After the Big Win on Improving Payment Equity for Duals, Where Do We Go From Here? Eric P. Goetsch, FSA, MAAA Dennis J. Hulet, FSA, MAAA John C. Wisniewski, ASA, MAAA, FLMI October 14, 2016

Medicare Advantage Risk Model Update Had Varying Impacts DSNPs ISNPs Full duals saw large increase in risk scores Partial duals saw large decrease in risk scores Overall a big win for duals and DSNPs ISNPs Unexpected large decrease in risk scores Institutional costs became much lower in years between data updates relative to community costs C-SNPs Not specifically impacted by latest major overhaul of risk adjustment October 14, 2016

Medicare-Medicaid Plans Same risk adjuster as regular Medicare Advantage Introduced in 2016 for MMPs, delayed to 2017 for Medicare Advantage Only difference is CMS does not apply the Part C FFS coding intensity adjustment in the first year or two of the dual demos New York only state that specifically risk adjusts the Medicaid payments for MMPs Using functional-based risk adjustment from existing managed LTC program Most states use CDPS to risk adjust their acute care programs October 14, 2016

PACE Specifically excluded from MA payment reform and MA quality bonus program Still being paid using pre-PPACA benchmarks and prior risk adjustment system Frailty adjustment made based on dual status and number of ADLs Risk scores based purely on diagnosis data; exempted from encounter data being incorporated into the risk scores October 14, 2016

FIDE SNP Same risk model as Medicare Advantage Incorporates frailty adjuster found in PACE model October 14, 2016

Questions October 14, 2016

Thank You! October 14, 2016