CurrentArizona Health Care Cost Containment SystemPolicy N/A

Arizona Long Term Care System Elderly and Physically Disabled Program Payment Reform Initiative

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This policy governs the AHCCCS Payment Reform Initiative for all ALTCS Elderly and Physically Disabled Contractors for dates of service on and after October 1, 2014. It establishes shared-savings requirements, quality contributions and distributions, contractor certifications, annual reconciliation, and related payment adjustments.

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyArizona Long Term Care System Elderly and Physically Disabled Program Payment Reform Initiative

Policy CodePolicy N/A

Change TypeRevision

Effective Date10/01/14

Next Review DateN/A

Key ActionALTCS EPD Contractors must participate in the AHCCCS Payment Reform Initiative and pursue quality-improvement activities through shared-savings payment arrangements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1%Quality contribution

5%Maximum quality distribution

5%EPD shared-savings minimum

2% + 2%Acute Care and Long Term Care minimums

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CurrentArizona Health Care Cost Containment SystemPolicy N/A

Arizona Long Term Care System Elderly and Physically Disabled Program Payment Reform Initiative

Customize your policy alerts

Sign up for all Arizona Health Care Cost Containment System policy alerts

Know when Arizona Health Care Cost Containment System releases new policies or updates existing guidance.

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Policy Summary

PayerArizona Health Care Cost Containment System

PolicyArizona Long Term Care System Elderly and Physically Disabled Program Payment Reform Initiative

Policy CodePolicy N/A

Change TypeRevision

Effective Date10/01/14

Next Review DateN/A

Key ActionALTCS EPD Contractors must participate in the AHCCCS Payment Reform Initiative and pursue quality-improvement activities through shared-savings payment arrangements.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1%Quality contribution

5%Maximum quality distribution

5%EPD shared-savings minimum

2% + 2%Acute Care and Long Term Care minimums

1.5%MA-DSNP shared-savings minimum

60 / 180 daysCertification deadlines

Shared-Savings Qualification and Distribution

Minimum shared-savings qualification criteria

A Contractor qualifies for a quality distribution only if ALL of the following requirements are met and certified for the measurement year:

ALL of the following

EPD contract requirements
- At least 5% of total prospective provider payments
  - At least 5% of the value of total prospective payments under all contracts executed with health care providers must be governed by shared-savings arrangements for the measurement year.>= 5%
  - At least 2% of total Acute Care service payments under all contracts executed for those services must be governed by shared-savings arrangements for the measurement year.>= 2%
  - At least 2% of total Long Term Care service payments under all contracts executed for those services must be governed by shared-savings arrangements for the measurement year.>= 2%
  - Additional contracts, at the Contractor's discretion, must be governed by shared-savings arrangements so that 5% of total spending under all contracts is governed by shared-savings arrangements for the measurement year.
MA-DSNP ALTCS EPD Duals requirement
- At least 1.5% of the value of total payments under all contracts with health care providers must be governed by shared-savings arrangements for the measurement year.>= 1.5%
Written shared-savings contracts must be executed no later than February 1.No later than February 1
Certification submissions
- Submit an initial Payment Reform Initiative Shared Savings Arrangement Certification to the DHCM Finance Manager within 60 days of the start of the measurement year, together with an executed copy and an electronic Excel copy.Within 60 days of the start of the measurement year
- Submit a final Payment Reform Initiative Shared Savings Arrangement Certification to the DHCM Finance Manager 180 days after the end of the measurement year, together with an executed copy and an electronic Excel copy.180 days after the end of the measurement year
- If the executed copy and electronic template differ, the executed copy prevails.

Quality distribution calculation and limits

Quality distributions are calculated independently for each selected QMPM and reconciled annually as follows:

ALL of the following

Each selected Quality Management Performance Measure is considered independently of the other measures, so a Contractor may earn a distribution on any or all QMPMs.
Performance Measure Score
- QMPM result is equal to or above the minimum standard
  - The Contractor's QMPM result is equal to or above the Quality Management Minimum Performance Standard.>= MinStd
  - Performance Measure Score = Q × S × ([CMeasure − MinStd] / MinStd).
- QMPM result is below the minimum standard

Payment Thresholds and Certification Deadlines

EPD total shared-savings arrangement minimum

MinimumAt least 5%

BasisValue of total prospective payments under all provider contracts

PeriodMeasurement year

EPD Acute Care shared-savings minimum

MinimumAt least 2%

BasisTotal Acute Care service payments under all provider contracts

PeriodMeasurement year

Contractor Responsibilities

Note

Participate in the Payment Reform Initiative

ALTCS EPD Contractors must participate in the AHCCCS Payment Reform Initiative for applicable dates of service and pursue quality-improvement activities that support improved health outcomes and cost savings through shared-savings payment arrangements.

Denial Risk

Meet minimum qualification requirements

To qualify for a quality distribution, the Contractor must meet and certify the minimum shared-savings qualifying criteria for both the EPD contract and the MA-DSNP contract for ALTCS EPD members. Failure to meet or certify these minimums disqualifies the Contractor from quality distributions for that measurement year, although its quality contribution remains assessed.

Key Terms

Adjustment Factor

PurposeEnsures the total quality contribution amount by QMPM equals the total quality distribution amount by QMPM

Applied toPerformance rank score

VariationVaries by QMPM and the number of Contractors meeting minimum standards

Measurement Year

PeriodThe period for which the PRI policy applies

BeginsOctober 1

EndsSeptember 30

Policy Summary

PayerArizona Health Care Cost Containment System

PolicyArizona Long Term Care System Elderly and Physically Disabled Program Payment Reform Initiative

Policy CodePolicy N/A

Change TypeRevision

Effective Date10/01/14

Next Review DateN/A

Key ActionALTCS EPD Contractors must participate in the AHCCCS Payment Reform Initiative and pursue quality-improvement activities through shared-savings payment arrangements.

