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4.3.6
Community Payment
A Community Factor payment is made when a beneficiary is not in an Institutional Plan,
is not in a Frailty Plan, and is under age 55.
The following chart follows the decision diagram in Figure 1, and lays out the rules for
choosing this payment type. If all the criteria for any of the scenarios are true, then the
payment calculation should be for a Community Factor payment.
For 2004, either...
Scenario A ...
Or
Scenario B ...
Or
Scenario C ...
a) The beneficiary is not
in hospice, &
a) The beneficiary is not
in hospice, &
a) The beneficiary is
not in hospice, &
b) The beneficiary is not
in ESRD, &
b) The beneficiary is not
in ESRD, &
b) The beneficiary is
not in ESRD, &
c) There is a RAF for the
beneficiary on the
Fu/RAS File, &
c) There is a RAF for the
beneficiary on the
Fu/RAS File, &
c) There is a RAF for
the beneficiary on
the Fu/RAS File, &
d) The beneficiary is
enrolled in an
Institutional (Mixed)
Plan,
d) The beneficiary is not
enrolled in an
Institutional (Mixed)
Plan, &
d) The beneficiary is
not enrolled in an
Institutional (Mixed)
Plan, &
e) The beneficiary does
not have an MDS flag,
&
e) The beneficiary is not
enrolled in a Frailty
Plan.
e) The beneficiary is
enrolled in a Frailty
Plan, &
f) The beneficiary is not
enrolled in a Frailty
Plan.
f) The beneficiary is
under age 55.
Appendix C provides a key between the rules above and the specific criteria to be applied by the system developers.
If this payment type is chosen, then MMCS and GHP will calculate the risk-adjusted
portion of the beneficiary's payment using the following formula:
RA Operational Specification
December 3, 2003
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