state of texas medicaid managed care star …...medicaid’s state of texas access reform (star)...

Prepared for:

Texas Health and Human Services Commission

Uniform Managed Care Contract 529-12-0002 V2.16

Prepared by:

Evan L. Dial, F.S.A., M.A.A.A.

Rudd and Wisdom, Inc.

June 26, 2015

STATE OF TEXAS

MEDICAID MANAGED CARE

STAR PROGRAM RATE SETTING

STATE FISCAL YEAR 2016

TABLE OF CONTENTS

I. Introduction ........................................................................................................................1

II. Overview of Rate Setting Methodology ............................................................................3

III. Adjustment Factors ............................................................................................................6

IV. Administrative Fees, Taxes and Risk Margin ..................................................................11

V. Summary ..........................................................................................................................12

VI. Actuarial Certification .....................................................................................................16

VII. Attachments .....................................................................................................................17

1

I. Introduction

Rudd and Wisdom, Inc. has been retained by the Texas Health and Human Services

Commission (HHSC) to develop the state fiscal year 2016 (FY2016, September 1, 2015

through August 31, 2016) premium rates for health plans participating in the Texas

Medicaid STAR program. This report presents the rating methodology and assumptions

used in developing the premium rates.

Medicaid’s State of Texas Access Reform (STAR) program provides primary, acute care, and

pharmacy services for low-income families, children, pregnant women, and some former foster

care youth. The program operates statewide with services delivered through managed care

organizations under contract with HHSC. There are thirteen STAR service delivery areas

(SDAs). STAR Medicaid members can select from at least two MCOs in each service delivery

area. There are a total of 18 MCOs serving different STAR SDAs throughout the state.

STAR is the program through which most people in Texas get their Medicaid coverage.

Rudd and Wisdom has provided actuarial services to the Texas Medicaid program for over

30 years. We have participated in the state’s managed care rating process since its inception

in 1993. This year, as in previous years, we have worked closely with HHSC in developing

the FY2016 health plan premium rates.

Rudd and Wisdom has relied on the following data sources as provided by HHSC, the

participating health plans and the agency’s External Quality Review Organization (EQRO):

Monthly enrollment by risk group and age group for each health plan. This includes

historical enrollment since September 2011 and a projection of future enrollment

through August 2016. These projections were prepared by HHS System Forecasting

staff.

Claim lag reports by risk group and age group for each health plan for the period

September 2011 through February 2015. These reports were prepared by the health

plans and include monthly paid claims by month of service.

Financial Statistical Reports (FSR) for each participating health plan for FY2013,

FY2014 and the first six months of FY2015. The FSR contains detailed information

regarding monthly enrollment, revenue, incurred claims and administrative expenses, as

reported by the health plan. These reports are prepared by the health plans and are

audited by an external audit organization.

Reports from the EQRO summarizing their analysis of the health plan’s encounter

claims data.

Reports from the health plans providing information on high volume claimants during

the experience period.

Current (FY2015) premium rates and Delivery Supplemental Payment rates by risk

group for each health plan.

The number of maternity deliveries by health plan and risk group for the period

September 2011 through November 2014.

Information from both HHSC and the health plans regarding recent changes in covered

2

services and provider reimbursement under the Medicaid program.

Information from the health plans regarding current and projected payment rates for

certain capitated services, such as mental health and vision.

Information regarding FY2014 third party reimbursement from each of the health plans.

FY2014 acuity risk adjustment analysis provided by the EQRO for each participating

health plan.

Information from the health plans regarding current and projected reinsurance premium

rates.

Information provided by HHSC regarding FY2014 health plan claims cost by type of

service for certain services. This information was obtained from the encounter database.

Information provided by HHSC regarding proposed FY2016 Medicaid provider

reimbursement rates.

Information provided by HHSC regarding newly capitated services previously paid by

HHSC.

After accumulating all of the information to be used in the rate setting process, a comparison of

the various sources of claims data was performed to check for consistency. Information

submitted by the health plans was compared to information submitted in prior years, the audited

Financial Statistical Reports (FSRs) and the detailed encounter data. All comparisons were done

by risk group as well as in aggregate. In the case of inconsistent information, follow up inquiries

were made with each applicable health plan until all information was corrected and reconciled

with the other data sources. Ultimately there was satisfactory consistency between all data

sources. Although the above data was reviewed for reasonableness, Rudd and Wisdom did not

audit the data.

In addition, to the review for reasonableness performed by Rudd and Wisdom HHSC employs

the Institute for Child Health Policy (ICHP) as an External Quality Review Organization. ICHP

reviews the detail encounter data and provides certification of the data quality. Below is an

excerpt from their data certification report:

Based on an administrative review, the EQRO considers the required data elements for all

MCO/(R)SA combinations in STAR to be accurate, and complete, meeting the following

components of Texas Government Code § 533.0131 for data certification purposes:

1. The encounter data for the most recent measurement year are complete, accurate, and

reliable.

2. No statistically significant variability in the encounter data is attributable to

incompleteness, inaccuracy, or other deficiency as compared to equivalent data for

similar populations and when evaluated against professionally accepted standards.

3

II. Overview of the Rate Setting Methodology

This report details the development of the medical component of the total premium rate.

Information regarding the carve-in of prescription drugs into the STAR program can be

found in the report titled State of Texas Medicaid Managed Care Rate Setting Pharmacy

Carve-in State Fiscal Year 2016.

The actuarial model used to derive the FY2016 STAR health plan premium rates relies

primarily on health plan financial experience. The historical claims experience for each

health plan (by area) was analyzed and estimates for the base period (FY2014) were

developed. These estimates were then projected forward to FY2016 using assumed trend

rates. Other plan expenditures such as capitated amounts, reinsurance costs and

administrative expenses were added to the claims component in order to project the total

FY2016 cost under the health plan. These projected total cost rates were determined

separately for each risk group for each health plan. The results of this analysis were then

combined for all health plans in a service area in order to develop a set of community rates

for each service area.

The managed care service areas used in the analysis were as follows:

• Bexar County Service Area (San Antonio)

• Dallas County Service Area (Dallas)

• El Paso County Service Area (El Paso)

• Harris County Service Area (Houston)

• Hidalgo County Service Area (Hidalgo)

• Jefferson County Service Area (Beaumont)

• Lubbock County Service Area (Lubbock)

• Nueces County Service Area (Corpus Christi)

• Tarrant County Service Area (Fort Worth)

• Travis County Service Area (Austin)

• Medicaid Rural Service Area - Central (MRSA Central)

• Medicaid Rural Service Area - Northeast (MRSA Northeast)

• Medicaid Rural Service Area - West (MRSA West)

The risk groups (or rating populations) used in the analysis are as follows:

• Children under Age One Year

• Children ages 1 - 5




• TANF Adults

• Pregnant Women

The services used in the analysis include the following:

• Inpatient Hospital

• Outpatient Hospital

4

• Physician Services

• Other Professional Services

• Lab, X-ray and Radiology Services

• Medical Supplies

• Behavioral Health Services (except in the Dallas service area)

• EPSDT Medical Services

• Family Planning and Genetics Services

• Comprehensive Care Program Services

• Vision Services

• Hearing Services

• Home Health Services

• Emergency Room Services

• Ambulance Services

• Prescription Drugs

Services specifically excluded from the analysis include:

• Dental and Orthodontia Services

We projected the FY2016 cost for each individual health plan by estimating their base

period (FY2014) average claims cost and then applying trend and other adjustment factors.

These adjustment factors are described in Section III. We added capitation expenses for

services capitated by the health plan (such as vision and behavioral health), a net cost of

reinsurance, a reasonable provision for administrative expenses and a risk margin.

Attachment 2 presents a description and an example of the experience analysis for a sample

health plan. This type of analysis was conducted for each health plan.

The analysis of base period claims experience for each health plan attempted to identify and

adjust for any distortions in the data. Significant variations in experience, including the

impact from unusually large individual claims, were investigated however no adjustments

were deemed to be necessary.

HHSC utilized the combination of two rating methodologies in setting the FY2016 STAR

premium rates – individual plan experience rating and community rating. The individual

plan experience rating method is described above and documented in Attachment 2. The

community rates are developed by a weighted average of the projected FY2016 cost for

each health plan in the service area. The weights used in this formula are the projected

FY2016 number of clients enrolled in each health plan by risk group. Attachment 3

presents the summary community rating exhibit for each service area along with a

description of the analysis.

The projected FY2016 average total per-capita cost in a service area is called the unadjusted

premium rate. This rate includes provision for all health care and administrative services to

be provided by the health plan. This rate is then separated into two components – (i) non-

maternity related expenses and (ii) maternity expenses. The premium rate for non-maternity

expenses is called the adjusted premium rate. These are the monthly rates paid to the health

plan. The amount paid for maternity expenses is called the Delivery Supplemental

Payment. More information on this adjustment is provided in Section III below under Risk

5

Risk Adjustment and in Attachment 8.

The base community rate in each service area was adjusted to reflect the health status, or

acuity, of the population enrolled in each health plan. The purpose of acuity risk adjustment

is to recognize the anticipated cost differential between multiple health plans in a service

area by analyzing the health status of their respective memberships. Additional information

regarding risk adjustment is included in Section III below under Risk Adjustment and in

Attachment 9.

The FY2016 STAR health plan premium rates were then defined as the following: the

minimum of (a) 110% of the rate developed using the individual experience of the plan and

(b) community rate with risk adjustment. This is the same methodology that was used

during the FY2015 STAR rate development and has been implemented in order to limit the

excessive profits achieved by health plans with significantly lower costs than the

community average. By limiting the final premium rates to no greater than 110% of the rate

developed using the individual experience of the plan, the STAR rates continue to

incentivize the efficient provision of services while limiting the ability of a relatively low

cost plan from benefiting from the higher community average premium rates.

6

III. Adjustment Factors

This section contains a description of the adjustment factors used in the FY2016 STAR

rate setting process.

Trend Factors

The rating methodology uses assumed trend factors to adjust the base period claims cost to

the projection period. The cost trend factors used in this analysis are a combination of

utilization and inflation components. The projected trend rate assumptions were

developed by the actuary based on an analysis of recent experience under the various

health plans. Trend assumptions for FY2015 vary by service area are established on a

statewide basis for FY2016. All trend assumptions vary by risk group.

The trend analysis included a review of health plan claims experience data through

February 28, 2015. Based on this information, estimates of monthly incurred claims were

made through December 2014. The claims cost and trend experience was reviewed

separately by service area and risk group. The service area trends were then combined into

a statewide average using a weighted average formula with estimated incurred claims as

the weights. All historical trends have been calculated as the average cost per member per

month during a specified time period (monthly, quarterly or annually) compared to the

same time period from the prior year. For example the FY2014 trend has been calculated

as the change in average cost per member per month during the period September 1, 2013

through August 31, 2014 (FY2014) compared to the average cost per member per month

during the period September 1, 2012 through August 31, 2013 (FY2013). The experience

trends for all time periods were adjusted to remove the impact of various provider

reimbursement changes and other revisions that have impacted the cost of the program.

The FY2015 trend assumptions were developed from two components: (i) the actual

estimated trend by service area for the period September 2014 through December 2014

and (ii) the projected trend for the period January 2015 through August 2015. The actual

trends for the period September 2014 through December 2014 were calculated separately

for each service delivery area. The projected trend for the period January 2015 through

August 2015 were projected using experience data from FY2012 (3/10 weight), FY2013

(3/10 weight), FY2014 (3/10 weight) and the first four month of FY2015 (1/10 weight).

The weighting of each time period was based on the number of months within each time

period. All projected statewide trends were limited to no less than 0.0%

Blending the area specific trends for the period September 2014 through December 2014

with the statewide projected trend for the period January 2015 through August 2015 was

done via the following formula:

FY2015 SDA Trend = (9/14-12/14 actual SDA trend) x 4 + (1/15-8/15 Statewide) x 8

12

7

The FY2016 trend assumptions were then developed on a statewide basis from a simple

average of the FY2012 trend, FY2013 trend, FY2014 trend and FY2015 trend.

The FY2015 and FY2016 trend assumptions were limited to no less than 0.0%.

Attachment 4 is a summary of the cost trend analysis. The chart below presents the

assumed annual trend rates for FY2015 and FY2016.

Under

Ages

Ages

Ages

Ages

TANF

Pregnant

Age 1

1-5

6-14

15-18

19-20

Adult

Women

FY2015

Bexar SDA

7.8%

5.7%

5.3%

1.0%

0.0%

0.0%

0.0%

Dallas SDA

0.0%

3.4%

7.5%

3.1%

0.0%

0.0%

1.5%

El Paso SDA

0.0%

2.8%

1.6%

2.2%

0.0%

0.0%

0.0%

Harris SDA

1.0%

5.2%

4.7%

0.8%

0.0%

0.0%

0.0%

Hidalgo SDA

0.0%

0.9%

3.4%

0.4%

0.0%

0.0%

0.0%

Jefferson SDA

0.0%

5.0%

5.8%

6.7%

0.0%

0.0%

0.0%

Lubbock SDA

0.3%

9.3%

5.2%

3.0%

0.0%

0.0%

0.0%

Nueces SDA

4.0%

4.6%

8.4%

0.0%

0.0%

0.0%

0.5%

Tarrant SDA

2.0%

4.8%

4.2%

4.5%

0.6%

0.0%

0.0%

Travis SDA

0.0%

4.6%

6.8%

1.9%

0.0%

0.0%

0.0%

MRSA Central SDA

9.2%

4.4%

6.2%

2.2%

0.0%

0.0%

0.0%

MRSA Northeast SDA

3.2%

5.1%

5.1%

4.4%

0.0%

0.0%

0.0%

MRSA West SDA

0.8%

3.3%

4.3%

0.0%

0.0%

0.0%

0.5%

FY2016

1.9%

3.9%

4.5%

2.2%

8.6%

0.0%

0.0%

Provider Reimbursement Adjustments

Medicaid provider reimbursement changes were recognized for the following services:

hospital inpatient reimbursement revisions, potentially preventable readmission

reimbursement reductions, potentially preventable complications reimbursement

reductions, rural hospital outpatient reimbursement revisions, and therapy reimbursement

reductions.

The rating adjustments for these provider reimbursement changes were calculated by

applying actual health plan encounter data to the old and new reimbursement basis and the

resulting impact determined. Attachment 5 presents a summary of the derivation of these

adjustment factors.

Newly Capitated Services

Effective September 1, 2014 mental health rehabilitation and targeted case management

services became capitated services under the STAR program. Previously these services

8

were carved out of STAR and paid on a fee-for-service basis. Exhibit H of Attachment 5

presents a summary of the derivation of these adjustment factors.

Related Party Adjustments

Beginning in FY2011, HHSC revised the rating methodology to exclude from the base

period claims experience any amounts paid by a health plan to a related party in excess of

100% of Medicaid. HHSC discussed with the health plans individually to determine (i)

which providers had an owner-relationship to the health plan and (ii) the basis on which

the health plan reimbursed the provider. All health plans in the affected service areas were

impacted because the related party adjustment lowered the community rate applicable to

all of the plans in that area. Exhibit A of Attachment 5 presents a summary of the

derivation of these adjustment factors.

Makena Utilization Increase

During FY2016 it is expected that utilization of Makena will increase as the currently

available compound (17P) will be less readily available. Makena has a significantly higher

price than 17P and will result in increased medical cost because it is currently administered

by a physician. Exhibit I of Attachment 5 presents as summary of the derivation of this

adjustment factor.

Long Acting Reversible Contraceptive (LARC)

Although a current benefit under managed care, hospitals do not receive separate

compensation for LARC insertion other than their typical maternity related

reimbursement. Effective January 1, 2016 LARC’s will be subject to a separate, additional

reimbursement. This increase in reimbursement is expected to result in an increase in

utilization. Exhibit J of Attachment 5 presents as summary of the derivation of this

adjustment factor.

Family Planning Exclusion

One of the health plans that participates in the STAR program does not provide family

planning services. HHSC provided a listing of those services that will not be provided by

this health plan. Adjustment factors were determined through an evaluation of the base

period experience for the area in which this plan operates. The premium rates for this

health plan have been reduced to reflect the reduced level of services provided.

Attachment 6 provides additional information regarding this adjustment.

Third Party Recoveries

The rating methodology includes a factor to recognize those health plans that do not satisfy

a minimum level of recoveries for coordination of benefits. Any plan that did not recover

at least 2.0% of claims had its projected claims cost reduced by 2.0% less their actual

percentage of recoveries. For example, if a health plan has third party recoveries (TPR) of

9

1.5% of claims, then their projected claims cost would be reduced by 0.5%. Any plan that

exceeded the minimum standard of 2.0% had no penalty applied. Additional information

regarding TPR is included in Attachment 7.

Risk Adjustment

Several risk adjustment techniques are employed in the rate setting methodology.

Premium rates are established separately by area of the state and risk group in order to

recognize the inherent geographical and demographical variation in the cost of delivering

care. In an attempt to treat the health plans more equitably regarding maternity expenses,

the methodology includes a separate rate for maternity services. In addition, the rating

methodology includes a health status adjustment.

The rate setting methodology incorporates a risk adjustment technique that is designed to

provide uniform treatment of the health plans for costs related to maternity services.

Maternity cases occur in several risk groups – Pregnant Women, TANF Adults, Ages 15-

18, and Ages 19-20. As a result, it is possible for one health plan to enroll a higher

percentage of TANF Adults, for example, who are pregnant and therefore generally more

expensive. In order to recognize the potential inequity that may arise between health

plans, HHSC developed this risk adjustment methodology. The goal is to reimburse the

plans uniformly for maternity delivery costs.

HHSC pays a delivery supplemental payment (DSP) for each delivery in a managed care

plan. The amount of the payment is a function of the average delivery cost in the service

area. Attachment 8 contains additional information regarding the DSP payment amounts.

In order to achieve cost neutrality, the projected cost of maternity expenses is subtracted

from the unadjusted premium rates. The resulting adjusted premium rates are the rates

actually paid to the health plans, in addition to any DSP amounts.

The base community rate in each service area was adjusted to reflect the health status, or

acuity, of the population enrolled in each health plan. The purpose of acuity risk

adjustment is to recognize the anticipated cost differential between multiple health plans in

a service area by analyzing the health status of their respective memberships. The risk

analysis was performed by the University of Florida’s Institute for Child Health Policy

(ICHP). The methodology used to calculate the acuity risk adjustment factors is the

Chronic Illness and Disability Payment System (CDPS). Additional information regarding

acuity risk adjustment is included in Attachment 9.

Although the results of the risk adjustment analysis were reviewed for reasonableness,

Rudd and Wisdom did not audit the risk adjustment data or the results of ICHP’s analysis.

Network Access Improvement Program (NAIP)

Effective March 1, 2015 several health plans implemented programs aimed at improving

network access for Medicaid members. The NAIP is designed to further the state's goal of

10

increasing the availability and effectiveness of primary care for Medicaid beneficiaries by

incentivizing various institutions to provide high quality, well-coordinated, and continuous

care.

Attachment 10 presents the development of the NAIP add-on amounts to be included in

the capitation rates effective September 1, 2015 along with further information concerning

the NAIP program.

Pay-for-Quality Program (P4Q)

The STAR Program includes the Quality Challenge Program. It creates incentives and

penalties for all health plans based on their performance on certain quality measures.

Health plans that excel on meeting the measures are eligible for a bonus of up to 4 percent

of their capitation rate; health plans that don’t meet their measures can lose up to 4 percent

of their capitation rate. In aggregate all premium dollars recouped through penalties are

dispersed back to the health plans eligible for the quality bonus. In sum, this program is

budget neutral and does not result in an overall net gain or a net loss from the aggregate

premium rates certified in this report. We have reviewed the various measures and have

concluded that it is reasonable to expect the health plans to achieve the targeted quality

measures and no further adjustment to the premium rates are necessary. Attachment 11

presents further information regarding the P4Q Program and its measures.

11

IV. Administrative Fees, Taxes and Risk Margin

The rating methodology includes an explicit provision for administrative services. The

amount allocated for administrative expenses is $8.00 pmpm plus 5.75% of gross

premium. This amount is intended to provide for all administrative-related services

performed by the health plan.

The administrative fee amounts were determined based on a review of (i) the

administrative fee provision included in Medicaid health plan premium rates in other

states, (ii) the reported administrative expenses of the STAR health plans and (iii) the

fees paid for similar services for other large Texas health plans.

The premium rates also include an amount for premium tax (1.75% of premium),

maintenance tax ($0.07 pmpm) and a risk margin (2.0% of premium).

The capitation rates included in this document do not include provision for the

Affordable Care Act (ACA) Health Insurance Providers Fee. HHSC will develop and

implement a procedure for reimbursing the health plans for (i) the ACA Health Insurance

Providers Fee, (ii) any applicable federal income tax impact resulting from payment of

the ACA Health Insurance Providers Fee and (iii) any applicable state premium tax

impact resulting from payment of the ACA Health Insurance Providers Fee. Such

reimbursement will be provided based on a CMS-approved methodology.

12

V. Summary

The chart below presents the results of the FY2016 STAR rating analysis and includes all

components of the premium – medical, prescription drug and NAIP. This report details

the development of the medical and NAIP components of the premium. Further

information regarding the prescription drug component of the premium rate can be found

in the report titled State of Texas Medicaid Managed Care Rate Setting Pharmacy Carve-in

State Fiscal Year 2016.

13

Under Ages Ages Ages Ages

Age 1 1-5 6-14 15-18 19-20

Monthly Adjusted Premium Rate

Aetna - Bexar 568.20 134.13 103.68 130.28 183.12

Amerigroup - Bexar 520.40 155.74 114.58 124.01 175.87

CFHP - Bexar 631.16 188.40 162.78 184.68 248.07

Superior - Bexar 643.32 185.94 157.80 173.25 239.54

Amerigroup - Dallas 471.12 182.69 151.11 173.20 232.85

Molina - Dallas 505.56 209.89 122.34 161.78 222.51

Parkland - Dallas 460.88 201.56 148.69 166.27 234.36

El Paso First - El Paso 542.90 183.49 163.87 181.37 181.42

Molina - El Paso 571.22 137.98 101.84 62.43 106.57

Superior - El Paso 605.54 180.09 157.54 196.85 198.72

Amerigroup - Harris 658.98 161.35 139.16 162.05 274.32

CHC - Harris 661.92 201.94 152.41 183.61 318.24

Molina - Harris 665.32 155.64 142.65 157.63 343.63

TCHP - Harris 523.35 164.46 143.18 182.72 303.61

United - Harris 722.98 221.80 178.77 232.86 416.49

Driscoll - Hidalgo 540.93 189.56 134.90 143.94 191.52

Molina - Hidalgo 492.42 170.42 141.58 147.15 204.80

Superior - Hidalgo 574.52 213.13 157.86 159.31 212.94

United - Hidalgo 576.19 205.10 152.96 152.19 232.05

Amerigroup - Jefferson 911.52 186.89 173.59 201.28 227.87

CHC - Jefferson 810.11 174.01 148.49 190.70 285.84

Molina - Jefferson 860.49 154.20 142.70 128.16 226.97

TCHP - Jefferson 708.81 149.53 146.62 176.23 293.69

United - Jefferson 758.59 203.04 173.25 221.09 233.63

Amerigroup - Lubbock 886.36 217.69 177.18 188.55 398.02

Firstcare - Lubbock 709.79 183.59 158.55 184.43 243.85

Superior - Lubbock 702.58 194.50 151.56 160.86 228.03

Christus - Nueces 881.92 216.71 164.97 193.98 218.54

Driscoll - Nueces 896.90 224.10 198.23 222.45 227.73

Superior - Nueces 809.63 232.62 200.47 192.53 159.56

Aetna - Tarrant 587.86 170.00 126.43 127.74 346.29

Amerigroup - Tarrant 553.32 164.56 143.71 165.01 314.62

Cook - Tarrant 557.65 182.91 160.25 182.06 317.31

Blue Cross - Travis 679.04 176.96 117.21 147.69 127.85

Sendero - Travis 691.29 193.36 132.29 178.63 204.82

Seton - Travis 563.75 162.51 116.92 159.71 173.12

Superior - Travis 669.91 162.76 136.60 170.54 199.63

Amerigroup - MRSA Central 580.81 122.30 108.97 113.60 184.56

Scott & White - MRSA Central 563.39 163.91 142.80 185.75 224.08

Superior - MRSA Central 557.03 140.86 125.49 150.02 199.97

Amerigroup - MRSA Northeast 661.48 148.58 130.48 154.29 345.05

Superior - MRSA Northeast 573.84 138.50 118.64 152.40 304.44

Amerigroup - MRSA West 617.17 184.35 165.62 197.62 354.10

Firstcare - MRSA West 585.19 179.45 157.70 199.60 279.58

Superior - MRSA West 545.89 147.38 139.56 171.64 242.43

14

Delivery

TANF Pregnant Supplemental

Adults Women Payment

Monthly Adjusted Premium Rate

Aetna - Bexar 334.08 339.23 3,266.59

Amerigroup - Bexar 384.84 378.81 3,266.59

CFHP - Bexar 420.20 472.94 3,266.59

Superior - Bexar 436.28 472.16 3,266.59

Amerigroup - Dallas 343.93 476.93 3,537.13

Molina - Dallas 405.72 475.83 3,537.13

Parkland - Dallas 321.19 477.30 3,537.13

El Paso First - El Paso 353.29 421.62 3,443.04

Molina - El Paso 334.97 334.69 3,443.04

Superior - El Paso 355.75 414.49 3,443.04

Amerigroup - Harris 467.50 487.10 3,519.20

CHC - Harris 425.43 535.48 3,519.20

Molina - Harris 531.21 448.76 3,519.20

TCHP - Harris 347.35 491.01 3,519.20

United - Harris 610.44 473.17 3,519.20

Driscoll - Hidalgo 318.35 377.09 3,409.95

Molina - Hidalgo 458.73 363.73 3,409.95

Superior - Hidalgo 409.98 384.43 3,409.95

United - Hidalgo 418.39 377.89 3,409.95

Amerigroup - Jefferson 520.00 564.88 3,394.58

CHC - Jefferson 409.47 503.74 3,394.58

Molina - Jefferson 444.00 496.16 3,394.58

TCHP - Jefferson 381.97 508.49 3,394.58

United - Jefferson 503.65 506.86 3,394.58

Amerigroup - Lubbock 404.10 486.59 3,230.39

Firstcare - Lubbock 448.82 435.43 3,230.39

Superior - Lubbock 377.33 441.16 3,230.39

Christus - Nueces 314.23 399.60 3,203.82

Driscoll - Nueces 358.43 515.39 3,203.82

Superior - Nueces 467.72 530.61 3,203.82

Aetna - Tarrant 350.81 402.30 3,635.64

Amerigroup - Tarrant 433.31 391.24 3,635.64

Cook - Tarrant 321.51 374.24 3,635.64

Blue Cross - Travis 360.79 555.57 3,247.49

Sendero - Travis 285.88 545.70 3,247.49

Seton - Travis 332.57 523.40 3,247.49

Superior - Travis 403.33 557.39 3,247.49

Amerigroup - MRSA Central 304.95 430.89 3,035.27

Scott & White - MRSA Central 365.37 446.14 3,035.27

Superior - MRSA Central 368.09 439.40 3,035.27

Amerigroup - MRSA Northeast 391.22 446.02 3,160.40

Superior - MRSA Northeast 383.48 454.25 3,160.40

Amerigroup - MRSA West 443.45 525.87 3,204.07

Firstcare - MRSA West 445.40 485.72 3,204.07

Superior - MRSA West 407.69 465.14 3,204.07

15

The above premium rates include provision for 1915(b)(3) waiver services. The STAR

health plans cover adult inpatient hospital days in excess of thirty. The chart below

presents the amount included in the FY2016 STAR health plan premium rates for

1915(b)(3) waiver services.

TANF Pregnant

Health Plan Adults Women

Monthly Premium Rate for 1915(b)(3) Services

All Plans/All Areas $ 3.85 $ 2.56

Attachment 1 presents additional information regarding the FY2016 rates.

