Organization : Archcare Community Life(Catholic MLTC ......Archcare Community Life(Catholic MLTC)...
Transcript of Organization : Archcare Community Life(Catholic MLTC ......Archcare Community Life(Catholic MLTC)...
Managed Long Term Care Medicaid Managed Care Operations Report
Organization : Archcare Community Life(Catholic MLTC) (03466800)
Coverage : Statewide
Period Ending : 6/30/2018
Dcn : 10162018062757
Date : Tuesday, October 16, 2018
Page 1
Configuration InformationConfiguration Information
Submission Type 0.1005 MLTCCRSubmission Year 0.1010 2018Submission Period 0.1011 Q02DCN 0.1004 10162018062757Submitter ID 0.1000 03466800Region ID 0.1003 1Region Name 0.1002 STATEWIDEName of Organization 0.10 ARCHCARE COMMUNITY LIFE(CATHOLIC MLTC) (03466800)Begin Date 0.34 01/01/2018End Date 0.35 06/30/2018
ContactsContact Person:
Name: 0.70 Timothy JohnsonTitle: 0.71 Senior Director of FinanceTelephone Number: 0.72 646-633-4737Fax Number: 0.73 646-633-4701Email Address: 0.82 [email protected]
CertifiersChief Executive Officer
Role 999930000.1 CEOName 999930000.2 Scott LaRueTitle 999930000.3 President, Chief Executive OfficerPhone Number 999930000.4 646-475-4868Fax Number 999930000.5 646-395-5902Email Address 999930000.6 [email protected]
Chief Financial Officer
Role 999930001.1 CFOName 999930001.2 Annmarie CovoneTitle 999930001.3 Executive VP/Chief Financial OfficerPhone Number 999930001.4 646-633-4702Fax Number 999930001.5 646-633-4701Email Address 999930001.6 [email protected]
AddressesMailing Address:
Item 0.66 ArchCare Community LifeLine 1 0.67 205 Lexington Avenue, 2nd FloorLine 2 0.68 New York, NY 10016Line 3 0.69
Additional InformationAdditional Information
Date Operations Started (MM/DD/YYYY):0.65 11/01/2012
Counties of OperationCounties of Operation:
Item 0.4 NY (MANHATTAN)County 0.5 QUEENSCounty 0.6 RICHMOND (STATEN ISLAND)County 0.7 BRONXCounty 0.8 KINGS (BROOKLYN)County 0.9 WESTCHESTERCounty 0.11 PUTNAM
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 2
Schedule ABalance Sheet
Assets Nonadmitted Assets Net AdmittedAssets
Net Admitted AssetsAs of 12/31
00010 02225 00011 00013 00014 00012
CURRENT ASSETS
Cash 0001 $32,230,454 $32,230,454 $5,158,551
Short-Term Investments 0002 $3,795,202 $3,795,202 $3,721,950
Premiums Receivable-net 0003 $3,409,984 $3,409,984 $18,219,713
Interest Receivable 0004
NYS Medicaid Reinsurance Recovery Receivable 0140
Other Receivables - Net 0006
Prepaid Expenses 0007 $183,178 $183,178 $190,588
Risk Share Receivable 0200
Aggregate Write-Ins for Current Assets (list below) 0008 $4,290,822 $4,290,822 $4,750,340
Due from Third Party Payors 0009 $4,290,822 $4,290,822 $4,750,340
0010
0011
0012
0013
TOTAL CURRENT ASSETS 0015 $43,909,640 $43,909,640 $32,041,142
OTHER ASSETS
NYS Escrow Account Balance 0016 $14,058,586 $14,058,586 $9,062,671
Amounts Due from Affiliates 0018 $8,371,883 $8,371,883 $1,931,995
Loan Escrow 0019
Long-Term Investments 0020
Intangible Investments and Goodwill 0111
Lease Acquisition Costs, Net 0112 $93,897 $93,897 $93,897
Security Deposit 0113 $102,500 $102,500 $102,500
0114
0115
0116
Other Restricted Assets 0017
Aggregate Write-Ins for Other Assets (list below) 0124
0024
0025
0026
0027
0028
TOTAL OTHER ASSETS 0030 $22,626,866 $22,626,866 $11,191,063
PROPERTY AND EQUIPMENT
Land 0031
Building and Improvements 0032
Construction In Progress 0035
Furniture and Equipment 0033 $3,071,376 $3,071,376 $2,723,505
Leasehold Improvements 0034 $3,132,099 $3,132,099 $2,997,754
Aggregate Write-Ins for Other Equipment (list below) 0137
0037
0038
0039
0040
0041
TOTAL PROPERTY AND EQUIPMENT 0045 $6,203,475 $6,203,475 $5,721,259
TOTAL ASSETS 0050 $72,739,981 $72,739,981 $48,953,464
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 3
Schedule ABalance Sheet (continued)
Current Year Previous Calendar Yearas of 12/31
00010 02226 00011 00012
CURRENT LIABILITIES
Accounts Payable 0051 $12,637,916 $13,511,662
Claims Payable 0052
Accrued Inpatient Claims (Not Reported) 0054
Accrued Physician Claims (Not Reported) 0055
Accrued Referral Claims (Not Reported) 0056
Accrued Other Medical 0057
Accrued Medical Incentive Pool 0058
Unearned Premiums 0059 $2,378,756 $5,000
Loans and Notes Payable 0060
Risk Share Payable 0201
Aggregate Write-Ins for Current Liabilities (list below) 0162 $40,008,223 $24,934,308
Incurred But not Reported (IBNR) 0062 $40,008,222 $21,163,142
Due to Third Party Payors 0063 $1 $3,771,166
0064
0065
0066
TOTAL CURRENT LIABILITES 0070 $55,024,895 $38,450,970
OTHER LIABILITIES
Loans and Notes 0071
Amounts Due to Affiliates 0072 $5,276,145 $243,630
Aggregate Write-Ins for Other Liabilities (list below) 0173 $191,783 $195,251
Deferred Rent Payable 0073 $191,783 $195,251
0074
0075
0076
0077
TOTAL OTHER LIABILITIES 0079 $5,467,928 $438,881
TOTAL LIABILITIES 0080 $60,492,823 $38,889,851
NET WORTH
Donated Capital 0121
Capital 0122
Paid In Surplus 0123
NYS Contingent Reserve Requirement 0081 $14,037,806 $9,047,062
Aggregate Write-Ins For Other Net Worth Items (List Below) 0183
0083
0084
0085
0086
0087
Unassigned Surplus 0089 ($1,790,647) $1,016,551
TOTAL NET WORTH EXCLUDING NON ADMITTED ASSETS 0105 $12,247,159 $10,063,613
TOTAL LIABILITIES AND NET WORTH EXCLUDING NON ADMITTED ASSETS 0110 $72,739,982 $48,953,464
TOTAL NET WORTH INCLUDING NON ADMITTED ASSETS 0090 $12,247,158 $10,063,613
TOTAL LIABILITIES AND NET WORTH INCLUDING NON ADMITTED ASSETS 0100 $72,739,981 $48,953,464
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 4
Schedule A1 - Net Worth Reconciliation
00030 30127 00031
Net Worth Last Year 0001 $10,063,613
Total Net Income 0002 $2,188,802
Change in nonadmitted assets 0020
Dividends to stockholders 0003
Withdrawals of equity 0004
Change in Net unrealized capital gains & losses less capital gains tax 0019 ($5,259)
Adjusted Net Worth 0005 $12,247,156
Current Net Worth 0006 $12,247,159
Difference 0007 $3
Explanations:
Rounding 0008 $3
0009
0010
0011
0012
0013
0014
0015
0016
0017
Total Explanations 0018 $3
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
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Schedule B - Revenue and Expense Statement - Total Line of Business Total PlanAmount
MedicaidEnrolleesAmount
OtherEnrolleesAmount
Total PlanPMPM
MedicaidPMPM
OtherPMPM
Total Plan Previous YearPMPM
(as of 12/31)
00110 02228 00111 00112 00113 00114 00115 00116 00117
Total Member Months 0001 21,705 21,705 $32,106.00
