Equity Programs (EP)
Frequently Asked Questions and Pairing Tables
- FAQs is also available in Portable Document Format (PDF)
As of 4/24/2017
I. Equity Program (EP) Frequently Asked Questions
| Item # | Category | Question | Response | Date Added/ Updated |
|---|---|---|---|---|
| 1 | Contracting | Assuming a signed agreement in place (between MCO and PPS), exactly how much time from the time when the initial EIP funding is received and the initial EIP funds will be released to the PPS? | This will depend on the plans´ processing timeframe and the schedule agreed upon in the MCO–PPS contract. DOH hopes that the processing time is quick and will be working with the plans and associations to ensure payments are disbursed expeditiously. Please note that in addition to the MCO–PPS contract being in place, a PPS must submit, and have the MCO approve an EIP activities report for the period. | |
| 2 | Contracting | Where can contracting guidance be found? | The plan and hospital associations have developed an EP contract template that was released to PPS and facilities in January 2016. As this is a template, PPS and MCOs can alter the contract template in ways that they feel will best meet the needs and goals of the partnership. | 3/15/17 |
| 3 | Contracting | Will there be any appeals process from DOH as a mediating entity should there be any disagreement between PPS and the plans? | EP has been constructed in such a way to reduce ambiguity. If a PPS is having a dispute with a plan over the level of participation in activities, metrics or payments, the expectation is that the MCO will work with the PPS to identify a resolution to the dispute. DOH does not expect a need for a formal appeals process, but should an issue arise for either a PPS or MCO, DOH should be informed of the dispute and, if needed, will help to resolve disputes. | |
| 4 | Contracting | Will PPS or MCOs be able to add a remediation period related to evidence for EIP activities? | DOH hopes that MCOs and PPS will work out any differences among reporting and payments on their own in a timely manner; hence, it is fine for the PPS and MCO to have a remediation period in the case that discrepancies arise. The duration of the remediation period will be left to the MCO/PPS to agree to, but DOH recommends that the PPS & MCO resolve any disputes quickly as a long period of remediation can significantly delay payment. In addition, DOH recommends that any mediation process and timeline are clearly outlined in all MCO–PPS EP contract. | |
| 5 | Contracting | DOH has said that this program is voluntary for plans. A plan may decide it doesn´t want to participate and wants to give the money back. What is the process for that? | If there is a plan that withdraws from the programs, DOH will try to move its paired PPS to another plan. It may take some time for adjustments in reporting and funding to take place after the switch. | |
| 6 | Contracting | What determines eligibility for participation in the EIP, EPP, and AHPP? | EP participation was determined by DOH from the final DSRIP valuation calculation and is focused on mitigating an inequity among PPS. DOH noted an inequity with Safety Net PPS and public PPS in a sole PPS county in relation to project 2.d.i. Whereas, all PPS participating in DSRIP are eligible for AHPP. | |
| 7 | Metrics & Activities | Is the PPS allowed to select more than 6 measures for EPP, is the PPS allowed to select more than 4 activities in EIP? | Given the fact that the activities and measures will be weighed evenly, PPS will be limited to 4 activities for EIP and 6 measures for EPP. Additionally, limiting the number of activities and measures will allow PPS to focus on improving targeted areas. | 3/15/17 |
| Metrics & Activities | Can the PPS change their EIP and/or EPP selection in later years? | Once EIP activities are selected, they cannot be changed for the given DSRIP Performance Year (April – March). However, if they so choose, PPS have the opportunity to select a new set of activities for EIP at the beginning of each new DSRIP performance year. EPP measures must remain the same throughout the program, with three exceptions: if a PPS chose a reporting–based measure with an unknown baseline that resulted in a denominator less than 30, the measure could have been changed at the start of DY2. The second exception is that if DOH finds there is an issue with low denominators putting EPP measurement at risk, it reserves the right to change EPP measurement selections during the midpoint assessment. DOH allowed a one–time exception between DY1 and DY2 of EPP that allowed PPS the opportunity to diversify their EPP measure selections across each of their paired MCOs. This must have been done by Friday, September 30th, 2016. |
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| 8 | Metrics & Activities | If the denominator of an EPP measure selected by a PPS falls below 30, what happens to the money that was scheduled to be rewarded for that measure? | If a denominator of a measure falls below 30, the EPP money is not forfeited. Instead, the measure is deemed as invalid during any year wherein its denominator is below 30 and the following year. The EPP money for that invalid measure is not lost, but is instead distributed to the remaining five measures, increasing their respective weights to make up for the invalid measure. | |