16

VI. Actuarial Certification of FY2016 STAR Health Plan Premium Rates

I, Evan L. Dial, am a principal with the firm of Rudd and Wisdom, Inc., Consulting

Actuaries (Rudd and Wisdom). I am a Fellow of the Society of Actuaries and a member of

the American Academy of Actuaries. I meet the Academy’s qualification standards for

rendering this opinion.

Rudd and Wisdom has been retained by the Texas Health and Human Services Commission

(HHSC) to assist in the development of their state fiscal year 2016 (FY2016) managed care

rate-setting methodology, assumptions and resulting premium rates and to provide the

actuarial certification required under Centers for Medicare and Medicaid Services (CMS)

requirements 42 CFR 438.6(c).

I certify that the FY2016 Health Plan premium rates developed by HHSC and Rudd and

Wisdom satisfy the following:

(a) The premium rates have been developed in accordance with generally accepted

actuarial principals and practices;

(b) The premium rates are appropriate for the populations and services covered under the

managed care contract; and

(c) The premium rates are actuarially sound as defined in the regulations.

We have relied on historical experience data and program information provided to us by

HHSC. We have reviewed the data for reasonableness but have not audited the data.

Please note that actual health plan contractor experience will differ from these projections.

Rudd and Wisdom has developed these rates on behalf of the State to demonstrate

compliance with the CMS requirements under 42 CFR 438.6(c). Any health plan

contracting with the State should analyze its own projected premium needs before deciding

whether to contract with the State.

Evan L. Dial, F.S.A., M.A.A.A.

17

VII. Attachments

18

Attachment 1

Summary of FY2016 STAR Rating Analysis

The attached exhibit presents summary information regarding the FY2016 rates. Included on the

exhibits are current (FY2015) premium rates split between medical, prescription drug, NAIP and

delivery supplemental payment (DSP) rates; FY2016 premium rates split between medical,

prescription drug, NAIP and DSP rates; and a comparison of FY2015 and FY2016 premium

rates.

Attachment 1

FY2016 STAR Rating Summary

Under Ages Ages Ages Ages TANF Pregnant

Health Plan Age 1 1-5 6-14 15-18 19-20 Adults Women DSP

Current (3/1/2015-8/31/2015) Medical Premium Rates pmpm

Aetna - Bexar 605.40 126.66 82.67 110.85 362.25 294.63 404.62 3,266.59

Amerigroup - Bexar 468.42 155.38 56.39 79.78 268.45 217.96 334.56 3,266.59

CFHP - Bexar 529.42 135.65 88.63 116.39 298.46 334.26 383.34 3,266.59

Superior - Bexar 619.17 149.49 95.09 122.30 391.73 346.97 403.38 3,266.59

Amerigroup - Dallas 495.19 143.46 92.54 114.66 303.35 258.95 378.65 3,537.13

Molina - Dallas 524.74 168.73 74.74 87.59 253.18 252.29 363.39 3,537.13

Parkland - Dallas 521.56 155.98 95.49 117.42 304.90 243.84 383.97 3,537.13

El Paso First - El Paso 501.22 119.21 88.33 100.96 243.12 249.90 328.54 3,443.04

Molina - El Paso 506.69 145.75 53.93 67.21 161.33 186.86 295.09 3,443.04

Superior - El Paso 623.33 129.72 91.08 106.11 271.16 252.00 327.71 3,443.04

Amerigroup - Harris 577.31 114.19 70.49 96.03 337.98 335.69 381.82 3,519.20

CHC - Harris 597.87 135.67 84.46 111.20 380.77 331.32 430.83 3,519.20

Molina - Harris 585.65 153.87 88.30 114.82 297.01 309.15 388.13 3,519.20

TCHP - Harris 521.08 143.84 102.36 135.98 377.97 299.83 418.15 3,519.20

United - Harris 587.76 172.27 94.05 129.95 432.02 396.76 410.52 3,519.20

Driscoll - Hidalgo 436.31 152.77 87.90 103.11 240.41 191.05 314.74 3,409.95

Molina - Hidalgo 428.58 165.38 105.34 100.66 285.12 273.07 317.02 3,409.95

Superior - Hidalgo 487.05 185.67 110.27 113.23 278.17 293.09 323.24 3,409.95

United - Hidalgo 458.46 190.85 103.15 112.47 307.94 271.03 321.79 3,409.95

Amerigroup - Jefferson 623.70 123.63 71.10 87.48 378.57 349.01 371.91 3,394.58

CHC - Jefferson 648.06 109.08 81.86 100.66 301.24 293.34 407.22 3,394.58

Molina - Jefferson 552.80 132.47 96.06 93.87 325.75 336.63 399.85 3,394.58

TCHP - Jefferson 671.26 112.26 87.07 116.60 340.46 309.23 423.25 3,394.58

United - Jefferson 617.53 107.53 78.31 91.21 274.94 351.23 394.14 3,394.58

Amerigroup - Lubbock 558.43 115.68 68.84 99.75 355.97 202.08 375.03 3,230.39

Firstcare - Lubbock 590.35 120.82 78.91 116.74 293.52 312.58 381.29 3,230.39

Superior - Lubbock 670.75 110.37 78.01 122.64 242.11 287.41 385.39 3,230.39

Christus - Nueces 596.14 156.18 104.38 129.43 207.65 212.50 418.60 3,203.82

Driscoll - Nueces 696.50 179.33 125.71 181.49 327.34 278.45 417.95 3,203.82

Superior - Nueces 803.68 186.36 124.69 159.07 333.36 345.33 433.83 3,203.82

Aetna - Tarrant 500.59 104.57 70.56 92.49 276.12 296.81 311.61 3,635.64

Amerigroup - Tarrant 529.48 139.81 85.91 115.05 268.12 320.99 310.47 3,635.64

Cook - Tarrant 584.42 163.95 120.81 160.25 288.30 255.60 306.46 3,635.64

Blue Cross - Travis 571.72 122.59 76.80 84.71 242.83 277.09 515.23 3,247.49

Sendero - Travis 491.47 186.07 76.75 108.67 147.48 201.30 476.30 3,247.49

Seton - Travis 465.51 124.34 78.95 101.22 226.65 233.14 458.11 3,247.49

Superior - Travis 602.93 141.94 91.09 114.80 266.34 327.74 523.55 3,247.49

Amerigroup - MRSA Central 494.98 102.61 75.63 85.35 258.66 247.14 379.70 3,035.27

Scott & White - MRSA Central 561.54 141.21 89.57 125.23 284.03 267.36 380.19 3,035.27

Superior - MRSA Central 515.16 120.00 82.50 99.77 288.92 282.62 395.83 3,035.27

Amerigroup - MRSA Northeast 493.35 116.28 79.09 101.91 260.20 274.93 400.24 3,160.40

Superior - MRSA Northeast 506.83 115.64 79.46 99.59 302.88 283.71 392.48 3,160.40

Amerigroup - MRSA West 591.64 115.13 76.60 99.56 266.87 235.19 393.30 3,204.07

Firstcare - MRSA West 564.90 115.69 80.99 105.22 305.82 309.63 392.42 3,204.07

Superior - MRSA West 521.71 103.89 82.87 108.07 320.78 286.58 396.31 3,204.07

19

Attachment 1




Current (3/1/2015-8/31/2015) Prescription Drug Premium Rates pmpm

Aetna - Bexar 22.03 19.61 38.28 33.67 31.44 103.75 48.20

Amerigroup - Bexar 19.16 27.04 29.34 27.23 26.19 86.25 44.79

CFHP - Bexar 19.26 21.00 41.03 35.35 25.91 117.70 45.66

Superior - Bexar 22.53 23.15 44.02 37.15 34.00 122.18 48.05

Amerigroup - Dallas 26.79 25.10 35.30 37.96 39.41 88.62 47.05

Molina - Dallas 28.39 29.52 28.51 29.00 32.89 86.34 45.16

Parkland - Dallas 28.22 27.29 36.42 38.87 39.61 83.45 47.71

El Paso First - El Paso 29.36 23.69 34.11 36.47 55.01 93.48 35.67

Molina - El Paso 29.68 28.97 20.83 24.28 36.50 69.90 32.04

Superior - El Paso 36.51 25.78 35.17 38.34 61.36 94.27 35.58

Amerigroup - Harris 32.34 22.96 28.21 28.75 34.28 124.31 52.82

CHC - Harris 29.98 24.43 30.26 29.81 34.58 109.86 53.37

Molina - Harris 29.37 27.70 31.64 30.78 26.97 102.50 48.08

TCHP - Harris 26.13 25.90 36.68 36.45 34.32 99.41 51.80

United - Harris 31.54 33.19 36.06 37.27 41.97 140.76 54.41

Driscoll - Hidalgo 49.78 40.13 37.65 41.19 33.99 90.92 47.58

Molina - Hidalgo 48.89 43.44 45.12 40.21 40.31 129.95 47.92

Superior - Hidalgo 55.56 48.77 47.23 45.23 39.32 139.48 48.86

United - Hidalgo 52.37 50.19 44.24 44.99 43.59 129.16 48.71

Amerigroup - Jefferson 37.66 35.89 45.04 39.93 59.88 140.51 43.40

CHC - Jefferson 37.18 30.09 49.26 43.66 45.27 112.21 45.15

Molina - Jefferson 31.72 36.54 57.81 40.71 48.96 128.76 44.33

TCHP - Jefferson 38.51 30.96 52.40 50.57 51.17 118.28 46.93

United - Jefferson 36.29 30.37 48.26 40.51 42.31 137.58 44.75

Amerigroup - Lubbock 24.10 23.29 30.76 28.98 85.80 83.25 37.90

Firstcare - Lubbock 25.48 24.33 35.26 33.91 70.75 128.78 38.53

Superior - Lubbock 29.02 22.28 34.95 35.72 58.51 118.72 39.05

Christus - Nueces 28.24 29.10 44.36 31.43 21.09 87.30 45.28

Driscoll - Nueces 32.99 33.41 53.45 44.61 32.71 113.45 45.08

Superior - Nueces 39.02 35.58 54.34 40.07 34.14 144.21 47.96

Aetna - Tarrant 21.09 15.00 25.17 27.11 56.70 110.33 51.92

Amerigroup - Tarrant 22.31 20.06 30.64 33.72 55.05 119.32 51.73

Cook - Tarrant 24.63 23.52 43.09 46.97 59.20 95.01 51.06

Blue Cross - Travis 23.08 15.84 24.91 25.11 25.83 95.28 43.76

Sendero - Travis 19.84 24.04 24.89 32.21 15.69 69.22 40.45

Seton - Travis 18.79 16.07 25.60 29.83 23.99 80.39 39.24

Superior - Travis 24.34 18.34 29.55 34.02 28.33 112.70 44.46

Amerigroup - MRSA Central 20.32 15.44 32.89 29.11 25.22 93.64 37.29

Scott & White - MRSA Central 23.39 21.55 39.51 43.32 28.09 102.75 37.87

Superior - MRSA Central 21.15 18.05 35.87 34.03 28.17 107.08 38.87

Amerigroup - MRSA Northeast 26.42 24.31 41.64 38.59 37.57 122.59 43.96

Superior - MRSA Northeast 27.14 24.18 41.83 37.71 43.73 126.50 43.11

Amerigroup - MRSA West 27.14 21.38 35.17 32.49 38.14 95.53 32.82

Firstcare - MRSA West 25.91 21.48 37.19 34.34 43.71 125.76 32.75

Superior - MRSA West 23.93 19.29 38.06 35.27 45.84 116.40 33.07

20

Attachment 1




Current (3/1/2015-8/31/2015) NAIP Premium Rates pmpm

Aetna - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00


CFHP - Bexar 22.29 22.29 22.29 22.29 22.29 22.29 22.29

Superior - Bexar 5.74 5.74 5.74 5.74 5.74 5.74 5.74


Molina - Dallas 16.80 16.80 16.80 16.80 16.80 16.80 16.80

Parkland - Dallas 13.51 13.51 13.51 13.51 13.51 13.51 13.51


Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - El Paso 25.42 25.42 25.42 25.42 25.42 25.42 25.42


CHC - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00

TCHP - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00

United - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00


United - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00


CHC - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00


TCHP - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00





Christus - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Driscoll - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Aetna - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Cook - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Sendero - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Seton - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00









21

Attachment 1




Current (3/1/2015-8/31/2015) Total Premium Rates pmpm

Aetna - Bexar 627.43 146.27 120.95 144.52 393.69 398.38 452.82 3,266.59


CFHP - Bexar 570.97 178.94 151.95 174.03 346.66 474.25 451.29 3,266.59

Superior - Bexar 647.44 178.38 144.85 165.19 431.47 474.89 457.17 3,266.59


Molina - Dallas 569.93 215.05 120.05 133.39 302.87 355.43 425.35 3,537.13

Parkland - Dallas 563.29 196.78 145.42 169.80 358.02 340.80 445.19 3,537.13


Molina - El Paso 536.37 174.72 74.76 91.49 197.83 256.76 327.13 3,443.04

Superior - El Paso 685.26 180.92 151.67 169.87 357.94 371.69 388.71 3,443.04


CHC - Harris 627.85 160.10 114.72 141.01 415.35 441.18 484.20 3,519.20

Molina - Harris 615.02 181.57 119.94 145.60 323.98 411.65 436.21 3,519.20

TCHP - Harris 547.21 169.74 139.04 172.43 412.29 399.24 469.95 3,519.20

United - Harris 619.30 205.46 130.11 167.22 473.99 537.52 464.93 3,519.20


Molina - Hidalgo 477.47 208.82 150.46 140.87 325.43 403.02 364.94 3,409.95


United - Hidalgo 510.83 241.04 147.39 157.46 351.53 400.19 370.50 3,409.95


CHC - Jefferson 685.24 139.17 131.12 144.32 346.51 405.55 452.37 3,394.58


TCHP - Jefferson 709.77 143.22 139.47 167.17 391.63 427.51 470.18 3,394.58





Christus - Nueces 624.38 185.28 148.74 160.86 228.74 299.80 463.88 3,203.82

Driscoll - Nueces 729.49 212.74 179.16 226.10 360.05 391.90 463.03 3,203.82

Superior - Nueces 842.70 221.94 179.03 199.14 367.50 489.54 481.79 3,203.82

Aetna - Tarrant 521.68 119.57 95.73 119.60 332.82 407.14 363.53 3,635.64


Cook - Tarrant 609.05 187.47 163.90 207.22 347.50 350.61 357.52 3,635.64


Sendero - Travis 511.31 210.11 101.64 140.88 163.17 270.52 516.75 3,247.49

Seton - Travis 484.30 140.41 104.55 131.05 250.64 313.53 497.35 3,247.49

Superior - Travis 627.27 160.28 120.64 148.82 294.67 440.44 568.01 3,247.49









22

Attachment 1




FY2016 Medical Premium Rates pmpm

Aetna - Bexar 549.14 111.08 70.40 94.14 150.64 242.69 289.31 3,266.59


CFHP - Bexar 582.74 136.62 92.79 116.22 183.59 285.51 392.02 3,266.59

Superior - Bexar 601.70 140.89 94.49 113.19 182.64 302.70 397.88 3,266.59


Molina - Dallas 460.75 163.28 75.05 106.63 173.48 288.85 413.62 3,537.13

Parkland - Dallas 418.96 156.48 93.72 110.07 183.61 226.45 415.14 3,537.13


Molina - El Paso 538.86 114.66 72.76 43.42 93.59 243.80 296.45 3,443.04

Superior - El Paso 542.36 124.22 90.69 115.63 147.64 236.65 340.02 3,443.04


CHC - Harris 606.98 146.37 90.57 122.10 244.52 300.95 452.59 3,519.20

Molina - Harris 637.90 131.62 104.56 124.37 290.35 403.12 400.89 3,519.20

TCHP - Harris 501.78 139.07 104.95 144.16 256.54 263.59 438.63 3,519.20

United - Harris 651.62 146.89 95.74 142.92 324.94 431.03 374.52 3,519.20


Molina - Hidalgo 450.18 129.61 94.65 102.25 159.89 312.27 315.77 3,409.95


United - Hidalgo 526.76 155.99 102.26 105.75 181.16 284.81 328.06 3,409.95


CHC - Jefferson 752.68 118.27 75.17 121.63 224.27 270.36 434.77 3,394.58


TCHP - Jefferson 679.66 118.80 89.36 129.48 252.66 268.70 461.93 3,394.58





Christus - Nueces 848.56 186.51 112.71 144.50 199.44 220.58 353.21 3,203.82

Driscoll - Nueces 865.28 189.92 140.31 173.49 206.39 260.27 468.76 3,203.82

Superior - Nueces 773.63 192.18 136.61 145.41 137.91 337.20 482.31 3,203.82

Aetna - Tarrant 561.41 146.46 93.01 98.13 228.02 249.92 348.33 3,635.64


Cook - Tarrant 532.56 157.58 117.89 139.86 208.94 229.05 324.03 3,635.64


Sendero - Travis 669.92 172.42 99.74 137.57 175.53 210.12 499.44 3,247.49

Seton - Travis 546.32 144.91 88.16 123.21 149.21 244.45 478.70 3,247.49

Superior - Travis 646.36 142.52 100.78 129.08 168.57 294.29 507.46 3,247.49









23

Attachment 1




FY2016 Prescription Drug Premium Rates pmpm

Aetna - Bexar 19.06 23.05 33.28 36.14 32.48 91.39 49.92


CFHP - Bexar 18.24 21.60 39.81 38.28 34.30 104.51 50.74

Superior - Bexar 18.84 22.27 40.53 37.28 34.12 110.80 51.50


Molina - Dallas 29.31 31.11 31.79 39.65 33.53 101.37 46.71

Parkland - Dallas 26.65 29.81 39.70 40.93 35.48 79.47 46.89


Molina - El Paso 32.36 23.32 29.08 19.01 12.98 91.17 38.24

Superior - El Paso 32.57 25.26 36.24 50.61 20.47 88.49 43.86


CHC - Harris 26.09 26.72 32.99 32.66 44.87 95.63 54.04

Molina - Harris 27.42 24.02 38.09 33.26 53.28 128.09 47.87

TCHP - Harris 21.57 25.39 38.23 38.56 47.07 83.76 52.38

United - Harris 28.71 32.26 40.38 47.29 48.90 136.76 56.00


Molina - Hidalgo 42.24 40.81 46.93 44.90 44.91 146.46 47.96


United - Hidalgo 49.43 49.11 50.70 46.44 50.89 133.58 49.83


CHC - Jefferson 32.28 30.59 48.17 43.92 36.42 113.96 43.82


TCHP - Jefferson 29.15 30.73 57.26 46.75 41.03 113.27 46.56





Christus - Nueces 33.36 30.20 52.26 49.48 19.10 93.65 46.39

Driscoll - Nueces 31.62 34.18 57.92 48.96 21.34 98.16 46.63

Superior - Nueces 33.07 37.51 60.93 44.19 18.72 127.59 45.37

Aetna - Tarrant 26.45 23.54 33.42 29.61 118.27 100.89 53.97


Cook - Tarrant 25.09 25.33 42.36 42.20 108.37 92.46 50.21


Sendero - Travis 21.37 20.94 32.55 41.06 29.29 75.76 46.26

Seton - Travis 17.43 17.60 28.76 36.50 23.91 88.12 44.70

Superior - Travis 20.62 17.31 32.89 38.53 28.13 106.11 47.00









24

Attachment 1




FY2016 NAIP Premium Rates pmpm

Aetna - Bexar 0.00 0.00 0.00 0.00 0.00 0.00 0.00


CFHP - Bexar 30.18 30.18 30.18 30.18 30.18 30.18 30.18

Superior - Bexar 22.78 22.78 22.78 22.78 22.78 22.78 22.78


Molina - Dallas 15.50 15.50 15.50 15.50 15.50 15.50 15.50

Parkland - Dallas 15.27 15.27 15.27 15.27 15.27 15.27 15.27


Molina - El Paso 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - El Paso 30.61 30.61 30.61 30.61 30.61 30.61 30.61


CHC - Harris 28.85 28.85 28.85 28.85 28.85 28.85 28.85

Molina - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00

TCHP - Harris 0.00 0.00 0.00 0.00 0.00 0.00 0.00

United - Harris 42.65 42.65 42.65 42.65 42.65 42.65 42.65


Molina - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00


United - Hidalgo 0.00 0.00 0.00 0.00 0.00 0.00 0.00


CHC - Jefferson 25.15 25.15 25.15 25.15 25.15 25.15 25.15


TCHP - Jefferson 0.00 0.00 0.00 0.00 0.00 0.00 0.00





Christus - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Driscoll - Nueces 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Nueces 2.93 2.93 2.93 2.93 2.93 2.93 2.93

Aetna - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Cook - Tarrant 0.00 0.00 0.00 0.00 0.00 0.00 0.00


Sendero - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Seton - Travis 0.00 0.00 0.00 0.00 0.00 0.00 0.00

