Risk transfer is a strategy of dealing with risks. Specifically, to help ensure that care quality is improved and beneficiary choice and access are protected, CMS will tie a meaningful percentage of the benchmark to performance on quality of care, while also monitoring to ensure that beneficiaries’ access to care is not adversely affected as a result of the model. The options below will consider this question primarily within the context of VBP Level Two arrangements, which may significantly limit the downside exposure for providers. Apply the requirements of Regulation 164 to all VBP Level Two and VBP Level Three arrangements and broaden the definition of Financial Risk Transfers to include VBP Level Two. This is done for a variety of reasons including insurance products and self-insurance strategies. Did you know that, dozens of times every day, you share risk? The DOH review process for risk-sharing arrangements would remain in place, but would be modified to address the VBP Levels. It describes situation when we transfer the risk to another person or entity such as insurance agency. Organizations have expressed interest in a model that draws upon private sector approaches to risk-sharing arrangements and payment with reduced administrative burden commensurate with the level of downside risk. With risk-sharing contracts, clinical and/or economic outcomes are measured and agreed upon prior to signing the contract, and payment is dependent on meeting the agreed-upon measures. The following policy options have been developed for the Subcommittee's consideration. Which of the following insurance options would be considered a risk sharing arrangement? Policy Question: Are the regulatory requirements that are in place for providers taking on downside risk appropriate for the transition to VBP, or should some alternate regulatory vehicle(s) be developed? The arrangement will be as follows: In exploring the role of aging in risk sharing an important question is to what extent the aging process can be foreseen. Accept. The payment model options available under Direct Contracting are expected to increase beneficiaries’ access to innovative, affordable care while maintaining all original Medicare benefits. Relative to existing initiatives, the payment model options also include a reduced set of quality measures that focuses mor… As of June, 2012, 21,770 indi-viduals had ria. These issues will require coordination between both the New York State Department of Health (DOH) and the Department of Financial Services (DFS). Risk sharing occurs when two parties identify a risk and agree to share the loss upon the occurrence of the loss due to the risk. The payment model options available under Direct Contracting aim to reduce expenditures while preserving or enhancing quality of care for beneficiaries. Some of these coverage options, including short-term policies, health care sharing ministries, and other insurance-like arrangements, such as discount cards and direct primary care contracts, were generally not considered individual market health insurance prior to the ACA and were not brought within the federal definition by the health law. In considering these options, the Subcommittee should also recommend the degree of State involvement required and related considerations and regulatory impacts associated with each option. The RFA describes the eligibility requirements, payment methodology, available benefit enhancements, and selection criteria. Another example is insurance, wherein, the buyer of insurance transfers its risk to an insurance company. What Is a Reciprocal Insurance Company?. Providers under Level Two arrangements could utilize Regulation 164 to avoid the potential application of full insurance requirements. VBP Level Three involves prepaid bundles (chronic and episodic) and other prepaid capitation arrangements. A model participant in any one of the payment model options available under Direct Contracting, referred to as a Direct Contracting Entity (DCE), may offer benefit enhancements and certain additional services to beneficiaries with no requirement that beneficiaries accept these benefits or services. The payment model options available under Direct Contracting will start in 2020 with an initial implementation period for organizations that want to align beneficiaries to meet the minimum beneficiary requirements. The payment model options are anticipated to appeal to a broad range of physician practices and other organizations because they are expected to reduce burden, support a focus on beneficiaries with complex, chronic conditions, and encourage participation from organizations that have not typically participated in Medicare FFS or CMS Innovation Center models. The payment model options available under Direct Contracting seek to reduce program expenditures and improve quality of care and health outcomes for Medicare beneficiaries through alignment of financial incentives and an emphasis on beneficiary choice and care delivery while maintaining access to care for beneficiaries, including patients with complex, chronic conditions and seriously ill populations. CMS hosted webinars about the DC Model Options for interested stakeholders: If you are interested in receiving additional information and updates specifically about the Direct Contracting Model Options, please subscribe to the Direct Contracting Model Options listserv. These payment schemes—called “performance-based risk-sharing arrangements” (PBRSAs)—involve a plan by which the performance of the product is tracked in