| 9 | Metrics & Activities | Will definitions for each of the EPP measures be provided? | The EPP measures are a subset of the DSRIP measures and are defined in the DSRIP Performance Measure Specification Guide. | |
| 10 | Metrics & Activities | Are MCO´s required to determine satisfactory performance for their respective PPS on EIP and EPP measures? | The plans will not have to evaluate the EPP performance measures. The EPP measures will be evaluated by the IA in the same manner as the DSRIP program. The plans should review PPS reports on EIP activities to determine whether expectations for the activities have been met. | |
| 11 | Metrics & Activities | Will it be transparent how the other PPS perform in EIP and EPP? | Yes. EPP dashboards and PPS performance on EIP activities can be found on the EP website. | |
| 12 | Metrics & Activities | Are MCOs intended to engage with the IA in order to flow payments or determine whether metrics have been met? | Besides submitting EP documentation to the IA for record–keeping purposes (submission of the EP contracts and EIP reports), there is no need for interaction between the plan and the IA. The IA will make a ruling on the performance in the regular DSRIP program that will carry over into EPP and the results will be made known to all parties involved. | |
| 13 | Metrics & Activities | How will each key activity in EIP be measured? Will it be specifically documented what evidence will be required for our participation in the initiatives listed? | DOH provided guidance for administering the Equity Programs including reporting templates for the MCOs and PPS to capture EIP, activities and funds. DOH provided suggestions for supporting documentation for EIP activities, including activities that may warrant financial substantiation. The suggestions provided are not an exhaustive. DOH expects that any potential documentation required to be submitted as part of the PPS participation in EIP activities will be communicated in each MCO–PPS contract or in a formal document signed by both the PPS and MCO. |
2/16/17 |
| 14 | Metrics & Activities | Could PPS negotiate an EIP activity or EPP measure not on the list? | No, the PPS cannot select an EIP activity or EPP measure that is not on the list. | |
| 15 | Metrics & Activities | Which EPP measures switch to P4P in DY2 or DY3? | A chart with measures is included in Section IV of this document. This chart specifies which EPP measures switch to P4P in DY2 or DY3. | 8/1/16 |
| 16 | Metrics & Activities | Is the measured activity of "Participation in fraud deterrence and surveillance activities" meant to be a PPS compliance plan? | The activities associated with "Participation in fraud deterrence and surveillance activities" may include but are not limited to: 1) a compliance plan 2) spending on IT or consulting spend to identify fraud, waste, and abuse (FWA), 3) monitoring and oversight by program administrators and legal Further details are provided in the EIP activity guidance document. |
3/15/17 |
| 17 | Metrics & Activities | Can a care management system count as an Electronic Health Record (EHR) system for the EHR implementation investment activity for the EIP? | A care management system cannot substitute an EHR to meet the EHR implementation investment activity for EIP. Although the two systems may be interoperable and can exchange data if they both exist in the same health system, they cannot serve as replacements to another. EIP was designed to emphasize a few key activities that will supplement DSRIP and this activity is specific to an EHR. | |
| 18 | Metrics & Activities | How can PPS continue to achieve activity in the Medicaid Accelerated Exchange (MAX) Series for EIP once the MAX Series ends in DY2? | The initial MAX program was originally concluded at the end of DY2. The PPS that participated received a certificate as proof of their achieved activity, which is valid through DY2. Beyond the formal workshops, DOH introduced the Train the Trainer (TTT) MAX series, which involves training participants to host their own MAX workshops. MAX TTT recruitment began in September 2016, and the workshops began in January 2017. MAX TTT will enable PPS to continue to select MAX as an EIP activity throughout the duration of DSRIP by either attending MAX TTT workshops, or conducting hosting their own MAX workshops with qualified personnel. | 2/16/17 |
| 19 | Metrics & Activities | Does participation in the "Train the Trainer" (TTT) program qualify as participation in the MAX Series? | Participation in either MAX Series training (TTT and/or Targeting Avoidable Readmissions for High Utilizers) will be sufficient to count as an EIP activity as long as at LEAST two (2) PPS representatives participate in the training over the reporting period. Before the introduction of the TTT and the Targeting Avoidable Readmissions for High Utilizers programs PPS had to have at least two (2) people complete the MAX Series training. Now PPS can have one (1) representative participate in the MAX program and one (1) representative participate in the TTT program over the same timeframe and that would count as two (2) people. | 12/5/16 |
| 20 | Metrics & Activities | If a PPS picks a high performance measure, is the DOH looking for a 10% gap to goal or 20% gap to goal for EPP funds? | EPP is aligned with traditional DSRIP performance. Therefore, if a PPS meets standard DSRIP measure of 10% reduction in gap to goal, it will meet the EPP requirement, even if the measure is eligible for High Performance. | |
