PROPOSAL
Maryland Register
Issue Date: January 5, 2018
Volume 45• Issue 1 • Pages 24—28
Title 10
MARYLAND DEPARTMENT OF HEALTH
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations
Authority: Health-General Article, §§2-104, 15-102.3, and 15-103; Insurance Article, §§15-112, 15-605, and 15-1008; Annotated Code of Maryland
Notice of Proposed Action
[18-005-P]
The Secretary of Health proposes to amend Regulation .19 under COMAR 10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations.
Statement of Purpose
The purpose of this action is to implement to the calendar year 2018 HealthChoice MCO’s rates.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
I. Summary of Economic Impact. The HealthChoice CY 2018 MCO rate adjustment is an increase of $54,656,699 above the FY 2018 appropriation or a 1.0 percent rate increase.
|
Revenue (R+/R-) |
|
II. Types of Economic Impact. |
Expenditure (E+/E-) |
Magnitude |
|
|
|
|
|
A. On issuing agency: |
(E+) |
$54,656,699 |
B. On other State agencies: |
NONE |
|
C. On local governments: |
NONE |
|
|
|
Benefit (+) Cost (-) |
Magnitude |
|
|
|
|
|
D. On regulated industries or trade groups: |
(+) |
$54,656,699 |
E. On other industries or trade groups: |
NONE |
|
F. Direct and indirect effects on public: |
NONE |
|
III. Assumptions. (Identified by Impact Letter and Number from Section II.) |
A. For CY 2018, there is a 1.0 percent rate increase or $54,656,699 increase to the Department’s expenses. |
D. For CY 2018, there is a 1.0 percent rate increase or $54,656,699 increase to the MCOs revenue. |
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499; TTY:800-735-2258, or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through February 5, 2018. A public hearing has not been scheduled.
.19 MCO Reimbursement.
A. (text unchanged)
B. Capitation Rate-Setting Methodology.
(1)—(3) (text unchanged)
(4) Except to the extent of adjustments required by §D of this regulation or by Regulations .19-1—.19-4 of this chapter, the Department shall make payments monthly at the rates specified in the following tables:
[(a)—(d)] (proposed for repeal)
(a) Rate Table for Families and Children Effective January 1, 2018 — December 31, 2018
|
Age/RAC |
Gender |
PMPM Baltimore City |
PMPM Montgomery County |
PMPM Rest of State |
|
Under age 1Birth Weight 1500 grams or less |
Both |
$9,987.05 |
$8,901.86 |
$9,187.53 |
|
Under age 1 Birth Weight over 1500 grams |
Both |
$471.18 |
$419.98 |
$433.46 |
|
1—5 |
Male |
$204.70 |
$182.45 |
$188.31 |
|
|
Female |
$181.00 |
$161.33 |
$166.51 |
|
6—14 |
Male |
$113.50 |
$101.17 |
$104.42 |
|
|
Female |
$109.36 |
$97.47 |
$100.60 |
|
15—0 |
Male |
$127.07 |
$113.27 |
$116.90 |
|
|
Female |
$166.02 |
$147.98 |
$152.73 |
|
21—44 |
Male |
$239.70 |
$194.36 |
$208.17 |
|
|
Female |
$367.45 |
$297.95 |
$319.12 |
|
45—64 |
Male |
$497.75 |
$403.60 |
$432.28 |
|
|
Female |
$575.16 |
$466.37 |
$499.51 |
ACG-adjusted cells |
|
|
|
|
|
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339 |
RAC 1F |
Both |
$240.89 |
$195.33 |
$209.21 |
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340 |
RAC 2F |
Both |
$392.90 |
$318.59 |
$341.22 |
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820 |
RAC 3F |
Both |
$517.22 |
$410.39 |
$449.19 |
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040 |
RAC 4F |
Both |
$725.53 |
$588.30 |
$630.10 |
ACG 4430, 4730, 4930, 5030, 5050 |
RAC 5F |
Both |
$1,017.64 |
$825.17 |
$883.79 |
ACG 4940, 5060 |
RAC 6F |
Both |
$1,289.01 |
$1,045.21 |
$1,119.46 |
ACG 5070 |
RAC 7F |
Both |
$1,985.36 |
$1,609.85 |
$1,724.22 |
ACG 100, 200, 300, 500, 600, 1100, 1600, 2000, 2400, 3400, 5100, 5110, 5200 |
RAC 1G |
Both |
$90.62 |
$80.78 |
$83.37 |
ACG 400, 700, 900, 1000, 1200, 1300, 1710, 1711, 1712, 1800, 1900, 2100, 2200, 2300, 2800, 2900, 3000, 3100, 5310 |
