Equity Programs (EP)

Demonstration Year 4 Guidance

Last Edited: March 9, 2018

Document Purpose

The purpose of this document is to provide Equity Programs (EP) participants information to progress into Demonstration Year (DY) 4. The guidance included herein covers both the Equity Infrastructure Program (EIP) and the Equity Performance Program (EPP). This document is designed to be useful to both Managed Care Organizations (MCOs) and Performing Provider Systems (PPS) participating in the programs. This document should be considered as a supplement to the Department´s regularly released EP FAQs, slides, and guidance documents.

This document:

  1. Restates DOH guidance on the purpose of the EPs, roles and responsibilities of program participants and program requirements.
  2. Explains DY4 updates and deadlines.
  3. Illustrates the timeline of the EP in relation to the wider Delivery System Reform Incentive Payment (DSRIP) Program.

Overall State EP Guidance

Theme State Guidance
Program Purpose and Compliance Equity Programs´ purpose

The purpose of the EPs is to mitigate inequities in PPS´ funding that arose during the DSRIP valuation process. The State designed the two programs to enhance and supplement DSRIP by creating programs that will serve to benefit the wider DSRIP program.

Each program benefits DSRIP goals differently. EIP is designed to enhance a PPS´ implementation of DSRIP by promoting participation in activities that are vital for DSRIP´s success, although they are not specifically funded through DSRIP. EPP is designed to enhance DSRIP by placing greater emphasis on key DSRIP metrics that are significant to State´s vision of healthcare transformation.

Equity Programs and compliance

The State reaffirms that the design of the EP and the payments made for prior years are in compliance as implemented. The State will continue to monitor the Programs to ensure their continued compliance with State and Federal law.
Timeline Equity Infrastructure Program (EIP): April 1, 2015 – March 31, 2020

Equity Performance Program (EPP): April 1, 2016 – March 31, 2021
Participant Roles The MCO´s role in the Equity Programs

  • Establish contracts with PPS.
  • Report measure and activity selection to the Independent Assessor (IA).
  • Report on funds distribution to DOH.
  • Ensure that reporting and funding cadence is appropriate and current.
  • For EIP, work with PPS to ensure that selected activities and potential pieces of evidence are still appropriate.
  • For EIP, direct funds to PPS that have met activity requirements.
  • For EIP, report to DOH and IA on EIP Activities.
  • For EPP, direct funds to PPS that have met performance measurement criteria.
The PPS´s role in the Equity Programs

  • Establish contracts with MCO(s).
  • Meet program requirements in order to receive program payments via MCO(s).
  • Distribute funds within PPS, with same restrictions (95/5 Safety Net Rule) as regular DSRIP payments.
  • Report on payment distribution to demonstrate that the 95/5 Rule is followed.
  • For EIP, work with MCO to ensure that selected activities and potential pieces of evidence are still appropriate.
  • Abide by PPS´ reporting requirements for EIP and EPP (covered below).
Reporting and Monitoring Requirements Reporting in EPP

The EPP is a performance–based program and funds should only flow from the MCO to the PPS when EPP performance objectives have been met. PPS will not have to provide any additional documentation or reporting to the MCO as EPP is based on performance measures already tracked within the DSRIP program by the IA. As part of DSRIP, the IA will perform a comparison between the PPS´ reported/achieved metrics and the PPS´ baseline metrics to will provide the percentage difference to the MCOs through DOH. Upon receipt and review of the metric tracking information provided by the IA, MCOs will remit a payment to PPS that meet or exceed the performance target for each metric. Please note that the EPP contractual agreements between the MCO and PPS govern the payment frequency for EPP.

Reporting in EIP

Like EPP, EIP is a performance–based program and funds should only flow from the MCO to the PPS when EIP activities have been completed. PPS will be required to report on and provide evidence of their activities to the MCOs. DOH has provided guidance and examples of appropriate evidence for each EIP project. However, DOH´s guidelines are only recommendations and the ultimate requirement for evidence in EIP should be agreed upon between the MCO and the PPS. The list of agreed upon activities and requirements may be included in the partner´s contractual agreement. MCOs will then remit a payment to the PPS upon the receipt, review, and approval of this evidence. Please note that the EIP contractual agreements between the MCO and PPS govern the evidence requirements as well as the reporting and payment frequency.

