Maryland Department of Health
Regulations

​
PROPOSAL
Maryland Register
Issue Date:  January 5, 2018
Volume 45• Issue 1 • Pages 24—28
 
Title 10
MARYLAND DEPARTMENT OF HEALTH
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations
Authority: Health-General Article, §§2-104, 15-102.3, and 15-103; Insurance Article, §§15-112, 15-605, and 15-1008; Annotated Code of Maryland
Notice of Proposed Action
[18-005-P]
The Secretary of Health proposes to amend Regulation .19 under COMAR 10.09.65 Maryland Medicaid Managed Care Program: Managed Care Organizations.
Statement of Purpose
The purpose of this action is to implement to the calendar year 2018 HealthChoice MCO’s rates.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
I. Summary of Economic Impact. The HealthChoice CY 2018 MCO rate adjustment is an increase of $54,656,699 above the FY 2018 appropriation or a 1.0 percent rate increase.
 
 
Revenue (R+/R-)
 
II. Types of Economic Impact.
Expenditure (E+/E-)
Magnitude
 
 
A. On issuing agency:
(E+)
$54,656,699
B. On other State agencies:
NONE
C. On local governments:
NONE
 
 
Benefit (+)
Cost (-)
Magnitude
 
 
D. On regulated industries or trade groups:
(+)
$54,656,699
E. On other industries or trade groups:
NONE
F. Direct and indirect effects on public:
NONE
III. Assumptions. (Identified by Impact Letter and Number from Section II.)
A. For CY 2018, there is a 1.0 percent rate increase or $54,656,699 increase to the Department’s expenses.
D. For CY 2018, there is a 1.0 percent rate increase or $54,656,699 increase to the MCOs revenue.
Economic Impact on Small Businesses
The proposed action has minimal or no economic impact on small businesses.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulation and Policy Coordination, Maryland Department of Health, 201 West Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499; TTY:800-735-2258, or email to mdh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through February 5, 2018. A public hearing has not been scheduled.
.19 MCO Reimbursement.
A. (text unchanged)
B. Capitation Rate-Setting Methodology.
(1)—(3) (text unchanged)
(4) Except to the extent of adjustments required by §D of this regulation or by Regulations .19-1—.19-4 of this chapter, the Department shall make payments monthly at the rates specified in the following tables:
[(a)—(d)] (proposed for repeal)
(a) Rate Table for Families and Children Effective January 1, 2018 — December 31, 2018
 
Age/RAC
Gender
PMPM Baltimore City
PMPM Montgomery County
PMPM Rest   of   State
 
Under age 1Birth Weight 1500 grams or less
Both
$9,987.05
$8,901.86
$9,187.53
 
Under age 1 Birth Weight over 1500 grams
Both
$471.18
$419.98
$433.46
 
1—5
Male
$204.70
$182.45
$188.31
 
 
Female
$181.00
$161.33
$166.51
 
6—14
Male
$113.50
$101.17
$104.42
 
 
Female
$109.36
$97.47
$100.60
 
15—0
Male
$127.07
$113.27
$116.90
 
 
Female
$166.02
$147.98
$152.73
 
21—44
Male
$239.70
$194.36
$208.17
 
 
Female
$367.45
$297.95
$319.12
 
45—64
Male
$497.75
$403.60
$432.28
 
 
Female
$575.16
$466.37
$499.51
ACG-adjusted cells
 
 
 
 
 
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339  
RAC 1F
Both
$240.89
$195.33
$209.21
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340  
RAC 2F
Both
$392.90
$318.59
$341.22
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820  
RAC 3F
Both
$517.22
$410.39
$449.19
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040  
RAC 4F
Both
$725.53
$588.30
$630.10
ACG 4430, 4730, 4930, 5030, 5050
RAC 5F
Both
$1,017.64
$825.17
$883.79
ACG 4940, 5060  
RAC 6F
Both
$1,289.01
$1,045.21
$1,119.46
ACG 5070  
RAC 7F
Both
$1,985.36
$1,609.85
$1,724.22
ACG 100, 200, 300, 500, 600, 1100, 1600, 2000, 2400, 3400, 5100, 5110, 5200  
RAC 1G
Both
$90.62
$80.78
$83.37
ACG 400, 700, 900, 1000, 1200, 1300, 1710, 1711, 1712, 1800, 1900, 2100, 2200, 2300, 2800, 2900, 3000, 3100, 5310  
RAC 2G
Both
$116.07
$103.46
$106.78
ACG 1720, 1721, 1722, 1731, 1732, 1730, 2500, 3200, 3300, 3500, 3800, 4210, 5230, 5339  
RAC 3G
Both
$149.48
$133.24
$137.51
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340  
RAC 4G
Both
$206.92
$184.33
$190.35
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820  
RAC 5G
Both
$324.44
$289.19
$298.47
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040  
RAC 6G
Both
$392.02
$349.42
$360.04
ACG 4430, 4730, 4930,4940, 5030, 5050, 5060, 5070  
RAC 7G
Both
$945.69
$842.93
$869.98
SOBRA Mothers  
 