a defined patient population over a specified period of time and the amount or level of reimbursement is based on the health and cost outcomes achieved. Risk is considered to be shared if there is no policyholder-specific correlation between premiums paid into a captive, for example, and losses paid from the captive's reserve pool. Unlike other strategies, there is nothing that happens to the risk itself, only its negative impact is redirected to a third party. The risk-sharing portion of an agreement may include clinical and/or economic outcomes that are measured and agreed upon prior to contract signing, and payment is … Consider these other important insurance options. It may be difficult to obtain consensus on the requirements from all stakeholders. Avoid. This is typically done in joint ventures (where equity owners share risks of the loss in proportion to their stakes in the venture), new ventures and relationships where each party shares actual operational control. Physician Incentive Plan (PIP) refers to any compensation arrangement to pay physicians or physician groups that may have the effect of reducing or limiting the services provided to any plan enrollee. The application period for this cohort will begin in the first quarter of 2021. MCOs are obligated to obtain approval from DOH in accordance with the regulations and Provider Contract Guidelines and from DFS in accordance with Regulation 164 prior to entering into a risk sharing arrangement. Provider Risk Sharing: Options and Considerations, Health & Safety in the Home, Workplace & Outdoors, Clinical Guidelines, Standards & Quality of Care, All Health Care Professionals & Patient Safety, Medicaid Analytics Performance Portal (MAPP), Managed Long Term Care Workforce Investment Program, Addressing the Opioid Epidemic in New York State, Learn About the Dangers of "Synthetic Marijuana", Help Increasing the Text Size in Your Web Browser, Per option, the Subcommittee should recommend whether the State should set a Statewide Standard or a. These issues are interrelated because Default Risk Reserve requirements that are placed on providers are only relevant when providers are participating in risk sharing arrangements with insurers such as Managed Care Organizations (MCOs). DOH financial review and approval is required for all MCO agreements that transfer financial risk for services to another entity, except for prepaid capitation which falls under Regulation 164 and DFS review. Contracting Arrangement Examples is also available in Portable Document Format (PDF, 152KB) Contracting Arrangement Examples. Option 2: Modify Regulation 164 or enact new regulations to develop separate requirements for VBP Level Two arrangements that mitigate business and cash flow risk. By aligning financial incentives, providing a prospectively determined and predictable revenue stream for participants, and putting a greater emphasis on beneficiary choice, the payment model options aim to: The payment model options available under Direct Contracting are expected to increase beneficiaries’ access to innovative, affordable care while maintaining all Original Medicare benefits. If a Contractor elects to operate a PIP, the Contractor agrees that: In any risk sharing arrangement, the MCO ultimately retains its statutory obligation to maintain full risk under NYS PHL § 4403(1)(c) on a prospective basis for the provision of comprehensive health services pursuant to a subscriber contract or governmental program. Leave Regulation 164 as it currently stands. Implied. There would be a reserve in place to cover potential losses (downside risk) and help protect the provider and MCO. The payment model options also aim to improve beneficiaries’ experience of care by reducing administrative burdens on practitioners, so that they can focus on what is most important, spending time with patients. It involves sharing (dividing) common risk among two or more persons. Apply the requirements of Regulation 164 to VBP Level Three Arrangements but not to Level Two arrangements. CMS expects that the use of voluntary alignment will attract organizations that previously were ineligible because of their low volume of Medicare FFS beneficiaries, such as organizations that currently operate in the MA program. Create or amend regulations to include alternative risk sharing requirements, particularly for VBP Level Two. Under Direct Contracting, there will be three types of DCEs with different characteristics and operational parameters. For a pharmaceutical company, risk-sharing agreements are a mechanism to gain or fast track market access by addressing payer concerns. Value Based Payment Arrangements Involving Risk Sharing. In this way, the buyer of call option transfers its risk to the writer of the call option. A: Current APMs include, but are not limited to, accountable care organizations (ACOs), Medicare Shared Savings Program (MSSP), pay for coordination, pay-for-performance (P4P), bundled payments, upside-and downside-shared savings programs, partial - or full-capitation, and global payments. Pooling risks together allows the higher costs of the less healthy to be offset by the relatively lower costs of the healthy, either in a plan overall or within a premium rating category. Risk sharing is the distribution of risk to multiple organizations or individuals. Developing separate, less burdensome requirements for providers sharing risk under a VBP Level Two arrangement would encourage provider participation by allowing flexibility from the insurance and/or Regulation 164 