CO Medicaid Community Mental Health Services Program Capitation Rate Setting -- 8.215
8.215 COMMUNITY MENTAL HEALTH SERVICES PROGRAM CAPITATION RATE SETTING
8.215.1 DEFINITIONS
Actuary – Individuals who both meet the qualifications of the division of insurance, and who also are Members of the American Academy of Actuaries, and therefore are able to provide for actuarial certification of Medicaid rates in accordance with 42 CFR 438.6(c).
The Department incorporates by reference 42 CFR 438.6(c). No amendments or later additions of this regulation are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and
Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library.
Actuarially sound rates – For a defined population, a per member per month risk capitation amount that meets the requirements of 42 CFR 438.6(c) and is certified as actuarially sound by an actuary acting in his/her professional capacity.
Behavioral health organization – the managed care entity contracting with the Department to provide behavioral health services to Medicaid eligible individuals on a risk contracting basis.
Enrollee – A person who is eligible for mental health services provided for in 10 CCR 2505-10 Section 8.212.4 from a behavioral health organization under a risk contract with the Department.
Independent actuary – An actuary contracted by the Department who has not and will not contract with a Colorado Medicaid provider during the rate setting or rate effective periods and whose employer has not and will not provide actuarial services to a behavioral health organization during the rate setting or rate effective periods.
8.215.2 LEGAL BASIS
The Medicaid community mental health services program is authorized by state law at 25.5-5-411, C.R.S. (2009)
8.215.3 GENERAL PROVISIONS
8.215.3.A. The Department shall make prepaid capitation payments based on actuarially certified rates to behavioral health organizations based upon a scope of services defined in the behavioral health organization contracts.
8.215.3.B. The Department shall contract with an independent actuary to prepare and certify actuarially sound rate ranges.
8.215.3.C. The Department’s contracts with the behavioral health organizations shall contain rates within the actuarially certified rate ranges prepared by the independent actuary.
8.215.3.D. Rates calculations shall include estimates of future utilization of covered services that are:
1. Relevant to the expected or reasonable use of services by the behavioral health organization’s enrollees, and
2. Based upon data that are of sufficient quality for rate setting. 8.215.3.E. To determine a reasonable cost of the service utilization described above in 8.215.3.D, the Department shall establish a price per unit of service. Such pricing:
1. Shall be consistent with the principles of actuarial soundness.
2. May be based upon the Medicaid fee-for-service payment for like services, provider costs, behavioral health organization contracted rates, or other sources.
8.215.3.G. Data used to set rates shall be made available in summary form to any interested stakeholder.
8.215.4 RATE SETTING TIMELINE
8.215.4.A The Department shall publish a rate setting timeline when starting the process of establishing actuarially sound rate ranges.
8.215.4.B. The rate setting timeline shall provide explicitly for stakeholder feedback as part of the rate setting process.
8.215.4.C. The independent actuary shall consider stakeholder feedback.
1. The decision to adopt the stakeholder feedback in the calculations of the actuarially sound rate ranges shall be at the discretion of the independent actuary.
2. Notwithstanding the above, the independent actuary is encouraged to adopt stakeholder feedback when, after consultation with the Department, the feedback provides for better quality or efficiency in the process of calculating actuarially sound rate ranges, and the feedback is consistent with principles of efficiency, economy and actuarial soundness.
8.215.5 CERTIFICATIONS
8.215.5.A. To the extent that the data used in rate setting come from the behavioral health organizations, the behavioral health organization shall provide a certification that the data supplied by the behavioral health organization to the Department are accurate, truthful and represent costs and utilization solely for services covered under the behavioral health organization contract for Medicaid eligible enrollees of that behavioral health organization.
8.215.5.B. In accordance with 25.5-5-404 (k) and prior to entering into a contract with the Department, the behavioral health organization shall certify that the rates set forth in the contract are sufficient to assure the financial stability of the behavioral health organization.
8.215.5.C. In accordance with 25.5-5-404 (l) and prior to entering into a contract with the Department, the behavioral health organization shall retain an actuary to certify that the capitation rates set forth in the contract between the behavioral health organization and the Department comply with all applicable federal and state requirements that govern said capitation payments. This certification must explicitly reference that the capitation rates conform to the federal requirement that rates be actuarially sound.
8.215.6 COST CONTAINMENT MECHANISMS
8.215.6.A. The Department shall establish cost-effective, capitated rates for community mental health services in a manner that includes cost containment mechanisms.
8.215.6.B. The cost containment mechanisms shall be consistent with the principles of actuarial soundness, as determined by the independent actuary.
8.215.6.C. These cost containment mechanisms shall include:
1. Limiting costs and data considered in rate setting to that reasonable based upon enrollees’ need for services within the scope of services in the behavioral health organizations’ contracts.
2. Establishing health status based risk adjusted case rates for a negotiated portion of the actuarially sound capitation rate. Case rates shall be calculated based upon a statewide average cost, providing BHOs an incentive for efficiency relative to peers.
3. Requiring that behavioral health organizations maintain medical loss ratios in excess of 77% of total Medicaid capitations. Medical loss ratios of less than 77% shall result in a refund due the Department in the amount the medical loss is less than that threshold.
8.215.6.D. The Department may, upon consultation and feedback from the behavioral health organizations and the stakeholder community, implement other cost containment mechanisms that it finds necessary to constrain rate growth to a level that is sustainable and appropriate.
