VBP QIP MCO Contract List Attestation

Submission Guidelines

  • Attestation is also available in Portable Document Format (PDF)

Every Facility participating in the Value Based Purchasing Quality Improvement Program (VBP QIP) is expected to enter into Level 1 (or greater) VBP arrangements compliant with the NYS VBP Roadmap by April 1, 2018, which total a minimum of 80% of Medicaid MCO contracted payments received by the Facility (as reported in the July 2017 MCO Contract List).

For program validity, it is the VBP QIP Facility's responsibility to send its VBP QIP paired Managed Care Organization (MCO) a completed VBP Contract Attestation form verifying the existence of the VBP contract(s).

VBP Contract Attestation forms must be signed by a senior leader from both the VBP QIP Facility and the MCO with whom the Facility is contracting. A Facility is expected to submit one (1) attestation per MCO with whom it signed a VBP contract(s). The Facility can attest for multiple VBP contracts signed with the same MCO in one (1) contact attestation form.

VBP QIP Contract Attestation Submission Timeline:

  1. April 1, 2017 deadline:
    1. Attestation can be submitted in lieu of a Letter of Intent (LOI) if a VBP contract is signed before April 1, 2017;
  2. July 1, 2017 deadline:
    1. At least one (1) attestation must be submitted on or before July 1, 2017 for a VBP contract;
    2. Attestations can be submitted in lieu of the LOIs if VBP contracts are signed on or before July 1, 2017;
  3. April 1, 2018 deadline:
    1. Attestations must be submitted for all contracts
    2. Attestations can also be submitted at any time between July 1, 2017 and April 1, 2018 if VBP contracts are signed by the due date of April 1, 2018;

In addition, VBP QIP Facilities will also submit completed VBP Contract Attestations forms to the NYSDOH for record keeping at vbp_qip@health.ny.gov with "VBP QIP – Contract Attestation" in the subject line.


Contract(s) Attestation

The VBP QIP Facility __________________________________ and MCO partner1 ____________________________________ hereby attest to signing a VBP contract(s) as defined by the New York State Value Based Payment Roadmap.

VBP Contract(s) Information

  1. Agreement is between an MCO and:
    • ☐ The VBP QIP Facility           ☐ a VBP Contractor (of which the VBP QIP facility is a member)
  2. VBP QIP Facility Name:

    Contact Person:

    Phone #:

    Email Address:
  3. MCO Name:

    Contact Person:

    Phone #:

    Email Address:
  4. Lead Contractor Name (if applicable):

    Contact Person:

    Phone #:

    Email Address:
  5. Please check the VBP level and arrangement type that apply to the signed contract(s):
    Type of arrangement/contract Level 1 Level 2 Level 3 Contract ID Effective Date End Date Lead
    Contractor
    Name2
    Total Care for General Population ☐ ☐ ☐        
    Integrated primary care ☐ ☐ ☐        
    Bundle (for all that apply) ☐ ☐ ☐        
    Chronic Bundle ☐ ☐ ☐        
    Maternity Bundle ☐ ☐ ☐        
    Other Bundle (Please Describe): ☐ ☐ ☐        
    Total Care for Subpopulation (Please list subpopulations included) ☐ ☐ ☐        
    Off‐menu (please describe if applicable): ☐ ☐ ☐        
    Off‐menu (please describe if applicable): ☐ ☐ ☐        
    Off‐menu (please describe if applicable): ☐ ☐ ☐        
  6. By signing below, the signer acknowledges and confirms that he/she not only has the authority to sign this document on behalf of his/her organization, but also that the VBP contract(s) he/she is attesting to is least the Level 1 arrangement compliant with the NYS VBP Roadmap.
VBP QIP Facility Name:                            _________________________________________________

Authorizing Representative Signature:   ____________________________________________                                Date ______________

Authorizing Representative Name:         ____________________________________________

Authorizing Representative Title:            ____________________________________________

MCO Name:                                                _________________________________________________

Authorizing Representative Signature:   ____________________________________________                                Date ______________

Authorizing Representative Name:         ____________________________________________

Authorizing Representative Title:            ____________________________________________


_____________________________

1. This should be the MCO partner executing a VBP contract with the VBP QIP Facility, which may or may not be the MCO paired with the facility for VBP QIP.  1
2. As per the LOI, a contract is between an MCO and either: (1) an IPA/ACO which the VBP QIP Facility has a VBP Agreement with; (2) "Lead Hospital" which the VBP QIP Facility has a VBP Agreement with; (3) the VBP QIP Facility. For #1 and 2, please specify the IPA/ACO/Lead contractor name in the last column.  2