(2) Community Tier 2 – Community High Behavioral Health (C2A) Enrollee meets the criteria of Section 4.2.A.3.a, but does not have one of the diagnoses or characteristics specified in Section 4.2.A.3.b (1). 4. Community Tier 1 – Community Other (C1) Enrollees will be classified as Community Other, if they do not meet F1, C2, or C3 criteria. Underlying Rate Structure for Medicare Components of the Capitation Rate Medicare will pay the Contractor a monthly capitation amount for the Medicare Parts A/B services (the Medicare A/B Component), risk adjusted using the Medicare Advantage CMS-HCC Model and the ESRD Model, except as specified in Section 4.2.D.1.a. Medicare will also pay the Contractor a monthly capitation amount for Medicare Part D services, risk adjusted using the Part D RxHCC Model (the Medicare Part D Component). Medicare A/B Component The Medicare baseline spending for Parts A/B services are a blend of the Medicare Fee For Service (FFS) standardized county rates and the Medicare Advantage projected payment rates for each year, weighted by the proportion of the target population projected to otherwise be in each program in the absence of the Demonstration. The FFS county rates will generally reflect amounts published with the April Medicare Advantage Final Rate Announcement, adjusted to fully incorporate more current hospital wage index and physician geographic practice cost index information; in this Demonstration, this adjustment was fully applied to the FFS county rates in 2013 and 2014, but the adjustment will otherwise use the same methodologies and timelines used to make the analogous adjustments in Medicare Advantage. CMS may also further adjust the Medicare FFS standardized county rates as necessary to calculate accurate payment rates for the Demonstration. To the extent that the published FFS
(2) Community Tier 2 – Community High Behavioral Health (C2A) Enrollee meets the criteria of Section 4.2.A.3.a, but does not have one of the diagnoses or characteristics specified in Section 4.2.A.3.b (1). 4. Community Tier 1 – Community Other (C1) Enrollees will be classified as Community Other, if they do not meet F1, C2, or C3 criteria. Underlying Rate Structure for Medicare Components of the Capitation Rate Medicare will pay the Contractor a monthly capitation amount for the Medicare Parts A/B services (the Medicare A/B Component), risk adjusted using the Medicare Advantage CMS-HCC Model and the ESRD Model, except as specified in Section 4.2.D.1.a. Medicare will also pay the Contractor a monthly capitation amount for Medicare Part D services, risk adjusted using the Part D RxHCC Model (the Medicare Part D Component). Medicare A/B Component The Medicare baseline spending for Parts A/B services are a blend of the Medicare Fee For Service (FFS) standardized county rates and the Medicare Advantage projected payment rates for each year, weighted by the proportion of the target population projected to otherwise be in each program in the absence of the Demonstration. The FFS county rates will generally reflect amounts published with the April Medicare Advantage Final Rate Announcement, adjusted to fully incorporate more current hospital wage index and physician geographic practice cost index information; in this Demonstration, this adjustment was fully applied to the FFS county rates in 2013 and 2014, but the adjustment will otherwise use the same methodologies and timelines used to make the analogous adjustments in Medicare Advantage. CMS may also further adjust the Medicare FFS standardized county rates as necessary to calculate accurate payment rates for the Demonstration. To the extent that the published FFS