Superior - Travis 2.93 2.93 2.93 2.93 2.93 2.93 2.93









25

Attachment 1




FY2016 Total Premium Rates pmpm

Aetna - Bexar 568.20 134.13 103.68 130.28 183.12 334.08 339.23 3,266.59


CFHP - Bexar 631.16 188.40 162.78 184.68 248.07 420.20 472.94 3,266.59

Superior - Bexar 643.32 185.94 157.80 173.25 239.54 436.28 472.16 3,266.59


Molina - Dallas 505.56 209.89 122.34 161.78 222.51 405.72 475.83 3,537.13

Parkland - Dallas 460.88 201.56 148.69 166.27 234.36 321.19 477.30 3,537.13


Molina - El Paso 571.22 137.98 101.84 62.43 106.57 334.97 334.69 3,443.04

Superior - El Paso 605.54 180.09 157.54 196.85 198.72 355.75 414.49 3,443.04


CHC - Harris 661.92 201.94 152.41 183.61 318.24 425.43 535.48 3,519.20

Molina - Harris 665.32 155.64 142.65 157.63 343.63 531.21 448.76 3,519.20

TCHP - Harris 523.35 164.46 143.18 182.72 303.61 347.35 491.01 3,519.20

United - Harris 722.98 221.80 178.77 232.86 416.49 610.44 473.17 3,519.20


Molina - Hidalgo 492.42 170.42 141.58 147.15 204.80 458.73 363.73 3,409.95


United - Hidalgo 576.19 205.10 152.96 152.19 232.05 418.39 377.89 3,409.95


CHC - Jefferson 810.11 174.01 148.49 190.70 285.84 409.47 503.74 3,394.58


TCHP - Jefferson 708.81 149.53 146.62 176.23 293.69 381.97 508.49 3,394.58





Christus - Nueces 881.92 216.71 164.97 193.98 218.54 314.23 399.60 3,203.82

Driscoll - Nueces 896.90 224.10 198.23 222.45 227.73 358.43 515.39 3,203.82

Superior - Nueces 809.63 232.62 200.47 192.53 159.56 467.72 530.61 3,203.82

Aetna - Tarrant 587.86 170.00 126.43 127.74 346.29 350.81 402.30 3,635.64


Cook - Tarrant 557.65 182.91 160.25 182.06 317.31 321.51 374.24 3,635.64


Sendero - Travis 691.29 193.36 132.29 178.63 204.82 285.88 545.70 3,247.49

Seton - Travis 563.75 162.51 116.92 159.71 173.12 332.57 523.40 3,247.49

Superior - Travis 669.91 162.76 136.60 170.54 199.63 403.33 557.39 3,247.49









26

Attachment 1




FY2016 Medical Premium Rate Change

Aetna - Bexar -9.3% -12.3% -14.8% -15.1% -58.4% -17.6% -28.5% 0.0%

Amerigroup - Bexar 6.7% -15.8% 44.7% 20.6% -44.6% 29.9% -2.6% 0.0%

CFHP - Bexar 10.1% 0.7% 4.7% -0.1% -38.5% -14.6% 2.3% 0.0%

Superior - Bexar -2.8% -5.8% -0.6% -7.4% -53.4% -12.8% -1.4% 0.0%

Amerigroup - Dallas -13.9% -3.4% 1.3% -1.2% -40.6% -6.7% 9.0% 0.0%

Molina - Dallas -12.2% -3.2% 0.4% 21.7% -31.5% 14.5% 13.8% 0.0%

Parkland - Dallas -19.7% 0.3% -1.9% -6.3% -39.8% -7.1% 8.1% 0.0%

El Paso First - El Paso -4.5% 3.0% 3.7% 0.4% -47.4% -7.5% 4.0% 0.0%

Molina - El Paso 6.3% -21.3% 34.9% -35.4% -42.0% 30.5% 0.5% 0.0%

Superior - El Paso -13.0% -4.2% -0.4% 9.0% -45.6% -6.1% 3.8% 0.0%

Amerigroup - Harris 3.5% -6.7% 6.8% 2.1% -41.8% -5.1% 5.1% 0.0%

CHC - Harris 1.5% 7.9% 7.2% 9.8% -35.8% -9.2% 5.1% 0.0%

Molina - Harris 8.9% -14.5% 18.4% 8.3% -2.2% 30.4% 3.3% 0.0%

TCHP - Harris -3.7% -3.3% 2.5% 6.0% -32.1% -12.1% 4.9% 0.0%

United - Harris 10.9% -14.7% 1.8% 10.0% -24.8% 8.6% -8.8% 0.0%

Driscoll - Hidalgo 13.3% -5.6% 2.6% -3.0% -37.8% 13.4% 4.0% 0.0%

Molina - Hidalgo 5.0% -21.6% -10.1% 1.6% -43.9% 14.4% -0.4% 0.0%

Superior - Hidalgo 6.9% -14.7% -7.3% -5.3% -41.6% -5.9% 1.9% 0.0%

United - Hidalgo 14.9% -18.3% -0.9% -6.0% -41.2% 5.1% 1.9% 0.0%

Amerigroup - Jefferson 34.0% -9.3% 13.0% 30.2% -59.4% -8.8% 27.6% 0.0%

CHC - Jefferson 16.1% 8.4% -8.2% 20.8% -25.6% -7.8% 6.8% 0.0%

Molina - Jefferson 49.3% -7.5% -9.5% 0.3% -40.1% -7.2% 12.7% 0.0%

TCHP - Jefferson 1.3% 5.8% 2.6% 11.0% -25.8% -13.1% 9.1% 0.0%

United - Jefferson 14.0% 34.2% 15.6% 69.1% -36.3% -6.2% 11.1% 0.0%

Amerigroup - Lubbock 44.0% 18.2% 24.0% 0.1% -17.7% 19.3% 4.1% 0.0%

Firstcare - Lubbock 12.6% 11.9% 20.0% 3.4% -35.5% -6.0% -2.1% 0.0%

Superior - Lubbock -2.7% 26.5% 10.3% -19.2% -29.4% -16.2% -3.0% 0.0%

Christus - Nueces 42.3% 19.4% 8.0% 11.6% -4.0% 3.8% -15.6% 0.0%

Driscoll - Nueces 24.2% 5.9% 11.6% -4.4% -36.9% -6.5% 12.2% 0.0%

Superior - Nueces -3.7% 3.1% 9.6% -8.6% -58.6% -2.4% 11.2% 0.0%

Aetna - Tarrant 12.1% 40.1% 31.8% 6.1% -17.4% -15.8% 11.8% 0.0%

Amerigroup - Tarrant -2.1% -5.1% 14.0% 3.1% -25.3% -6.2% 6.2% 0.0%

Cook - Tarrant -8.9% -3.9% -2.4% -12.7% -27.5% -10.4% 5.7% 0.0%

Blue Cross - Travis 15.1% 28.7% 15.1% 34.3% -54.9% -4.3% -1.3% 0.0%

Sendero - Travis 36.3% -7.3% 30.0% 26.6% 19.0% 4.4% 4.9% 0.0%

Seton - Travis 17.4% 16.5% 11.7% 21.7% -34.2% 4.9% 4.5% 0.0%

Superior - Travis 7.2% 0.4% 10.6% 12.4% -36.7% -10.2% -3.1% 0.0%

Amerigroup - MRSA Central 12.7% 0.9% -3.3% -4.1% -37.5% -10.6% 3.1% 0.0%

Scott & White - MRSA Central -3.4% -0.3% 8.9% 8.6% -30.3% -0.5% 7.1% 0.0%

Superior - MRSA Central 3.1% -3.1% -0.7% 6.0% -40.5% -6.6% 0.0% 0.0%

Amerigroup - MRSA Northeast 27.9% 3.3% 5.9% 6.0% 15.9% -1.2% 0.2% 0.0%

Superior - MRSA Northeast 8.3% -1.9% -2.8% 8.4% -11.7% -5.7% 4.5% 0.0%

Amerigroup - MRSA West -9.5% -10.5% -8.2% 0.2% -8.7% 13.3% 9.0% 0.0%

Firstcare - MRSA West -6.4% 3.7% 1.1% 13.6% -33.8% -7.8% 5.7% 0.0%

Superior - MRSA West -3.0% 2.6% -2.8% 2.6% -42.4% -5.7% 3.6% 0.0%

27

Attachment 1




FY2016 Prescription Drug Premium Rate Change

Aetna - Bexar -13.5% 17.5% -13.1% 7.3% 3.3% -11.9% 3.6%

Amerigroup - Bexar -2.1% -14.6% 6.2% -4.6% -3.5% 15.8% 14.5%

CFHP - Bexar -5.3% 2.9% -3.0% 8.3% 32.4% -11.2% 11.1%

Superior - Bexar -16.4% -3.8% -7.9% 0.3% 0.4% -9.3% 7.2%

Amerigroup - Dallas 1.2% 5.2% 12.4% 11.0% -11.6% -4.4% -1.0%

Molina - Dallas 3.2% 5.4% 11.5% 36.7% 1.9% 17.4% 3.4%

Parkland - Dallas -5.6% 9.2% 9.0% 5.3% -10.4% -4.8% -1.7%

El Paso First - El Paso -2.1% 5.4% 7.3% 21.6% -67.7% -7.5% 23.6%

Molina - El Paso 9.0% -19.5% 39.6% -21.7% -64.4% 30.4% 19.4%

Superior - El Paso -10.8% -2.0% 3.0% 32.0% -66.6% -6.1% 23.3%

Amerigroup - Harris -11.4% -3.4% 10.6% 9.0% 31.1% -6.5% 0.7%

CHC - Harris -13.0% 9.4% 9.0% 9.6% 29.8% -13.0% 1.3%

Molina - Harris -6.6% -13.3% 20.4% 8.1% 97.6% 25.0% -0.4%

TCHP - Harris -17.5% -2.0% 4.2% 5.8% 37.2% -15.7% 1.1%

United - Harris -9.0% -2.8% 12.0% 26.9% 16.5% -2.8% 2.9%

Driscoll - Hidalgo -6.8% 13.1% 18.8% 6.6% 23.6% 11.8% 4.5%

Molina - Hidalgo -13.6% -6.1% 4.0% 11.7% 11.4% 12.7% 0.1%

Superior - Hidalgo -12.1% 2.2% 7.3% 4.2% 16.0% -7.3% 2.4%

United - Hidalgo -5.6% -2.2% 14.6% 3.2% 16.7% 3.4% 2.3%

Amerigroup - Jefferson -10.3% -9.2% 13.5% 13.3% -46.5% 13.7% 10.7%

CHC - Jefferson -13.2% 1.7% -2.2% 0.6% -19.5% 1.6% -2.9%

Molina - Jefferson 11.5% -13.3% -3.6% -16.5% -35.2% 2.3% 2.5%

TCHP - Jefferson -24.3% -0.7% 9.3% -7.6% -19.8% -4.2% -0.8%

United - Jefferson -13.1% 17.0% 23.3% 7.7% -17.0% 9.6% 1.9%

Amerigroup - Lubbock 18.3% 17.0% 24.1% 20.7% -40.1% 31.4% 11.7%

Firstcare - Lubbock -7.5% 10.8% 20.1% 24.6% -53.1% 3.6% 5.0%

Superior - Lubbock -20.3% 25.0% 10.1% -2.8% -48.7% -7.9% 3.7%

Christus - Nueces 18.1% 3.8% 17.8% 57.4% -9.4% 7.3% 2.5%

Driscoll - Nueces -4.2% 2.3% 8.4% 9.8% -34.8% -13.5% 3.4%

Superior - Nueces -15.2% 5.4% 12.1% 10.3% -45.2% -11.5% -5.4%

Aetna - Tarrant 25.4% 56.9% 32.8% 9.2% 108.6% -8.6% 3.9%

Amerigroup - Tarrant 9.5% 6.3% 14.9% 6.2% 88.6% 1.9% -1.3%

Cook - Tarrant 1.9% 7.7% -1.7% -10.2% 83.1% -2.7% -1.7%

Blue Cross - Travis -9.1% 21.0% 15.8% 35.2% -29.2% 0.3% 7.6%

Sendero - Travis 7.7% -12.9% 30.8% 27.5% 86.7% 9.4% 14.4%

Seton - Travis -7.2% 9.5% 12.3% 22.4% -0.3% 9.6% 13.9%

Superior - Travis -15.3% -5.6% 11.3% 13.3% -0.7% -5.8% 5.7%

Amerigroup - MRSA Central 5.1% 9.8% 3.3% 2.8% -16.0% -12.1% 0.3%

Scott & White - MRSA Central -11.2% 7.1% 14.6% 14.8% -7.5% -3.4% 2.7%

Superior - MRSA Central -3.8% 5.5% 6.0% 13.7% -20.0% -8.1% -2.6%

Amerigroup - MRSA Northeast 8.7% 9.5% 7.9% 15.3% 11.0% -4.0% -2.1%

Superior - MRSA Northeast -8.0% 3.8% -1.0% 17.9% -15.4% -8.4% 2.0%

Amerigroup - MRSA West -26.2% -9.2% -4.9% 11.0% 27.4% 20.5% 7.2%

Firstcare - MRSA West -23.7% 5.3% 4.8% 25.9% -7.7% -2.0% 3.9%

Superior - MRSA West -20.9% 4.1% 0.7% 13.6% -19.6% 0.3% 1.9%

28

Attachment 1




FY2016 NAIP Premium Rate Change

Aetna - Bexar 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Bexar 1.7% 1.7% 1.7% 1.7% 1.7% 1.7% 1.7%

CFHP - Bexar 35.4% 35.4% 35.4% 35.4% 35.4% 35.4% 35.4%

Superior - Bexar 296.9% 296.9% 296.9% 296.9% 296.9% 296.9% 296.9%

Amerigroup - Dallas 11.5% 11.5% 11.5% 11.5% 11.5% 11.5% 11.5%

Molina - Dallas -7.7% -7.7% -7.7% -7.7% -7.7% -7.7% -7.7%

Parkland - Dallas 13.0% 13.0% 13.0% 13.0% 13.0% 13.0% 13.0%

El Paso First - El Paso 8.4% 8.4% 8.4% 8.4% 8.4% 8.4% 8.4%

Molina - El Paso 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - El Paso 20.4% 20.4% 20.4% 20.4% 20.4% 20.4% 20.4%

Amerigroup - Harris 7.0% 7.0% 7.0% 7.0% 7.0% 7.0% 7.0%

CHC - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Molina - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TCHP - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Harris 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Driscoll - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Molina - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Hidalgo 210.1% 210.1% 210.1% 210.1% 210.1% 210.1% 210.1%

United - Hidalgo 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Jefferson 2266.3% 2266.3% 2266.3% 2266.3% 2266.3% 2266.3% 2266.3%

CHC - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Molina - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

TCHP - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

United - Jefferson 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Lubbock 371.0% 371.0% 371.0% 371.0% 371.0% 371.0% 371.0%

Firstcare - Lubbock 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Lubbock 334.6% 334.6% 334.6% 334.6% 334.6% 334.6% 334.6%

Christus - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Driscoll - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Nueces 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Aetna - Tarrant 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - Tarrant 59.4% 59.4% 59.4% 59.4% 59.4% 59.4% 59.4%

Cook - Tarrant 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Blue Cross - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Sendero - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Seton - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - Travis 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - MRSA Central -72.7% -72.7% -72.7% -72.7% -72.7% -72.7% -72.7%

Scott & White - MRSA Central 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - MRSA Central 150.7% 150.7% 150.7% 150.7% 150.7% 150.7% 150.7%

Amerigroup - MRSA Northeast -72.7% -72.7% -72.7% -72.7% -72.7% -72.7% -72.7%

Superior - MRSA Northeast 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Amerigroup - MRSA West 280.8% 280.8% 280.8% 280.8% 280.8% 280.8% 280.8%

Firstcare - MRSA West 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

Superior - MRSA West 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

29

Attachment 1




FY2016 Total Premium Rate Change

Aetna - Bexar -9.4% -8.3% -14.3% -9.9% -53.5% -16.1% -25.1% 0.0%

Amerigroup - Bexar 6.3% -15.5% 30.9% 14.0% -40.7% 25.8% -0.6% 0.0%

CFHP - Bexar 10.5% 5.3% 7.1% 6.1% -28.4% -11.4% 4.8% 0.0%

Superior - Bexar -0.6% 4.2% 8.9% 4.9% -44.5% -8.1% 3.3% 0.0%

Amerigroup - Dallas -12.4% -0.9% 5.1% 2.8% -35.1% -5.4% 8.0% 0.0%

Molina - Dallas -11.3% -2.4% 1.9% 21.3% -26.5% 14.1% 11.9% 0.0%

Parkland - Dallas -18.2% 2.4% 2.2% -2.1% -34.5% -5.8% 7.2% 0.0%

El Paso First - El Paso -3.7% 4.4% 5.5% 6.5% -45.2% -6.1% 6.2% 0.0%

Molina - El Paso 6.5% -21.0% 36.2% -31.8% -46.1% 30.5% 2.3% 0.0%

Superior - El Paso -11.6% -0.5% 3.9% 15.9% -44.5% -4.3% 6.6% 0.0%

Amerigroup - Harris 2.9% -3.8% 7.7% 4.3% -31.9% -4.7% 4.7% 0.0%

CHC - Harris 5.4% 26.1% 32.9% 30.2% -23.4% -3.6% 10.6% 0.0%

Molina - Harris 8.2% -14.3% 18.9% 8.3% 6.1% 29.0% 2.9% 0.0%

TCHP - Harris -4.4% -3.1% 3.0% 6.0% -26.4% -13.0% 4.5% 0.0%

United - Harris 16.7% 8.0% 37.4% 39.3% -12.1% 13.6% 1.8% 0.0%

Driscoll - Hidalgo 11.3% -1.7% 7.4% -0.2% -30.2% 12.9% 4.1% 0.0%

Molina - Hidalgo 3.1% -18.4% -5.9% 4.5% -37.1% 13.8% -0.3% 0.0%

Superior - Hidalgo 5.6% -9.7% -0.8% -0.5% -33.3% -5.6% 2.9% 0.0%

United - Hidalgo 12.8% -14.9% 3.8% -3.3% -34.0% 4.5% 2.0% 0.0%

Amerigroup - Jefferson 37.5% 15.9% 47.2% 55.8% -48.2% 5.8% 35.4% 0.0%

CHC - Jefferson 18.2% 25.0% 13.2% 32.1% -17.5% 1.0% 11.4% 0.0%

Molina - Jefferson 47.2% -8.8% -7.3% -4.8% -39.4% -4.6% 11.7% 0.0%

TCHP - Jefferson -0.1% 4.4% 5.1% 5.4% -25.0% -10.7% 8.1% 0.0%

United - Jefferson 16.0% 47.2% 36.9% 67.8% -26.4% 3.0% 15.5% 0.0%

Amerigroup - Lubbock 49.2% 44.8% 59.6% 34.6% -12.2% 36.2% 14.7% 0.0%

Firstcare - Lubbock 15.3% 26.5% 38.9% 22.4% -33.1% 1.7% 3.7% 0.0%

Superior - Lubbock -0.5% 40.1% 27.2% -2.3% -25.7% -8.5% 2.4% 0.0%

Christus - Nueces 41.2% 17.0% 10.9% 20.6% -4.5% 4.8% -13.9% 0.0%

Driscoll - Nueces 22.9% 5.3% 10.6% -1.6% -36.8% -8.5% 11.3% 0.0%

Superior - Nueces -3.9% 4.8% 12.0% -3.3% -56.6% -4.5% 10.1% 0.0%

Aetna - Tarrant 12.7% 42.2% 32.1% 6.8% 4.0% -13.8% 10.7% 0.0%

Amerigroup - Tarrant -0.9% -1.2% 16.7% 6.2% -4.6% -3.0% 6.1% 0.0%

Cook - Tarrant -8.4% -2.4% -2.2% -12.1% -8.7% -8.3% 4.7% 0.0%

Blue Cross - Travis 14.2% 27.8% 15.2% 34.5% -52.4% -3.1% -0.6% 0.0%

Sendero - Travis 35.2% -8.0% 30.2% 26.8% 25.5% 5.7% 5.6% 0.0%

Seton - Travis 16.4% 15.7% 11.8% 21.9% -30.9% 6.1% 5.2% 0.0%

Superior - Travis 6.8% 1.5% 13.2% 14.6% -32.3% -8.4% -1.9% 0.0%

Amerigroup - MRSA Central 11.3% -1.9% -5.4% -6.2% -36.5% -12.2% 1.7% 0.0%

Scott & White - MRSA Central -3.7% 0.7% 10.6% 10.2% -28.2% -1.3% 6.7% 0.0%

Superior - MRSA Central 3.4% 0.4% 4.1% 10.3% -37.4% -6.1% 0.6% 0.0%

Amerigroup - MRSA Northeast 25.7% 0.9% 2.5% 4.9% 13.4% -3.2% -1.1% 0.0%

Superior - MRSA Northeast 7.5% -0.9% -2.2% 11.0% -12.2% -6.5% 4.3% 0.0%

Amerigroup - MRSA West -2.8% 20.7% 29.4% 33.3% 10.2% 27.8% 18.9% 0.0%

Firstcare - MRSA West -1.0% 30.8% 33.4% 43.0% -20.0% 2.3% 14.2% 0.0%

Superior - MRSA West 0.0% 19.6% 15.4% 19.7% -33.9% 1.2% 8.3% 0.0%

30

31

Attachment 2

Individual Health Plan Experience Analysis

The following exhibits present a summary of the experience analysis performed for each health

plan. The exhibits in this section use hypothetical experience data from a sample health plan.

The actual analysis is based on experience data provided by each health plan. This data was

checked for reasonableness by comparing to other data sources provided by HHSC, the EQRO

and the health plan. Below is a brief description of each of the exhibits contained in this

attachment.

Exhibit A. This exhibit shows monthly enrollment and number of maternity deliveries by risk

group for the period September 2011 through February 2015. All of this information was

provided by HHSC.

Exhibit B. This exhibit shows a sample of a claim lag report for one risk group. This report

includes claim amounts by payment month and month of service. We analyzed claims

experience for the period September 2011 through February 2015.

Exhibit C. This exhibit shows the calculation of estimated monthly incurred claims for one risk

group. The report includes the following information: (i) monthly enrollment, (ii) claim amounts

incurred in that month and paid through February 28, 2015, (iii) estimated proportion of that

month’s incurred claims paid through February 28, 2015 (completion factor), (iv) estimated

incurred claims, (v) estimated incurred claims pmpm and (vi) the ratio of this month’s incurred

claims pmpm to the same statistic from one year ago (trend factor). The assumed completion

factors were derived based on the actual historical claims payment pattern of the health plan

using standard actuarial techniques. The claims payment patterns were analyzed by duration

since incurral to determine the average percentage of claims paid after each successive month.

Exhibit D. This exhibit is a summary of the sample health plan’s projected FY2016 cost based

on the health plan’s actual experience. The top of the exhibit shows summary base period

(FY2014) enrollment and claims experience. Next is projected FY2016 enrollment. Trend

assumptions for FY2015 and FY2016 are used to project the average base period claims cost to

FY2016. Adjustment factors are used to recognize the cost impact of benefit and provider

reimbursement changes. Combining these factors results in projected FY2016 incurred claims.

In addition to incurred claims, provision is also made for services that are capitated by the health

plan, such as vision and behavioral health services. The cost of reinsurance is also considered.

In developing the cost of reinsurance, an assumption is made regarding how much the health

plan is expected to receive in reinsurance recoveries (reimbursements from the reinsurance

company for large claims). We have assumed that the net cost of reinsurance (reinsurance

premium less reinsurance recoveries) is the minimum of (a) the actual reinsurance premium rate

and (b) $0.75 pmpm.

A provision for administrative expenses is included in the amount of $8.00 pmpm and 5.75% of

gross premium. Additional provisions are also included for premium tax (1.75% of premium),

maintenance tax ($0.07 pmpm) and risk margin (2.0% of premium).

32

At the bottom of Exhibit D is a summary of the projected FY2016 cost based on the above

assumptions. Cost projections are presented both with and without the inclusion of maternity

expenses.

Attachment 2 - Exhibit A

Sample HMO

Enrollment and Premium Experience

Number of Members

Age Age Age Age Age TANF Pregnant Total

Month <1 1-5 6-14 15-18 19-20 Adults Women Members

Sep-11 8,889 28,063 30,464 8,556 344 3,418 4,639 84,373

Oct-11 8,789 27,975 30,515 8,587 319 3,511 4,502 84,198

Nov-11 8,804 28,499 31,171 8,772 343 3,638 4,559 85,786

Dec-11 8,830 28,596 31,428 8,841 364 3,821 4,567 86,447

Jan-12 8,838 28,265 31,351 8,825 388 3,935 4,493 86,095

Feb-12 8,921 28,264 31,548 8,930 363 3,962 4,611 86,599

Mar-12 9,076 28,716 31,622 8,790 355 3,930 4,678 87,167

Apr-12 9,068 29,225 32,218 8,950 382 3,963 4,847 88,653

May-12 9,116 29,193 32,319 8,944 364 4,026 4,919 88,881

Jun-12 9,095 29,224 32,515 8,885 363 4,088 4,965 89,135

Jul-12 9,124 29,220 32,685 8,911 377 4,169 5,095 89,581

Aug-12 9,127 29,034 32,455 8,825 363 4,152 5,232 89,188

Sep-12 9,149 28,885 32,410 8,726 365 4,149 5,284 88,968

Oct-12 9,102 28,741 32,332 8,584 337 4,073 5,061 88,230

Nov-12 9,123 29,197 32,756 8,739 354 4,041 4,951 89,161

Dec-12 9,267 29,604 33,337 8,909 406 4,273 4,880 90,676

Jan-13 9,419 29,538 33,548 8,999 400 4,383 4,783 91,070

Feb-13 9,463 29,220 33,427 9,001 398 4,359 4,885 90,753

Mar-13 9,496 29,160 33,245 8,993 390 4,442 4,957 90,683

Apr-13 9,518 29,523 33,814 9,012 412 4,489 4,990 91,758

May-13 9,602 29,320 33,979 8,980 390 4,544 5,064 91,879

Jun-13 9,632 29,430 34,286 9,030 385 4,606 5,168 92,537

Jul-13 9,727 29,580 34,650 9,143 385 4,661 5,356 93,502

Aug-13 9,677 29,230 34,488 9,115 364 4,556 5,286 92,716

Sep-13 9,832 29,213 34,684 9,124 378 4,625 5,294 93,150

Oct-13 9,756 28,938 34,435 9,018 361 4,634 5,194 92,336

Nov-13 9,657 29,117 34,803 9,009 375 4,674 5,140 92,775

Dec-13 9,710 28,703 34,533 8,974 362 4,557 4,851 91,690

Jan-14 9,634 27,972 33,776 8,774 323 4,335 4,643 89,457

Feb-14 9,637 27,786 33,872 8,714 314 4,320 4,674 89,317

Mar-14 9,567 27,346 33,384 8,620 309 4,245 4,636 88,107

Apr-14 9,479 27,446 34,223 8,876 303 4,438 4,901 89,666

May-14 9,410 27,462 34,917 9,132 320 4,645 5,044 90,930

Jun-14 9,294 27,916 35,853 9,600 302 4,780 5,135 92,880

Jul-14 9,476 29,088 37,664 10,204 315 5,225 5,264 97,236

Aug-14 9,527 29,576 38,891 10,635 299 5,449 5,324 99,701

Sep-14 9,569 30,153 40,099 11,057 302 5,703 5,473 102,356

Oct-14 9,640 30,483 40,965 11,373 307 5,838 5,587 104,193

Nov-14 9,613 30,633 41,618 11,599 324 5,920 5,518 105,225

Dec-14 9,822 30,846 42,235 11,827 323 6,030 5,657 106,741

Jan-15 9,748 30,477 42,025 11,855 305 5,937 5,453 105,800

Feb-15 9,744 30,134 41,601 11,818 277 5,804 5,315 104,694

FY2012 107,677 344,274 380,291 105,816 4,325 46,613 57,107 1,046,103

FY2013 113,175 351,428 402,272 107,231 4,586 52,576 60,665 1,091,933

FY2014 114,979 340,563 421,035 110,680 3,961 55,927 60,100 1,107,245

9/14-2/15 58,137 182,726 248,543 69,529 1,838 35,233 33,002 629,008

33


Sample HMO

Enrollment and Premium Experience

Number of Deliveries

Age Age Age Age Age TANF Pregnant Total

Month <1 1-5 6-14 15-18 19-20 Adults Women Deliveries

Sep-11 - - - 25 1 57 512 595

Oct-11 - - - 15 1 50 474 540

Nov-11 - - - 23 1 58 452 534

Dec-11 - - - 19 1 50 497 567

Jan-12 - - - 23 1 55 498 577

Feb-12 - - - 26 1 52 515 594

Mar-12 - - - 21 1 64 495 581

Apr-12 - - - 17 1 49 461 528

May-12 - - - 20 1 52 509 582

Jun-12 - - - 21 1 54 478 554

Jul-12 - - - 20 1 49 544 614

Aug-12 - - - 16 1 59 606 682

Sep-12 - - - 17 1 60 559 637

Oct-12 - - - 22 1 55 535 613

Nov-12 - - - 31 1 53 507 592

Dec-12 - - - 19 1 73 531 624

Jan-13 - - - 15 1 64 557 637

Feb-13 - - - 17 1 54 506 578

Mar-13 - - - 17 1 50 493 561

Apr-13 - - - 17 1 60 458 536

May-13 - - - 16 1 59 506 582

Jun-13 - - - 20 1 73 493 587

Jul-13 - - - 23 1 55 536 615

Aug-13 - - - 13 1 67 611 692

Sep-13 - - - 12 11 65 523 611

Oct-13 - - - 10 2 61 519 592

Nov-13 - - 2 4 6 57 528 597

Dec-13 - - - 9 10 67 581 667

Jan-14 - - 1 9 7 69 558 644

Feb-14 - - - 7 4 37 474 522

Mar-14 - - - 8 3 34 521 566

Apr-14 - - - 9 3 28 487 527

May-14 - - - 6 1 22 518 547

Jun-14 - - - 7 1 11 505 524

Jul-14 - - - 2 1 13 559 575

Aug-14 - - - 5 1 10 606 622

Sep-14 - - - 7 2 7 571 587

Oct-14 - - - 6 1 11 551 569

Nov-14 - - 0 11 5 63 551 631

Dec-14 - - 0 9 6 60 542 618

Jan-15 - - 0 8 6 56 529 600

Feb-15 - - 0 8 5 50 524 588

FY2012 - - - 248 10 649 6,041 6,948

FY2013 - - - 229 10 723 6,292 7,254

FY2014 - - 3 88 50 474 6,379 6,994

9/14-2/15 - - 2 50 25 248 3,268 3,593

34

Attachment 2 - Exhibit B

Sample HMO

Claims Lag Report

Month

Incurred Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14

<1

Sep-12 27,104 -61,274 -73,775 -444 2,222 -21 -77 -15,685 187 -1,631 -7,959 -9,359 11,481 -3,650 52 -225

Oct-12 109,902 -346,955 305,432 -117,139 2,903 119,252 401 1,283 -12,167 -6,180 -2,452 -428 10,525 -23,215 8 -165

Nov-12 -3,425 -21,289 15,325 -179,883 1,721 613 1,134 1,368 -9,413 -1,002 -1,454 -131,257 133,702 -153 104 -23,600

Dec-12 4,097 -13,953 -33,061 -16,280 -36,520 -44 -294 838 0 -8,222 13,893 -225,015 229,131 -78 326 -3,010

Jan-13 -344 -10,070 5,174 -566 -380 125 -469 737 29,901 -2,251 -3,400 -134,818 146,825 -8 37 -5,934

Feb-13 61,202 71,223 266 -7,040 366 344 391 1,537 -1,140 -2,035 -744 -63,730 76,986 0 -58 -5,336

Mar-13 449,149 -3,716 -21,925 -6,655 -1,897 -188 0 1,013 2,463 -847 -8,502 -23,208 34,724 -233 25 -429

Apr-13 196,441 914,315 172,003 -6,024 52,496 85,968 -316 145 339 -200 -6,395 -125,764 130,731 -1,951 0 -4,923

May-13 656,672 348,616 335,058 21,087 2,970 2,227 1,436 -1,208 6 -1,002 -245,842 -35,395 40,273 -31 1,691 -2,458

Jun-13 329,142 308,437 373,833 498,735 157,891 7,136 -29,300 364,481 779 -1,795 30,845 -3,518 25,824 -41 -42 -1,012

Jul-13 930,867 381,551 735,516 52,924 14,373 3,660 -5,036 3,892 489,946 2,444 1,041 696,131 -9,009 -927 545 -1,022

Aug-13 1,746,823 1,440,946 628,898 696,679 208,441 129,009 159,862 11,552 62,141 31,943 -546 1,393 -12,408 -686 166,031 -16,811

Sep-13 694,272 1,796,894 875,425 679,579 46,613 584,820 2,457 7,931 9,940 -6,864 3,577 2,147 -9,382 -344,087 1,013 153,005

Oct-13 791,209 1,480,719 1,442,124 419,473 217,682 33,126 -46,994 74,696 48,296 76,065 -13,855 48,973 32,564 14,384 -101,849

Nov-13 643,860 2,340,712 746,521 317,296 76,205 -64,789 344,896 181,670 11,524 -26,552 160,767 -159,690 13,723 48,250

Dec-13 1,042,779 1,698,818 1,020,673 229,709 617,854 -8,054 147,321 367,168 -107,192 74,822 4,402 9,943 -9,490

Jan-14 1,054,658 1,920,639 1,450,271 604,314 963,190 30,529 19,717 452,188 -17,781 -11,466 76,541 125,199

Feb-14 1,022,753 1,715,783 859,037 612,429 -30,736 371,333 12,889 45,727 -28,132 27,913 -18,263

Mar-14 864,150 1,885,744 700,681 352,130 644,204 223,507 -2,792 1,971 -4,297 -1,098

Apr-14 990,514 1,513,321 686,604 180,770 364,393 317,704 -3,713 -7,210 461,245

May-14 920,695 1,366,809 1,146,683 555,341 497,558 13,678 38,753 227,444

Jun-14 857,937 1,554,631 978,790 589,471 56,424 101,366 27,531

Jul-14 978,040 1,667,947 798,993 933,737 709,346 313,506

Aug-14 845,257 1,706,414 1,046,569 356,589 670,464

Sep-14 1,088,149 2,272,327 966,321 513,580

Oct-14 979,169 1,560,357 1,113,265

Nov-14 810,005 1,974,429

Dec-14 1,089,659

Jan-15

Feb-15

4,708,646 6,295,856 5,743,475 6,337,121 4,370,536 5,435,348 4,499,433 5,223,564 5,694,836 3,642,918 5,122,197 4,899,892 6,117,408 4,762,780 4,843,466 6,521,952