Financial substantiation in EIP

Financial substantiation is only required for a subset of the evidence noted for the EIP activities. DOH has provided guidance for EIP financial substantiation, which is available on the website. However, DOH´s guidelines are only recommendations, meaning that the ultimate requirement for evidence in EIP should be established in the contractual agreement between the MCO and PPS.

MCO reporting in the Equity Programs

MCOs must submit payment reports to DOH noting the amounts paid to their paired PPS for each Equity Program. MCO payment reporting will occur quarterly on their MMCOR submissions. In addition, MCOs must submit EIP activity reports to DOH noting their paired PPS´ activities and the MCOs determination on whether the evidence supporting the PPS´ completion of activities is sufficient to remit an EIP payment to the PPS.

Monitoring Funds in the Equity Programs

Like in DSRIP, once a PPS completes its activities (or achieves its metrics) it is awarded a performance payment. MCOs are not responsible for auditing the Equity Program payments or the use of funds earned by the PPS. The MCOs´ responsibility is to administrate the Equity Programs throughout their duration by making sure programmatic objectives are met.

DY4 EIP Activity Selection

For each new EP Demonstration Year, PPS have the opportunity to change some or all of their selected activities for the Equity Infrastructure Program. If an EP contract specifically states that EIP activities can be updated annually, then the contract does not need to be formally amended for EIP activity changes. However, documentation noting EIP activity changes, signed by both the MCO and PPS must be sent to both the Department and the Independent Assessor (dsrip_ia@pcgus.com) by March 31st, 2018. Please note that if a PPS chooses the same activities from one EIP Activity Year to the next, although not required, DOH still advises the EP partners to submit documentation stating the same activities have been selected for the upcoming year for documentation in case of an audit by a governing entity.

DY4 Reporting and Payment Frequency Updates

Along with the opportunity to select new EIP activities, a PPS may also elect to change the frequency in which it reports evidence for its selected activities. EP Partners should have documentation relating to EIP reporting and payment frequency, either in a contract or a separate document signed by both parties noting reporting and payment frequencies for the DY.

* Please note, a PPS may not be paid more frequently than it reports activities. Hence, reports and payments may only be submitted and distributed on a monthly or quarterly basis. Example 1: A PPS which reports to their MCO monthly may receive payments on a monthly or quarterly basis. Example 2: A PPS which reports quarterly may only receive payments on a quarterly basis.

EPP Pay for Performance Measures

As of DY2, EPP measures are "locked" and cannot be changed for the remainder of the program. As a requirement to participate in the Equity Performance Program, at least one of the PPS´ six selected measures for each paired MCO must switch from P4R to P4P in either DY2 or DY3. All unearned EPP funds will flow to the AHPP pool and PPS will have the opportunity to potentially earn more dollars (See ´Unearned EP Funds and AHPP´) through meeting AHPP requirements.
Funds Flow Funding for the Equity Programs

The EP award amounts for each program by PPS are listed on pages 11 and 12. The amounts listed are DY annual base amounts and will remain the same for the 5 years of the equity programs. It is the State´s commitment to ensure that MCOs have adequate resources to administer the program without having MCOs advance their own funds prior to receiving funding from the State. Additionally, MCOs should only forward funds once a PPS successfully meets its metrics for EPP or the PPS provides sufficient evidence to support their efforts for their selected EIP activities.

Rate Calculation and Reconciliation

Rates are set at the beginning of the Demonstration Year (April) for both EIP and EPP, and in July for AHPP based on enrollment projections. Throughout the Demonstration Year, there may be reconciliations in the form of rate adjustments. Plans will be paid the most recently adjusted rate. However, all reconciliations must go through DOB review and CMS approval. It can take a very long time for CMS to approve rate adjustments, so we ask that participants be patient as the process progresses.