RAC 2G |
Both |
$116.07 |
$103.46 |
$106.78 |
ACG 1720, 1721, 1722, 1731, 1732, 1730, 2500, 3200, 3300, 3500, 3800, 4210, 5230, 5339 |
RAC 3G |
Both |
$149.48 |
$133.24 |
$137.51 |
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340 |
RAC 4G |
Both |
$206.92 |
$184.33 |
$190.35 |
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820 |
RAC 5G |
Both |
$324.44 |
$289.19 |
$298.47 |
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040 |
RAC 6G |
Both |
$392.02 |
$349.42 |
$360.04 |
ACG 4430, 4730, 4930,4940, 5030, 5050, 5060, 5070 |
RAC 7G |
Both |
$945.69 |
$842.93 |
$869.98 |
SOBRA Mothers |
|
|
$849.58 |
$688.89 |
$737.83 |
Persons with HIV |
ALL |
Both |
$652.47 |
$652.47 |
$652.47 |
(b) Rate Table for Disabled Individuals Effective January 1, 2018—December 31, 2018
|
Age/RAC |
Gender |
PMPM Baltimore City |
PMPM Montgomery County |
PMPM Rest of State |
|
Under Age 1 |
Both |
$7,898.31 |
$7,898.31 |
$7,898.31 |
|
1—5 |
Male |
$1,759.19 |
$1,759.19 |
$1,759.19 |
|
|
Female |
$909.25 |
$909.25 |
$909.25 |
|
6—14 |
Male |
$322.27 |
$322.27 |
$322.27 |
|
|
Female |
$410.32 |
$410.32 |
$410.32 |
|
15—20 |
Male |
$223.20 |
$223.20 |
$223.20 |
|
|
Female |
$256.31 |
$256.31 |
$256.31 |
|
21—44 |
Male |
$689.95 |
$603.17 |
$607.00 |
|
|
Female |
$907.12 |
$793.3 |
$798.07 |
|
45—64 |
Male |
$1,848.47 |
$1,616.00 |
$1,626.26 |
|
45—64 |
Female |
$1,815.23 |
$1,586.94 |
$1,597.01 |
ACG-adjusted cells |
|
|
|
|
|
ACG 100, 200, 300, 1100, 1300, 1400, 1500, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1900, 2400, 2600, 2900, 3400, 5100, 5110, 5200, 5310 |
RAC 10 |
Both |
$304.32 |
$266.05 |
$267.74 |
ACG 400, 500, 700, 900, 1000, 1200, 1740, 1741, 1742, 1750, 1751, 1752 1800, 2000, 2100, 2200, 2300, 2500, 2700, 2800, 3000, 3100, 3200, 3300, 3500, 3900, 4000, 4310, 5330 |
RAC 11 |
Both |
$343.20 |
$300.04 |
$301.94 |
ACG 600, 1760, 1761, 1762, 3600, 3700, 4100, 4320, 4410, 4710, 4810, 4820 |
RAC 12 |
Both |
$695.13 |
$607.70 |
$611.56 |
ACG 3800, 4210, 4220, 4330, 4420, 4720, 4910, 5320 |
RAC 13 |
Both |
$788.52 |
$689.35 |
$693.73 |
ACG 800, 4430, 4510, 4610, 5040, 5340 |
RAC 14 |
Both |
$1,066.84 |
$932.67 |
$938.59 |
ACG 1770, 1771, 1772, 4520, 4620, 4830, 4920, 5050 |
RAC 15 |
Both |
$1,356.31 |
$1,185.73 |
$1,193.26 |
ACG 4730, 4930, 5010 |
RAC 16 |
Both |
$1,404.91 |
$1,228.22 |
$1,236.01 |
ACG 4940, 5020, 5060 |
RAC 17 |
Both |
$2,089.06 |
$1,826.33 |
$1,837.93 |
ACG 5030, 5070 |
RAC 18 |
Both |
$3,853.42 |
$3,368.79 |
$3,390.18 |
Persons with AIDS |
All |
Both |
$2,081.63 |
$1,422.67 |
$1,422.67 |
Persons with HIV |
All |
Both |
$1,973.79 |
$1,973.79 |
$1,973.79 |
(c) Rate Table for Supplemental Payments for Delivery/Newborn and Hepatitis C Therapy Effective January 1, 2018—December 31, 2018
|
Age |
Gender |
Baltimore City |
Montgomery County |
Rest of State |
Supplemental Payment Cells |
|
|
|
|
|
Delivery/Newborn-all births except live birth weight 1,500 grams or less and gestational age of 21 weeks or more |
All |
Both |
$16,277.91 |
$12,494.41 |
$13,533.35 |
Delivery/Newborn-live birth weight 1,500 grams or less and a gestational age of 21 weeks or more |
All |
Both |
$86,874.19 |
$86,874.19 |
$86,874.19 |
Delivery/Newborn by same enrollee-subsequent live birth weight 1,500 grams or less with a gestational age less than 21 weeks or does not meet the requirements in §B.(4)(i) of this regulation |
All |
Both |
$16,277.91 |
$12,494.41 |
$13,533.35 |
Hepatitis C Therapy 98% payment |
All |
Both |
$26,312.06 |
$26,312.06 |
$26,312.06 |
Hepatitis C 8 week treatment PMPM |
All |
Both |
$1,073.96 |
$1,073.96 |
$1,073.96 |
Hepatitis C 12 week treatment PMPM |
All |
Both |
$1,610.94 |
$1,610.94 |
$1,610.94 |
Hepatitis C 24 week treatment PMPM |
All |
Both |
$3,221.88 |
$3221.88 |
$3221.88 |
Hepatitis C 48 week treatment PMPM |
