Medicaid HMO Medical Loss Ratio Guide

Transcription

1 Medicaid HMO Medical Loss Ratio Guide Companion Guide Version Number: 1.7 July 20,

2 Table of Contents 1 MLR Instruction Introduction... 4 Background... 4 Contract... 4 Reporting Timeframes... 4 MLR Reporting Format and Naming Convention... 4 Sending the MLR to DHS... 4 MLR Questions... 5 MLR Guide and MS Excel Template Location... 5 Non-Disclosure of Trade Secrets... 5 Acknowledgement BC+/SSI MLR - Statement of Revenue and Expenses... 6 Template Database Format... 6 Cumulative Reporting... 6 Calendar Year Reporting... 6 Reporting is on a Financial Statement Basis... 6 Schedule Details Template Sections Preparer Information: Section Period: Section HMO Name: Section Program and Sub-Program: Section Rate Region: Section Total Member Months: Section 10 7 Revenue: Sections Total Capitation Payments (Net of P4P withhold): Section Total Access Payments: Section Total Maternity Kick Payments: Section Total CDPS Adjustments: Section Total P4P Withhold Payments: Section P a g e

3 Total Other Payments: Section Total Other Reductions to Revenue: Section Optional Total Supplemental Exhibit Reductions to Revenue: Section Subtotal Revenue: Section 19 9 Expenses: Sections Hospital/Medical Benefits: Section Other Professional Services (Net of Dental): Section Other Professional Services - Dental: Section Outside Referrals: Section Emergency Room and Out of Area: Section Prescription Drug: Section Aggregate Write-Ins for Other Hospital & Medical (Net of Access Payments): Section Aggregate Write-Ins for Other Hospital & Medical - Access Payments: Section Incentive Pool, Withhold Adjustments & Bonus Amounts: Section Net Reinsurance Recoveries: Section Optional Improving Health Care Quality Expenses: Section Optional Claim Adjustment Expenses: Section Subtotal Expenses: Section Net Income (loss): Section Supplemental Information: Section Net Cash Expenses: Section Total IBNR: Section General Administrative Expenses: Section Net Subrogation Recoveries: Section Sub-Capitated Payment Schedule Background Service Category: Section Sub-capitated Provider Group: Section Sub-capitated Provider Group National Provider Identification (NPI): Section Sub-capitated Per Member Per Month (PMPM) Amount: Section Sub-capitated Enrollment: Section Sub-capitated Member Months: Section Sub-capitated Total Payments: Section Appendix 1 - Badgercare Plus and SSI Rate Regions P a g e

4 Medical Loss Ratio (MLR) Reporting Instructions 1 MLR Instruction Introduction Background This companion guide is designed for the use by Health Maintenance Organizations (HMOs) to report Medical Loss Ratio (MLR) financial data to the Department of Health Services (DHS) for the Medicaid (MA) Badgercare Plus (BC+) and Supplemental Security Income (SSI) programs. Contract The MLR report is required by the BC+ and SSI contract. The contract language can be found in ARTICLE VII Computer/Data Reporting System, Data, Records and Reports; Section J, Medical Loss Ratio Reporting. Reporting Timeframes HMO(s) are required to submit quarterly MLR reports during each calendar year. The report is due to DHS 60 days after the end of each quarter for the first three quarters and 90 days after the fourth quarter. An annual MLR report will be required by July 1 st for the prior calendar year. The annual MLR report revises the 4 th Qtr report with any audit findings. If no audit corrections are necessary the 4 th Qtr report can be resent as the annual report. Report schedule is as follows: Quarter Time Period Due Date 1 st Qtr Jan Mar May 31 2 nd Qtr Apr - Jun Aug 31 3 rd Qtr Jul - Sep Nov 30 4 th Qtr Oct Dec March 31 Annual Report Jan Dec Jul 1 MLR Reporting Format and Naming Convention The MLR report will be required to be sent in a Microsoft (MS) Excel format. The report should use the following naming convention; HMONAME_MLR_QTR_CCYYMMDD An example of the naming convention is; MOLINA_HEALTHCARE_MLR_Q1_ Sending the MLR to DHS The MLR report should be submitted to the Bureau of Fiscal Management (BFM) via (DHSDHCAABFM@dhs.wisconsin.gov). 4 P a g e