8.215.1 DEFINITIONS
Actuary – Individuals who both meet the qualifications of the division of insurance, and who also are Members of the American Academy of Actuaries, and therefore are able to provide for actuarial certification of Medicaid rates in accordance with 42 CFR 438.6(c).
The Department incorporates by reference 42 CFR 438.6(c). No amendments or later additions of this regulation are incorporated. Copies are available for inspection from the following person at the following address: Custodian of Records, Colorado Department of Health Care Policy and
Financing, 1570 Grant Street, Denver, CO 80203. Any material that has been incorporated by reference in this rule may be examined at any state publications depository library.
Actuarially sound rates – For a defined population, a per member per month risk capitation amount that meets the requirements of 42 CFR 438.6(c) and is certified as actuarially sound by an actuary acting in his/her professional capacity.
Behavioral health organization – the managed care entity contracting with the Department to provide behavioral health services to Medicaid eligible individuals on a risk contracting basis.
Enrollee – A person who is eligible for mental health services provided for in 10 CCR 2505-10 Section 8.212.4 from a behavioral health organization under a risk contract with the Department.
Independent actuary – An actuary contracted by the Department who has not and will not contract with a Colorado Medicaid provider during the rate setting or rate effective periods and whose employer has not and will not provide actuarial services to a behavioral health organization during the rate setting or rate effective periods.
8.215.2 LEGAL BASIS
The Medicaid community mental health services program is authorized by state law at 25.5-5-411, C.R.S. (2009)
8.215.3 GENERAL PROVISIONS
8.215.3.A. The Department shall make prepaid capitation payments based on actuarially certified rates to behavioral health organizations based upon a scope of services defined in the behavioral health organization contracts.
8.215.3.B. The Department shall contract with an independent actuary to prepare and certify actuarially sound rate ranges.
8.215.3.C. The Department’s contracts with the behavioral health organizations shall contain rates within the actuarially certified rate ranges prepared by the independent actuary.
8.215.3.D. Rates calculations shall include estimates of future utilization of covered services that are:
1. Relevant to the expected or reasonable use of services by the behavioral health organization’s enrollees, and
2. Based upon data that are of sufficient quality for rate setting. 8.215.3.E. To determine a reasonable cost of the service utilization described above in 8.215.3.D, the Department shall establish a price per unit of service. Such pricing:
1. Shall be consistent with the principles of actuarial soundness.
2. May be based upon the Medicaid fee-for-service payment for like services, provider costs, behavioral health organization contracted rates, or other sources.
8.215.3.G. Data used to set rates shall be made available in summary form to any interested stakeholder.
8.215.4 RATE SETTING TIMELINE
8.215.4.A The Department shall publish a rate setting timeline when starting the process of establishing actuarially sound rate ranges.
8.215.4.B. The rate setting timeline shall provide explicitly for stakeholder feedback as part of the rate setting process.
8.215.4.C. The independent actuary shall consider stakeholder feedback.
1. The decision to adopt the stakeholder feedback in the calculations of the actuarially sound rate ranges shall be at the discretion of the independent actuary.
2. Notwithstanding the above, the independent actuary is encouraged to adopt stakeholder feedback when, after consultation with the Department, the feedback provides for better quality or efficiency in the process of calculating actuarially sound rate ranges, and the feedback is consistent with principles of efficiency, economy and actuarial soundness.
8.215.5 CERTIFICATIONS
8.215.5.A. To the extent that the data used in rate setting come from the behavioral health organizations, the behavioral health organization shall provide a certification that the data supplied by the behavioral health organization to the Department are accurate, truthful and represent costs and utilization solely for services covered under the behavioral health organization contract for Medicaid eligible enrollees of that behavioral health organization.
8.215.5.B. In accordance with 25.5-5-404 (k) and prior to entering into a contract with the Department, the behavioral health organization shall certify that the rates set forth in the contract are sufficient to assure the financial stability of the behavioral health organization.
8.215.5.C. In accordance with 25.5-5-404 (l) and prior to entering into a contract with the Department, the behavioral health organization shall retain an actuary to certify that the capitation rates set forth in the contract between the behavioral health organization and the Department comply with all applicable federal and state requirements that govern said capitation payments. This certification must explicitly reference that the capitation rates conform to the federal requirement that rates be actuarially sound.
8.215.6 COST CONTAINMENT MECHANISMS
8.215.6.A. The Department shall establish cost-effective, capitated rates for community mental health services in a manner that includes cost containment mechanisms.
8.215.6.B. The cost containment mechanisms shall be consistent with the principles of actuarial soundness, as determined by the independent actuary.
8.215.6.C. These cost containment mechanisms shall include:
1. Limiting costs and data considered in rate setting to that reasonable based upon enrollees’ need for services within the scope of services in the behavioral health organizations’ contracts.
2. Establishing health status based risk adjusted case rates for a negotiated portion of the actuarially sound capitation rate. Case rates shall be calculated based upon a statewide average cost, providing BHOs an incentive for efficiency relative to peers.
3. Requiring that behavioral health organizations maintain medical loss ratios in excess of 77% of total Medicaid capitations. Medical loss ratios of less than 77% shall result in a refund due the Department in the amount the medical loss is less than that threshold.
8.215.6.D. The Department may, upon consultation and feedback from the behavioral health organizations and the stakeholder community, implement other cost containment mechanisms that it finds necessary to constrain rate growth to a level that is sustainable and appropriate.