Others titles
- Medicare Advantage Risk Rates For All Plans Except Program of All Inclusive Care for the Elderly
- Medicare Risk Adjustments All Plans Except PACE
- Medicare Advantage Risk Adjustments
Keywords
- Medicare Advantage Benchmarks
- Medicare Advantage Risk Rates
- Medicare Advantage Rates
- Adjusted Average Per Capita Cost Methodology
- Medicare Fees
- Medicare Risk Scores
- Fee-for-Service Medicare Costs
- Medicare Payments
- Advantage Payment Rates
Medicare Advantage Risk Rate For All Plans Except PACE
This dataset contains information on Medicare Advantage (MA) risk rates for all plans except Program of All-Inclusive Care for the Elderly (PACE) plans. Health plans that participate in the MA program receive monthly capitation payments for each Medicare enrollee.
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Description
Medicare managed healthcare options have been available to some Medicare beneficiaries since 1982 and Medicare has paid health plans a monthly per person county rate. The monthly per person, or “per capita,” county rates were determined under the Adjusted Average Per Capita Cost (AAPCC). AAPCCs are five-year moving averages per beneficiary spending at the county level for fee-for-service Medicare. The county rates were used as the base rates for paying MA plans in 2004 and 2005. Beginning in 2006, however, the county rates were used to create benchmarks against which the plans will bid. Rates were set through competitive bid, rather than administered pricing. The benchmark for each plan was a weighted average of the county rates for the counties in the plan’s service area. The Centers for Medicare and Medicaid Services (CMS) based the Medicare payment is used for private plan on the relationship between the bid and its benchmark. Medicare payments are also based on enrolled beneficiaries’ demographics and health risk characteristics. Section 1853(a)(3) of the Social Security Act required the Secretary to develop and implement a new risk-adjustment methodology to be used to adjust the county-wide rates to reflect the expected relative health status of each enrollee. Key components of the Medicare Advantage rates include: 1) Revision to the risk-adjustment model to better account for fully dual eligible beneficiaries. 2) Adjustment to certain measures within the Star Ratings program for socioeconomic status. 3) Update to the blended risk scores using 75 percent of the risk score calculated using data from the Risk Adjustment Processing System (RAPS) and 25 percent of the risk score calculated using encounter data. 4) Incentives to Medicare Advantage organizations to offer plans with lower maximum out-of-pocket limits.
The purpose of risk adjustment is to use health status indicators to improve the accuracy of payments and establish incentives for plans to enroll and treat less healthy Medicare beneficiaries. The base payment for an enrollee is the base rate for the enrollee’s county of residence, multiplied by the enrollee’s risk measure. Coordinated care plans, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and PACE plans are generally required to reimburse non-contracting providers at least the original Medicare rate for Medicare covered services.
About this Dataset
Data Info
Date Created | 2016-04-04 |
---|---|
Last Modified | 2022-07-29 |
Version | 2022-07-29 |
Update Frequency |
Annual |
Temporal Coverage |
2016-2023 |
Spatial Coverage |
United States |
Source | John Snow Labs; Centers for Medicare and Medicaid Services; |
Source License URL | |
Source License Requirements |
N/A |
Source Citation |
N/A |
Keywords | Medicare Advantage Benchmarks, Medicare Advantage Risk Rates, Medicare Advantage Rates, Adjusted Average Per Capita Cost Methodology, Medicare Fees, Medicare Risk Scores, Fee-for-Service Medicare Costs, Medicare Payments, Advantage Payment Rates |
Other Titles | Medicare Advantage Risk Rates For All Plans Except Program of All Inclusive Care for the Elderly, Medicare Risk Adjustments All Plans Except PACE, Medicare Advantage Risk Adjustments |
Data Fields
Name | Description | Type | Constraints |
---|---|---|---|
County_FIPS_Code | The 5 digits county Federal Information Processing Standard (FIPS) code | string | - |
State_Abbreviation | Name of state for which risk score is calculated | string | - |
County | County Name for which risk score is calculated | string | - |