| 21 | Metrics & Activities | Will PPS be given an opportunity to change their EPP measure selections for each of their paired MCOs in order to diversify their selections? | PPS participating in the EP were given a one–time opportunity in August/September of 2016 to diversify their EPP measure selections. The changes to their measures were only accepted if (a) the MCO agreed to the changes and (b) the revised contract was submitted to the IA and DOH by Friday September 30th, 2016. The new EPP measure selections did not apply to DY1 of the program, but apply to DY2– DY5. There are no further opportunities for measure changes/diversification in EPP. | 2/16/17 |
| 22 | Metrics & Activities | Are MCOs allowed to change EPP metrics if their paired PPS is not meeting goals on a particular metric? | No, EPP measures cannot be changed for any reason past September 30th 2016, including for poor PPS performance. | 3/15/17 |
| 23 | Metrics & Activities | Are PPS required to have a formal amendment when changing EIP activities? | 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 summarizing activity changes must be signed by both parties and sent to both DOH and the IA. EIP activity changes will not be permitted, under any circumstance, during the program year. Activity changes must occur between program years. DOH advises all MCOs and PPS partners to document all proceedings for both of the EP on an annual basis in case of a program audit in the future. Annually, there should be documentation for EIP activity selection, either as a contract amendment or a separate document signed by both parties, that notes selected EIP activities as well as reporting and payment frequencies (regardless of whether or not activities, reporting or payment frequency changes). |
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| 24 | Metrics & Activities | What is the basis for 4/9 EIP activities? | The number of activities was selected with the goal of shifting PPS activities and spending towards activities that generally support the DSRIP program. | 3/15/17 |
| 25 | Metrics & Activities | When must EPP measures must switch from P4R to P4P? | One of the six EPP measures selected must switch to P4P from P4R in DY2 or DY3. The remaining five measures can switch to P4P anytime between DY2–DY5. | 9/1/16 |
| 26 | Payment | Why will the funds be disbursed via MCOs? | Funds are flowed through the MCOs to more actively engage PPS with their VBP contracting partners in uniting strategies for the health of the communities they serve. | |
| 27 | Payment | Do the EP funds count towards a PPS VBP goal of "90% of our funds paid through contracts with the MCOs" VBP goals? | No. The funds should not be included in the numerator nor in the denominator of the total managed care spending in the state. As such this will not count towards the 90% VBP goal. | 3/15/17 |
| 29 | Payment | What are the MCO–PPS Assignment and award amounts? | Please see the tables in Sections II and III at the end of this document to find the MCO–PPS pairings and award amounts. | |
| 30 | Payment | Are the values listed within the EIP and EPP pairings tables the actual amounts the MCOs and PPS should expect to receive? | The values listed with the pairings tables represent the total funding the PPS should receive from the MCO in that year if the PPS meets all of its EIP activities or EPP measures. Funding remains constant throughout the 5 years of the program. MCOs should refer to the breakout in their rate schedules for further detail on administrative and surplus amounts. | 2/16/17 |
| 31 | Payment | Will the MCO admin payments be included in the PPS´ disbursement amount? | No. The administrative adjustment add–on will not come out of the amount going to the PPS. It will be a separate amount on top of the disbursement to the PPS. | |
| 32 | Payment | Will the PMPMs be separately identified so that MCOs/PPS know how much is tied to EIP vs. EPP? | DOH will provide MCOs with the award amounts for EIP and EPP, and will separately identify the amounts in the schedules they are given annually. | |
| 33 | Payment | PPS will not be receiving EPP payments for DY1. Does this mean that the funds will now be divided and distributed over the course of four years? | No. Payments will still be made over five years. However, EPP payments will be distributed over five years starting in April 2016, so it would be as if there is a DY6. | |
| 34 | Payment | Are the MCOs basing the EPP payments on the quarterly achievement reports or the annual achievement reports? | MCOs should base payment reports from the IA related to PPS EPP measure achievement, so no additional measure achievement work needs to be completed on their part. | |
| 35 | Payment | Are first year EPP payments made based on MY1 data (7/14/14 – 6/30/15)? | Yes, first year EPP payments are based on MY1 data. Since EPP aligns with DSRIP, subsequent EPP payments up to Year 5, when the Program ends, will similarly align with MY data of the corresponding year. | |
| 36 | Payment | PPS´s doesn´t receive the full allocated funding for EIP activities completed. How are MCOs to deal with this shortfall? | There may be shortfalls due to the drop in expected member– month volume. The Department is aware of these circumstances. The Department is able to remedy such circumstances through reconciliation in a subsequent rate package. If possible, the Department suggests that Plans keep the Facilities fully funded for each period under the guarantee that Plans will be made whole by the Department via subsequent rate adjustments. The DOH is working with CMS to obtain approval for rate adjustments. Once the rates are approved, any shortfalls that may have occurred should be resolved. |
