Common use of Value-Based Programs Administration Clause in Contracts

Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay providers for reaching agreed-upon cost/quality goals in the following ways: Per member per month, provider incentives, gain share, risk share, retrospective settlements, prospective settlements, share of target savings, Care Coordination Fees and/or other allowed amounts. The Host Blue may pass these provider payments to BlueCross, which BlueCross will pass directly on to Employer as either an amount included in the price of the claim or an amount charged separately in addition to the claim. When such amounts are included in the price of the claim, the claim may be billed using one of the following pricing methods, as determined by the Host Blue: • Actual Pricing: The charge to accounts for Value-Based Programs incentives/Shared Savings settlements is part of the claim. These charges are passed to Employer via an enhanced provider fee schedule. • Supplemental Factor: The charge to accounts for Value- Based Programs incentives/Shared Savings settlements is a supplemental amount that is included in the claim as an amount based on a specified supplemental factor (e.g., a small percentage increase in the claim amount). The supplemental factor may be adjusted from time to time. This pricing method may be used only for non-attributed Value- Based Programs. When such amounts are billed separately from the price of the claim, they may be billed as follows: 1.2.2.1.1. Per Member Per Month (PMPM) Billings: Per Member Per Month ▇▇▇▇▇▇▇▇ for Value-Based Programs incentives/Shared Savings settlements to accounts are outside of the claim system. BlueCross will pass these Host Blue charges directly through to Employer as a separately identified amount on the group ▇▇▇▇▇▇▇▇. The amounts used to calculate either the supplemental factors for estimated pricing or PMPM ▇▇▇▇▇▇▇▇ are fixed amounts that are estimated to be necessary to finance the cost of a particular Value-Based Program. Because amounts are estimates, there may be positive or negative differences based on actual experience, and such differences will be accounted for in a variance account maintained by the Host Blue (in the same manner as described in the BlueCard claim pricing section above) until the end of the applicable Value-Based Program payment and/or reconciliation measurement period. The amounts needed to fund a Value- Based Program may be changed before the end of the measurement period DocuSign Envelope ID: CD93B45A-0105-43E7-9602-5AE5EB65AF29 DocuSign Envelope ID: 00C2B362-1FE5-4A7F-86FB-24039505711D if it is determined that amounts being collected are projected to exceed the amount necessary to fund the program or if they are projected to be insufficient to fund the program. At the end of the Value-Based Program payment and/or reconciliation measurement period for these arrangements, Host Blues will take one of the following actions: 1.2.2.1.2. Use any surplus in funds in the variance account to fund Value-Based Program payments or reconciliation amounts in the next measurement period. 1.2.2.1.3. Address any deficit in funds in the variance account through an adjustment to the PMPM billing amount or the reconciliation billing amount for the next measurement period. The Host Blue will not receive compensation resulting from how estimated, average or PMPM price methods, described above, are calculated. If Employer terminates, Employer will not receive a refund or charge from the variance account. This is because any resulting surpluses or deficits would be eventually exhausted through prospective adjustment to the settlement ▇▇▇▇▇▇▇▇ in the case of Value-Based Programs. The measurement period for determining these surpluses or deficits may differ from the term of this Agreement. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume/number of claims processed and variance account balance. Variance account balances may earn interest, and interest is earned at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts. Note: Members will not bear any portion of the cost of Value-Based Programs except when a Host Blue uses either average pricing or actual pricing to pay providers under Value-Based Programs.