5 MLR Questions Questions concerning the MLR report should be directed to BFM via phone: or MLR Guide and MS Excel Template Location The MLR Guide can be found on the ForwardHealth portal at; Organization/reports_data/reportsData.htm.spage The MS Excel MLR Report Template - Database Format can be found on the ForwardHealth portal at; Organization/reports_data/reportsData.htm.spage Non-Disclosure of Trade Secrets The MLR Report is covered under Article VII, L Non-Disclosure of Trade Secrets, contract language below; 1. To the extent that encounter records, medical-loss ratio reports, or other submissions/reports include or have the capacity to reveal amount(s) paid by the HMO to provider(s), the HMO and the Department agree that those records, reports or submissions constitute trade secrets under the Wisconsin Uniform Trade Secrets Act, Wis. Stats., s (1)(c). Such records, reports or submissions are thus exempt from disclosure under s (5), Wis. Stats. regardless of whether said information is specifically, separately designated as such by the HMO at the time of submission or reporting to the Department. 2. If the Department receives an open records request, subpoena, or similar request involving the information described in Paragraph 1, the Department shall notify the HMO of the request without unreasonable delay. Upon such request, the Department shall take all reasonable steps to prevent the disclosure of such information. In the event that disclosure of information is compelled pursuant to a writ of mandamus or other court order, the Department agrees to redact any otherwise proprietary, confidential, or trade secret information prior to said disclosure, subject to the terms of the order. 3. In the event the designation of the confidentiality of this information is challenged, the HMO agrees to provide legal counsel or other necessary assistance to defend the designation of records, reports, or submissions as a trade secret. The Department shall, without charge to the HMO, reasonably cooperate with such defense, to include providing legal counsel, testimony, and attestations 5 P a g e

6 regarding the protection of confidential and proprietary information that qualifies as a trade secret. Notwithstanding the foregoing, the HMO shall have the sole right and discretion to settle, compromise, or otherwise resolve such defense. Should any order or judgment be issued against the Department, the HMO will hold the Department harmless and indemnify the Department for costs and damages assessed against the Department as a result of designating records, reports, or submissions as trade secret(s). Acknowledgement References to the National Association of Insurance Commissioner s (NAIC) Annual and Quarterly Statement Instructions/Blank Health provided with permission from NAIC. 2 BC+/SSI MLR - Statement of Revenue and Expenses Template Database Format The Statement of Revenue and Expenses will provide specific financial data about the BC+ and SSI programs. The template consists of two MS Excel tabs. The tabs represent MLR Report Summary Statement of Revenue and Expense and a Sub- Capitated Payment Schedule. HMO(s) will be required to complete each tab if they are contracted to deliver BC+ and SSI services. Cumulative Reporting All totals used in the report should be cumulative from quarter to quarter e.g. the 2 nd quarter totals should include the updated 1 st quarter totals and the 2 nd quarter totals. Calendar Year Reporting Reporting is based on a calendar year (January December). Reporting is on a Financial Statement Basis The information reported in the MLR report should be on a financial statement basis and should correspond to the audited NAIC annual statement reported to Office of the Commissioner of Insurance (OCI) for Medicaid. Schedule Details DHS may request that a HMO provide a detailed schedule for each section listed in the MLR report. 6 P a g e