35

Attachment 2 - Exhibit C

Sample HMO

Estimated Claims Experience

Inc & Pd Compl Est Inc Est Inc

Month Members Claims Factor Claims pmpm Trend

Sep-11 8,889 5,568,036 1.000 5,568,036 626.40

Oct-11 8,789 4,105,336 1.000 4,105,336 467.10

Nov-11 8,804 4,393,010 1.000 4,393,010 498.98

Dec-11 8,830 5,450,688 1.000 5,450,688 617.29

Jan-12 8,838 4,222,501 1.000 4,222,501 477.77

Feb-12 8,921 5,820,757 1.000 5,820,757 652.48

Mar-12 9,076 5,497,505 1.000 5,497,505 605.72

Apr-12 9,068 3,523,154 1.000 3,523,154 388.53

May-12 9,116 4,998,038 1.000 4,998,038 548.27

Jun-12 9,095 5,073,071 1.000 5,073,071 557.79

Jul-12 9,124 6,591,756 1.000 6,591,756 722.46

Aug-12 9,127 4,007,656 1.000 4,007,656 439.10

Sep-12 9,149 4,827,405 1.000 4,827,405 527.64 0.842

Oct-12 9,102 5,993,544 1.000 5,993,544 658.49 1.410

Nov-12 9,123 5,439,184 1.000 5,439,184 596.21 1.195

Dec-12 9,267 6,376,812 1.000 6,376,812 688.12 1.115

Jan-13 9,419 5,388,817 1.000 5,388,817 572.12 1.197

Feb-13 9,463 4,190,812 1.000 4,190,812 442.86 0.679

Mar-13 9,496 4,248,673 1.000 4,248,673 447.42 0.739

Apr-13 9,518 6,149,566 1.000 6,149,566 646.10 1.663

May-13 9,602 6,306,788 1.000 6,306,788 656.82 1.198

Jun-13 9,632 5,448,097 1.000 5,448,097 565.62 1.014

Jul-13 9,727 6,254,666 1.000 6,254,666 643.02 0.890

Aug-13 9,677 6,159,111 1.000 6,159,111 636.47 1.449

Sep-13 9,832 4,496,955 1.000 4,496,955 457.38 0.867

Oct-13 9,756 4,516,829 1.000 4,516,829 462.98 0.703

Nov-13 9,657 4,634,966 0.999 4,639,606 480.44 0.806

Dec-13 9,710 5,088,636 0.998 5,098,834 525.11 0.763

Jan-14 9,634 6,665,737 0.999 6,672,409 692.59 1.211

Feb-14 9,637 4,597,858 0.999 4,602,460 477.58 1.078

Mar-14 9,567 4,661,407 0.998 4,670,748 488.21 1.091

Apr-14 9,479 4,507,875 0.999 4,512,387 476.04 0.737

May-14 9,410 5,331,797 0.990 5,385,654 572.33 0.871

Jun-14 9,294 4,171,207 0.986 4,230,433 455.18 0.805

Jul-14 9,476 5,425,646 0.966 5,616,611 592.72 0.922

Aug-14 9,527 4,666,528 0.944 4,943,356 518.87 0.815

Sep-14 9,569 5,359,396 0.930 5,762,791 602.24 1.317

Oct-14 9,640 5,358,307 0.904 5,927,331 614.86 1.328

Nov-14 9,613 4,583,030 0.812 5,644,126 587.12 1.222

Dec-14 9,822 4,613,264 0.711 6,488,416 660.59 1.258

FY2012 107,677 59,251,507 550.27

FY2013 113,175 66,783,476 590.09 1.072

FY2014 114,979 59,386,282 516.50 0.875

9/13-12/13 38,955 18,752,223 481.38

9/14-12/14 38,645 23,822,664 616.46 1.281

Age <1

36

Attachment 2 - Exhibit D

Sample HMO

Rating Period: 9/1/2015 - 8/31/2016

Age <1 Age 1-5

Amount pmpm Amount pmpm

FY2014 Experience Period

Member Months 114,979 340,563

Estimated Incurred Claims 59,386,282 516.50 37,197,996 109.23

Projected FY2016 Member Months 119,554 373,675

Annual Cost Trend Assumptions

FY2015 7.8 % 5.7 %

FY2016 1.9 % 3.9 %

Provider Reimbursement Adjustment 0.9989 0.9489

Other Reimbursement Changes 1.0000 1.0005

Inpatient Reimbursement Changes 1.0178 1.0052

Out-of-Network Adjustment 1.0000 1.0000

Third Party Recovery Adjustment 1.0000 1.0000

Projected FY2016 Incurred Claims 68,961,520 576.83 42,775,714 114.47

Capitation Expenses

Vision 209,219 1.75 653,932 1.75

Behavioral Health 239,107 2.00 747,350 2.00

PCP 358,661 3.00 1,121,026 3.00

Other 0 0.00 0 0.00

Total 806,986 6.75 2,522,308 6.75

Reinsurance Expenses

Gross Premium 4,782 0.04 14,947 0.04

Projected Reinsurance Recoveries 0 0.00 0 0.00

Net Reinsurance Cost 4,782 0.04 14,947 0.04

Administrative Expenses

Fixed Amount 956,428 8.00 2,989,402 8.00

Percentage of Premium 4,494,409 5.75% 3,070,597 5.75%

Total 5,450,837 45.59 6,059,999 16.22

Risk Margin 1,563,273 2.00% 1,068,034 2.00%

Premium Tax 1,367,864 1.75% 934,530 1.75%

Maintenance Tax 8,369 0.07 26,157 0.07

Projected Total Cost

With deliveries 78,163,630 653.80 53,401,688 142.91

Deliveries 0 0.00 0 0.00

Without deliveries 78,163,630 653.80 53,401,688 142.91

37

38

Attachment 3

Community Experience Analysis

The following exhibits present a summary of the experience analysis performed for each service

area. HHSC utilizes an adjusted community rating methodology in setting the STAR premium

rates. The base community rates by risk group vary by service area but are the same for each

health plan in a service area. The community rates are developed by a weighted average of the

projected FY2016 cost for each health plan in the service area. The weights used in this formula

are the projected number of FY2016 clients enrolled in each health plan.

Below is a brief description of the exhibits contained in this attachment. The exhibits present the

derivation of the FY2016 STAR community rates for the following service areas:

Exhibit A – Bexar Service Area

Exhibit B – Dallas Service Area

Exhibit C – El Paso Service Area

Exhibit D – Harris Service Area

Exhibit E – Hidalgo Service Area

Exhibit F – Jefferson Service Area

Exhibit G – Lubbock Service Area

Exhibit H – Nueces Service Area

Exhibit I – Tarrant Service Area

Exhibit J – Travis Service Area

Exhibit K – MRSA Central Service Area

Exhibit L – MRSA Northeast Service Area

Exhibit M – MRSA West Service Area

These exhibits show projected FY2016 experience for each of the service areas. These amounts

were derived by summing amounts from each individual health plan in the service area. The

experience analysis for individual health plans is described in Attachment 2. The top portion of

the exhibit shows summary base period (FY2014) experience and projected FY2016 enrollment

and incurred claims experience.

In addition to incurred claims, provision is also made for services that are capitated by the health

plans, such as vision and behavioral health services. The cost of reinsurance is also considered.

In developing the cost of reinsurance we make an assumption regarding how much the health

plan is expected to receive in reinsurance recoveries (reimbursements from the reinsurance

company for large claims). We have assumed that the net cost of reinsurance (reinsurance

premium less reinsurance recoveries) is the minimum of (a) the actual reinsurance premium rate

and (b) $0.75 pmpm.

A provision for administrative expenses is included in the amount of $8.00 pmpm and 5.75% of

gross premium. Additional provisions are also included for premium tax (1.75% of premium),

maintenance tax ($0.07 pmpm) and risk margin (2.0% of premium).

The bottom of the exhibit shows a summary of the projected FY2016 cost based on these

assumptions. Cost projections are presented both with and without the inclusion of maternity

expenses



Bexar SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18

Amount pmpm Amount pmpm Amount pmpm Amount pmpm


Member Months 237,121 769,863 1,017,719 284,175

Estimated Incurred Claims 112,385,447 473.96 85,099,137 110.54 66,532,883 65.37 25,262,196 88.90

Projected FY2016 Member Months 256,366 859,698 1,320,448 397,235


FY2015 7.8 % 5.7 % 5.3 % 1.0 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %

Provider Reimbursement Adjustment 0.9989 0.9489 0.9864 1.0017

Other Reimbursement Changes 1.0000 1.0005 1.0083 1.0083

Inpatient Reimbursement Changes 1.0156 1.0049 1.0053 1.0072

Out-of-Network Adjustment 1.0000 1.0000 1.0000 1.0000

Third Party Recovery Adjustment 1.0000 1.0000 1.0000 1.0000

Projected FY2016 Incurred Claims 135,408,281 528.18 99,563,965 115.81 94,974,917 71.93 37,079,346 93.34

Capitation & Other Expenses/Refunds 481,875 1.88 2,043,564 2.38 2,944,027 2.23 813,455 2.05

Net Reinsurance Cost 100,867 0.39 350,644 0.41 585,350 0.44 182,160 0.46


Fixed Amount 2,050,929 8.00 6,877,584 8.00 10,563,583 8.00 3,177,883 8.00

Percentage of Premium 8,771,761 5.75% 6,918,803 5.75% 6,935,600 5.75% 2,622,804 5.75%

Total 10,822,691 42.22 13,796,387 16.05 17,499,183 13.25 5,800,686 14.60

Risk Margin 3,051,047 2.00% 2,406,540 2.00% 2,412,383 2.00% 912,280 2.00%

Premium Tax 2,669,667 1.75% 2,105,723 1.75% 2,110,835 1.75% 798,245 1.75%

Maintenance Tax 17,946 0.07 60,179 0.07 92,431 0.07 27,806 0.07


With deliveries (Unadjusted) 152,552,373 595.06 120,327,001 139.96 120,619,125 91.35 45,613,978 114.83

Deliveries 0 0.00 0 0.00 0 0.00 755,888 1.90

Without deliveries (Adjusted) 152,552,373 595.06 120,327,001 139.96 120,619,125 91.35 44,858,090 112.93

39



Bexar SDA Total


Member Months

Estimated Incurred Claims

Projected FY2016 Member Months


FY2015

FY2016

Provider Reimbursement Adjustment

Other Reimbursement Changes

Inpatient Reimbursement Changes

Out-of-Network Adjustment

Third Party Recovery Adjustment

Projected FY2016 Incurred Claims

Capitation & Other Expenses/Refunds

Net Reinsurance Cost


Fixed Amount

Percentage of Premium

Total

Risk Margin

Premium Tax

Maintenance Tax


With deliveries (Unadjusted)

Deliveries

Without deliveries (Adjusted)

Age 19-20 TANF Adults Pregnant Women Total


8,664 128,319 126,291 2,572,152

1,498,241 172.93 33,803,496 263.43 79,435,278 628.98 404,016,678 157.07

8,456 173,061 144,290 3,159,554

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0006 1.0017 1.0011

1.0023 1.0058 1.0089

1.0115 1.0118 1.0188

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

1,611,004 190.52 46,475,163 268.55 93,391,668 647.25 508,504,345 160.94

20,605 2.44 408,897 2.36 249,588 1.73 6,962,010 2.20

3,443 0.41 72,510 0.42 54,206 0.38 1,349,180 0.43

67,646 8.00 1,384,486 8.00 1,154,319 8.00 25,276,430 8.00

108,220 5.75% 3,072,163 5.75% 6,027,009 5.75% 34,456,359 5.75%

175,866 20.80 4,456,649 25.75 7,181,328 49.77 59,732,789 18.91

37,642 2.00% 1,068,578 2.00% 2,096,351 2.00% 11,984,821 2.00%

32,937 1.75% 935,006 1.75% 1,834,307 1.75% 10,486,718 1.75%

592 0.07 12,114 0.07 10,100 0.07 221,169 0.07

1,882,088 222.58 53,428,919 308.73 104,817,548 726.44 599,241,031 189.66

355,559 42.05 3,718,101 21.48 47,912,428 332.06 52,741,975 16.69

1,526,529 180.53 49,710,818 287.24 56,905,120 394.38 546,499,056 172.97

40



Dallas SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 349,925 1,338,586 1,777,386 449,147


Projected FY2016 Member Months 350,797 1,496,884 2,352,061 643,019


FY2015 0.0 % 3.4 % 7.5 % 3.1 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 2,806,374 8.00 11,975,075 8.00 18,816,490 8.00 5,144,150 8.00


Total 11,392,876 32.48 24,734,177 16.52 31,398,547 13.35 9,364,664 14.56

Risk Margin 2,986,609 2.00% 4,437,949 2.00% 4,376,368 2.00% 1,468,005 2.00%

Premium Tax 2,613,283 1.75% 3,883,205 1.75% 3,829,322 1.75% 1,284,504 1.75%

Maintenance Tax 24,556 0.07 104,782 0.07 164,644 0.07 45,011 0.07



Deliveries 0 0.00 0 0.00 0 0.00 1,583,186 2.46


41



Dallas SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




9,144 124,349 153,596 4,202,134

1,732,121 189.42 29,877,775 240.27 103,273,925 672.38 583,327,856 138.82

8,983 167,055 180,521 5,199,319

0.0 % 0.0 % 1.5 %

8.6 % 0.0 % 0.0 %

1.0007 1.0010 1.0003

1.0000 1.0000 1.0090

1.0056 0.9815 1.0159

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

1,859,471 207.01 39,435,767 236.07 126,319,294 699.75 720,165,446 138.51

3,574 0.40 174,757 1.05 -401,026 -2.22 6,630,858 1.28

3,519 0.39 61,544 0.37 72,707 0.40 2,071,318 0.40

71,861 8.00 1,336,437 8.00 1,444,165 8.00 41,594,551 8.00

123,200 5.75% 2,606,256 5.75% 8,097,511 5.75% 48,975,141 5.75%

195,060 21.72 3,942,693 23.60 9,541,676 52.86 90,569,692 17.42

42,852 2.00% 906,524 2.00% 2,816,525 2.00% 17,034,832 2.00%

37,496 1.75% 793,208 1.75% 2,464,460 1.75% 14,905,478 1.75%

629 0.07 11,694 0.07 12,636 0.07 363,952 0.07

2,142,600 238.53 45,326,187 271.33 140,826,272 780.11 851,741,576 163.82

512,834 57.09 4,783,326 28.63 66,123,119 366.29 73,002,464 14.04

1,629,766 181.44 40,542,862 242.69 74,703,153 413.82 778,739,112 149.78

42



El Paso SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 110,945 382,824 564,845 192,119


Projected FY2016 Member Months 113,285 419,128 696,318 247,776


FY2015 0.0 % 2.8 % 1.6 % 2.2 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 906,281 8.00 3,353,025 8.00 5,570,546 8.00 1,982,207 8.00


Total 4,205,795 37.13 6,322,274 15.08 9,200,875 13.21 3,527,945 14.24

Risk Margin 1,147,657 2.00% 1,032,782 2.00% 1,262,723 2.00% 537,648 2.00%

Premium Tax 1,004,200 1.75% 903,684 1.75% 1,104,883 1.75% 470,442 1.75%

Maintenance Tax 7,930 0.07 29,339 0.07 48,742 0.07 17,344 0.07



Deliveries 0 0.00 0 0.00 0 0.00 509,636 2.06


43



El Paso SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




4,329 53,480 54,454 1,362,995

575,941 133.04 11,109,263 207.73 31,184,583 572.68 172,960,089 126.90

3,977 67,479 60,181 1,608,144

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0000 0.9993 1.0000

1.0064 1.0196 1.0157

1.0331 1.0342 1.0551

1.0000 1.0000 1.0000

0.9936 0.9936 0.9931

593,629 149.26 14,676,043 217.49 36,678,361 609.47 215,130,016 133.78

6,220 1.56 189,095 2.80 27,085 0.45 4,656,727 2.90

1,515 0.38 29,678 0.44 27,129 0.45 658,262 0.41

31,816 8.00 539,831 8.00 481,446 8.00 12,865,152 8.00

40,247 5.75% 980,954 5.75% 2,364,694 5.75% 14,830,726 5.75%

72,064 18.12 1,520,785 22.54 2,846,140 47.29 27,695,878 17.22

13,999 2.00% 341,202 2.00% 822,502 2.00% 5,158,513 2.00%

12,249 1.75% 298,551 1.75% 719,690 1.75% 4,513,699 1.75%

278 0.07 4,724 0.07 4,213 0.07 112,570 0.07

699,954 176.00 17,060,078 252.82 41,125,120 683.36 257,925,666 160.39

157,344 39.56 1,257,866 18.64 20,667,495 343.42 22,592,342 14.05

542,610 136.43 15,802,211 234.18 20,457,625 339.94 235,333,324 146.34

44



Harris SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 661,356 2,228,877 2,803,053 735,628


Projected FY2016 Member Months 697,210 2,516,076 3,750,190 1,058,737


FY2015 1.0 % 5.2 % 4.7 % 0.8 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %







Capitation & Other Expenses/Refunds -2,565,316 -3.68 7,714,603 3.07 11,928,758 3.18 3,103,576 2.93

Net Reinsurance Cost 323,075 0.46 1,101,871 0.44 1,560,347 0.42 427,723 0.40


Fixed Amount 5,577,680 8.00 20,128,612 8.00 30,001,519 8.00 8,469,893 8.00


Total 28,830,581 41.35 40,454,155 16.08 51,118,978 13.63 16,830,164 15.90

Risk Margin 8,087,966 2.00% 7,069,754 2.00% 7,345,203 2.00% 2,907,920 2.00%

Premium Tax 7,076,970 1.75% 6,186,035 1.75% 6,427,053 1.75% 2,544,430 1.75%

Maintenance Tax 48,805 0.07 176,125 0.07 262,513 0.07 74,112 0.07



Deliveries 0 0.00 0 0.00 0 0.00 2,395,875 2.26


45



Harris SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




16,409 221,246 276,831 6,943,400

3,888,407 236.97 68,561,587 309.89 198,369,098 716.57 1,116,501,398 160.80

15,981 311,080 322,651 8,671,925

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0005 1.0008 1.0007

1.0012 1.0043 1.0089

1.0171 1.0133 1.0226

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

4,189,905 262.19 98,184,797 315.63 238,694,521 739.79 1,402,575,995 161.74

19,207 1.20 123,056 0.40 -389,571 -1.21 19,934,311 2.30

6,960 0.44 123,690 0.40 154,583 0.48 3,698,250 0.43

127,845 8.00 2,488,643 8.00 2,581,211 8.00 69,375,402 8.00

276,066 5.75% 6,413,440 5.75% 15,316,178 5.75% 95,061,859 5.75%

403,910 25.28 8,902,083 28.62 17,897,390 55.47 164,437,261 18.96

96,023 2.00% 2,230,762 2.00% 5,327,366 2.00% 33,064,994 2.00%

84,020 1.75% 1,951,916 1.75% 4,661,446 1.75% 28,931,870 1.75%

1,119 0.07 21,776 0.07 22,586 0.07 607,035 0.07

4,801,144 300.44 111,538,079 358.55 266,368,320 825.56 1,653,249,716 190.64

791,566 49.53 8,900,538 28.61 121,690,945 377.16 133,778,924 15.43

4,009,578 250.90 102,637,541 329.94 144,677,375 448.40 1,519,470,792 175.22

46

Attachment 3 - Exhibit E


Hidalgo SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 315,311 1,167,574 1,680,615 505,565


Projected FY2016 Member Months 325,452 1,250,782 2,006,062 642,942


FY2015 0.0 % 0.9 % 3.4 % 0.4 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %







Capitation & Other Expenses/Refunds 5,188,736 15.94 3,910,233 3.13 5,762,764 2.87 1,839,837 2.86



Fixed Amount 2,603,618 8.00 10,006,259 8.00 16,048,493 8.00 5,143,532 8.00


Total 12,026,889 36.95 20,798,130 16.63 27,416,603 13.67 9,134,148 14.21

Risk Margin 3,277,659 2.00% 3,753,694 2.00% 3,954,125 2.00% 1,388,040 2.00%

Premium Tax 2,867,952 1.75% 3,284,482 1.75% 3,459,860 1.75% 1,214,535 1.75%

Maintenance Tax 22,782 0.07 87,555 0.07 140,424 0.07 45,006 0.07



Deliveries 0 0.00 0 0.00 0 0.00 2,068,354 3.22


47



Hidalgo SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




11,676 132,276 135,406 3,948,423

1,852,849 158.69 33,211,163 251.07 75,923,041 560.70 546,991,186 138.53

10,207 155,852 152,913 4,544,210

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0019 0.9993 1.0010

1.0090 1.0108 1.0109

1.0166 1.0211 1.0310

1.0000 1.0000 1.0000

0.9982 0.9981 0.9989

1,804,437 176.78 40,281,452 258.46 89,349,027 584.31 639,617,887 140.75

33,227 3.26 483,585 3.10 2,934,153 19.19 20,152,535 4.43

2,253 0.22 31,169 0.20 48,417 0.32 1,001,363 0.22

81,656 8.00 1,246,814 8.00 1,223,306 8.00 36,353,679 8.00

122,134 5.75% 2,671,935 5.75% 5,944,776 5.75% 44,312,712 5.75%

203,790 19.97 3,918,749 25.14 7,168,083 46.88 80,666,391 17.75

42,482 2.00% 929,369 2.00% 2,067,748 2.00% 15,413,117 2.00%

37,171 1.75% 813,198 1.75% 1,809,280 1.75% 13,486,478 1.75%

714 0.07 10,910 0.07 10,704 0.07 318,095 0.07

2,124,075 208.10 46,468,431 298.16 103,387,412 676.12 770,655,866 169.59

458,253 44.90 3,835,477 24.61 53,414,562 349.31 59,776,645 13.15

1,665,822 163.20 42,632,954 273.55 49,972,850 326.81 710,879,221 156.44

48

Attachment 3 - Exhibit F


Jefferson SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 76,089 237,907 300,396 85,620




FY2015 0.0 % 5.0 % 5.8 % 6.7 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %







Capitation & Other Expenses/Refunds -4,856 -0.06 477,967 1.80 679,280 1.80 176,624 1.54



Fixed Amount 638,059 8.00 2,120,851 8.00 3,018,899 8.00 915,306 8.00

Percentage of Premium 3,365,933 5.75% 1,863,240 5.75% 1,841,057 5.75% 824,788 5.75%

Total 4,003,992 50.20 3,984,091 15.03 4,859,956 12.88 1,740,095 15.21

Risk Margin 1,170,759 2.00% 648,083 2.00% 640,367 2.00% 286,883 2.00%

Premium Tax 1,024,414 1.75% 567,073 1.75% 560,322 1.75% 251,023 1.75%

Maintenance Tax 5,583 0.07 18,557 0.07 26,415 0.07 8,009 0.07



Deliveries 0 0.00 0 0.00 0 0.00 260,348 2.28


49



Jefferson SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




2,940 43,769 40,491 787,211

615,318 209.29 12,416,041 283.67 27,798,300 686.53 135,840,061 172.56

2,348 55,954 47,176 942,118

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0109 1.0045 1.0025

1.0023 1.0051 1.0104

1.0147 1.0122 1.0175

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

548,727 233.68 16,220,468 289.89 33,381,010 707.59 165,991,958 176.19

3,743 1.59 23,879 0.43 -43,339 -0.92 1,313,297 1.39

968 0.41 20,840 0.37 18,687 0.40 378,768 0.40

18,785 8.00 447,634 8.00 377,407 8.00 7,536,942 8.00

36,367 5.75% 1,062,113 5.75% 2,143,515 5.75% 11,137,014 5.75%

55,153 23.49 1,509,747 26.98 2,520,923 53.44 18,673,956 19.82

12,649 2.00% 369,431 2.00% 745,571 2.00% 3,873,744 2.00%

11,068 1.75% 323,252 1.75% 652,374 1.75% 3,389,526 1.75%

164 0.07 3,917 0.07 3,302 0.07 65,948 0.07

632,473 269.35 18,471,533 330.12 37,278,528 790.20 193,687,197 205.59

103,046 43.88 1,274,069 22.77 15,983,438 338.80 17,620,901 18.70

529,426 225.46 17,197,465 307.35 21,295,090 451.40 176,066,296 186.88

50

Attachment 3 - Exhibit G


Lubbock SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 80,179 237,421 305,327 79,332




FY2015 0.3 % 9.3 % 5.2 % 3.0 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %







Capitation & Other Expenses/Refunds 64,412 0.76 203,761 0.77 294,765 0.75 82,772 0.76



Fixed Amount 673,646 8.00 2,106,330 8.00 3,141,852 8.00 871,318 8.00

Percentage of Premium 3,277,236 5.75% 2,072,445 5.75% 2,047,998 5.75% 702,886 5.75%

Total 3,950,882 46.92 4,178,775 15.87 5,189,851 13.21 1,574,204 14.45

Risk Margin 1,139,908 2.00% 720,850 2.00% 712,347 2.00% 244,482 2.00%

Premium Tax 997,420 1.75% 630,744 1.75% 623,304 1.75% 213,922 1.75%

Maintenance Tax 5,894 0.07 18,430 0.07 27,491 0.07 7,624 0.07



Deliveries 0 0.00 0 0.00 0 0.00 160,149 1.47


51



Lubbock SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




2,416 36,746 45,759 787,181

410,641 169.97 8,885,716 241.81 27,042,360 590.98 131,296,118 166.79

2,549 48,240 47,961 947,893

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0126 1.0118 1.0062

1.0012 1.0058 1.0085

1.0118 1.0180 1.0275

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

482,604 189.34 12,084,749 250.51 29,553,081 616.19 161,755,434 170.65

1,896 0.74 41,475 0.86 35,073 0.73 724,155 0.76

1,118 0.44 17,992 0.37 21,179 0.44 402,837 0.42

20,391 8.00 385,920 8.00 383,689 8.00 7,583,146 8.00

32,161 5.75% 796,328 5.75% 1,905,847 5.75% 10,834,901 5.75%

52,552 20.62 1,182,248 24.51 2,289,536 47.74 18,418,047 19.43

11,186 2.00% 276,984 2.00% 662,903 2.00% 3,768,661 2.00%

9,788 1.75% 242,361 1.75% 580,040 1.75% 3,297,579 1.75%

178 0.07 3,377 0.07 3,357 0.07 66,353 0.07

559,322 219.44 13,849,185 287.09 33,145,170 691.08 188,433,066 198.79

61,854 24.27 1,057,319 21.92 15,151,255 315.91 16,430,577 17.33

497,468 195.17 12,791,867 265.17 17,993,914 375.18 172,002,489 181.46

52

Attachment 3 - Exhibit H


Nueces SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 85,323 254,654 340,305 94,635




FY2015 4.0 % 4.6 % 8.4 % 0.0 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %







Capitation & Other Expenses/Refunds 5,484,314 60.30 5,782,762 20.43 8,758,535 20.23 2,587,728 20.20



Fixed Amount 727,604 8.00 2,264,362 8.00 3,463,922 8.00 1,024,711 8.00


Total 5,292,511 58.19 5,395,544 19.06 6,968,243 16.09 2,292,303 17.90

Risk Margin 1,587,793 2.00% 1,089,107 2.00% 1,218,894 2.00% 440,901 2.00%

Premium Tax 1,389,319 1.75% 952,968 1.75% 1,066,532 1.75% 385,789 1.75%

Maintenance Tax 6,367 0.07 19,813 0.07 30,309 0.07 8,966 0.07



Deliveries 0 0.00 0 0.00 0 0.00 319,110 2.49


53



Nueces SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




3,132 40,787 49,091 867,926

562,626 179.64 9,952,067 244.00 29,554,157 602.03 172,448,965 198.69

2,888 53,905 54,135 1,046,003

0.0 % 0.0 % 0.5 %

8.6 % 0.0 % 0.0 %

1.0074 1.0140 1.0045

1.0081 1.0108 1.0141

1.0210 1.0226 1.0355

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

584,179 202.28 13,785,731 255.74 34,549,612 638.21 214,476,362 205.04

63,971 22.15 939,085 17.42 3,410,684 63.00 27,027,080 25.84

1,618 0.56 27,613 0.51 34,462 0.64 582,942 0.56

23,103 8.00 431,239 8.00 433,080 8.00 8,368,022 8.00

42,764 5.75% 964,948 5.75% 2,441,788 5.75% 15,917,501 5.75%

65,868 22.81 1,396,187 25.90 2,874,868 53.11 24,285,523 23.22

14,875 2.00% 335,634 2.00% 849,318 2.00% 5,536,522 2.00%

13,015 1.75% 293,680 1.75% 743,153 1.75% 4,844,457 1.75%

202 0.07 3,773 0.07 3,789 0.07 73,220 0.07

743,727 257.53 16,781,703 311.32 42,465,886 784.44 276,826,105 264.65

166,350 57.60 1,599,173 29.67 17,166,254 317.10 19,250,887 18.40

577,377 199.93 15,182,530 281.65 25,299,632 467.34 257,575,218 246.25

54

Attachment 3 - Exhibit I


Tarrant SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 267,380 832,870 1,075,715 271,619


