| Appendix 1: Medicare Advantage Medical Utilization and Expenditure Experience |
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| Contract number |
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| PBP |
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| Organization Name |
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| Reporting period |
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(1) |
(2) |
(3) |
(4) |
(5) |
(6) |
(7) |
(8) |
(9) |
(10) |
(11) |
(12) |
(13) |
| Medical Expenses |
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Utilization |
Plan Experience |
Allowed cost |
Cost sharing |
Total |
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Total |
Total Member |
Allowed |
Total |
Supplemental |
Medicare |
Supplemental |
supplemental |
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Member |
Utilizers |
Utilization |
Total |
Plan |
cost |
cost |
Medicare |
benefits |
actuarial |
benefits |
benefits |
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Service Category |
Months Cov. |
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Type |
Utilization |
reimb. |
sharing |
(6 + 7) |
covered |
(8+9) |
equivalent |
(11-7) |
(10+12) |
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| a. |
Inpatient Facility |
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$- |
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$- |
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$- |
$- |
| b. |
Skilled Nursing Facility |
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$- |
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$- |
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$- |
$- |
| c. |
Home Health |
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$- |
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$- |
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$- |
$- |
| d. |
Ambulance |
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$- |
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$- |
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$- |
$- |
| e. |
DME/Prosthetics/Supplies |
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$- |
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$- |
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$- |
$- |
| f. |
OP Facility - Emergency |
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$- |
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$- |
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$- |
$- |
| g. |
OP Facility - Surgery |
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$- |
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$- |
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$- |
$- |
| h. |
OP Facility - Other |
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$- |
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$- |
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$- |
$- |
| i. |
Professional |
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$- |
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$- |
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$- |
$- |
| j. |
Part B Rx |
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$- |
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$- |
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$- |
$- |
| k. |
Other Medicare Part B |
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$- |
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$- |
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$- |
$- |
| l. |
Transportation (Non-Covered) |
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$- |
$- |
$- |
$- |
$- |
$- |
| m. |
Dental (Non-Covered) |
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$- |
$- |
$- |
$- |
$- |
$- |
| n. |
Vision (Non-Covered) |
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$- |
$- |
$- |
$- |
$- |
$- |
| o. |
Hearing (Non-Covered) |
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$- |
$- |
$- |
$- |
$- |
$- |
| p. |
Health & Education (Non-Covd) |
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$- |
$- |
$- |
$- |
$- |
$- |
| q. |
Other Non-Covered |
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$- |
$- |
$- |
$- |
$- |
$- |
| r. |
Total Medical Expenses |
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$- |
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$- |
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$- |
$- |
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| Supplemental data |
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| Total Enrollees |
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| Member months |
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| Premiums collected |
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| CMS revenue collected |
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| Plan CMS Part A & Part B Revenues Collected |
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| Reserve for outstanding claims |
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| Notes |
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| 1. Form to be completed at the plan level. |
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| 2. Utilization types: A - Admits; D - Days; BP - Benefit period; V - visits; P - procedures; T - Trips; S - Scripts; O - other; U - Data is unavailable |
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| 3. Medicare actuarial equivalent cost sharing to be developed using actuarial equivalent factors contained in MA bid pricing tool. |
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| 4. Premiums collected include payments from plan enrollees, employer/union groups, State Medicaid agencies, and other third parties. |
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| 5. Optional supplemental benefits, revenues, and member months are to be excluded. |
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