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Value-Based Payment Contract Requirements for Medicare-Medicaid Plans: DOH Releases FAQs and LeadingAge NY Submits Comments

With the March 31st deadline looming for Medicaid Advantage Plus (MAP), Programs of All-Inclusive Care for the Elderly (PACE), and Fully Integrated Duals Advantage (FIDA) value-based payment (VBP) contracting, the Department of Health (DOH) released answers to frequently asked questions (FAQs). The FAQs provide some additional information about the expected structure of these arrangements but leave many issues unresolved.

Notably, the FAQs indicate that, unlike the partially-capitated plans, the Medicare-Medicaid plans (or "integrated plans") are required to enter into arrangements that, at a minimum, provide for shared savings. Contracts that provide for quality bonuses alone will not satisfy the requirements. The Department expects integrated plans to contract with networks of providers such as accountable care organizations (ACOs), independent provider associations (IPAs), or individual providers that will be held financially accountable for reducing spending and maintaining or improving performance on quality measures. These VBP arrangements must include a method for attributing beneficiaries to a particular provider (typically either a primary care physician or a home care agency), for calculating a target budget based on total spending for all covered services, and for calculating savings (and excess spending, if applicable) in relation to the target. In addition, these arrangements must incorporate performance on specified quality measures. PACE programs are subject to an additional requirement to contract with independent community-based organizations for an intervention that addresses social determinants of health. Contracts with providers may be retroactive to Jan. 1, 2018, and plans will be penalized if they do not achieve the target of 10 percent of expenditures paid through VBP arrangements.

LeadingAge NY submitted comments and questions about these requirements last week and has requested an extension of the March 31st deadline. We are collecting additional questions and comments from members and encourage members to submit them to us here and to DOH here.

The FAQs are available here. A presentation to the Department's VBP Work Group is available here. DOH memoranda about the VBP requirement for integrated plans are available at the links below. 

Proposed VBP quality measures for PACE are available here and for MAP and FIDA here. These measure sets have not yet been formally adopted by the Department. Integrated plans may also opt to include long term care measures adopted for the partially-capitated MLTC program in their VBP arrangements. Those measures are available here. The timeline for data reporting on partially-capitated MLTC quality measures is available here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-868-8383 ext. 124