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    PROPOSAL
    Maryland Register
    Issue Date:  December 9, 2016
    Volume 43 • Issue 25• Pages 1394—1398
     
    Title 10
    DEPARTMENT OF HEALTH AND MENTAL HYGIENE
    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
    [16-327-P]
    The Secretary of Health and Mental Hygiene 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 repeal the calendar year 2015 HealthChoice MCO’s rates, to implement the calendar year 2017 HealthChoice MCO’s rates and to clarify the interim rate adjustment methodology.
    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 2016, MCO interim rate adjustment is an overall increase of $23,393,246. This was primarily the result of increasing physician fees to 94 percent of Medicare rates, adjusting for HSCRC hospital rate changes and the redetermination impact.
    The HealthChoice CY 2017 MCO rate adjustment is an increase of $109,202,607 above the appropriation or a 1.0 percent rate increase. This increase includes an observed medical trend increase of 2.8 percent overall.
    The combined total related to the MCO CY 2016 Interim rate adjustment of $23,393,246 and the CY 2017 rate increase of $109,202,607 is $132,595,853.
     
     
    Revenue (R+/R-)
     
    II. Types of Economic Impact.
    Expenditure (E+/E-)
    Magnitude
     

     
    A. On issuing agency:
    (E+)
    $132,595,853
    B. On other State agencies:
    NONE
    C. On local governments:
    NONE
     
     
    Benefit (+)
    Cost (-)
    Magnitude
     

     
    D. On regulated industries or trade groups:
    (+)
    $132,595,853
    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 2016 the interim rate adjustment is an overall increase of $23,393,246 in general funds.
    For CY 2017, there is a 1.0 percent rate increase or $109,202,607 increase to the Department’s expenses.
    D. For CY 2016 the interim rate adjustment is an overall increase of $23,393,246 in general funds.
    For CY 2017, there is a 1.0 percent rate increase or $109,202,607 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, Department of Health and Mental Hygiene, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499 (TTY 800-735-2258), or email to dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through January 9, 2017. 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)—(h)] (proposed for repeal)
    (a) Rate Table for Families and Children Effective January 1, 2017 — December 31, 2017.
     
    Age/RAC
    Gender
    PMPM Baltimore City
    PMPM Montgomery County
    PMPM Rest of State
     
    Under age 1 Birth Weight 1500 grams or less
    Both
    $9,079.56
    $8,246.40
    $8,469.74
     
    Under age 1 Birth Weight over 1500 grams
    Both
    $516.80
    $469.38
    $482.09
     
    1-5
    Male
    $199.52
    $181.21
    $186.12
     
     
    Female
    $169.36
    $153.82
    $157.98
     
    6-14
    Male
    $108.93
    $98.93
    $101.61
     
     
    Female
    $99.99
    $90.82
    $93.28
     
    15-20
    Male
    $116.34
    $105.67
    $108.53
     
     
    Female
    $160.01
    $145.32
    $149.26
     
    21-44
    Male
    $237.39
    $182.28
    $200.17
     
     
    Female
    $364.91
    $280.20
    $307.70
     
    45-64
    Male
    $494.42
    $379.64
    $416.90
     
     
    Female
    $562.02
    $431.54
    $473.90
    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
    $234.90
    $180.37
    $198.07
    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
    $376.44
    $289.05
    $317.42
    ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820  
    RAC 3F
    Both
    $523.51
    $401.98
    $441.43
    ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040  
    RAC 4F
    Both
    $722.68
    $554.91
    $609.38
     
    ACG 4430, 4730, 4930, 5030, 5050
    RAC 5F
    Both
    $957.37
    $735.12
    $807.28
    ACG 4940, 5060  
    RAC 6F
    Both
    $1,263.62
    $970.27
    $1,065.51
    ACG 5070  
    RAC 7F
    Both
    $1,962.90
    $1,507.21
    $1,655.16
    ACG 100, 200, 300, 500, 600, 1100, 1600, 2000, 2400, 3400, 5100, 5110, 5200  
    RAC 1G
    Both
    $86.50
    $78.56
    $80.69
    ACG 400, 700, 900, 1000, 1200, 1300, 1710, 1711, 1712, 1800, 1900, 2100, 2200, 2300, 2800, 2900, 3000, 3100, 5310  
    RAC 2G
    Both
    $111.43
    $101.21
    $103.95
    ACG 1720, 1721, 1722, 1731, 1732, 1730, 2500, 3200, 3300, 3500, 3800, 4210, 5230, 5339  
    RAC 3G
    Both
    $144.82
    $131.53
    $135.09
    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
    $198.35
    $180.14
    $185.02
    ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820  
    RAC 5G
    Both
    $306.82
    $278.67
    $286.21
    ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040  
    RAC 6G
    Both
    $349.10
    $317.07
    $325.65
    ACG 4430, 4730, 4930,4940, 5030, 5050, 5060, 5070  
    RAC 7G
    Both
    $885.12
    $803.90
    $825.67
    SOBRA Mothers  
     
     
    $850.46
    $653.02
    $717.12  
    Persons with HIV
    ALL
    Both
    $648.67
    $648.67
    $648.67
     
    (b) Rate Table for Disabled Individuals Effective January 1, 2017—December 31, 2017.
     