Revenue
Medicare Part C Premium Revenue 0401 $0.00
Medicare Part D Premium Revenue 0402 $0.00
Medicaid Premium Revenue 0003 $101,988,313 $101,988,313 $4,698.84 $4,698.84 $4,619.26
Other Payor Premium Revenue 0004 $0.00
Spenddown and NAMI 0013 $3,742,550 $3,742,550 $172.43 $172.43 $164.69
Coordination of Benefits(COB) 0014 $0.00 $0.00
Reinsurance Recoveries 0077 $0.00 $0.00
Net Investment Income (Schedule G) 0016 $94,633 $94,633 $4.36 $4.36 $2.33
HR&R Revenue 0018 $0.00 $0.00
Quality Incentive Pool Award 0416 $0.00 $0.00
Quality Incentive VAPP 0417 $0.00 $0.00
Minimum Wage 0419 $10,079,088 $10,079,088 $464.37 $464.37
Other Revenue (Double click Below)
0019 $0.00 $0.00
0020 $0.00 $0.00
TOTAL PREMIUM REVENUE 0010 $105,730,863 $105,730,863 $4,871.27 $4,871.27 $4,783.95
TOTAL REVENUE 0030 $115,904,584 $115,904,584 $5,339.99 $5,339.99 $4,786.28
Expenses
Medical and Hospital Expenses
Inpatient:Acute Medical/Surgical 0031
Inpatient:Mental Health/Substance/Abuse 0032
Inpatient Maternity Delivery 0403
Total Hospital Inpatient Care 0404
Other Medical and Hospital:
Primary Care Physician 0034
Specialty Care 0035
Prenatal/Postpartum Maternity Services 0405
Ambulatory Surgery 0036
Outpatient/Physical Rehab/Therapy 0406 $13,479 $13,479 $0.62 $0.62 $0.62
Other Professional Services 0037 $36,094 $36,094 $1.66 $1.66 $0.50
Emergency Room 0038
Outpatient Mental Health 0039
Outpatient Drug and Alcohol Treatment 0040
Dental 0041 $243,169 $243,169 $11.20 $11.20 $11.07
Pharmacy-Part D 0407
Pharmacy-Non-Part D 0408
Home Health Care 0409 $744,377 $744,377 $34.30 $34.30 $56.77
Nursing Facility 0033 $25,969,986 $25,969,986 $1,196.50 $1,196.50 $1,278.44
Transportation - Emergent 0410
Transportation - Non Emergent 0411 $2,154,188 $2,154,188 $99.25 $99.25 $102.68
Diagnostic Test/Lab/X-Ray 0048
Family Planning 0412
Vision Care Inc. Eyeglasses 0049 $12,531 $12,531 $0.58 $0.58 $0.50
Foot Care 0050 $17,392 $17,392 $0.80 $0.80 $0.68
Durable Medical Equipment & Supplies 0060 $892,422 $892,422 $41.12 $41.12 $39.81
Personal Care 0057 $50,354,620 $50,354,620 $2,319.95 $2,319.95 $2,584.48
CDPAP 0125 $8,396,199 $8,396,199 $386.83 $386.83
Personal Emergency Response Services 0062 $156,536 $156,536 $7.21 $7.21 $8.68
Home Delivered and Congregate Meals 0064 $44,681 $44,681 $2.06 $2.06 $2.48
Adult Day Health Care 0044 $766,088 $766,088 $35.30 $35.30 $11.98
Social Day Care 0045 $176,621 $176,621 $8.14 $8.14 $10.84
Other Medical Services 0413 $0.00 $0.00
GROSS MEDICAL & HOSPITAL EXPENSES 0075 $89,978,383 $89,978,383 $4,145.51 $4,145.51 $4,109.53
PLUS: Reinsurance Premium Cost(1) 0015 $0.00 $0.00
Global Capitation Surplus/(Loss) 0415 $0.00 $0.00 $0.00
Quality Incentive VAPP 0418 $0.00 $0.00 $0.00
Minimum Wage 0420 $10,079,088 $10,079,088 $464.37 $464.37 $0.00
Incentive Pool Adjustment 0076 $0.00 $0.00 $4,273.07
TOTAL MEDICAL & HOSPITAL EXPENSES 0080 $100,057,471 $100,057,471 $4,609.88 $4,609.88 $8,382.60
Care Management (Schedule D-2) 0047 $4,206,957 $4,206,957 $0 $193.82 $193.82 $219.63
Administration
Allowable Administration Expenses (Schedule D-3) 0081 $7,264,412 $7,264,412 $0 $334.69 $334.69 $334.69 $384.86
TOTAL EXPENSES 0085 $111,528,840 $111,528,840 $0 $5,138.39 $5,138.39 $8,987.09
Premium Income(Loss) 0086 ($5,797,977) ($5,797,977) $0 ($267.13) ($267.13) ($4,203.14)
Nonallowable Administrative Expenses 0098 $938,438 $938,438 $0 $43.24 $43.24 $55.00
Operating Incomes(Loss) 0090 $3,437,306 $3,437,306 $0 $158.36 $158.36 ($4,255.81)
Aggregate Write-ins for Other Expenses 0095 $0.00 $0.00
Prior Period Adjustments and Extraordinary Items 0096 $0.00 $0.00
Provision for Taxes 0093 $0.00 $0.00
Adj. For Prior Period IBNR Adjustment 0094 ($35,053) ($35,053) ($1.61) ($1.61) $5.80
NET INCOME (LOSS) 0100 $3,472,359 $3,472,359 $0 $159.98 $159.98 $17.73
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
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Schedule B Consolidated Revenue and Expense Summary
All Lines of Business
PACE Partial MedicareAdvantage
MedicaidAdvantage
Plus
FIDA DISCO HARP Other Total
00120 02229 00121 00122 00123 00126 00127 00128 00129 00124 00125
Members 1001 712 3,796 4,508
Member Months 0001 4,119 21,705 25,824
Revenue
Medicare Part C Premium Revenue 0401 $12,319,711 $12,319,711
Medicare Part D Premium Revenue 0402 $3,158,849 $3,158,849
Medicaid Premium Revenue 0003 $21,704,590 $101,988,313 $123,692,903
Other Payor Premium Revenue 0004 $108,186 $108,186
Spenddown and NAMI 0013 $429,761 $3,742,550 $4,172,311
Coordination of Benefits(COB) 0014
Reinsurance Recoveries 0077 $54,053 $54,053
Net Investment Income (Schedule G) 0016 $7,214 $94,633 $101,847
HR&R Revenue 0018
Quality Incentive Pool Award 0416
Quality Incentive VAPP 0417
Minimum Wage 0419 $1,909,400 $10,079,088 $11,988,488
Other Revenue
Grants/Contributions/Other Revenue 0019 $1,582,662 $1,582,662
Social Day Care Revenue 0020 $132,279 $132,279
TOTAL PREMIUM REVENUE 0010 $37,721,097 $105,730,863 $143,451,960
TOTAL REVENUE 0030 $41,406,705 $115,904,584 $157,311,289
Expenses
Medical and Hospital Expenses
Inpatient:Acute Medical/Surgical 0031 $4,608,888 $4,608,888
Inpatient:Mental Health/Substance/Abuse 0032
Inpatient Maternity Delivery 0403
Total Hospital Inpatient Care 0404 $4,608,888 $4,608,888
Other Medical and Hospital:
Primary Care Physician 0034 $1,297,080 $1,297,080
Specialty Care 0035 $227,386 $227,386
Prenatal/Postpartum Maternity Services 0405
Ambulatory Surgery 0036
Outpatient/Physical Rehab/Therapy 0406 $957,386 $13,479 $970,865
Other Professional Services 0037 $907,412 $36,094 $943,506
Emergency Room 0038 $78,672 $78,672
Outpatient Mental Health 0039 $151,376 $151,376
Outpatient Drug and Alcohol Treatment 0040
Dental 0041 $50,766 $243,169 $293,935
Pharmacy-Part D 0407 $2,500,845 $2,500,845
Pharmacy-Non-Part D 0408 $77,346 $77,346
Home Health Care 0409 $13,394,021 $744,377 $14,138,398
Nursing Facility 0033 $2,511,953 $25,969,986 $28,481,939
Transportation - Emergent 0410 $138,337 $138,337
Transportation - Non Emergent 0411 $2,058,765 $2,154,188 $4,212,953
Diagnostic Test/Lab/X-Ray 0048 $452,531 $452,531
Family Planning 0412
Vision Care Inc. Eyeglasses 0049 $83,772 $12,531 $96,303
Foot Care 0050 $103,167 $17,392 $120,559
Durable Medical Equipment & Supplies 0060 $381,966 $892,422 $1,274,388
Personal Care 0057 $50,354,620 $50,354,620
CDPAP 0125 $8,396,199 $8,396,199
Personal Emergency Response Services 0062 $10,922 $156,536 $167,458