3/15/17 |
| 38 | Payment | Did the EPP DY1 payments retroactive to April 2016 cover the entire year or will there be other payments after December 2016? | The EPP DY1 payments from the April 2016 rate package approved in November 2016 was retroactive to April 2016. The payment amount covered April 2016 to December 2016. MCOs will receive monthly payments going forward for the rest of the year. | 2/16/17 |
| 39 | Payment | Is there a set time the MCOs will receive EPP payments each month? | Capitation payments are made once every month, and usually occur in the beginning of every month. Payments are usually made the first full week of each month, but this may be dependent on where the cycle lands – as it relates to the month in question. Supplemental payments (VBP, EP, EPP, AHPP) are a component of this capitation payment, and therefore follow the same timeline. | 3/15/17 |
| 40 | Performance | Would performance criteria be gap–to–goal or purely negotiated? | The performance criteria per EPP measure will be gap–to– goal as is done for the DSRIP program, and will be calculated by the DSRIP IA. | |
| 41 | Performance | Must EIP activities be centrally coordinated by the PPS or can they be undertaken independently by PPS partner organization(s)? | EIP activities can be undertaken independently by one or more PPS partner organizations, but the PPS will be held responsible for reporting on participation in EIP activities. | |
| 42 | Performance | Can a large investment at one PPS partner suffice as evidence for completion of an EIP activity? For example, the installation of an EHR system for a partner that services a majority of the PPS´ members. | EHR and other investments that will be used as evidence for an activity should be meaningful. While EIP awards and evidence do not need to be a 1:1 ratio, the PPS should use their judgment to interpret meaningful, but if they worry that the financial investment wouldn´t be significant enough to pass the evidence test, the PPS should think about submitting another form of evidence. Finally, if a PPS is making a significant EHR investment in one partner and would like to use this evidence as justification for an activity, the PPS should be able state why the investment in one partner will provide PPS–wide benefit. | |
| 43 | Performance | Assuming these EIP activities may be documented at the partner organization level, can these activities be occurring separate from their participation in a DSRIP project? | PPS participating in EIP can take on activities not related to an ongoing PPS project, but PPS participating in EPP have to choose measures tied to a current PPS project outcome. | |
| 44 | Performance | Will EPP metrics follow the same pay for reporting and pay for performance (P4R/P4P) schedule as the DSRIP performance payments for each metric? | Yes, the metrics will follow the same P4R /P4P schedule as the DSRIP performance payments. However, EPP lags behind DSRIP by 1 year, because EPP payments rely on the Measurement Year being fully complete All performance period lags, exceptions and changes made to the regular DSRIP requirements would apply to the EPP. Section VIII in this document provides a timeline for EP annual awards. | |
| 45 | Performance | Would performance be based on the entire PPS attributed population or the attributed population between the MCO and PPS? | The performance measurement criteria will be the same as in DSRIP, based on the entire PPS attributed population and gap–to–goal. | 3/15/17 |
| 46 | Performance | Will a PPS be able to earn partial payments for EIP activities and EPP measures? | The PPS can earn part of the payment for a period in each of the Equity Programs. A PPS can earn partial payment in two ways for EPP measures. A PPS will earn one sixth of the total allocated funding for each EPP measure the PPS fully meets. Therefore, if a PPS fully meets 4 of their 6 EPP measures the PPS will earn four sixths of the total allocated EPP funding. The PPS can then earn partial funding for each of the EPP measures that were not fully met. The DOH is in discussions with CMS to determine the methodology to be used for calculating partial payments. DOH will send notice to participating facilities as soon as this process becomes finalized. If a PPS were to provide ample evidence for 3 EIP activities but partial/insufficient information for the 4th activity, the PPS would end up earning payments for those activities where sufficient evidence was provided in that period. Meaning, the PPS would earn 75% of the payment for that reporting period. A PPS cannot earn partial payment for EIP activities which have not been fully completed. Note all EIP activities and all EPP measures are weighted equally (one fourth for each EIP activity, one sixth for each EPP measure). |
3/15/17 |
| 48 | Performance | How frequently will MCO´s receive the EPP IA report for each PPS? | MCOs will receive EPP performance reports annually from the IA as part of the DSRIP PPS Q4 performance report notification. | 3/15/17 |