requirements. Direct Contracting will be an Advanced Alternative Payment Model (APM) starting in its first performance year (2021). Currency risk sharing is a contractual agreement between counterparties to a trade or deal to share in any losses due to currency risk or exchange rate fluctuations. The current definition of financial risk transfer under Regulation 164 does not address the concept of VBP Level Two arrangements. For any questions, please email the Direct Contracting Model team at DPC@cms.hhs.gov. Regulation 164 states that unless the financial security deposit (FSD) requirement is met, providers are barred from entering into an agreement to share financial risk through a capitation arrangement with either an insurer or any entity certified pursuant to Article 44 of the New York State Public Health Law. The payment model options also aim to improve beneficiaries’ experience of care by reducing administrative burdens on practitioners, so that they can focus on what is most important, spending time with patients. Option 1: Leave Regulation 164 as it currently stands. Results from the submitted clinical trials Apply the requirements of Regulation 164 to VBP Level Three Arrangements but not to Level Two arrangements. There are two voluntary risk-sharing payment model options as well as a third payment model option for which CMS will release more information later this year: The Professional and Global options aim to attract a range of health care providers operating under a common governance structure, with attention given to advancing primary care as a means to better managing health care overall. Relative to existing CMS initiatives, the payment model options place an emphasis on voluntary alignment, empowering beneficiaries to choose the health care providers with whom they want to have a care relationship. Traditional insurance … Health Insurance Risk-Sharing Plan (HIRSP) The health insurance risk-sharing plan (HIRSP) offers health insurance coverage to Wisconsin residents who cannot purchase ade-quate private coverage due to a medical condi-tion, or who have lost employer-sponsored group health insurance. Gain-sharing arrangement: ... Medicare: U.S. social insurance program that provides health insurance access to individuals including those 65 years of age or older, as well as younger individuals with end-stage renal disease (ESRD) or ... sharing financial risk (i.e., payment reform) to better align incentives to provide quality care at more CMS will be hosting webinars for Direct Contracting; please continue to check this site for updates. Medicaid risk-sharing arrangements are not on the decline, as is risk sharing in other types of health insurance. Managing risk is an important component of life, and insurance is a common way to mitigate many types of risk and loss. The AIFA Oncologic Working Group suggested two risk sharing arrangements for new anti-cancer medicines to enhance their reimbursement potential based on: Epidemiological data for the disease. The new payment model options also present an opportunity to test novel methods for organizations to manage Medicare FFS expenditures. Risk participation is an agreement where a bank sells its exposure to a contingent obligation to another financial institution. Risk & Risk Sharing Definition. Proposition: ABC Insurance Co. has received a proposal for fire insurance, from a textile mill for an amount of $1,00,00,000, The company’s retention for this class of business is $10,00,000, A 9-line surplus treaty exists. Five performance years will follow, beginning in April 2021. VBP Level Two retains the FFS payment structure and shared savings concept of VBP Level One, but contains two differences for providers: the opportunity for a higher percentage of shared savings and the potential for shared losses (downside risk). In summary, payers engage in risk-sharing agreements as a means to improve the cost effectiveness of new therapies. Relative to existing initiatives, the payment model options also include a reduced set of quality measures that focuses more on outcomes and beneficiary experience than on process. Furthermore, even with provider underperformance, the healthcare delivery risks primarily remain with the insurer. Option 3: Apply the requirements of Regulation 164 to all VBP Level Two and VBP Level Three arrangements and broaden the definition of Financial Risk Transfers to also include VBP Level Two. PY1 applicants have received their participation notification. The DOH contract review process and requirements would remain, but be modified to reflect the VBP Levels. The payment model options available under Direct Contracting take significant steps toward providing a prospectively determined revenue stream for model participants. The payment model options available under Direct Contracting create opportunities for a broad range of organizations to participate with the Centers for Medicare & Medicaid Services (CMS) in testing the next evolution of risk-sharing arrangements to produce value and high quality health care. The Regulatory Impact Subcommittee (Subcommittee) is tasked with providing recommendations regarding the policy question and related policy options below which deal with the regulatory and procedural framework surrounding provider risk sharing. A model participant in any one of the payment model options available under Direct Contracting, a DCE, may offer benefit enhancements and certain additional services to beneficiaries with no requirement that beneficiaries accept these benefits or services. Global