Home Delivered and Congregate Meals 0064 $227,613 $44,681 $272,294
Adult Day Health Care 0044 $3,600 $766,088 $769,688
Social Day Care 0045 $3,309,170 $176,621 $3,485,791
Supplemental Benefits 0099
Other Medical Services 0413 $32,450 $32,450
GROSS MEDICAL & HOSPITAL EXPENSES 0075 $33,565,424 $89,978,383 $123,543,807
PLUS: Reinsurance Premium Cost(1) 0015 $15,026 $15,026
Global Capitation Surplus/(Loss) 0415
Quality Incentive VAPP 0418
Minimum Wage 0420 $1,909,400 $10,079,088 $11,988,488
Incentive Pool Adjustment 0076
TOTAL MEDICAL & HOSPITAL EXPENSES 0080 $35,489,850 $100,057,471 $135,547,321
Care Management 0047 $1,557,117 $4,206,957 $5,764,074
Administration
Allowable Administration Expenses 0081 $4,959,557 $7,264,412 $12,223,969
TOTAL EXPENSES 0085 $42,006,524 $111,528,840 $153,535,364
Premium Income(Loss) 0086 ($4,285,427) ($5,797,977) ($10,083,404)
Nonallowable Administrative Expenses 0098 $237,381 $938,438 $1,175,819
Operating Incomes(Loss) 0090 ($837,200) $3,437,306 $2,600,106
Aggregate Write-ins for Other Expenses 0095
Prior Period Adjustments and Extraordinary Items 0096
Provision for Taxes 0093
Adj. For Prior Period IBNR Adjustment 0094 $446,357 ($35,053) $411,304
NET INCOME (LOSS) 0100 ($1,283,557) $3,472,359 $2,188,802
(1) Plans purchasing reinsurance should enter its reinsurance costs on this line.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 7
Schedule B-1 - Medicaid Revenue and Expense Analysis Community MedicaidCurrent
YTD
MedicaidCurrent YTD
PMPM
MedicaidPrevious Calendar
Year PMPMas of 12/31
00210 22210 00211 00212 00213
Medicaid Member Months 0101 18,795 27,717
Revenue
Medicare Part C Premium Revenue 0501
Medicare Part D Premium Revenue 0502
Medicaid Premium Revenue 0103 $86,966,046 $4,627.08 $4,619.26
Other Payor Premium Revenue 0104
Spenddown and NAMI 0113 $867,973 $46.18 $164.69
Coordination of Benefits(COB) 0114 $0.00
Reinsurance Recoveries 0177 $0.00
Net Investment Income 0116 $81,948 $4.36 $2.33
HR&R Revenue 0118 $0.00
Quality Incentive Pool Award 0416 $0.00
Quality Incentive VAPP 0417 $0.00
Minimum Wage 0419 $10,079,088 $536.26
Other Revenue (Double Click Below)
0119 $0.00
0120 $0.00
TOTAL PREMIUM REVENUE 0110 $87,834,019 $4,673.27 $4,783.95
TOTAL REVENUE 0130 $97,995,055 $5,213.89 $4,786.28
Expenses
Medical and Hospital Expenses
Inpatient Acute Medical Surgical 0131
Inpatient Mental Health & Substance Abuse 0132
Inpatient Maternity Delivery 0503
Total Hospital Inpatient Care 0504
Other Medical and Hospital:
Primary Care Physician 0134
Specialty Care 0135
Prenatal/Postpartum Maternity Services 0505
Ambulatory Surgery 0136
Outpatient/Physical Rehab/Therapy 0506 $13,479 $0.72 $0.62
Other Professional Services 0137 $36,025 $1.92 $0.50
Emergency Room (In/Out of Area) 0138
Outpatient: Mental Health 0139
Outpatient Drug & Alcohol Treatment 0140
Dental 0141 $243,169 $12.94 $11.07
Pharmacy-Part D 0507
Pharmacy-Non-Part D 0508
Home Health Care 0509 $744,377 $39.61 $56.77
Nursing Facility 0133 $927,048 $49.32 $1,278.44
Transportation - Emergent 0510
Transportation - Non Emergent 0511 $2,055,341 $109.36 $102.68
Diagnostic Testing, Lab & X-Ray 0148
Family Planning 0512
Vision Care Inc. Eyeglasses 0149 $2,748 $0.15 $0.50
Foot Care 0150 $14,741 $0.78 $0.68
Durable Medical Equipment & Other 0160 $886,146 $47.15 $39.81
Personal Care 0157 $50,279,262 $2,675.14 $2,584.48
CDPAP 0125 $8,393,821 $446.60 $163.53
Personal Emergency Response Services 0162 $156,281 $8.32 $8.68
Home Delivered and Congregate Meals 0164 $44,510 $2.37 $2.48
Adult Day Care 0144 $765,494 $40.73 $11.98
Social Day Care 0145 $174,567 $9.29 $10.84
Other Medical Services: (Enter labels on Exhibit B)
0513 $0.00
0514 $0.00
0515 $0.00
0516 $0.00
0517 $0.00
Total: Other Medical Services 0530 $0.00
GROSS MEDICAL & HOSPITAL EXPENSES 0175 $64,737,009 $3,444.37 $4,273.06
PLUS: Reinsurance Premium Cost 0115 $0.00
Global Capitation Surplus/(Loss) 0415 $0.00
Quality Incentive VAPP 0418 $0.00
Minimum Wage 0420 $10,079,088 $536
Incentive Pool Adjustment 0176 $0.00
TOTAL MEDICAL & HOSPITAL EXPENSES 0180 $74,816,097 $3,980.64 $4,273.06
Care Management (Schedule D-2) 0147 $3,026,792 $161.04 $219.63
Administration
Allowable Administration Expenses (Schedule D-3) 0181 $6,290,469 $334.69 $384.86
TOTAL EXPENSES 0185 $84,133,357 $4,476.37 $4,877.55
Premium Income(Loss) 0186 $3,700,662 $196.90 ($93.60)
Nonallowable Expense 0198 $812,621 $43.24 $55.00
Operating Incomes(Loss) 0190 $13,049,077 $694.28 ($146.27)
Aggregate Write-ins for Other Expenses 0195
Prior Period Adjustments and Extraordinary Items 0196
Provision for Taxes 0193
Adj. For Prior Period IBNR Adjustment 0194
NET INCOME (LOSS) 0199
(1) Plans purchasing reinsurance should enter its reinsurance costs on this line.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 8
Schedule B-1 - Medicaid Revenue and Expense Analysis Nursing Home Permanent Placement MedicaidCurrent
YTD
MedicaidCurrent YTD
PMPM
MedicaidPrevious Calendar
Year PMPMas of 12/31
00224 22411 00225 00226 00227
Medicaid Member Months 0101 2,910 4,389
Revenue
Medicare Part C Premium Revenue 0501
Medicare Part D Premium Revenue 0502
Medicaid Premium Revenue 0103 $15,022,267 $5,162.29 $4,619.26
Other Payor Premium Revenue 0104
Spenddown and NAMI 0113 $2,874,577 $987.83 $164.69
Coordination of Benefits(COB) 0114 $0.00
Reinsurance Recoveries 0177 $0.00
Net Investment Income 0116 $12,685 $4.36 $2.33
HR&R Revenue 0118 $0.00
Quality Incentive Pool Award 0416 $0.00
Quality Incentive VAPP 0417 $0.00
Minimum Wage 0419 $0.00
Other Revenue (Double Click Below)
0119 $0.00
0120 $0.00
TOTAL PREMIUM REVENUE 0110 $17,896,844 $6,150.12 $4,783.95
TOTAL REVENUE 0130 $17,909,529 $6,154.48 $4,786.28
Expenses
Medical and Hospital Expenses
Inpatient Acute Medical Surgical 0131
Inpatient Mental Health & Substance Abuse 0132
Inpatient Maternity Delivery 0503
Total Hospital Inpatient Care 0504
Other Medical and Hospital:
Primary Care Physician 0134
Specialty Care 0135
Prenatal/Postpartum Maternity Services 0505
Ambulatory Surgery 0136
Outpatient/Physical Rehab/Therapy 0506 $0.00 $0.62
Other Professional Services 0137 $69 $0.02 $0.50
Emergency Room (In/Out of Area) 0138
Outpatient: Mental Health 0139
Outpatient Drug & Alcohol Treatment 0140
Dental 0141 $0.00 $11.07
Pharmacy-Part D 0507
Pharmacy-Non-Part D 0508
Home Health Care 0509 $0.00 $56.77
Nursing Facility 0133 $25,042,938 $8,605.82 $1,278.44