SourceLink

On This Page

The Contractor's QMPM result is below the Quality Management Minimum Performance Standard.< MinStd
Performance Measure Score = 0.

Performance Rank Score = A × Q × R.

Quality Distribution = Performance Measure Score + Performance Rank Score.

The maximum distribution across all QMPMs to any Contractor is limited to 5% of annual Prospective Gross Capitation attributable to the ALTCS/EPD Payment Reform Initiative.<= 5%

Quality contributions and quality distributions are settled through an annual reconciliation performed on a contract-year basis.

Any amount due to or from the Contractor after reconciliation is paid or recouped through a future monthly capitation payment.

EPD Long Term Care shared-savings minimum

MinimumAt least 2%

BasisTotal Long Term Care service payments under all provider contracts

PeriodMeasurement year

MA-DSNP ALTCS EPD Duals shared-savings minimum

MinimumAt least 1.5%

BasisValue of total payments under all provider contracts

PopulationALTCS EPD Duals under the MA-DSNP contract

Quality contribution

Assessment1% of Prospective Gross Capitation

PurposeFunds quality distributions

ExclusionAcute Care Only payments are excluded

Maximum quality distribution

Maximum5% of annual Prospective Gross Capitation

ScopeProspective Gross Capitation attributable to the ALTCS/EPD PRI

ApplicationMaximum distribution across all QMPMs to any Contractor

Initial certification deadline

DeadlineWithin 60 days of the start of the measurement year

SubmissionInitial Payment Reform Initiative Shared Savings Arrangement Certification

RecipientDHCM Finance Manager

Final certification deadline

Deadline180 days after the end of the measurement year

SubmissionFinal Payment Reform Initiative Shared Savings Arrangement Certification

RecipientDHCM Finance Manager

Contract execution deadline

DeadlineNo later than February 1

RequirementWritten shared-savings contracts shall be executed

Applies toContracts governed by shared-savings arrangements

Billing Rule

Satisfy EPD shared-savings thresholds

For the EPD contract, shared-savings arrangements must govern at least 5% of the value of total prospective payments under all contracts executed with health care providers for the measurement year.

At least 2% of total Acute Care service payments must be governed by shared-savings arrangements.
At least 2% of total Long Term Care service payments must be governed by shared-savings arrangements.
Additional contracts must bring the total governed spend to 5%.

Billing Rule

Satisfy MA-DSNP shared-savings threshold

For the MA-DSNP contract for ALTCS EPD Duals, shared-savings arrangements must govern at least 1.5% of the value of total payments under all contracts with health care providers for the measurement year.

Documentation Required

Execute shared-savings contracts

Execute all written shared-savings arrangement contracts no later than February 1.

Documentation Required

Submit shared-savings certifications

Certify that the minimums will be met by submitting both an executed copy and an electronic Excel copy of the Payment Reform Initiative Shared Savings Arrangement Certification to the DHCM Finance Manager.

Submit the initial certification within 60 days of the start of the measurement year.
Submit the final certification 180 days after the end of the measurement year.
If the executed copy and electronic template differ, the executed copy prevails.

Documentation Required

Maintain auditable certification records

Retain certification materials for potential review because AHCCCS reserves the right to require an audit of the certifications included in Attachment C.

Billing Rule

Review annual reconciliation

Review the reconciliation data provided by AHCCCS and submit comments by the written deadline provided by AHCCCS. After the review period, AHCCCS will evaluate the comments and address issues as warranted.

The reconciliation establishes the amount due to or due from the Contractor.
Any resulting amount due to or from the Contractor is paid or recouped through a future monthly capitation payment.

Performance Measure Score

TypeOne of the two scores used in calculating the quality distribution

BasisContractor performance relative to minimum performance standards

Standards established byCQM

Performance Rank Score

TypeOne of the two scores used in calculating the quality distribution

BasisPure ranking of the Contractor’s performance

Used forCalculating the quality distribution

Premium Tax

DefinitionTax imposed pursuant to A.R.S. §36-2905

Applies toAll payments made to Contractors

PeriodContract year

Prospective Gross Capitation

FrequencyPayments made monthly to Contractors

Before adjustments forNursing Facility enhanced payments

IncludesMedical expense, reinsurance offset, share-of-cost offset, administration, case management, risk/contingency, premium tax, and subsequent amendments

Quality Management Performance Measures

DefinitionHealth care quality measures utilized by CQM

PRI useSubsets of these measures were selected for use in the PRI

ReferenceSee highlighted rows in Attachment A

Quality Management Measurement Report

FrequencyAnnual

IssuerCQM

ContentsResults by Contractor on QMPMs

Quality Management Minimum Performance Standard

DefinitionMinimum standard established by CQM for each QMPM

Established byCQM

Used to calculatePerformance measure score

Quality Contribution

DefinitionSpecified percentage of all Contractors’ Prospective Gross Capitation payments

AssessmentThrough a reconciliation process

PurposeFunds the PRI

Quality Distribution

DefinitionAmounts returned to Contractors by QMPM

Based onPerformance measure score and performance rank score

Recipient basisContractor results by QMPM

Rank Factor

DefinitionFactor applied in calculating a Contractor’s quality distribution amount

BasisContractor’s rank for the performance rank score

Used inQuality distribution calculation

Scaling Factor

DefinitionFactor applied in calculating a Contractor’s quality distribution amount

BasisPerformance measurement score

Used inQuality distribution calculation

Arrangement

FormWritten contract between a Contractor and provider

PurposeDesigned to achieve cost savings and quantifiable improved outcomes

SavingsShared between the Contractor and the provider