FFS_Rate_Current_Year | The Medicare fee for service (FFS) rate; rebasing of Fee-for-Service (FFS) Counties CMS is necessary to rebase FFS county rates at least every three years, and has done so each year since 2012; rebasing is designed to update the county base rates to ensure they reflect spending model across the country for Original Medicare | number | level : Ratio |
IME_Phase_Out_Dollar_Amount_Current_Year | Phase-out of the incremental payments for Indirect Medical Education (IME); IME Phase-out represents phase-out of the incremental payments for IME resulted from including incremental amounts in both the health plans’ premium payments from CMS and the payments made directly to such hospitals by CMS | number | - |
Pre_ACA_Rate_Excludes_Phased_Out_IME_Current_Year | Pre Affordable Care Act Rate Excluding Phased out Indirect Medical Education | number | level : Ratio |
Pre_ACA_Rate_Includes_Phased_Out_IME_Current_Year | Pre Affordable Care Act Rate Including Phased out Indirect Medical Education | number | level : Ratio |
Rate_Category_Current_Year | Specifies whether the Medicare rate category is minimum update or fee-for-service | string | - |
Minimum_Update_Rate_Following_Year | The Minimum Update Rate for the coming year is the current year Pre-ACA Rate including all IME x coming year Adjusted Growth Factor x Risk Score Model Adjustment Factor | number | level : Ratio |
Risk_Score_Model_Adjustment_Factors | Risk Score adjustment factor; a risk score which indicates how costly the enrollee is expected to be relative to the national average beneficiary; the purpose of the risk scores is to adjust MA payments so that they accurately reflect how much each MA enrollee would be expected to cost | number | level : Ratio |
Graduate_Medical_Education_Factor_Following_Year | Graduate medical education expense factor | number | level : Ratio |
DOD_Veterans_Combined_Adjstment_Factor_Following_Year | Combined adjustment the Department of Defense (DOD) eligible beneficiaries and veterans | number | level : Ratio |
Average_Geographic_Adjustment_Factor_Following_Year | Adjustment on geographic regions; the Average Geographic Adjustment (AGA) re-pricing adjusts individual county rates to reflect each county’s historical 5-year rolling average FFS cost relative to the FFS national average | number | level : Ratio |
FFS_Including_All_IME_Following_Year | Rebasing of FFS Counties CMS is necessary to rebase FFS county rates at least every three years, and has done so each year since 2012; FFS Rate including all IME = FFS United States Per Capita Costs (USPCC) x AGA x (1 - GME factor) x (DOD Adjustment Factor + VA Adjustment factor - 1) x Credibility Factor | number | level : Ratio |
Is_Credibility_Adjusted | Credibility adjusted or not | boolean | - |
Credibility_Factors | Credibility factor | number | level : Ratio |
IME_Factor_Following_Year | Indirect medical education factor | number | level : Ratio |
IME_Phase_Out_Factor_Following_Year | The IME phase out factor | number | level : Ratio |
IME_Phase_Out_Dollar_Amount_Following_Year | The IME Phase out amount | number | - |
FFS_Rate_Excluding_Phase_Out_IME_Following_Year | FFS rate excluding phase out IME | number | level : Ratio |
Pre_Affordable_Care_Act_Rate_Excludes_Phased_Out_IME_Following_Year | Pre affordable care act rate excluding phase out IME | number | level : Ratio |
Pre_Affordable_Care_Act_Rate_Category_Following_Year | Pre affordable care act rate category | string | - |
Transition_Years | Number of years | number | level : Ratio |
Quartile_Percent_Factor | Quartile factor in percent | number | level : Ratio |
Is_Urban_Floor_In_2004 | Urban floor or not | boolean | - |
MA_Penetration_Rate_Dec_2009 | Medicare advantage penetration | number | level : Ratio |
Is_MA_Penetration_Is_At_Least_25_Percent | Medicare advantage penetration is at least 25% | boolean | - |
FFS_Rate_Including_Graduate_Medical_Education_Following_Year | The FFS rate including GME | number | level : Ratio |
Is_FFS_Rate_Less_Than_FFS_US_Per_Capita_Cost_Following_Year | FFS rate is less than FFS US per capita cost | boolean | - |
Is_Qualifying_County | County character | boolean | - |
Is_All_Bonus_Rates_Capped | Bonus rates capped; Quality Bonus represents the impact of changes in bonus money associated with Star Quality ratings; for 2015, this also included the impact of the sunset of the Star demonstration program from CMS | boolean | - |
Is_Five_Percent_Bonus_Rate_Capped | Bonus rate capped 5% | boolean | - |
Is_Percent_Rate_Bonus_Capped | Bonus rate capped 3.5% | boolean | - |
Is_Zero_Percent_Bonus_Rate_Capped | Bonus rate 0% capped | boolean | - |