Unearned EP Funds and AHPP

Unearned EP funds will be held in a separate portion of the AHPP pool that can be earned by EP-eligible PPSs only. EP-eligible PPSs may earn payments from this pool if they meet the AHPP performance thresholds for that year (a PPS must earn achievement values for at least 50% of its AHPP measures to receive its AHPP payment). EP-eligible PPSs that meet their AHPP requirements will earn a portion of the regular AHPP pool-$50 million annually, distributed across all PPS that meet AHPP performance in that given year-as well as a portion of the unearned EP funds set aside for EP-eligible PPS. Unearned EP funds will be distributed proportionally, based on the relative award weightings of the PPS within EP. Participants should note that while unearned EIP DY5 funds will flow into AHPP Year 5, unearned EPP DY5 funds will not flow into AHPP the following year and will be lost. Please also note that the AHPP requirements differ from EPP requirements, such that EPP measure achievement does not necessarily ensure that PPS will earn AHPP payments.
Contracting Expectations Equity Programs contracts and contract extensions

The State expects MCOs and PPS to either renew contracts over the course of the programs or create a contract that lasts for the duration of the programs. Ultimately, it is the responsibility of the participants to negotiate contracts that are acceptable to all parties, so that all aspects of the program can progress uninterrupted. In addition, participants should include in their contracts a remediation period, in order to resolve any disputes that may arise during the duration of the Programs.

Contract Modifications

If partners choose to modify EP contracts for DY4, they must submit updated contracts no later than Friday, March 31st, 2018. While EIP activities, reporting and payment frequencies may be altered, EPP measures are final and cannot be changed for the remainder of the program. MCOs must submit updated contracts to the IA at dsrip_ia@pcgus.com and DOH at dsrip_ssp@health.ny.gov with the MCO name, PPS name, and "updated EP contract" in the subject line. Additionally, MCOs should copy their PPS partners on the email.
Partial Payment EPP Partial Payments

For P4P metrics (DY2–DY5), the PPS may earn funds associated with the measure in proportion to the progress made in achieving the annual performance target during the Measurement Year (MY). Based on progress towards this target (i.e., closing the gap-to-goal by 10%), partial achievement can be earned based on reaching the thresholds below:
Progress Towards Annual Performance Target Gap–to–Goal Reduction % of EPP Funds Earned for the Measure
100% (full achievement) ≥10% 100%
75% ≥7.5% 75%
50% ≥5% 50%
25% ≥2.5% 25%
<25% <2.5% 0%
The performance criteria per EPP measure is based on the gap–to–goal methodology in the DSRIP program, and will be calculated by the DSRIP IA. Note that unlike in the DSRIP program, each metric is weighted evenly, regardless of project selection.

EPP Partial AV Example

The following example is intended to demonstrate how the partial achievement of EPP measures and payments will work. PPS A is participating in the Equity Performance Program and has a $6 million EPP annual valuation. Each measure in EPP is weighted equally, therefore each measure is worth $1 million for PPS A in EPP Year 3, which is based on MY3 performance. The final two columns show the proportion of funds earned based on PPS A´s measure results.

Measure Potential EPP Payments MY2 Rate (Baseline for MY3 Performance) MY3 Measure Result MY3 Annual Improvement Target Statewide Performance Goal 10% Gap–to–Goal Actual Change % Change Achieved % of Funds Earned EPP Y3 Dollars Earned
Children´s Access to Primary Care – 7 to 11 years $1,000,000 40% 43.7% 46.0% 100% 6 3.7 3.7/6 = 61.7% 50% $500,000
Children´s Access to Primary Care – 12 to 19 years $1,000,000 40% 48.2% 45.9% 98.8% 5.9 8.2 8.2/5.9 = 138.9% 100% $1,000,000
Prenatal and Postpartum Care – Postpartum Visits $1,000,000 40% 41.3% 44.2% 81.6% 4.2 1.3 1.3/4.2 = 30.9% 25% $250,000
Prenatal and Postpartum Care – Timeliness of Prenatal Care $1,000,000 40% 46.7% 45.4% 93.9% 5.4 6.7 6.7/5.4 = 124.1% 100% $1,000,000
Well Care Visits in the first 15 months (5 or more Visits $1,000,000 40% 44.9% 45.3% 93.3% 5.3 4.9 4.9/5.3 = 92.4% 75% $750,000
Childhood Immunization Status (Combination 3 – 4313314) $1,000,000 40% 40.3% 44.8% 88.4% 4.8 0.3 0.3/4.8 = 6.3% 0% $0
Total EPP Year 3 Dollars Earned: $3,500,000
Total Unearned EPP Year 3 EPP Dollars (will be available in DY4 of AHPP) $2,500,000

*In EPP, each measure is equally weighted, unlike in DSRIP.

