1. 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

2. 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

3. 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

4. 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

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

6. Questions
October 14, 2016

7. Thank You!
October 14, 2016