The Robert Wood Johnson Foundation provided funding for development, simulation, and validation of the methodology. A complete description of the methodology and calculations used in The HIPC's tisk assessment/adjustment analysis can be obtained from the authors at the California Managed Risk Medical Insurance Board, Suite 200, 818 K Street, Sacramento, California 95814.
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Normal maternity is excluded because the costs for these cases should be reflected in premium rates that already allow for age rating; in addition, sex is one of the factors in the risk assessment, and sex-based risk in the non-Medicare population largely reflects the costs of providing maternity services. Mental health and chemical dependency are excluded because The HIPC's standard benefit design provides limited coverage for mental health and chemical dependency treatment; in addition, coding for mental health and chemical dependency cases is often less precise than it is for many physical illnesses. Trauma cases are excluded because these cases may represent one-time costs and thus are less likely to be indicative of future costs; in addition, it would be difficult for health plans to avoid these cases through any design of their delivery system, since the individual occurrence of trauma is highly unpredictable.
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The weight for the "other" population is expected to change for each annual risk assessment. This weight is calculated as the remainder value after all persons with marker diagnoses are considered. For the most recent calculation, the weight is 0.932.
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A formula is used that creates a blended score with varying weight given to the plan's score and The HIPC's average score. Plans with 500 members on the analysis date receive a score that is calculated as 25 percent of the plan's RAV and 75 percent of The HIPC's average RAV. Plans with 750 members on the analysis date have a weighting of 60 percent and 40 percent, respectively. Plans with 1,000 or more members receive their own RAV.
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The use of a ±5 percent threshold for risk maldistribution is a compromise reached by the work group. Some members advocated use of a broader threshold or a maximum cap on the amount of dollars subject to transfer. Others advocated zero tolerance of risk maldistribution. The ±5 percent threshold acknowledges the imprecision inherent in the method while still significantly contributing to addressing issues of risk maldistribution.
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Risk adjustment transfer amounts from "payer" health plans to "receiver" health plans will be made by The HIPC administrator as part of The HIPC's regular premium collection and payment process. Payer health plans will receive subscriber premiums from which risk adjustment transfer payment amounts have been deducted. Receiver health plans will receive subscriber premium amounts to which a risk adjustment transfer amount has been added. The remaining funds will be held by The HIPC and distributed at the end of the benefit year. The fund withhold will be used to prorate payments to receiver health plans if incoming risk adjustment transfer amounts are insufficient to cover risk adjustment payments. This could occur if a payer health plan loses significant enrollment during the year or if receiver health plans have disproportionate growth during the year. Payments from payer health plans are the only source of funds for making transfer payments to receiver health plans.
* 이 정보는 Elsevier사의 SCOPUS DB에서 KISTI가 분석하여 추출한 것입니다.