Five_Percent_Bonus_Rate_Following_Year | 5% bonus rate | number | level : Ratio |
Percent_Bonus_Rate_Following_Year | 3.5% bonus rate | number | level : Ratio |
Zero_Percent_Bonus_Rate_Following_Year | 0% bonus rate | number | level : Ratio |
Data Preview
County FIPS Code | State Abbreviation | County | FFS Rate Current Year | IME Phase Out Dollar Amount Current Year | Pre ACA Rate Excludes Phased Out IME Current Year | Pre ACA Rate Includes Phased Out IME Current Year | Rate Category Current Year | Minimum Update Rate Following Year | Risk Score Model Adjustment Factors | Graduate Medical Education Factor Following Year | DOD Veterans Combined Adjstment Factor Following Year | Average Geographic Adjustment Factor Following Year | FFS Including All IME Following Year | Is Credibility Adjusted | Credibility Factors | IME Factor Following Year | IME Phase Out Factor Following Year | IME Phase Out Dollar Amount Following Year | FFS Rate Excluding Phase Out IME Following Year | Pre Affordable Care Act Rate Excludes Phased Out IME Following Year | Pre Affordable Care Act Rate Category Following Year | Transition Years | Quartile Percent Factor | Is Urban Floor In 2004 | MA Penetration Rate Dec 2009 | Is MA Penetration Is At Least 25 Percent | FFS Rate Including Graduate Medical Education Following Year | Is FFS Rate Less Than FFS US Per Capita Cost Following Year | Is Qualifying County | Is All Bonus Rates Capped | Is Five Percent Bonus Rate Capped | Is Percent Rate Bonus Capped | Is Zero Percent Bonus Rate Capped | Five Percent Bonus Rate Following Year | Percent Bonus Rate Following Year | Zero Percent Bonus Rate Following Year |
1000 | AL | AUTAUGA | 971.38 | 10.26 | 1145.66 | 1158.3 | M | 1213.32 | 1.0 | 1.0 | 0.94 | 1014.8 | False | 1.0 | 0.0108 | 1 | 10.96 | 1002.3 | 1200.82 | M | 4 | 1.075 | True | 0.332 | True | 1017.99 | True | True | False | False | False | False | 1177.7 | 1147.63 | 1077.47 | |
1010 | AL | BALDWIN | 923.37 | 5.5 | 1151.87 | 1158.3 | M | 1213.32 | 1.0 | 1.0 | 0.92 | 984.88 | False | 1.0 | 0.006547 | 1 | 6.45 | 977.7 | 1206.14 | M | 4 | 1.15 | True | 0.26899999999999996 | True | 987.23 | True | True | False | True | False | False | 1206.14 | 1192.79 | 1124.36 | |
1020 | AL | BARBOUR | 970.32 | 4.94 | 1055.0 | 1061.65 | M | 1116.92 | 1.0 | 1.01 | 0.95 | 1028.76 | False | 1.0 | 0.006045 | 1 | 6.22 | 1020.64 | 1108.8 | M | 4 | 1.075 | False | 0.2006 | False | 1030.83 | True | False | False | True | True | False | 1108.8 | 1108.8 | 1097.19 | |
1030 | AL | BIBB | 979.05 | 11.49 | 1190.05 | 1204.87 | M | 1245.7 | 0.99 | 1.0 | 0.96 | 1037.08 | False | 1.0 | 0.01223 | 1 | 12.68 | 1021.59 | 1230.21 | M | 6 | 1.075 | True | 0.3559 | True | 1042.01 | True | True | False | False | False | False | 1200.37 | 1169.72 | 1098.21 | |
1040 | AL | BLOUNT | 977.12 | 10.61 | 1140.26 | 1154.8 | M | 1193.08 | 0.99 | 1.02 | 0.95 | 1043.34 | False | 1.0 | 0.010443000000000001 | 1 | 10.9 | 1029.73 | 1179.47 | M | 4 | 1.075 | True | 0.4108 | True | 1048.04 | True | True | False | True | False | False | 1179.47 | 1179.04 | 1106.96 | |
1050 | AL | BULLOCK | 876.68 | 6.76 | 1039.97 | 1048.04 | M | 1097.82 | 1.0 | 0.99 | 0.87 | 929.31 | True | 1.0051139999999998 | 0.00773 | 1 | 7.18 | 921.1 | 1089.61 | M | 2 | 1.15 | False | 0.2436 | False | 931.63 | True | False | False | True | True | False | 1089.61 | 1089.61 | 1059.26 | |
1060 | AL | BUTLER | 921.28 | 6.24 | 1146.1 | 1153.72 | M | 1210.68 | 1.0 | 1.0 | 0.89 | 961.56 | False | 1.0 | 0.007316 | 1 | 7.03 | 953.27 | 1202.39 | M | 2 | 1.15 | False | 0.1446 | False | 963.7 | True | False | False | False | False | False | 1143.92 | 1129.62 | 1096.26 | |
1070 | AL | CALHOUN | 951.49 | 6.13 | 1039.16 | 1048.04 | M | 1097.82 | 1.0 | 1.0 | 0.95 | 1017.59 | False | 1.0 | 0.006813 | 1 | 6.93 | 1008.52 | 1088.75 | M | 2 | 1.075 | False | 0.1275 | False | 1019.81 | True | False | False | True | True | False | 1088.75 | 1088.75 | 1084.16 | |
1080 | AL | CHAMBERS | 812.81 | 4.09 | 1042.73 | 1048.04 | M | 1097.82 | 1.0 | 1.0 | 0.81 | 872.68 | False | 1.0 | 0.00554 | 1 | 4.83 | 866.5 | 1091.64 | M | 2 | 1.15 | False | 0.156 | False | 874.77 | True | False | False | False | False | False | 1039.8 | 1026.8 | 996.47 | |
1090 | AL | CHEROKEE | 969.81 | 11.02 | 1052.31 | 1065.56 | M | 1112.91 | 1.0 | 1.0 | 0.96 | 1038.55 | False | 1.0 | 0.013733 | 1 | 14.26 | 1022.51 | 1096.87 | M | 2 | 1.075 | False | 0.1569 | False | 1042.18 | True | False | True | True | True | True | 1096.87 | 1096.87 | 1096.87 |