Value Based Payment Quality Improvement Program

Service Exclusion Waiver Application

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

A. Purpose of Application

VBP QIP is linked to and supportive of the New York State (NYS) Delivery System Reform Incentive Payment (DSRIP) program, given the focus in the DSRIP program on the transition from fee-for-service to value-based payment arrangements. The Pay for Reporting requirement in DY4 mandated that 80% of all facility's Medicaid Managed Care dollars be in a VBP arrangement. However, DOH understood that there were conditions outside of the VBP QIP facilities' control that impeded their ability to reach the 80% P4R benchmark by the deadline. This application allows facilities that feel as though they are affected by these conditions to apply for the Service Exclusion Waiver. IF APPROVED: DOH may require additional reporting by the facility in order to monitor progress towards VBP, ensure sufficient dollars are captured in these VBP arrangements, or determine the level of effort the facility has taken to partner with other local healthcare providers. The details of the additional reporting requirements will be finalized upon approval.

B. What is a Service Exclusion Waiver

A Service Exclusion Waiver will adjust the VBP QIP P4R requirement to include Medicaid Managed Care dollars associated with only Inpatient Services and Emergency Room Visits as opposed to all Medicaid Managed Care dollars.

C. Reason for Applying

Check all that apply: ☐ Low Attribution: No PCP Connectivity ☐ Low Attribution: Other ☐ Rural Designation ☐ Excess Service Capacity ☐ Other

Please explain:

D. Financial Sustainability Effort

Please fill out the table below detailing any healthcare providers with whom you have attempted to partner or will attempt to partner. These potential partners may include IPAs, ACOs, or larger hospital systems. You may add rows if needed.

Name of Facility	Type of Facility

E. Medicaid Managed Care Volume by MCO

Please use the table below to outline your 2016 Medicaid Managed Care dollars by MCO. If you have a VBP contract in place with the MCO or anticipate having a contract in place by July 1, 2018, select the checkbox in the ´Contract in Place´ column.

Name of MCO	Contract in Place	2016 Total MMC Dollars	2016 Inpatient and ED MMC Dollars
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