Transportation - Emergent 0510
Transportation - Non Emergent 0511 $98,847 $33.97 $102.68
Diagnostic Testing, Lab & X-Ray 0148
Family Planning 0512
Vision Care Inc. Eyeglasses 0149 $9,783 $3.36 $0.50
Foot Care 0150 $2,651 $0.91 $0.68
Durable Medical Equipment & Other 0160 $6,276 $2.16 $39.81
Personal Care 0157 $75,358 $25.90 $2,584.48
CDPAP 0125 $2,378 $0.82 $163.53
Personal Emergency Response Services 0162 $255 $0.09 $8.68
Home Delivered and Congregate Meals 0164 $171 $0.06 $2.48
Adult Day Care 0144 $594 $0.20 $11.98
Social Day Care 0145 $2,054 $0.71 $10.84
Other Medical Services: (Enter labels on Exhibit B)
0513 $0.00
0514 $0.00
0515 $0.00
0516 $0.00
0517 $0.00
Total: Other Medical Services 0530 $0.00
GROSS MEDICAL & HOSPITAL EXPENSES 0175 $25,241,374 $8,674.01 $4,273.06
PLUS: Reinsurance Premium Cost 0115 $0.00
Global Capitation Surplus/(Loss) 0415 $0.00
Quality Incentive VAPP 0418 $0.00
Minimum Wage 0420 $0
Incentive Pool Adjustment 0176 $0.00
TOTAL MEDICAL & HOSPITAL EXPENSES 0180 $25,241,374 $8,674.01 $4,273.06
Care Management (Schedule D-2) 0147 $1,180,165 $405.56 $219.63
Administration
Allowable Administration Expenses (Schedule D-3) 0181 $973,943 $334.69 $384.86
TOTAL EXPENSES 0185 $27,395,483 $9,414.26 $4,877.55
Premium Income(Loss) 0186 ($9,498,639) ($3,264.14) ($93.60)
Nonallowable Expense 0198 $125,817 $43.24 $55.00
Operating Incomes(Loss) 0190 ($9,611,771) ($3,303.01) ($146.27)
Aggregate Write-ins for Other Expenses 0195
Prior Period Adjustments and Extraordinary Items 0196
Provision for Taxes 0193
Adj. For Prior Period IBNR Adjustment 0194
NET INCOME (LOSS) 0199
* Total actual hours paid during the report period.|
(Includes vacation, sick and holiday time)/(weeks in report period x standard hrs. per workweek)|
** Care Management Supervisor ratio is to CM EMPLOYEES, not to enrollees.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 9
Schedule D-2 - Care Management *F.T.E.s Salary and Fringes *F.T.E.s Salary and Fringes Total **Staffing Ratios
00610 61016 00611 00612 00614 00615 00617 00618
Care Management Supervisor 0001 7.36 $653,774 $653,774 7:39
Care Manager 0002 28.71 $1,545,239 3.74 $805,158 $2,350,397 32:3796
Other - (Double click Below)
Social Services 0004 10.42 $517,406 $517,406 10:3796
Reassessment Nurse 0005 10.15 $685,380 $685,380 10:3796
0006
0007
0008
0009
0010
0011
0012
0013
TOTAL CARE MANAGEMENT 0025 56.64 $3,401,799 3.74 $805,158 $4,206,957 29.96
PACE Center Staff 0026
Non-PACE Center Staff 0027 56.64 $3,401,799 3.74 $805,158 $4,206,957
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 10
Schedule D-2A - Care Management Expense - Contracted Services Panel Size (Members) Member Months Contracted Fee PMPM Contracted Care Management Expense Reported on Table D-2
00619 00620 00621 00622 00623 00624
CASSENA CARE IPA LLC 0001 $382,859
EDISON HOME HEALTH CARE 0002 $42,951
FAMILY HOME HEALTH CARE INC 0004 $1,971
GREATER NEW YORK HOME HEALTH CARE LLC 0005 $72,103
SPLIT ROCK REHABILITATION & HEALTH CARE CENTER LLC 0006 $305,274
0007
0008
0009
0010
0011
0012
0013
0014
0015
0016
0017
0018
0019
0020
0021
0022
0023
0024
TOTAL CONTRACTED CARE MANAGEMENT 0025 $805,158
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 11
Schedule D-3 - Administration Expense - Total Total Direct Expense Total Contracted Expense Total Administration Expense
00710 71017 00713 00716 00719
Rent ($0 for Occupancy of Own Building) 0001 $44,718 $293,862 $338,580
Salaries and Fringe Benefits (Schedule D-3B) 0002 $2,072,248 $265,969 $2,338,217
Legal Fees amd Expenses 0003 $13,230 $13,230
Utilization Management/Quality Improvement 0004 $29,785 $29,785
Traveling Expense 0005 $6,765 $6,765
Advertising 0006
Marketing 0026 $57,792 $57,792
Finance, Auditing & Actuarial 0007 $11,564 $37,190 $48,754
Claims Processing 0008 $15,295 $707,688 $722,983
Provider Relations, Recruitment & Contracting 0009
Member Services 0010 $184,580 $184,580
Management Information System(MIS) 0011 $177,949 $155,902 $333,851
Telephone, Postage, Express & Telegraph 0012 $169,324 $169,324
Printing & Stationary 0013 $17,653 $17,653
Occupancy, Depreciation & Amortization 0014 $88,019 $16,325 $104,344
Rental of Equipment 0015 $6,761 $6,761
Boards, Bureaus and Association Fees 0016 $17,190 $17,190
Insurance, Except for Real Estate 0017 $9,837 $9,837
Collection and Bank Service Charge 0018
Payroll Taxes 0019 $179,951 $179,951
Other Taxes (Excluding Fed. Inc. Tax & RE Tax) 0020
Intake and Enrollment 0022
Employee Recruitment and Retention 0024 $130,030 $130,030
Franchise Tax 0045
Aggregate Write-in for Other Expenses 0099 $2,554,785 $2,554,785
(Double click on lines 51 - 59 Below)
Total Allowable Administration Expense 0030 $5,602,896 $1,661,516 $7,264,412
Nonallowable Administration
Contributions and Donations 0032
Lobbying Expenses 0033
Entertainment costs 0034
Interest, Fines and Penalties 0035
Uncollectible Spenddown and NAMI 0060 $918,353 $918,353
State Income Taxes 0061
Other Nonallowable expenses 0036 $20,085 $20,085
Total Nonallowable expenses 0037 $938,438 $938,438
Total Administration Expense 0100 $6,541,334 $1,661,516 $8,202,850
CHCS Administrative Fees 0051 $2,437,776 $2,437,776
Other Administrative Expenses 0052 $117,009 $117,009
0053
0054
0055
0056
0057
0058
0059
Summary of Items on the Note Pad 0097
Total of Items 0051-0097 (Line 0099 Above) 0098 $2,554,785 $2,554,785
Statewide Member Months 0096 $21,705
Note: Report all contracts, such as management contracts, legal services, claims processing, financial services,|
actuarial, etc., for services that are reported as administrative expenses by the plan.|
(1) Under Type of Affiliation, enter the number code of all that apply.|
1. None|
2. Common Ownership|
3. Common Board of Directors|
4. Part of same Holding Company System|
5. Share Key Personnel
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 12
Schedule D-3A - Administrative Expense - Contracted Services Service Performed (1)Type of
Affiliation
MLTC Expense
00721 72118 00722 00723 00724
Name of Contractor (Double click Below)
BLUE CHIP BLDG MAINTENANCE INC 0001 Building Maintenance 1 $16,325
CHCS 0002 Rent 3 $293,862
MEDITURE, LLC 0003 Care Management Software 1 $155,902
SPS COMMUNITY SOLUTIONS 0004 Consulting 1 $189,770
TRISTATE BENEFIT SOLUTIONS 0005 Claims Processing 1 $707,688
GREENKEY 0006 Agency 1 $265,969
PKF O'CONNOR DAVIES 0007 Financial Statement Audit 1 $32,000
