182-557-0200  <<  182-557-0225 >>   182-557-0300

WAC 182-557-0225

Health home servicesMethodology for calculating a person's risk score.

The agency uses eight steps to calculate a person's risk score.
(1) Step 1. Collect paid claims and health plan encounter data. The agency obtains a set of paid fee-for-service claims and managed care encounters for a client.
(a) For clients age seventeen and younger, the agency uses all paid claims and encounters within the last twenty-four months.
(b) For clients age eighteen and older, the agency uses all paid claims and encounters within the last fifteen months.
(i) The claims and encounters include the international classification of diseases (ICD) diagnosis codes and national drug codes (NDC) submitted by health care providers. These are used in steps 2 and 3 to create a set of risk categories.
(ii) The agency uses two algorithms developed by the University of San Diego:
(A) Chronic illness and disability payment system (CDPS) which assigns ICD diagnosis codes to CDPS risk categories (see Table 3 in subsection (5)(b) of this section); and
(B) Medical Rx (MRx) which assigns NDCs to MRx risk categories (see Table 2 in subsection (3)(b) of this section).
(2) Step 2. Group ICD diagnosis codes into chronic illness and disability payment system risk categories.
(a) To group ICD diagnosis codes into the CDPS risk categories (see Table 1 in (b) of this subsection), the agency uses an ICD diagnosis code to CDPS risk categories crosswalk in subsection (1)(b)(ii)(A) of this section. Each of the ICD diagnosis codes listed is assigned to one risk category. If an ICD diagnosis code is not listed in the crosswalk it does not map to a risk category that is used in the calculation of the risk score.
(b) Table 1. Titles of Chronic Illness and Disability Payment System Risk Categories
CARVH
Cardiovascular, very high
CARM
Cardiovascular, medium
CARL
Cardiovascular, low
CAREL
Cardiovascular, extra low
PSYH
Psychiatric, high
PSYM
Psychiatric, medium
PSYML
Psychiatric, medium low
PSYL
Psychiatric, low
SKCM
Skeletal, medium
SKCL
Skeletal, low
SKCVL
Skeletal, very low
CNSH
Central Nervous System, high
CNSM
Central Nervous System, medium
CNSL
Central Nervous System, low
PULVH
Pulmonary, very high
PULH
Pulmonary, high
PULM
Pulmonary, medium
PULL
Pulmonary, low
GIH
Gastro, high
GIM
Gastro, medium
GIL
Gastro, low
DIA1H
Diabetes, type 1 high
DIA1M
Diabetes, type 1 medium
DIA2M
Diabetes, type 2 medium
DIA2L
Diabetes, type 2 low
SKNH
Skin, high
SKNL
Skin, low
SKNVL
Skin, very low
RENEH
Renal, extra high
RENVH
Renal, very high
RENM
Renal, medium
RENL
Renal, low
SUBL
Substance abuse, low
SUBVL
Substance abuse, very low
CANVH
Cancer, very high
CANH
Cancer, high
CANM
Cancer, medium
CANL
Cancer, low
DDM
Developmental Disability, medium
DDL
Developmental Disability, low
GENEL
Genital, extra low
METH
Metabolic, high
METM
Metabolic, medium
METVL
Metabolic, very low
PRGCMP
Pregnancy, complete
PRGINC
Pregnancy, incomplete
EYEL
Eye, low
EYEVL
Eye, very low
CERL
Cerebrovascular, low