EP Helpful Resources

DOH has developed helpful EP resources and other information that is housed at the Supplemental DSRIP Program website. Resources include:

  • Frequently Asked Questions
  • EIP Financial Substantiation Guidance
    • EIP IT TOM Guidance
    • EIP Health Home Enrollment Additional Guidance
  • Reporting Table Templates
  • Measure / Activity Selections
  • Annual Performance Results
  • EP Webinar Slides

EP Reporting

MCOs and PPS should be reporting at the frequency defined at the table below.

Report Completed by Submitted to Frequency Location
EP Contracts PPS & MCO IA & DOH Annually dsrip_ia@pcgus.com dsrip_ssp@health.ny.gov
MCO EP Frequency Table MCO IA & DOH Annually dsrip_ia@pcgus.com dsrip_ssp@health.ny.gov
MCO EIP Activity Table MCO IA & DOH Based on EP Contracts dsrip_ia@pcgus.com dsrip_ssp@health.ny.gov
MCO EIP Payment Table MCO IA & DOH Based on EP Contracts dsrip_ia@pcgus.com dsrip_ssp@health.ny.gov
MCO EPP Payment Table MCO IA & DOH Based on EP Contracts dsrip_ia@pcgus.com dsrip_ssp@health.ny.gov
PPS EIP Activity Table PPS MCOs Based on EP Contracts MCO contact emails
Supporting Documentation for EIP Activity participation PPS MCOs Based on EP Contracts MCO contact emails
Supporting Documentation for EIP Activity participation MCO (reviewed by MCO after being sent by PPS) IA Based on EP Contracts dsrip_ia@pcgus.com

EP Timeline and Annual Awards

EP Timeline

award

* Quarterly reports are generally due on the last day of the month following the close of the quarter

EIP Pairings and Annual Award Table

PPS MCO
  Affinity Health Plan Amerigroup HealthFirst HealthNow Health Insurance Plan Hudson Health Plan IHA Metro Plus Fidelis Today´s Options United Health Plan YourCare Total PPS Award
Advocate Community Providers $2,424,076 $5,599,273 $13,649,410 $0 $0 $0 $0 $3,726,371 $7,418,074 $0 $2,143,674 $0 $34,960,878
Bronx–Lebanon Hospital Center $1,235,727 $1,002,451 $3,151,232 $0 $0 $0 $0 $1,032,479 $1,505,388 $0 $0 $0 $7,927,277
Central New York Care Collaborative, Inc. $0 $0 $0 $0 $0 $0 $0 $0 $11,414,893 $2,277,929 $3,689,524 $0 $17,382,346
Maimonides Medical Center $0 $6,269,107 $5,581,778 $0 $1,546,836 $0 $0 $2,523,976 $3,774,417 $0 $6,866,713 $0 $26,562,827
Millennium Collaborative Care $0 $0 $0 $716,613 $0 $0 $1,056,367 $0 $1,377,887 $0 $0 $803,053 $3,953,920
Montefiore Medical Center $2,062,728 $0 $0 $0 $0 $6,350,154 $0 $0 $3,771,797 $0 $0 $0 $12,184,679
Mount Sinai PPS, LLC $1,467,996 $3,984,792 $8,175,377 $0 $2,957,818 $0 $0 $2,700,514 $4,532,702 $0 $1,581,868 $0 $25,401,067
Nassau Queens PPS, LLC $676,535 $1,053,158 $1,378,090 $0 $976,786 $0 $0 $388,977 $1,329,331 $0 $1,066,533 $0 $6,869,410
New York–Presbyterian/Queens $0 $447,539 $757,571 $0 $149,270 $0 $0 $179,286 $305,165 $0 $196,998 $0 $2,035,829
NYU Lutheran Medical Center $0 $2,188,935 $992,895 $0 $391,619 $0 $0 $0 $424,775 $0 $1,545,819 $0 $5,544,043
Refuah Community Health Collaborative $0 $0 $0 $0 $0 $0 $0 $0 $2,357,889 $0 $0 $0 $2,357,889
SBH Health System $3,736,968 $1,697,415 $9,095,929 $0 $1,716,903 $0 $0 $1,801,385 $3,079,975 $0 $0 $0 $21,128,575
Sisters of Charity Hospital of Buffalo, NY $0 $0 $0 $759,587 $0 $0 $974,364 $0 $2,258,837 $0 $0 $778,548 $4,771,336
State University of New York at Stony Brook University Hospital $1,846,215 $0 $2,711,826 $0 $1,808,953 $0 $0 $0 $2,758,804 $0 $2,668,526 $0 $11,794,324
The New York and Presbyterian Hospital $962,795 $497,630 $2,522,501 $0 $0 $0 $0 $0 $742,674 $0 $0 $0 $4,725,600
Total MCO Funding $14,413,040 $22,740,300 $48,016,609 $1,476,200 $9,548,185 $6,350,154 $2,030,731 $12,352,988 $47,052,608 $2,277,929 $19,759,655 $1,581,601 $187,600,000

