C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 417—HEALTH MAINTENANCE ORGANIZATIONS, COMPETITIVE MEDICAL PLANS, AND HEALTH CARE PREPAYMENT PLANS › Subpart P—Medicare Payment: Risk Basis

42 C.F.R. § 417.588

Computation of adjusted average per capita cost (AAPCC)

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(a) Basic data. In computing the AAPCC, CMS uses the U.S. per capita incurred cost and adjusts it by the factors specified in paragraph (c) of this section to establish an AAPCC for each class of Medicare enrollees.

(b) Advance notice to the HMO or CMP. Before the beginning of a contract period, CMS informs the HMO or CMP of the specific adjustment factors it will use in computing the AAPCC.

(c) Adjustment factors—(1) Geographic. CMS makes an adjustment to reflect the relative level of Medicare expenditures for beneficiaries who reside in the HMO's or CMP's geographic area (or a similar area). This adjustment is based on reimbursement for Medicare covered services and uses the most accurate and timely data that pertain to the HMO's or CMP's geographic area and that is available to CMS when it makes the determination.

(2) Enrollment. CMS makes a further adjustment to remove the cost effect of all area Medicare beneficiaries who are enrolled in the HMO or CMP or another HMO or CMP.

(3) Age, sex, and disability status. CMS makes adjustments to reflect the age and sex distribution and the disability status of the HMO's or CMP's enrollees based on Medicare program experience and available data that indicate cost differences that result from those factors.

(4) Other relevant factors. If accurate data are available and appropriate, CMS makes adjustments to reflect welfare and institutional status and other relevant factors.

[50 FR 1346, Jan. 10, 1985, as amended at 58 FR 38083, July 15, 1993; 60 FR 46232, Sept. 6, 1995]
Notes of Decisions
Cited in 2 cases, 1998–2000 · leading case: Zamora-Quezada v. HealthTexas Med. Grp., 34 F. Supp. 2d 433 (W.D. Tex. 1998).
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Zamora-Quezada v. HealthTexas Med. Grp., 34 F. Supp. 2d 433 (W.D. Tex. 1998). “584 (1997) (HCFA payment allowances for covered services to HMOs with risk contracts); 42 C.F.R. § 417.588 (1997) (computation of adjusted AAPCC).”
Minnesota Ex Rel. Hatch v. United States, 102 F. Supp. 2d 1115 (D. Minnesota 2000). “§ 1395mm(a)(4); see 42 C.F.R. § 417.588 (c). For each Medicare beneficiary enrolled in a managed care organization, Medicare paid the organization 95% of the AAPCC rate corresponding to the demographic class to which each beneficiary was assigned.”
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