April 2017 LOI
- Guidelines is also available in Portable Document Format (PDF)
VBP QIP Submission Guidelines
Every facility participating in the Value Based Purchasing Quality Improvement Program (VBP QIP) is expected to submit at least one (1) signed Letter of Intent (LOI) to its VBP QIP paired Managed Care Organization (MCO) by no later than April 1, 2017, stating that the facility and a Medicaid MCO (of its choice) are expecting to enter into a Level 1 (or higher) VBP contract consistent with the expectations outlined in the New York State Value Based Purchasing Roadmap by July 1, 2017.
VBP QIP Facilities must submit this LOI not only to their VBP QIP paired MCO for review, but also to the NYSDOH for record keeping. All submissions should be sent by no later than April 1, 2017. LOI submission to the NYSDOH should be sent to: vbp_qip@health.ny.gov with "VBP QIP – LOI" in the subject line.
Letter of Intent
The VBP QIP Facility1 __________________________and MCO partner2 _______________________ hereby agree on the intent to sign at least a Level 1 VBP arrangement, as defined by the New York State Value Based Payment Roadmap, by no later than July 1, 2017.
The VBP QIP Facility and MCO submit this LOI based on the following conditions:
- VBP Contract / Contract Addendum Date: By July 1, 2017, a VBP contract / contract addendum must be submitted to the New York State (NYS) Department of Health (DOH). The facility will also send its VBP QIP paired MCO a VBP QIP Contract Attestation signed by a senior leader from both the VBP QIP facility and the facility's partnering Medicaid MCO stating the existence of a qualifying VBP contract.
- Timeline: The VBP contract signed by July 1, 2017 must have an effective date of no later than July 1, 2017.
- Scope: The VBP contract must be consistent with the NYS VBP Roadmap as well as the VBP QIP Facility Plan Guidance document.
VBP Contract Information
- MCO Name: __________________________________________________________
Contact Person: ________________________________________________________
Phone #: ______________________________________________________________
Email Address: _________________________________________________________ - VBP QIP Facility Name: ___________________________________________________
Contact Person: _________________________________________________________
Phone #: ______________________________________________________________
Email Address: _________________________________________________________ - Anticipated Effective Date of the contract [mm/dd/yyyy]: ____________________________
- Agreement is between an MCO and:
☐ The VBP QIP Facility ☐ a VBP Contractor (of which the VBP QIP facility is a member) - If the contract is between a MCO and a VBP Contractor, please provide the following information for the VBP Contracting entity:
VBP Contracting Entity Name: ________________________________________________
Primary Contact Name and Title: _____________________________________________
Address: ________________________________________________________________
City: _______________________________ State: ______________ Zip: ______________
Contact Phone: ___________________ Contact Email: _____________________________ - Please check all of the corresponding VBP levels and arrangement types the facility intends to apply to its contract with this Medicaid MCO:
| Level 1 | Level 2 | Level 3 | |
|---|---|---|---|
| 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): | ☐ | ☐ | ☐ |
VBP QIP Facility Name: __________________________________
Authorizing Signature: ____________________________________ Date ______________
Authorizing Signature Name: _______________________________
Authorizing Signature Title: _________________________________
MCO Name: ____________________________________________
Authorizing Signature: ____________________________________ Date ______________
Authorizing Signature Name: _______________________________
Authorizing Signature Title: _________________________________
________________________________________
1. A VBP QIP Facility may enter a VBP contract as a primary VBP Contractor or as a member/partner of a larger VBP contracting entity. 1
2. 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. 2
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