MCO Funds Flow Visual-Current

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Presentation transcript:

MCO Funds Flow Visual-Current HCA MCO Actuarially-sound Per Member Per Month Premium/Rate Primary Care Provider Hospital Specialty Care Provider Deliver Medicaid State Plan Services to Medicaid Beneficiaries $ $ per service Mental Health Provider Pharmacy Benefit <<LL – I think we could merge the Finance & Data/Technology slides into 1>>

Experience + Age/Gender + Risk + Geography + Enhancements = Premium MLR – Medical Loss Ratio Percent of premium spent on medical Generally, services that are claim based Primary care, facility, specialty care, pharmacy, behavioral health Encounter data requirements Some services can be re-classified as medical within contract constraints MLR IOI SG&A SG&A – Sales, General and Administrative Percent of premium for administration Assumed load is set % for rate setting 8.5% for AH Family, SCHIP 6.55% for AH BD Examples: Enrolling members, paying claims, ID cards, member/provider services IOI – Internal Operating Income i.e. Profit Limited by Gain Share Program in contract 3-5% requires 50% payback >5% requires 100% payback

HCP-LAN VBP Spectrum

Value Based Contracting Fee For Service (FFS) Payment for services rendered FFS with Gain Share Payment for services rendered Quality metrics MLR Threshold Distribution of funds when below threshold and quality metrics met FFS with Shared Risk Payment for services rendered Quality metrics MLR Threshold Distribution of funds when below threshold and quality metrics met Withhold when above threshold Full Risk Capitation Payment as a percent of premium or PMPM Quality metrics Sometimes delegation Service Based Value Based

BHO Funds Flow Visual-Current HCA/DSHS BHO Actuarially-sound Per Member Per Month Premium/Rate Serious Mental Illness Provider Substance Use Disorder Provider SMI & SUD Provider Deliver Medicaid State Plan Services for Serious Mental Illness and Substance Use Disorder to Medicaid Beneficiaries $ Crisis Services <<LL – I think we could merge the Finance & Data/Technology slides into 1>> I added the language about MCOs being contracted for the full continuum of physical health; note: long term care, dental, SUD, and MH for SMI/SED carved out.

Detailed HCP-LAN VBP Spectrum