Office Hours: Direct Contracting Model Options - Payment Part Two
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This document summarizes a presentation on payment and financing options for the Direct Contracting model. It outlines different payment methodologies for primary care, non-primary care, and other FFS claims under global and professional risk arrangements. It provides examples of calculating shared savings and losses based on benchmarks and risk corridors. Questions from participants are invited on payment/finance, benefit enhancements, application and eligibility, alignment, and general topics. The timeline for the model through 2021 is also presented.
Office Hours: Direct Contracting Model Options - Payment Part Two
- 1. Direct Contracting: Global and Professional Options Payment Office Hours: Part 2 February 11, 2020 Center for Medicare and Medicaid Innovation Centers for Medicare & Medicaid Services (CMS) 1
- 2. Office Hours Agenda 2 Today’s Q&A Topics • Payment / Finance • Benefit Enhancements and Patient Engagement Incentives • Application and Eligibility • Alignment • Open Q&A The financial methodology described in this webinar is still in development and is subject to change. CMS will release additional information as it becomes available.
- 4. Primary Care Claims Non-Primary Care Claims Other FFS Claims DC Participant Providers Preferred Providers DC Participant Providers Preferred Providers Other Providers All Claims % of Claims Reduced % of Claims NOT Reduced % of Claims Reduced % of Claims NOT Reduced % of Claims Reduced % of Claims NOT Reduced All Claims 6 Total Cost of Care Total Cost of Care Primary Care Capitation Total Care Capitation Enhanced PCC Primary Care Capitation Paid through FFS Claims Advanced Payment Paid through FFS Claims Advanced Payment Paid through FFS Claims Total Care Capitation Paid through FFS Claims Total Care Capitation N/A – All Claims Reduced Total Care Capitation Paid through FFS Claims What Claims are Included in the Capitation and Advanced Payments?
- 5. Example of Final Reconciliation (Global, TCC) 4 $940 PBPM Performance Year Benchmark $1000 PBPM vs. Total Care Capitation1 $530 PBPM FFS Claims Payments $410 PBPM Gross Savings $60 PBPM (6% of benchmark) After the Performance Year is completed, CMS compares all Medicare FFS expenditures for services delivered to aligned beneficiaries against the DCE’s performance year benchmark to determine shared savings or shared losses Global Risk Corridor 0-25% DCE Risk 100% $60 x 100% = $60 PBPM $60 PBPM 1. The Total Care Capitation amount will not be reconciled directly against claims covered by the TCC and will be included in expenditures as it was paid to the DCE Final PY Benchmark Total PY Expenditures Application of Risk Corridors Gross Savings Shared Savings
- 6. Example of Final Reconciliation (Professional, PCC) 5 $940 PBPM Performance Year Benchmark $1000 PBPM vs. Gross Savings $60 PBPM (6% of benchmark) After the Performance Year is completed, CMS compares all Medicare FFS expenditures for services delivered to aligned beneficiaries against the DCE’s performance year benchmark to determine shared savings or shared losses Professional Risk Corridor 0-5% 5-10% DCE Risk 50% 35% $50 x 50% = $25 PBPM $10 x 35% = $3.5 PBPM $28.5 PBPM 1. Advanced Payments will be directly reconciled against claims reductions before calculation of total expenditures 2. The Base PCC amount will not be reconciled directly against claims covered by the PCC and will be included in expenditures 3. The Enhanced PCC amount will be fully recouped by CMS before determination of savings / losses; it is not part of expenditures Final PY Benchmark Total PY Expenditures Gross Savings Application of Risk Corridors Shared Savings 7% of Benchmark ($70 PBPM) FFS Claims Payments $410 PBPM Advanced Payments1 $500 PBPM Base PCC2 $30 PBPM Enhanced PCC3 $40 PBPM
- 7. Direct Contracting Payment / Finance 7 Payment / Finance Q&A Please submit questions via the Q&A pod to the right of your screen. Specific questions about your organization can be submitted to DPC@cms.hhs.gov
- 9. Direct Contracting Benefit Enhancements 9 Benefit Enhancements and Patient Engagement Incentives Q&A Please submit questions via the Q&A pod to the right of your screen. Specific questions about your organization can be submitted to DPC@cms.hhs.gov
- 11. Direct Contracting Application & Eligibility 11 Application & Eligibility Q&A Please submit questions via the Q&A pod to the right of your screen. Specific questions about your organization can be submitted to DPC@cms.hhs.gov
- 12. Alignment
- 13. Direct Contracting Alignment 13 Alignment Q&A Please submit questions via the Q&A pod to the right of your screen. Specific questions about your organization can be submitted to DPC@cms.hhs.gov
- 14. Open Q&A
- 15. Direct Contracting Open Q&A 15 Open Q&A Please submit questions via the Q&A pod to the right of your screen. Specific questions about your organization can be submitted to DPC@cms.hhs.gov
- 16. Model Timeline
- 17. Model Timeline 17 This timeline may be subject to change. Please check the Directing Contracting webpage for webinar and office hour dates and times. Timeline Implementation Period (IP) DCE Applicants Performance Period (PY1) DCE Applicants Application Period November 25, 2019 – February 25, 2020 (Application tool opened December 20, 2019) March 2020 – May 2020 DCE Selection May 2020 September 2020 Deadline for applicants to sign and return Participant Agreement (PA) June 2020 (IP PA) December 2020 (Performance Period PA) December 2020 Initial Voluntary Alignment Outreach and start of IP or PY June 2020 January 2021
- 18. Audience Poll 18 How likely are you to apply to participate in the Direct Contracting model? a) Very likely b) Likely c) Unlikely d) Very unlikely e) Unsure
- 19. 19 Direct Contracting Webpage (includes link to application): https://innovation.cms.gov/initiatives/direct-contracting-model-options/ Email: DPC@cms.hhs.gov Salesforce Support: CMMIForceSupport@cms.hhs.gov Contact Information