Medicare Advantage Risk Rates For PACE Plans

$179 / year

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.

Complexity

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

Date Created

2016-04-04

Last Modified

2020-04-05

Version

2020-04-05

Update Frequency

Annual

Temporal Coverage

2016-2020

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

NameDescriptionTypeConstraints
Current_YearThe year to which the risk score is calculateddate-
Following_YearThe coming year, to which the calculated values are provideddate-
County_FIPS_CodeThe 5 digits county Federal Information Processing Standard (FIPS) codestring-
State_AbbreviationName of state for which risk score is calculatedstring-
CountyCounty name for which risk score is calculatedstring-
FFS_Rate_Current_YearThe fee-for-service ratenumberlevel : Ratio
Minimum_Update_Rate_Current_Yearnumberlevel : Ratio
PACE_Rate_Current_YearPACE ratenumberlevel : Ratio
Rate_Category_Current_YearMedicare Rate categorystring-
Minimum_Update_Rate_Following_YearThe following year Minimum Update Rate = current year PACE Rate x current year Adjusted Growth Rate x Risk Score Modelnumberlevel : Ratio
Risk_Score_Model_Adjustment_FactorsAdjustment for risk scorenumberlevel : Ratio
Graduate_Medical_Education_Factor_Following_YearGraduate medical education expense factornumberlevel : Ratio
DOD_Adjustment_Factor_Following_YearAdjustment for the Department of Defense (DOD) eligible beneficiariesnumberlevel : Ratio
Veteran_Affairs_Adjustment_Factor_Following_YearAdjustment for veteransnumberlevel : Ratio
DOD_Veterans_Combined_Adjstment_Factor_Following_YearCombined adjustment the Department of Defense (DOD) eligible beneficiaries and veteransnumberlevel : Ratio
Average_Geographic_Adjustment_Factor_Following_YearAdjustment for geographic regionnumberlevel : Ratio
FFS_Rate_Including_All_IME_Following_YearFFS rate including the indirect medical educationnumberlevel : Ratio
Is_Credibility_AdjustedAdjustment for credibilityboolean-
Credibility_FactorsAdjustment factornumberlevel : Ratio
PACE_Rate_Following_YearPACE ratenumberlevel : Ratio
Rate_Category_Following_YearMedicare rate categorystring-
Current YearFollowing YearCounty FIPS CodeState AbbreviationCountyFFS Rate Current YearMinimum Update Rate Current YearPACE Rate Current YearRate Category Current YearMinimum Update Rate Following YearRisk Score Model Adjustment FactorsGraduate Medical Education Factor Following YearDOD Adjustment Factor Following YearVeteran Affairs Adjustment Factor Following YearDOD Veterans Combined Adjstment Factor Following YearAverage Geographic Adjustment Factor Following YearFFS Rate Including All IME Following YearIs Credibility AdjustedCredibility FactorsPACE Rate Following YearRate Category Following Year
201820191000ALAutauga779.91920.62920.62Minimum update975.211.00.00250.99670.9187813.91False1.0975.21Minimum update
201820191010ALBaldwin757.88920.62920.62Minimum update975.211.00.00161.00270.9018804.44False1.0975.21Minimum update
201820191020ALBarbour740.21864.32864.32Minimum update908.970.99280.00121.01230.8729786.36False1.0908.97Minimum update
201820191030ALBibb779.78948.14948.14Minimum update1003.630.99930.00441.00410.9327830.84False1.01003.63Minimum update
201820191040ALBlount778.12958.22958.22Minimum update1004.460.98960.0061.01050.9128816.95False1.01004.46Minimum update
201820191050ALBullock696.49832.98832.98Minimum update882.381.00.00181.00890.8411754.79False1.0882.38Minimum update
201820191060ALButler771.38901.4901.4Minimum update959.181.00450.00191.00030.9026802.97False1.0959.18Minimum update
201820191070ALCalhoun775.0832.98832.98Minimum update882.381.00.00220.99340.9042798.67False1.0882.38Minimum update
201820191080ALChambers665.5832.98832.98Minimum update882.381.00.00131.00450.7715689.66False1.0882.38Minimum update
201820191090ALCherokee789.91846.66846.66Minimum update883.670.98530.00271.00650.9155818.79False1.0883.67Minimum update