 25.03 1,233.02 23.45 747.31



Superior - Lubbock 9.49 1,023.97 10.45 559.21

Superior - Nueces 23.95 1,508.15 31.62 981.12

United - Nueces 13.40 1,495.64 13.36 732.23

Amerigroup - Tarrant 23.00 1,172.54 41.05 510.24

HealthSpring - Tarrant 16.84 1,250.23 16.64 548.93

Amerigroup - Travis 16.19 1,863.54 24.32 868.90

United - Travis 21.67 1,123.89 22.42 672.22

Superior - MRSA Central 11.20 1,350.11 12.64 645.63

United - MRSA Central 14.79 1,233.51 18.27 520.49

Health Spring - MRSA Northeast 26.03 1,293.85 29.06 570.59


Amerigroup - MRSA West 20.50 1,403.39 34.81 669.96

Superior - MRSA West 8.41 1,187.83 11.45 477.20

(3) LTC Premium prior multiplied by CFC eligible percentage.

256

257

Attachment 15

Pay for Quality Program

The Pay-for-Quality (P4Q) Program creates incentives and disincentives for managed care

organizations based on their performance on certain quality measures. Health plans that excel on

meeting the measures are eligible for a bonus while health plans that don’t meet their measures

are subject to a penalty.

The table below provides a description of the at risk and bonus measures for the 2019 calendar

year.

At-Risk Measures

Source Measure Description Data Period

3M Potentially

Preventable

Emergency

Room Visits

(PPVs)

Hospital emergency room or freestanding

emergency medical care facility treatment

provided for a condition that could be provided

in a nonemergency setting

Jan. 1 - Dec. 31

measurement year

HEDIS Appropriate

Treatment

for Children

with Upper

Respiratory

Infection

(URI)

Percentage of children 3 months - 18 years of

age who were diagnosed with upper respiratory

infection and were not dispensed an antibiotic

prescription on or three days after the episode

July 1, prior year -

June 30,

measurement year

HEDIS Prenatal and

Postpartum

Care (PPC)*

Timeliness of Prenatal Care: the percentage

of deliveries that received a prenatal care

visit as a member of the organization in the

first trimester or within 42 days of

enrollment in the organization

Postpartum Care: the percentage of

deliveries that had a postpartum visit on or

between 21 and 56 days after delivery

November 6, prior

year - December

31, measurement

year

HEDIS Well Child

Visits in the

First 15

months of

Life (W15)*

Percentage of members who turned 15 months

old during the measurement year and who had

six or more well-child visits with a PCP during

their first 15 months of life

October 1, two

years prior -

December 31,

measurement year

Bonus Pool Measures

Source Measure Description

3M Potentially

preventable

admissions

(PPAs)

Hospital admission that may have been

prevented with access to ambulatory care or

health care coordination.

Jan. 1 - Dec. 31

measurement year

258

CMS Low Birth

Weight

Percentage of live births that weighed less

than 2,500 grams (5.51 pounds)

Jan. 1 - Dec. 31

measurement

year

CAHPS Children

with good

access to

urgent care

Percent of caregivers who, when surveyed,

responded their child always got urgent care for

illness, injury or condition as soon as needed

Surveys

conducted

between Jan. 1 -

Dec. 31

measurement year

CAHPS Adults rating

their health

MCO a 9 or

10

Percent of adult members who rated their MCO

a 9 or 10 (on a scale of 0-10) when surveyed

Surveys

conducted

between Jan. 1 -

Dec. 31

measurement year

The medical P4Q program assesses MCOs based on three categories:

Performance Against Benchmarks

Performance Against Self (comparison of an MCO's performance to their prior year

performance)

Bonus pool measures

The performance against self and performance against benchmarks measures are the at-risk

components of the program: MCOs can lose money based on their performance on these

measures. Utilizing both the performance against self and performance against benchmarks

rewards high performing MCOs while still incentivizing improvement regardless of current level

of performance. The total percent capitation earned/lost for each at-risk measure in a program is

added to determine the total capitation earned/lost for each MCO across all at-risk measures for

that program.

The bonus pool measures provide an additional way for MCOs to earn rewards, without the risk

of losing money. Bonus pool measures encourage improvement in new areas with no financial

risk to the health MCOs.

Three percent of the MCOs' capitation is at-risk. The MCOs’ at-risk capitation is distributed

equally across the at-risk measures. Some HEDIS quality measures have submeasures. The

capitation at-risk for that measure will be divided evenly across the submeasures.