 
$849.58
$688.89
$737.83  
Persons with HIV
ALL
Both
$652.47
$652.47
$652.47
(b) Rate Table for Disabled Individuals Effective January 1, 2018—December 31, 2018
 
Age/RAC
Gender
PMPM   Baltimore   City
PMPM Montgomery County
PMPM Rest of State
 
Under Age 1
Both
$7,898.31
$7,898.31
$7,898.31
 
1—5
Male
$1,759.19
$1,759.19
$1,759.19
 
 
Female
$909.25
$909.25
$909.25
 
6—14
Male
$322.27
$322.27
$322.27
 
 
Female
$410.32
$410.32
$410.32
 
15—20
Male
$223.20
$223.20
$223.20
 
 
Female
$256.31
$256.31
$256.31
 
21—44
Male
$689.95
$603.17
$607.00
 
 
Female
$907.12
$793.3
$798.07
 
45—64
Male
$1,848.47
$1,616.00
$1,626.26
 
45—64
Female
$1,815.23
$1,586.94
$1,597.01
ACG-adjusted cells
 
 
 
 
 
ACG 100, 200, 300, 1100, 1300, 1400, 1500, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1900, 2400, 2600, 2900, 3400, 5100, 5110, 5200, 5310  
RAC 10
Both
$304.32
$266.05
$267.74
ACG 400, 500, 700, 900, 1000, 1200, 1740, 1741, 1742, 1750, 1751, 1752 1800, 2000, 2100, 2200, 2300, 2500, 2700, 2800, 3000, 3100, 3200, 3300, 3500, 3900, 4000, 4310, 5330  
RAC 11
Both
$343.20
$300.04
$301.94
ACG 600, 1760, 1761, 1762, 3600, 3700, 4100, 4320, 4410, 4710, 4810, 4820  
RAC 12
Both
$695.13
$607.70
$611.56
ACG 3800, 4210, 4220, 4330, 4420, 4720, 4910, 5320  
RAC 13
Both
$788.52
$689.35
$693.73
ACG 800, 4430, 4510, 4610, 5040, 5340  
RAC 14
Both
$1,066.84
$932.67
$938.59
ACG 1770, 1771, 1772, 4520, 4620, 4830, 4920, 5050  
RAC 15
Both
$1,356.31
$1,185.73
$1,193.26
ACG 4730, 4930, 5010  
RAC 16
Both
$1,404.91
$1,228.22
$1,236.01
ACG 4940, 5020, 5060  
RAC 17
Both
$2,089.06
$1,826.33
$1,837.93
ACG 5030, 5070  
RAC 18
Both
$3,853.42
$3,368.79
$3,390.18
Persons with AIDS  
All
Both
$2,081.63
$1,422.67
$1,422.67
Persons with HIV
All
Both
$1,973.79
$1,973.79
$1,973.79
(c) Rate Table for Supplemental Payments for Delivery/Newborn and Hepatitis C Therapy Effective January 1, 2018—December 31, 2018
Age
Gender
Baltimore City
Montgomery County
Rest of State
Supplemental Payment Cells
 
 
 
 
 
Delivery/Newborn-all births except live birth weight 1,500 grams or less and gestational age of 21 weeks or more  
All
Both
$16,277.91
$12,494.41
$13,533.35
Delivery/Newborn-live birth weight 1,500 grams or less and a gestational age of 21 weeks or more
All
Both
$86,874.19
$86,874.19
$86,874.19
Delivery/Newborn by same enrollee-subsequent live birth weight 1,500 grams or less with a gestational age less than 21 weeks or does not meet the requirements in §B.(4)(i) of this regulation
All
Both
$16,277.91
$12,494.41
$13,533.35
Hepatitis C Therapy 98% payment
All
Both
$26,312.06
$26,312.06
$26,312.06
Hepatitis C 8 week treatment PMPM
All
Both
$1,073.96
$1,073.96
$1,073.96
Hepatitis C 12 week treatment PMPM
All
Both
$1,610.94
$1,610.94
$1,610.94
Hepatitis C 24 week treatment PMPM
All
Both
$3,221.88
$3221.88
$3221.88
Hepatitis C 48 week treatment PMPM
All
Both
$6,443.76
$6,443.76
$6,443.76
Hepatitis C 12-24 week treatment PMPM
All
Both
$1,610.94
$1,610.94
$1,610.94
Hepatitis C 12 week retreatment PMPM
All
Both
$1,610.94
$1,610.94
$1,610.94
Hepatitis C 24 week retreatment PMPM
All
Both
$3,221.88
$3,221.88
$3,221.88
Hepatitis C 48 week retreatment PMPM
All
Both
$6,443.76
$6,443.76
$6,443.76
Hepatitis C 12-24 week retreatment PMPM
All
Both
$1,610.94
$1,610.94
$1,610.94
Hepatitis C SVR Runout
All
Both
$536.98
$536.98
$536.98
(d) Rate Table for Childless Adult Population Effective January 1, 2018—December 31, 2018
 
