<aside> 💡 This chapter covers topics include calculation of annual MA capitation rates, plan-specific payment rates, adjustments to payment rates (including risk adjustment), and other payment rules. We highlight information relating to RA.
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<aside> 📔 Table of Contents
NOTE: This initial version of the chapter does not include all details of MA payment calculations, in particular details on the risk adjustment method.
Chapter 8 sets forth the policies and methods CMS follows in determining the amount of payment a Medicare Advantage (MA) organization will receive from CMS for coverage of non-prescription drug benefits for Medicare beneficiaries who are enrolled in coordinated care plans (including MA regional plans), private fee-for-service plans, and medical savings account plans offered by the organization. Topics include calculation of annual MA capitation rates, plan-specific payment rates, adjustments to payment rates (including risk adjustment), and other payment rules.
The regulations that govern these policies and methods are set forth in Part 422 Subparts G and J of the Code of Federal Regulations, and are based primarily on §§1853, 1854, and 1858 of the Social Security Act (the Act), as amended by the Medicare Modernization Act (MMA) of 2003.
(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)
<aside> 💡 CMS makes advance monthly payments to an MA organization for each enrollee in an MA plan for coverage of original Medicare benefits in an MA payment area for a month.
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<aside> 💡 In the case of an enrollee in an MA-PD plan, the MA organization also receives payment for coverage of Part D prescription drug benefits, including: direct and reinsurance subsidy payments for qualified prescription drug coverage, and reimbursement for the beneficiary drug premium, and the cost sharing reductions applicable to low-income individuals enrolled in the plan.
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(Rev. 89; Issued: 11-02-07; Effective/Implementation: 11-02-07)