Others titles
- Medicare Advantage Risk Rates For PACE Plans
- Medicare Advantage Risk Rates For Program of All Inclusive Care For the Elderly Plans
Keywords
- Medicare Advantage PACE Plans
- Medicare Health Plans
- PACE Programs
- Medicare Advantage Prescription Drugs Plans
- Medicare Payments
- Medicare Rates
- FFS Rates
- Medicare Risk Scores
- Advantage Payment Rates
Medicare Advantage Risk Rates For PACE Plans
This dataset contains information on Medicare Advantage (MA) risk rates for 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. 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.
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
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 PACE Plans, Medicare Health Plans, PACE Programs, Medicare Advantage Prescription Drugs Plans, Medicare Payments, Medicare Rates, FFS Rates, Medicare Risk Scores, Advantage Payment Rates |
Other Titles | Medicare Advantage Risk Rates For PACE Plans, Medicare Advantage Risk Rates For Program of All Inclusive Care For the Elderly Plans |
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 fee-for-service rate | number | level : Ratio |
Minimum_Update_Rate_Current_Year | number | level : Ratio | |
PACE_Rate_Current_Year | PACE rate | number | level : Ratio |
Rate_Category_Current_Year | Medicare Rate category | string | - |
Minimum_Update_Rate_Following_Year | The following year Minimum Update Rate = current year PACE Rate x current year Adjusted Growth Rate x Risk Score Model | number | level : Ratio |
Risk_Score_Model_Adjustment_Factors | Adjustment for risk score | number | level : Ratio |
Graduate_Medical_Education_Factor_Following_Year | Graduate medical education expense factor | number | level : Ratio |
VADOD_Adjustment_Factor_Following_Year | Veteran affairs adjustment for the Department of Defense (DOD) eligible beneficiaries | number | level : Ratio |
AGA_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 | Adjustment for credibility | boolean | - |
Credibility_Factors | Adjustment factor | number | level : Ratio |
PACE_Rate_Following_Year | PACE rate | number | level : Ratio |
Rate_Category_Following_Year | Medicare rate category | string | - |
Data Preview
County FIPS Code | State Abbreviation | County | FFS Rate Current Year | Minimum Update Rate Current Year | PACE Rate Current Year | Rate Category Current Year | Minimum Update Rate Following Year | Risk Score Model Adjustment Factors | Graduate Medical Education Factor Following Year | VADOD Adjustment Factor Following Year | AGA Factor Following Year | FFS Including All IME Following Year | Is Credibility Adjusted | Credibility Factors | PACE Rate Following Year | Rate Category Following Year |
1000 | AL | AUTAUGA | 974.81 | 1158.3 | 1158.3 | M | 1213.32 | 1.0 | 0.00314 | 0.99887 | 0.94519 | 1015.16 | False | 1.0 | 1213.32 | M |
1010 | AL | BALDWIN | 929.85 | 1158.3 | 1158.3 | M | 1213.32 | 1.0 | 0.00238 | 1.00005 | 0.91707 | 986.87 | False | 1.0 | 1213.32 | M |
1020 | AL | BARBOUR | 972.09 | 1073.64 | 1073.64 | M | 1123.25 | 0.99877 | 0.00201 | 1.00712 | 0.9451200000000001 | 1024.63 | False | 1.0 | 1123.25 | M |
1030 | AL | BIBB | 981.16 | 1186.44 | 1186.44 | M | 1229.41 | 0.9892299999999999 | 0.00473 | 1.0015399999999999 | 0.96857 | 1041.39 | False | 1.0 | 1229.41 | M |
1040 | AL | BLOUNT | 978.98 | 1157.03 | 1157.03 | M | 1195.82 | 0.98666 | 0.00449 | 1.02 | 0.9544799999999999 | 1045.42 | False | 1.0 | 1195.82 | M |
1050 | AL | BULLOCK | 878.74 | 1048.04 | 1048.04 | M | 1097.82 | 1.0 | 0.00249 | 0.99093 | 0.8686200000000001 | 930.62 | True | 1.0049 | 1097.82 | M |
1060 | AL | BUTLER | 921.99 | 1160.93 | 1160.93 | M | 1217.29 | 1.001 | 0.0022199999999999998 | 1.0034 | 0.89018 | 961.3 | False | 1.0 | 1217.29 | M |
1070 | AL | CALHOUN | 957.04 | 1048.04 | 1048.04 | M | 1097.82 | 1.0 | 0.00218 | 0.99713 | 0.9546600000000001 | 1024.53 | False | 1.0 | 1097.82 | M |
1080 | AL | CHAMBERS | 813.07 | 1048.04 | 1048.04 | M | 1097.82 | 1.0 | 0.0023899999999999998 | 1.0045 | 0.8061699999999999 | 871.39 | False | 1.0 | 1097.82 | M |
1090 | AL | CHEROKEE | 972.72 | 1051.24 | 1051.24 | M | 1093.79 | 0.99329 | 0.0034799999999999996 | 1.00443 | 0.96091 | 1037.43 | False | 1.0 | 1093.79 | M |