Health Watch 2013 Payment Reform

Question 1

Financial alignment demonstrations

Capitation development

Answer 1

1. The calculation process (excluding Part D)
   
   1. 1 projected baseline costs in absence of the demonstration
   2. 2 apply savings percentages
   3. 3 apply withhold percentages
   4. 4 apply any prospective risk adjustment mechanisms
   5. 5 apply any retrospective risk mitigation mechanisms
2. Plans will receive three separate payments
   
   2. 1 Medicare Part A/B - the baseline projection will blend projections for individuals moving from Medicare FFs and those moving from Medicare Advantage
   3. 2 Medicaid
      
      2. 2.1 For states that currently include dual eligibles in their Medicaid MC programs, the baseline projection represents Mc capitation rates
      3. 2.2 for other states, the baseline projection represents historical FFs experience projected to the appropriate time period
3. 3 Part D: the capitation rate will be set at national average bid amount each year

Question 2

Capitated model:

1. Sources of cost savings
2. Savings development process

Answer 2

1. Source of savings
   
   1. 1 acute care
   2. 2 Behavioral health
   3. 3 Long-term care
   4. 4 Administrative costs
2. Savings development process
   
   2. 1 CMS provides savings calculations to each state
   3. 2 The savings percentages may vary by state
   4. 3 savings percentages expected to increase each year
   5. 4 the same savings % will be applied to Part A/B and Medicaid components

Question 3

Discuss ACA Financial Alignment Demonstrations

Answer 3

1. Capitated Model
   
   1. 1 includes a three-way contract between the state, CMS and participated health plans
   2. 2 the health plan receives prospective capitation that reflects anticipated program savings allowing the state and CMS to share in anticipated savings up front
   3. 3 health plan is responsible for care for Medicare and Medicaid benefits
2. Managed Fee-For-Service (FFS) model
   
   2. 1 The state is responsible for coordinating care for dual eligibles
   3. 2 the state will share in overall Federal savings on a retrospective basis