CMS Pub. 100-16, ch. mc86c17d, § 30.1.3

The CMS recognizes the greater intensity of services and frequency of health care

utilization among Medicare beneficiaries than among commercial membership. Since

there is no one-to-one equivalence between Medicare and commercial members in this

respect, a utilization adjustment factor is incorporated in calculating enrollment capacity.

The utilization adjustment factor represents the number of commercial members the

organization could serve for every one Medicare member served over the course of the

contract year. The organization also provides backup documentation and discussion of

the methodology employed in the calculations. For example, if the data show that

Medicare utilization is three times that of commercial members, the capacity for new

commercial members is three times what it would be for new Medicare members.

Therefore, if the available capacity is for 3,000 additional commercial members in the

next contract period, and the organization anticipates filling 1,500 of those slots with

commercial members, the remaining 1,500 slots must be divided by three. That is, full

capacity is reached if the organization enrolls 500 Medicare members in addition to the

1,500 commercial members, based on a ratio of one Medicare vacancy to every three

commercial vacancies.