BHT took into consideration many factors when designing the funds flow model for Medicaid Transformation Project achievement. The BHT Board intends for the funding to support the region’s ability to hit Pay-for-Performance measures and support real transformation to the delivery of care. To do that, we wanted to maximize investments in primary care and behavioral health Partnering Providers, so the model acknowledges that volume matters if we want to ensure that population level impact occurs. We also wanted to demonstrate our commitment to equity, so there is emphasis on provider level activities to support equity. And as always, our goals were to get dollars into the hands of our providers and—while we are trying to develop a regional system—to honor provider choice/independence.
Below are the funds flow models approved by the BHT Board at their November 28, 2018 meeting.
Pay-for-Reporting Funds Flow Model
Based on a unanimous recommendation from the Waiver Finance Workgroup, the Board has approved the following Pay-for-Reporting funds flow model for behavioral health and primary care Partnering Providers for 2019, 2020, and 2021. The Board approved this Partnering Provider Volume Calculation POLICY which outlines how the numbers were calculated, the tiers, and the dispute resolution process. .
Partnering Providers will be divided into 3 groups based on volume and allocated earning potential based on that volume.
1,200 or less Beneficiaries
An optional Tribal Carve Out will be offered to Tribal Partners who wish to opt out of Pay-for-Reporting. The Tribal Carve Out requires identification of other Transformation efforts undertaken and continued participation in Tribal Partner Leaders Council and county-based Collaborative.
Unearned funds will be placed in a pool, to be distributed at the recommendation of Waiver Finance Workgroup and approved by BHT Board.
The funds will be earned by a combination of hitting milestones developed by the Partnering Provider in their Final Transformation Plan and meeting Pay-for-Achievement measures selected from a BHT-provided list.
40% - Transformation Plan milestones
40% - Pay-for-Achievement measures
20% - Equity Pay-for-Achievement measures
How many dollars are there?
The following table shows the potential Pay-for-Reporting earnings, per partner.
Pay-for-Performance Funds Flow Model
Pay-for-Performance funds are earned by the region meeting the measures created by the Health Care Authority (HCA). These dollars will be earned based on 25% of Pay-for-Performance Project funds in 2019, 50% of Pay-for-Performance Project funds in 2020, and 75% of Pay-for-Performance Project funds in 2021. Please note that 2019 Pay-for-Performance funds will be distributed by HCA in 2021; 2020 Pay-for-Performance funds in 2022; and 2021 Pay-for-Performance funds in 2023.
Based on a unanimous recommendation from the Waiver Finance Workgroup, the Board has approved the following model to allocate the 85% of the region’s Pay-for-Performance funds earned for distribution to behavioral health and primary care Partnering Providers. The dollars will be allocated by volume to large- and medium-sized providers as follows:
75% of earnings to Large: serves 20,001+ Medicaid patients
25% of earning to Medium: serves 1,201-20,000 Medicaid patients
How many dollars are there?
The following table shows the potential Pay-for-Performance earnings for the BHT region.
Notes on Volume
The Board approved this Partnering Provider Volume Calculation POLICY which outlines how the numbers were calculated, the tiers, and the dispute resolution process.
How many Partners are in each volume group?*
4 providers with 20,001+ beneficiaries, comprising approx. 75% of the Medicaid volume in our region.
14 partners fall into the 1,201-20,000 group, comprising approx. 20% of Medicaid volume in our region.
25 partners fall into the under 1200 group, comprising approx. 5% of Medicaid volume in our region.
*Based on 2016 data. Volume will ultimately be calculated on 2017 data once received from HCA.
How is BHT calculating volume numbers?
BHT is utilizing third-party data from the Health Care Authority (HCA) to establish an unduplicated count of Medicaid beneficiaries for each Partnering Provider.
Only fully eligible Medicaid and SCHIP clients are included. Duals with Medicare and individuals with Third Party Liability (TPL) are excluded from the count.
Only Medicaid clients that reside in BHT’s six counties are counted. No continuous enrollment criteria were imposed.
Counts are based on paid fee-for-service (FFS) claims and accepted MCO encounters, including BHO (RSN) encounters.