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Medicaid Reform: Risk-Adjusted Rates Used to Pay Medicaid Reform Health Plans Could Be Used to Pay All Medicaid Capitated Plans, Report No. 08-54, September 2008
Full report in PDF format

  • As required by state law, the Agency for Health Care Administration has phased in a method that pays Medicaid Reform capitated plans monthly rates that are risk-adjusted to reflect the health status of plans’ beneficiaries.  With risk-adjusted rates, the agency pays higher rates to plans that serve beneficiaries who are sicker and have greater health care needs than plans that serve healthier beneficiaries.  The agency currently uses the Medicaid Rx model which uses pharmacy claims and demographic data to calculate these rates.  By 2009, it expects to begin phasing in another model, the CDPS that will rely on diagnostic data from the agency’s newly developed encounter data system and may continue using pharmacy data as well.
  • The advantage of risk-adjusted rates is that they better match capitated plan payments to the health status and costs of each beneficiary.  Regardless of whether Medicaid Reform expands beyond the pilot counties, once AHCA gains experience using encounter data to set risk-adjusted rates, the Legislature should consider directing the agency to also use risk-adjusted rates to pay non-Reform capitated plans.

Which Government Program Summaries contain related information?

Medicaid Health Care Services
Agency for Health Care Administration

What other OPPAGA-related materials are available?

  • Report No. 09-29 Medicaid Reform: Legislature Should Delay Expansion Until More Information Is Available to Evaluate Success,published in June 2009.
  • Report No. 08-64 Medicaid Reform:  Reform Provider Network Requirements Same as Traditional Medicaid; Improvements Needed to Ensure Beneficiaries Have Access to Specialty Providers, published in November 2008.
  • Report No. 08-55 Medicaid Reform: Oversight to Ensure Beneficiaries Receive Needed Prescription Drugs Can Be Improved; Information Difficult for Beneficiaries to Locate and Compare, published in September 2008.
  • Report No. 08-46 Medicaid Reform: Choice Counseling Goal Met, But Some Beneficiaries Experience Difficulties Selecting a Health Plan That Best Meets Their Needs, published in July 2008.
  • Report No. 08-45 Medicaid Reform: Beneficiaries Earn Enhanced Benefits Credits But Spend Only a Small Proportion, published in July 2008.
  • Report No. 08-40 Medicaid Reform: Two-Thirds of the Initial Pilot Counties’ Beneficiaries Are Enrolled in Reform Plans, published in June 2008.
  • Report No. 08-38 Medicaid Reform: More Managed Care Options Available; Differences Limited by Federal and State Requirements, published in June 2008.
  • Report No. 08-37 Medicaid Reform: Few Beneficiaries Have Participated in the Opt-Out Program, published in June 2008.

Copies of this report in print or alternate accessible format may be obtained by telephone (850/488-0021), by FAX (850/487-9213), in person, or by mail (OPPAGA Report Production, Claude Pepper Building, Room 312, 111 W. Madison St., Tallahassee, FL 32399-1475).
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