     
    Age/RAC
    Gender
    PMPM   Baltimore   City
    PMPM Montgomery County
    PMPM Rest   of State
     
    Under Age 1
    Both
    $6,465.12
    $6,465.12
    $6,465.12
     
    1-5
    Male
    $1,664.34
    $1,664.34
    $1,664.34
     
     
    Female
    $1,444.43
    $1,444.43
    $1,444.43
     
    6-14
    Male
    $311.82
    $311.82
    $311.82
     
     
    Female
    $546.20
    $546.20
    $456.20
     
    15-20
    Male
    $225.06
    $225.06
    $225.06
     
     
    Female
    $326.94
    $326.94
    $326.94
     
    21-44
    Male
    $856.35
    $726.80
    $793.46
     
     
    Female
    $1,160.01
    $984.52
    $1,074.82
     
    45-64
    Male
    $1,942.90
    $1,648.96
    $1,800.21
     
     
    Female
    $1,808.14
    $1,534.59
    $1,675.35
    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
    $281.02
    $238.50
    $260.38
    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
    $339.48
    $288.12
    $314.55
    ACG 600, 1760, 1761, 1762, 3600, 3700, 4100, 4320, 4410, 4710, 4810, 4820  
    RAC 12
    Both
    $658.09
    $558.53
    $609.76
    ACG 3800, 4210, 4220, 4330, 4420, 4720, 4910, 5320  
    RAC13
    Both
    $748.80
    $635.51
    $693.80
    ACG 800, 4430, 4510, 4610, 5040, 5340  
    RAC14
    Both
    $931.42
    $790.51
    $863.02
    ACG 1770, 1771, 1772, 4520, 4620, 4830, 4920, 5050  
    RAC15
    Both
    $1,265.48
    $1,074.03
    $1,172.54
    ACG 4730, 4930, 5010  
    RAC16
    Both
    $1,344.28
    $1,140.90
    $1,245.55
    ACG 4940, 5020, 5060  
    RAC17
    Both
    $1,967.45
    $1,669.79
    $1,822.95
    ACG 5030, 5070  
    RAC 18
    Both
    $3,491.82
    $2,963.55
    $3,235.37
    Persons with AIDS  
    All
    Both
    $2,229.83
    $1,259.72
    $1,259.72
    Persons with HIV
    All
    Both
    $1,860.15
    $1,860.15
    $1,860.15
     
    (c) Rate Table for Supplemental Payments for Delivery/Newborn and Hepatitis C Therapy Effective January 1, 2017—December 31, 2017.
     
     
    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  
    All
    Both
    $13,946.08
    $10,543.25
    $11,299.98
    Delivery/Newborn-live birth weight 1,500 grams or less
    All
    Both
    $69,697.48
    $69,697.48
    $69,697.48
    Delivery/Newborn by same enrollee-subsequent live birth weight 1,500 grams or less
    All
    Both
    $13,946.08
    $10,543.25
    $11,299.98
    Hepatitis C Therapy (per member per month)
    All
    Both
    $30,527.57
    $30,527.57
    $30,527.57
     
    (d) Rate Table for Childless Adult Population Effective January 1, 2017—December 31, 2017.
     
     
    Age/RAC
    Gender
    PMPM Baltimore City
    Montgomery County
    PMPM Rest of State
     
    19-44
    Male
    $504.81
    $349.55
    $472.77
     
    19-44
    Female
    $627.27
    $434.35
    $587.45
     
    45-64
    Male
    $989.05
    $684.86
    $926.27
     
    45-64
    Female
    $996.05
    $689.71
    $932.88
    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
    $230.96
    $159.93
    $216.31
    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
    $426.45
    $295.30
    $399.39
    ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820
    RAC 3H
    Both
    $674.07
    $466.76
    $631.29
    ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040
    RAC 4H
    Both
    $717.46
    $496.80
    $671.93
    ACG 4430, 4730, 4930, 5030, 5050
    RAC 5H
    Both
    $920.66
    $637.50
    $862.23
    ACG 4940, 5060
    RAC 6H
    Both
    $1,177.86
    $815.60
    $1,103.10
    ACG 5070
    RAC 7H
    Both
    $1,690.20
    $1,170.37
    $1,582.93
    HIV
    19-64
    Both
    $835.92
    $835.92
    $835.92
    [(i)] (e)—[l] (h) (text unchanged)
    (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, [2015] 2017, an increase or decrease in the [preliminary current year Statewide Medicaid MCO] inpatient hospital per capita as calculated [using data provided annually by the Health Services Cost Review Commission (HSCRC) during the agreed on rate setting timeline as compared to the data originally available relative to the Statewide HSCRC derived inpatient all-payer per capita and updated information for the prior period years; or] 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 [preliminary current year Statewide Medicaid MCO] outpatient hospital per capita as calculated [using data provided annually by the Health Services Cost Review Commission during the agreed on rate setting timeline as compared to the data originally available relative to the Statewide HSCRC derived outpatient all-payer per capita and updated information for prior period years] 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.
    (3)—(6) (text unchanged)
    VAN T. MITCHELL
    Secretary of Health and Mental Hygiene