AIDSH
AIDS, high
INFH
Infectious, high
HIVM
HIV, medium
INFM
Infectious, medium
INFL
Infectious, low
HEMEH
Hematological, extra high
HEMVH
Hematological, very high
HEMM
Hematological, medium
HEML
Hematological, low
(3) Step 3. Group national drug codes (NDCs) into MRx risk categories.
(a) To group the NDC codes into MRx risk categories (see Table 2 in (b) of this subsection), the agency uses a NDC code to MRx risk categories crosswalk in subsection (1)(b)(ii)(B) of this section.
(b) Table 2. Titles of Medicaid Rx Risk Categories
MRx1
Alcoholism
MRx2
Alzheimer's
MRx3
Anti-coagulants
MRx4
Asthma/COPD
MRx5
Attention Deficit
MRx6
Burns
MRx7
Cardiac
MRx8
Cystic Fibrosis
MRx9
Depression/Anxiety
MRx10
Diabetes
MRx11
EENT
MRx12
ESRD/Renal
MRx13
Folate Deficiency
MRx14
CMV Retinitis
MRx15
Gastric Acid Disorder
MRx16
Glaucoma
MRx17
Gout
MRx18
Growth Hormone
MRx19
Hemophilia/von Willebrands
MRx20
Hepatitis
MRx21
Herpes
MRx22
HIV
MRx23
Hyperlipidemia
MRx24
Infections, high
MRx25
Infections, medium
MRx26
Infections, low
MRx27
Inflammatory/Autoimmune
MRx28
Insomnia
MRx29
Iron Deficiency
MRx30
Irrigating Solution
MRx31
Liver Disease
MRx32
Malignancies
MRx33
Multiple Sclerosis/Paralysis
MRx34
Nausea
MRx35
Neurogenic Bladder
MRx36
Osteoporosis/Pagets
MRx37
Pain
MRx38
Parkinsons/Tremor
MRx39
Prenatal Care
MRx40
Psychotic Illness/Bipolar
MRx41
Replacement Solution
MRx42
Seizure Disorders
MRx43
Thyroid Disorder
MRx44
Transplant
MRx45
Tuberculosis
(4) Step 4. Remove duplicate risk categories. After mapping all diagnosis and drug codes to the risk categories, the agency eliminates duplicates of each client's risk categories so that there is only one occurrence of any risk category for each client.
(5) Step 5. Select the highest CDPS risk category within a disease group.
(a) The agency organizes CPDS risk categories into risk category groups of different intensity levels. The high risk category in each group is used in the calculation of the risk score. The lower level risk categories are eliminated from further calculations.
(b) Table 3. Chronic Disease Payment System Risk Category Groups
Group Description
Risk Categories (Ordered Highest to Lowest Intensity)
AIDS/HIV and Infection
AIDSH, INFH, HIVM, INFM, INFL
Cancer
CANVH, CANH, CANM, CANL
Cardiovascular
CARVH, CARM, CARL, CAREL
Central Nervous System
CNSH, CNSM, CNSL
Diabetes
DIA1H, DIA1M, DIA2M, DIA2L
Developmental Disability
DDM, DDL
Eye
EYEL, EYEVL
Gastrointestinal
GIH, GIM, GIL
Hematological
HEMEH, HEMVH, HEMM, HEML
Metabolic
METH, METM, METVL
Pregnancy
PRGCMP, PRGINC
Psychiatric
PSYH, PSYM, PSYML, PSYL
Substance Abuse
SUBL, SUBVL
Pulmonary
PULVH, PULH, PULM, PULL
Renal
RENEH, RENVH, RENM, RENL
Skeletal
SKCM, SKCL, SKCVL
Skin
SKNH, SKNL, SKNVL
(6) Step 6. Determine age/gender category.
(a) For each client, the agency selects the appropriate age/gender category. The eleven categories are listed in Table 4 in (b) of this subsection. The categories for ages below five and above sixty-five are gender neutral.
(b) Table 4. Age/Gender Categories
Age
Gender
 