Projected FY2016 Member Months 285,868 963,314 1,468,940 398,426


FY2015 2.0 % 4.8 % 4.2 % 4.5 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 2,286,948 8.00 7,706,514 8.00 11,751,518 8.00 3,187,407 8.00


Total 11,103,054 38.84 15,733,999 16.33 20,618,508 14.04 6,067,204 15.23

Risk Margin 3,066,472 2.00% 2,792,169 2.00% 3,084,170 2.00% 1,001,669 2.00%

Premium Tax 2,683,163 1.75% 2,443,148 1.75% 2,698,649 1.75% 876,460 1.75%

Maintenance Tax 20,011 0.07 67,432 0.07 102,826 0.07 27,890 0.07



Deliveries 0 0.00 0 0.00 0 0.00 868,724 2.18


55



Tarrant SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




6,224 104,169 122,772 2,680,749

1,236,185 198.62 25,863,582 248.28 74,025,539 602.95 427,969,653 159.65

6,329 144,201 142,947 3,410,025

0.6 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0006 1.0017 1.0007

1.0003 1.0041 1.0095

1.0116 1.0192 1.0317

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

1,390,461 219.71 36,702,072 254.52 89,829,712 628.41 546,748,704 160.34

-2,049 -0.32 209,834 1.46 -299,166 -2.09 4,517,467 1.32

2,922 0.46 68,917 0.48 75,653 0.53 1,549,334 0.45

50,630 8.00 1,153,607 8.00 1,143,575 8.00 27,280,199 8.00

91,645 5.75% 2,423,547 5.75% 5,766,505 5.75% 36,872,076 5.75%

142,275 22.48 3,577,154 24.81 6,910,081 48.34 64,152,275 18.81

31,876 2.00% 842,973 2.00% 2,005,741 2.00% 12,825,070 2.00%

27,892 1.75% 737,601 1.75% 1,755,023 1.75% 11,221,936 1.75%

443 0.07 10,094 0.07 10,006 0.07 238,702 0.07

1,593,820 251.84 42,148,645 292.29 100,287,051 701.57 641,253,488 188.05

265,304 41.92 3,708,550 25.72 52,429,837 366.78 57,272,414 16.80

1,328,516 209.92 38,440,095 266.57 47,857,214 334.79 583,981,073 171.25

56

Attachment 3 - Exhibit J


Travis SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 148,868 480,631 605,230 147,252




FY2015 0.0 % 4.6 % 6.8 % 1.9 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 1,274,996 8.00 4,335,559 8.00 6,504,428 8.00 1,727,611 8.00


Total 7,146,698 44.84 8,938,692 16.49 11,064,179 13.61 3,319,930 15.37

Risk Margin 2,042,331 2.00% 1,601,090 2.00% 1,586,000 2.00% 553,850 2.00%

Premium Tax 1,787,040 1.75% 1,400,954 1.75% 1,387,750 1.75% 484,619 1.75%

Maintenance Tax 11,156 0.07 37,936 0.07 56,914 0.07 15,117 0.07



Deliveries 0 0.00 0 0.00 0 0.00 413,963 1.92


57



Travis SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




4,064 69,820 64,588 1,520,455

634,439 156.11 17,341,173 248.37 45,683,524 707.31 257,028,199 169.05

3,477 87,286 72,918 1,894,005

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0024 1.0046 1.0017

1.0005 1.0068 1.0097

1.0157 1.0140 1.0247

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

600,436 172.70 22,233,907 254.72 53,453,027 733.06 319,145,964 168.50

9,307 2.68 229,845 2.63 195,297 2.68 5,011,644 2.65

586 0.17 17,170 0.20 14,109 0.19 325,407 0.17

27,814 8.00 698,289 8.00 583,345 8.00 15,152,041 8.00

40,560 5.75% 1,473,100 5.75% 3,446,879 5.75% 21,587,446 5.75%

68,375 19.67 2,171,389 24.88 4,030,224 55.27 36,739,488 19.40

14,108 2.00% 512,383 2.00% 1,198,915 2.00% 7,508,677 2.00%

12,344 1.75% 448,335 1.75% 1,049,050 1.75% 6,570,092 1.75%

243 0.07 6,110 0.07 5,104 0.07 132,580 0.07

705,399 202.89 25,619,139 293.51 59,945,727 822.10 375,433,852 198.22

155,814 44.82 1,782,249 20.42 23,146,703 317.43 25,498,730 13.46

549,585 158.07 23,836,889 273.09 36,799,023 504.66 349,935,122 184.76

58

Attachment 3 - Exhibit K


MRSA Central SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 128,035 404,809 503,221 134,142




FY2015 9.2 % 4.4 % 6.2 % 2.2 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 1,114,960 8.00 3,685,522 8.00 5,365,078 8.00 1,511,585 8.00


Total 5,435,298 39.00 6,905,735 14.99 8,635,007 12.88 2,745,941 14.53

Risk Margin 1,502,726 2.00% 1,120,074 2.00% 1,137,367 2.00% 429,341 2.00%

Premium Tax 1,314,885 1.75% 980,065 1.75% 995,196 1.75% 375,674 1.75%

Maintenance Tax 9,756 0.07 32,248 0.07 46,944 0.07 13,226 0.07



Deliveries 0 0.00 0 0.00 0 0.00 489,047 2.59


59

Attachment 3 - Exhibit K


MRSA Central SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




4,276 67,226 66,065 1,307,774

764,793 178.86 15,582,160 231.79 39,012,613 590.52 187,233,012 143.17

3,793 84,089 74,848 1,622,374

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0187 1.0188 1.0069

1.0008 1.0060 1.0092

1.0224 1.0261 1.0400

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

767,963 202.47 20,497,823 243.76 46,710,073 624.06 243,648,202 150.18

4,205 1.11 86,950 1.03 81,817 1.09 1,904,286 1.17

1,172 0.31 29,245 0.35 23,757 0.32 446,462 0.28

30,343 8.00 672,714 8.00 598,787 8.00 12,978,988 8.00

51,080 5.75% 1,352,846 5.75% 3,012,852 5.75% 16,461,615 5.75%

81,423 21.47 2,025,560 24.09 3,611,639 48.25 29,440,603 18.15

17,767 2.00% 470,555 2.00% 1,047,949 2.00% 5,725,779 2.00%

15,546 1.75% 411,736 1.75% 916,955 1.75% 5,010,057 1.75%

266 0.07 5,886 0.07 5,239 0.07 113,566 0.07

888,341 234.21 23,527,754 279.80 52,397,429 700.05 286,288,955 176.46

206,179 54.36 1,811,050 21.54 22,474,828 300.27 24,981,103 15.40

682,162 179.85 21,716,705 258.26 29,922,601 399.78 261,307,851 161.07

60

Attachment 3 - Exhibit L


MRSA Northeast SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 166,748 534,431 680,355 184,371




FY2015 3.2 % 5.1 % 5.1 % 4.4 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 1,350,672 8.00 4,763,988 8.00 7,027,259 8.00 2,017,674 8.00


Total 6,924,507 41.01 8,726,460 14.65 11,045,913 12.57 3,615,456 14.34

Risk Margin 1,938,725 2.00% 1,378,251 2.00% 1,397,793 2.00% 555,750 2.00%

Premium Tax 1,696,385 1.75% 1,205,970 1.75% 1,223,068 1.75% 486,281 1.75%

Maintenance Tax 11,818 0.07 41,685 0.07 61,489 0.07 17,655 0.07



Deliveries 0 0.00 0 0.00 0 0.00 557,958 2.21


61

Attachment 3 - Exhibit L


MRSA Northeast SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




5,145 80,422 84,718 1,736,190

1,354,053 263.18 19,462,109 242.00 53,768,469 634.68 251,868,202 145.07

4,681 97,743 96,710 2,094,084

0.0 % 0.0 % 0.0 %

8.6 % 0.0 % 0.0 %

1.0112 1.0181 1.0079

1.0011 1.0065 1.0102

1.0032 1.0198 1.0198

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

1,358,800 290.26 24,718,428 252.89 63,733,013 659.01 309,605,627 147.85

8,130 1.74 169,481 1.73 169,529 1.75 3,641,731 1.74

270 0.06 5,682 0.06 5,335 0.06 120,064 0.06

37,451 8.00 781,943 8.00 773,682 8.00 16,752,669 8.00

89,267 5.75% 1,631,753 5.75% 4,110,032 5.75% 20,983,794 5.75%

126,717 27.07 2,413,696 24.69 4,883,714 50.50 37,736,464 18.02

31,049 2.00% 567,566 2.00% 1,429,576 2.00% 7,298,711 2.00%

27,168 1.75% 496,621 1.75% 1,250,879 1.75% 6,386,372 1.75%

328 0.07 6,842 0.07 6,770 0.07 146,586 0.07

1,552,463 331.63 28,378,315 290.34 71,478,817 739.10 364,935,555 174.27

243,932 52.11 2,075,764 21.24 32,068,248 331.59 34,945,902 16.69

1,308,530 279.52 26,302,551 269.10 39,410,569 407.51 329,989,653 157.58

62

Attachment 3 - Exhibit M


MRSA West SDA Total

Age <1 Age 1-5 Age 6-14 Age 15-18



Member Months 168,507 446,109 575,394 152,831




FY2015 0.8 % 3.3 % 4.3 % 0.0 %

FY2016 1.9 % 3.9 % 4.5 % 2.2 %










Fixed Amount 1,403,609 8.00 4,053,952 8.00 6,047,690 8.00 1,722,230 8.00


Total 6,662,892 37.98 7,287,624 14.38 9,481,246 12.54 3,127,549 14.53

Risk Margin 1,829,316 2.00% 1,124,756 2.00% 1,194,280 2.00% 488,807 2.00%

Premium Tax 1,600,651 1.75% 984,161 1.75% 1,044,995 1.75% 427,706 1.75%

Maintenance Tax 12,282 0.07 35,472 0.07 52,917 0.07 15,070 0.07



Deliveries 0 0.00 0 0.00 0 0.00 347,224 1.61


63

Attachment 3 - Exhibit M


MRSA West SDA Total


Member Months




FY2015

FY2016










Fixed Amount


Total

Risk Margin

Premium Tax

Maintenance Tax



Deliveries




4,914 63,863 90,585 1,502,204

879,592 179.00 15,903,540 249.03 57,207,454 631.53 229,245,879 152.61

5,038 80,727 101,475 1,840,675

0.0 % 0.0 % 0.5 %

8.6 % 0.0 % 0.0 %

1.0188 1.0230 1.0114

1.0005 1.0067 1.0091

1.0085 1.0132 1.0146

1.0000 1.0000 1.0000

1.0000 1.0000 1.0000

1,006,663 199.83 20,976,557 259.85 66,691,803 657.22 282,764,051 153.62

5,391 1.07 92,196 1.14 95,430 0.94 2,081,106 1.13

1,746 0.35 24,925 0.31 42,223 0.42 579,968 0.32

40,301 8.00 645,817 8.00 811,801 8.00 14,725,400 8.00

66,996 5.75% 1,381,598 5.75% 4,298,100 5.75% 19,078,524 5.75%

107,297 21.30 2,027,415 25.11 5,109,901 50.36 33,803,924 18.36

23,303 2.00% 480,556 2.00% 1,494,991 2.00% 6,636,008 2.00%

20,390 1.75% 420,486 1.75% 1,308,117 1.75% 5,806,507 1.75%

353 0.07 5,651 0.07 7,103 0.07 128,847 0.07

1,165,142 231.29 24,027,785 297.64 74,749,570 736.63 331,800,410 180.26

137,351 27.27 1,826,375 22.62 32,618,830 321.45 34,929,780 18.98

1,027,790 204.02 22,201,410 275.02 42,130,740 415.18 296,870,630 161.28

64

65

Attachment 4

Trend Analysis

The FY2016 rating methodology uses assumed trend factors to adjust the base period claims cost

to the projection period. The cost trend factors used in this analysis are a combination of

utilization and inflation components. The projected trend rate assumptions were developed by

the actuary based on an analysis of recent experience under the various health plans. Trend

assumptions vary by service area for FY2015 and are established on a statewide basis for

FY2016. All trend assumptions vary by risk group.

The trend analysis included a review of health plan claims experience data through February 28,

2015. Based on this information, estimates of monthly incurred claims were made through

December 2014. The claims cost and trend experience was reviewed separately by service area

and risk group.

Exhibit A provides a summary of the FY2012, FY2013, FY2014 and FY2015 trends by service

area and risk group. The FY2015 trend represents the trend during the period September 2014

through December 2014. All trends have been calculated as the average cost per member per

month during the specified time period compared to the same time period during the prior fiscal

year. For example, the FY2014 trend is calculated as the average cost per member per month

during FY2014 divided by the average cost per member per month during FY2013. All trends

have been adjusted to remove the impact of the various provider reimbursement changes that

have impacted the program.

On Exhibit A, the service area trends have been combined into a statewide weighted average by

weighting the service area specific trends by each area’s proportion of the total incurred claims.

The Hidalgo service area has been excluded from the statewide weighted average because this

area has experienced significant managed care savings resulting in reductions in the average cost

since it effective date of March 1, 2012. Due to these managed care reductions, the Hidalgo

service area experience is not indicative of the underlying statewide trend and has therefore been

excluded.

The FY2015 trend assumptions were developed from two components: (i) the actual service area

specific estimated trend for the period September 2014 through December 2014 and (ii) the

statewide projected trend for the period January 2015 through August 2015. The trends for the

final eight months of FY2015 were projected using statewide experience from FY2012 (3/10

weight), FY2013 (3/10 weight), FY2014 (3/10 weight) and 9/2014-12/2014 (1/10 weight). The

weighting of each time period was based on the number of months within each time period. All

projected statewide trends were limited to no less than 0.0%

Blending the area specific trends for the period September 2014 through December 2014 with

the statewide projected trend for the period January 2015 through August 2015 was done via the

following formula:

FY2015 SDA Trend = (9/14-12/14 actual SDA trend) x 4 + (1/15-8/15 Statewide) x 8

12

66

Exhibit B provides a summary of the derivation of the FY2015 service area and statewide trend

components.

The FY2016 trend assumptions were then developed from a simple average of the FY2012 trend,

FY2013 trend, FY2014 trend and FY2015 trend.

Exhibit C provides a summary of the final FY2015 and FY2016 trend assumptions.


FY2016 STAR Rating

Analysis of STAR HMO Cost Trend Factors

Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis

Age <1

FY2012 1.057 1.022 1.066 1.089 0.943 0.957 1.073 0.930

FY2013 0.947 1.005 1.158 1.002 1.109 1.034 1.106 1.134 1.060 1.001

FY2014 0.941 0.849 0.868 0.988 1.076 1.120 1.100 1.174 0.962 1.138

FY2015 1.197 0.744 0.926 0.994 0.904 0.861 0.971 1.083 1.022 0.897

Age 1-5

FY2012 1.055 1.028 0.973 1.057 1.017 1.052 1.145 1.022

FY2013 1.007 1.053 1.094 1.097 0.839 1.027 1.078 1.038 0.972 1.011

FY2014 0.988 0.996 1.000 0.996 0.876 1.060 1.105 1.059 1.028 1.041

FY2015 1.093 1.024 1.007 1.077 0.950 1.073 1.201 1.060 1.068 1.061

Age 6-14

FY2012 1.091 1.042 1.037 1.041 0.978 1.008 1.138 1.096

FY2013 0.982 1.048 1.134 1.076 0.829 1.040 1.082 1.046 0.993 1.002

FY2014 0.988 0.955 1.041 1.042 0.929 0.969 1.133 1.121 1.083 1.072

FY2015 1.069 1.136 0.957 1.049 1.011 1.084 1.066 1.161 1.037 1.113

Age 15-18

FY2012 1.047 1.028 1.030 1.019 0.942 1.074 1.112 0.918

FY2013 0.989 1.056 1.067 1.023 0.948 0.912 1.078 1.054 1.099 0.993

FY2014 0.923 0.947 1.002 1.093 0.929 1.095 0.879 0.973 0.917 1.103

FY2015 0.986 1.049 1.022 0.978 0.968 1.155 1.044 0.922 1.091 1.013

Age 19-20

FY2012 1.320 1.772 1.086 1.596 1.509 1.243 1.656 1.203

FY2013 0.931 0.963 0.878 0.927 1.045 0.977 0.830 0.958 0.831 1.021

FY2014 0.701 0.859 0.730 0.914 0.752 0.892 0.837 0.860 1.001 0.864

FY2015 0.700 0.668 0.828 0.748 0.619 0.639 0.448 0.639 0.866 0.728

67


FY2016 STAR Rating


Bexar Dallas El Paso Harris Hidalgo Jefferson Lubbock Nueces Tarrant Travis

TANF Adult

FY2012 1.000 1.077 0.953 1.042 0.873 0.984 1.108 1.124

FY2013 0.863 0.970 1.004 0.946 1.021 1.075 1.013 0.942 0.910 1.027

FY2014 0.892 0.923 0.972 0.941 0.999 0.944 0.975 0.908 0.883 0.932

FY2015 0.806 0.821 0.972 0.803 0.879 0.824 0.944 0.736 0.798 0.821

Pregnant Women

FY2012 1.053 1.001 0.998 1.007 0.994 0.975 0.981 0.966

FY2013 0.880 0.979 1.062 0.999 0.992 1.020 0.995 0.955 0.949 1.003

FY2014 0.979 1.010 0.962 1.022 0.988 1.047 0.976 0.986 1.011 0.963

FY2015 0.994 1.046 0.946 0.975 0.977 0.970 0.994 1.016 0.977 0.973

Footnotes

(1) Hidalgo SDA excluded from the statewide weighted average trend calculation due to significant managed care savings that have resulted from

STAR expansion into the Hidalgo SDA effective March 1, 2012.

68


FY2016 STAR Rating


MRSA MRSA MRSA Weighted

Central Northeast West Average (1)

Age <1

FY2012 1.047

FY2013 1.068 0.975 0.933 1.020

FY2014 0.914 1.133 0.946 0.994

FY2015 1.238 1.060 0.987 1.002

Age 1-5

FY2012 1.054

FY2013 1.049 0.967 0.984 1.046

FY2014 0.994 0.982 0.989 1.007

FY2015 1.054 1.075 1.020 1.064

Age 6-14

FY2012 1.061

FY2013 1.044 1.075 1.000 1.044

FY2014 0.977 0.964 0.929 1.021

FY2015 1.095 1.061 1.039 1.073

Age 15-18

FY2012 1.031

FY2013 0.875 0.938 1.030 1.030

FY2014 1.015 1.004 1.017 1.009

FY2015 1.020 1.088 0.873 1.014

Age 19-20

FY2012 1.492

FY2013 1.228 0.960 1.040 0.943

FY2014 0.884 1.323 0.828 0.910

FY2015 0.697 0.586 0.843 0.724

69


FY2016 STAR Rating


MRSA MRSA MRSA Weighted

Central Northeast West Average (1)

TANF Adult

FY2012 1.040

FY2013 1.211 0.993 1.051 0.967

FY2014 0.932 0.951 0.948 0.929

FY2015 0.878 0.888 0.816 0.828

Pregnant Women

FY2012 1.004

FY2013 1.076 1.022 0.973 0.982

FY2014 0.976 1.008 1.020 1.003

FY2015 1.001 0.981 1.016 0.993

Footnotes

(1) Hidalgo SDA excluded from the statewide weighted average trend calculation due to significant managed care savings that have resulted from

STAR expansion into the Hidalgo SDA effective March 1, 2012.

70


FY2016 STAR Rating

Average Historical Trends

FY2012 FY2013 FY2014 9/14-12/14 (2)

Statewide Average Trend (1)

Age <1 4.7 % 2.0 % -0.6 % 0.2 %

Age 1-5 5.4 % 4.6 % 0.7 % 6.4 %

Age 6-14 6.1 % 4.4 % 2.1 % 7.3 %

Age 15-18 3.1 % 3.0 % 0.9 % 1.4 %

Age 19-20 49.2 % -5.7 % -9.0 % -27.6 %

TANF - Adults 4.0 % -3.3 % -7.1 % -17.2 %

Pregnant Women 0.4 % -1.8 % 0.3 % -0.7 %

Age Age Age Age Age TANF Pregnant

<1 1-5 6-14 15-18 19-20 Adult Women

9/2014-12/2014 (2)

Bexar 19.7 % 9.3 % 6.9 % -1.4 % -30.0 % -19.4 % -0.6 %

Dallas -25.6 % 2.4 % 13.6 % 4.9 % -33.2 % -17.9 % 4.6 %

El Paso -7.4 % 0.7 % -4.3 % 2.2 % -17.2 % -2.8 % -5.4 %

Harris -0.6 % 7.7 % 4.9 % -2.2 % -25.2 % -19.7 % -2.5 %

Hidalgo -9.6 % -5.0 % 1.1 % -3.2 % -38.1 % -12.1 % -2.3 %

Jefferson -13.9 % 7.3 % 8.4 % 15.5 % -36.1 % -17.6 % -3.0 %

Lubbock -2.9 % 20.1 % 6.6 % 4.4 % -55.2 % -5.6 % -0.6 %

Nueces 8.3 % 6.0 % 16.1 % -7.8 % -36.1 % -26.4 % 1.6 %

Tarrant 2.2 % 6.8 % 3.7 % 9.1 % -13.4 % -20.2 % -2.3 %

Travis -10.3 % 6.1 % 11.3 % 1.3 % -27.2 % -17.9 % -2.7 %

MRSA Central 23.8 % 5.4 % 9.5 % 2.0 % -30.3 % -12.2 % 0.1 %

MRSA Northeast 6.0 % 7.5 % 6.1 % 8.8 % -41.4 % -11.2 % -1.9 %

MRSA West -1.3 % 2.0 % 3.9 % -12.7 % -15.7 % -18.4 % 1.6 %

Statewide Average 0.2 % 6.4 % 7.3 % 1.4 % -27.6 % -17.2 % -0.7 %

1/2015-8/2015 (3) 1.9 % 3.9 % 4.5 % 2.2 % 7.6 % 0.0 % 0.0 %

Footnotes

(1) All trends are net of reimbursement changes.

(2) Average trend during the period 9/1/2014-12/31/2014.

(3) Assumed trend during the period 1/1/2015-8/31/2015. Equals weighted average of the Statewide FY2012, FY2013, FY2014 and 9/14-12/14 trends.

Weighted based on number of months. Limited to no less than 0.0%.

71


FY2016 STAR Rating

Trend Assumptions


<1 1-5 6-14 15-18 19-20 Adult Women

FY2015 (1)

Bexar 7.8 % 5.7 % 5.3 % 1.0 % 0.0 % 0.0 % 0.0 %

Dallas 0.0 % 3.4 % 7.5 % 3.1 % 0.0 % 0.0 % 1.5 %

El Paso 0.0 % 2.8 % 1.6 % 2.2 % 0.0 % 0.0 % 0.0 %

Harris 1.0 % 5.2 % 4.7 % 0.8 % 0.0 % 0.0 % 0.0 %

Hidalgo 0.0 % 0.9 % 3.4 % 0.4 % 0.0 % 0.0 % 0.0 %

Jefferson 0.0 % 5.0 % 5.8 % 6.7 % 0.0 % 0.0 % 0.0 %

Lubbock 0.3 % 9.3 % 5.2 % 3.0 % 0.0 % 0.0 % 0.0 %

Nueces 4.0 % 4.6 % 8.4 % 0.0 % 0.0 % 0.0 % 0.5 %

Tarrant 2.0 % 4.8 % 4.2 % 4.5 % 0.6 % 0.0 % 0.0 %

Travis 0.0 % 4.6 % 6.8 % 1.9 % 0.0 % 0.0 % 0.0 %

MRSA Central 9.2 % 4.4 % 6.2 % 2.2 % 0.0 % 0.0 % 0.0 %

MRSA Northeast 3.2 % 5.1 % 5.1 % 4.4 % 0.0 % 0.0 % 0.0 %

MRSA West 0.8 % 3.3 % 4.3 % 0.0 % 0.0 % 0.0 % 0.5 %

Statewide Average 1.3 % 4.7 % 5.4 % 2.0 % 0.0 % 0.0 % 0.0 %

FY2016 (2) 1.9 % 3.9 % 4.5 % 2.2 % 8.6 % 0.0 % 0.0 %

Footnotes

(1) Weighted Average trend based on SDA specific actual (9/14-12/14) and statewide projected (1/15-8/15) trends. Weighted based on number of months.

(2) Statewide projected trends based on FY2012-FY2015 average trends weighted equally.

72

73

Attachment 5

Provider Reimbursement and Benefit Revisions Effective During FY2014, FY2015 and FY2016

This attachment presents information regarding rating adjustments for the various provider

reimbursement and benefit revisions that became effective (or will become effective) after the

base period used in rate setting (FY2014) and before the end of FY2016.

All adjustments have been calculated through an analysis of health plan encounter data repriced

using the old and new reimbursement terms and the impact determined as the relative change in

cost.

Effective September 1, 2010, HHSC revised the rating methodology to exclude from the claims

experience base any amounts paid by a health plan to a related party in excess of 100% of

Medicaid. Attached Exhibit A presents a summary of the derivation of the rating adjustment

factors.

Effective September 1, 2014 and again on September 1, 2015 HHSC revised the standard dollar

amounts applied to the inpatient reimbursement for certain children’s, safety net and trauma

hospitals. Exhibit B presents a summary of the derivation of the rating adjustment factors.

Effective May 1, 2013 HHSC implemented revisions to hospital reimbursement to account for

Potentially Preventable Readmissions (PPR). The reimbursement reductions amount to 1-2%

depending on a hospitals performance during the evaluation time period. New PPR lists will

become effective September 1, 2015. Exhibit C presents a summary of the derivation of the

rating adjustment factors.

Effective March 1, 2014 HHSC implemented revisions to hospital reimbursement to account for

Potentially Preventable Complications (PPC). The reimbursement reductions amount to 2-2.5%

depending on a hospitals performance during the evaluation time period. New PPC lists will

become effective September 1, 2015. Exhibit D presents a summary of the derivation of the

rating adjustment factors.

Effective September 1, 2015 HHSC will implement revisions to outpatient rural hospital

reimbursement. Exhibits E and F present the rating adjustment factors for non-imaging services

and imaging services, respectively.

Effective September 1, 2015 HHSC will implement revisions to the reimbursement for therapy

services. Exhibit G presents a summary of the derivation of the rating adjustment factors

Effective September 1, 2014 mental health rehabilitation and targeted case management services

became capitated under the program. Prior to this time these services were paid on a fee-for-

service basis. Exhibit H presents a summary of the derivation of the rating adjustment factors.

Effective June 15, 2015 HHSC has placed Makena on the preferred drug list (PDL) which is

expected to increase the utilization of the physician administered drug amongst pregnant women.

Exhibit I presents a summary of the derivation of the rating adjustment factors.

74

Effective January 1, 2016 HHSC will increase the reimbursement for Long Acting Reversible

Contraceptives (LARCs). As a result of the increased reimbursement it is expected that

utilization will increase. Exhibit J presents a summary of the derivation of the rating adjustment

factor for pregnant women.