0008
0009
0010
0011
0012
0013
0014
0015
0016
0017
0018
0019
0020
Total (Should equal Schedule D-3, Column 00716, line 100) 0050 $1,661,516
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 13
Schedule D-3B - Administrative Expense - Personnel Expense MLTCFTEs
MLTCSalaries and
Fringe Benefits
MLTCFTEs
MLTCSalaries and
Fringe Benefits
MLTCFTEs
MLTCSalaries and
Fringe Benefits
00750 75019 00751 00752 00753 00754 00755 00756
Administrative Category
Executive Management 0001 1.00 $181,085 1.00 $181,085
Administrative Support 0075 4.67 $234,411 0.18 $18,059 4.85 $252,470
Employee Recruitment and Retention 0002
Medical Director 0003 0.13 0.11 $81,022 0.24 $81,022
Legal Services 0004
Utilization Management/Quality Improvement 0005 11.80 $519,957 $47,449 11.80 $567,406
Advertising 0006
Marketing 0016 4.00 $168,968 4.00 $168,968
Finance, Auditing and Actuarial 0007 0.95 $34,402 $1 0.95 $34,403
Claims Processing 0008 1.00 $38,017 0.16 $16,400 1.16 $54,417
Provider Relations, Cre. & Contr. 0009 3.74 $138,470 3.74 $138,470
Member Services 0010 10.92 $408,039 10.92 $408,039
Management Information Sys. 0011 $1 $1
Intake and Enrollment 0012 5.20 $249,529 1.03 $103,039 6.23 $352,568
Aggregate Write-in for Other Admin. 0049 1.56 $99,370 ($2) 1.56 $99,368
Totals 0050 44.97 $2,072,248 1.48 $265,969 46.45 $2,338,217
Detail; Aggregate Write-in (Double click Below)
Corporate Compliance 0025 1.56 $99,370 1.56 $99,370
Finance/Management Info Systems (Net Zero) 0026 ($2) ($2)
0027
0028
0029
Summary of Write-ins From Notepad 0030
Totals (Lines 0025-0030) To Line 49 0048 1.56 $99,370 ($2) 1.56 $99,368
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 14
Schedule D-6Claims Analysis
A.Total
Expenses(B+C+D)
B.Claims
Paid
C.Claims
Reported ButNot Paid
D.Claims
IncurredBut Not
Reported(IBNR)
E.IBNR as a Percent of
Total(D/A)
02022 02021 01014 01011 01012 01013 01016
A. Claims Incurred During Current Period
Category of Service
Inpatient 0001
Nursing Home 0002 $25,969,986 $15,985,443 $9,984,543 38.45%
Physician(s) 0003
Emergency Room 0005
Home Health Care 0013 $744,377 $587,870 $0 $156,507 21.03%
Personal Care 0014 $50,354,620 $35,794,133 $0 $14,560,487 28.92%
CDPAP 0120 $8,396,199 $6,014,551 $0 $2,381,647 28.37%
Other Medical Services 0007 $4,513,201 $3,818,104 $0 $695,097 15.40%
TOTAL 0025 $89,978,383 $62,200,101 $0 $27,778,282 30.87%
Total Expenses - Capitated 0051 $3,472,119
Total Expenses - Paid FFS 0052 $86,506,264 32.11%
Number of Claims Processed 0053 137,982
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 15
Schedule D-6Claims Analysis (continued)1
A.On ClaimsIncurredDuring
Prior Years
B.On ClaimsIncurredDuring
Current Year
C.On ClaimsIncurredDuring
Prior Years
D.On ClaimsIncurredDuring
Current Year
E.Total
UnpaidClaims
(A+B+C+D)
22121 22123 01011 01012 01013 01014 01015
B. Claims Unpaid
Category of Service
Inpatient 0026
Nursing Home 0027 $99,898 $9,984,543 $10,084,441
Physician(s) 0028
Emergency Room 0030
Home Health Care 0038 $0 $2,937 $156,507 $159,444
Personal Care 0039 $0 $316,995 $14,560,487 $14,877,482
CDPAP 0125 $0 $51,746 $2,381,647 $2,433,393
Other Medical Services 0032 $0 $26,951 $695,097 $722,048
TOTAL 0050 $0 $498,527 $27,778,282 $28,276,809
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 16
Schedule D-6Claims Analysis (continued)2
A.IBNR On Claims Incurred
4 Years Prior to theReporting Period
B.IBNR On Claims Incurred
3 Years Prior to theReporting Period
C.IBNR on Claims Incurred
2 Years Prior to theReporting Period
D.IBNR on Claims Incurred
1 Year Prior to theReporting Period
E.Total Prior Period IBNR
(A+B+C+D)
00241 24125 01025 01021 01022 01023 01024
C. Summary of Prior Period IBNR
Category of Service
Inpatient 0026
Nursing Home 0027 99,898 99,898
Physician(s) 0028
Emergency Room 0030
Home Health Care 0038 2,937 2,937
Personal Care 0039 316,995 316,995
CDPAP 0130 51,746 51,746
Other Medical Services 0032 26,951 26,951
TOTAL 0050 498,527 498,527
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 17
Schedule D-6 - Claims Analysis(continued)3
Current Period Year 1 Prior to theReporting Period
Year 2 Prior to theReporting Period
07481 07491 01017 01018 01019
D. Global Capitation Reconciliation(Total Plan)
Member Months 0009
Premium Revenue 0010
Total Global Capitation Paid 0001
Additional Plan Payments 0006
Total Global Capitation Payments 0007
Actual Claims Paid 0002
Claims Reported but Not Paid 0003
Claims Incurred but Not Reported 0004
Total Global Capitation Expenses 0008
IPA/Providers' Surplus or (Loss) 0005
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 18
Schedule D-7Premium Receivables
Total Dollars inthe Category
Up to 30 Days 30 Days to 59Days
60 Days to 89Days
90 Days to 119 120 Days to 365Days
Over One Year
01050 105026 01051 01052 01053 01054 01055 01056 01057
Premium Receivables Categories
Medicaid 0001 1,965,956 1,254,834 225,871 102,449 95,547 287,255
Medicare 0002
Private Pay 0003 226,046 12,210 21,235 17,660 4,675 25,812 144,454
Spenddown/NAMI 0004 7,036,802 707,056 636,873 343,440 214,378 1,457,976 3,677,079
Allowance for Doubtful Accounts (Entered as Negative) 0005 -5,818,820 -226,244 -1,771,043 -3,821,533
Other - (Double click Below)
0006
0007
0008
0009
Total By Aging Category 0010 3,409,984 1,974,100 883,979 463,549 88,356 0 0
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 19
Schedule FIBNR
Reserve Calculation
AClaims Reported
(Paid and Unpaid)
BPercent
Complete
CEstimatedExpense
(A/B)
DAdjustment
EProjected Expense
(C + D)
FIBNR Reserve
(E-A)
00271 27128 01101 01102 01103 01104 01105 01106
Description
December 0001
November 0002
October 0003
September 0004
August 0005
July 0006
June 0007 $3,239,181 20.41665% 15,865,395 0 $15,865,395 $12,626,213
May 0008 $8,058,084 48.18701% 16,722,524 0 $16,722,524 $8,664,440
April 0009 $10,833,672 72.54845% 14,933,017 0 $14,933,017 $4,099,345
March 0010 $13,994,111 93.75332% 14,926,523 0 $14,926,523 $932,412
February 0011 $12,541,142 94.94318% 13,209,103 0 $13,209,103 $667,961
January 0012 $13,533,910 94.49852% 14,321,822 0 $14,321,822 $787,911
CURRENT YEAR TOTAL 0020 $62,200,101 89,978,383 0 $89,978,383 $27,778,282
PERCENT COMPLETED Yes=1,No=2
Historical Experience 0021 1
Authorized Claims 0022 2
Other (Explain on Notepad) 0023 2
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 20
Schedule GSchedule of
Net Investment Income
Amount Accrued During the Year
