Common use of Alternative Payment Methodologies Clause in Contracts

Alternative Payment Methodologies. As a core objective of this Agreement EOHHS seeks to significantly reduce the use of fee-for- service payment as a payment methodology and to replace fee-for-service payment with Alternative Payment Methodologies that provide incentives for better quality, outcomes and more efficient delivery of health services EOHHS requires that the Contractor progressively incorporate value based Alternative Payment Methodologies into their contracts with providers. Within this framework primary emphasis is given to total cost of care arrangements with EOHHS certified Accountable Entities. EOHHS is committed to development of partnerships between health plans and provider based organizations using accountable care delivery models that integrate medical care, behavioral health, substance use disorders, community health, public health, social determinants, related social services, and LTSS, supported by innovative payment and care delivery models that establish shared financial accountability across all partners, with a demonstrated approach to continue to grow and develop the model of integration and accountability. For each contract period, the Contractor will meet or exceed the requirements set forth Transitioning to Alternative Payment Methodologies: Requirements for Medicaid Managed Care Partners for the percent of their total payments made to providers using EOHHS approved alternative payment methods. APM contracts may not include the delegation of network contracting, provider payment, and/or claims processes, member services, or grievance and appeals functions without the express written consent of EOHHS. For any other function (e.g. care management) that is delegated, the Contractor must have an established process for assessing the capability of the subcontractor to assume responsibility for the delegated function(s) and have an established policy and procedure for overseeing performance of such function(s). The Contractor must have a written plan for its monitoring and oversight of the performance of all contracts with providers using APMs. Such oversight will include ensuring compliance with all requirements pertaining to marketing, member communications, and member choice. Upon request by EOHHS, the Contractor will submit an electronic copy of its written plan for monitoring and oversight of all APM subcontractors. The Contractor is required to develop and implement subcontracts with providers including Alternative Payment Methodologies as set forth in Transitioning to Alternative Payment Methodologies: Requirements for Medicaid Managed Care Partners. This document sets forth the requirements of the Rhode Island Executive Office of Health and Human Services (EOHHS) for managed care organizations contracted with EOHHS as Medicaid Managed Care Organizations (MCOs). For contracts with entities certified as comprehensive Accountable Entities, subcontracts between the health plan and the certified AE will be in compliance Transitioning to Alternative Payment Methodologies: Requirements for Medicaid Managed Care Partners for the applicable time period. The Contractor’s compliance with these requirements pertains to the applicable type of certified AE and the applicable time period (e.g., the Contract Period). EOHHS will review the Contractor’s Accountable Entity contract to assure compliance with requirements before granting approval. Transparency in such arrangements is required in conformance with 42 C.F.R § 438.6i. Based on 42 C.F.R. § 436.6(g), any Contractor/AE risk arrangements must stipulate that the EOHHS and the DHHS may inspect and audit any financial records of the Contractor or its subcontractors. Any physician incentive plans must comply with the requirements in 42 C.F.R. § 438.3(i), § 422.208” and § 422.210. In order to align with the state fiscal year, beginning January 1, 2018, all contracts with AEs will have a performance period that ends on June 30. All total cost of care calculations will be based on a performance period ending June 30. MCOs are required to participate in primary care capitation policy, planning, and design processes led by OHIC and EOHHS and leveraging the technical expertise of contractors, including but not limited to Bailit Health and CTC-RI. Participation shall include attendance at relevant meetings, providing requested data, financial analysis, design preferences, and any other such effort to support the development of both financial and clinical models to enable implementation of primary care capitation. The MCO shall also simulate practice revenues under the designed model to test the efficacy of the model per guidance from EOHHS.