The maximum bonus or penalty in the P4Q program is 3.0%; however the typical results are far

below these limits.

Historically the impact of the P4Q program on total premium has been immaterial. HHSC

performed simulations on the FY2014 and FY2015 managed care data and the average impact by

MCO was less 0.1%. As a result, we do not believe the P4Q program has a material impact on

the premium rate development.

259

Attachment 16

FY2019 STAR+PLUS Rate Certification Index

The index below includes the pages of this report that correspond to the applicable sections of

the 2018-2019 Medicaid Managed Care Rate Development Guide, dated May 2018.

Section I. Medicaid Managed Care Rates

1. General Information

A. Rate Development Standards

i. Rates are for the period September 1, 2018 through August 31, 2019

(FY2019).

ii. (a) The certification letter is on page 18 of the report.

(b) The final capitation rates are shown on pages 16-17 of the report.

(c) (i) See pages 1 and 4 through 6 of the report.

(ii) See page 1 of the report.

(iii) See page 1 of the report.

(iv) Not applicable. There have been no changes since the prior

certification.

(v) Pages 223-227 (NAIP), 228-233 (QIPP), 234-249 (UHRIP) and 257-

258 (P4Q).

(vi) Not applicable.

iii. Acknowledged.

iv. Acknowledged.

v. Acknowledged.

vi. Acknowledged.

vii. Acknowledged.

260

viii. Acknowledged.

B. Appropriate Documentation

i. Acknowledged.

ii. Acknowledged.

iii. See pages 250 through 256 of the report.

iv. (a) See pages 20 through 42 of the report.

(b) Not applicable. All rating adjustment factors have been included in the

report.

2. Data


i. (a) Acknowledged.

(b) Acknowledged.

(c) Acknowledged.

(d) Not applicable.


i. (a) See pages 1 through 3 of the report.

ii. (a) See pages 1 through 3 of the report.

(b) See pages 2 through 3 of the report.

(c) See pages 2 through 3 of the report.

(d) Not applicable.

iii. (a) Base period data is fully credible.

(b) See page 4 of the report.

261

(c) No errors found in the data.

(d) See pages 149 through 182 of the report.

(e) Value added services and non-capitated services have been excluded from

the analysis.

3. Projected benefit Costs and Trends


i. Acknowledged.

ii. Acknowledged.

iii. Acknowledged.

iv. Acknowledged.

v. See pages 150 through 151 and pages 170 through 171 of the report.

vi. See page 151 of the report.


i. See pages 16 through 17 and Attachment 1 pages 20 through 42 of the report.

ii. See Attachment 3 pages 50 through 130 of the report. There have been no

significant changes in the development of the benefit cost since the last

certification.

iii. (a) See Attachment 4 pages 131 through 148 of the report.

(b) See Attachment 4 pages 131 through 148 of the report.

(c) See Attachment 4 pages 131 through 148 of the report.

(d) See Attachment 4 pages 131 through 148 of the report.

(e) Not applicable.

iv. Not applicable.

262

v. The STAR+PLUS program stipulates the following provisions related to in

lieu of services:

- The MCO may provide inpatient services for acute psychiatric conditions

in a free-standing psychiatric hospital in lieu of an acute care inpatient

hospital setting.

- The MCO may provide substance use disorder treatment services in a

chemical dependency treatment facility in lieu of an acute care inpatient

hospital setting.

- For individuals between the ages of 21 and 64, services are provided in

IMDs only in lieu of an acute care hospital setting. IMD services for

individuals under age 21 and age 65 and over are covered pursuant to the

Texas state plan.

The cost for in lieu of services are not tracked from other services and are

included in the rate development and are not treated differently than any other

category of service. Historically these services have made up roughly 1.0% of

total base period claims.

vi. (a) Restorative enrollment can occur when an individual is deemed to have

been Medicaid eligible during a prior period. If the individual was eligible for

and enrolled in Medicaid managed care during the prior six months, then the

individual is retrospectively enrolled in the same managed care plan as their

prior enrollment segment. The managed care plan is then retrospectively

responsible for all Medicaid expenses incurred during this retrospective period

and is also paid a retrospective premium for this time period.

(b) All claims paid during retroactive enrollment periods are included in the

base period data used to develop the FY2019 premium rate.