00291 29130 01201
INVESTMENT INCOME
Interest Income 0001 $16,123
Dividend and Real Estate Income 0002
Net Realized Capital Gains or Losses 0003 $44,902
Other Investment Income 0004 $41,400
TOTAL INVESTMENT INCOME 0010 $102,425
DEDUCTIONS
Investment Expenses 0011 $7,792
Interest Expense 0012
Interest on Claims Paid after 45 Days 0014
Other Deductions 0013
TOTAL DEDUCTIONS 0020 $7,792
NET INVESTMENT INCOME 0025 $94,633
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 21
Schedule G-1Schedule of Adjustments for Prior Period IBNR
Amount of Write-off
03111 311132 01202
Details of Adj for Prior Period IBNR on line 94 cc 112
1 Year Prior to the Reporting Period 0001 ($35,053)
2 Years Prior to the Reporting Period 0002
3 Years Prior to the Reporting Period 0003
4 Years Prior to the Reporting Period 0004
TOTAL ADJUSTMENTS FOR PRIOR PERIOD IBNR 0010 ($35,053)
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 22
Schedule G-2Total Plan Schedule of Aggregate Write-ins for Other Expenses
Amount of Write-off
01213 121333 01214
Details of Write-ins aggregated on line 0095 from Schedule B:
0001
0002
0003
0004
0005
Non-State Plan Services 0006
Increase in Reserves for A&H Contracts 0007
TOTAL PLAN SCHEDULE OF AGGREGATE WRITE-INS 0099
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 23
Schedule G-3Total Plan Schedule of Prior Period Revenue Adjustments and Extraordinary Items
Amount of Write-off
01223 12234 01224
Details of Extraordinary Items on line 0096 from Schedule B:
Adjustment for Prior Period Revenue 0001
Adjustment for Prior Period HR & R Revenue 0002
0003
0004
0005
0006
0007
0008
0009
All Other 0010
TOTAL EXTRAORDINARY ITEMS 0099
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 24
Schedule G-4Schedule of Recovered Provider Payments
For Services Provided in Prior Periods
Amount of Recovered Payments
00351 35136 01225
Details of Prior Period Provider Recoveries included in the Prior Period IBNR Schedule:
1 Year Prior to Reporting Period 0001
2 Years Prior to Reporting Period 0002
3 Years Prior to the Reporting Period 0003
4 Years Prior to the Reporting Period 0004
TOTAL RECOVERIES INCLUDED IN PRIOR PERIOD IBNR ADJUSTMENT 0099
Individually list all health care creditors of $5,000 or more or 10% of total claims payable (reported, excluding amounts withheld), whichever is larger.|
See additional directions in the report instructions.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 25
Schedule HClaims Payable
Aging Analysis of Unpaid Claims
1-30 Days 31-45 Days 46-90 Days 91 + Days Total
01600 160037 01604 01605 01606 01607 01603
Claims Payable (Reported) Detail Below 0001
0002
0003
0004
0005
0006
0007
0008
0009
0010
0011
0012
0013
0014
0015
0016
0017
0018
0019
0020
0021
0022
0023
0024
0025
Sum of Individually Listed Claims Payable 0026
Aggregate Accounts Not Individually Listed 0028
Totals 0029
(1) TYPE OF AFFILIATION (Enter number code for type of affiliation)|
1. Common Ownership|
2. Common Board of Directors|
3. Part of the Same Holding Company System|
4. Share Key Personnel
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 26
Schedule I - Schedule of Plan's Transactions with AnyAffiliate
(1)Type ofAffiliatio
n
CapitalContributions
Purchases, Sales, orExchanges of Loans,
Securities, Real Estate,Mortgage Loans orOther Investments
Income/(Disbursements) Incurred in
Connection withGuarantees or
Undertakings for theBenefit of any
Affiliate(s)
ManagementAgreements andAdministrative
Service Contracts
MedicalServices
Any Other MaterialActivity Not in the
Ordinary Course ofthe Insurer's
Business
TOTALS
01401 140138 01402 01403 01404 01405 01406 01407 01408 01409
Names of Insurers and Parent, Subsidiaries or Affiliates
(Double click Below)
Catholic Health Care System 0001 1 ($2,437,776) ($697,695) ($3,135,471)
ArchCare Community Life (MLTC) 0002 1 $2,437,776 $697,695 $3,135,471
0003
0004
0005
0006
0007
0008
0009
0010
0011
0012
0013
0014
0015
0016
0017
0018
0019
0020
0021
0022
0023
0024
0025
0026
0027
0028
0029
0030
0031
0032
0033
TOTAL 0999 $0 $0 $0
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 27
Schedule J - Schedule of Claims and Interest Penalties PaidDuring the Year
TotalClaim Count
TotalDollar Value
Number of CleanClaims Paid in Excess
of 45 Days
Dollar Value of CleanClaims Paid in Excess
of 45 Days
Number of CleanClaims in Excess of 45
Days For WhichInterest Was Paid
Interest Paid DuringYear
00391 39140 01501 01502 01503 01504 01505 01506
Account Description
Inpatient 0001
Nursing Facility 0002 3,276 $15,985,443 $12,850
Physicians 0003
Home Health Care 0006 904 $593,695 $1,070
Personal Care 0007 91,066 $41,942,503 $6,640
CDPAP 0004 14,865 $7,033,392 $1,084
Other Medical Services 0005 27,871 $3,818,104 $422
TOTAL 0025 137,982 $69,373,137 $22,066
a) Disenrollments should be entered as positive numbers. The program will automatically reduce the totals.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 28
Exhibit A1 - Analysis of Enrolled Population TotalEnrollees
(End of Prior Period)
Net Shifts AmongGroups
YTD
New EnrolleesYTD
DisenrollmentsYTD
Total Enrollment
03100 310041 03101 03105 03102 03103 03104
PREMIUM GROUP
Community 0003 2,829 -26 905 423 3,285
Nursing Home Permanent Placement 0004 449 26 114 78 511
Other Medicaid Enrollees: (Double click Below)
0010
0011
0012
0013
0014
Total Medicaid Members 0020 3,278 0 1,019 501 3,796
Non-Medicaid Enrollees 0021
TOTALS 0030 3,278 0 1,019 501 3,796
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 29
Exhibit A2 - Analysis of Enrolled Population By County Community Nursing HomePermanent Placement
TOTAL MEDICAIDMEMBER MONTHS TO
DATE
NON-MEDICAIDENROLLEE MONTHS
TOTAL MEMBERMONTHS TO DATE
03200 03421 03201 03202 03206 03207 03208
MEMBER MONTHS BREAKDOWN BY COUNTY
Region/County
One/New York City 0001 2,546 337 2,883 2,883
One/Nassau 0002
One/Rockland 0003
One/Suffolk 0004
One/Westchester 0005 4,717 1,238 5,955 5,955
Two/Monroe 0006
Two/Onondaga 0007
Two/Orange 0008
Three/Erie 0009
Three/Herkimer 0010
Three/Oneida 0011
Three/Schenectady 0012
Other Enrollees: (Double click Below)
Four/Putnam County 0020 343 60 403 403
One/Bronx County 0021 3,938 684 4,622 4,622
One/Kings County 0022 3,871 130 4,001 4,001
One/Richmond County 0023 1,501 234 1,735 1,735
One/Queens County 0024 1,879 227 2,106 2,106
Total Member Months to Date 0030 18,795 2,910 21,705 21,705
PACE plans should only complete rows 2 and 13.
