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Contract Payment Policy – updated March 2020
How Do I Get Paid?
Project Funds FAQ
Update 09/2021 – Pay-for-Performance Funds Flow model updated to reflect Sept 2021 Board decisions.
BHT took into consideration many factors when designing the funds flow model for Medicaid Transformation Project achievement. The BHT Board intends for the funding to support the region’s ability to hit Pay-for-Performance measures and support real transformation to the delivery of care. To do that, we wanted to maximize investments in primary care and behavioral health Partnering Providers, so the model acknowledges that volume matters if we want to ensure that population level impact occurs. We also wanted to demonstrate our commitment to equity, so there is emphasis on provider level activities to support equity. And as always, our goals were to get dollars into the hands of our providers and—while we are trying to develop a regional system—to honor provider choice/independence.
Below are the funds flow models approved by the BHT Board at their November 28, 2018 meeting.
Pay-for-Reporting Funds Flow Model
Based on a unanimous recommendation from the Waiver Finance Workgroup, the Board has approved the following Pay-for-Reporting funds flow model for behavioral health and primary care Partnering Providers for 2019, 2020, and 2021. The Board approved this Partnering Provider Volume Calculation POLICY which outlines how the numbers were calculated, the tiers, and the dispute resolution process. .
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Partnering Providers will be divided into 3 groups based on volume and allocated earning potential based on that volume.
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20,001+ Beneficiaries
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1,201-20,000 Beneficiaries
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1,200 or less Beneficiaries
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An optional Tribal Carve Out will be offered to Tribal Partners who wish to opt out of Pay-for-Reporting. The Tribal Carve Out requires identification of other Transformation efforts undertaken and continued participation in Tribal Partner Leaders Council and county-based Collaborative.
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Unearned funds will be placed in a pool, to be distributed at the recommendation of Waiver Finance Workgroup and approved by BHT Board.
The funds will be earned by a combination of hitting milestones developed by the Partnering Provider in their Final Transformation Plan and meeting Pay-for-Achievement measures selected from a BHT-provided list.
40% – Transformation Plan milestones
40% – Pay-for-Achievement measures
20% – Equity Activities & Measures
How many dollars are there?
The following table shows the potential Pay-for-Reporting earnings, per partner.
Contract Payment Schedule
Partners will receive three payments during the contract period, with the third payment based on achievement:
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Payment 1: Contract signing
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Payment 2: Completion of mid-contract reporting on Milestones and P4A measures
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Payment 3: Achievement of Milestones and P4A measures based on results of end-of-contract reporting.
The following payments proportions for Year 2 and Year 3 contracts was approved by the Board in March 2020. This mirrors how the funding levels from HCA are divided between reporting and achievement for these years. The Board previously approved the Year 1 division.
This payment schedule applies to the contract dollars for Transformation Plan milestones (40%) and Pay-for-Achievement measures (40%). The contract dollars for Equity Activities & Measures (20%) is reporting-based only.
Pay-for-Performance Funds Flow Model
Pay-for-Performance funds are earned by the region meeting the measures created by the Health Care Authority (HCA). These dollars will be earned based on 25% of Pay-for-Performance Project funds in 2019, 50% of Pay-for-Performance Project funds in 2020, and 75% of Pay-for-Performance Project funds in 2021. Please note that 2019 Pay-for-Performance funds will be distributed by HCA in 2021; 2020 Pay-for-Performance funds in 2022; and 2021 Pay-for-Performance funds in 2023.
Based on a unanimous recommendation from the Waiver Finance Workgroup, the Board has approved the following model to allocate the 85% of the region’s Pay-for-Performance funds earned for distribution to behavioral health and primary care Partnering Providers. The dollars will be allocated by volume to large- and medium-sized providers as follows:
75% of earnings to Large: serves 20,001+ Medicaid patients
25% of earning to Medium: serves 1,201-20,000 Medicaid patients
How do partners earn dollars? – updated September 2021
Large and medium volume Partnering Providers will receive their portion of the 2019 and 2020 P4P measurement year dollars for completed respective Year 1 and Year 2 Transformation contracts .
Large and medium volume Partnering Providers will earn 2021 P4P dollars based on expectations in Year 3 contracts.
How many dollars are there?
The following table shows the potential Pay-for-Performance earnings for the BHT region.
Notes on Volume
The Board approved this Partnering Provider Volume Calculation POLICY which outlines how the numbers were calculated, the tiers, and the dispute resolution process.
How many Partners are in each volume group?
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4 providers in Large, comprising approx. 75% of the Medicaid volume in our region.
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17 partners in Medium, comprising approx. 20% of Medicaid volume in our region.
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18 partners Small, comprising approx. 5% of Medicaid volume in our region.
How is BHT calculating volume numbers?
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BHT is utilizing third-party data from the Health Care Authority (HCA) to establish an unduplicated count of Medicaid beneficiaries for each Partnering Provider.
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Only fully eligible Medicaid and SCHIP clients are included. Duals with Medicare and individuals with Third Party Liability (TPL) are excluded from the count.
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Only Medicaid clients that reside in BHT’s six counties are counted. No continuous enrollment criteria were imposed.
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Counts are based on paid fee-for-service (FFS) claims and accepted MCO encounters, including BHO (RSN) encounters.
