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OHP Rate Development

Process Overview

The Oregon Health Plan (OHP) is our state Medicaid program. It provides health coverage for low-income Oregonians that include working families, children, pregnant women, single adults, seniors and more. The Oregon Health Authority (OHA) has contracted with a variety of health entities, known as Coordinated Care Organizations or CCOs, to manage and deliver health care for most of these people eligible for Medicaid. OHA pays CCOs to cover these individuals with capitation rates. Capitation rates are a predetermined payment that depends on the individual's OHP eligibility status and is paid to CCOs on a monthly basis dependent on enrollment.

These capitation rates are developed and certified by OHA's actuaries on a yearly basis. The process and methodology used to develop capitation rates are governed by federal and state regulations. CMS requires Oregon's capitation rates be Actuarially Sound and follow applicable Actuarially Standards of Practice, which are developed by the American Academy of Actuaries.

To learn more about Oregon's capitation rates and future rate setting cycles, please review this brief on Rate Setting for Coordinated Care Organizations, or review the most recent capitation rate reports listed in the sections below.

OHA Releases 2018 Rates for Oregon's Coordinated Care Organizations

The Oregon Health Authority (OHA) has released the 2018 capitation rates for Oregon's coordinated care organizations (CCOs). Oregon's 16 CCOs contract with the state to manage and deliver health care to Oregonians on the Oregon Health Plan (OHP), the state's Medicaid insurance program. OHA pays a per-member-per-month fee to CCOs to manage OHP members' physical, behavioral and oral health care.

The average rate increase among Oregon’s CCOs is 3.3 percent. As part of its federal waiver with the Centers for Medicare & Medicaid Services (CMS), Oregon has pledged to contain rate increases to 3.4 percent per year or less.  

“These rates show that Oregon can contain costs while at the same time improving quality and transforming health care in the state,” said Patrick Allen, Director of the Oregon Health Authority. “One in four Oregonians now receives health care through our innovative coordinated care model. That’s something all Oregonians should be proud of.” 

Rate setting takes into account several factors, including differences in regional costs, population disease risk and hospital reimbursement. The state contracts with Optumas, an actuarial consulting firm, to assist in the rate development. The 2018 capitation rates have been certified by Optumas as actuarially sound. 

OHA gives CCOs an opportunity to review the rates before they are submitted to CMS. It also works with the CCOs and the actuary to ensure that the methodology behind the rate setting is rigorous, equitable and compliant with federal requirements. 

CMS has approved Oregon’s CCO rates for the past three years. OHA took extra steps this year to ensure the rate-setting process is fully transparent and independently verified. This includes two additional reviews, by a second Medicaid-qualified actuary and an independent law firm.  Results of these reviews are below:

2018 Regulatory Review of Rate Setting Process
OHA Secondary Review Final Report

See a full list of Oregon’s 2018 CCO capitation rates below. 

2018 Aggregate CCO Rate Comparison

2015-2018 Capitation Rate Reports

2015-2018 Contract Rate Sheets

2015 & 2016 Rate Methodology

Questions?

Please contact:
Actuarial Services


For more information

  
American Academy of Actuaries
CMS Medicaid Home
Coordinated Care Organizations
Forecasting Reports
Health Evidence Review Commission (HERC)
Oregon Health Plan
Rates Advisory Panel

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