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 30
Exhibit A3 - Hospital and Nursing Facility Utilization FirstQuarter
SecondQuarter
ThirdQuarter
FourthQuarter
TOTALY-T-D
04311 431144 03301 03302 03303 03304 03305
HOSPITAL AND NURSING FACILIITY DAYS
Hospital Days For Period 0001
Total Number of Enrollees Receiving Nursing Facility
Care During Quarter, Excl. Respite 0002
Total Number of Admissions to Nursing Facility during Quarter, excluding respite 0013
Breakdown of Nursing Facility Days, Excl. Respite:
Total Number of Days Covered 100% by Medicare 0003
Total Number of Days Covered by Medicare & MLTC Plan (Medicaid Co-Pay days) 0004 1,632 1,826 3,458
Total Number of Days Covered 100% by MLTC Plan 0005 31,002 34,699 65,701
Total Number of Days Covered by Other Payors 0006
Total Number of Nursing Facility Days of Care, Excl. Respite 0010 32,634 36,525 69,159
Total Number of Enrollees Receiving Nursing Facility
Care During Quarter For Respite 0011
Total Number of Nursing Facility Days for Respite 0012
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 31
Exhibit A4 - Nursing Facility Discharges 0 - 30 31 - 60 61 - 90 91 - 180 181 - 365 366+ TOTAL
00451 45146 03401 03402 03403 03404 03405 03406 03407
FIRST QUARTER:
Death 0001
Other 0002
Total 0003
SECOND QUARTER:
Death 0004
Other: 0005
Total 0006
THIRD QUARTER:
Death 0007
Other 0008
Total 0009
FOURTH QUARTER:
Death 0010
Other 0011
Total 0012
TOTAL Y-T-D:
Death 0020
Other 0021
Total 0030
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 32
Exhibit A5 - Personal Care Hours Year-to-Date Member Months Total Number of Hours
00471 47148 03501 03502
MEMBER BREAKDOWN BY USE
Category Based on Hours per Month
700+ hours per month 0001 140 102,030
480-699 hours per month 0002 123 73,253
320-479 hours per month 0003 1,488 558,237
240-319 hours per month 0004 1,016 273,313
160-239 hours per month 0005 2,623 495,394
80-159 hours per month 0006 7,047 810,469
1-79 hours per month 0007 5,131 168,554
TOTALS 0010 17,568 2,481,250
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 33
Exhibit A6 - Home Health Care and PCA Hours Year-to-Date Member Months Total Number of Hours
00491 49150 03503 03504
MEMBER BREAKDOWN BY USE
Category Based on Hours per Month
700+ hours per month 0001 140 102,030
480-699 hours per month 0002 123 73,253
320-479 hours per month 0003 1,488 558,237
240-319 hours per month 0004 1,016 273,313
160-239 hours per month 0005 2,623 495,394
80-159 hours per month 0006 7,047 810,469
1-79 hours per month 0007 5,131 170,653
TOTALS 0010 17,568 2,483,349
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 34
Exhibit A7 - CDPAP Hours Year-to-Date Member Months Total Number of Hours
00492 49155 03505 03506
MEMBER BREAKDOWN BY USE
Category Based on Hours per Month
700+ hours per month 0001 16 11,695
480-699 hours per month 0002 13 7,382
320-479 hours per month 0003 160 59,630
240-319 hours per month 0004 199 52,890
160-239 hours per month 0005 581 112,254
80-159 hours per month 0006 1,243 147,304
1-79 hours per month 0007 462 18,601
TOTALS 0010 2,674 409,756
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 35
Exhibit B - Utilization of Services: Total Medicaid ServiceUnits
Total Number OfService Units
(Actual)
Total Number ofService Units
(Accrued)
Unit Cost Avg. Number Of ServiceUnits
Used Per Enrollee PerYear
04010 401051 04011 04012 04016 04017 04015
Inpatient Medical/Surgical 0001 Days
Inpatient Medical/Surgical 0051 Discharges
Inpatient Mental Health/Substance Abuse 0002 Days
Inpatient Mental Health/Substance Abuse 0052 Discharges
Inpatient: Maternity Delivery 0047 Days
Inpatient: Maternity Delivery 0048 Discharges
Primary Care Physician 0004 Visits
Specialty Care 0033 Visits
Prenatal/Postpartum Maternity Services 0049 Visits
Ambulatory Surgery 0005 Procedures
Outpatient/Physical Rehab/Therapy 0050 Visits 121 308 $43.76 0.17
Other Professional Services 0053 Visits 45 146 $247.22 0.08
Emergency Room 0006 Visits
Outpatient Mental Health 0007 Visits
Outpatient Drug & Alcohol Treatment 0008 Visits
Dental 0009 Visits 4,053 4,053 $60.00 2.24
Pharmacy - Part D 0054
Pharmacy - Non Part D 0055
Home Health Care 0056 Hours 1,487 2,099 $354.63 1.16
Home Health Care 0083 Visits 523 1,134 $656.42 0.63
Nursing Facility 0003 Days 40,368 69,159 $375.51 38.24
Transportation - Emergent 0057 One Way Trips
Transportation - Non Emergent 0058 One Way Trips 69,001 70,637 $30.50 39.05
Diagnostic Testing, Lab & X-Ray 0016
Family Planning 0059 Visits
Vision Care Inc. Eyeglasses 0017 Visits 49 113 $110.89 0.06
Foot Care 0018 Visits 257 563 $30.89 0.31
Durable Medical Equipment & Other 0028
Personal Care 0025 Hours 1,726,197 2,481,250 $20.29 1,371.80
CDPAP 0045 Hours 285,062 409,756 $20.49 226.54
Personal Emergency Response Services 0030 No. Of Units 4,836 6,326 $24.74 3.50
Home Delivered and Congregate Meals 0032 No. Of Meals 5,035 6,378 $7.01 3.53
Adult Day Care 0012 Days 9,229 12,321 $62.18 6.81
Social Day Care 0013 Days 509 1,357 $130.16 0.75
Other Medical Services:
(Double click below)
0035 0.00
0036 0.00
0037 0.00
0038 0.00
0039 0.00
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 36
Exhibit B-1 - Medicaid Utilization of Services Community ServiceUnits
Total Number OfService Units
(Actual)
Total Number ofService Units
(Accrued)
Unit Cost Avg. Number OfService Units
Used Per EnrolleePer Year
04010 401052 04011 04012 04016 04017 04015
Inpatient Medical/Surgical 0101 Days
Inpatient Medical/Surgical 0151 Discharges
Inpatient Mental Health/Substance Abuse 0102 Days
Inpatient Mental Health/Substance Abuse 0152 Discharges
Inpatient: Maternity Delivery 0147 Days
Inpatient: Maternity Delivery 0148 Discharges
Primary Care Physician 0104 Visits
Specialty Care 0133 Visits
Prenatal/Postpartum Maternity Services 0149 Visits
Ambulatory Surgery 0105 Procedures
Outpatient/Physical Rehab/Therapy 0150 Visits 121 308 $43.76 0.20
Other Professional Services 0153 Visits 44 145 $248.45 0.09
Emergency Room 0106 Visits
Outpatient Mental Health 0107 Visits
Outpatient Drug & Alcohol Treatment 0108 Visits
Dental 0109 Visits 4,053 4,053 $60.00 2.59
