TERMS USED IN FINANCIAL STATISTICAL REPORTS (FSRs)

Transcription

1 TERMS USED IN FINANCIAL STATISTICAL REPORTS (FSRs) Total Member Months - Number of members enrolled in each month. YTD is the sum of the individual month s membership. Revenues: Premiums Capitation payments paid to MCOs (Managed Care Organization) by HHSC. Delivery Supplemental Payments A one-time per pregnancy supplemental payment made by HHSC to STAR, CHIP MCOs. Pharmacy Premiums - Pharmacy capitation payments paid to MCOs by HHSC Investment Income All interest and dividend income resulting from investment of funds received. Other Revenue Any and all income generated from other sources. Premium Taxes Premium taxes incurred by MCOs for premiums applicable to the reported period. Maintenance Taxes Maintenance taxes incurred by MCOs for premiums applicable to the reported period. Medical Expenses: Fee for Service Non-capitated payments for services rendered to the members. Capitated Services Includes PCPs and Hospitals capitation payments which are amounts paid to providers that do not pay claims to other providers from the capitation payments and also the capitation paid to subcontractors in which the capitation is the funding source for paying claims for healthcare services performed in each Texas service area. Net Reinsurance Cost Total reinsurance premiums paid by the MCO net of reinsurance recoveries. IBNR Accrual Incurred But Not Reported (IBNR) accrual medical expenses are an estimate of the expected healthcare expenses incurred, but not paid, based on claims lag schedules and completion factors, as well as any counts of services rendered but not billed, e.g., pre-authorized hospital days. Administrative Expenses includes those expenses that are directly or indirectly in support of the Texas Medicaid/CHIP operations of the MCO. Administrative expenses include Salaries, Wages and other benefits, Payroll taxes, Utilities and Maintenance, Auditing and other consulting expenses etc. Performance Assessment Amount of at-risk premium recouped by HHSC for failure to meet the performance expectation for which the MCO is at risk. Quality Challenge Award Amount awarded to the MCO for superior clinical quality, service delivery, access to care or member satisfaction. Liquidated Damages - Amount assessed by HHSC as penalty for non-compliance with contract requirements. Updated August 2012

2 HHSC FINANCIAL STATISTICAL REPORT (FSR) MCO name: Amerigroup / Wellpoint State Fiscal Year: 2016 Program: STAR Submission Date: 3/31/2016 Service Area: Harris / Houston Submission Type: Quarterly Rptg Period End Date: 2/29/2016 Part 1: Summary Income Statement Incurred Months: Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16 Jun-16 Jul-16 Aug-16 YTD HHSC Managed Care contract costs 1 Member Months 112, , , , , , ,995 2 Average Monthly Member Months ,499 Revenues: 3 Medical Premiums 19,716,316 19,841,851 19,703,455 19,327,374 18,888,920 18,270, ,748,897 4 Delivery Supplemental Payments 1,442,872 1,270,431 1,280,989 1,319,700 1,249, , ,527,569 5 Pharmacy Premiums 3,708,474 3,744,674 3,731,460 3,663,021 3,612,739 3,526, ,987,135 6 Investment Income 141, , , ,884 96, , ,580 7 Health Insurance Providers Fee Reimbursement Other Revenue Total Gross Revenues 25,009,356 25,009,213 24,897,501 24,448,979 23,847,629 22,874, ,087, Health Insurance Providers Fee & Related Costs 0 11 Health Insurance Providers Fee (NAIP) Premium Taxes 431, , , , , ,335 2,538, Maintenance Taxes 7,337 7,383 7,370 7,257 7,152 6,985 43, Net Revenues 24,570,772 24,566,833 24,457,602 24,016,295 23,424,835 22,469, ,505,521 Medical Expenses: 15 Fee-For-Service 17,118,626 17,247,533 16,149,793 14,960,257 13,915,353 7,907, ,298, Capitated Services 246, , , , , , ,446, Patient Centered Medical Home Services Net Reinsurance cost 3,838 3,862 3,855 3,796 3,741 3, , IBNR Accrual - Medical 16,737 1,601, ,875 1,637,382 2,583,702 7,588, ,851, Total Medical Expenses 17,385,285 19,100,009 16,820,726 16,840,724 16,739,860 15,732, ,619, Prescription Expenses (excluding PBM Admin) 3,487,047 3,855,993 3,316,314 3,351,927 3,560,001 3,865, ,436, Total Medical and Prescription Expenses 20,872,332 22,956,002 20,137,040 20,192,651 20,299,861 19,597, ,055, Administrative Expenses 1,887,318 1,827,342 1,748,623 2,211,669 1,769,142 1,715,874 11,159, Total Expenses 22,759,651 24,783,344 21,885,663 22,404,320 22,069,003 21,313, ,215, Net Income Before Taxes 1,811,121 (216,511) 2,571,939 1,611,975 1,355,832 1,155, ,289, % Medical Exp to Net Revenues 70.8% 77.7% 68.8% 70.1% 71.5% 70.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 71.5% 27 % Prescription Exp to Net Revenues 14.2% 15.7% 13.6% 14.0% 15.2% 17.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 14.9% 28 % Total Medical and Prescription to Net Rev. (MLR) 84.9% 93.4% 82.3% 84.1% 86.7% 87.2% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 86.4% 29 % Admin Exp to Net Revenues 7.7% 7.4% 7.1% 9.2% 7.6% 7.6% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 7.8% 30 % Net Income to Net Revenues 7.4% -0.9% 10.5% 6.7% 5.8% 5.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 5.8% 31 % Adj. Admin to Net Revenues 9.0% 8.8% 8.4% 10.9% 8.9% 9.1% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 9.2% (excludes taxes and Prescription pass through) Post-income items: 32 Performance Assessment Note: Except where stated otherwise, reporting is on an incurred basis (that is, reported in the period corresponding to dates of service, rather than to date paid). All prior quarters' data must be updated to reflect the most recent revised IBNR estimates. Part 1 Summary Income Statement 6/8/2016