PBP offers the highest risk sharing arrangement—100% savings/losses—and provides two payment options: Primary Care Capitation (described above) or Total Care Capitation, capitated, risk-adjusted monthly payment for all services provided by DC Participants and preferred providers with whom the DCE has an agreement. The Center for Medicare and Medicaid Innovation (Innovation Center) is excited to announce that. Risk-Sharing Arrangement Depending on the payment option chosen, DCEs will be at risk for either a portion or all of the total cost of care for Parts A and B services for aligned beneficiaries. This method will require the development of new or revised regulations, safeguards, and may even require legislative support. Further, through refinements in CMS benchmarking methodology and risk adjustment, CMS is aligning financial incentives to attract organizations that manage the complex chronic, and seriously ill beneficiary populations. Relative to existing CMS initiatives, the payment model options place an emphasis on voluntary alignment, empowering beneficiaries to choose the health care providers with whom they want to have a care relationship. IPAs may share risk for the provision of medical services with MCOs, and to subcapitate or otherwise compensate providers and IPAs with which it has contracted. Developing specific safeguards that mitigate risks inherent to a VBP Level Two arrangement would still ensure that providers are capable of fulfilling their obligations to Medicaid members. Contractor agrees to submit to DOH annual reports containing the information on its PIP in accordance with 42 CFR §§ 438.6(h), 422.208 and 422.210. If the PIP places physician(s) at a substantial financial risk for services that it referred but did not furnish, for an amount beyond the risk threshold of 25% of potential payments for covered services, the MA Organization must assure that all physician(s) at risk have a stop-loss agreement in place. Which of the following insurance options would be considered a risk-sharing arrangement A) Surplus lines B) Reciprocal C) Stock D) Mutual. There would a reduced likelihood of excess cash reserves sitting idle. The application period for Performance Year 1 (PY1) has closed. If you are interested in receiving CMS Innovation Center updates, including about Direct Contracting Model Options, subscribe to the CMS Innovation Center listserv. Because Level Two involves retrospective reconciliation of payments to determine whether there are savings or losses, it represents a grey area in the regulatory framework. The next Subcommittee meeting will focus on developing policy recommendations related to provider risk sharing and default risk reserves. PY1 applicants have received their participation notification. All contracts require submission of a contract certification statement and a non-financial review to DOH for compliance with all provider contracting guidelines. Modify Regulation 164 or enact new regulations (whether in the insurance, health, or other titles) to develop separate requirements for VBP Level Two arrangements that mitigate business and cash flow risk. New regulations or considerations would need to be considered and developed to address this gap. Option 1: Leave Regulation 164 as it currently stands. A Standard is required when it is crucial to the success of the NYS Medicaid Payment Reform Roadmap that all MCOs and Providers follow the same method. Providers would not be subject to the risk sharing requirements with MCOs and, if excluded from the definition of financial risk transfer, providers who engage in Level Two arrangements would be absolved of the FSD risk sharing requirement. A federal government website managed and paid for by the U.S. Centers for Medicare & Update: The Center for Medicare and Medicaid Innovation (Innovation Center) is excited to announce that 51 Direct Contracting Entities (DCEs) are participating in the Implementation Period of the Direct Contracting Model for Global and Professional Options, which runs from October 1, 2020 through March 31, 2021. Building on lessons learned from initiatives involving Medicare Accountable Care Organizations (ACOs), such as the Medicare Shared Savings Program (MSSP) and the Next Generation ACO (NGACO) Model, the payment model options available under Direct Contracting also leverage innovative approaches from Medicare Advantage (MA) and private sector risk-sharing arrangements. This is achieved by reducing uncertainty related to drug performance and cost impact. Risk is the probability of an event occurring in a given time period. We request the Subcommittee to consider whether the requirements of Regulation 164 should be modified to include Level Two arrangements by changing the definition of financial risk transfer along with other related changes that may be needed to effectuate this change. 