Health Status Adjusted Total Medical Expenses

(1) TME by Physician Group and Physician Local Practice Group. (a) Reporting Requirements. 1. Payers shall report TME by Physician Group and Physician Local Practice Group for Massachusetts Members required to select a primary care physician. 2. Payers shall report TME for Physician Groups and Physician Local Practice Groups Physician Local Practice Groups with at least 36,000 Member Months for the calendar year. Payers shall report TME separately for Medicaid and Commonwealth Care (combined), Medicare, commercial full-claim, and commercial partial-claim plans. Commercial (self and fully insured) data for physicians' groups or zip codes for which the Payer is able to collect information on all direct medical claims and subcarrier claims shall be reported in the full-claim category. Commercial (self and fully insured) data for physicians' groups or zip codes that do not include all medical and subcarrier claims shall be reported in the partial-claim category. Payers must include the full amount paid for medical claims, including amounts paid under stop-loss or reinsurance agreements, even if the Payer was not directly providing payment for those services. Payers shall not include data for which they are the secondary or tertiary payer such as Medicare Supplement. 4. Payers shall report TME data in the aggregate for all Physician Groups and Physician Local Practice Groups with fewer than 36,000 Member Months for the calendar year. 5. Payers shall attribute Non-claims Payments to a Provider at the Local Practice Group Level and thereafter at the Physician Group Level. If direct attribution is not possible, Payers shall allocate Non-claims Payments by Member Months. 6. Payers must report the risk adjustment tool and version used to report the Health Status Adjustment Score. The Division may specify additional requirements for reporting the Health Status Adjustment Score by Administrative Bulletin or in the Data Specification Manual. (b) Required Data Elements. 1. DHCFP Provider Number 2. OrgID or Payer's Internal Provider Number 3. Physician Group Name 4. Local Practice Group Name 5. Pediatric Indicator 6. Member Months (annual) 7. Health Status Adjustment Score 8. Normalized Health Status Adjustment Score: the Health Status Adjustment Score divided by the Payer's average health status adjustment score. Total Allowed Medical Claims (annual): the medical claims expenses by the following subcategories: hospital inpatient, hospital outpatient, professional physician, other professional, pharmacy, and other. 10. Total Non-claims Payments (annual): the non-claims payments by the following subcategories: incentive programs, risk settlements, care management expenses, and other. (c) Calculation of TME by Physician Group and Physician Local Practice Group. Based upon the data specified in 114.5 CMR 23.04(1)(b) the Division shall calculate TME by Physician Group and Physician Local Practice Group by summing Total Medical Claims and Total Non-claims Payments to obtain Total Payments. PMPM Unadjusted TME will be calculated by dividing Total Payments by Member Months. PMPM Health Status Adjusted TME: will be calculated by dividing PMPM Unadjusted TME by the Health Status Adjustment Score. PMPM Normalized Health Status Adjusted TME will be calculated by dividing PMPM Unadjusted TME by the Normalized Health Status Adjustment Score. Payers will be provided a copy of the calculation. (2) TME by Zip Code. (a) Reporting Requirements. 1. Payers shall report TME by zip code for all Massachusetts Members based on the zip code of the Member. The Division shall not publicly report zip code TME data unless aggregated to an amount appropriate to protect patient confidentiality. 2. Payers shall separately report TME for Members whose plans require the selection of a primary care provider and TME for Members not required to select a primary care provider. Payers shall report TME separately for Medicaid and Commonwealth Care (combined), Medicare, commercial full-claim, and commercial partial-claim plans. Commercial (self and fully insured) data for physicians' groups or zip codes for which the Payer is able to collect information on all direct medical claims and subcarrier claims shall be reported in the full-claim category. Commercial (self and fully insured) data for physicians' groups or zip codes that do not include all medical and subcarrier claims shall be reported in the partial-claim category. Payers must include the full amount paid for medical claims, including amounts paid under stop-loss or reinsurance agreements, even if the Payer was not directly providing payment for those services. Payers shall not include data for which they are the secondary or tertiary payer such as Medicare Supplement. 4. Payers shall allocate Non-claims Payments by Member Months. 5. Payers must report the risk adjustment tool and version used to report the Health Status Adjustment Score. The Division may specify additional requirements for reporting the Health Status Adjustment Score by Administrative Bulletin or in the Data Specification Manual. (b) Required Data Elements. 1. Member Zip Code 2. PCP/No PCP Member Designation 3. Member Months (annual) 4. Health Status Adjustment Score 5. Normalized Health Status Adjustment Score: the Health Status Adjustment Score divided by the Payer's average health status adjustment score. Total Allowed Medical Claims (annual): the sum of medical claims expenses designated into the following subcategories: hospital inpatient, hospital outpatient, professional physician, other professional, pharmacy, and other. 7. Total Non-claims Payments (annual): the sum of non-claims payments. (c) Calculation of TME by Zip Code. Based upon the data specified in 114.5 CMR 23.04(2)(b) the Division shall calculate TME by Zip Code by summing Total Medical Claims and Total Non-claims Payments to obtain Total Payments. PMPM Unadjusted TME will be calculated by dividing Total Payments by Member Months. PMPM Health Status Adjusted TME will be calculated by dividing PMPM Unadjusted TME by the Health Status Adjustment Score. PMPM Normalized Health Status Adjusted TME will be calculated by dividing PMPM Unadjusted TME by the Normalized Health Status Adjustment Score. Payers will be provided a copy of the calculation. (3) Due Dates. (a) Annual Reports. Beginning in 2012, annually on June 1st Payers must submit preliminary TME reports for the prior Calendar Year and final TME reports for the Calendar Year ending 17 months prior. (b) Initial Filing. For Calendar Year 2009, Payers must submit the required reports by March 31, 2011. Payers must submit preliminary Calendar Year 2010 TME data by June 1, 2011.