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Maternity Checklist for Fully Capitated MCOs

Checklist is also available in Portable Document Format (PDF)

(Updated 05/2022)

1	Plan Name
2	IPA/ ACO/ Provider Name
#	Verifying Questions	Review (at least one box per category must be checked)	Description	Specify Contract Page Number
(1) Type of Arrangement (as per the Roadmap)	Does the contract match the Roadmap arrangement definition?	☐	Roadmap (page 4-5): All Medicaid covered services included in the episodes for all pregnant individuals (+/− their newborns) eligible for Mainstream Managed Care (with the exception of duals). The services included in a Maternity arrangement shall be defined within each contract and include the related timeframes. State-suggested components and timeframes are included below. Maternity Care arrangement components: Prenatal (270 days prior to delivery) Delivery - Vaginal or Cesarean Hospital Neonatal Services Postpartum (84 days post discharge for pregnant individual) Newborn (30 days post discharge for the newborn)
(2) Definition and Scope of Services	Does the scope of services state that it will match the VBP Roadmap definition?	☐	Roadmap (page 4-5): All Medicaid covered services included in the episodes for all pregnant individuals (+/− their newborns) eligible for Mainstream Managed Care (with the exception of duals). The services included in a Maternity arrangement shall be defined within each contract and include the related timeframes. State-suggested components and timeframes are included below. Maternity Care arrangement components: Prenatal (270 days prior to delivery) Delivery - Vaginal or Cesarean Hospital Neonatal Services Postpartum (84 days post discharge for pregnant individual) Newborn (30 days post discharge for the newborn) If the VBP arrangement includes carved-out services, has any other changes that do not meet on-menu definitions, or are not among the allowed population exclusions, then it is considered an "off-menu" arrangement and is subject to additional review by NYS, but may still be eligible for approval. Additional details related to on-menu arrangements and acceptable exclusions may be found in the VBP Roadmap.
(2) Definition and Scope of Services	OR does the contract list all of the episodes (see "Description" column)?	☐
(3a) Quality measure selection for Shared Savings/Losses	Does the contract include the appropriate quality measures to determine shared savings/losses?	☐	Roadmap (page 7): & Maternity Measure set, which will be updated annually The list of quality measures to be used for the calculation of shared savings and losses shall be included in the contract. In the quality measures to be included, at least one (1) Category 1 P4P quality measure shall be selected from the NYS- approved Maternity Quality Measure set found on the VBP Resource Library under the VBP Quality Measure section.
(3b) Quality Measure Reporting	Does the contract commit to reporting on all Category 1 quality measures approved by NYS?	☐	Roadmap (page 13-14): For on-menu contracts, all agreed upon Category 1 quality measures (P4P as well as any applicable P4R) approved by NYS must be reported. Inclusion of measure reporting requirements beyond Category 1 is optional. To assist in the reporting process, the 2022 VBP Reporting Requirements Technical Specifications Manual will be available under the VBP Quality Measures Tab for Measurement Year 2022 when finalized. If at least one (1) reportable Category 1 measure is missing, this arrangement will be considered off-menu and will be reviewed by the Off-Menu Committee.
(4) Risk Level	Does the contract describe the level of risk chosen by the contracting parties?	☐	Roadmap (page 5-6 & 18-19): Level 1: FFS with Retrospective Reconciliation – Upside Only Risk Level 2: FFS with Retrospective Reconciliation – Upside and Downside Risk Level 3: Prospective Payments- Upside and Downside Risk (PMPM or Bundled Payments). The VBP contractor should strongly consider negotiating risk-mitigation strategies with the MCO, such as stop-loss arrangements, reinsurance, withholds, and risk-corridors. The level of risk must be described in the contract and match the definitions for Contracting Levels 1 through 3 in Appendix A-4 of the VBP Roadmap.
(5) Shared Savings/Losses	Does the risk level correspond with the shared savings/losses minimums?	☐	Roadmap (page 5-6 & 18-19): NYS does not mandate a specific shared savings/losses distribution methodology, but the potential shared savings, as well as potential shared losses, must be described in the contract and match the definitions for Contracting Levels 1 through 3 in Appendix A-4 of the VBP Roadmap. Level 1: Minimum of 40% of shared savings must be allocated to the VBP contractor Level 2: Minimum of 20% of potential losses must be allocated to the VBP contractor, with a cap of 3% of the target budget in the first year of the Level 2 contract and 5% from the second year on. Below these levels, the VBP arrangement is counted as a Level 1 arrangement. Level 3: N/A
(6) Attribution	Does the contract describe the attributed population?	☐	Roadmap (page 6 & 19-20): While NYS does not mandate a specific methodology to be used to attribute members to a VBP arrangement, the contract shall specify the attribution methodology. Such methodology shall describe: Inclusion criteria: Which members will be attributed to an arrangement, and thus included for the purposes of quality measurement and target budget setting; and Exclusion criteria: Which members will be excluded.
(7) Target Budget	Does the contract describe the Target Budget Baseline Setting and Calculation in this arrangement?	☐	Roadmap (page 6-7 & 20-21): NYS does not mandate a specific methodology to be used to calculate a target budget for an arrangement. However, the contracts shall specify that a target budget will be used and the method of calculation, including the frequency of budget rebasing. MCOs and VBP contractors with more than one line of business covered by one contract shall establish target budgets separately for each line of business contained within a contract. When calculating target budgets, providers and plans could consider both the provider's historical cost and the regional benchmark/MCO average during their negotiation process.
(8a) Social Care Needs	If this is a Level 2 or higher contract, does it commit to implementing at least one intervention to address social care needs?	☐	Roadmap (page 7-8): VBP contractors in Level 2 or Level 3 agreements are required to implement at least one intervention that addresses social care needs. The intervention cannot be a Medicaid billable service.
(8b) Social Care Needs Reporting	If this contract receives social care need-targeted funding, does it commit to reporting on fund utilization?	☐	Roadmap (page 14): All social care need-targeted funding shall be reported by the MCO to NYS using the Social Determinants of Health Intervention Status Report template.
(9) Contracting with Not-for-profit Community Based Organizations (starting January 2018)	If this is a Level 2 or higher contract, does it commit to contract with at least one not- for-profit Community Based Organization?	☐	Roadmap (page 8-9): All Level 2 and 3 VBP arrangements shall include a minimum of one not-for-profit Community Based Organization.