Methodology

Stars math explainer

If contract crosses to 4 Stars, model a 5 percent benchmark increase on $X PMPM for Y member months. Include a double‑bonus county toggle for 10 percent and a rebate percentage selector (50/65/70) to show interaction with rebates. [M‑01] KFF · Urban Institute.

2025 Star Ratings influence 2026 QBP. [M‑02] CMS.

Access, patient experience, and complaints measures are weight 4 through 2025 and weight 2 beginning in 2026. [M‑03] 42 CFR §422.166.

MA rebate step function increases with Stars (commonly 50%/65%/70%). Document your chosen percentage in the calculator. Urban Institute · MedPAC.

RAF math explainer

Formula: added revenue PMPY = PMPM × 12 × delta RAF percent. We surface the PMPM assumption inline and keep the $141 to $282 PMPY example range. Vytivo.

Utilization reductions

We remove hard point estimates and cite systematic reviews: “RCTs of device‑based monitoring show reduced hospital service use in a majority of trials.” We model a conservative range and let buyers set the final assumption. [M‑07] Nature (systematic reviews).

Medicaid Core Set mapping

We list the Adult and Child Core Set measures we map to with links. State policy and incentives vary. Medicaid Core Set.

ACA QRS and QHP Survey mapping

We link to the 2025 QRS technical and operational documents and spell out which survey domains the UX aims to move. CMS QRS + QHP Survey (2025).

Metrics capture plan (Patient Access API)

We tag Vytivo client calls with an app ID so your platform can split out Vytivo usage in its 2025 logs. We also provide client‑side event counts that you can reconcile against gateway logs for the CMS report due March 31, 2026.

HHS‑HCC documentation completeness

We link to the 2025 DIY instructions and note: “actuaries should calibrate transfer sensitivity by state.” HHS‑HCC DIY (2025).

Readability and accessibility

We document readability targets and how we measure grade level and multilingual QA.

Experimental design

One‑pager on pilot design, MDE, and attribution. Plan for a 90–120 day matched cohort or stepped‑wedge pilot with confidence intervals.

Summary

Stars, RAF, utilization and churn: how we calculate ROI

• Stars: if your contract crosses to 4.0, we model a 5 percent benchmark increase on your PMPM and member months, with a toggle for double‑bonus counties. 2025 ratings affect 2026 payments. KFF
• RAF: added PMPY = PMPM × 12 × delta RAF percent. We display PMPM assumptions inline.
• Medicaid: we model regained withhold and utilization savings, with state withhold percent user‑set. Core Set
• ACA: we model churn reduction, support deflection and an HHS‑HCC documentation completeness scenario calibrated by your actuaries using HHS DIY. HHS DIY