| 49 | Program Governance | What role will CMS have in the Equity Programs? | CMS will review the PMPM rates that will be used to effectuate the funds flowing from the MCOs to the PPS. In addition, CMS may review the details of the program and may request additional information as needed. Like with any other Medicaid program receiving federal funding, CMS can terminate their funding and support for this program if CMS does not feel the program meets certain stipulations. The Department does not have reason to believe that this will occur. | |
| 50 | Program Governance | Where can EP program governance be found? | The documents that should be used for Program governance by participants are the EP FAQs and the EP Guidance document, both of which are available on the EP website. As well, updates are given through monthly webinar decks available on the DOH EP website. There is no longer a formalized Governance Document required for EP. | 4/25/17 |
| 51 | Reporting | Are templates or guidance available for reporting standards and demonstration/ measurement of PPS´ EIP activities? | Yes, reporting guidance and templates can be found at the EP website. | 3/15/17 |
| 52 | Reporting | Many of the EPP measures are typically collected through annual Healthcare Effectiveness Data and Information Set (HEDIS) reports. It is not realistic to report those measure every quarter. Will NYS DOH or MCOs assist in data collection for EPP? | The measurement periods being used in the EP are the same measurement periods used in DSRIP so there is no additional data collection required. DOH will provide MCOs with the data on the EPP measures selected by their PPS partners from the DSRIP Quarterly Reports and annual HEDIS reports. | |
| 53 | Reporting | Can MCOs use reporting tables other than the templates provided by DOH? | MCOs can use other templates to report EP to DOHs, as long as the template used captures the same information included in the DOH–provided reporting tables. All EIP reporting templates should be sent to the DSRIP IA at: dsrip_ia@pcgus.com and DOH at: dsrip_ssp@health.ny.gov with reference to the "Equity Programs" in the email subject line. | 8/1/16 |
| 54 | Reporting | In the PPS EIP reporting table provided by DOH for EIP activities, one of the required fields is the expense related to each selected EIP activity. Are PPS required to show financial investment as evidence of participation in every EIP measure? | Although financial substantiation is not required for most activities, there are some instances where DOH recommends financial substantiation of investments should be required as part of a PPS´ evidence. DOH created an EIP Financial Substantiation document identifying which pieces of evidence for EIP activities DOH recommends that should be accompanied by financial supporting documentation. However, evidence of participation is left to the discretion of the MCOs and PPS as outlined in their EP contract. | |
| 55 | Reporting | If an MCO feels strongly that a piece of evidence requires financial substantiation but it is not listed in DOH´s financial substantiation document, can the MCO require proof of meaningful investment beyond what is listed in DOH´s document? | DOH´s EIP Financial Substantiation document providers a set of recommendations on which pieces of evidence that should be validated through financial substantiation, but it is up to the MCO and PPS to negotiate this amongst themselves. So long as it is agreed to by the PPS, the MCO can require additional pieces of evidence be proven through financial substantiation beyond what DOH recommends. | |
| 56 | Reporting | From one EIP activity year to the next, how does evidence of participation change? The PPS cannot provide the documentation for the same activity, correct? | DOH Medical Directors have tried to be as comprehensive without being restrictive in the type of evidence that demonstrates participation in EIP activities in the EIP Activities Guide that has been provided by DOH. For example, under Capital Spending, a PPS might submit two contractor agreements during two different reporting periods as long as the contract is not the same contract for the same work. Two projects on two different sites using the same contractor is approvable. Using the same contract each year for the same work is not. | |
| 57 | Reporting | Is the evidence listed in the DOH–provided EIP Activity Guide exhaustive, or can a PPS provide evidence that is not listed within the guide? | The evidence listed in the DOH–provided EIP Activities Guide is not exhaustive, therefore additional evidence demonstrating any of the activities listed in the guide can be negotiated in the MCO–PPS contract and submitted by the PPS. If the MCO & PPS do agree to other forms of evidence to substantiate the activity, the State asks that the parties provide explanation in their contract. | |
| 58 | Reporting | Do periodical updates and/or progress reports qualify for evidence for participation in an activity for EIP? | No, updates and progress reports do not count as evidence for participation in an activity. For example, if the evidence at hand is a contract between the PPS and another party, only the contract itself can serve as evidence, not a progress report on the to–be– completed contract. If a PPS and its MCOs agree to multiple reporting periods for EIP in a single year, a distinct piece of evidence will be required in each reporting period of the year to demonstrate activity – one piece of completed evidence after a series of progress reports will not be sufficient. | |