For ease of reporting purposes, the numerous provider reimbursement adjustments described

above have been consolidated in the community rating exhibits included in Attachment 3. The

key below includes a description of where each adjustment has been included in Attachment 3.

Attachment 3 Heading Attachment 5 Exhibits


Exhibits E, F and G

Other Reimbursement Changes Exhibits H, I and J

Inpatient Reimbursement Changes Exhibits A, B, C and D


FY2016 STAR Rating


Limit Reimbursement to Related Parties


<1 1-5 6-14 15-18 19-20 Adult Women SSI Total

Estimated Cost Impact (1)

CFHP -202,720 -26,220 -18,993 -31,460 -474 -11,453 -65,004 0 -356,324

Driscoll - Hid -678,933 -21,548 -31,730 -6,662 0 0 0 0 -738,873

Driscoll - Nue -1,449,265 -139,327 -118,052 -36,687 0 0 0 0 -1,743,331

Parkland -333,771 -694,217 -478,859 -405,791 -30,317 -1,162,493 -1,355,377 0 -4,460,824

TCHP-Harris -606,613 -1,770,185 -1,868,479 -886,613 -3,507 -16,450 -187,607 0 -5,339,453

TCHP-Jeff -30,569 -67,444 -47,474 -32,712 0 -292 -4,813 0 -183,304

All Other 0 0 0 0 0 0 0 0 0

Total -3,301,870 -2,718,940 -2,563,587 -1,399,924 -34,298 -1,190,688 -1,612,802 0 -12,822,109

FY2014 Total Incurred Claims (2)

CFHP 34,895,067 37,069,194 32,170,050 12,686,953 666,865 12,605,706 26,073,716 0 156,167,550

Driscoll - Hid 31,940,434 17,356,369 15,444,875 6,367,444 371,944 3,826,600 21,176,104 0 96,483,770

Driscoll - Nue 41,734,914 21,466,012 18,612,611 7,676,600 404,240 4,667,270 23,593,434 0 118,155,080

Parkland 57,778,068 84,987,269 57,439,412 18,461,818 832,841 13,675,075 48,758,063 0 281,932,545

TCHP-Harris 92,366,136 120,867,418 109,393,551 42,472,535 1,098,281 14,596,048 53,462,935 0 434,256,904

TCHP-Jeff 11,238,716 8,744,062 6,757,059 2,439,540 196,863 2,742,428 6,552,480 0 38,671,148

All Other 948,518,313 704,460,115 546,292,964 200,015,186 11,574,614 251,421,659 633,489,445 285,145,235 3,580,917,531

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

Rate Adjustment - by Plan (3)

CFHP -0.58 % -0.07 % -0.06 % -0.25 % -0.07 % -0.09 % -0.25 % -0.23 %

Driscoll - Hid -2.13 % -0.12 % -0.21 % -0.10 % 0.00 % 0.00 % 0.00 % -0.77 %

Driscoll - Nue -3.47 % -0.65 % -0.63 % -0.48 % 0.00 % 0.00 % 0.00 % -1.48 %

Parkland -0.58 % -0.82 % -0.83 % -2.20 % -3.64 % -8.50 % -2.78 % -1.58 %

TCHP-Harris -0.66 % -1.46 % -1.71 % -2.09 % -0.32 % -0.11 % -0.35 % -1.23 %

TCHP-Jeff -0.27 % -0.77 % -0.70 % -1.34 % 0.00 % -0.01 % -0.07 % -0.47 %

All Other 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Total -0.27 % -0.27 % -0.33 % -0.48 % -0.23 % -0.39 % -0.20 % 0.00 % -0.27 %

75


FY2016 STAR Rating


Limit Reimbursement to Related Parties



Rate Adjustment - by SDA (3)

Bexar -0.21 % -0.03 % -0.03 % -0.13 % -0.04 % -0.04 % -0.09 %

Dallas -0.26 % -0.43 % -0.40 % -0.98 % -1.61 % -3.53 % -1.27 %

El Paso 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Harris -0.21 % -0.76 % -1.00 % -1.18 % -0.13 % -0.03 % -0.11 %

Hidalgo -0.70 % -0.02 % -0.03 % -0.02 % 0.00 % 0.00 % 0.00 %

Jefferson -0.08 % -0.32 % -0.29 % -0.46 % 0.00 % 0.00 % -0.02 %

Lubbock 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Nueces -2.92 % -0.44 % -0.43 % -0.34 % 0.00 % 0.00 % 0.00 %

Tarrant 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Travis 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

MRSA Central 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

MRSA Northeast 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

MRSA West 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Footnotes:

(1) Equals the cost impact from limiting reimbursement to a related party to 100% of Medicaid.

(2) Equals FY2014 health plan fee-for-service claims for all services (ICHP provided encounter data).

(3) Additional cost divided by FY2014 Total Incurred Claims.

(4) Adjustment factor applied by service delivery area.

76


FY2016 STAR Rating


Hospital Reimbursement Changes - Standard Dollar Amount



Estimated Cost Impact of SDA Changes (1)

Bexar 2,632,249 500,805 404,965 247,052 23,309 533,128 1,969,343 0 6,310,851

Dallas 711,891 -347,410 -224,776 116,592 39,018 597,838 3,139,053 0 4,032,206

El Paso 4,349,948 1,900,446 2,560,011 1,073,821 19,923 381,624 1,613,285 0 11,899,058

Harris 9,017,034 1,928,018 1,810,523 866,802 64,751 962,169 4,658,892 0 19,308,189

Hidalgo 4,112,268 749,945 789,257 463,816 34,738 776,440 2,496,188 0 9,422,652

Jefferson 1,086,311 170,480 87,122 99,831 8,915 167,252 501,461 0 2,121,370

Lubbock 2,958,418 362,818 371,016 110,116 6,305 201,866 922,080 0 4,932,618

Nueces 1,977,222 382,935 362,984 194,083 12,992 243,939 1,099,226 0 4,273,379

Tarrant 1,886,793 130,066 228,128 279,498 16,084 515,943 2,233,951 0 5,290,463

Travis 2,023,824 280,088 285,645 179,941 11,578 274,036 1,097,811 0 4,152,924

MRSA Central 1,777,919 302,683 264,905 160,387 16,217 370,720 1,339,287 2,976,129 7,208,247

MRSA Northeast 1,373,269 86,470 114,889 144,936 17,960 432,757 1,158,624 3,522,293 6,851,198

MRSA West 2,211,688 365,343 332,069 111,028 11,623 311,119 1,268,117 2,109,659 6,720,646

Total 36,118,833 6,812,686 7,386,737 4,047,903 283,413 5,768,831 23,497,317 8,608,081 92,523,801


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

77


FY2016 STAR Rating


Hospital Reimbursement Changes - Standard Dollar Amount



Rate Adjustment (3)

Bexar 2.50 % 0.60 % 0.66 % 1.03 % 1.54 % 1.57 % 2.60 % 1.64 %

Dallas 0.62 % -0.22 % -0.19 % 0.29 % 2.36 % 1.91 % 3.09 % 0.71 %

El Paso 10.08 % 5.50 % 7.91 % 7.77 % 3.36 % 3.34 % 5.37 % 7.17 %

Harris 2.95 % 0.82 % 0.95 % 1.14 % 1.97 % 1.43 % 2.40 % 1.80 %

Hidalgo 3.28 % 0.53 % 0.70 % 1.24 % 1.97 % 2.34 % 3.41 % 1.79 %

Jefferson 2.51 % 0.81 % 0.52 % 1.33 % 1.67 % 1.36 % 1.83 % 1.65 %

Lubbock 6.78 % 1.55 % 2.02 % 1.74 % 1.55 % 2.26 % 3.51 % 3.87 %

Nueces 3.64 % 1.14 % 1.30 % 1.77 % 2.31 % 2.54 % 3.77 % 2.57 %

Tarrant 1.64 % 0.14 % 0.28 % 1.10 % 1.32 % 1.93 % 3.14 % 1.28 %

Travis 2.64 % 0.51 % 0.75 % 1.45 % 1.69 % 1.53 % 2.49 % 1.70 %

MRSA Central 3.92 % 0.86 % 1.05 % 1.64 % 2.29 % 2.66 % 4.03 % 4.31 % 3.10 %

MRSA Northeast 1.86 % 0.19 % 0.34 % 1.03 % 1.34 % 2.11 % 2.25 % 2.78 % 1.87 %

MRSA West 3.07 % 1.02 % 1.14 % 0.91 % 1.32 % 1.89 % 2.28 % 2.36 % 2.16 %

Total 2.96 % 0.68 % 0.94 % 1.40 % 1.87 % 1.90 % 2.89 % 3.02 % 1.97 %

Footnotes:

(1) Equals the cost impact from application of the revised hospital Standard Dollar Amounts effective 9/1/2015.



78


FY2016 STAR Rating


Potentially Preventable Readmission (PPR) Reductions



Estimated Cost Impact of PPR Revisions (1)

Bexar 2,585 578 -4,632 -586 157 1,827 5,752 0 5,679

Dallas -12,493 247 -146 -2,572 -918 -19,206 -96,024 0 -131,111

El Paso -105,488 -32,687 -28,446 -9,156 -341 3,995 3,039 0 -169,083

Harris 383,033 16,559 13,006 5,162 900 19,599 122,426 0 560,684

Hidalgo -30,675 -4,165 -1,953 -4,967 -1,760 -26,604 -77,277 0 -147,402

Jefferson 75,112 746 1,155 634 -137 3,333 26,537 0 107,381

Lubbock -31,421 -1,292 -2,911 -216 -115 -3,094 -15,056 0 -54,104

Nueces 104,950 10,243 8,862 3,801 129 2,109 25,984 0 156,078

Tarrant 47,642 209 -5,271 -3,825 1,958 8,950 36,101 0 85,764

Travis 55,378 19,962 15,834 3,572 -598 -6,768 -3,756 0 83,625

MRSA Central 38,415 1,726 1,515 1,326 104 452 3,065 10,744 57,347

MRSA Northeast 69,031 -958 6 1,525 -3,902 -3,565 9,816 -33,681 38,272

MRSA West 6,713 837 1,844 777 -68 -2,238 8,830 -18,605 -1,910

Total 602,782 12,004 -1,137 -4,524 -4,591 -21,210 49,437 -41,542 591,220


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

79


FY2016 STAR Rating


Potentially Preventable Readmission (PPR) Reductions



Rate Adjustment (3)

Bexar 0.00 % 0.00 % -0.01 % 0.00 % 0.01 % 0.01 % 0.01 % 0.00 %

Dallas -0.01 % 0.00 % 0.00 % -0.01 % -0.06 % -0.06 % -0.09 % -0.02 %

El Paso -0.24 % -0.09 % -0.09 % -0.07 % -0.06 % 0.03 % 0.01 % -0.10 %

Harris 0.13 % 0.01 % 0.01 % 0.01 % 0.03 % 0.03 % 0.06 % 0.05 %

Hidalgo -0.02 % 0.00 % 0.00 % -0.01 % -0.10 % -0.08 % -0.11 % -0.03 %

Jefferson 0.17 % 0.00 % 0.01 % 0.01 % -0.03 % 0.03 % 0.10 % 0.08 %

Lubbock -0.07 % -0.01 % -0.02 % 0.00 % -0.03 % -0.03 % -0.06 % -0.04 %

Nueces 0.19 % 0.03 % 0.03 % 0.03 % 0.02 % 0.02 % 0.09 % 0.09 %

Tarrant 0.04 % 0.00 % -0.01 % -0.02 % 0.16 % 0.03 % 0.05 % 0.02 %

Travis 0.07 % 0.04 % 0.04 % 0.03 % -0.09 % -0.04 % -0.01 % 0.03 %

MRSA Central 0.08 % 0.00 % 0.01 % 0.01 % 0.01 % 0.00 % 0.01 % 0.02 % 0.02 %

MRSA Northeast 0.09 % 0.00 % 0.00 % 0.01 % -0.29 % -0.02 % 0.02 % -0.03 % 0.01 %

MRSA West 0.01 % 0.00 % 0.01 % 0.01 % -0.01 % -0.01 % 0.02 % -0.02 % 0.00 %

Total 0.05 % 0.00 % 0.00 % 0.00 % -0.03 % -0.01 % 0.01 % -0.01 % 0.01 %

Footnotes:

(1) Equals the net cost/savings resulting from PPR reductions that will become effective 9/1/2015 versus those effective during FY2014.



80


FY2016 STAR Rating


Potentially Preventable Complications (PPC) Reductions



Estimated Cost Impact of PPC Revisions (1)

Bexar -741,298 -66,045 -54,936 -42,455 -5,369 -119,162 -466,249 0 -1,495,515

Dallas -103,378 3,085 4,892 -5,502 -1,647 -35,162 -98,977 0 -236,689

El Paso -86,819 -34,391 -38,453 -11,315 51 5,731 37,013 0 -128,184

Harris -208,999 -41,899 -71,077 -60,053 -5,219 -64,990 -169,408 0 -621,644

Hidalgo -704,976 -59,257 -60,256 -33,618 -3,500 -45,782 -137,039 0 -1,044,428

Jefferson -112,689 -3,837 -6,639 -4,303 -888 -20,988 -43,819 0 -193,162

Lubbock -233,677 -21,045 -23,884 -8,266 -1,348 -37,183 -177,182 0 -502,586

Nueces -632,842 -73,849 -62,060 -29,986 -1,291 -28,192 -87,717 0 -915,937

Tarrant -40,145 -988 -5,019 7,083 -3,926 -10,158 -14,060 0 -67,212

Travis -511,931 -139,279 -155,959 -55,779 -208 -15,871 -2,920 0 -881,947

MRSA Central -62,154 -14,068 -20,459 -2,173 -439 -6,493 -12,714 -79,720 -198,219

MRSA Northeast -6,708 -5,659 -6,742 -10,283 -9,584 -23,578 -145,978 -314,389 -522,920

MRSA West -418,886 -44,335 -27,010 -26,216 -4,006 -89,728 -457,067 -562,409 -1,629,656

Total -3,864,502 -501,567 -527,602 -282,865 -37,374 -491,555 -1,776,117 -956,517 -8,438,099


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

81


FY2016 STAR Rating


Potentially Preventable Complications (PPC) Reductions



Rate Adjustment (3)

Bexar -0.70 % -0.08 % -0.09 % -0.18 % -0.35 % -0.35 % -0.62 % -0.39 %

Dallas -0.09 % 0.00 % 0.00 % -0.01 % -0.10 % -0.11 % -0.10 % -0.04 %

El Paso -0.20 % -0.10 % -0.12 % -0.08 % 0.01 % 0.05 % 0.12 % -0.08 %

Harris -0.07 % -0.02 % -0.04 % -0.08 % -0.16 % -0.10 % -0.09 % -0.06 %

Hidalgo -0.56 % -0.04 % -0.05 % -0.09 % -0.20 % -0.14 % -0.19 % -0.20 %

Jefferson -0.26 % -0.02 % -0.04 % -0.06 % -0.17 % -0.17 % -0.16 % -0.15 %

Lubbock -0.54 % -0.09 % -0.13 % -0.13 % -0.33 % -0.42 % -0.67 % -0.39 %

Nueces -1.17 % -0.22 % -0.22 % -0.27 % -0.23 % -0.29 % -0.30 % -0.55 %

Tarrant -0.03 % 0.00 % -0.01 % 0.03 % -0.32 % -0.04 % -0.02 % -0.02 %

Travis -0.67 % -0.25 % -0.41 % -0.45 % -0.03 % -0.09 % -0.01 % -0.36 %

MRSA Central -0.14 % -0.04 % -0.08 % -0.02 % -0.06 % -0.05 % -0.04 % -0.12 % -0.09 %

MRSA Northeast -0.01 % -0.01 % -0.02 % -0.07 % -0.72 % -0.11 % -0.28 % -0.25 % -0.14 %

MRSA West -0.58 % -0.12 % -0.09 % -0.21 % -0.45 % -0.55 % -0.82 % -0.63 % -0.52 %

Total -0.32 % -0.05 % -0.07 % -0.10 % -0.25 % -0.16 % -0.22 % -0.34 % -0.18 %

Footnotes:

(1) Equals the net cost/savings resulting from PPC reductions that will become effective 9/1/2015 versus those effective during FY2014.



82


FY2016 STAR Rating


Outpatient Rural Hospital Reimbursement Increase



Estimated Cost Impact of Reimbursement Increase (1)

Bexar 24,173 68,753 102,739 71,407 857 79,593 82,575 0 430,098

Dallas 20,168 59,444 43,591 19,832 1,176 33,155 29,548 0 206,914

El Paso 1,271 685 2,211 2,104 119 582 277 0 7,247

Harris 33,144 104,603 151,435 56,854 2,168 97,963 131,790 0 577,956

Hidalgo 36,819 105,202 81,746 52,744 3,632 39,639 73,629 0 393,412

Jefferson 18,231 50,441 45,542 28,999 5,504 62,770 63,460 0 274,947

Lubbock 28,404 65,244 80,772 55,706 4,923 101,320 151,783 0 488,152

Nueces 69,106 142,531 144,185 83,452 4,007 132,577 126,024 0 701,881

Tarrant 19,559 45,009 51,495 32,124 681 61,792 40,042 0 250,702

Travis 30,877 67,617 72,282 43,322 1,551 82,493 69,335 0 367,478

MRSA Central 102,597 280,930 255,029 156,371 12,704 247,031 210,020 763,312 2,027,994

MRSA Northeast 161,757 464,610 351,424 199,541 13,934 340,780 367,057 1,318,965 3,218,068

MRSA West 226,405 595,744 446,180 271,245 15,577 354,133 596,892 1,292,634 3,798,809

Total 772,511 2,050,812 1,828,629 1,073,701 66,832 1,633,829 1,942,433 3,374,911 12,743,658


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

83


FY2016 STAR Rating


Outpatient Rural Hospital Reimbursement Increase



Rate Adjustment (3)

Bexar 0.02 % 0.08 % 0.17 % 0.30 % 0.06 % 0.23 % 0.11 % 0.11 %

Dallas 0.02 % 0.04 % 0.04 % 0.05 % 0.07 % 0.11 % 0.03 % 0.04 %

El Paso 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.01 % 0.00 % 0.00 %

Harris 0.01 % 0.04 % 0.08 % 0.07 % 0.07 % 0.15 % 0.07 % 0.05 %

Hidalgo 0.03 % 0.07 % 0.07 % 0.14 % 0.21 % 0.12 % 0.10 % 0.07 %

Jefferson 0.04 % 0.24 % 0.27 % 0.39 % 1.03 % 0.51 % 0.23 % 0.21 %

Lubbock 0.07 % 0.28 % 0.44 % 0.88 % 1.21 % 1.13 % 0.58 % 0.38 %

Nueces 0.13 % 0.42 % 0.52 % 0.76 % 0.71 % 1.38 % 0.43 % 0.42 %

Tarrant 0.02 % 0.05 % 0.06 % 0.13 % 0.06 % 0.23 % 0.06 % 0.06 %

Travis 0.04 % 0.12 % 0.19 % 0.35 % 0.23 % 0.46 % 0.16 % 0.15 %

MRSA Central 0.23 % 0.80 % 1.01 % 1.60 % 1.79 % 1.77 % 0.63 % 1.11 % 0.87 %

MRSA Northeast 0.22 % 1.02 % 1.04 % 1.42 % 1.04 % 1.66 % 0.71 % 1.04 % 0.88 %

MRSA West 0.31 % 1.66 % 1.53 % 2.22 % 1.77 % 2.15 % 1.07 % 1.45 % 1.22 %

Total 0.06 % 0.21 % 0.23 % 0.37 % 0.44 % 0.54 % 0.24 % 1.18 % 0.27 %

Footnotes:

(1) Equals the increased cost due to revised outpatient rural hospital reimbursement effective 9/1/2015. Excludes imaging reimbursement increase.



84


FY2016 STAR Rating


Outpatient Rural Hospital Imaging Reimbursement Increase



Estimated Cost Impact of Reimbursement Increase (1)

Bexar 1,045 2,319 5,901 3,653 89 4,846 3,639 0 21,492

Dallas 986 2,184 2,962 1,831 82 2,629 1,744 0 12,418

El Paso 76 30 84 116 6 78 47 0 437

Harris 1,870 4,254 6,880 3,635 134 4,181 3,382 0 24,336

Hidalgo 2,900 6,334 11,293 7,241 343 4,149 7,804 0 40,064

Jefferson 1,422 3,430 5,762 3,950 298 6,423 4,234 0 25,519

Lubbock 1,889 4,584 9,799 5,295 229 5,130 9,808 0 36,734

Nueces 2,386 5,128 11,025 6,552 253 7,226 9,429 0 41,999

Tarrant 1,298 2,306 6,018 4,154 205 9,038 8,220 0 31,239

Travis 1,152 2,721 5,951 3,181 137 4,597 3,028 0 20,767

MRSA Central 4,671 10,906 20,600 14,149 650 18,168 18,529 48,147 135,820

MRSA Northeast 13,212 25,963 41,100 26,808 1,122 33,928 38,708 112,042 292,883

MRSA West 10,151 20,109 40,405 26,826 1,190 29,151 39,202 85,867 252,901

Total 43,058 90,268 167,780 107,391 4,738 129,544 147,774 246,056 936,609


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

85


FY2016 STAR Rating


Outpatient Rural Hospital Imaging Reimbursement Increase



Rate Adjustment (3)

Bexar 0.00 % 0.00 % 0.01 % 0.02 % 0.01 % 0.01 % 0.00 % 0.01 %

Dallas 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.00 %

El Paso 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 %

Harris 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.00 %

Hidalgo 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.01 % 0.01 % 0.01 %

Jefferson 0.00 % 0.02 % 0.03 % 0.05 % 0.06 % 0.05 % 0.02 % 0.02 %

Lubbock 0.00 % 0.02 % 0.05 % 0.08 % 0.06 % 0.06 % 0.04 % 0.03 %

Nueces 0.00 % 0.02 % 0.04 % 0.06 % 0.04 % 0.08 % 0.03 % 0.03 %

Tarrant 0.00 % 0.00 % 0.01 % 0.02 % 0.02 % 0.03 % 0.01 % 0.01 %

Travis 0.00 % 0.00 % 0.02 % 0.03 % 0.02 % 0.03 % 0.01 % 0.01 %

MRSA Central 0.01 % 0.03 % 0.08 % 0.14 % 0.09 % 0.13 % 0.06 % 0.07 % 0.06 %

MRSA Northeast 0.02 % 0.06 % 0.12 % 0.19 % 0.08 % 0.17 % 0.08 % 0.09 % 0.08 %

MRSA West 0.01 % 0.06 % 0.14 % 0.22 % 0.14 % 0.18 % 0.07 % 0.10 % 0.08 %

Total 0.00 % 0.01 % 0.02 % 0.04 % 0.03 % 0.04 % 0.02 % 0.09 % 0.02 %

Footnotes:

(1) Equals the increased cost due to revised outpatient rural hospital imaging reimbursement effective 9/1/2015.



86


FY2016 STAR Rating


Therapy Reimbursement Reductions



Impact of Reimbursement Reduction (1)

Bexar -138,070 -4,335,484 -947,597 -36,397 -217 -22,087 -3,045 0 -5,482,897

Dallas -104,843 -4,614,893 -964,137 -26,264 -20 -7,793 -925 0 -5,718,876

El Paso -47,533 -1,031,467 -297,133 -45,188 -119 -8,786 -957 0 -1,431,184

Harris -112,112 -7,621,844 -1,721,403 -58,713 -789 -52,348 -7,796 0 -9,575,004

Hidalgo -93,427 -5,672,282 -2,269,573 -137,646 -626 -66,905 -3,853 0 -8,244,310

Jefferson -6,675 -413,410 -72,307 -5,884 0 -13,363 -592 0 -512,231

Lubbock -42,051 -641,765 -113,447 -842 -26 -850 0 0 -798,982

Nueces -16,009 -240,452 -52,366 -7,831 -43 -5,683 -2,873 0 -325,257

Tarrant -62,175 -3,974,887 -790,259 -32,645 -206 -25,259 -2,525 0 -4,887,955

Travis -52,276 -1,930,427 -387,801 -9,772 -52 -6,125 -663 0 -2,387,116

MRSA Central -20,082 -1,112,511 -140,032 -3,379 -80 -2,575 -71 -278,291 -1,557,020

MRSA Northeast -32,996 -724,082 -135,474 -11,217 0 -4,325 -126 -264,868 -1,173,086

MRSA West -56,867 -395,743 -93,620 -8,433 -225 -5,229 -1,247 -95,093 -656,457

Total -785,115 -32,709,245 -7,985,150 -384,212 -2,403 -221,328 -24,672 -638,251 -42,750,376


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

87


FY2016 STAR Rating


Therapy Reimbursement Reductions



Rate Adjustment (3)

Bexar -0.13 % -5.19 % -1.54 % -0.15 % -0.01 % -0.07 % 0.00 % -1.42 %

Dallas -0.09 % -2.92 % -0.81 % -0.07 % 0.00 % -0.02 % 0.00 % -1.01 %

El Paso -0.11 % -2.99 % -0.92 % -0.33 % -0.02 % -0.08 % 0.00 % -0.86 %

Harris -0.04 % -3.24 % -0.90 % -0.08 % -0.02 % -0.08 % 0.00 % -0.89 %

Hidalgo -0.07 % -4.01 % -2.01 % -0.37 % -0.04 % -0.20 % -0.01 % -1.57 %

Jefferson -0.02 % -1.96 % -0.43 % -0.08 % 0.00 % -0.11 % 0.00 % -0.40 %

Lubbock -0.10 % -2.74 % -0.62 % -0.01 % -0.01 % -0.01 % 0.00 % -0.63 %

Nueces -0.03 % -0.72 % -0.19 % -0.07 % -0.01 % -0.06 % -0.01 % -0.20 %

Tarrant -0.05 % -4.28 % -0.97 % -0.13 % -0.02 % -0.09 % 0.00 % -1.18 %

Travis -0.07 % -3.52 % -1.02 % -0.08 % -0.01 % -0.03 % 0.00 % -0.98 %

MRSA Central -0.04 % -3.16 % -0.56 % -0.03 % -0.01 % -0.02 % 0.00 % -0.40 % -0.67 %

MRSA Northeast -0.04 % -1.59 % -0.40 % -0.08 % 0.00 % -0.02 % 0.00 % -0.21 % -0.32 %

MRSA West -0.08 % -1.10 % -0.32 % -0.07 % -0.03 % -0.03 % 0.00 % -0.11 % -0.21 %

Total -0.06 % -3.29 % -1.02 % -0.13 % -0.02 % -0.07 % 0.00 % -0.22 % -0.91 %

Footnotes:

(1) Equals the cost reduction resulting from the therapy reimbursement changes effective 9/1/2015.