7 3 Template Sections The Statement of Revenue and Expenses is broken down into several sections Preparer Information: Section 1-3 The preparers contact information for the report. If multiple people are involved, only the person responsible for resolving questions should be listed Period: Section 4-5 The quarter and year of the MLR report HMO Name: Section 6 HMO should use the same name for each report Program and Sub-Program: Section 7-8 HMO(s) are required to subdivide financial data by MA program. The BC+ program consists of the Standard and Childless Adult (CLA) programs. The SSI program consists of MA Only and Duals programs. SSI MA Only and Duals represent a rollup of Med Stat 21, SSI Related and MAPP groups. The HMO(s) will only be required to report at the MA Only and Dual levels. SSI Duals are defined as an SSI member entitled to receive Medicare. The medical status codes used to define each program can be found in the contract, Article V, Functions and Duties of the Department; Section A, Enrollment Determination. HMO(s) can also use the rate cell field from the Capitation Payment Listing Report to determine program by referencing the rate cell description found on the FowardHealth Portal at; Organization/Providers/financial.htm.spage Rate Region: Section 9 HMO(s) can use the HIPAA 834 report to determine a member s county and appendix 1 for the corresponding rate region Total Member Months: Section 10 The member months are calculated by adding up the program members for each month in the quarter. 7 P a g e

8 Revenue: Sections HMO(s) are required to report accrued premium income generated by the MA programs Total Capitation Payments (Net of P4P withhold): Section 11 Total capitation payments by program Total Access Payments: Section 12 Total access payments (hospital, critical access, and ASC) by program. Access payments must be reported regionally. If the information is unavailable, HMOs may calculate the regional access payments as proration of the member months for each region e.g. total member month for all regions = 100 and region 1 = 10 member months than 10% of the total access payments should be allocated to region Total Maternity Kick Payments: Section 13 Total maternity kick payments by program. expected kick payments in the reporting period. This includes accrued revenue for Total CDPS Adjustments: Section 14 The net CDPS total by program Total P4P Withhold Payments: Section 15 Total accrued P4P payments by program for the period Total Other Payments: Section 16 All other MA payments associated with each program made to the HMO. If the other payment is used as an offset to an expense line item it should be reported in the corresponding expense section and not in this section Total Other Reductions to Revenue: Section 17 The net other reductions to revenue by program e.g. reinsurance premiums, etc Optional Total Supplemental Exhibit Reductions to Revenue: Section 18 and Supplemental Blank and should include any taxes, fees and assessments associated with Medicaid revenue and would be included on the Supplemental Health Care Exhibit. This optional section should only be used if the HMO is reporting information in the optional Claims Adjustment Expense and Improving Health Care Quality sections of the expenses. Both sections are related to the Supplemental Health Care Exhibit which is not required by Medicaid. 8 P a g e

9 Subtotal Revenue: Section 19 Subtotal of sections Expenses: Sections HMO(s) are required to report accrued expenses which are net of applicable coordination of benefits, deductibles, co-payments, risk share, and provider discounts. Expense line items are defined by NAIC in the Annual and Quarterly Statement Instructions/Blank Health in the Statement of Revenue and Expenses, except where dental and access payment expenses are reported in separated subcategories. HMO(s) should use the Wisconsin prescribed differences from NAIC statutory accounting principles per the Wisconsin Office of the Commissioner of Insurance (OCI) Hospital/Medical Benefits: Section Other Professional Services (Net of Dental): Section 21, net of dental expenses which should be reported in section Other Professional Services - Dental: Section 22 Dental expenses for the period Outside Referrals: Section Emergency Room and Out of Area: Section Prescription Drug: Section Aggregate Write-Ins for Other Hospital & Medical (Net of Access Payments): Section 26, net of access payments which should be reported in section 27 9 P a g e

10 Aggregate Write-Ins for Other Hospital & Medical - Access Payments: Section 27 Total access payments (hospital, critical access, and ASC) by program. Access payments must be reported regionally. If the information is unavailable, HMOs may calculate the regional access payments as the proration of the member months for each region e.g. total member month for all regions = 100 and region 1 = 10 member months than 10% of the total access payments should be allocated to region 1.do not have to be reported regionally Incentive Pool, Withhold Adjustments & Bonus Amounts: Section Net Reinsurance Recoveries: Section Optional Improving Health Care Quality Expenses: Section 30 and Supplemental Blank and should include any health improvement and health information technology expenses associated with Medicaid included on the Supplemental Health Care Exhibit. This optional section should only be used if the HMO is reporting information in the optional Total Supplemental Exhibit Reductions to Revenue section of revenues. The section is related to the Supplemental Health Care Exhibit which is not required by Medicaid Optional Claim Adjustment Expenses: Section 31 and Supplemental Blank and should include any cost containment and other claim adjustment expenses not included in qualify of expenses above and associated with Medicaid included on the Supplemental Health Care Exhibit. This optional section should only be used if the HMO is reporting information in the optional Total Supplemental Exhibit Reductions to Revenue section of revenues. The section is related to the Supplemental Health Care Exhibit which is not required by Medicaid Subtotal Expenses: Section 32 Subtotal of sections Net Income (loss): Section 33 Section 19 minus Section P a g e