Age/RAC
Gender
PMPM Baltimore City
Montgomery County
PMPM Rest of State
 
19—44
Male
$355.45
$275.16
$316.05
 
19—44
Female
$406.33
$314.58
$361.30
 
45—64
Male
$933.15
$768.90
$883.08
 
45—64
Female
$859.44
$665.38
$764.19
ACG-adjusted cells
 
 
 
 
 
ACG 100, 200, 300, 400, 500, 600, 700, 900, 1000, 1100, 1200, 1300, 1600, 1710, 1711, 1712, 1720, 1721, 1722, 1730, 1731, 1732, 1800, 1900, 2000, 2100, 2200, 2300, 2400, 2500, 2800, 2900, 3000, 3100, 3200, 3300, 3400, 3500, 3800, 4210, 5100, 5110, 5200 5230, 5310, 5339
RAC 1H
Both
$323.87
$250.74
$287.97
ACG 800, 1740, 1741, 1742, 1750, 2700, 3600, 1750, 1751, 1752, 2700, 3600, 3700, 3900, 4000, 4100, 4220, 4310, 4410, 4510, 4610, 4710, 4720, 4810, 5340
RAC 2H
Both
$490.76
$379.95
$436.37
ACG 1400, 1500, 1750, 1761, 1762, 1770, 1771, 1772, 2600, 4320, 4520, 4620, 4820
RAC 3H
Both
$514.21
$398.10
$457.22
ACG 4330, 4420, 4830, 4910, 4920, 5010, 5020, 5040
RAC 4H
Both
$876.30
$678.44
$779.18
ACG 4430, 4730, 4930, 5030, 5050
RAC 5H
Both
$1,110.13
$1,859.46
$987.09
ACG 4940, 5060
RAC 6H
Both
$1,426.39
$1,104.32
$1,268.31
ACG 5070
RAC 7H
Both
$2,278.39
$1,763.94
$2,025.88
HIV
19-64
Both
$591.40
$591.40
$591.41
(e)—(h) (text unchanged)
(i) An MCO is eligible to receive the subsequent very low birth weight payment in §B(4)(c) of this regulation if the mother:
(i) Had a prior spontaneous preterm delivery;
(ii) Has a current singleton pregnancy;
(iii) Is eligible to receive hydroxyprogesterone caproate;
(iv) Has received the first hydroxyprogesterone caproate injection between 16 weeks gestation and 24 weeks gestation and continued receiving injections until delivery or week 37 gestation; and
(v) Has received at least 2 hydroxyprogesterone caproate injections.
(5) (text unchanged)
C. (text unchanged)
D. Interim Rates Adjustments.
(1) (text unchanged)
(2) The Department shall adjust the payment rates specified in §B(4)(a)—(d) of this regulation to reflect service cost changes that qualify under §D(3) of this regulation and result from:
(a)—(b) (text unchanged)
[(c) Effective January 1, 2017, an increase or decrease in the inpatient hospital per capita as calculated by the multiplication of:
(i) The change in the restated unit cost provided annually by the Health Service Cost Review Commission (HSCRC) as compared to the data originally provided; and
(ii) The change in the restated recommended utilization, adjusted for case mix, position of the Department’s rate certifying actuary as compared to the originally provided utilization position; or
(d) An increase or decrease in the outpatient hospital per capita as calculated by the multiplication of:
(i) The change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided; and
(ii) The change in the restated recommended utilization, adjusted for case mix, position of the Department’s rate certifying actuary as compared to the originally provided utilization position; or
(e) Other changes or circumstances the Department determines are necessary to ensure the rates are actuarially sound.]
(c) An increase or decrease in the inpatient charge per case as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided; or
(d) An increase or decrease in the outpatient charge per visit as calculated by the change in the restated unit cost provided annually by the HSCRC as compared to the data originally provided.
(3)—(6) (text unchanged)
DENNIS SCHRADER
Secretary of Health