7500 Security Boulevard, Baltimore, MD 21244, https://app1.innovation.cms.gov/dcrfa/dcrfaLogin, Webinar: Direct Contracting Model Options - Professional and Global Options Overview, Office Hours: Direct Contracting Model Options - Overview, DCE Types and Alignment, Webinar: Direct Contracting Model Options - Benefit Enhancements, Webinar: Direct Contracting Model Options - Application, Office Hours: Direct Contracting Model Options - Benefit Enhancements and Application Overview, Webinar: Direct Contracting Model Options - Payment Part One, Webinar: Direct Contracting Model Options - Payment Part Two, Office Hours: Direct Contracting Model Options - Payment Part One, Office Hours: Direct Contracting Model Options - Payment Part Two, Webinar: Direct Contracting Model Options - Financial Methodology, Office Hours: Direct Contracting Model Options - Financial Methodology Question and Answer Session, Webinars: Direct Contracting Model Options - Overview Series, Direct Contracting Model Options listserv, Fact Sheet - Professional and Global Options, Frequently Asked Questions - October 2020 (PDF), Financial Frequently Asked Questions - October 2020 (PDF), Application Best Practices and Checklist (PDF), CMS Primary Cares Initiative One-Pager (PDF), Geographic Population-based Payment Request for Information (PDF), Model Overview for State Insurance Regulators, Companion to Financial Operating Guide Overview - Standard DCE (PDF), Companion to Financial Operating Guide Overview - High Need Population DCE (PDF), Companion to Financial Operating Guide Overview - New Entrant DCE (PDF), Capitation and Advanced Payment Mechanisms (PDF), Companion to Capitation and Advanced Payment Mechanisms (PDF), Call: Direct Contracting Model Options - COVID-19 Flexibilities (June 4, 2020). Industry providers describe "risk sharing" as a method by which a captive/trust acts as a small reinsurer to the larger entity. In consideration of the endorsement for full insurance by the Commissioner of loans covering the units set-aside in Article I, Paragraph A of this Agreement, and in order to comply with the requirements of the risk-sharing program established by Section 542(c) and the regulations adopted by the Commissioner The DOH review process for risk-sharing arrangements would remain in place, but would be modified to address the VBP Levels. The purpose of the FSD is to ensure that providers are financially stable and are able to fulfill their commitment to Medicaid members following the receipt of prepayments from plans for providing those services. Each payment model option includes features aimed at encouraging organizations focused on care for patients with complex, chronic conditions, and seriously ill populations to participate. Risk Treatment This is the complete list of articles we have written about risk treatment . Medicaid Services. For example, the deductibles and premiums you pay for insurance are a form of risk sharing—you accept responsibility for a small portion of the risk, while transferring the larger portion of the risk to the insurer. The application portal can be found using the link below. VBP Level One involves fee-for-service (FFS) payment plus shared savings (upside only) and is therefore not relevant for a discussion around risk sharing. Because Level Two is not a prepaid capitation arrangement, the existing regulatory structure would not include Level Two arrangements under the current definition as it stands, and it would remain unclear whether Level Two would constitute a transfer of financial risk. In addition to organizations that have traditionally provided services to a Medicare FFS population, Direct Contracting will provide new opportunities for organizations without significant experience in FFS to enter into value-based care arrangements. The Office of General Counsel issued the following opinion on April 28, 2004, representing the position of the New York State Insurance Department. No payment will be made to a Provider as an inducement to reduce or limit medically necessary services to an Enrollee. Option Risk Arrangement Professional PBP 50% Savings/Losses Global PBP 100% Savings/Losses Geographic PBP (proposed) 100% Savings/Losses 24 These three types of DCEs are: Organizations have expressed interest in a model that draws upon private sector approaches to risk-sharing arrangements and payment with reduced administrative burden commensurate with the level of downside risk. Even in situations of risk transfer, it is common to share some risk. There is a risk of duplicative coverage for the same risks depending on how the "financial risk transfer" is defined. The providers must either: Are the regulatory requirements that are in place for providers taking on downside risk appropriate for the transition to VBP, or should some alternate regulatory vehicle(s) be developed? The Request for Applications (RFA) (PDF) is now available. By providing flexible payment model options with regard to, for example, risk-sharing arrangements, financial protections and benefit enhancements, CMS expects that the payment model options under Direct Contracting will be attractive to NGACO participants, as well as organizations that have experience with risk-based contracts in MA, but have not to date participated in Medicare FFS or CMS Innovation Center models. Current DOH Financial Review Criteria for Specific Non-Prepaid Arrangements: DFS Regulation 164 provides guidance concerning the Financial Risk Transfer arrangements and outlines the requirements for providers that do not obtain an insurance license to enter into such arrangements. These agreements are … Providers may have a financial security deposit requirement despite payments from MCOs occurring on a retrospective, FFS basis. Risk Sharing is an entirely different concept. CMS recently approved the VBP Roadmap. Direct Contracting is a set of three voluntary payment model options aimed at reducing expenditures and preserving or enhancing quality of care for beneficiaries in Medicare fee-for-service (FFS). The payment model options available under Direct Contracting take significant steps toward providing a prospectively determined revenue stream for model participants. 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