11 Supplemental Information: Section Sections are defined by the National Association of Insurance (NAIC) in the Annual and Quarterly Statement Instructions/Blank Health in the Statement of Revenue and Expenses. The other sections will be used by DHS in managing outstanding liability associated with the MA programs, including Incurred but Not Reported (IBNR) costs. All sections have to be reported by rate region and program. If the information is unavailable, HMOs may use the same proration used to calculate the Access Payments by region Net Cash Expenses: Section 34 The net cash expenses paid for sections and section 28 if applicable for the period. Cash based expenses are defined as having a date of payment in the period being reported. Optional Section should not be included Total IBNR: Section 35 The Total IBNR per NAIC and OCI standards reported in sections and section 28. Optional Section should not be included General Administrative Expenses: Section Net Subrogation Recoveries: Section 37 Per the contract, Addendum III, Guidelines for the Coordination of Services between the HMO, Targeted Case Management (TCM) Agencies, and the Child Welfare Agencies; Section B, Coordination of Benefits Quarterly Report Form and Instructions for Completing the Form. 4 Sub-Capitated Payment Schedule Background As part of the encounter data project, HMO(s) were instructed to report sub-capitated payment arrangement as part of the MLR report. Sub-capitated payments represent a flat fee used to cover all services provided for a particular period of time e.g. monthly. All encounters are reported using ANSI Code 24 (Charges are covered under a capitation agreement/managed care plan) should be reported per the schedule guidelines below. The Department will treat all HMO paid amounts for encounters using ANSI Code 24 as zero. This schedule will be used to supplement paid encounter amounts using the ANSI code. 11 P a g e

12 4.1.1 Service Category: Section 1 The general service category to which the sub-capitated payment is being applied, e.g. dental, etc Sub-capitated Provider Group: Section 2 The provider or provider group receiving the sub-capitated payment Sub-capitated Provider Group National Provider Identification (NPI): Section 3 The provider or provider group NPI receiving the sub-capitated payment Sub-capitated Per Member Per Month (PMPM) Amount: Section 4 The PMPM amount paid to the provider or provider group Sub-capitated Enrollment: Section 5 Identify if the sub-capitated payment applies to all or some of the HMO(s) MA membership. Valid fields are (All or Partial) Sub-capitated Member Months: Section 6 The number of member months in which a sub-capitated payment was received Sub-capitated Total Payments: Section 7 The total amount of sub-capitated payments 12 P a g e

13 5 Appendix 1 - Badgercare Plus and SSI Rate Regions Douglas Bayfield Iron Ashland Vilas Burnett Polk Washburn Barron Sawyer Rusk Price Oneida Forest Florence Marinette Taylor Lincoln Langlade St. Croix Pierce Dunn Pepin Buffalo Chippewa Eau Claire Tremp - ealeau Clark Jackson Marathon Portage Wood Meno - minee Shawano Waupaca Oconto Outagamie Brown Door Kewaunee Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 La Crosse Vernon Crawford Monroe Grant Richland Juneau Iowa Lafayette Adams Sauk Green Waushara Marq - uette Columbia Dane Green Lake Rock Winnebgo Fond Du Lac Dodge Jefferson Walworth Calu - met Waukesha Manitowoc Sheboygan Ozaukee Racine Kenosha Washington Milwaukee 13 P a g e