| 59 | Reporting | For quarterly MCO–to–DOH reports, is there a specific deadline/date the MCO submit this report to DOH? | The report to DOH must be received by DOH by the end of the quarter following the reporting period. This includes 30 days for a PPS to provide any required information to the MCO. An additional 30 days following PPS submission of their evidence for an MCO to review and make any necessary determinations. Lastly, 30 days for the MCO to compile and submit the report by the end of the quarter following the reporting period. | 4/25/17 |
| 60 | Reporting | In instances when the MCO is paired/contracted with more than one PPS, what is the frequency in which the MCO should submit a report to DOH outlining the payments that were made to the PPS? | MCOs should submit reporting templates to DOH at the same frequency they submit payment or withhold payment to the PPS. | |
| 61 | Reporting | What EP related information/documentation should each MCO submit to the DSRIP IA? | Please refer to the EP Reporting Frequency and Recipient chart in section VI of this FAQ Document which outlines the frequency of reporting and to whom the reports should be sent to. | 3/15/17 |
| 62 | Reporting | Will DOH provide guidance on how a PPS should report on EPP and EIP funds distribution, and whether it should align with the 95/5 Safety Net/non–Safety Net Rule? | The reporting guidance for EIP and EPP aligns with reporting guidance for DSRIP. Performance payments are subject to the same restrictions and reporting requirements, including the 95/5 Safety Net/non–Safety Net Rule. | |
| 63 | Reporting | When evaluating whether a PPS is in compliance with the 95/5 DSRIP Safety Net Rule, is spending across all programs evaluated in aggregate, or is each program (DSRIP, EIP, and EPP) evaluated separately? | The 95/5 Safety Net Rule is applied twice to each PPS – once for DSRIP, and once for State Supplemental Programs. This means that a PPS must be compliant with the 95/5 Safety Net Rule for DSRIP, and it must be separately compliant with the rule for EIP, EPP, and AHPP in aggregate. | |
| 64 | Reporting | If an MCO and PPS agree evidence must be used to support activity in the first EIP quarterly report of a year, and thereafter attestation is sufficient for all future quarters of the year, will it be compliant with DOH reporting requirements? | This would not be in compliance with DOH guidance and may be an issue if audited by an outside governing agency. However, the decision should be made between MCO and PPS partners. The DOH recommends documentation of evidence of EIP activities in DY2 and subsequent years be provided, but it is up to each MCO/PPS pairing to make the decision and document in their contract. |
3/15/17 |
| 68 | Reporting | When are the changes to EIP activities for DY3 due? | For any changes in EIP activities, or changes in payment and/or reporting cadence for either EPP or EIP, the DOH & Independent Assessor needs to have this documented with formal signatures from both parties by March 31, 2017 in order to activate the change for the start of DY3. | 3/15/17 |
| 65 | Reporting | For EPP, DOH stated that at least one of the measures selected must be Pay for Performance (P4P) in DY2 or DY3. Does this mean other measures will be evaluated as Pay for Reporting (P4R)? | A PPS must select 6 out of the 25 available EPP measures, and one of the six measures must be a measure that transitions from P4R to P4P in DY2 or DY3. The remaining five selected measures can switch to P4P in any year. No EPP measures remain P4R for the duration of the Program. Please refer to the Equity Performance Program (EPP) Measures Chart in section IV. |
8/1/16 |
| 66 | Reporting | For PPS that report on EIP quarterly, do reports need to be submitted the day that the quarter ends or can reports be submitted within a month after the end of the quarter? | PPSs are allowed to submit their reports to the MCO within a month of the quarter ending. MCOs should then submit their corresponding report to DOH and the IA within a month of receiving the report from their paired PPS. | 10/12/16 |
| 67 | Reporting/ Payment Timing | Will the State offer guidance on how MCOs are to pay the PPS? | DOH will not offer official guidance, but it has offered suggestions. It is important to note that PPS can only get paid for activities performed and measurement targets achieved; prospective payments (or unsubstantiated payments) are not allowed in this program. The state has suggested that MCOs and PPS align EPP payments with the DSRIP performance reporting timeline to ensure that PPS payments are tied to PPS performance achievement. In addition, it is important for MCOs and PPS to agree to an EIP reporting timeframe that allows PPS to report on activities performed and MCOs to substantiate activities prior to payment. |
3/15/17 |
| 77 | Reporting/ Payment Timing | What is the general timeframe for MCOs to submit EIP evidence to the IA? | Each PPS and MCO pairing should have their own reporting frequency established in their contract. Generally, the MCOs should submit evidence to the IA within a month of receiving the report from their paired PPS. | 3/15/17 |