88


FY2016 STAR Rating


Mental Health Rehab Carve-In



Estimated Cost Impact of Newly Capitated Services (1)

Bexar 0 42,123 511,307 198,296 3,514 197,855 47,179 0 1,000,274

Dallas 0 2,429 7,247 3,734 0 865 1,149 0 15,423

El Paso 0 1,310 241,171 131,899 3,793 212,673 27,170 0 618,016

Harris 0 124,440 1,622,010 726,236 3,933 286,592 78,179 0 2,841,391

Hidalgo 0 406,267 2,817,452 832,256 10,261 357,710 72,651 0 4,496,597

Jefferson 0 87,863 751,627 199,419 1,204 63,078 20,387 0 1,123,578

Lubbock 0 40,355 348,416 109,909 496 48,190 11,948 0 559,314

Nueces 0 41,557 394,527 117,590 1,186 89,381 11,737 0 655,979

Tarrant 0 93,393 538,749 127,015 332 99,325 31,042 0 889,857

Travis 0 40,358 619,232 251,583 310 119,672 16,226 0 1,047,380

MRSA Central 0 58,561 421,190 150,913 556 76,336 12,408 1,656,996 2,376,960

MRSA Northeast 0 137,096 1,137,179 266,200 1,537 127,045 37,703 3,174,204 4,880,964

MRSA West 0 66,985 857,390 256,352 442 106,706 34,916 3,291,329 4,614,121

Total 0 1,142,737 10,267,497 3,371,403 27,564 1,785,428 402,694 8,122,530 25,119,853


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

89


FY2016 STAR Rating


Mental Health Rehab Carve-In



Rate Adjustment (3)

Bexar 0.00 % 0.05 % 0.83 % 0.83 % 0.23 % 0.58 % 0.06 % 0.26 %

Dallas 0.00 % 0.00 % 0.01 % 0.01 % 0.00 % 0.00 % 0.00 % 0.00 %

El Paso 0.00 % 0.00 % 0.75 % 0.95 % 0.64 % 1.86 % 0.09 % 0.37 %

Harris 0.00 % 0.05 % 0.85 % 0.96 % 0.12 % 0.43 % 0.04 % 0.27 %

Hidalgo 0.00 % 0.29 % 2.50 % 2.23 % 0.58 % 1.08 % 0.10 % 0.86 %

Jefferson 0.00 % 0.42 % 4.49 % 2.66 % 0.23 % 0.51 % 0.07 % 0.87 %

Lubbock 0.00 % 0.17 % 1.90 % 1.74 % 0.12 % 0.54 % 0.05 % 0.44 %

Nueces 0.00 % 0.12 % 1.41 % 1.07 % 0.21 % 0.93 % 0.04 % 0.39 %

Tarrant 0.00 % 0.10 % 0.66 % 0.50 % 0.03 % 0.37 % 0.04 % 0.21 %

Travis 0.00 % 0.07 % 1.63 % 2.03 % 0.05 % 0.67 % 0.04 % 0.43 %

MRSA Central 0.00 % 0.17 % 1.67 % 1.54 % 0.08 % 0.55 % 0.04 % 2.40 % 1.02 %

MRSA Northeast 0.00 % 0.30 % 3.37 % 1.89 % 0.11 % 0.62 % 0.07 % 2.51 % 1.33 %

MRSA West 0.00 % 0.19 % 2.94 % 2.10 % 0.05 % 0.65 % 0.06 % 3.68 % 1.48 %

Total 0.00 % 0.11 % 1.31 % 1.16 % 0.18 % 0.59 % 0.05 % 2.85 % 0.53 %

Footnotes:

(1) Equals the cost resulting from capitating these services into the STAR program.



90


FY2016 STAR Rating





Impact of Utilization Increase (1)

Bexar 0 0 0 0 0 0 43,098 0 43,098

Dallas 0 0 0 0 0 4 131,434 0 131,438

El Paso 0 0 0 1,400 0 11,201 210,392 0 222,993

Harris 0 0 0 0 0 0 147,561 0 147,561

Hidalgo 0 0 0 14,001 5,602 83 163,870 0 183,556

Jefferson 0 0 0 0 0 0 55,287 0 55,287

Lubbock 0 0 0 0 0 3,775 7,003 0 10,778

Nueces 0 0 0 7 3,360 14,711 172,763 0 190,841

Tarrant 0 0 0 0 0 10,038 97,113 0 107,151

Travis 0 0 0 0 0 2,391 69,468 0 71,858

MRSA Central 0 0 0 0 0 7,001 36,954 0 43,955

MRSA Northeast 0 0 0 0 0 7,001 92,437 43 99,481

MRSA West 0 0 0 0 0 3,500 46,620 0 50,120

Total 0 0 0 15,408 8,962 59,705 1,273,998 43 1,358,116


Bexar 105,289,965 83,467,459 61,358,337 23,985,641 1,513,566 33,957,214 75,743,945 0 385,316,126

Dallas 114,821,144 157,913,576 118,303,313 40,204,138 1,653,314 31,300,416 101,587,484 0 565,783,386

El Paso 43,154,251 34,553,570 32,364,236 13,820,084 592,938 11,425,871 30,042,550 0 165,953,500

Harris 305,662,159 235,124,098 190,581,376 76,035,300 3,286,854 67,284,541 194,120,513 0 1,072,094,841

Hidalgo 125,374,026 141,499,045 112,750,989 37,404,551 1,763,370 33,181,177 73,201,983 0 525,175,142

Jefferson 43,279,341 21,046,855 16,754,177 7,506,062 533,814 12,297,911 27,402,233 0 128,820,392

Lubbock 43,634,477 23,407,586 18,367,107 6,328,496 406,788 8,932,123 26,270,099 0 127,346,677

Nueces 54,319,273 33,590,759 27,921,818 10,965,128 562,414 9,603,911 29,157,175 0 166,120,479

Tarrant 115,048,343 92,904,182 81,474,333 25,408,945 1,218,496 26,732,783 71,144,936 0 413,932,017

Travis 76,660,000 54,919,299 38,086,037 12,409,721 685,110 17,910,856 44,088,783 0 244,759,805

MRSA Central 45,355,083 35,195,750 25,229,047 9,779,697 708,155 13,936,830 33,232,927 69,051,705 232,489,195

MRSA Northeast 73,831,646 45,510,290 33,790,868 14,071,480 1,340,292 20,509,823 51,494,391 126,701,202 367,249,992

MRSA West 72,041,940 35,817,970 29,128,883 12,200,833 880,536 16,461,329 55,619,160 89,392,328 311,542,978

Total 1,218,471,648 994,950,440 786,110,521 290,120,075 15,145,646 303,534,786 813,106,177 285,145,235 4,706,584,528

91


FY2016 STAR Rating





Rate Adjustment (3)

Bexar 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.06 % 0.01 %

Dallas 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.13 % 0.02 %

El Paso 0.00 % 0.00 % 0.00 % 0.01 % 0.00 % 0.10 % 0.70 % 0.13 %

Harris 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.08 % 0.01 %

Hidalgo 0.00 % 0.00 % 0.00 % 0.04 % 0.32 % 0.00 % 0.22 % 0.03 %

Jefferson 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.20 % 0.04 %

Lubbock 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.04 % 0.03 % 0.01 %

Nueces 0.00 % 0.00 % 0.00 % 0.00 % 0.60 % 0.15 % 0.59 % 0.11 %

Tarrant 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.04 % 0.14 % 0.03 %

Travis 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.01 % 0.16 % 0.03 %

MRSA Central 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.05 % 0.11 % 0.00 % 0.02 %

MRSA Northeast 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.03 % 0.18 % 0.00 % 0.03 %

MRSA West 0.00 % 0.00 % 0.00 % 0.00 % 0.00 % 0.02 % 0.08 % 0.00 % 0.02 %

Total 0.00 % 0.00 % 0.00 % 0.01 % 0.06 % 0.02 % 0.16 % 0.00 % 0.03 %

Footnotes:

(1) Equals the unit cost difference between Makena and Compound 17P. Assumes Makena utilization will increase by 50%.



92


FY2016 STAR Rating


Increased LARC Utilization

Pregnant

Women

Projected Cost Increase (1) 6,234,000

FY2014 Total Incurred Claims (2) 813,106,177

Rate Adjustment (3) 0.77%

Footnotes:

(1) Equals the projected cost resulting from increased utilization. Estimate provided by HHSC.



93

94

Attachment 6

Family Planning Adjustment

One of the health plans that participates in the STAR program does not provide family planning

services. For this health plan, family planning services will be provided through FFS. HHSC

provided a listing of those services that will not be provided by this health plan. Using base

period claims experience, we determined the per member per month cost expected to be

represented by these family planning services. The premium rates for the health plan that does

not provide family planning services have been reduced accordingly. The attached exhibit

presents a summary of the family planning reduction factors associated with the applicable

health plan.

Attachment 6

FY2016 STAR Rating

Projected FY2016 Family Planning Cost PMPM

Risk Group Travis

Age <1 $ 0.00

Age 1-5 0.00

Age 6-14 0.00

Age 15-18 0.33

Age 19-20 1.65

TANF Adults 2.25

Pregnant Women 6.95

95

96

Attachment 7

Third Party Recoveries

The rating methodology includes a factor to recognize those health plans that do not satisfy a

minimum level of recoveries for coordination of benefits. Any plan that did not recover at least

2.0% of claims had its projected claims cost reduced by 2.0% less their actual percentage of

recoveries. For example, if a specific health plan has third party recoveries (TPR) of 1.5% of

claims, then their projected claims cost would be reduced by 0.5%. Any plan that exceeded the

minimum TPR standard of 2.0% had no penalty applied.

The attached chart presents a summary of TPR experience for FY2014.

Attachment 7

FY2016 STAR Rating

Analysis of Third Party Recovery (TPR) Experience

FY2014 FY2014 Inc. Adjustment

Health Plan TPR Claims TPR/Claims Factor

Aetna - Bexar 1,075,168 31,025,956 3.5 % 1.0000

Amerigroup - Bexar 793,185 16,109,184 4.9 % 1.0000

CFHP - Bexar 9,698,473 141,605,114 6.8 % 1.0000

Superior - Bexar 16,898,845 170,476,799 9.9 % 1.0000

Amerigroup - Dallas 7,223,805 243,448,320 3.0 % 1.0000

Molina - Dallas 2,089,850 31,359,065 6.7 % 1.0000

Parkland - Dallas 11,100,684 266,888,564 4.2 % 1.0000

El Paso First - El Paso 499,977 72,929,071 0.7 % 0.9869

Molina - El Paso 205,737 7,332,336 2.8 % 1.0000

Superior - El Paso 7,723,391 76,619,377 10.1 % 1.0000

Amerigroup - Harris 3,975,829 128,859,259 3.1 % 1.0000

CHC - Harris 23,257,848 379,366,032 6.1 % 1.0000

Molina - Harris 925,047 19,796,607 4.7 % 1.0000

TCHP - Harris 19,559,281 396,441,408 4.9 % 1.0000

United - Harris 1,386,412 66,775,773 2.1 % 1.0000

Driscoll - Hidalgo 3,639,480 88,895,621 4.1 % 1.0000

Molina - Hidalgo 2,081,584 74,014,302 2.8 % 1.0000

Superior - Hidalgo 13,580,118 248,047,036 5.5 % 1.0000

United - Hidalgo 1,131,050 90,923,415 1.2 % 0.9924

Amerigroup - Jefferson 231,130 10,449,655 2.2 % 1.0000

CHC - Jefferson 3,502,870 42,608,658 8.2 % 1.0000

Molina - Jefferson 396,748 9,905,699 4.0 % 1.0000

TCHP - Jefferson 3,226,384 36,210,318 8.9 % 1.0000

United - Jefferson 412,688 20,611,408 2.0 % 1.0000

Amerigroup - Lubbock 872,133 19,319,776 4.5 % 1.0000

Firstcare - Lubbock 2,152,292 60,821,610 3.5 % 1.0000

Superior - Lubbock 4,007,391 39,147,215 10.2 % 1.0000

Christus - Nueces 950,170 12,551,789 7.6 % 1.0000

Driscoll - Nueces 6,699,053 107,799,552 6.2 % 1.0000

Superior - Nueces 3,236,145 33,790,624 9.6 % 1.0000

Aetna - Tarrant 2,701,963 94,335,648 2.9 % 1.0000

Amerigroup - Tarrant 3,523,720 149,783,941 2.4 % 1.0000

Cook - Tarrant 11,459,271 146,909,029 7.8 % 1.0000

BCBS - Travis 4,501,996 34,139,828 13.2 % 1.0000

Sendero - Travis 1,066,610 28,930,088 3.7 % 1.0000

Seton - Travis 1,139,025 18,504,558 6.2 % 1.0000

Superior - Travis 13,023,780 149,860,921 8.7 % 1.0000

Amerigroup - MRSA Central 1,678,997 32,375,779 5.2 % 1.0000

Scott & White - MRSA Central 2,963,878 33,558,216 8.8 % 1.0000

Superior - MRSA Central 8,853,537 86,153,032 10.3 % 1.0000

Amerigroup - MRSA Northeast 4,716,097 78,118,954 6.0 % 1.0000

Superior - MRSA Northeast 12,084,662 151,025,993 8.0 % 1.0000

Amerigroup - MRSA West 2,038,635 34,899,549 5.8 % 1.0000

Firstcare - MRSA West 3,059,012 93,794,719 3.3 % 1.0000

Superior - MRSA West 5,423,336 79,745,698 6.8 % 1.0000

Total 230,767,287 4,156,265,497 5.6 %

97

98

Attachment 8

Delivery Supplemental Payment

The rate setting methodology incorporates a risk adjustment technique that is designed to provide

uniform treatment of the health plans for costs related to maternity delivery services. Maternity

cases occur in several risk groups – Pregnant Women, TANF Adults, and various children age

groups. As a result, it is possible for one health plan to enroll a higher percentage of TANF

Adults who are pregnant and therefore generally more expensive. In order to recognize the

potential inequity that might arise between health plans, HHSC developed this risk adjustment

methodology. The goal is to reimburse the plans uniformly for maternity expenses.

The State pays a delivery supplemental payment (DSP) for each delivery in a managed care plan.

The amount of the payment is a function of the average delivery cost in the area. The attached

exhibit presents the FY2016 DSP payment rates by area.

In order to achieve cost neutrality, the projected cost of maternity expenses is subtracted from the

unadjusted premium rates. The resulting adjusted premium rates are the rates actually paid to the

health plans in addition to any DSP amounts.

Attachment 8

FY2016 STAR Rating

Delivery Supplemental Payment (DSP) Rates per Delivery

Service DSP Amount

Delivery Area FY2015 FY2016

Bexar SDA $ 3,266.59 $ 3,266.59

Dallas SDA 3,537.13 3,537.13

El Paso SDA 3,443.04 3,443.04

Harris SDA 3,519.20 3,519.20

Hidalgo SDA 3,409.95 3,409.95

Jefferson SDA 3,394.58 3,394.58

Lubbock SDA 3,230.39 3,230.39

Nueces SDA 3,203.82 3,203.82

Tarrant SDA 3,635.64 3,635.64

Travis SDA 3,247.49 3,247.49

MRSA Central SDA 3,035.27 3,035.27

MRSA Northeast SDA 3,160.40 3,160.40

MRSA West SDA 3,204.07 3,204.07

99

100

Attachment 9

Acuity Risk Adjustment

The rate setting methodology incorporates a risk adjustment technique that is designed to adjust

the base community rate in each service area to reflect the health status, or acuity, of the

population enrolled in each health plan. The purpose of acuity risk adjustment is to recognize

the anticipated cost differential between multiple health plans in a service area by analyzing the

health status of their respective memberships. The risk analysis was performed by the University

of Florida’s Institute for Child Health Policy (ICHP). The methodology used to calculate the risk

adjustment is the Chronic Illness and Disability Payment System (CDPS). The attached exhibits

(provided by ICHP) present a summary of the risk adjustment analysis. There is a separate

exhibit for each risk group (Exhibits A-G).

The column titled Case Mix on the chart is the risk adjustment factor. It is the ratio of the

predicted average cost of the individual health plan’s membership divided by the predicted

average cost of the entire service area’s membership.

If necessary, an additional adjustment was made to the risk adjustment factors to ensure that, in

total, they produce the same premium as the community rates (budget neutral). Exhibit H

summarizes the raw, unadjusted risk adjustment factors (case-mix), the budget neutral

adjustment applied equally to each risk group within each service area along with the resulting

adjusted risk adjustment factors.

The adjusted risk adjustment factor is applied to the community rate for each health plan and risk

group.


Reporting Period: Sep 1, 2013 to Aug 31, 2014

SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM

Payment Case Mix Spend Ratio

CDPS

TEXAS STAR MCO (<1 Year of Age) 228,082 100.00 714.73 714.73 1.00 1.00

Bexar 19,755 100.00 732.88 759.95 1.00 0.96

Aetna 2,326 11.77 557.51 777.12 1.02 0.72

Amerigroup 861 4.36 725.08 764.50 1.01 0.95

Community First Health Plan (CFHP) 7,468 37.80 658.22 743.84 0.98 0.88

Superior 9,100 46.06 835.85 768.04 1.01 1.09

Dallas 27,082 100.00 497.18 585.37 1.00 0.85

Amerigroup 12,698 46.89 457.20 586.88 1.00 0.78

Molina 2,004 7.40 602.28 634.32 1.08 0.95

Parkland 12,380 45.71 520.49 576.80 0.99 0.90

El Paso 9,024 100.00 650.84 683.17 1.00 0.95

El Paso First Health Plan 4,819 53.40 606.54 641.48 0.94 0.95

Molina 281 3.11 1,061.54 722.47 1.06 1.47

Superior 3,924 43.48 674.77 727.16 1.06 0.93

Harris 54,019 100.00 753.60 677.59 1.00 1.11

Amerigroup 7,021 13.00 726.62 772.33 1.14 0.94

Community Health Choice (CHC) 22,419 41.50 806.87 703.25 1.04 1.15

Molina 877 1.62 937.98 739.08 1.09 1.27

Texas Children's Health Plan (TCHP) 19,187 35.52 682.10 581.37 0.86 1.17

United Health Care (United) 4,515 8.36 776.40 773.66 1.14 1.00

Hidalgo 25,423 100.00 646.54 747.18 1.00 0.87

Driscoll Health Plan 7,388 29.06 668.57 731.82 0.98 0.91

Molina 3,619 14.24 650.59 666.19 0.89 0.98

Superior 9,911 38.98 682.24 770.60 1.03 0.89


Jefferson 6,219 100.00 966.02 847.80 1.00 1.14

Amerigroup 532 8.55 1,053.93 907.28 1.07 1.16

Community Health Choice (CHC) 2,249 36.16 1,078.17 867.11 1.02 1.24

Molina 403 6.48 1,399.41 950.56 1.12 1.47



Lubbock 6,772 100.00 928.62 910.63 1.00 1.02

Amerigroup 953 14.07 1,417.48 1,074.30 1.18 1.32

Firstcare 3,386 50.00 778.25 888.05 0.98 0.88

Sueprior 2,433 35.93 926.04 871.64 0.96 1.06

MRSA Central 10,802 100.00 595.55 777.97 1.00 0.77

Amerigroup 1,619 14.99 769.29 804.36 1.03 0.96

Scott & White 4,010 37.12 496.19 782.68 1.01 0.63

Superior 5,173 47.89 614.45 766.15 0.98 0.80

TEXAS STAR MCO CDPS SA/Health Plan Risk

STAR MCO

101



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 13,546 100.00 762.31 767.60 1.00 0.99

Amerigroup 4,218 31.14 735.86 843.73 1.10 0.87

Superior 9,328 68.86 774.00 733.95 0.96 1.05

MRSA West 13,864 100.00 674.73 663.50 1.00 1.02

Amerigroup 2,194 15.83 774.60 681.05 1.03 1.14

Firstcare 6,522 47.04 684.54 672.51 1.01 1.02

Superior 5,148 37.13 618.11 644.05 0.97 0.96

Nueces 7,013 100.00 1,048.06 865.65 1.00 1.21

Christus 397 5.66 917.46 904.47 1.04 1.01

Driscoll 5,658 80.68 1,065.62 857.34 0.99 1.24

Superior 958 13.66 1,000.82 896.75 1.04 1.12

Tarrant 22,161 100.00 708.87 719.03 1.00 0.99

Aetna 6,861 30.96 741.87 751.40 1.05 0.99

Amerigroup 7,435 33.55 675.58 693.78 0.96 0.97

Cook 7,865 35.49 709.46 712.80 0.99 1.00

Travis 12,402 100.00 812.54 693.67 1.00 1.17

Blue Cross Blue Shield (BCBS) 2,717 21.91 696.57 711.70 1.03 0.98

Sendero 1,554 12.53 1,035.30 724.55 1.04 1.43

Seton 1,360 10.97 585.22 590.87 0.85 0.99

Superior 6,771 54.60 849.76 699.07 1.01 1.22

Note: CDPS results are based on information in enrollment and encounter datasets. CDPS results were obtained for those enrollees who

had been in the program for at least 1 months (age<1) and for those who had been in the program for at least 6 months (age≥1)

(permitting one month lapse in enrollment within the 6 months period).

102



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

TEXAS STAR MCO (Age 1 to 5) 800,695 100.00 150.29 150.29 1.00 1.00

Bexar 66,321 100.00 147.59 152.36 1.00 0.97

Aetna 7,477 11.27 114.91 158.67 1.04 0.72

Amerigroup 3,365 5.07 117.13 158.85 1.04 0.74


Superior 29,554 44.56 149.95 153.30 1.01 0.98

Dallas 113,569 100.00 164.40 153.14 1.00 1.07

Amerigroup 52,936 46.61 153.65 142.97 0.93 1.07

Molina 4,727 4.16 154.31 168.45 1.10 0.92

Parkland 55,906 49.23 175.33 161.43 1.05 1.09

El Paso 32,704 100.00 132.36 142.93 1.00 0.93


Molina 1,120 3.42 126.36 133.00 0.93 0.95

Superior 16,029 49.01 123.35 144.09 1.01 0.86

Harris 190,823 100.00 147.73 130.41 1.00 1.13

Amerigroup 32,132 16.84 100.16 112.98 0.87 0.89


Molina 3,560 1.87 102.42 122.43 0.94 0.84



Hidalgo 100,412 100.00 169.39 191.78 1.00 0.88


Molina 17,900 17.83 129.47 165.54 0.86 0.78

Superior 44,949 44.76 195.47 202.25 1.05 0.97


Jefferson 20,765 100.00 138.11 164.90 1.00 0.84

Amerigroup 1,627 7.84 118.57 170.14 1.03 0.70


Molina 1,141 5.49 119.55 165.41 1.00 0.72



Lubbock 20,506 100.00 137.21 148.78 1.00 0.92

Amerigroup 2,688 13.11 123.65 148.62 1.00 0.83

Firstcare 10,845 52.89 146.52 146.89 0.99 1.00

Sueprior 6,973 34.00 127.79 151.79 1.02 0.84

MRSA Central 34,748 100.00 128.42 142.69 1.00 0.90

Amerigroup 6,845 19.70 130.18 122.42 0.86 1.06

Scott & White 9,875 28.42 138.08 166.53 1.17 0.83

Superior 18,028 51.88 122.56 137.47 0.96 0.89


STAR MCO

103



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 46,264 100.00 131.80 136.16 1.00 0.97

Amerigroup 15,689 33.91 134.18 141.43 1.04 0.95

Superior 30,575 66.09 130.58 133.47 0.98 0.98

MRSA West 39,389 100.00 122.11 139.75 1.00 0.87

Amerigroup 6,593 16.74 108.38 129.57 0.93 0.84

Firstcare 15,235 38.68 138.41 150.83 1.08 0.92

Superior 17,561 44.58 113.11 133.94 0.96 0.84

Nueces 22,196 100.00 186.41 167.32 1.00 1.11

Christus 2,019 9.10 191.03 145.73 0.87 1.31

Driscoll 14,548 65.54 184.21 164.96 0.99 1.12

Superior 5,629 25.36 190.48 181.02 1.08 1.05

Tarrant 71,800 100.00 148.09 154.17 1.00 0.96

Aetna 13,764 19.17 134.60 156.08 1.01 0.86

Amerigroup 30,946 43.10 128.30 141.39 0.92 0.91

Cook 27,090 37.73 177.73 167.93 1.09 1.06

Travis 41,198 100.00 156.63 143.13 1.00 1.09


Sendero 3,942 9.57 202.97 167.80 1.17 1.21

Seton 4,145 10.06 142.25 141.03 0.99 1.01

Superior 28,968 70.31 152.12 138.70 0.97 1.10




104



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

TEXAS STAR MCO (Age 6 to 14) 1,012,913 100.00 99.83 99.83 1.00 1.00

Bexar 84,759 100.00 99.18 99.75 1.00 0.99

Aetna 7,366 8.69 75.24 84.61 0.85 0.89

Amerigroup 3,150 3.72 68.94 79.25 0.79 0.87


Superior 35,075 41.38 96.69 103.04 1.03 0.94

Dallas 146,779 100.00 98.31 92.11 1.00 1.07

Amerigroup 73,471 50.06 95.81 92.68 1.01 1.03

Molina 4,712 3.21 73.75 74.23 0.81 0.99

Parkland 68,596 46.73 102.59 92.69 1.01 1.11

El Paso 46,626 100.00 91.36 102.62 1.00 0.89


Molina 1,251 2.68 65.88 82.37 0.80 0.80

Superior 22,992 49.31 88.76 102.67 1.00 0.86

Harris 231,671 100.00 97.71 86.72 1.00 1.13

Amerigroup 44,647 19.27 67.79 76.23 0.88 0.89


Molina 4,316 1.86 102.13 93.06 1.07 1.10



Hidalgo 141,248 100.00 110.85 137.57 1.00 0.81


Molina 26,442 18.72 94.21 131.85 0.96 0.71

Superior 65,835 46.61 122.37 142.42 1.04 0.86


Jefferson 25,119 100.00 102.46 106.57 1.00 0.96

Amerigroup 2,406 9.58 96.34 100.46 0.94 0.96


Molina 1,369 5.45 110.15 109.56 1.03 1.01



Lubbock 25,293 100.00 93.34 89.71 1.00 1.04

Amerigroup 2,610 10.32 70.89 84.33 0.94 0.84

Firstcare 13,856 54.78 103.54 93.61 1.04 1.11

Sueprior 8,827 34.90 83.66 85.08 0.95 0.98

MRSA Central 41,779 100.00 92.74 96.84 1.00 0.96

Amerigroup 8,469 20.27 87.18 84.21 0.87 1.04

Scott & White 10,864 26.00 93.92 112.22 1.16 0.84

Superior 22,446 53.73 94.26 94.26 0.97 1.00


STAR MCO

105



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 56,546 100.00 91.73 90.51 1.00 1.01

Amerigroup 19,986 35.34 100.06 95.33 1.05 1.05

Superior 36,560 64.66 87.20 87.89 0.97 0.99

MRSA West 47,169 100.00 86.38 88.87 1.00 0.97

Amerigroup 9,000 19.08 78.50 79.03 0.89 0.99

Firstcare 16,482 34.94 91.44 92.05 1.04 0.99

Superior 21,687 45.98 85.76 90.49 1.02 0.95

Nueces 28,333 100.00 130.81 109.18 1.00 1.20

Christus 2,866 10.12 109.23 98.19 0.90 1.11

Driscoll 18,533 65.41 130.89 108.84 1.00 1.20

Superior 6,934 24.47 139.21 114.49 1.05 1.22

Tarrant 87,931 100.00 105.45 100.85 1.00 1.05

Aetna 9,726 11.06 87.35 89.61 0.89 0.97

Amerigroup 45,983 52.29 93.89 94.38 0.94 0.99

Cook 32,222 36.64 127.63 113.58 1.13 1.12

Travis 49,660 100.00 93.39 88.65 1.00 1.05


Sendero 2,459 4.95 104.38 90.04 1.02 1.16

Seton 4,077 8.21 93.02 79.59 0.90 1.17

Superior 36,793 74.09 94.03 90.98 1.03 1.03




106



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


Bexar 23,372 100.00 121.88 122.77 1.00 0.99

Aetna 2,395 10.25 81.76 119.31 0.97 0.69

Amerigroup 940 4.02 92.78 85.76 0.70 1.08


Superior 9,124 39.04 111.00 123.07 1.00 0.90

Dallas 36,817 100.00 120.97 105.90 1.00 1.14

Amerigroup 19,678 53.45 121.67 107.48 1.01 1.13

Molina 1,430 3.88 126.31 101.11 0.95 1.25

Parkland 15,709 42.67 119.62 104.37 0.99 1.15

El Paso 15,666 100.00 111.18 131.73 1.00 0.84


Molina 459 2.93 55.83 53.61 0.41 1.04

Superior 7,665 48.93 108.45 142.75 1.08 0.76

Harris 59,912 100.00 129.42 107.08 1.00 1.21

Amerigroup 12,195 20.35 85.34 93.76 0.88 0.91


Molina 1,371 2.29 88.18 99.52 0.93 0.89



Hidalgo 42,235 100.00 112.53 156.20 1.00 0.72


Molina 7,507 17.77 107.38 152.34 0.98 0.70

Superior 19,096 45.21 114.50 159.81 1.02 0.72


Jefferson 7,069 100.00 124.14 125.60 1.00 0.99

Amerigroup 770 10.89 88.49 127.96 1.02 0.69


Molina 408 5.77 106.32 96.14 0.77 1.11



Lubbock 6,619 100.00 114.15 111.97 1.00 1.02

Amerigroup 734 11.09 99.94 101.10 0.90 0.99

Firstcare 3,483 52.62 121.39 122.15 1.09 0.99

Sueprior 2,402 36.29 107.78 100.36 0.90 1.07

MRSA Central 11,070 100.00 111.95 124.73 1.00 0.90

Amerigroup 2,128 19.22 111.31 93.34 0.75 1.19

Scott & White 3,038 27.44 117.78 155.09 1.24 0.76

Superior 5,904 53.33 109.24 120.64 0.97 0.91


STAR MCO

107



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 15,306 100.00 112.32 111.43 1.00 1.01