Pharmacy - Part D 0154
Pharmacy - Non Part D 0155
Home Health Care 0156 Hours 1,487 2,099 $354.63 1.34
Home Health Care 0183 Visits 523 1,134 $656.42 0.72
Nursing Facility 0103 Days 1,170 2,198 $421.77 1.40
Transportation - Emergent 0157 One Way Trips
Transportation - Non Emergent 0158 One Way Trips 66,298 67,870 $30.28 43.33
Diagnostic Testing, Lab & X-Ray 0116
Family Planning 0159 Visits
Vision Care Inc. Eyeglasses 0117 Visits 16 30 $91.60 0.02
Foot Care 0118 Visits 194 454 $32.47 0.29
Durable Medical Equipment & Other 0128
Personal Care 0125 Hours 1,723,994 2,478,083 $20.29 1,582.18
CDPAP 0145 Hours 284,994 409,657 $20.49 261.55
Personal Emergency Response Services 0130 No. Of Units 4,828 6,316 $24.74 4.03
Home Delivered and Congregate Meals 0132 No. Of Meals 5,017 6,355 $7.00 4.06
Adult Day Care 0112 Days 9,223 12,313 $62.17 7.86
Social Day Care 0113 Days 501 1,339 $130.37 0.85
Other Medical Services:
(Enter labels on Exhibit B)
0135 0.00
0136 0.00
0137 0.00
0138 0.00
0139 0.00
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 37
Exhibit B-1 - Medicaid Utilization of Services Nursing Home Permanent Placement ServiceUnits
Total Number OfService Units
(Actual)
Total Number ofService Units
(Accrued)
Unit Cost Avg. Number OfService Units
Used Per EnrolleePer Year
04019 401953 04020 04021 04022 04023 04024
Inpatient Medical/Surgical 0101 Days
Inpatient Medical/Surgical 0151 Discharges
Inpatient Mental Health/Substance Abuse 0102 Days
Inpatient Mental Health/Substance Abuse 0152 Discharges
Inpatient: Maternity Delivery 0147 Days
Inpatient: Maternity Delivery 0148 Discharges
Primary Care Physician 0104 Visits
Specialty Care 0133 Visits
Prenatal/Postpartum Maternity Services 0149 Visits
Ambulatory Surgery 0105 Procedures
Outpatient/Physical Rehab/Therapy 0150 Visits 0.00
Other Professional Services 0153 Visits 1 1 $69.00 0.00
Emergency Room 0106 Visits
Outpatient Mental Health 0107 Visits
Outpatient Drug & Alcohol Treatment 0108 Visits
Dental 0109 Visits 0.00
Pharmacy - Part D 0154
Pharmacy - Non Part D 0155
Home Health Care 0156 Hours 0.00
Home Health Care 0183 Visits 0.00
Nursing Facility 0103 Days 39,198 66,961 $373.99 276.13
Transportation - Emergent 0157 One Way Trips
Transportation - Non Emergent 0158 One Way Trips 2,703 2,767 $35.72 11.41
Diagnostic Testing, Lab & X-Ray 0116
Family Planning 0159 Visits
Vision Care Inc. Eyeglasses 0117 Visits 33 83 $117.87 0.34
Foot Care 0118 Visits 63 109 $24.32 0.45
Durable Medical Equipment & Other 0128 0.16
Personal Care 0125 Hours 2,203 3,167 $23.79 13.06
CDPAP 0145 Hours 69 99 $24.02 0.41
Personal Emergency Response Services 0130 No. Of Units 8 10 $25.50 0.04
Home Delivered and Congregate Meals 0132 No. Of Meals 18 23 $7.43 0.09
Adult Day Care 0112 Days 6 8 $74.25 0.03
Social Day Care 0113 Days 8 18 $114.11 0.07
Other Medical Services:
(Enter labels on Exhibit B)
0135 0.00
0136 0.00
0137 0.00
0138 0.00
0139 0.00
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 38
Exhibit B-2 - Medicaid Utilization of HHC Services Community ServiceUnits
Medicaid TotalNumber of
Service Units(Actual)
Medicaid TotalNumber of
Service Units(Accrued)
Medicaid TotalCost
Medicaid UnitCost
Medicaid Avg.Number of
Service UnitsUsed Per Enrollee
Per Year
04010 401056 04011 04012 04016 04018 04017 04015
Home Health Care Aide 0500 Hours 1,487 2,099 $78,343 $37.32 1.34
Home Health Care-Other 0501 Visits 523 1,133 $666,034 $587.85 0.72
Total Home Health Care 0502 $744,377
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 39
Exhibit B-2 - Medicaid Utilization of HHC Services Nursing Home Permanent Placement ServiceUnits
Medicaid TotalNumber of
Service Units(Actual)
Medicaid TotalNumber of
Service Units(Accrued)
Medicaid TotalCost
Medicaid UnitCost
Medicaid Avg.Number of
Service UnitsUsed Per
Enrollee PerYear
04031 403157 04032 04033 04034 04035 04036 04037
Home Health Care Aide 0500 Hours 0.00
Home Health Care-Other 0501 Visits 0.00
Total Home Health Care 0502
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 40
Exhibit B-2 - Utilization of HHC Services - Total Medicaid ServiceUnits
Medicaid TotalNumber of
Service Units(Actual)
Medicaid TotalNumber of
Service Units(Accrued)
Medicaid Total Cost Medicaid Unit Cost Medicaid Avg.Number of Service
UnitsUsed Per Enrollee
Per Year
04010 401060 04011 04012 04016 04018 04017 04015
Home Health Care Aide 0400 Hours 1,487 2,099 $78,343 $37.32 1.2
Home Health Care-Other 0401 Visits 523 1,133 $666,034 $587.85 0.6
Total Home Health Care 0402 $744,377
Archcare Community Life(Catholic MLTC) (03466800) DCN : 10162018062757Period Ending : 6/30/2018 Created : Tuesday, October 16, 2018
Page 41
Exhibit C - Number of Enrollees Utilizing Services Number of Enrollees
06101 610162 05000
Identify the number of enrollees during the quarter that used the following services:
NURSING FACILITY (NF) ONLY
Enrollees that were in a nursing facility for the entire quarter 0001 483
PACE CENTER SOCIAL DAY CARE PROGRAM
Count only enrollees who used the PACE Social Day Care Program
but did not use personal care, home health care or NF. 0002
Count only enrollees who used the PACE Social Day Care Program
and personal care and/or home health care. 0003
Total PACE Center Care Program 0012
PERSONAL CARE (PC) ONLY
Count only enrollees who used personal care but did not use NF,
PACE Social Day, or Home Health Care. 0004 2,894
CDPAP ONLY
Count only enrollees who used only CDPAP
CDPAP 0015 90
HOME HEALTH CARE (HHC) ONLY
Count only enrollees who used home health care service but did not use NF,
PACE Social Day Care, or PC.
Nursing and Therapies only 0007
HHA and Nursing and/or Therapies 0008 17
Total Home Health Care 0009 17
PERSONAL CARE AND HOME HEALTH CARE ONLY
Count only enrollees that used PC and HHC but did not use NF or PACE Social Day. 0010 247
NURSING FACILITY AND PERSONAL CARE OR HOME HEALTH CARE
Count enrollees who were in a NF AND used personal care or Home Health
Personal care 0013 65
Number of enrollees who did not use PACE Social Day, Personal Care,
Home Health Care, or any Nursing Facility 0011
Total Number of Enrollees 0014 3,796