Note 1: Values in the table represent DY annual base amounts. Values remain constant for the five years of the Equity Programs.

Note 2: Amounts listed are PPS award amounts and do not include administrative or surplus fees.

EPP Pairings Table and Annual Award Table

PPS MCO
  Affinity Health Plan Amerigroup Fidelis Health Insurance Plan Healthfirst HealthNow IHA Metro Plus MVP Today´s Options United Health Plan YourCare Total PPS Award
Advocate Community Providers $1,616,050 $3,732,849 $4,945,383 $0 $9,099,607 $0 $0 $2,484,247 $0 $0 $1,429,116 $0 $23,307,252
Bronx–Lebanon Hospital Center $823,818 $668,301 $1,003,592 $0 $2,100,821 $0 $0 $688,320 $0 $0 $0 $0 $5,284,852
Central New York Care Collaborative, Inc. $0 $0 $7,973,519 $0 $0 $0 $0 $0 $0 $2,486,038 $2,577,202 $0 $13,036,759
Lutheran Medical Center $0 $1,459,290 $283,184 $261,079 $661,930 $0 $0 $0 $0 $0 $1,030,546 $0 $3,696,029
Maimonides medical Center $0 $4,179,405 $2,516,278 $1,031,224 $3,721,185 $0 $0 $1,682,651 $0 $0 $4,577,808 $0 $17,708,551
Millennium Collaborative Care (ECMC) $0 $0 $1,033,415 $0 $0 $537,460 $792,275 $0 $0 $0 $0 $602,290 $2,965,440
Montefiore Hudson Valley Collaborative $1,375,152 $0 $2,514,531 $0 $0 $0 $0 $0 $4,233,436 $0 $0 $0 $8,123,119
Mount Sinai Hospitals Group $978,664 $2,656,528 $3,021,801 $1,971,879 $5,450,252 $0 $0 $1,800,342 $0 $0 $1,054,579 $0 $16,934,045
Nassau Queens PPS $507,401 $789,869 $996,997 $732,590 $1,033,567 $0 $0 $291,734 $0 $0 $799,899 $0 $5,152,057
Refuah Community Health Collaborative $0 $0 $1,571,926 $0 $0 $0 $0 $0 $0 $0 $0 $0 $1,571,926
SBH Health System (St. Barnabas) $2,491,312 $1,131,610 $2,053,317 $1,144,602 $6,063,953 $0 $0 $1,200,923 $0 $0 $0 $0 $14,085,717
Sisters of Charity Hospital of Buffalo, NY $0 $0 $1,505,892 $0 $0 $506,391 $649,576 $0 $0 $0 $0 $519,032 $3,180,891
Stony Brook University Hospital $1,384,661 $0 $2,069,103 $1,356,715 $2,033,869 $0 $0 $0 $0 $0 $2,001,395 $0 $8,845,743
The New York and Presbyterian Hospital $641,864 $331,753 $495,116 $0 $1,681,668 $0 $0 $0 $0 $0 $0 $0 $3,150,401
The New York Presbyterian Queens $0 $298,359 $203,443 $99,513 $505,049 $0 $0 $119,522 $0 $0 $131,332 $0 $1,357,218
Total MCO Funding $9,818,922 $15,247,964 $32,187,497 $6,597,602 $32,351,901 $1,043,851 $1,441,851 $8,267,739 $4,233,436 $2,486,038 $13,601,877 $1,121,322 $128,400,000

Note 1: Values in the table represent DY annual base amounts. Values remain constant for the five years of the Equity Programs.

Note 2: Amounts listed are PPS award amounts and do not include administrative or surplus fees.