Amerigroup 5,437 35.52 106.58 111.47 1.00 0.96

Superior 9,869 64.48 115.47 111.41 1.00 1.04

MRSA West 12,658 100.00 118.15 120.88 1.00 0.98

Amerigroup 2,272 17.95 99.14 107.51 0.89 0.92

Firstcare 4,722 37.30 119.66 128.88 1.07 0.93

Superior 5,664 44.75 124.43 119.49 0.99 1.04

Nueces 7,734 100.00 159.00 141.10 1.00 1.13

Christus 749 9.68 130.10 146.10 1.04 0.89

Driscoll 5,029 65.02 165.96 144.55 1.02 1.15

Superior 1,956 25.29 151.90 130.46 0.92 1.16

Tarrant 22,071 100.00 132.76 127.67 1.00 1.04

Aetna 3,006 13.62 93.10 101.42 0.79 0.92

Amerigroup 11,116 50.36 125.71 122.64 0.96 1.03

Cook 7,949 36.02 157.47 144.55 1.13 1.09

Travis 12,023 100.00 132.41 110.04 1.00 1.20


Sendero 637 5.30 335.67 119.22 1.08 2.82

Seton 1,231 10.24 132.19 107.06 0.97 1.23

Superior 8,545 71.07 122.48 111.86 1.02 1.09




108



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


Bexar 2,406 100.00 119.85 124.56 1.00 0.96

Aetna 282 11.72 119.51 120.56 0.97 0.99

Amerigroup 128 5.32 88.82 93.82 0.75 0.95


Superior 980 40.73 113.65 126.67 1.02 0.90

Dallas 3,481 100.00 104.09 106.57 1.00 0.98

Amerigroup 1,839 52.83 97.95 105.92 0.99 0.92

Molina 157 4.51 123.38 101.92 0.96 1.21

Parkland 1,485 42.66 109.53 107.87 1.01 1.02

El Paso 1,832 100.00 93.61 113.64 1.00 0.82

El Paso First Health Plan 888 48.47 87.42 106.55 0.94 0.82

Molina 53 2.89 71.64 77.92 0.69 0.92

Superior 891 48.64 101.15 122.92 1.08 0.82

Harris 5,624 100.00 134.52 104.36 1.00 1.29

Amerigroup 1,253 22.28 92.99 101.47 0.97 0.92


Molina 149 2.65 157.61 120.31 1.15 1.31


United Health Care (United) 346 6.15 138.11 110.43 1.06 1.25

Hidalgo 4,450 100.00 103.87 127.00 1.00 0.82

Driscoll Health Plan 692 15.55 94.69 115.74 0.91 0.82

Molina 798 17.93 118.63 123.76 0.97 0.96

Superior 1,971 44.29 103.08 125.70 0.99 0.82


Jefferson 711 100.00 112.09 121.99 1.00 0.92

Amerigroup 91 12.80 83.43 106.87 0.88 0.78

Community Health Choice (CHC) 240 33.76 106.42 121.42 1.00 0.88

Molina 40 5.63 123.23 105.72 0.87 1.17

Texas Children's Health Plan (TCHP) 199 27.99 131.03 136.79 1.12 0.96


Lubbock 514 100.00 120.22 126.42 1.00 0.95

Amerigroup 67 13.04 135.09 188.23 1.49 0.72

Firstcare 272 52.92 127.51 121.56 0.96 1.05

Sueprior 175 34.05 103.18 109.90 0.87 0.94

MRSA Central 1,032 100.00 99.67 129.33 1.00 0.77

Amerigroup 223 21.61 102.25 118.11 0.91 0.87

Scott & White 288 27.91 92.96 144.83 1.12 0.64

Superior 521 50.48 102.20 125.67 0.97 0.81


STAR MCO

109



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 1,407 100.00 148.73 132.71 1.00 1.12

Amerigroup 528 37.53 202.29 142.86 1.08 1.42

Superior 879 62.47 117.09 126.72 0.95 0.92

MRSA West 1,075 100.00 118.13 125.07 1.00 0.94

Amerigroup 213 19.81 135.15 149.85 1.20 0.90

Firstcare 408 37.95 108.78 124.47 1.00 0.87

Superior 454 42.23 118.32 113.68 0.91 1.04

Nueces 769 100.00 128.93 115.49 1.00 1.12

Christus 83 10.79 84.77 108.00 0.94 0.78

Driscoll 485 63.07 126.00 120.70 1.05 1.04

Superior 201 26.14 153.27 105.89 0.92 1.45

Tarrant 1,981 100.00 119.64 114.33 1.00 1.05

Aetna 346 17.47 80.80 125.41 1.10 0.64

Amerigroup 995 50.23 142.98 110.12 0.96 1.30

Cook 640 32.31 104.20 114.92 1.01 0.91

Travis 1,124 100.00 100.33 102.65 1.00 0.98

Blue Cross Blue Shield (BCBS) 130 11.57 62.27 70.12 0.68 0.89

Sendero 68 6.05 106.16 112.32 1.09 0.95

Seton 116 10.32 92.36 96.54 0.94 0.96

Superior 810 72.06 107.01 107.87 1.05 0.99




110



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

TEXAS STAR MCO (AFDC Adults) 73,093 100.00 352.49 352.49 1.00 1.00

Bexar 8,134 100.00 356.85 353.13 1.00 1.01

Aetna 917 11.27 258.51 306.10 0.87 0.84

Amerigroup 766 9.42 317.85 334.43 0.95 0.95


Superior 3,611 44.39 379.06 371.10 1.05 1.02

Dallas 7,448 100.00 308.53 311.44 1.00 0.99

Amerigroup 3,774 50.67 291.94 311.86 1.00 0.94

Molina 849 11.40 367.36 373.05 1.20 0.98

Parkland 2,825 37.93 313.28 292.45 0.94 1.07

El Paso 3,550 100.00 283.13 318.36 1.00 0.89


Molina 350 9.86 423.01 330.70 1.04 1.28

Superior 1,498 42.20 288.65 321.00 1.01 0.90

Harris 13,331 100.00 387.27 351.15 1.00 1.10

Amerigroup 2,891 21.69 389.88 387.71 1.10 1.01


Molina 467 3.50 430.23 427.11 1.22 1.01



Hidalgo 9,095 100.00 355.68 378.78 1.00 0.94


Molina 1,856 20.41 451.27 423.92 1.12 1.06

Superior 4,049 44.52 329.91 374.31 0.99 0.88


Jefferson 2,768 100.00 393.95 377.98 1.00 1.04

Amerigroup 298 10.77 448.22 468.83 1.24 0.96


Molina 247 8.92 478.38 386.48 1.02 1.24



Lubbock 2,298 100.00 350.35 360.11 1.00 0.97

Amerigroup 564 24.54 327.83 331.82 0.92 0.99

Firstcare 893 38.86 422.94 404.66 1.12 1.05

Sueprior 841 36.60 288.36 331.75 0.92 0.87

MRSA Central 4,234 100.00 314.69 341.02 1.00 0.92

Amerigroup 799 18.87 312.16 293.44 0.86 1.06

Scott & White 1,513 35.73 300.40 353.67 1.04 0.85

Superior 1,922 45.39 327.01 350.95 1.03 0.93


STAR MCO

111



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 5,089 100.00 375.50 390.04 1.00 0.96

Amerigroup 2,020 39.69 414.17 393.66 1.01 1.05

Superior 3,069 60.31 350.04 387.67 0.99 0.90

MRSA West 3,895 100.00 366.30 357.47 1.00 1.02

Amerigroup 753 19.33 337.79 345.93 0.97 0.98

Firstcare 1,514 38.87 368.20 370.36 1.04 0.99

Superior 1,628 41.80 377.65 350.77 0.98 1.08

Nueces 2,647 100.00 323.15 358.80 1.00 0.90

Christus 520 19.64 247.48 310.19 0.86 0.80

Driscoll 1,140 43.07 292.25 325.14 0.91 0.90

Superior 987 37.29 398.21 422.63 1.18 0.94

Tarrant 6,328 100.00 369.96 379.45 1.00 0.97

Aetna 2,147 33.93 309.77 351.26 0.93 0.88

Amerigroup 2,930 46.30 452.93 423.30 1.12 1.07

Cook 1,251 19.77 272.93 321.93 0.85 0.85

Travis 4,276 100.00 328.10 295.98 1.00 1.11

Blue Cross Blue Shield (BCBS) 706 16.51 297.89 285.28 0.96 1.04

Sendero 444 10.38 276.18 226.04 0.76 1.22

Seton 533 12.46 328.89 265.40 0.90 1.24

Superior 2,593 60.64 344.68 316.59 1.07 1.09




112



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS

TEXAS STAR MCO (Pregnant Woman) 122,637 100.00 545.34 545.34 1.00 1.00

Bexar 12,017 100.00 538.66 543.75 1.00 0.99

Aetna 1,274 10.60 417.02 531.72 0.98 0.78

Amerigroup 532 4.43 453.98 546.17 1.00 0.83


Superior 5,859 48.76 590.38 548.55 1.01 1.08

Dallas 14,287 100.00 571.99 550.24 1.00 1.04

Amerigroup 6,439 45.07 565.83 548.55 1.00 1.03

Molina 1,086 7.60 610.39 549.88 1.00 1.11

Parkland 6,762 47.33 571.68 551.90 1.00 1.04

El Paso 5,173 100.00 485.33 522.75 1.00 0.93


Molina 119 2.30 515.42 455.84 0.87 1.13

Superior 2,310 44.65 517.07 522.85 1.00 0.99

Harris 25,508 100.00 605.68 547.54 1.00 1.11

Amerigroup 3,809 14.93 528.87 543.86 0.99 0.97


Molina 372 1.46 579.01 489.38 0.89 1.18



Hidalgo 13,188 100.00 459.41 515.31 1.00 0.89


Molina 1,749 13.26 473.61 497.98 0.97 0.95

Superior 5,119 38.82 471.36 519.58 1.01 0.91


Jefferson 3,871 100.00 588.94 562.70 1.00 1.05

Amerigroup 343 8.86 582.12 595.83 1.06 0.98


Molina 282 7.28 634.10 563.57 1.00 1.13



Lubbock 4,259 100.00 502.61 551.29 1.00 0.91

Amerigroup 554 13.01 503.81 573.01 1.04 0.88

Firstcare 2,234 52.45 487.37 547.90 0.99 0.89

Sueprior 1,471 34.54 525.21 548.20 0.99 0.96

MRSA Central 6,224 100.00 515.64 571.89 1.00 0.90

Amerigroup 989 15.89 536.08 560.99 0.98 0.96

Scott & White 2,204 35.41 468.95 583.28 1.02 0.80

Superior 3,031 48.70 542.64 567.23 0.99 0.96


STAR MCO

113



SDA/Health Plan

Number of

Enrollees

Percent

Affected

Actual

PMPM

Expenditures

Based on Paid

Amounts

Predicted

PMPM


CDPS


STAR MCO

MRSA Northeast 7,975 100.00 548.18 564.92 1.00 0.97

Amerigroup 2,434 30.52 513.17 556.18 0.98 0.92

Superior 5,541 69.48 563.62 568.77 1.01 0.99

MRSA West 8,402 100.00 536.86 536.20 1.00 1.00

Amerigroup 1,180 14.04 545.99 553.70 1.03 0.99

Firstcare 4,203 50.02 523.05 535.63 1.00 0.98

Superior 3,019 35.93 552.33 530.28 0.99 1.04

Nueces 4,682 100.00 509.64 527.24 1.00 0.97

Christus 272 5.81 461.46 526.41 1.00 0.88

Driscoll 3,828 81.76 511.10 529.21 1.00 0.97

Superior 582 12.43 523.13 514.83 0.98 1.02

Tarrant 11,118 100.00 504.24 566.05 1.00 0.89

Aetna 4,035 36.29 507.02 589.31 1.04 0.86

Amerigroup 3,536 31.80 514.62 557.66 0.99 0.92

Cook 3,547 31.90 490.55 548.20 0.97 0.89

Travis 5,933 100.00 630.59 534.14 1.00 1.18


Sendero 690 11.63 729.62 528.09 0.99 1.38

Seton 437 7.37 505.75 513.51 0.96 0.98

Superior 3,546 59.77 651.62 536.57 1.00 1.21




114


FY2016 STAR Rating

Adjusted Acuity Scores


<1 1-5 6-14 15-18 19-20 Adult Women

Unadjusted Acuity Scores (1)

Aetna - Bexar 1.0226 1.0414 0.8483 0.9717 0.9679 0.8668 0.9779


CFHP - Bexar 0.9788 0.9756 1.0144 1.0293 1.0222 0.9912 0.9940

Superior - Bexar 1.0106 1.0061 1.0330 1.0024 1.0169 1.0509 1.0088


Molina - Dallas 1.0836 1.1000 0.8058 0.9547 0.9564 1.1978 0.9993

Parkland - Dallas 0.9854 1.0541 1.0063 0.9855 1.0122 0.9390 1.0030


Molina - El Paso 1.0575 0.9305 0.8026 0.4069 0.6857 1.0388 0.8720

Superior - El Paso 1.0644 1.0081 1.0004 1.0836 1.0816 1.0083 1.0002


CHC - Harris 1.0379 1.0441 0.9295 0.9125 0.9708 0.9081 1.0091

Molina - Harris 1.0907 0.9389 1.0731 0.9294 1.1528 1.2163 0.8938

TCHP - Harris 0.8580 0.9920 1.0770 1.0773 1.0185 0.7953 0.9779

United - Harris 1.1418 1.2606 1.1377 1.3212 1.0582 1.2986 1.0456


Molina - Hidalgo 0.8916 0.8632 0.9584 0.9753 0.9745 1.1192 0.9664


United - Hidalgo 1.0433 1.0389 1.0355 1.0086 1.1041 1.0207 1.0040


CHC - Jefferson 1.0228 0.9684 0.8885 0.9888 0.9953 0.8851 0.9661


TCHP - Jefferson 0.9236 0.9727 1.0563 1.0526 1.1213 0.8796 1.0264





Christus - Nueces 1.0448 0.8710 0.8993 1.0354 0.9352 0.8645 0.9984

Driscoll - Nueces 0.9904 0.9859 0.9968 1.0244 1.0451 0.9062 1.0037

Superior - Nueces 1.0359 1.0819 1.0486 0.9246 0.9169 1.1779 0.9765

Aetna - Tarrant 1.0450 1.0124 0.8886 0.7944 1.0969 0.9257 1.0411


Cook - Tarrant 0.9913 1.0893 1.1263 1.1322 1.0052 0.8484 0.9685


Sendero - Travis 1.0445 1.1724 1.0157 1.0834 1.0942 0.7637 0.9887

Seton - Travis 0.8518 0.9853 0.8978 0.9729 0.9404 0.8967 0.9614

Superior - Travis 1.0078 0.9691 1.0263 1.0165 1.0509 1.0697 1.0045









115


FY2016 STAR Rating



<1 1-5 6-14 15-18 19-20 Adult Women

Budget Neutrality Adjustment (2)

Aetna - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000


CFHP - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000

Superior - Bexar 1.0005 1.0005 1.0013 0.9999 0.9948 1.0028 1.0000


Molina - Dallas 0.9988 1.0014 1.0011 1.0000 0.9998 0.9936 1.0002

Parkland - Dallas 0.9988 1.0014 1.0011 1.0000 0.9998 0.9936 1.0002


Molina - El Paso 1.0060 1.0002 0.9997 1.0025 1.0004 1.0022 1.0001

Superior - El Paso 1.0060 1.0002 0.9997 1.0025 1.0004 1.0022 1.0001


CHC - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003

Molina - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003

TCHP - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003

United - Harris 1.0083 0.9979 0.9950 0.9907 1.0039 1.0045 1.0003


Molina - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999


United - Hidalgo 1.0027 1.0006 1.0021 1.0011 1.0053 1.0200 0.9999


CHC - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970


TCHP - Jefferson 1.0027 0.9992 0.9970 0.9993 0.9994 0.9939 0.9970





Christus - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993

Driscoll - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993

Superior - Nueces 1.0009 1.0013 1.0000 0.9985 0.9878 1.0197 0.9993

Aetna - Tarrant 1.0016 0.9982 0.9970 1.0001 0.9902 1.0128 0.9994


Cook - Tarrant 1.0016 0.9982 0.9970 1.0001 0.9902 1.0128 0.9994


Sendero - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010

Seton - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010

Superior - Travis 1.0010 0.9956 1.0068 1.0053 1.0148 1.0075 1.0010









116


FY2016 STAR Rating



<1 1-5 6-14 15-18 19-20 Adult Women

Budget Neutral Acuity Scores (3)

Aetna - Bexar 1.0231 1.0419 0.8494 0.9716 0.9629 0.8692 0.9779


CFHP - Bexar 0.9793 0.9761 1.0158 1.0292 1.0170 0.9940 0.9940

Superior - Bexar 1.0112 1.0066 1.0344 1.0023 1.0117 1.0538 1.0089


Molina - Dallas 1.0824 1.1015 0.8067 0.9547 0.9562 1.1902 0.9995

Parkland - Dallas 0.9842 1.0556 1.0074 0.9855 1.0120 0.9331 1.0032


Molina - El Paso 1.0638 0.9307 0.8024 0.4080 0.6859 1.0411 0.8721

Superior - El Paso 1.0707 1.0082 1.0002 1.0864 1.0821 1.0105 1.0003


CHC - Harris 1.0465 1.0418 0.9248 0.9040 0.9746 0.9122 1.0093

Molina - Harris 1.0998 0.9368 1.0677 0.9208 1.1572 1.2218 0.8940

TCHP - Harris 0.8651 0.9899 1.0717 1.0673 1.0225 0.7989 0.9782

United - Harris 1.1512 1.2579 1.1320 1.3090 1.0622 1.3044 1.0459


Molina - Hidalgo 0.8940 0.8638 0.9604 0.9764 0.9797 1.1415 0.9662


United - Hidalgo 1.0461 1.0396 1.0376 1.0097 1.1100 1.0412 1.0039


CHC - Jefferson 1.0255 0.9676 0.8859 0.9881 0.9947 0.8796 0.9632


TCHP - Jefferson 0.9260 0.9719 1.0531 1.0518 1.1206 0.8743 1.0233





Christus - Nueces 1.0458 0.8721 0.8993 1.0338 0.9238 0.8816 0.9977

Driscoll - Nueces 0.9913 0.9871 0.9968 1.0228 1.0323 0.9241 1.0030

Superior - Nueces 1.0368 1.0833 1.0486 0.9231 0.9057 1.2011 0.9758

Aetna - Tarrant 1.0467 1.0106 0.8860 0.7945 1.0862 0.9375 1.0404


Cook - Tarrant 0.9930 1.0873 1.1230 1.1323 0.9953 0.8592 0.9679


Sendero - Travis 1.0456 1.1672 1.0226 1.0891 1.1104 0.7694 0.9896

Seton - Travis 0.8526 0.9810 0.9039 0.9780 0.9544 0.9034 0.9623

Superior - Travis 1.0088 0.9648 1.0332 1.0219 1.0664 1.0776 1.0055









Footnotes:

(1) Raw acuity scores as developed by ICHP. Equals the case mix factors from Exhibits A-G.

(2) Budget neutral adjustment applied uniformly within each service area to ensure acuity adjustment is budget neutral in total.

(3) Adjusted acuity scores applied to FY2016 Community Rates.

117

118

Attachment 10

Network Access Improvement Program (NAIP)

Effective March 1, 2015 several health plans implemented programs aimed at improving

network access for Medicaid members. The NAIP is designed to further the state's goal of

increasing the availability and effectiveness of primary care for Medicaid beneficiaries by

incentivizing various institutions to provide quality, well-coordinated, and continuous care. The

NAIP is intended to achieve the following objectives regarding health-related institutions (HRI):

Improve the availability of and Medicaid access to primary care physicians. This

program may also target specialist physicians willing to provide a medical home to

managed care members with special needs and conditions, and advanced practice

registered nurses (APRNs) and physician assistants (PAs) practicing under the

supervision of an HRI staff provider.

Enhance the coordination and continuity of services and quality of care of Medicaid

managed care members who receive primary care services through those physician

practices.

Increase access to primary care in these settings, underscoring the importance of primary

care residency programs and influencing future physician participation.

Promote provider education on Medicaid program requirements and the specialized needs

of Medicaid recipients.

Measure progress through increased primary care access and physician compliance with

selected quality objectives, to be determined later.

Similarly, the NAIP is intended to achieve the following objectives relating to public hospitals:

Improve the availability, quality and coordination of primary and specialty care services

provided by public hospitals;

Promote provider education on Medicaid program requirements and the specialized needs

of Medicaid recipients;

Measure progress through increased care access and physician compliance with quality

objectives.

The above-stated objectives will lead to better health outcomes for Medicaid beneficiaries and

decreased overall healthcare costs for the Medicaid program.

The NAIPs were developed independently by various managed care organizations and providers.

The NAIPs outline the services to be provided by the providers, measurements to evaluate their

effectiveness and the cost to be paid by the managed care organizations. The NAIP amounts

impact all STAR risk groups.

The attached exhibit summarizes each of the NAIPs by health plan, service area and program.

The participating provider has been removed from the exhibit in order to maintain the privacy of

these negotiated arrangements.

Attachment 10

FY2016 STAR Rating

Network Access Improvement Program (NAIP) Summary

MCO (1) Impacted Programs SDAs Impacted

Contracted

Cost (2)

Projected Member

Months (3) PMPM Impact

Amerigroup STAR, STAR+PLUS Lubbock, MRSA West 7,522,250 531,315 14.16


Amerigroup STAR, STAR+PLUS Tarrant, MRSA West 4,782,360 2,085,291 2.29

Amerigroup STAR Dallas 22,780,000 2,557,783 8.91


Amerigroup STAR, STAR+PLUS El Paso, MRSA West 2,663,700 454,522 5.86


Amerigroup STAR, STAR+PLUS Harris 45,553,955 1,699,281 26.81

Amerigroup STAR, STAR+PLUS Jefferson 4,835,250 133,437 36.24

Amerigroup STAR, STAR+PLUS Harris, Jefferson 7,456,009 1,832,718 4.07

Amerigroup STAR, STAR+PLUS Dallas 1,400,000 2,557,783 0.55

Amerigroup STAR, STAR+PLUS Dallas, Tarrant 27,400,000 4,249,288 6.45

Amerigroup STAR, STAR+PLUS

Bexar, Dallas, El Paso, Harris,

Jefferson, Lubbock, Tarrant, Travis,

MRSAs 14,400,000 7,945,331 1.81

CFHP STAR Bexar 41,828,301 1,385,796 30.18

CHC STAR Harris 36,600,000 2,650,907 13.81

CHC STAR Harris 28,479,891 2,650,907 10.74

CHC STAR Jefferson 6,015,781 288,546 20.85

CHC STAR Harris, Jefferson 12,631,735 2,939,453 4.30

El Paso First STAR El Paso 27,000,000 806,632 33.47

El Paso First STAR El Paso 1,800,000 806,632 2.23

FirstCare STAR MRSA West 10,600,000 691,360 15.33

FirstCare STAR Lubbock, MRSA West 25,796,182 1,200,195 21.49

Molina STAR Dallas 3,779,681 243,865 15.50

Parkland STAR Dallas 34,990,000 2,291,169 15.27

Superior STAR, STAR+PLUS Bexar 27,286,963 1,528,854 17.85

Superior STAR, STAR+PLUS Bexar, Hidalgo, MRSA Central 22,488,634 4,563,659 4.93

Superior STAR, STAR+PLUS Travis, Nueces, MRSA West 7,184,766 2,449,044 2.93

Superior STAR El Paso 20,250,014 733,403 27.61

Superior STAR, STAR+PLUS Lubbock, MRSA West 23,326,336 1,310,818 17.80

Superior STAR El Paso 2,200,140 733,403 3.00

Superior STAR, STAR+PLUS Lubbock 3,498,950 380,567 9.19

Superior STAR, STAR+PLUS MRSA Central 559,832 912,213 0.61

119

Attachment 10

FY2016 STAR Rating

Network Access Improvement Program (NAIP) Summary

MCO (1) Impacted Programs SDAs Impacted

Contracted

Cost (2)

Projected Member

Months (3) PMPM Impact

United STAR Harris 13,369,339 522,090 25.61

United STAR, STAR+PLUS Harris 10,299,178 804,544 12.80

United STAR, STAR+PLUS Jefferson 3,724,540 195,895 19.01

United STAR, STAR+PLUS Harris, Jefferson 4,239,824 1,000,439 4.24

Foootnotes:

(1) MCOs may have NAIP arrangements with multiple providers.

(2) Based on contracted amounts between MCOs and providers.

(3) Based on HHSC most recent caseload forecast. Includes all (i) all STAR Risk Groups, (ii) STAR+PLUS Medicaid Only OCC,

(iii) STAR+PLUS Medicaid Only HCBS and (iv) IDD <21 and >21.

120

121

Attachment 11

Pay-for-Quality Program (P4Q)

The Texas P4Q Program is based on the concept of incremental improvement where each health

plan is (1) incentivized to improve its own quality performance each year and (2) evaluated

based on its success in achieving such improvement. A gap closure approach to each P4Q quality

measure is used where a minimum threshold is set, establishing a minimum quality score at

which health plans become eligible to earn positive quality points. Health plans with scores

below the minimum threshold for a measure will not be eligible to earn positive points for

incremental improvement, but will not be penalized as long as they show year-to-year

improvement in the measure. An attainment goal is specified which represents a recognized level

of excellence for the specific quality measure. Both minimum thresholds and attainment goals

are determined at the discretion of HHSC.

The P4Q measures include:

1. Healthcare effectiveness data information set Quality of Care Measures

o Well-child visits for 3, 4, 5, and 6 year olds

o Adolescent well care

o Prenatal and postpartum care

2. Potentially Preventable Events

o Potentially Preventable Admissions

o Potentially Preventable Readmissions

o Potentially Preventable Emergency Department Visits

o Potentially Preventable Complications

Each health plan is expected to close the gap between the attainment goal and the health plan's

baseline performance by 15 percent each year. This 15 percent annual gap closure target is not

referring to a 15 percentage point annual increase in the measure, but is 15 percent of the

difference between the attainment goal and the health plan’s 2013 (baseline) performance. For

example, if a health plan’s current performance is 60 percent for the measure and the attainment

goal is 70 percent, the gap is 70 percent - 60 percent or 10 percentage points. Correspondingly,

15 percent of the gap equals 0.15 x 10 percentage points or 1.5 percentage points. The 15 percent

annual gap closure target will be achieved if the health plan improves from 60 percent to 61.5

percent on the measure. Higher scores on the Healthcare Effectiveness Data Information Set

(HEDIS®) measures correspond to higher quality. However, lower Potentially Preventable Event

(PPE) expenditures are indicative of higher quality. For this reason, improvement for the PPE

measures is defined by a reduction in PPE expenditures. PPE expenditures are calculated using

standardized resource units rather than paid amounts to eliminate any extraneous market-based

variation that is present in the paid amounts.

state of texas medicaid managed care star …...medicaid’s state of texas access reform (star)...

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