| 69 | Reporting/ Payment Timing | If the PPS fails initially to meet the criteria, then no payment. If the PPS subsequently meets the criteria, do they receive all of the funds received by the MCO? | Funds are tied to the performance period, if a PPS does not meet the criteria in a performance period, the PPS will not receive the funds for the performance period. If the PPS meets the criteria in the following performance period, the PPS will receive the funds for second performance period. A PPS will not receive funds for a previous performance period for meeting criteria in a subsequent performance period. Unearned EP funds will flow into the AHPP pool. These additional funds will only be earnable through AHPP by PPS that are participating in the EP. |
8/1/16 |
| 70 | Reporting/ Payment Timing | What is the timeline of the Equity Programs? | The programs will run concurrent with the DSRIP program, which runs from April to March each year. Payments for EIP began in January 2016 and payments for EPP began in April 2016. | |
| 72 | Reporting/ Payment Timing | Does reporting need to occur on the same timeline as payments or can reporting be less frequent? | PPS and MCOs can negotiate the reporting and payment schedule, however a PPS may not be paid more frequently than it reports activities. Starting in DY3, a PPS can choose to report to its EP paired MCO for EIP activities on either monthly or quarterly basis (PPS will no longer have the option to report on a semi– annually or annually for EIP). For example, a PPS which reports to their MCO monthly may receive payments on a monthly or quarterly basis. Additionally, a PPS which reports quarterly may only receive payments on a quarterly basis. | 3/15/17 |
| 73 | Reporting/ Payment Timing | Once a PPS provides evidence of participation, does it have to continue to provide evidence or is it done for the activity year? | PPS will need to provide evidence of participation in EIP activities for each reporting period (e.g., monthly or quarterly). Evidence should be distinctly from that reporting period. | 3/15/17 |
| 74 | Reporting/ Payment Timing | Must the evidence of participation be effective in the reporting period? | Evidence for meaningful activity must occur in the reporting time period for each of the 4 selected activities. If the reporting period quarterly, then four pieces of evidence covering the period for each report need to be provided | |
| 75 | Reporting/ Payment Timing | Can MCO´s prepay the PPS or does reporting need to occur prior to PPS being paid for a given time period? | There can be no pre–payment for either EPP or EIP. The timing of the payments have to be such that even if they are made monthly, the time period that the payment is being reported on has already passed. | |
| 76 | Reporting/ Payment Timing | If an MCO is late in making payments to their paired PPS and is late submitting reports to DOH, can the PPS terminate their partnership with that MCO? | No, but DOH will do everything it can to work with the PPS and the MCO in the partnership to ensure that problems get resolved. If there is no improvement or resolution, then DOH will take further action. The DOH should be notified of any issues as soon as possible. |
9/1/16 |
| 78 | Use of Funds | If we don´t have capital awards yet, what funds can we spend for the capital infrastructure activities (the nine activities that relate to capital spend)? | If you have resources already deployed on a capital infrastructure activity, then you may want to consider selecting that activity for the EIP program. If resources are not already deployed to a capital infrastructure activity and it is not feasible to deploy resources, consider selecting another one of the 9 EIP activities. Again, there is no prospective reporting and payments in the Equity Programs. | |
| 79 | Use of Funds | What restrictions are on EP funds? | Performance payments earned by PPS through EIP or EPP will be subject to the same restrictions regarding usage of funds as DSRIP performance payments under the waiver. | |
| 80 | Use of Funds | Will the 95/5 Safety Net rule apply to the initial PPS–to–provider payments for EIP and EPP? | Performance payments earned by PPS through EIP or EPP will be subject to the same restrictions regarding distribution by PPS leads to Safety Net & non–Safety Net Providers as performance payments under the main DSRIP program. | |
| 81 | Use of Funds | Once a payment is received by a PPS from an MCO for meeting an EIP activity or EPP metric, will the MCO be required to oversee that the payment is spent in a certain manner or within a certain time period? | Like in DSRIP, once PPS receive EIP or EPP performance payments they may use the funds as they see fit without further MCO oversight. That being said, there will still be oversight on EIP and EPP funds to make sure PPS follow the 95–5 Safety Net/ non–Safety Net rule. | |
| 82 | Other | Are the Equity Programs in compliance with State and Federal regulations? | Yes, the State affirms that the design of the EPs and the payments made for the prior year are in compliance as implemented. The State will continue to monitor the Programs to ensure continued compliance with State and Federal laws. |
II. Equity Infrastructure Program (EIP) Pairing 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 DSRIP Year (DY) 2 base amounts. Values remain constant for the 5 years of the Equity Programs.
Note 2: Amounts listed are PPS award amounts and do not include administrative or surplus fees.
|top of section| |top of page|III. Equity Performance Program (EPP) Pairing 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 DSRIP Year (DY) 2 base amounts. Values remain constant for the 5 years of the Equity Programs.