Value-Based Programs Administration. Under Value-Based Programs, a Host Blue may pay providers Providers for reaching agreed-upon cost/quality goals in the following ways: Per member per month, provider incentives, gain share, risk share, retrospective settlements, prospective settlementsProvider Incentives, a share of target savings, Care Coordination Coordinator Fees and/or other allowed amounts. The Host Blue may pass these provider Provider payments to BlueCrossAnthem Blue Cross Life and Health, which BlueCross Anthem Blue Cross Life and Health will pass directly on to Employer as Plan Sponsor in the form of either an amount included in the price of the claim Claim or an amount charged separately in addition to the claimClaim. When such amounts are included in the price of the claimClaim, the claim Claim may be billed using one of the following pricing methods, as determined by the Host Blue: • Actual Pricing • Claim Based (Actual Pricing: ): The charge to accounts for Value-Based Programs incentives/Shared Savings settlements is part of the claimClaim. These charges are passed to Employer via an enhanced provider fee schedule. • Supplemental Factor: Estimated/Average Pricing • Claim Based (Estimated Pricing): The charge to accounts for Value- Value-Based Programs incentives/Shared Shared-Savings settlements is a supplemental amount that is included in the claim Claim as an amount based on a specified supplemental factor (e.g.factor. • In such cases, a small percentage increase in Anthem Blue Cross Life and Health will pass any supplemental amounts on to Plan Sponsor as follows: it will be included as part of the claim amount). The supplemental factor may be adjusted from time to time. This pricing method may be used only for non-attributed Value- Based ProgramsClaims charge on the invoice. When such amounts are billed separately from in addition to the price of the claimClaim, they may be billed as follows: 1.2.2.1.1. : • Per Member Per Month (PMPM) Billings▇▇▇▇▇▇▇▇: Per Member Per Month ▇▇▇▇▇▇▇▇ for Value-Based Programs incentives/Shared Shared-Savings settlements to accounts are outside of the claim Claim system. BlueCross Anthem Blue Cross Life and Health will pass these Host Blue charges directly through to Employer Plan Sponsor as a separately identified amount on the group ▇▇▇▇▇▇▇▇invoice. The amounts used to calculate either the supplemental factors for estimated pricing or PMPM ▇▇▇▇▇▇▇▇ are fixed estimates. This means that Host Blues cannot determine final amounts that are estimated to be necessary to finance for these arrangements at the cost time when Members incur Claims for Covered Services. Consequently, Host Blues may hold some portion of a particular Value-Based Program. Because the amounts are estimates, there may be positive or negative differences based on actual experience, and Plan Sponsor pays under such differences will be accounted for in a variance account maintained by the Host Blue (in the same manner as described in the BlueCard claim pricing section above) arrangements until the end of the applicable Value-Based Program payment and/or reconciliation measurement period. The amounts needed to fund a Value- Based Program may be changed before the end of the measurement period DocuSign Envelope ID: CD93B45A-0105-43E7-9602-5AE5EB65AF29 DocuSign Envelope ID: 00C2B362-1FE5-4A7F-86FB-24039505711D if it is determined that amounts being collected are projected to exceed the amount necessary to fund the program or if they are projected to be insufficient to fund the program. At the end of the Value-Based Program payment and/or reconciliation measurement period for these arrangements, Host Blues will take one of the following actions: 1.2.2.1.2. : • Use any surplus in funds in the variance account to fund Value-Based Program payments or reconciliation amounts amount in the next measurement period. 1.2.2.1.3. • Address any deficit in funds in the variance account through an adjustment to the PMPM per-member-per-month billing amount or the reconciliation billing amount for the next measurement period. The Host Blue will not receive compensation resulting from how estimated, average measurement period for determining these surpluses or PMPM price methods, described above, are calculated. If Employer terminates, Employer will not receive a refund or charge deficits may differ from the variance accountterm of this Agreement. This is because any resulting Such surpluses or deficits would be eventually exhausted through prospective adjustment to the settlement ▇▇▇▇▇▇▇▇ in the case of Value-Based Programs. The measurement period for determining these surpluses or deficits may differ from the term of this Agreement. Variance account balances are small amounts relative to the overall paid claims amounts and will be liquidated over time. The timeframe for their liquidation depends on variables, including, but not limited to, overall volume/number of claims processed and variance account balance. Variance account balances may earn interest, and interest is earned at the federal funds or similar rate. Host Blues may retain interest earned on funds held in variance accounts. Note: Members will not bear any portion of the cost of Value-Based Programs except when a Host Blue uses Blues use either average pricing or actual pricing to pay providers Providers under Value-Based Programs.