The data is based on OP contracts completed on or after 1/1/2019, with projections and budgets as of 2025-09-30.

The following charts show the counts and mlr experience by target and achieved outcome

Counts
TargetOutcome III IV V
III 6 2 NA
IV NA 19 4
V NA NA 8
MLR
TargetOutcome III IV V
III 0.941 1.136 NA
IV NA 0.918 0.772
V NA NA 0.954

The case mix is mostly ABI and SCI contracts

Diagnosis Type Case Complexity Count MLR
ABI 4 1 123.7%
ABI 5 10 86.1%
ABI 6 8 95.2%
Amputation 4 3 88.2%
Amputation 5 1 67.4%
Burn Injury 4 2 120.6%
Multiple Trauma 4 1 92.7%
SCI 5 6 111.0%
SCI 6 7 83.0%
Effective Year Count Ultimate Projections Ultimate Price MLR
2015 1 907,155 1,249,992 72.6%
2016 1 2,202,181 2,152,419 102.3%
2017 6 8,593,236 7,360,098 116.8%
2018 8 13,800,033 15,192,226 90.8%
2019 5 7,248,811 9,639,655 75.2%
2020 4 7,481,501 8,665,611 86.3%
2021 7 14,465,603 12,696,226 113.9%
2022 5 7,870,975 8,993,779 87.5%
2023 2 1,635,012 2,872,458 56.9%

Most patients were confined at their residence at the end of the contract

Confinement Locations Count Ultimate Projections Ultimate Price MLR
Private residence 19 27,687,967 29,613,073 93.5%
Residential facility 6 11,149,583 10,633,497 104.9%
Subacute facility 3 6,103,003 7,610,412 80.2%
Skilled nursing facility 3 5,588,310 5,740,700 97.3%
Long-term acute hospital 2 4,715,498 4,722,650 99.8%
Acute hospital 2 4,357,705 3,982,706 109.4%
Hotel/Temporary housing 3 2,732,138 4,113,674 66.4%
Post-acute rehabilitation 1 1,870,301 2,405,752 77.7%

Overall, the 31 contracts that were still confined at outcome achivement and contract end, were over budget by 17%

Budget Reforecast Variance Overunder
52,622,347 64,303,326 -11,680,979 22%

The following shows the budget differences by Summary Service Code, showing a concentration in inpatient and outpatient costs

Summary Code Summary Desc Budget Reforecast Variance Overunder
9000 In-Patient Hospitalization 24,787,691 31,683,049 -6,895,358 28%
9100 Out-Patient/Day Treatment 7,710,787 13,179,187 -5,468,400 71%
9200 Lab/Diagnostic Services 272,139 297,784 -25,645 9%
9300 Management Services 2,502,831 4,428,912 -1,926,080 77%
9400 Physician & Professional Fees 3,653,354 4,501,470 -848,116 23%
9500 Personal Care Attendant Fees 2,531,607 3,103,162 -571,555 23%
9600 Transportation 1,774,458 1,957,750 -183,292 10%
9700 Durable Medical Equipment 1,419,903 1,702,184 -282,281 20%
9900 Miscellaneous 7,969,576 3,449,829 4,519,748 -57%

Finally, the detail codes with the most impact are shown in order below. The outpatient shortfalls are mostly due to Post Acute Rhab and Surgeries