(c) All enrollment data during retroactive enrollment periods are included in

the base period data used to develop the FY2019 premium rate.

(d) No adjustments are necessary to account for retroactive enrollment periods

because the enrollment criteria has not changed from the base period to the

rating period. All retroactive enrollment and claims information has been

included in the base period data, the trend calculations and all other

adjustment factors.

vii. See Attachments 5 through 7 pages 149 through 182 of the report.

viii. See Attachments 5 through 7 pages 149 through 182 of the report.

4. Special Contract Provisions Related to Payment

A. Incentive Arrangements

263

i. Rate Development Standards

Acknowledged.

ii. Appropriate Documentation

(a) See Attachment 15 pages 257 through 258 of the report.

B. Withhold Arrangements


Acknowledged.


(a) See Attachment 15 pages 257 through 258 of the report.

C. Risk-Sharing Arrangements


Not applicable.


HHSC includes an experience rebate provision in its uniform managed care

contracts which requires the MCOs to return a portion of net income before

taxes if greater than the specified percentages. The net income is measured by

the financial statistical reports (FSRs) submitted by the MCOs and audited by

an external auditor. Net income is aggregated across all programs and service

delivery areas. The aggregated net income is shared as follows:

Pre-tax Income as a

% of Revenues

MCO

Share

HHSC

Share

≤ 3% 100% 0%

> 3% and ≤ 5% 80% 20%

> 5% and ≤ 7% 60% 40%

> 7% and ≤ 9% 40% 60%

> 9% and ≤ 12% 20% 80%

> 12% 0% 100%

264

D. Delivery System and Provider Payment Initiatives


Acknowledged.


(a) See Attachment 12 pages 228 through 233 and Attachment 13 pages 234

through 249 of the report for a description of the QIPP and UHRIP

programs. See Attachment 1 page 42 for the estimated value of these

programs.

E. Pass-Through Payments


Acknowledged.


(a) See Attachment 11 pages 223 through 227.

(b) See Attachment 11 pages 223 through 227.

5. Projected Non-Benefit Costs


i. Acknowledged.

ii. Acknowledged.

iii. Acknowledged.

iv. Acknowledged.


i. See page 15 of the report.

ii. See page 15 of the report.

iii. (a) See page 15 of the report.

(b) Not applicable.

265

(c) Not applicable.

(d) See page 15 of the report.

(e) See Attachment 1 pages 20 through 42.

(f) See page 15 of the report.

6. Risk Adjustment and Acuity Adjustments


i. Acknowledged.

ii. Acknowledged.

iii. Acknowledged.


i. See Attachments 8 and 9 pages 183 through 206 of the report.

ii. Not applicable, risk adjustment is only applied on a prospective basis.

iii. No material changes have been made to the risk adjustment model applied to

acute care other than annual updates of the data since the last rating period.

The long term care risk adjustment factors have been assigned 100%

credibility which is an increase from the 75% used in the FY2018 rate

development. Risk adjustment has been applied in a budget neutral manner in

accordance with 42 CFR 438.5(g).

iv. See Attachments 8 and 9 pages 183 through 206 of the report.

Section II. Medicaid Managed Care Rates with Long-Term Services and

Supports

1. Managed Long-Term Services and Supports

A. Acknowledged.

B. Long term care rate development follows the same methodology as all other services

described throughout the report.

C. Appropriate Documentation

i. (a) Rates are set for the risk groups specified on page 5 of the report. This is a

“non-blended” approach.

266

(b) Rate cells are specified on page 5 of the report. Description of the rate

setting methodology is included in Attachment 3 pages 50 through 130 of

the report. All trend analysis and other adjustment factors follow the same

methodology as described throughout the report.

(c) Not applicable.

(d) LTSS has been managed under STAR+PLUS since its inception. The

impact of managing these services on utilization and unit costs of services

is reflected in the base period utilized in the rate development and requires

no further adjustments.

(e) LTSS has been managed under STAR+PLUS since its inception. The

impact of managing these services on utilization and unit costs of services

is reflected in the base period utilized in the rate development and requires

no further adjustments.

ii. The development of the administrative cost is described on page 15 of the

report. Service coordination expenditures are based on the amounts reported

by the MCO as discussed on page 2 of the report.

iii. The rate setting is based on historical managed care data for all services,

including long term care. The managed care data is fully credible and

therefore no reliance is necessary on outside studies or research.

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