CMS Ruling Changes Stop-Loss Deductibles

Jul 2, 2016

We’ve recently noticed a trend going on with some of our current clients and potential clients that have approached us.

The Health Plans are advising capitated providers that they must abide by the CMS rules and guidelines in reference to stop-loss deductible limits.

One of the items that we noted was that each individual Health Plan is using their own membership capitated to the provider for the stop-loss level.

However we recommend that you check the CMS ruling as, more than likely, you are able to combine all memberships from each Health Plan that capitates you.

Here is the section in the CMS Manual System Pub. 100-16 Transmittal 67

Pooling of Patients

Any entity that meets the pooling conditions of this section may pool commercial, Medicare, and Medicaid enrollees or the enrollees of several MA organizations with which a physician or physician group has contracts.

  1. It is otherwise consistent with the relevant contracts governing the compensation arrangements for the physician or physician group;
  2. The physician or physician group is at risk for referral services with respect to each of the categories of patients being pooled;
  3. The terms of the compensation arrangements permit the physician or physician   group to spread the risk across the categories of patients being pooled;
  4. The distribution of payments to physicians from the risk pool is not calculated  separately by patient category; and
  5. The terms of the risk borne by the physician or physician group are comparable for all categories   patients being pooled.

Please call with any questions (818) 541-7900 or email