Summary Code Summary Desc Budget Reforecast Variance Overunder
9003 Med/Surg 9,399,048 12,265,588 -2,866,540 30%
9102 Post Acute Residential 3,669,250 6,533,302 -2,864,052 78%
9310 Time 2,002,920 4,092,991 -2,090,071 104%
9004 Acute Rehab 7,621,686 9,696,633 -2,074,947 27%
9006 Subacute 2,696,249 4,474,895 -1,778,646 66%
9105 Out Patient Surgical Facility Visit 481,183 1,799,951 -1,318,767 274%
9108 Residential Placement 0 582,208 -582,208 Inf
9002 ICU 2,421,175 2,919,070 -497,895 21%
9490 Other-Physician&Prof Fees 1,947,719 2,416,148 -468,430 24%
9907 Interpretive Services 319,150 710,371 -391,221 123%
9925 PMD Time 429,480 819,346 -389,866 91%
9515 PCA Family Member 91,560 425,775 -334,215 365%
9110 Nursing Services & RN Visits 841,483 1,167,140 -325,657 39%
9090 Other-Inpatient 0 288,963 -288,963 Inf
9422 Dental 72,680 355,264 -282,584 389%
9505 PCA Services 2,440,047 2,677,387 -237,340 10%
9475 Plastic 31,270 264,187 -232,917 745%
9170 Medical Supplies-Outpatient 238,322 456,311 -217,989 91%
9985 PPO Savings -218,562 -28,538 -190,024 -87%
9180 Medications-Outpatient 798,911 979,098 -180,187 23%
9007 Skilled Nursing Facility 406,828 583,662 -176,834 43%
9103 Neurobehavioral 234,000 401,464 -167,464 72%
9120 Physical Therapy-Outpatient 419,934 586,526 -166,592 40%
9611 Ambulance 146,741 254,446 -107,705 73%
9720 Wheel Chair 583,221 689,487 -106,266 18%
9421 Psychiatry 0 103,064 -103,064 Inf
9715 Orthosis 28,293 109,810 -81,517 288%
9005 Emergency Room 147,905 224,145 -76,240 52%
9610 Transportation 803,099 864,046 -60,947 8%
9300 Management Services 70,500 127,000 -56,500 80%
9713 Hospital Bed 159,903 205,189 -45,286 28%
9710 Durable Medical Equipment-Misc. 263,291 305,797 -42,506 16%
9716 Prosthesis 300,721 337,342 -36,621 12%
9980 Administrative Fee 0 32,691 -32,691 Inf
9290 Other-Lab/Diagnostic Srvcs 171,744 201,209 -29,465 17%
9480 Urology 9,944 39,297 -29,354 295%
9045 Surgeries 0 28,799 -28,799 Inf
9190 Other-Outpatient 27,479 54,315 -26,836 98%
9460 Orthopedics 56,425 78,413 -21,988 39%
9930 Medical Specialist Consultant 17,600 33,050 -15,450 88%
9920 Clinical Specialist 132,350 146,950 -14,600 11%
9613 Mileage 9,658 23,651 -13,993 145%
9915 Family Costs-R&B, Travel, Meal 54,311 67,407 -13,096 24%
9450 Neuropsychology 3,000 11,000 -8,000 267%
9240 CT Scan 1,164 5,820 -4,656 400%
9712 Grab Bars 2,708 6,773 -4,065 150%
9410 Attending Physician 0 4,035 -4,035 Inf
9485 Radiologist 949 4,733 -3,784 399%
9430 Neurology 0 2,000 -2,000 Inf
9470 Physiatry 4,194 5,594 -1,400 33%
9104 Pain Management 0 1,000 -1,000 Inf
9612 Air Ambulance 814,829 815,475 -646 0%
9426 Gastroenterologist 7,978 8,039 -61 1%
9940 Reinsurance 1,330,161 1,330,162 -1 0%
9327 Communications Costs 260 260 0 0%
9412 Burn 12,599 12,599 0 0%
9614 Transportation-Misc. 131 131 0 0%
9714 Jobst Garments 4,824 4,824 0 0%
9965 UE 319,050 319,050 0 0%
9270 Swallowing Evaluation 212 0 212 -100%
9326 Travel Costs 896 476 420 -47%
9280 Ultrasound 472 0 472 -100%
9245 X-rays 858 279 579 -68%
9260 Urodynamic Studies 1,308 654 654 -50%
9415 Cardiology 1,738 1,058 681 -39%
9255 EEG/EMG 1,023 322 701 -69%
9711 Bedside Commode 1,310 589 721 -55%
9718 Roho Cushion 18,509 17,262 1,247 -7%
9440 Neuro-ophthamology 1,938 0 1,938 -100%
9210 Lab Services-Technical 91,850 89,500 2,350 -3%
9241 MRI 3,508 0 3,508 -100%
9186 Home Evaluation-Outpatient 5,360 125 5,235 -98%
9719 Shower Chair 22,727 15,745 6,982 -31%
9160 Vocational Assessment 17,850 9,480 8,370 -47%
9458 Ophthamology 10,741 179 10,562 -98%
9185 Drivers Evaluation-Outpatient 25,380 12,910 12,470 -49%
9423 ENT 15,965 0 15,965 -100%
9165 Work Hardening 44,687 27,499 17,188 -38%
9970 State Surcharge/Carrier Admin 38,089 19,339 18,750 -49%
9717 Ramp 34,396 9,368 25,028 -73%
9150 Counseling 30,951 1,836 29,115 -94%
9325 Travel Mileage 68,385 35,614 32,771 -48%
9439 General Surgeon 286,383 245,837 40,546 -14%
9101 Day Treatment 478,316 433,400 44,916 -9%
9009 Pain Program 69,846 0 69,846 -100%
9140 Speech/Language Therapy-Outpatient 155,368 28,957 126,411 -81%
9130 Occupational Therapy-Outpatient 242,314 103,666 138,647 -57%
9010 Room & Board 154,926 0 154,926 -100%
9320 Travel Time 359,870 172,570 187,300 -52%
9455 Neurosurgery 1,189,833 950,023 239,810 -20%
9008 Long Term Residential Placement 1,870,028 1,201,293 668,734 -36%
9950 Clinical Risk Margin 5,547,947 0 5,547,947 -100%