ROSS HEALTH ACTUARIAL


MANAGED CARE RISK MODELING DECISION SUPPORT


 
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SERVICES FOR THE MEDICAID MARKET

Ross Health Actuarial has extensive experience helping payers, providers, and state governments in evaluating the financial impact of Medicaid managed care programs. The Medicaid market presents a number of challenges, including:

Premium Rating Restrictions. HCFA limits Medicaid HMO rates to the Upper Payment Limit (UPL), a projection of what FFS Medicaid would have cost for a similar population. With regulated and often low FFS fee schedules (particularly for physicians), HMO administrative expenses, and a state goal to generate savings compared to FFS, the combined effect is to make Medicaid rate development a potentially contentious effort. We have the experience to help you sort through these issues.

Information Needs. Increasing managed care enrollment has resulted in an eroding FFS claim base, which complicates the state effort to develop rates in relation to the UPL. For HMO's and providers, Medicaid utilization patterns differ dramatically between FFS and managed care. Meanwhile, states are moving ahead with risk-adjustment rating methodologies. Ross Health Actuarial has the tools and experience to help you respond to this continuously evolving environment.

Services include:

  • UPL rate development and certification. 
  • Medicaid HMO capitation rate development. 
  • Waiver program cost estimates. 
  • Development of SCHIP/Healthy Kids cost estimates. 
  • Competitive bidding rate development and assistance. 
  • Assisting providers with capitation and risk-sharing proposals for the Medicaid market.

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