Md. Code Regs. 10.67.04.19-1

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.67.04.19-1 - MCO-Specific Case Mix Adjustment for HIV and AIDS with Hepatitis C

A. To reflect the higher level of risk associated with providing covered health care services pursuant to COMAR 10.67.67 to HIV/AIDS enrollees who also have Hepatitis C, the Department shall, to the extent provided by this regulation, make MCO-specific adjustments to payments for enrollees in HIV and AIDS payment categories to reflect the proportion of an MCO's HIV/AIDS enrollees who also have Hepatitis C.

B. Identification of HIV/AIDS Enrollees with Hepatitis C.

(1) For each MCO, the Department shall consider historical encounter and fee-for-service data for enrollees assigned to HIV and AIDS payment categories:

(a) For the initial assessment period, as of June of the calendar year before the rate year; and

(b) For the mid-year assessment period, as of December of the calendar year before the rate year.

(2) For each MCO, the Department shall determine which of the HIV/AIDS enrollees meeting the criteria set forth in §B(1) of this regulation also have Hepatitis C.

(3) The Department shall use encounter and fee-for-service data documenting services provided to the HIV/AIDS enrollees identified in accordance with §B(1) of this regulation for the appropriate historical diagnostic period:

(a) For the initial assessment period, through June of the calendar year before the rate year; and

(b) For the mid-year assessment period, through December of the calendar year before the rate year.

C. Methodology for Determining MCO-specific HIV and AIDS Case Mix Measures. For each MCO, the Department shall:

(1) Based on encounter and fee-for-service data from the appropriate historical diagnostic period, classify the MCO's HIV/AIDS enrollees identified pursuant to §B of this regulation as either:

(a) Hepatitis C-infected; or

(b) Hepatitis C-uninfected.

(2) Average relative value for HIV and AIDS payment categories are as follows:

(a) Apply weights reflecting costs associated with Hepatitis C-infected and Hepatitis C-uninfected enrollees in each HIV and AIDS payment category to the MCO-specific distribution of HIV/AIDS enrollees who are Hepatitis C-infected or Hepatitis C-uninfected, as determined pursuant to §C(1) of this regulation; and

(b) For each MCO, use the results of the calculations specified in §C(2)(a) of this regulation to separately calculate an average relative value for each of the HIV and AIDS payment categories.

(3) To determine an MCO's relative case mix factors, each MCO's relative values determined pursuant to §C(2)(b) of this regulation are divided by the overall average relative value determined pursuant to §C(2)(a) of this regulation.

D. Methodology for MCO-Specific Case Mix-Adjusted HIV and AIDS Rates. For each MCO, the Department shall:

(1) Calculate MCO-specific HIV and AIDS relative case mix factors for each HIV and AIDS payment group pursuant to §C(3) of this regulation;

(2) Calculate MCO-specific HIV and AIDS rates for the rate adjustment period by multiplying the risk adjustment factor derived pursuant to §D(1) of this regulation by the value specified for each HIV and AIDS payment group for the rate year; and

(3) Apply a budget neutrality adjustment to the values derived pursuant to §D(2) of this regulation so that the aggregate of payments to all MCOs pursuant to this regulation are equivalent to the aggregate of all payments that would be due to all MCOs in the absence of this regulation.

E. Case Mix Updates. The Department shall:

(1) Update current enrollees' region of residence and enrollment categories by repeating the calculations in §§B-D of this regulation every 6 months using residence and enrollment data as of the enrollment month specified below:

(a) For the initial assessment period of each rate year, June of the calendar year before the rate year; and

(b) For the mid-year assessment period of each rate year, December of the calendar year before the rate year; and

(2) For rate adjustment periods beginning January 1 and July 1 of each rate year, use each MCO's updated Hepatitis C-infected and Hepatitis C-uninfected distribution to compute its risk adjusted HIV and AIDS payment rates for each rate adjustment period, as described in §D of this regulation.

Md. Code Regs. 10.67.04.19-1

Regulations .19-1 recodified from 10.09.65.19-1 effective 46:22 Md. R. 976, eff. 11/1/2019