Age <1
 
 
 
Age 1 to 4
 
 
 
Age 5 to 14
 
Male
 
Age 5 to 14
 
Female
 
Age 15 to 24
 
Male
 
Age 15 to 24
 
Female
 
Age 25 to 44
 
Male
 
Age 25 to 44
 
Female
 
Age 45 to 64
 
Male
 
Age 45 to 64
 
Female
 
Age 65+
 
 
(7) Step 7. Apply risk weights.
(a) The agency assigns each risk category and age/gender category a weight. The weight comes from either the model for clients who are age seventeen and younger or from the model for clients age eighteen and older.
(b) In each model there are three types of weights.
(i) Age/gender – Weights that correspond to the age/gender category of a client.
(ii) CDPS – Weights that correspond to fifty-eight of the CDPS risk categories.
(iii) MRx – Weights that correspond to forty-five of the MRx risk categories.
(c) Table 5. Risk Score Weights
Category Type
Category
Description
Weights for Children
(age <18)
Weights for Adults
(age 18+)
Age/Gender
Age <1
Clients of age less than 1
0.40671
0.00000
 
Age 1 to 4
Clients age 1 to 4
0.40671
0.00000
 
Age 5 to 14, Male
Male clients age 5 to 14
0.28867
0.00000
 
Age 5 to 14, Female
Female clients age 5 to 14
0.29441
0.00000
 
Age 15 to 24, Male
Male clients age 15 to 24
0.22630
-0.01629
 
Age 15 to 24, Female
Female clients age 15 to 24
0.26930
0.03640
 
Age 25 to 44, Male
Male clients age 25 to 44
0.00000
0.04374
 
Age 25 to 44, Female
Female clients age 25 to 44
0.00000
0.06923
 
Age 45 to 64, Male
Male clients age 45 to 64
0.00000
0.13321
 
Age 45 to 64, Female
Female clients age 45 to 64
0.00000
0.06841
 
Age 65+
Clients age 65 and older
0.00000
-0.05623
CDPS
CARVH
Cardiovascular, very high
0.53941
2.86702
 