Note 2: Amounts listed are PPS award amounts and do not include administrative or surplus fees.
|top of section| |top of page|IV. Equity Performance Program (EPP) Measures Chart
| EPP Measures** | |
|---|---|
| Children´s Access to Primary Care – 12 to 24 months | Children´s Access to Primary Care – 25 months to 6 years |
| Children´s Access to Primary Care – 7 to 11 years | Children´s Access to Primary Care – 12 to 19 years |
| Prenatal and Postpartum Care – Postpartum Visits | Prenatal and Postpartum Care – Timeliness of Prenatal Care |
| Well Care Visits in the first 15 months (5 or more Visits) | Childhood Immunization Status (Combination 3 – 4313314) |
| Frequency of Ongoing Prenatal Care (81% or more) | Follow–up care for Children Prescribed ADHD Medications – Continuation Phase |
| Follow–up care for Children Prescribed ADHD Medications – Initiation Phase | Chlamydia Screening (16 – 24 Years) |
| Lead Screening in Children | Med. Assist. w/ Smoking & Tobacco Use Cessation – Discussed Cessation Medication |
| Med. Assist. w/ Smoking & Tobacco Use Cessation – Discussed Cessation Strategies | Comprehensive Diabetes Care |
| Controlling high blood pressure | Diabetes screening for persons with schizophrenia or Bipolar Disease who are using Antipsychotic Medication |
| Comprehensive Diabetes screening – All Three Tests | Adherence to anti–psychotic medications for individuals with schizophrenia |
| Diabetes monitoring for persons with schizophrenia | Behavioral Health – follow up after hospitalization for mental illness (30 day) |
| Initiation and Engagement in Alcohol and Other Drug Dependence Treatment (IET) within 14 days of substance abuse episode | Follow–up on Alcohol and Other Drug Dependence Treatment (IET) within 44 days of initial engagement |
| Behavioral Health – follow up after hospitalization for mental illness (7 day) | |
*EPP metrics chosen must remain the same for all five years of the Program.
**At least one of the six EPP measures chosen must switch to P4P in DY2 or DY3. Metrics in red switch to P4P in DY2 or DY3
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V. Equity Infrastructure Program (EIP) Activities
| EIP Activities** |
|---|
| Participation in IT TOM initiatives |
| Participation in one of the MAX Series projects |
| Participation in expanded HH enrolment |
| EHR implementation investment |
| Capital spending on primary / behavioral health integration |
| Participation in a state recognized tobacco cessation program |
| Participation in state efforts to end HIV/AIDS |
| Participation in fraud deterrence and surveillance activities |
| Infrastructure spending related to SHIN–NY / RHIO |
*Chosen EIP Activities can be changed annually, before the start of each Demonstration Year
**Note that evidence for these Activities as listed in the Evidence Guide is not exhaustive, and can be expanded on by the MCO and PPS
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VI. Equity Programs (EP) Reporting Frequency and Recipient
| Report | Completed by | Submitted to | Frequency | Location |
|---|---|---|---|---|
| EP Contracts | PPS & MCO | IA | Annually | dsrip_ia@pcgus.com |
| MCO EP Frequency Table | MCO | IA & DOH | Annually | dsrip_ia@pcgus.com bmcfhelp@health.ny.gov |
| MCO EIP Activity Table | MCO | IA & DOH | Based on EP Contracts | dsrip_ia@pcgus.com bmcfhelp@health.ny.gov |
| MCO EIP Payment Table | MCO | IA & DOH | Based on EP Contracts | dsrip_ia@pcgus.com bmcfhelp@health.ny.gov |
| MCO EPP Payment Table | MCO | IA & DOH | Based on EP Contracts | dsrip_ia@pcgus.com bmcfhelp@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 |
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VII. Equity Programs Acronym List
| Acronym | Definition |
|---|---|
| AHPP | Additional High Performance Program |
| CMS | Center for Medicare and Medicaid Services |
| DOH | Department of Health |
| DSRIP | Delivery System Reform Incentive Payment |
| DY | Demonstration Year |
| EHR | Electronic Health Record |
| EIP | Equity Infrastructure Program |
| EP | Equity Programs |
| EPP | Equity Performance Program |
| FAQs | Frequently Asked Questions |
| FWA | Fraud, Waste, and Abuse |
| HEDIS | Health Effectiveness Data and Information Set |
| IA | Independent Assessor |
| MAPP | Medicaid Analytics Performance Portal |
| MAX | Medicaid Accelerated Exchange |
| MCO | Managed Care Organization |
| MY | Measurement Year |
| NYS | New York State |
| PPS | Performing Provider System |
| P4P | Pay For Performance |
| P4R | Pay For Reporting |
| QE | Qualified Entity |
| RHIO | Regional Health Information Organization |
| SFY | State Fiscal Year |
| SHIN-NY | Statewide Health Information Network for New York |
| SNE | Safety Net Equity |
| TTT | Train the Trainer |
VIII. Equity Program Timeline and Annual Awards
* Quarterly reports are generally due on the last day of the month following the close of the quarter
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