All |
Both |
$6,443.76 |
$6,443.76 |
$6,443.76 |
Hepatitis C 12-24 week treatment PMPM |
All |
Both |
$1,610.94 |
$1,610.94 |
$1,610.94 |
Hepatitis C 12 week retreatment PMPM |
All |
Both |
$1,610.94 |
$1,610.94 |
$1,610.94 |
Hepatitis C 24 week retreatment PMPM |
All |
Both |
$3,221.88 |
$3,221.88 |
$3,221.88 |
Hepatitis C 48 week retreatment PMPM |
All |
Both |
$6,443.76 |
$6,443.76 |
$6,443.76 |
Hepatitis C 12-24 week retreatment PMPM |
All |
Both |
$1,610.94 |
$1,610.94 |
$1,610.94 |
Hepatitis C SVR Runout |
All |
Both |
$536.98 |
$536.98 |
$536.98 |
(d) Rate Table for Childless Adult Population Effective January 1, 2018—December 31, 2018
|
Age/RAC |
Gender |
PMPM Baltimore City |
Montgomery County |
PMPM Rest of State |
|
19—44 |
Male |
$355.45 |
$275.16 |
$316.05 |
|
19—44 |
Female |
$406.33 |
$314.58 |
$361.30 |
|
45—64 |
Male |
$933.15 |
$768.90 |
$883.08 |
|
45—64 |
Female |
$859.44 |
$665.38 |
$764.19 |
ACG-adjusted cells |
|
|
|
|
|
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339 |
RAC 1H |
Both |
$323.87 |
$250.74 |
$287.97 |
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340 |
RAC 2H |
Both |
$490.76 |
$379.95 |
$436.37 |
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820 |
RAC 3H |
Both |
$514.21 |
$398.10 |
$457.22 |
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040 |
RAC 4H |
Both |
$876.30 |
$678.44 |
$779.18 |
ACG 4430, 4730, 4930, 5030, 5050 |
RAC 5H |
Both |
$1,110.13 |
$1,859.46 |
$987.09 |
ACG 4940, 5060 |
RAC 6H |
Both |
$1,426.39 |
$1,104.32 |
$1,268.31 |
ACG 5070 |
RAC 7H |
Both |
$2,278.39 |
$1,763.94 |
$2,025.88 |
HIV |
19-64 |
Both |
$591.40 |
$591.40 |
$591.41 |
(e)—(h) (text unchanged)
(i) An MCO is eligible to receive the subsequent very low birth weight payment in §B(4)(c) of this regulation if the mother:
(i) Had a prior spontaneous preterm delivery;
(ii) Has a current singleton pregnancy;
(iii) Is eligible to receive hydroxyprogesterone caproate;
(iv) Has received the first hydroxyprogesterone caproate injection between 16 weeks gestation and 24 weeks gestation and continued receiving injections until delivery or week 37 gestation; and
(v) Has received at least 2 hydroxyprogesterone caproate injections.
(5) (text unchanged)
C. (text unchanged)
D. Interim Rates Adjustments.
(1) (text unchanged)
(2) The Department shall adjust the payment rates specified in §B(4)(a)—(d) of this regulation to reflect service cost changes that qualify under §D(3) of this regulation and result from:
(a)—(b) (text unchanged)
[(c) Effective January 1, 2017, an increase or decrease in the inpatient hospital per capita as calculated by the multiplication of:
(i) The change in the restated unit cost provided annually by the Health Service Cost Review Commission (HSCRC) as compared to the data originally provided; and
(ii) The change in the restated recommended utilization, adjusted for case mix, position of the Department’s rate certifying actuary as compared to the originally provided utilization position; or
(d) An increase or decrease in the outpatient hospital per capita as calculated by the multiplication of:
(i) The change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided; and
(ii) The change in the restated recommended utilization, adjusted for case mix, position of the Department’s rate certifying actuary as compared to the originally provided utilization position; or
(e) Other changes or circumstances the Department determines are necessary to ensure the rates are actuarially sound.]
(c) An increase or decrease in the inpatient charge per case as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided; or
(d) An increase or decrease in the outpatient charge per visit as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided.
(3)—(6) (text unchanged)
DENNIS SCHRADER
Secretary of Health