CARM
Cardiovascular, medium
0.23927
0.73492
 
CARL
Cardiovascular, low
0.18510
0.24620
 
CAREL
Cardiovascular, extra low
0.06589
0.06225
 
PSYH
Psychiatric, high
0.47759
0.27085
 
PSYM
Psychiatric, medium
0.31301
0.00000
 
PSYML
Psychiatric, medium low
0.16307
0.00000
 
PSYL
Psychiatric, low
0.10344
0.00000
 
SKCM
Skeletal, medium
0.23477
0.42212
 
SKCL
Skeletal, low
0.10630
0.15467
 
SKCVL
Skeletal, very low
0.07873
0.06773
 
CNSH
Central Nervous System, high
0.30440
0.78090
 
CNSM
Central Nervous System, medium
0.34386
0.40886
 
CNSL
Central Nervous System, low
0.16334
0.18261
 
PULVH
Pulmonary, very high
1.28955
4.01723
 
PULH
Pulmonary, high
0.67772
0.39309
 
PULM
Pulmonary, medium
0.39768
0.31774
 
PULL
Pulmonary, low
0.14708
0.13017
 
GIH
Gastro, high
0.78046
1.34924
 
GIM
Gastro, medium
0.29755
0.24372
 
GIL
Gastro, low
0.14579
0.05104
 
DIA1H
Diabetes, type 1 high
0.31680
1.04302
 
DIA1M
Diabetes, type 1 medium
0.31680
0.23620
 
DIA2M
Diabetes, type 2 medium
0.16101
0.17581
 
DIA2L
Diabetes, type 2 low
0.16101
0.09635
 
SKNH
Skin, high
0.49898
0.37981
 
SKNL
Skin, low
0.25185
0.45155
 
SKNVL
Skin, very low
0.07523
0.02119
 
RENEH
Renal, extra high
2.43609
3.41999
 
RENVH
Renal, very high
0.93888
0.69251
 
RENM
Renal, medium
0.33261
0.92846
 
RENL
Renal, low
0.17492
0.17220
 
SUBL
Substance Abuse, low
0.27104
0.16104
 
SUBVL
Substance Abuse, very low
0.04493
0.08784
 
CANVH
Cancer, very high
1.31064
2.80074
 
CANH
Cancer, high
0.57909
0.97173
 
CANM
Cancer, medium
0.29642
0.38022
 
CANL
Cancer, low
0.15058
0.22625
 
DDM
Developmental Disability, medium
0.31414
0.27818
 
DDL
Developmental Disability, low
0.11095
0.05913
 
GENEL
Genital, extra low
0.02242
0.01121
 
METH
Metabolic, high
0.51575
0.47226
 
METM
Metabolic, medium
0.33856
0.11310
 
METVL
Metabolic, very low
0.14658
0.18678
 
PRGCMP
Pregnancy, complete
0.00000
0.00000
 
PRGINC
Pregnancy, incomplete
0.17563
0.51636
 
EYEL
Eye, low
0.11538
0.13271
 
EYEVL
Eye, very low
0.04094
0.00000
 
CERL
Cerebrovascular, low
0.10623
0.00000
 
AIDSH
AIDS, high
0.91357
0.47361
 
INFH
Infectious, high
0.91357
0.79689
 
HIVM
HIV, medium
0.60245
0.07937
 
INFM
Infectious, medium
0.41047
0.79689
 
INFL
Infectious, low
0.15311
0.05617
 
HEMEH
Hematological, extra high
2.80021
12.71981
 
HEMVH
Hematological, very high
0.97895
3.08836
 
HEMM
Hematological, medium
0.46032
0.63211
 
HEML
Hematological, low
0.17762
0.25601
MRx
MRx1
Alcoholism
0.11051
0.01924
 
MRx2
Alzheimer's
0.00000
0.08112
 
MRx3
Anti-coagulants
0.31281
0.13523
 
MRx4
Asthma/COPD
0.09825
0.05751
 
MRx5
Attention Deficit
0.00000
0.00779
 
MRx6
Burns
0.13977
0.00000
 
MRx7
Cardiac
0.09177
0.06425
 
MRx8
Cystic Fibrosis
0.48222
0.37265
 
MRx9
Depression/Anxiety
0.07013
0.09436
 
MRx10
Diabetes
0.16852
0.17046
 
MRx11
EENT
0.00000
0.00072
 
MRx12
ESRD/Renal
1.32358
1.20707
 
MRx13
Folate Deficiency
0.17618
0.11899
 
MRx14
CMV Retinitis
0.41138
0.00000
 
MRx15
Gastric Acid Disorder
0.11001
0.15470
 
MRx16
Glaucoma
0.03738
0.12971
 
MRx17
Gout
0.00000
0.00000
 
MRx18
Growth Hormone
0.97620
1.59521
 
MRx19
Hemophilia/von Willebrands
11.68858
89.14461
 
MRx20
Hepatitis
0.16213
0.00000
 
MRx21
Herpes
0.04497
0.01725
 
MRx22
HIV
0.69702
1.01178
 
MRx23
Hyperlipidemia
0.00000
0.03791
 
MRx24
Infections, high
1.23096
1.51663
 
MRx25
Infections, medium
0.07841
0.06192
 
MRx26
Infections, low
0.00000
0.00918
 
MRx27
Inflammatory/Autoimmune
0.09058
0.20046
 
MRx28
Insomnia
0.08510
0.06437
 
MRx29
Iron Deficiency
0.12948
0.15054
 
MRx30
Irrigating Solution
0.64194
0.16387
 
MRx31
Liver Disease
0.34084
0.22681
 
MRx32
Malignancies
0.36730
0.44200
 
MRx33
Multiple Sclerosis/Paralysis
0.03542
0.04353
 
MRx34
Nausea
0.16101
0.17120
 
MRx35
Neurogenic Bladder
0.13864
0.07675
 
MRx36
Osteoporosis/Pagets
0.00000
0.00000
 
MRx37
Pain
0.04154
0.04151
 
MRx38
Parkinsons/Tremor
0.17179
0.06257
 
MRx39
Prenatal Care
0.00000
0.13192
 
MRx40
Psychotic Illness/Bipolar
0.24399
0.20274
 
MRx41
Replacement Solution
0.47152
1.49405
 
MRx42
Seizure Disorders
0.23418
0.19837
 
MRx43
Thyroid Disorder
0.04267
0.06326
 
MRx44
Transplant
0.34858
0.05810
 
MRx45
Tuberculosis
0.22778
0.00000
(8) Step 8. Sum risk weights to obtain the risk score.
After obtaining the weights that correspond to a client's age/gender category and set of risk categories, the agency takes a sum of the values of all of the weights. This sum is the risk score for a client.
[Statutory Authority: RCW 41.05.021 and 41.05.160. WSR 17-24-111, § 182-557-0225, filed 12/6/17, effective 1/6/18; WSR 15-17-065, § 182-557-0225, filed 8/14/15, effective 9/14/15.]
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